Deficiency Records for Carmel Hills Wellness and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Carmel Hills Wellness and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-07 | 2023-09-08 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-09-07 | 2023-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-08-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-29 | 2023-05-13 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-29 | 2023-05-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-29 | 2023-05-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-29 | 2023-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-29 | 2023-05-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-29 | 2023-05-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-29 | 2023-05-13 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-29 | 2023-05-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-05-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-03-29 | 2023-05-13 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-29 | 2023-05-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-29 | 2023-05-13 | N |
| Keep all essential equipment working safely. | Health | 2023-03-29 | 2023-05-13 | N |
| Have policies on smoking. | Health | 2023-03-29 | 2023-05-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-29 | 2023-05-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-29 | 2023-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-29 | 2023-05-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-05-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-29 | 2023-05-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-29 | 2023-05-13 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-29 | 2023-05-13 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-03-29 | 2023-05-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have an externally vented heating system. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-10 | 2023-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-10 | 2023-02-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-10 | 2023-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-25 | 2022-12-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-10-25 | 2022-12-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-10-25 | 2022-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-01 | 2022-10-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-10-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-31 | 2022-03-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-10 | 2021-08-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-06 | 2021-07-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-06 | 2021-06-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-03-09 | 2020-04-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-03-09 | 2020-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-09 | 2020-04-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-09 | 2020-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-09 | 2020-04-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-09 | 2020-04-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-09 | 2020-04-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-09 | 2020-04-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-03-09 | 2020-04-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-03-09 | 2020-04-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-03-09 | 2020-04-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-03-09 | 2020-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-09 | 2020-04-23 | N |
| Keep all essential equipment working safely. | Health | 2020-03-09 | 2020-04-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-09 | 2020-04-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-09 | 2020-04-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-09 | 2020-04-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-09 | 2020-04-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-16 | 2019-03-01 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2019-01-16 | 2019-03-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-16 | 2019-03-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-16 | 2019-03-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-16 | 2019-03-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-16 | 2019-03-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-01-16 | 2019-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-16 | 2019-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-16 | 2019-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-16 | 2019-03-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-16 | 2019-03-01 | N |
