A list of the most recent deficiencies for The Carrolton of Williamston. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-27 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-27 | 2023-03-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-27 | 2023-03-07 | Y |
| Meet other general requirements. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-13 | 2023-02-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-18 | 2022-12-30 | 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 | 2022-11-18 | 2022-12-30 | 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 | 2022-11-18 | 2022-12-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-18 | 2022-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-12-30 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-18 | 2022-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-18 | 2022-12-23 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-11-18 | 2022-12-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-18 | 2022-12-21 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-11-18 | 2022-12-21 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-11-18 | 2022-12-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-11-18 | 2022-12-21 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-11-18 | 2022-12-21 | N |
| 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 | 2022-11-18 | 2022-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-18 | 2022-12-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-18 | 2022-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-18 | 2022-12-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-11-18 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-18 | 2022-12-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-24 | 2021-07-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-10 | 2021-07-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-10 | 2021-07-08 | N |
| 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 | 2021-06-10 | 2021-07-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-10 | 2021-07-08 | 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 | 2021-06-10 | 2021-07-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-10 | 2021-07-08 | N |
| 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 | 2021-06-10 | 2021-07-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-10 | 2021-07-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-22 | 2020-01-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-22 | 2020-01-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-22 | 2020-01-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-11-22 | 2020-01-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-22 | 2020-01-06 | 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 | 2019-11-22 | 2020-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-22 | 2020-01-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-22 | 2020-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-06 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-22 | 2020-01-06 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-11-22 | 2019-12-19 | N |
