A list of the most recent deficiencies for The Carrolton of Plymouth. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-16 | 2023-05-03 | N |
| 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 | 2023-02-16 | 2023-03-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-16 | 2023-03-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-16 | 2023-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-15 | 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 | 2023-02-16 | 2023-03-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-16 | 2023-03-15 | 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 | 2023-02-16 | 2023-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-15 | N |
| Provide or obtain dental services for each resident. | Health | 2023-02-16 | 2023-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-16 | 2023-03-15 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-02-16 | 2023-03-15 | 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 | 2023-02-16 | 2023-03-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-16 | 2023-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-16 | 2023-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-28 | 2021-08-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-08-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-28 | 2021-08-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-28 | 2021-08-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-06-04 | 2019-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-04 | 2019-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-04 | 2019-06-21 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-04-19 | 2019-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-19 | 2019-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-19 | 2019-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-19 | 2019-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-19 | 2019-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-19 | 2019-05-08 | N |
