Deficiency Records for Carlin Springs Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Carlin Springs Health 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-27 | 2022-10-19 | 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 | 2022-07-27 | 2022-10-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-27 | 2022-10-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-10-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-07-27 | 2022-10-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-27 | 2022-10-19 | 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 | 2022-07-27 | 2022-10-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-10-19 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-27 | 2022-09-21 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-07-27 | 2022-09-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-27 | 2022-09-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-27 | 2022-09-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-21 | N |
| Keep all essential equipment working safely. | Health | 2022-07-27 | 2022-09-21 | 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 | 2022-07-27 | 2022-09-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-27 | 2022-09-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-27 | 2022-09-21 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-27 | 2022-09-21 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-07-27 | 2022-09-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-27 | 2022-09-21 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-23 | 2022-09-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-23 | 2022-09-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-04 | 2022-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-04 | 2022-06-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-15 | 2021-10-27 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-09-15 | 2021-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-15 | 2021-10-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-15 | 2021-10-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-15 | 2021-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-15 | 2021-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-15 | 2021-10-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-15 | 2021-10-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-15 | 2021-10-27 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-09-15 | 2021-10-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-15 | 2021-10-27 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-09-15 | 2021-10-27 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-08 | 2020-04-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-08 | 2020-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-08 | 2020-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-03-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-01-08 | 2020-03-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-08 | 2020-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-08 | 2020-03-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-01-08 | 2020-03-12 | 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 | 2019-02-07 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-07 | 2019-04-16 | 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 | 2019-02-07 | 2019-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-04-16 | 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 | 2019-02-07 | 2019-04-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-07 | 2019-03-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-03-23 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-02-07 | 2019-03-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-07 | 2019-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-07 | 2019-03-23 | N |
| Post nurse staffing information every day. | Health | 2019-02-07 | 2019-03-23 | 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 | 2019-02-07 | 2019-03-23 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-07 | 2019-03-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-07 | 2019-03-23 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-02-07 | 2019-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-02-07 | 2019-03-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-07 | 2019-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-23 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-01-09 | 2018-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-09 | 2018-02-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-09 | 2018-02-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-09 | 2018-02-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-01-09 | 2018-02-07 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-04 | 2017-11-07 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-10-04 | 2017-11-07 | N |
