A list of the most recent deficiencies for The Springs at The Carlotta. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-19 | 2024-02-01 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-10 | 2023-08-18 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-03 | 2023-03-02 | 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 | 2023-02-03 | 2023-03-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-03-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-25 | 2023-02-24 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-06 | 2023-02-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-06 | 2023-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-06 | 2023-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-06 | 2023-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-06 | 2023-02-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-06 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-04-04 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-29 | 2021-08-23 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-19 | 2019-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-24 | 2019-11-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-24 | 2019-11-25 | 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 | 2019-10-24 | 2019-11-25 | 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 | 2019-10-24 | 2019-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-24 | 2019-11-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Develop a communication plan. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-08 | 2019-02-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-29 | 2019-01-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-29 | 2019-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2019-01-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-07 | 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 | 2018-11-29 | 2019-01-07 | 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 | 2018-11-29 | 2019-01-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-29 | 2019-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-29 | 2019-01-07 | N |
