A list of the most recent deficiencies for Carlmont Gardens Nursing Center. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-01 | 2023-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-01 | 2023-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-01 | 2023-08-09 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-01 | 2023-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-08-01 | Y |
| 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 | 2021-11-19 | 2022-01-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-19 | 2022-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-19 | 2022-01-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-19 | 2022-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2022-01-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2022-01-04 | N |
| Keep all essential equipment working safely. | Health | 2021-11-19 | 2022-01-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-23 | 2021-12-23 | 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 | 2021-11-23 | 2021-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-23 | 2021-12-23 | 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 | 2019-06-07 | 2019-10-11 | 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 | 2019-06-07 | 2019-10-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-07 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-07 | 2019-10-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-07 | 2019-08-16 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-07 | 2019-08-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-07 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-07 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-07 | 2019-08-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-07 | 2019-08-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-06-07 | 2019-08-16 | N |
| Post nurse staffing information every day. | Health | 2019-06-07 | 2019-08-16 | 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 | 2019-06-07 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-07 | 2019-08-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-24 | 2018-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-24 | 2018-12-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-07-24 | 2018-12-27 | 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 | 2018-07-24 | 2018-12-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-07-24 | 2018-11-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-24 | 2018-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| 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 | 2018-07-24 | 2018-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-24 | 2018-11-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-24 | 2018-11-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-24 | 2018-11-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-24 | 2018-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-07-24 | 2018-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-24 | 2018-11-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-24 | 2018-11-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-17 | 2018-10-30 | N |
