A list of the most recent deficiencies for Carriage House Manor. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2023-07-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-27 | 2023-07-31 | 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 | 2023-04-26 | 2023-06-02 | 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 | 2023-04-26 | 2023-06-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-05-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-26 | 2023-05-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-04-26 | 2023-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-26 | 2023-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-26 | 2023-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-26 | 2023-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-26 | 2023-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-31 | 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 | 2022-03-03 | 2022-03-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-03-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-03 | 2022-03-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-03 | 2022-03-23 | 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 | 2022-03-03 | 2022-03-23 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-03-03 | 2022-03-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-03 | 2022-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-04 | 2022-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-04 | 2022-03-08 | 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 | 2022-03-04 | 2022-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-23 | 2019-12-20 | 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 | 2019-10-23 | 2019-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-23 | 2019-12-06 | 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 | 2019-10-24 | 2019-10-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-24 | 2019-10-25 | N |
