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Deficiency Records for Carson Nursing and Rehabilitation Center
A list of the most recent deficiencies for Carson Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Carson Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-22 | 2024-04-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-20 | 2024-04-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-20 | 2024-04-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-02-20 | 2024-04-07 | 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 | 2024-02-20 | 2024-04-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-02-20 | 2024-04-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-20 | 2024-04-07 | 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 | 2024-02-20 | 2024-04-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2024-02-20 | 2024-04-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-20 | 2024-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-20 | 2024-04-07 | 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 | 2024-02-20 | 2024-04-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-20 | 2024-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-20 | 2024-04-07 | 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 | 2024-02-20 | 2024-04-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-20 | 2024-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-20 | 2024-04-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-20 | 2024-04-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-20 | 2024-04-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-20 | 2024-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-20 | 2024-04-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-20 | 2024-04-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-20 | 2024-04-07 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-20 | 2024-04-07 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-02-20 | 2024-04-07 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-02-20 | 2024-04-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-20 | 2024-04-07 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-02-20 | 2024-04-07 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide training in compliance and ethics. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-02-20 | 2024-04-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-22 | 2024-04-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-16 | 2023-11-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-06 | 2023-10-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-03 | 2023-07-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-07-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-07-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-08 | 2023-04-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-01 | 2023-01-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-01 | 2023-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-01 | 2023-01-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-01 | 2023-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-01 | 2023-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2023-01-23 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-12-01 | 2023-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-01 | 2023-01-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-01 | 2023-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-01 | 2023-01-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-01 | 2023-01-23 | 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 | 2022-12-01 | 2023-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2023-01-23 | N |
| Dispose of garbage and refuse properly. | Health | 2022-12-01 | 2023-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-01 | 2023-01-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-01 | 2023-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2023-01-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-01 | 2023-01-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-01 | 2023-01-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-01 | 2023-01-23 | N |
| Report COVID19 data to residents and families. | Health | 2022-12-01 | 2023-01-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-01 | 2023-01-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-01 | 2023-01-23 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-01 | 2023-01-23 | 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 | 2022-12-01 | 2023-01-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2023-01-23 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-08 | 2023-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-12 | 2022-11-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-12 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-12 | 2022-11-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-17 | 2022-09-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-27 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-03-15 | 2022-04-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-15 | 2022-04-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-09 | 2022-01-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-09 | 2022-01-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-09 | 2022-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-09 | 2022-01-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-09 | 2022-01-14 | 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 | 2021-12-09 | 2022-01-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-09 | 2022-01-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-09 | 2022-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-09 | 2022-01-14 | 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 | 2021-12-09 | 2022-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-14 | N |
| Dispose of garbage and refuse properly. | Health | 2021-12-09 | 2022-01-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-09 | 2022-01-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-09 | 2022-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-14 | 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 | 2021-12-15 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
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