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Deficiency Records for Carmel Mountain Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Carmel Mountain Rehabilitation and Healthcare 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 Carmel Mountain Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-30 | 2024-08-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-10 | 2024-06-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-10 | 2024-06-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-10 | 2024-06-21 | 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 | 2024-05-10 | 2024-06-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-10 | 2024-06-21 | 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 | 2024-05-10 | 2024-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-10 | 2024-06-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-10 | 2024-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-10 | 2024-06-21 | 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 | 2024-05-10 | 2024-06-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-10 | 2024-06-21 | 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 | 2024-05-10 | 2024-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-10 | 2024-06-21 | 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 | 2024-05-10 | 2024-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-10 | 2024-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-10 | 2024-06-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-10 | 2024-06-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-14 | 2024-05-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-28 | 2023-08-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-28 | 2023-08-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-28 | 2023-08-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-28 | 2023-08-28 | 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 | 2023-07-28 | 2023-08-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-28 | 2023-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-28 | 2023-08-28 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-01 | 2023-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-01 | 2023-08-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-10 | 2023-03-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-10 | 2023-03-06 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-30 | 2019-06-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-30 | 2019-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-30 | 2019-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-21 | 2019-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-21 | 2019-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-21 | 2019-04-15 | N |
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