Inspection Results » Carlmont Gardens Nursing Center

Health Inspection on July 24, 2018 ^[1]

1. Pattern: Immediate jeopardy to the resident health or safety

   • Provide and implement an infection prevention and control program. (Corrected 2018-11-05)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-05)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-11-05)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-11-05)
   • 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 (Corrected 2018-11-05)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-05)
   • 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. (Corrected 2018-11-05)
   • Implement a program that monitors antibiotic use. (Corrected 2018-11-05)
   • 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. (Corrected 2018-12-27)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-05)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-11-05)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-11-05)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-12-27)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-11-05)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-12-27)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2018-12-27)
   • Ensure that residents are free from significant medication errors. (Corrected 2018-11-05)
   • 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. (Corrected 2018-11-05)
   • 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. (Corrected 2018-11-05)
   • Assess the resident when there is a significant change in condition (Corrected 2018-11-05)