Inspection Results » Carroll Manor Nursing & Rehab

Health Inspection on September 11, 2018 ^[1]

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

   • Provide and implement an infection prevention and control program. (Corrected 2018-11-11)
   • Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. (Corrected 2018-11-11)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2018-11-11)

2. 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 2018-11-11)
   • Respond appropriately to all alleged violations. (Corrected 2018-11-11)
   • Keep all essential equipment working safely. (Corrected 2018-11-11)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-11)
   • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2018-11-11)
   • 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. (Corrected 2018-11-11)

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

   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-11-11)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2018-11-11)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-11)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2018-11-11)
   • 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 ne (Corrected 2018-11-11)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-11)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. (Corrected 2018-11-11)
   • 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. (Corrected 2018-11-11)
   • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (Corrected 2018-11-11)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-11-11)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-11-11)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-11-11)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-11-11)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-11-11)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-11-11)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-11)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-11-11)