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Carondelet Manor
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Details
Costs
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CMS Inspection Results
The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.
- 12/06/2007 Health Survey for Carondelet Manor
| Administration | ||
| Deficiency | Scope | Level of Harm |
| Train all employees on what to do in an emergency. | Widespread | Minimal harm or potential for actual harm |
| Follow all laws and professional standards. | Isolated | Minimal harm or potential for actual harm |
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Provide needed housekeeping and maintenance. | Pattern | Minimal harm or potential for actual harm |
| Make sure that the nursing home area is free of dangers that cause accidents. | Pattern | Minimal harm or potential for actual harm |
| Keep safe, clean and homelike surroundings. | Isolated | Minimal harm or potential for actual harm |
| Make sure that staff members wash their hands when needed. | Isolated | Minimal harm or potential for actual harm |
| Mistreatment | ||
| Deficiency | Scope | Level of Harm |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Store, cook, and give out food in a safe and clean way. | Widespread | Minimal harm or potential for actual harm |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Isolated | Minimal harm or potential for actual harm |
| Provide food in a way that meets a resident's needs. | Isolated | Minimal harm or potential for actual harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Pattern | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Pattern | Minimal harm or potential for actual harm |
| offer Flu or Pneumococal vaccine to some residents. | Pattern | Minimal harm or potential for actual harm |
| Give professional services that follow each resident's written care plan. | Isolated | Minimal harm or potential for actual harm |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | Isolated | Minimal harm or potential for actual harm |
| Resident Assessment | ||
| Deficiency | Scope | Level of Harm |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Isolated | Minimal harm or potential for actual harm |
| Make sure that doctors visit residents regularly, as required. | Isolated | Minimal harm or potential for actual harm |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | Isolated | Minimal harm or potential for actual harm |
- 12/06/2007 Fire Safety Survey for Carondelet Manor
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Pattern | Minimal harm or potential for actual harm |
| Corridor Walls and Doors | ||
| Deficiency | Scope | Level of Harm |
| corridor and hallway doors that block smoke. | Pattern | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| properly installed electrical wiring and equipment. | Pattern | Minimal harm or potential for actual harm |
| Hazardous Area | ||
| Deficiency | Scope | Level of Harm |
| construction that can resist fire for one hour or an approved fire extinguishing system. | Pattern | Minimal harm or potential for actual harm |
| Laboratories | ||
| Deficiency | Scope | Level of Harm |
| proper facilities for the use and storage of combustible liquids. | Isolated | Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control | ||
| Deficiency | Scope | Level of Harm |
| walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. | Pattern | Minimal harm or potential for actual harm |
- 11/09/2006 Health Survey for Carondelet Manor
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Keep safe, clean and homelike surroundings. | Pattern | Minimal harm or potential for actual harm |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable. | Isolated | Minimal harm or potential for actual harm |
| Make sure that staff members wash their hands when needed. | Isolated | Minimal harm or potential for actual harm |
| Have a program to keep infection from spreading. | Isolated | Minimal harm or potential for actual harm |
| Mistreatment | ||
| Deficiency | Scope | Level of Harm |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Provide food in a way that meets a resident's needs. | Isolated | Minimal harm or potential for actual harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Isolated | Minimal harm or potential for actual harm |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | Isolated | Minimal harm or potential for actual harm |
| Provide activities to meet the needs of each resident. | Isolated | Minimal harm or potential for actual harm |
| Give each resident care and services to get or keep the highest quality of life possible. | Isolated | Minimal harm or potential for actual harm |
| Resident Assessment | ||
| Deficiency | Scope | Level of Harm |
| Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress. | Isolated | Minimal harm or potential for actual harm |
| Check and update (if needed) each resident's assessment every 3 months. | Isolated | Minimal harm or potential for actual harm |
| Make a complete assessment that covers all questions for areas that are listed in official regulations. | Isolated | Minimal harm or potential for actual harm |
- 11/09/2006 Fire Safety Survey for Carondelet Manor
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Widespread | Minimal harm or potential for actual harm |
| Corridor Walls and Doors | ||
| Deficiency | Scope | Level of Harm |
| corridor and hallway doors that block smoke. | Isolated | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| weekly inspections and monthly testing of generators. | Isolated | Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills | ||
| Deficiency | Scope | Level of Harm |
| record of quarterly fire drills for each shift under varying conditions. | Widespread | Minimal harm or potential for actual harm |
| Furnishings and Decorations | ||
| Deficiency | Scope | Level of Harm |
| restrictions on the use of flammable curtains. | Isolated | Minimal harm or potential for actual harm |
| Illumination and Emergency Power | ||
| Deficiency | Scope | Level of Harm |
| proper backup exit lighting. | Pattern | Minimal harm or potential for actual harm |
- 10/03/2005 Health Survey for Carondelet Manor
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Make sure that staff members wash their hands when needed. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. | Pattern | Minimal harm or potential for actual harm |
| Give professional services that meet a professional standard of quality. | Isolated | Minimal harm or potential for actual harm |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Minimal harm or potential for actual harm |
| Resident Assessment | ||
| Deficiency | Scope | Level of Harm |
| Make a complete assessment that covers all questions for areas that are listed in official regulations. | Isolated | Minimal harm or potential for actual harm |
| 1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. | Isolated | Minimal harm or potential for actual harm |
| Keep assessments completed in the preceding 15 months in the resident's active record. | Pattern | Potential for minimal harm |
| Make sure that doctors visit residents regularly, as required. | Pattern | Potential for minimal harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Have a private telephone available for use. | Pattern | Minimal harm or potential for actual harm |
- 10/03/2005 Fire Safety Survey for Carondelet Manor
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Widespread | Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills | ||
| Deficiency | Scope | Level of Harm |
| did not have a written emergency evacuation plan. | Widespread | Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control | ||
| Deficiency | Scope | Level of Harm |
| walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. | Pattern | Minimal harm or potential for actual harm |
| Vertical Openings | ||
| Deficiency | Scope | Level of Harm |
| exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors. | Pattern | Minimal harm or potential for actual harm |
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