CARLETON SENIOR CARE AND REHAB - WELLSBORO, PA

Complaint Deficiency

• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Potential for minimal harm
  • Scope: Many
• Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide proof that all residents' personal money which is deposited with the nursing home, is secure
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide activities to meet the interests and needs of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Ensure the activities program is directed by a qualified professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give each resident enough fluids to keep them healthy and prevent dehydration
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that residents are safe from serious medication errors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop policies and procedures for influenza and pneumococcal immunizations
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Offer other nutritional food to each resident who will not eat the food served
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that special or therapeutic diets are ordered by the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A two-hour-resistant firewall in common walls
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide proof that all residents' personal money which is deposited with the nursing home, is secure
  • Harm: Potential for minimal harm
  • Scope: Many
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A two-hour-resistant firewall in common walls
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many

Staff Information

Quality Measures