A list of the most recent deficiencies for Ascension Living Carroll Manor. 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? |
|---|---|---|---|---|
| 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 | 2023-05-30 | 2023-08-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-30 | 2023-08-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-30 | 2023-08-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-08-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-30 | 2023-08-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-30 | 2023-08-07 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-30 | 2023-08-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-30 | 2023-08-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-30 | 2023-08-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-30 | 2023-08-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-30 | 2023-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-17 | 2023-08-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-17 | 2023-08-07 | 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 | 2021-07-28 | 2021-09-17 | N |
| 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. | Health | 2021-07-28 | 2021-09-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-28 | 2021-09-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-28 | 2021-09-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-09-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-28 | 2021-09-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-28 | 2021-09-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-28 | 2021-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-09-17 | 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 | 2021-07-28 | 2021-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-09-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-28 | 2021-09-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-28 | 2021-09-17 | 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 | 2021-07-28 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-28 | 2021-09-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-28 | 2021-09-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-09-17 | N |
| Keep all essential equipment working safely. | Health | 2021-07-28 | 2021-09-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-28 | 2021-09-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-23 | 2021-09-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-09-27 | 2019-10-27 | 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 | 2019-09-27 | 2019-10-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-27 | 2019-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-27 | 2019-10-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-27 | 2019-10-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-27 | 2019-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-27 | 2019-10-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-27 | 2019-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-27 | 2019-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-10-27 | N |
| Keep all essential equipment working safely. | Health | 2019-09-27 | 2019-10-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-09-27 | 2019-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-24 | 2019-10-27 | N |
