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Deficiency Records for Ascension Living Carroll Manor
View the most recent health deficiencies and inspection results for Ascension Living Carroll Manor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Ascension Living Carroll Manor. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2026-01-05 | 2026-01-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2026-01-05 | 2026-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-25 | 2025-01-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-25 | 2025-01-11 | Y |
| 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 | 2024-09-25 | 2025-01-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-25 | 2025-01-11 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-09-25 | 2025-01-11 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-09-25 | 2024-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-09-25 | 2024-10-15 | Y |
| 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. | Health | 2024-09-25 | 2024-10-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-25 | 2024-10-15 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-09-25 | 2024-10-15 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-09-25 | 2024-10-15 | Y |
| Keep all essential equipment working safely. | Health | 2024-09-25 | 2024-10-15 | Y |
| 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. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-25 | 2024-10-15 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-09-25 | 2024-10-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-25 | 2024-10-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-09-25 | 2024-10-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-25 | 2024-10-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-25 | 2024-10-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 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 | 2021-07-28 | 2021-09-17 | N |
| Keep all essential equipment working safely. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | 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 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-28 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-03-24 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-03-24 | Not Fixed | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-09-25 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-25 | Not Fixed | Y |