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Deficiency Records for Carroll Park Healthcare
View the most recent health deficiencies and inspection results for Carroll Park Healthcare. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Carroll Park Healthcare. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-03-04 | 2026-04-08 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-11-26 | 2026-02-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2025-11-26 | 2026-02-12 | 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 | 2025-11-26 | 2025-12-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2025-11-26 | 2025-12-22 | 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 | 2025-11-26 | 2025-12-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-11-26 | 2025-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-11-26 | 2025-12-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-11-26 | 2025-12-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2025-11-26 | 2025-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-11-26 | 2025-12-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-14 | 2025-06-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-05-14 | 2025-06-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-05-14 | 2025-06-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-05-14 | 2025-06-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-05-14 | 2025-06-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-05-14 | 2025-06-20 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2025-05-14 | 2025-06-20 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-05-14 | 2025-06-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-05-14 | 2025-06-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2025-05-14 | 2025-06-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-20 | 2024-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2024-05-13 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-20 | 2024-05-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-20 | 2024-05-13 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-20 | 2024-05-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-20 | 2024-05-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-20 | 2024-05-13 | Y |
| 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 | 2023-11-20 | 2024-05-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-20 | 2024-05-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-20 | 2024-05-13 | 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 | 2023-11-20 | 2024-05-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2024-04-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-20 | 2024-04-08 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-20 | 2024-04-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-20 | 2024-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2024-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2024-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2024-02-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-20 | 2024-02-14 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-11-20 | 2024-01-05 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-11-20 | 2024-01-05 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-20 | 2024-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-20 | 2024-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-20 | 2024-01-05 | N |
| 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 | 2023-11-20 | 2024-01-05 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-20 | 2024-01-05 | 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 | 2023-11-20 | 2024-01-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-20 | 2024-01-05 | Y |
| 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. | Health | 2023-11-20 | 2024-01-05 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-20 | 2024-01-05 | Y |
| Keep all essential equipment working safely. | Health | 2023-11-20 | 2024-01-05 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-11-20 | 2024-01-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-20 | 2024-01-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-20 | 2024-01-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-20 | 2024-01-05 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-20 | 2024-01-05 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-20 | 2024-01-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-20 | 2024-01-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-20 | 2024-01-05 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-11-20 | 2024-01-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-20 | 2024-01-05 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-20 | 2024-01-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-20 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-20 | 2024-01-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-20 | 2024-01-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-20 | 2024-01-05 | 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 | 2023-11-20 | 2024-01-05 | 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 | 2023-11-20 | 2024-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-20 | 2024-01-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-11-20 | 2024-01-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-20 | 2024-01-05 | N |
| Meet other general requirements. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-20 | 2023-12-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-20 | 2023-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-20 | 2023-11-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-20 | 2023-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-20 | 2023-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-20 | 2023-11-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-11 | 2020-02-27 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide appropriate foot care. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-11 | 2020-02-27 | N |
| 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 | 2019-12-11 | 2020-02-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-11 | 2020-02-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2019-12-11 | 2020-02-27 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide or obtain dental services for each resident. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-12-11 | 2020-02-27 | N |
| 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 | 2019-12-11 | 2020-02-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-11 | 2020-02-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-11 | 2020-02-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-11 | 2020-02-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-11 | 2020-02-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-11 | 2020-02-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-12-11 | 2020-02-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-11 | 2020-02-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-11 | 2020-02-27 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-12-11 | 2020-02-27 | 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 | 2019-12-11 | 2020-02-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-11 | 2020-02-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-11 | 2020-02-27 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-12-11 | 2020-02-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-12-11 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-11 | 2020-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-11 | 2020-01-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-12-11 | 2020-01-16 | N |