A list of the most recent deficiencies for Carroll Park Healthcare. 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? |
|---|---|---|---|---|
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-07-15 | 2022-08-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-23 | 2022-05-19 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-23 | 2022-05-19 | 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 | 2022-03-23 | 2022-05-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-23 | 2022-05-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-23 | 2022-05-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-23 | 2022-05-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-09 | 2022-02-03 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-11-09 | 2022-02-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-11-09 | 2021-12-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-09 | 2021-12-02 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-09 | 2021-12-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-31 | 2021-04-21 | Y |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 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 |
| 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 |
| Observe each nurse aide's job performance and give regular training. | 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 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 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | 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 medication error rates are not 5 percent or greater. | 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 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 |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-12-11 | 2020-02-27 | N |
| Provide or obtain dental services for each resident. | 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 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 and emergencies. | 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 |
| 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 |
| Establish emergency prep training and testing. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-05 | 2020-01-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-08-22 | 2018-10-31 | N |
| Meet other general requirements. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Meet other general requirements. | Fire Safety | 2018-08-22 | 2018-10-05 | 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 | 2018-08-22 | 2018-10-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2018-08-22 | 2018-10-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-22 | 2018-10-05 | 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 | 2018-07-19 | 2018-08-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-07-19 | 2018-08-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-07-19 | 2018-08-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-19 | 2018-08-31 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-19 | 2018-08-31 | 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 | 2018-07-19 | 2018-08-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-07-19 | 2018-08-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-07-19 | 2018-08-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-19 | 2018-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-19 | 2018-08-31 | 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 | 2018-07-19 | 2018-08-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-19 | 2018-08-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-19 | 2018-08-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-07-19 | 2018-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-19 | 2018-08-31 | 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 | 2018-07-19 | 2018-08-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-19 | 2018-08-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-19 | 2018-08-31 | 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 | 2018-07-19 | 2018-08-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-19 | 2018-08-31 | 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 | 2018-07-19 | 2018-08-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-07-19 | 2018-08-31 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-07-19 | 2018-08-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-19 | 2018-08-31 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-07-19 | 2018-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-19 | 2018-08-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-19 | 2018-08-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-07-19 | 2018-08-31 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-03-24 | 2017-05-08 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-24 | 2017-05-08 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-24 | 2017-05-08 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-24 | 2017-05-08 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-24 | 2017-05-08 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-24 | 2017-05-08 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-24 | 2017-05-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-24 | 2017-05-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-24 | 2017-05-08 | 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 | 2017-03-22 | 2017-04-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-03-22 | 2017-04-28 | 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 | 2017-03-22 | 2017-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-22 | 2017-04-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-22 | 2017-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-22 | 2017-04-28 | N |
