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 |
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 |