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Deficiency Records for Carroll Lutheran Village
View the most recent health deficiencies and inspection results for Carroll Lutheran Village. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Carroll Lutheran Village. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-06-06 | 2025-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-06 | 2025-07-03 | 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 | 2025-06-06 | 2025-07-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-06-06 | 2025-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-06-06 | 2025-07-03 | 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 | 2025-06-06 | 2025-07-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-02 | 2022-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-02 | 2022-01-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-02 | 2022-01-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-02 | 2022-01-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-02 | 2022-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-02 | 2021-10-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-02 | 2021-10-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-02 | 2021-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-10-20 | 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 | 2021-09-02 | 2021-10-20 | 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 | 2021-09-02 | 2021-10-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-02 | 2021-10-20 | 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 | 2021-09-02 | 2021-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-02 | 2021-10-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-02 | 2021-10-20 | 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 | 2021-09-02 | 2021-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-02 | 2021-10-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-02 | 2021-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-25 | 2018-11-06 | 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 | 2018-09-25 | 2018-11-06 | 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 | 2018-09-25 | 2018-11-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-25 | 2018-11-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-25 | 2018-11-06 | 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 | 2018-09-25 | 2018-11-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-09-25 | 2018-11-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-25 | 2018-11-06 | 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 | 2018-09-25 | 2018-11-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-25 | 2018-11-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-25 | 2018-11-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-25 | 2018-11-06 | 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 | 2018-09-25 | 2018-10-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-25 | 2018-10-31 | N |