A list of the most recent deficiencies for Carroll Lutheran Village. 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 exits that are accessible at all times. | Fire Safety | 2021-11-23 | 2022-01-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-23 | 2022-01-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-23 | 2022-01-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-23 | 2022-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-23 | 2022-01-06 | 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 |
| 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary 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 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 |
| 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 |
| 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-02 | 2021-10-20 | Y |
| 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 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-03 | 2021-06-20 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-06-03 | 2021-06-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-18 | 2021-05-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-18 | 2021-05-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-18 | 2021-05-14 | Y |
| Post nurse staffing information every day. | Health | 2021-03-18 | 2021-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-05-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 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 |
| 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 |
| Prepare residents for a safe transfer or discharge from the nursing home. | 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary 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 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 |
| 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 that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-24 | 2018-10-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-24 | 2018-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-06-29 | 2017-08-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-06-29 | 2017-08-22 | 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 | 2017-06-29 | 2017-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-29 | 2017-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-06-29 | 2017-08-22 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2017-06-29 | 2017-08-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-29 | 2017-08-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-26 | 2017-08-11 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-26 | 2017-08-11 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-06-26 | 2017-08-11 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-06-26 | 2017-08-11 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-06-26 | 2017-08-11 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-26 | 2017-08-11 | N |
| Keep all essential equipment working safely. | Health | 2017-06-26 | 2017-08-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-06-26 | 2017-08-11 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-26 | 2017-08-11 | N |
