Most Recent Deficiencies for Carroll Lutheran Village

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Updated as of August 01, 2022

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
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 2020-07-17 2020-09-01 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2020-07-17 2020-09-01 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2020-07-17 2020-09-01 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2020-07-17 2020-09-01 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2020-07-17 2020-09-01 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-06-10 2020-07-09 N
Provide and implement an infection prevention and control program. Health 2020-06-10 2020-07-09 N
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