Deficiency Records for Carroll Lutheran Village
Updated as of May 01, 2020
This is not the most recent data for Carroll Lutheran Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 ne | 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-17 | 2018-05-31 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-04-17 | 2018-05-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-11 | 2018-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-11 | 2018-02-02 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-01-11 | 2018-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-11 | 2018-02-02 | Y |
| 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 |
| 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 |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-26 | 2017-08-11 | 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 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-06-26 | 2017-08-11 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-06-27 | 2016-08-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-06-27 | 2016-08-26 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-06-27 | 2016-08-26 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-06-27 | 2016-08-26 | 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 | 2016-06-27 | 2016-08-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-06-27 | 2016-08-26 | N |
| Provide housekeeping and maintenance services. | Health | 2016-06-27 | 2016-08-26 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-06-27 | 2016-08-26 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2016-06-27 | 2016-08-26 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-06-27 | 2016-08-26 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-06-27 | 2016-08-26 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-06-27 | 2016-08-26 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-06-27 | 2016-08-26 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2016-06-27 | 2016-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-06-27 | 2016-08-26 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-06-27 | 2016-08-26 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-06-27 | 2016-08-26 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-06-27 | 2016-08-26 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-06-27 | 2016-08-26 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-06-27 | 2016-08-26 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-06-27 | 2016-08-26 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-06-27 | 2016-08-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-06-27 | 2016-08-26 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | Health | 2016-06-27 | 2016-08-26 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-06-27 | 2016-08-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-06-27 | 2016-08-26 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-06-21 | 2016-07-22 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-06-21 | 2016-07-22 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-06-21 | 2016-07-22 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-06-21 | 2016-07-22 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-06-21 | 2016-07-22 | N |
