Deficiency Records for Carroll Lutheran Village
Updated as of June 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 |