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Deficiency Records for Carroll House
A list of the most recent deficiencies for Carroll House. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Carroll House. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-30 | 2024-07-12 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-05-30 | 2024-07-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-05-30 | 2024-07-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-05-30 | 2024-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-30 | 2024-07-12 | 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 | 2024-05-30 | 2024-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-30 | 2024-07-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-05-30 | 2024-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-30 | 2024-07-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-30 | 2024-07-12 | 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 | 2024-05-30 | 2024-07-12 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-30 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-30 | 2024-07-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-30 | 2024-07-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-30 | 2024-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-30 | 2024-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-26 | 2024-02-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-28 | 2023-02-03 | 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 | 2022-10-28 | 2023-02-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-28 | 2023-02-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-28 | 2022-12-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-28 | 2022-12-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-28 | 2022-12-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-28 | 2022-12-12 | 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 | 2022-10-28 | 2022-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-12-12 | 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 | 2022-10-28 | 2022-12-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-12 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-28 | 2022-12-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-28 | 2022-12-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Use approved construction type or materials. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-04 | 2022-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-19 | 2019-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-28 | Not Fixed | N |
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