Carroll Lutheran Village

In the surveyor’s words

From the most serious findings on record at Carroll Lutheran Village, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Sep 2, 2021

  Based on medical record and employee file review and interviews, it was determined that the facility failed to have an effective system in place to ensure that newly hired geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to independently care for residents. This was found to be evident for two out of the two recently hired GNAs selected for review (GNA #28 and #32) and had the potential to affect all of the residents. The findings include: On 8/30/21, review of Resident #66's medical record revealed the resident had resided at the facility for several years and whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Sep 2, 2021

  Based on observations and interviews of the facility's kitchen, dietary staff and nursing staff, it was determined that 1) the facility failed to ensure food was stored and dated properly, 2) the facility failed to ensure food was stored and maintained in a safe manner to reduce the risk of foodborne illness, and 3) the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents. The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF867Sep 2, 2021

  Based on review of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance program as evidenced by the identification of deficiencies related to food safety requirements for the past 3 annual surveys and again during the current survey; and the identification of deficiencies related to Infection Prevention and Control on three surveys since the start of the COVID pandemic. The failure to identify and develop appropriate plans of corrections to correct quality deficiencies places all residents at risk. The findings include: 1. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2025

  Based on observations of the facility's kitchen, review of kitchen records, and interview of dietary staff, it was determined that the facility failed to store food items to maintain the integrity of the specific item, and prevent ice from building up on the floor in the walk-in freezer. These deficient practices have the potential to affect all residents served food out of the facility's kitchen identified during the recertification survey. The findings include: Surveyor's initial observation of the kitchen, accompanied by dietary shift supervisor #23 on 05/29/25 at 08:36 AM, revealed that: - Caramel topping, artificially flavored, was dated as 04/24 without labeling the year. […]

• No harm, potential for more than minimal, patternF641Sep 2, 2021

  Based on observation, medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 of 36 residents (#20, #11, #53, #60, #120, #4) reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. […]