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Carroll Lutheran Village

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About Carroll Lutheran Village

General Information

Legal Business NameCarroll Lutheran Village Inc
Ownership TypeNon Profit - Church Related
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareSeptember 14, 1981 (36 years)
Capacity103
Residents91
Percent Occupied88%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityYes
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Carroll Lutheran Village

Carroll Lutheran Village
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Maryland Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

June 27, 2016 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmComplaint+InspectionEstablish 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
FManyPotential for HarmComplaint+InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
FManyPotential for HarmComplaint+InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmComplaint+InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmComplaint+InspectionGive residents a notice of rights, rules, services and charges.
ESomePotential for HarmComplaint+InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmComplaint+InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
ESomePotential for HarmComplaint+InspectionConduct initial and periodic assessments of each resident's functional capacity.
ESomePotential for HarmComplaint+InspectionProvide housekeeping and maintenance services.
CManyPotential for Minimal HarmComplaint+InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmComplaint+InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
DFewPotential for HarmComplaint+Inspection1) 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.
DFewPotential for HarmComplaint+InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
DFewPotential for HarmComplaint+InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
DFewPotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaint+InspectionDevelop 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.
DFewPotential for HarmComplaint+InspectionEnsure 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.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+InspectionReview or revise the resident's care plan after any major change in physical or mental health.
DFewPotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaint+InspectionEnsure residents maintain acceptable nutritional status.

March 11, 2016 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintKeep clinical record information safe.
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaintAssure that each residentís assessment is updated at least once every 3 months.

October 21, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
CManyPotential for Minimal HarmComplaintAllow residents to easily view the results of the nursing home's most recent inspection.

June 5, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmHealth InspectionEnsure 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.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmHealth InspectionProvide care for each resident in a way that maintains or improves their quality of life.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.
DFewPotential for HarmHealth InspectionProvide routine and 24-hour emergency dental care for each resident.

March 20, 2015 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Carroll Lutheran Village require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 55min
2hr 30min
ReportedExpected
CNA
1hr 20min
40min
ReportedExpected
LPN
50min
1hr
ReportedExpected
RN
5hr 5min
4hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 1hr 5min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

97.6%
83.7%
83.9%
83.9%
95.2%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
70.9%
69.9%
82.9%
94.7%
92.7%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
63.3%
45.5%
53.3%
57.8%
58.7%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of low risk long-stay residents who lose control of their bowels or bladder
18.9%
16.5%
20.3%
15.3%
18.6%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents who received an antianxiety or hypnotic medication
10.7%
15.6%
7.6%
11.0%
21.7%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents whose ability to move independently worsened
15.2%
15.7%
14.5%
11.8%
13.9%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents who received an antipsychotic medication
6.9%
12.8%
8.1%
6.9%
18.0%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents whose need for help with daily activities has increased
8.7%
4.3%
5.6%
0.0%
5.4%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents who self-report moderate to severe pain
15.4%
12.2%
8.2%
6.8%
6.4%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents who lose too much weight
9.4%
9.1%
7.1%
3.5%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of high risk long-stay residents with pressure ulcers
11.1%
-
4.8%
6.1%
4.5%
Q4 2015Q1 2016Q2 2016Q3 2016MD
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents who have depressive symptoms
3.8%
8.4%
8.2%
3.9%
4.1%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents with a urinary tract infection
0.0%
0.0%
1.3%
1.3%
2.8%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents experiencing one or more falls with major injury
5.2%
4.3%
3.4%
3.3%
2.1%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.5%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

45.2%
51.9%
67.4%
68.6%
81.9%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
74.5%
59.3%
59.3%
59.3%
82.2%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
90.5%
90.9%
76.2%
75.8%
64.8%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of short-stay residents who made improvements in function
12.5%
8.3%
8.3%
-
13.7%
Q4 2015Q1 2016Q2 2016Q3 2016MD
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
1.6%
1.4%
3.7%
2.0%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of short-stay residents who newly received an antipsychotic medication
1.1%
0.0%
0.8%
2.1%
1.3%
Q4 2015Q1 2016Q2 2016Q3 2016MD
Percentage of short-stay residents with pressure ulcers that are new or worsened