CARROLL LUTHERAN VILLAGE

Nursing Home Inspector

200 ST. LUKE'S CIRCLE
WESTMINSTER, MD 21157
Carroll County
Phone: 410-848-0225
Provider Number: 215133
Last Inspection: 06/26/2017

About the Nursing Home

Number of Beds: 103
Number of Residents: 96
Beds Available: 7
Percent Occupancy: 93%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

29

Facility
33

County
29

MD
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

29

2017
98

2016
56

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/26/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/11/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 8/11/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 8/11/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Isolated : Minimal 3 8/11/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 8/11/2017
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 8/11/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 8/11/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 8/11/2017
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated : Minimal 3 8/11/2017
 

6/27/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 8/26/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 8/26/2016
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 8/26/2016
 
Failed To: 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. Isolated : Minimal 3 8/26/2016
 
Failed To: 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. Isolated : Minimal 3 8/26/2016
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 8/26/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/26/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 8/26/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 8/26/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Widespread : Minimal 5 8/26/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 8/26/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 8/26/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 8/26/2016
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 8/26/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 8/26/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 8/26/2016
 
Failed To: 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. Isolated : Minimal 3 8/26/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 8/26/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 8/26/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 8/26/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 8/26/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 8/26/2016
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated : Minimal 3 8/26/2016
 
Failed To: 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 Widespread : Minimal 5 8/26/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 8/26/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 8/26/2016
 

6/5/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 8/24/2015
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 8/24/2015
 
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Pattern : Minimal 4 8/24/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/24/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 8/24/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 8/24/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 8/24/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 8/24/2015
 
Failed To: Ensure 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. Pattern : Minimal 4 8/24/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 8/24/2015
 
Failed To: 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. Pattern : Minimal 4 8/24/2015
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 8/24/2015
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Isolated : Minimal 3 8/24/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 8/24/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 8/24/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/27/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/12/2017
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 3/10/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/12/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 3/10/2017
 

3/11/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 4/10/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 4/10/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 4/10/2016
 
Failed To: Keep clinical record information safe. Pattern : Minimal 4 4/10/2016
 

10/21/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 11/6/2015
 

3/20/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/14/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/14/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MD State Avg
Number of Residents 96 80.30 107.44
Registered Nurses 1.13 0.84 0.94
Licensed Practical / Vocational Nurses 1.18 0.82 0.87
Certified Nursing Assistants 2.33 2.69 2.35
Total Staff Hours 4.64 4.35 4.16

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MD State Avg%
of high risk long-stay residents with pressure ulcers 5 6 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 94 97 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 89 96 95
of long-stay residents experiencing one or more falls with major injury 2 3 2
of long-stay residents who have depressive symptoms 8 4 3
of long-stay residents who lose too much weight 9 5 6
of long-stay residents who received an antianxiety or hypnotic medication 14 24 18
of long-stay residents who received an antipsychotic medication 12 20 12
of long-stay residents who self-report moderate to severe pain 2 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 12 21 21
of long-stay residents whose need for help with daily activities has increased 11 15 17
of long-stay residents with a catheter inserted and left in their bladder 3 2 1
of long-stay residents with a urinary tract infection 1 4 3
of low risk long-stay residents who lose control of their bowels or bladder 59 67 58
of short-stay residents assessed and appropriately given the pneumococcal vaccine 70 81 83
of short-stay residents who had an outpatient emergency department visit 17 11 10
of short-stay residents who made improvements in function 78 65 67
of short-stay residents who newly received an antipsychotic medication 2 2 1
of short-stay residents who self-report moderate to severe pain 9 11 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 66 82 82
of short-stay residents who were rehospitalized after a nursing home admission 23 20 20
of short-stay residents who were successfully discharged to the community 59 54 55
of short-stay residents with pressure ulcers that are new or worsened 3 1 1