Federal Nursing-Home Survey Record
ASCENSION LIVING CARROLL MANOR
Does ASCENSION LIVING CARROLL MANOR have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), ASCENSION LIVING CARROLL MANOR (CCN 095034), in WASHINGTON, DC, has federal inspection findings on its record. In its current inspection cycle, CMS cited the facility for 28 deficiencies; the most serious carries scope/severity J on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2024-09-25. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $16,801 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
The Federal Record
At its most recent federal inspection, CMS cited this facility for an Immediate Jeopardy deficiency.
Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
Scope & Severity — current cycle
Civil money penalties on file
$16,801
CMS has $16,801 in civil money penalties on file against this facility. CMS also records 76 day(s) of payment denial.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 4 · CMS state average: 3.5
Deficiency timeline — full federal history
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Keep all essential equipment working safely.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide routine and 24-hour emergency dental care for each resident.
Assist a resident in gaining access to vision and hearing services.
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.
Ensure medication error rates are not 5 percent or greater.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide safe, appropriate pain management for a resident who requires such services.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Ensure each resident receives an accurate assessment.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide and implement an infection prevention and control program.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Make sure that a working call system is available in each resident's bathroom and bathing area.
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.
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.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide and implement an infection prevention and control program.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure each resident receives an accurate assessment.
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Keep all essential equipment working safely.
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 necessary and PRN use is limited.
Provide safe and appropriate respiratory care for a resident when needed.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Document what happened
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Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.