Carroll Healthcare Center INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility Quality Assurance plan, the facility failed to ensure resident possessions were maintained securely and treated with respect. This affected three residents (#41, #42 and #43) of three closed resident records reviewed.Findings Include:Review of the complaint log revealed the facility lockbox was misplaced affecting Resident's #41 and #42. The result stated it was believed facility lock box was thrown away when the office was cleaned. The resident's families were notified. The Police were notified. The residents' families did not state they felt anything was stolen.The facility was asked for an investigation into the missing lockbox. The paperwork provided included a progress note from Resident #41's record. Review of the progress note indicated the resident expired on [DATE] at 8:45 AM. Eyeglasses, wristwatch and a signet ring were sent with the remains at 1:30 PM. On [DATE] at 4:01 P.M. social service spoke with the resident's granddaughter and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and policy review, the facility failed to ensure infection control protocols were maintained when performing incontinence care. This affected one resident (#28) of one resident observed for incontinence care The facility identified nine always incontinent residents.Findings Include:Observation on 09/10/25 at 11:02 A.M. of incontinence care for Resident #28 with Certified Nurse Aide (CNA) #50 revealed the CNA washed her hands, and put a barrier on the overbed table. The CNA placed a basin of warm water on the table with towels, washcloths, shampoo and body wash, barrier cream and plastic trash bags. The CNA provided privacy with the use of a bath blanket to cover the resident's pelvic area. The CNA released the incontinence brief, soaked a washcloth with water and applied a body wash. The CNA cleansed the resident from front to back appropriately, changing areas on the washcloth with each wipe and repeated the process with rinse water. The CNA dried the resident with a towel and the resident rolled to her right side and the process was repeated using…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a resident received a clear, liquid diet, as ordered by the physician, prior to a scheduled colonoscopy (a medical procedure used to examine the rectum and colon for abnormalities). This affected one resident (#44) of two residents reviewed for discharge. The facility census was 40. Findings include: Review of the closed medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of sigmoid colon, dementia, weakness, and diabetes mellitus. The resident was discharged on 03/24/25 after leaving the facility against medical advice (AMA). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/18/24, revealed Resident #44 had moderately impaired cognition. The resident required set-up staff assistance for eating. Review of a physician order, dated 03/11/25, revealed the order for a clear liquid diet only on 03/24/25 for colonoscopy scheduled on 03/25/25.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff the facility failed to ensure new nutritional interventions were attempted for a resident with altered nutrition. This affected one resident (#5) of two reviewed for nutrition. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, dementia, Alzheimer's disease, pre-glaucoma, macular degeneration, cystic mastopathy of the breast, hyperlipidemia, and intermittent explosive disorder. Review of the plan of care dated 07/04/24 revealed Resident #5 had a potential risk for altered nutrition related to declining meals, makes meal selections meal to meal, snack requests and purchases with poor dietary lifestyle, counsel possibly related to irreversible cognitive deficit that denies educational reward or benefits given her inability to comprehend, process and retain information, history of food group refusals and can be easily agitated with attempts to discuss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record review, policy review and staff interview the facility failed to ensure infection control protocols were implemented when a urinary drainage collection device was kept off the floor. This affected one resident (#98) of one residents reviewed for indwelling urinary catheter use. Findings include: Observations on 05/05/25 at 11:50 A.M. revealed Resident #98 sitting in a wheelchair in his room, a urinary collection bag was observed attached underneath the wheelchair and was touching the floor. Additional observation on 05/06/25 at 8:21 A.M. and again at 10:19 A.M. again revealed the resident sitting in a wheelchair with the urinary collection bag under the wheelchair and touching the floor. Review of Resident #98's medical record revealed an admission date of 05/04/25 with diagnoses that included urinary retention, flaccid neuropathic bladder, obstructive and reflux uropathy and benign prostate hypertrophy. Review of physician's orders revealed on 05/05/25 revealed the use of a indwelling urinary catheter to continuous gravity due to urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, hospital record review, policy review and staff interview the facility failed to ensure appropriate indications for use of an antibiotic for Resident #101. This affected one resident (#101) of six residents reviewed for antibiotic use. Findings include: Review of Resident #101's medical record revealed an admission date of 04/27/25 with diagnoses that included fall with left tibia fracture, diabetes mellitus, congestive heart failure and atrial fibrillation. Further review of the medical record including an admission minimum data set (MDS) 3.0 assessment with a reference date of 05/03/25 revealed the resident had an independent and intact cognition level. Additional review of the medical record including physician's orders revealed on 04/29/25 cefdinir (antibiotic) 300 milligrams (mg) twice daily was initiated due to leukocytosis (elevated white blood cell level). Additionally, on 05/01/25 the resident was prescribed cipro 250 mg twice daily for a urinary tract infection. The cefdinir was discontinued when started on cipro. Review of the Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure timely notification of a physician regarding a resident's change in condition. This affected one resident (#42) of three residents reviewed for change in condition. Findings include: Review of Resident #42's closed medical record revealed diagnoses including right hip fracture, type two diabetes mellitus, protein calorie malnutrition, anxiety disorder, adjustment disorder, and hypertension. Resident #42 was hospitalized from [DATE] to [DATE] after sustaining a fall and broken hip. A nursing note dated [DATE] at 5:30 A.M. indicated Resident #42's respiratory rate was 48 at 2:00 A.M. Blood pressure recording was 115/56, heart rate was 82 and oxygen saturation level was 92%. The On Call service was notified but no return phone call was received. At 3:30 A.M., Resident #42's respiratory rate was 44 and her oxygen saturation was 91%. The On Call service was contacted again but never returned a call. A nursing note dated [DATE] at 8:04 A.M.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility-reported incident (FRI) including investigation, observations, staff and resident interviews and review of policies, the facility failed to ensure a resident's narcotic pain medication was not misappropriated. This affected one resident (#4) of one resident reviewed related to a FRI. Findings include: Review of Resident #4's medical record revealed diagnoses included diabetes mellitus and chronic pain syndrome. An order with a start date of 12/25/23 was written for percocet (narcotic pain medication) 10/325 milligrams (mg) every six hours as needed for pain. The January 2024 Medication Administration Record (MAR) revealed Resident #4 was interviewed regarding pain every shift. The January 2024 MAR indicated the percocet was administered 14 times between 01/01/24 and 01/25/24. The morning of 01/26/24 a pain severity level of four on a scale…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and facility policy review, the facility failed to ensure the kitchen was clean and sanitary and items were dated. This had the potential to affect all residents except Resident #33, who was identified as receiving nothing by mouth. The facility census was 40. Findings include: Observation on 05/01/23 from 8:12 A.M. to 8:30 A.M. with Dietary Manager #144 of the kitchen and outside area where the walk-in cooler and freezer were located revealed the following concerns: • In the three door reach-in in freezer was observed one gallon storage bag of six breadsticks undated, one half of an opened and resealed factory bag of peas and carrots undated, one half of an opened and resealed factory bag of spinach undated, four individual servings of sauerkraut wrapped in plastic wrap not labeled or dated, one gallon storage (one half full) of mushrooms undated, and one half of a box of hamburger patties open to air. • Observation of the walk-in freezer located on the outside of the building revealed an accumulation of black dust blowing from the condenser fans. •…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure Resident #18, who was highly visibly impaired and dependent on staff, was able to locate call light, and Resident #142's call light was within reach. This affected two residents (#18 and #142) of 16 residents screened for call lights. The facility census was 40. Findings include: 1. Review of medical record for Resident #18 revealed an admission date of 12/29/22 and pertinent diagnoses included cerebral infarction (stroke) due to thrombosis (blood clot) of right posterior cerebral (brain) artery, major depressive disorder, restless and agitation, and repeated falls. Review of care plan dated 12/29/22 revealed Resident #18 required limited to extensive assistance, had a potential risk for falls related to poor safety awareness and repeated falls, was blind related to cataracts. Interventions included explaining use of call light and assess ability to use as needed. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview and review of facility policy the facility failed to ensure a physician ordered appointment for an orthopedic consult for Resident #20 was scheduled timely to address her chronic pain and failed to assess the effectiveness of her pain medications. This affected one resident (Resident #20) of 12 residents reviewed for pain management. The facility census was 41. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the right shoulder, chronic pain, osteoporosis, pain in the joints of the left hand, trigger finger left index finger, and pain in the right and left knee. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition, required supervision for all activities of daily living (ADLs), had diagnoses of osteoarthritis, right shoulder pain, chronic pain, and osteoporosis. She received scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.