Arbors at Carroll

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to wear appropriate personal protective equipment during a mechanical lift transfer of a resident who was on enhanced barrier precautions. This affected one (Resident #17) of three residents reviewed for mechanical lift transfers. The facility census was 93 residents.

Inspectors wroteBased on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure Resident #3 was treated with dignity when his indwelling urinary catheter collection bag was not covered and was visible from the hallway. This affected one (Resident #3) of one resident reviewed for catheters. The facility census was 91.

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to provide privacy while incontinence care was provided. This affected one resident (#22) of one resident reviewed for bowel and bladder. The facility census was 91. Findings Include:Review of the medical record for Resident #22 revealed an initial admission date of 01/06/23 with diagnoses including cerebrovascular accident with left sided hemiplegia, dementia, convulsions, diabetes mellitus, chronic kidney disease, dysphagia, seizures, peripheral vascular disease, celiac artery compression syndrome, hypertension, insomnia and anxiety disorder. Review of the plan of care dated 10/11/23 revealed the resident had bowel and bladder incontinence related to impaired mobility and physical limitations. [...]

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to provide off-loading (a critical technique used to reduce pressure on specific areas of the body, particularly in wound care) for a stage III pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling or undermining). This affected one resident (#21) of one resident reviewed for pressure ulcers. The facility census was 91. [...]

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to provide timely podiatry care for Residents #30 and #51. This affected 2 residents (#30 and #51) of 9 residents reviewed for activities of daily living. The facility census was 91. Findings Include:1. Record review for Resident #30 revealed the resident was admitted to the facility on [DATE] with diagnoses including: spinal stenosis, diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis, muscle weakness, cognitive communication deficit, major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was dependent on staff for personal hygiene. Further review of the medical record revealed Resident #30 was last seen by podiatry services in the facility on 10/21/25. [...]

Inspectors wroteBased observation, staff and resident interviews, medical record review, and review of facility policy on dental services, the facility failed to ensure residents received timely dental services related to dentures. This affected one (#3) of three residents reviewed for dental. The facility census was 91.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure safe storage and labeling of medications. This affected eight residents (#49, #56, #57, #58, #62, #63, #68 and #70) of 29 who received medications for the medication cart on South Long Hall. The facility census was 95.

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to ensure residents who were dependent on staff for assistance received turning and repositioning and transferring to a char as ordered by the physician. This affected one (Resident #59) of two residents reviewed for positioning. The facility census was 96.

Inspectors wroteBased on interview, record review, and review of facility policy the facility failed to ensure a referral to an ophthalmologist for cataract surgery was made for Resident #17. This affected one resident (#17) of two residents reviewed for communication and sensory. The facility census was 96.

Inspectors wroteBased on medical record review, staff interview, facility fall investigation reports, and facility policy review, the facility failed to develop and implement timely interventions after a resident fall. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 96. Findings Include: Resident #1 was admitted to the facility on [DATE]. Her diagnoses were conversion disorder, intellectual disabilities, aneurysm of heart, hypertension, hyperparathyroidism, chronic obstructive pulmonary disease, lack of coordination, dysphagia, dementia, major depressive disorder, spondylosis, muscle weakness, cognitive communication deficit, difficulty walking, osteoarthritis, hypothyroidism, osteoporosis, and hypertensive heart disease. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 11/18/24, revealed she had a mild cognitive impairment. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure dietician recommendations were implemented timely and orders were followed. This affected 2 (Residents #12 and #74) of six residents reviewed for nutrition. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/06/10. Medical diagnoses included chronic kidney disease, dysphasia, muscle weakness, major depressive disorder, cognitive communication deficit, anemia, gastro-esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #12's care plan dated 10/31/23 revealed the resident was at risk for altered nutritional status related to therapeutic diet, and medical diagnosis that include hypertension, peripheral vascular disease, depression, cognitive communication deficit, anemia, and GERD. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected two residents (#73 and #43) of two residents reviewed for trauma informed care. The facility census was 96.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected one resident (Resident #81) of two residents reviewed for pain management. The facility census was 96.

Inspectors wroteBased on interview and medical record review the facility failed to ensure medication parameters were in place and followed for Resident #34, #69, and #79, who received blood pressure medication. This affected three residents (#34, #69, and #79) of six residents who were reviewed for medication administration. The facility census was 96.

Inspectors wroteBased on interview, medical record review and review of facility policy, the facility failed to complete laboratory testing as ordered by the physician for Resident #81. This affected one resident (#81) of two residents reviewed for hydration. The facility census was 96.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure dietary spreadsheets were followed and all food items on the spreadsheets were offered to the residents according to their needs on a level three dysphagia diet. This affected 14 residents, (Residents #6, #10, #14, #17, #31, #33, #48, #59, #61, #64, #66, #72, #85, and #89) the facility identified as having physician orders for a level three dysphagia diet, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. [...]

Inspectors wroteBased on observation, staff interview, review of the pureed ham recipe and facility policy, the facility failed to ensure pureed foods were prepared to the appropriate pureed consistency. This affected nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to follow proper hand hygiene protocols during pureed food preparation. This had the potential to affect all nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. [...]

Inspectors wroteBased on record review, staff interviews, review of laboratory test results, review of McGreer's criteria for infections, and facility policy review, the facility failed to follow antibiotic stewardship policies and procedures prior to starting antibiotic treatment for two residents (Residents #43, and #84). The facility also failed to ensure laboratory test results were received prior to starting antibiotic treatment for one resident (Resident #11). The deficient practices affected three residents (Residents #11, #43, and #84) of seven residents reviewed for infections and antibiotic use. The facility census was 88. Findings Include: Review of the medical record for Resident #11 revealed an initial admission date on 06/08/21 and a readmission date on 10/23/23. [...]

Inspectors wroteBased on observations, medical record review, resident interview, and staff interview, the facility failed to comprehensively assess Resident #84's dental status. This affected one resident (#84) of 27 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and hemiplegia. Review of a nursing admission assessment dated [DATE] revealed it stated Resident #84 does not use dentures or partials and edentulous was not marked. Review of an initial nutrition assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Review of an admission Minimum Data Set (MDS) assessment completed 08/11/23 revealed Resident #84 was not edentulous and did not have broken or loose dentures. [...]

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to provide showers as scheduled to Resident #46. The deficient practice affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type II diabetes mellitus, chronic obstructive pulmonary disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to ensure timely treatment was initiated urinary tract infections. This affected two residents (#43 and #84) of six residents reviewed for antibiotic use/urinary tract infections. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #84 revealed an admission date of 08/04/23 with diagnoses including diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed Resident #84 received the last dose of an antibiotic and stated she feels a little better but not all the way. The resident continued to be slightly confused at times. The nurse updated the nurse practitioner who said it was okay to get another urine culture if needed in the morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. [...]

Inspectors wroteBased on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #39 received treatment to maintain vision abilities. This affected one resident (#39) of one resident reviewed for communication/sensory abilities. The facility census was 88. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 03/10/23 with diagnoses including end stage renal disease, diabetes, and psychosis. Record review revealed the resident went out of the facility three times weekly for dialysis. Review of an annual Minimum Data Set (MDS) assessment completed 01/01/24 revealed Resident #39 had a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition (a score of 8-12 = moderately impaired cognition and a score of 13-15 = intact cognition). [...]

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer to Resident #19's nose caused by his glasses. This affected one resident (#19) of four residents reviewed for pressure ulcers. The census was 88. Findings Include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cerebral infarction, anxiety disorder, diverticulitis, major depressive disorder, cognitive communication deficit, hyperlipidemia, contracture of left hand, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 01/01/24, revealed Resident #19 was cognitively intact. [...]

Inspectors wroteBased on observations, resident interview, staff interview, and medical record review, the facility failed to ensure Resident #85 received services to prevent decrease in range of motion and to maintain or improve mobility. This affected one resident (#85) of three residents reviewed for positioning/mobility. The facility census was 88. Findings Include: Review of the medical record for Resident #85 revealed an admission date of 06/07/23 with diagnoses including cerebral infarction (stroke) with hemiplegia and hemiparesis (muscle weakness/paralysis). Review of a quarterly Minimum Data Set (MDS) assessment completed 12/12/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #85 had impairment in range of motion on one side, upper and lower. The resident was dependent upon staff for transfers. [...]

Inspectors wroteBased on record review, staff interview, review of fall investigations, and facility policy review, the facility failed to complete neurological checks following unwitnessed falls for Resident #17. The deficient practice affected one resident (#17) of two residents reviewed for falls. The facility census was 88. Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 08/07/23 and a readmission date of 09/21/23. Medical diagnoses included Alzheimer's disease, history of falling, and type II diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was rarely or never understood. Per staff assessment, Resident #17 had moderately impaired cognition. [...]

Inspectors wroteBased on observation, medical record review, review of facility policy and staff interviews, the facility did not ensure all physician ordered nutritional interventions to prevent weight loss were consistently implemented for Resident #53. This affected one resident (Resident #53) of five residents reviewed for nutrition. The facility census was 88. Findings Include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, acute respiratory failure, cardiomyopathy, dysphagia, muscle weakness, hypertension, polyneuropathy, anxiety disorder, depression, and hypotension. [...]

Inspectors wroteBased on observations, medical record review, staff interview, and review of the facility list of medications not to be crushed, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 15% and included four medication errors of 26 medication administration opportunities. This affected one resident (Resident #39) of six residents observed for medication administration. The facility census was 88.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were administered medication in accordance with physician orders and prescribing instructions for use of the medications. This affected two residents (Residents #46 and #297) of six residents reviewed for medication administration. The facility census was 88.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide timely dental care and services for one resident (Resident #46). This affected one resident (Resident #46) of one reviewed for dental services. The facility census was 88. Findings Include: Review of the medical record for Resident #46 revealed an admission date on 11/18/23. Medical diagnoses included heart failure, acute and chronic respiratory failure, type two diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure residents were free from misappropriation when residents' controlled narcotic pain medication was not misappropriated. This affected 18 residents (#10, #17, #22, #26, #29, #42, #47, #53, #67, #89, #90, #91, #92, #93, #94, #95, #96, and #97) identified by the facility during their investigation into an allegation of misappropriation as having had their controlled narcotic pain medications misappropriated.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a self reporting incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure a resident was free from verbal/ emotional abuse. This affected one (Resident #46) of one residents reviewed for abuse.