Carroll Health and Rehab LLC

Inspectors wroteBased on record review and interviews, the facility failed to document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility by : A.) failing to document that appropriate discharge information was given to the resident for 2 (#1, #5) sampled residents and B.) failing to provide residents with the original LaPost document at the time of discharge as noted in the LaPost Implementation Guide for 3 (#1, #4, #5) of 3 sampled residents who had been discharged from the facility.

Inspectors wroteI. Based on observation, record reviews and interviews the facility failed to have an adequate system in place to ensure residents at risk for elopement are supervised to prevent elopement from the facility for 1 (#73) of 3 (#8, #72, and #73) residents reviewed for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. Resident #73 was picked up by police on 07/22/2025 at 6:28 a.m. after being notified of Resident #73 pacing on the four-lane highway approximately 0.9 miles from the facility. The police returned Resident #73 to the facility on [DATE] at 6:52 a.m. without injury. Resident #73 exited the building through a window in his room. The deficient practice had the likelihood to cause more than minimal harm to any residents residing in the facility at risk for elopement. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility had: 1) excessively low weekend staff during Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025 and 2) insufficient staff on: 06/08/2025, 06/14/2025, 06/22/2025, and 06/28/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure that individual financial records are available to the resident through quarterly statements for 1 (#6) of 1 (#6) residents reviewed for personal funds out of a total sample of 37 residents.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#1, #2, #22, #43) of 6 (#1, #2, #6, #22, #40, #43) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 1) ensure a physician's order for bed rails was obtained for residents, 2) assess residents for risk of entrapment from bed rails prior to the installation of bed rails, and 3) ensure care plans reflected the use of bed rails for 4 (#2, #6, #50, #65) of 4 residents reviewed for bedrails.

Inspectors wroteBased on observation of medication administration, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The facility had a 19.35% medication error rate with 6 medication errors for 2 (#26, #29) of 5 (#26, #29, #46, #49, #57) residents observed for medication administration. The facility had 6 medication administration errors out of 31 opportunities. The facility's current census was 65 residents.

Inspectors wroteBased on record review and interview the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents have the right to be free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms by having residents with orders for psychotropic medications greater than 14 days for 2 (#5 and #23) of 5 (#1, #5, #6, #12 and #23) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#40) of 1 resident reviewed for contractures and 2 (#72, #73) of 3 (#8, #72, #73) residents reviewed for elopement.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents received care consistent with professional standards of practice to prevent pressure ulcers for 1 (#11) of 3 (#11, #47, #50) residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections for 1 (#75) of 2 (#4 & #75) residents reviewed for urinary catheter.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor lab results for a resident receiving anti-seizure medication for 1 (#12) of 5 (#1, #5, #6, #12, #23) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properly store the ice scoop utilized in serving ice to residents in a sanitary manner.

Inspectors wroteBased on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing to ensure that Enhanced Barrier Precautions (EBP) were implemented as ordered for 1 (#47) of 3 (#11, #47, #50) residents reviewed for pressure ulcers.

Inspectors wroteBased on record reviews and interview, the facility failed to provide in-services, at least 12 hours in a year, sufficient to ensure the continued competence of Certified Nursing Assistants (CNA) for 3 (S12CNA, S14CNA, S15CNA) of 5 (S11CNA, S12CNA, S13CNA, S14CNA, S15CNA) CNAs reviewed for in-service training.

Inspectors wroteBased on record reviews and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #73) of 3 (#8, #72 and #73) sampled residents reviewed for elopement. S3Director of Nursing (DON) failed to 1) notify staff that Resident #73 was assessed to be at risk for elopement and 2) initiate the interim care plan with appropriate interventions to prevent elopement after S3DON assessed Resident #73 to be at risk for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. Resident #73 was picked up by police on 07/22/2025 at 6:28 a.m. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 (#2, #5, #6, and #7) of 4 residents reviewed for infection control. S7Certified Nursing Assistant (CNA) failed to clean the whirlpool according to manufacturer's guidelines. Residents #2, #5, #6, and #7 received whirlpool baths three times a week while having open wounds to their body. Residents #2, #5, #6 and #7 were currently receiving antibiotics related to wound infections.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent cross contamination for 1 (#1) of 1 (#1) residents observed for wound care. The deficient practice was evidenced by the Wound Care Nurse (WCN) contaminating a cream used to treat a resident's burn and by storing a contaminated bottle of Dermal Wound Cleanser (DWC) inside of the wound care cart.

Inspectors wroteBased on record reviews and interviews, the facility failed to immediately consult the resident's physician when a resident had a change in condition or started a new treatment for 1 (#1) of 3 (#1, #3, and #4) residents reviewed for accidents. The deficient practice was evidenced by the nurse failing to notify the physician in a timely manner after she observed blisters on resident #1's skin.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (#7) of 1 (#7) residents observed smoking in an unsafe manner. The deficient practice was evidenced by resident #7 tossing his lit cigarette butt on the concrete when left unsupervised outside in the smoking area.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure policies were being followed for 1 (#10) of 7 (#5, #7, #8, #9, #10, #11, and #12) residents reviewed for smoking. The deficient practice was evidenced by the facility not having documented evidence of a Safe Smoking Evaluation completed quarterly for resident #7.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by having environmental concerns throughout the inside and outside of the building. This deficient practice had the potential to affect 51 residents that resided in the building.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 4 (#1, #2, #3, and #6) of 4 residents. The facility failed to have documentation of wound care, tracheostomy care, and medication administration.

Inspectors wroteBased on record review and interviews the facility failed to ensure the residents' environment remained as free of accident hazards as is possible for 1 (#5) of 3 (#1, #5 and #8) residents reviewed for accident hazards. The facility failed to complete an Accident and Incident Report per the facility's policy and the facility failed to perform a thorough investigation after resident #1 was found to have illegal drugs in his possession.

Inspectors wroteBased on record reviews, observations, policy review, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 1 (#2) of 3 (#1, #2, and #6) residents reviewed for enhanced barrier precautions.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure a resident with wounds or history of wounds received necessary treatment and services, consistent with professional standards of practice to promote healing, to prevent infection, and to prevent wounds for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure weekly skin assessments were performed.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the residents' right to be free from verbal and mental abuse for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents.

Inspectors wroteBased on record review and interviews, the provider failed to: 1) ensure an alleged violation involving verbal and mental abuse witnessed by staff was reported immediately to the Administrator and Director of Nursing and 2) ensure all allegations of verbal abuse/mental abuse were reported immediately, but no later than 2 hours after the allegation was made to State Survey Agency in accordance with State Laws for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to be incompliance with all applicable Federal, State, and Local Laws, regulations, and codes by S1Administrator response time from residence to facility being over one hour.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs for 5 (#15, #17, #18, #26, #29 and #43) of 5 sampled residents and had the potential to affect all 44 residents that reside in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment. The deficient practice affected 9 (#8, #11, #15, #17, #23, #26, #27, #29 & #49) of 9 sampled residents and had the potential to affect all 44 residents that resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to the stage agency and one or more law enforcement entities for 1 (#34) of 1 (#34) residents reviewed for misappropriation of resident property.

Inspectors wroteBased on record review and interviews the facility failed to ensure all alleged violations of misappropriation of resident property are thoroughly investigated in a timely manner for 1 (#34) of 1 (#34) resident reviewed for personal property.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for 3 (#6, #17 #23) of 4 (#6, #11, #17, #23) sampled residents for Activities of Daily Living as evidenced by, 1) failing to ensure resident's clothing was clean and free of food debris and 2) failing to ensure resident's fingernails and toenails were trimmed and clean.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 5 (S20Certified Nursing Assistant (CNA), S21CNA, S22CNA, S23CNA, and S24CNA) personnel records reviewed.

Inspectors wroteBased on observation of the medication pass, review of physician orders and interview, the facility failed to ensure that it is free from a medication error rate of 5% or greater by having 4 errors out of 33 opportunities for a medication error rate of 12.12%. (Residents #41, #13)

Inspectors wroteBased on observations and interviews, the facility failed to prepare and distribute food in accordance with professional standards for food service safety by failing to ensure food was defrosted properly. This deficient practice had the potential to affect 44 residents who received meals served from the kitchen.

Inspectors wroteBased on review of the Quality Assessment and Assurance (QAA) record and interview, the facility failed to have documented evidence of having a QAA meeting at least quarterly for the year 2024.

Inspectors wroteBased on observation, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions for 5 (#24, #25, #26, #45, #255) of 5 (#24, #25, #26, #45, #255) residents reviewed for enhanced barrier precautions.

Inspectors wroteBased on interview and review of the facility's Infection Control Records, the facility failed to designate an individual/individuals as the Infection Preventionist, who is responsible for the facility's infection prevention and control program.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 11 (#9, #11, #15, #18, #24, #27, #29, #33, #43, #47, and #49) of 11 sampled residents and had the potential to affect all 44 residents that resided in the facility.

Inspectors wroteBased on record reviews and interview, the facility failed to provide in-service training for nurse aides to ensure competency for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) of 5 personnel records reviewed. The facility failed to ensure: 1.) S20CNA, S21CNA, S22CNA, and S23CNA received training in resident abuse, 2) S20CNA, S23CNA, and S24CNA received training in dementia management and 3) S21CNA and S24CNA who were employed greater than one year received 12 hours of inservice training yearly.

Inspectors wroteBased on record reviews and interview, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days after the resident was discharged from the facility for 3 (#10, #31 and #40) of 3 residents reviewed for assessments.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure residents who received respiratory care are provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#20 & #34) of 2 residents reviewed for respiratory care. The facility failed to ensure: 1.) resident #20 was administered oxygen via nasal cannula per the physician orders and 2.) resident #34's nebulizer mask and tubing was stored in a plastic bag when not in use.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) initially upon hire and monthly thereafter for 5 (S20CNA, S21CNA, S22CNA, S23CNA and S24CNA), and the facility also failed to ensure the CNA registry was verified upon hire for 1 (S20CNA) for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) personnel files reviewed.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#31) of 1 (#31) resident reviewed for nutrition. The facility failed to notify the Registered Dietician regarding a resident's significant weight loss.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#14 and #17) of 6 (#10, 14, 17, 21, 22 and 31) residents reviewed for unnecessary medications. The facility failed to obtain lab work for residents #14 and #17 as ordered by the physician.

Inspectors wroteBased on review of the Quality Assessment and Assurance (QAA) record and interview the facility failed to have documented evidence of having QAA meeting as least quarterly for the year 2023.