Carroll Park Healthcare

Inspectors wroteBased on complaint, reviews of a clinical record, and staff interview, it was determined that the facility failed to notify Resident #2's representative in a timely manner after a fall in the shower room. This was evident for 1 (Resident #2) out of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a clinical records, and resident and staff interviews, it was determined that the facility staff failed to provide treatment to maintain dental health for Resident #1. This is evident for 1 out of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on a review of administrative records, medical records, and interviews with family members and facility staff, it was determined that the facility failed to ensure residents' rights were protected by restricting visitation in residents' rooms. This deficient practice was identified for 1 (#5) of 5 residents reviewed during a complaint investigation conducted at the facility.

Inspectors wroteBased on medical record review and interviews it was determined the facility failed to ensure that a comprehensive care plan was revised, and to ensure a scheduled care plan meeting was conducted. These deficient practices were identified for 2 (#1, #5) of 5 residents reviewed during a complaint investigation conducted at the facility.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure that enteral nutrition was administered in accordance with physician orders and accepted standards of nursing practice for 1 (#4) of 3 residents reviewed for enteral feedings. This deficient practice resulted in the resident receiving significantly less enteral nutrition than ordered due to incomplete physician orders and the facility's failure to ensure the feeding was administered as prescribed.

Inspectors wroteBased on record review and interviews, the facility failed to implement physician orders, and to provide the necessary care and services to assess, monitor, and timely respond to changes in a resident's condition. This was evident in 2 (#1, #4) of 5 residents reviewed for quality of care; treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility failed to ensure a physician's medically necessary visit addressed a resident's change in clinical status regarding swallowing difficulties and subsequent follow-up orders. This was evident for 1 (#1) out of 1 resident reviewed during the complaint survey.

Inspectors wroteBased on observations and interviews with the facility staff it was determined the facility failed to ensure that a resident call bell was within reach. This was found to be evident for 1 (#5) of 6 residents observed during a complaint survey conducted at the facility.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to obtain Resident #66 complete admission orders necessary for appropriate care. This was evident for 1 (Resident #66) out of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on resident record reviews and staff interviews, it was determined that the facility failed to complete a comprehensive assessment within 14 days of a significant change in the resident's condition. This was evident for 1 (Resident #11) of 6 residents reviewed for Minimum Data Set( MDS) assessments during the facility's recertification/ complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that facility staff failed to accurately code the resident's status on the Minimum Data Set assessment. This deficient practice was identified for 2 (Resident #100 and #2) out of 6 residents reviewed for Minimum Data Set assessments. The MDS is a federally mandated, comprehensive, standardized clinical assessment tool of all residents in Medicare/Medicaid nursing homes that evaluates functional capabilities and health needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care that they need.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to implement a care plan with interventions regarding Resident #66's indwelling catheter. This was evident for 1 (Resident #66) out of 1 residents reviewed for urinary catheter.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide care in accordance with the standards of practice, when Resident #28 was documented to not have a stool for 8 days (from 05/03/2026 to 05/10/2026) and no PRN bowel protocol medications were ordered or administered nor were abdominal assessments documented in the progress notes as per facility policy. This was evident for 1 (Resident #28) out of 18 residents reviewed for quality of care.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have the provider respond to Medication Regimen Review recommendations in a timely manner. This was evident for 3 (Resident #2, #8 and #63) out of 5 residents reviewed for unnecessary medications. Facility 's Medication Regimen Review (MRR) Policy and Procedure. It is the policy of this facility that each resident's medication regimen shall be reviewed by a qualified consultant pharmacist at least monthly, and more frequently as clinically indicated, to identify medication irregularities, unnecessary medications, adverse outcomes, monitoring deficiencies, and opportunities for optimization. POLICY STANDARDS: 1. Every resident shall receive a monthly medication regimen review. 2 Medication irregularities shall be promptly reported. 3. Provider responses shall be documented. 4. [...]

Inspectors wroteBased on record review and observation, it was determined that the facility did not ensure that enhanced barrier precautions were maintained while Resident #28 received wound care on 05/12/2026. This was evident for 1 (Resident #28) out of 2 residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and staff interviews it was determined that the facility failed to ensure a resident was free of abuse. This was evident for 1(Resident # 3) out of 1 resident reviewed for abuse during the complaint survey

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to store and process linens to prevent the spread of infection This was evident for 1 out of 1 observation made in the facility's laundry room.

Inspectors wroteBased on interviews and medical record review it was determined that the facility failed to honor the resident's preferences of getting showers. This was evident for 1 (Resident #84) of 1 resident reviewed for choices during the survey. The Findings Include: On 11/20/2025 at 12:33 PM, Resident #84 expressed a concern that they had not received a shower since being moved to the second floor in early November. The resident stated that they have only been provided with bed baths and that a physical shower has not been done. On 1/21/2025 at 11:07 AM, review of the resident's Annual MDS from 2/3/2025, under section F- Preferences, revealed that during an interview with the resident for daily/activity preferences it is very important that the resident is able to choose how they are bathed. [...]

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure an advance directive was on file for a resident. This deficient practice was evident for 1 (#75) of 4 residents review for advance directive during the annual survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to provide evidence that a level 1 preadmission screening and resident review (PASARR) was completed prior to admission, or at the time of admission for a resident with a mental disability. This deficient practice was evident for one resident (#47) reviewed for PASARR during the annual survey.

Inspectors wroteBased on interviews and record reviews, it was determined that facility staff failed to ensure the resident's discharge planning needs were addressed and failed to follow up on the resident's request for discharge. This deficient practice was evident for one (#52) resident reviewed for discharge planning during the annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to conduct quarterly care plan meetings. This was evident for 2 (Resident #3 and Resident #52) out of 3 residents reviewed for care planning.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to maintain professional standards of practice by 1) ensuring a resident with congestive heart failure (CHF) had their weights adequately monitored, and 2) maintaining correct medication administration documentation. This deficient practice was evident for 1 (#75) of 1 resident reviewed for professional standards of practice and 2 (Resident #22 and #18) out of 6 residents observed for medication administration during the annual survey.

Inspectors wroteBased on interview and medical record reviews, it was determined that the facility failed to provide treatment/services to maintain vision. This was evident for 1 (Resident #2) of 2 residents reviewed for vision during the survey. The Findings Include: On 11/19/2025 at 8:24 AM, during an interview with Resident #2, they stated that they had itchy scratchy eyes. They stated that they had not seen an eye doctor. On 11/21/2025 at 8:31 AM, a review of the resident's medical records revealed that on 6/6/2025 an order was placed for ophthalmology consult for decreased vision, on 9/4/2025 an order for an ophthalmology consult for an eye evaluation, and on 10/10/2025 there was an order placed for an ophthalmology consult. On 11/21/2025 at 9:12 AM, the medical provider visit notes were reviewed. The physician note on 5/28/25 stated that the resident requested to be seen by an ophthalmologist. [...]

Inspectors wroteBased on observations and record review, it was determined the facility failed to maintain an effective pest control program. This had the potential to affect all residents.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to maintain records of investigation documentation. This was evident for 2 (Resident #38 and #53) out of 10 residents reviewed for facility reported incidents.

Inspectors wroteBased on review of facility investigation and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 1 (MD00216920) of 46 Facility Reported Incidents (FRIs) reviewed during an annual survey.

Inspectors wroteBased on review of records and interviews, it was determined that the facility failed to implement its abuse policy. This was evident for 1 (Resident #61) of 5 residents reviewed for abuse allegations.

Inspectors wroteBased on record review and staff interviews, the facility failed to report (1.) unusual occurrences, (2.) allegations of abuse in the required timeframe and (3.) allegations of abuse to a law enforcement agency. This was evident for 3 (Resident #58, #59 and #90) out of 10 residents reviewed for facility reported incidents.

Inspectors wroteBased on observation, interviews, and record reviews, it was determined that facility staff failed to 1) ensure the resident's nutritional status was accurately assessed, documented, and up to date in accordance with healthcare standard of care guidelines and 2) provide services that meet professional standards by not following written physician orders. This deficient practice was evident for 2 residents (#13 and #67) reviewed during the annual survey. Based on record reviews, observations, and interviews, it was determined that facility failed to provide services that meet professional standards by not following written physician orders. This was found to be evident for Resident #67 during the annual survey.

Inspectors wroteBased on interviews, observations and record reviews, it was determined that facility staff failed to ensure that wound care treatment was completed as ordered by the physician. This deficient practice was evident for 1 (#13) of 5 residents reviewed for physician orders during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that facility staff failed to ensure that geriatric nursing assistant (GNA) maintained an active certification. This deficient practice was evident in 1 out of 7 GNA employee files reviewed during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistant (GNA). This deficient practice was evident in 7 out of 7 GNA's annual performance reviewed during the annual survey.

Inspectors wroteBased on record review and staff interview, it was determined the facility staff documented inaccurate data in the resident's chart. This was evident in 1 out of 6 resident's reviewed in the recertification survey.

Inspectors wroteBased on review of medical records, facility policies, facility investigation reports, interviews, and observations, it was determined that the facility failed to: 1. Assess known smokers on admission, re-assess residents deemed as safe smokers after they were found to be unsafely smoking, and adequately supervise residents while smoking. 2. Failed to prevent a Resident with documented unsafe use of smoking material from having smoking material in their room. 3. Failed to ensure that a resident's room was free from hazards. This was evident for 8 of 27 residents reviewed for smoking/accidents. (Resident #78, #41, #90, #63, #28, #463, #464 and, #368)

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE drug overdoses). The first identified occurrence was on [DATE] (Resident #131) which resulted in resident death. Without effective QAPI intervention, 22 additional drug overdose SPAEs occurred (Residents #2, #53, #58, #63, #66, #76, #90, #93, #101, #118, #132, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, and #420). The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 10:00 AM on [DATE].

Inspectors wroteBased on observation, interviews, and medical record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This was evident for 1 resident (# 266) out of 1 reviewed for CPR initiation. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 3:00 PM on [DATE]. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE].

Inspectors wroteBased on medical record review, review of pharmacy records, review of a facility's program description, and interviews with staff it was determined that the facility: (1) failed to timely implement physician instructions and orders related to SUD treatment, and (2) failed to effectively plan care for residents with Substance Abuse Disorder (SUD) and (3) failed to initiate a Substance Use Disorder care plan for Residents identified with Substance Use Disorders. This was evident for 5 (Residents #147, #90, #101, #141 & #154) of 18 residents reviewed for Substance Use Disorder during survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death.

Inspectors wroteBased on observation and interview, it was determined that the facility's staff failed to ensure a sanitary and safe interior environment. This was evident for 1 (Resident#4) out of 8 residents reviewed for sanitary and safe environment.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen.

Inspectors wroteBased on observation, staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1. Failure to ensure substantial compliance with regulations that were identified as deficient 2. Failure to implement plans of correction resulting in an immediate jeopardy for the safety of residents who required supervision while smoking by failing to adequately supervise those residents, 3. Failure to implement plans of correction related to residents ' behavioral health by failing to identify, monitor and prevent the additional occurrences of substance abuse, 4. [...]

Inspectors wroteBased on Interviews, observation, and record review, it was determined that the facility staff failed to ensure that resident rooms were free from mice. This was evident for 2 residents (#23 and #16) of 140 residents reviewed during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to facilitate care plan meetings for residents. This was evident for 5 residents, (#59, #159, #463, #465 and #467) of 5 residents reviewed for care planning.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to inform residents of their right to formulate advanced directives. This was found evident for 5 out of 7 (Resident #55, #22, #15, #67, and #27) residents reviewed for advanced directives during an annual and complaint survey.

Inspectors wroteBased on clinical record review, review of facility abuse investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse were reported to the state agency. This was evident for 3 (#150, #22, and #90) out of 30 residents reviewed for abuse.

Inspectors wroteBased on clinical record review, review of facility investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse are thoroughly investigated and accurately reported with inclusion of details such as but not limited to reported injury and witness statements. This was evident for 12 (#119, #161, #165, #365, #374, #22, #42, #115, #63, #369, #70, and #128) out of 30 residents reviewed for abuse.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, it was determined that the facility failed to ensure a care plan was developed for a resident who was an active smoker upon the completion of resident's comprehensive assessment at admission and failed to review, to revise a resident's care plan after a quarterly assessment, to ensure that care plan meetings took place in a timely manner, to ensure a Power of Attorney (POA) was invited to a care plan meeting. This was evident for 6 (Resident #109, #10, #371, #33, #39, and #67) of 12 residents reviewed for care plan timing and revision.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure that 1) prescribed medications are correctly transcribed and administered, 2) insulin sliding scale parameters were included on the medication order for a resident receiving insulin, 3) report changes in baseline conditions and health concerns verbalized by residents. and 4) to create a new medication order in the resident's electronic record, once the order had been changed, and facility staff administered narcotics with conflicting orders. [...]

Inspectors wroteBased on clinical record review, review of complaint intakes, observation, and staff interview it was determined that the facility staff failed to ensure residents received quality care regarding, but not limited to, medication administration, catheter care, conduct and document accurate nursing assessment, promptly identify and intervene for an acute change in a resident's condition and to provide an emergency medication (Glucagon) timely to a resident (Resident #108) with a finger stick result of 41mg/dl. This was evident for 10 (#121, #161, #364, #381, #63, #16, #517, #162, #131, and #108) out of 140 residents in the survey sample for the annual recertification and complaint survey.

Inspectors wroteBased on clinical record review, observation, and staff interview it was determined that the facility staff failed to appropriately administer pain medications as ordered. This was evident for 3 (#15, #63, and #517) residents out of 11 residents reviewed for pain management.

Inspectors wroteBased on record reviews, and staff interviews it was determined that the facility staff failed to put a system in place to ensure that prescribed medications are correctly transcribed and administered. This was evident for 1 (Resident # 46) of 1 residents reviewed for medication administration concerns during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature was maintained for the medication refrigerator and 2) expired medications were properly disposed of and 3) narcotic medications were adequately wasted, and 4) to maintain a safe and effective system for securing medications and treatments in designated carts on the nursing unit. This was found to be evident in 2 out of 3 medication storage rooms observed in the facility and 2 of 3 medication carts observed out of 6 medication carts in the facility.

Inspectors wroteBased on observation, interviews, review of a complaint, review of administrative documents and record review, it was determined that the facility failed to keep accurate resident records in accordance with professional standards, to accurately display residents' names outside of their rooms, and to ensure that when the nursing staff destroy Schedule II medication, the administrative records were accurate. This was evident of 5 out of 140 (Resident #22, #8, #79, #64, #517, and #162) residents reviewed for accuracy of documentation on annual and complaint survey.

Inspectors wroteBased on interviews, and review of employee records, it was determined that the facility failed to have a qualified, full-time Social Worker employed to oversee the social service duties. This was found evident during 5 months in 2022.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to; 1) keep a sanitary environment. This was found evident on 1 out of 3 floors observed and 2) failed to keep a functional and comfortable environment for 2 of 2 (Resident #84 and #59) random rooms observed on an annual and complaint survey.

Inspectors wroteBased on interview and observation, the facility failed to provide a bariatric bedside commode for a resident's use. This was evident for 1 (# 417) out of 2 residents reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to honor the resident's right to participate in family events outside the facility. This was evident for 1 (Resident #46) out of 1 resident reviewed for resident rights.

Inspectors wroteBased on complaint, reviews of a closed record, a staff interview, it was determined that a resident was not given an admission contract. This was evident for 1 (Resident #141) of 112 intakes reviewed during an annual certification survey.

Inspectors wroteBased on reviews of a facility reported incident and staff interview, it was determined that a staff member removed money from a resident's account without the resident's permission. This was evident for 1 of 112 intakes reviewed during an annual recertification survey.

Inspectors wroteBased on clinical record review, review of a complaint, and staff interview it was determined that the facility failed to ensure proper planning on an issued 30 day discharge.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to: 1) provide written notice with the reason for transfer to a resident and 2) failed to notify the Ombudsman of residents that transferred timely. This was found evident of 2 of 7 (Resident #22 & #517) Residents reviewed for hospitalization during an annual and complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to implement a process to ensure that residents and resident representatives were made aware of the facilities bed hold policy upon transfer to the hospital. This was found to be evident for 2 (Resident #517 and #22) of 7 residents reviewed for hospitalizations during the investigative portion of the survey.

Inspectors wroteBased on record review and interview the facility failed to accurately assess a resident for antipsychotic medications and to accurately document an assessment. This was found to be evident for 2 (# 92 and #115) out of 8 residents reviewed for Minimum Data Set (MDS) accuracy.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a baseline care plan for a resident, requiring hemodialysis treatments and experiencing recurrent hypoglycemic episodes, that meets the professional standards of quality care. This was evident for 1 (Resident #517) of 13 residents investigated for care planning.

Inspectors wroteBased on record review and interview it was determined that the facility failed to create a comprehensive care plan. This was found evident for 2 out of 13 (Resident #78 and #8) reviewed for care planning during an annual and complaint survey.

Inspectors wroteBased on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' discharge goals are evaluated and planned. This was evident for 3 (#71, #165, #46) of the 7 residents reviewed for the discharge process.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility staff failed to provide necessary activities of daily living (ADL) care based on the resident's level of daily living needs. This was evident for 1 (Resident # 8) out of 6 residents reviewed for Activities of Daily Living (ADL) level of care.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility failed to provide on-going personalized activities for the residents. This was evident for 3 (Resident #4, #59, and #23) out of 5 residents reviewed for personalized activities.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen therapy equipment. This was found to be evident for 1 (# 416) out of 1 resident observed on oxygen therapy.

Inspectors wroteBased on record review and interview it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (#568) of 1 resident reviewed for trauma informed care.

Inspectors wroteBased on interviews with staff, and review of medical records, it was determined that the facility failed to appropriately treat a resident diagnosed with a mental disorder. This was evident of 2 of 4 residents (Resident #115 & #78) reviewed for mental health services during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure social work assisted a resident with their needs. This was evident for 1 (#385) out of 140 residents in the survey sample.

Inspectors wroteBased on review of medical records, medication monitoring/control records and interview with staff, it was determined the facility failed to implement a system to consistently and accurately reconcile controlled medications. This was evident for 2 out of 6 narcotic log binders reviewed during the recertification survey.

Inspectors wroteBased on record review, interview and observation, the facility failed to prescribe a therapeutic diet for a resident. This was based on 1 (# 124) out of 1 resident reviewed for correct dietary orders.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harborage and feeding of pests.

Inspectors wroteBased on record review and interview, the facility failed to initiate a Quality Assurance and Performance Improvement (QAPI) plan. This was evident for 1 out of 1 QAPI plan reviewed during the annual survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that clean linen was protected from contamination, to ensure isolation carts contained Personal Protective Equipment (PPE), and to maintain effective infection prevention practices. This was evident for 1 (3rd floor) of 3 floors observed for the handling of linens, for 7 out of 7 isolation carts observed, and for 1 of 3 random observations during an annual and complaint survey.

Inspectors wroteBased on clinical record review and family interview it was determined that the facility failed to ensure that a resident had access to a working adaptive device. This was evident for 1 (#121) out of the 140 residents that are part of the survey sample.

Inspectors wroteBased on interview and record review the facility to ensure that Agency Staff received facility training prior to working. This was found to be evident for 1 (# 62) out of 1 Agency Staff interviewed regarding facility training.

Inspectors wroteBased on reviews of a facility reported incident, a nursing assistant's employee files, and staff interview, it was determined that the facility failed to confirm an agency nursing assistant had abuse, neglect, exploitation, and misappropriation of resident property education before allowing the agency nursing assistant to work with residents in the facility. This was evident for 1 of 12 nursing assistants reviewed during an annual recertification survey.