Carrollton Manor, Incorporated

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to protect the residents' right to be free from physical and/or verbal abuse by two residents (R) (101 and R70) of the five of eleven residents R89, R102, R103, R57, and R90 reviewed for abuse. The facility's failure to ensure residents were protected from abuse resulted in actual physical harm to R89, R102, and R103, and created the potential for other residents in the facility to experience physical and/or psychological abuse.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to implement pressure ulcer prevention measures and timely treatment and interventions for one of four residents (Resident (R) 28) reviewed for pressure ulcers. This failure contributed to the development and subsequent decline of a potentially avoidable stage III pressure ulcer on R28's sacrum. Actual harm was identified to have occurred on 04/20/2026 when R28 was noted to have developed a Stage III pressure ulcer to the sacrum after interventions to prevent pressure ulcers were not implemented in a timely manner.

Inspectors wroteBased on record review, staff and family interviews, and facility policy review, the facility failed to ensure a written notice of transfer and/or a written bed hold notice was initiated on four of four residents (R) (R1, R9, R3, and R10) reviewed for facility-initiated emergent transfer to the hospital. This failure had the potential to contribute to the possibility for denial of re-admission and loss of the resident's home following hospitalization.

Inspectors wroteBased on document review, staff interviews, and policy review, the facility failed to ensure the menus were developed to meet residents' nutritional needs by failing to indicate portion sizes for all 86 facility residents and failing to indicate substitutions for omitted foods. This failure had the potential to lead to weight loss, malnutrition, or dissatisfaction with meals for all residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that food stored in the kitchen pantry, refrigerators, and freezer was appropriately labeled and dated, covered, and maintained at proper temperature. Additionally, the facility failed to ensure the vents above the stove, ceiling lights, air vents, and standing fans in the kitchen were clean. These failures had the potential to increase the risk of foodborne illness and infection among all 86 facility residents.

Inspectors wroteBased on staff interviews, record review, and policy review, the facility failed to identify issues prior to their identification by the survey team and failed to implement and maintain an effective, ongoing Quality Assurance and Performance Improvement (QAPI) program that addressed identified concerns and ensured corrective actions were implemented and sustained. Specifically, the facility was unable to provide any Performance Improvement Plans (PIPs) completed in the last year and failed to address ongoing physical and verbal abuse by one resident toward other residents, allowing the abuse to continue.

Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed to develop a documented water management plan that included an assessment to identify where Legionella and other waterborne pathogens could grow and spread and what control measures were in place, and the facility failed to implement a program of enhanced barrier precautions (EBP) to assist in the prevention of cross contamination for residents with areas of risk. Specifically, appropriate personal protective equipment (PPE) was not worn for one resident (Resident (R) 3) during high contact care, hand hygiene was not performed during a tube feeding for R28, and signage on the door for R88 was not clear as to the procedures for contact isolation for visitors. These failures had the potential to affect all residents in the facility.

Inspectors wroteBased on facility document review, staff interview, and facility policy review, the facility failed to ensure an antibiotic stewardship program was developed and implemented. This failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms (commonly called superbugs) from unnecessary or inappropriate antibiotic use for all 86 residents currently residing in the facility.

Inspectors wroteBased on observations, staff interviews, review of Manufacturer's Instructions for Use (MIFU), and policy review, the facility failed to ensure bed frames, mattresses, and bed rails were inspected and maintained per the MIFU for six of six residents (Resident (R) 2, R5, R24, R28, R33, and R57) reviewed for bed rail use. This deficient practice has the potential for bed malfunction, failure, or entrapment, which could lead to resident injury.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure five of five Certified Nurse Aides (Certified Nurse Aide (CNA) 1, CNA2, CNA3, CNA4, and CNA5) reviewed for training received annual training to review the facility's Quality Assurance and Performance Improvement (QAPI) Program. This failure created a potential for staff to be unaware of their role in the facility's QAPI program and how to communicate their concerns, problems, or opportunities for improvement to the facility's QAPI committee.

Inspectors wroteBased on document review and staff interview, the facility failed to complete an annual performance review for four of four Certified Nurse Aides (Certified Nurse Aide (CNA) 2, CNA3, CNA4, and CNA5) reviewed who were employed by the facility for more than one year. This failure had the potential for missed identification of performance problems, unsafe care, and missed training opportunities based on the evaluation.

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure the dining experience was dignified for one resident (R) (R56) of 34 sampled residents. The deficient practice had the potential to contribute to depression, anxiety, decreased food intake, and dissatisfaction with meals for R56.

Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to provide evidence that residents and/or their representatives were informed of the risks, benefits, and available treatment options before restraints were initiated for two of seven residents reviewed for restraints (Resident (R) 21 and R56) and before psychotropic medications were initiated for four of five residents reviewed for unnecessary medication (R33, R12, R38, and R70) from a total sample of 34 residents. This deficient practice could result in residents being restrained or receiving medications without clinical necessity.

Inspectors wroteBased on record review, document review, staff interviews, policy review, and Centers for Medicare and Medicaid (CMS) guidance review, the facility failed to ensure two of three residents (R) (R24 and R90) who were reviewed for Beneficiary Notices received a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This deficient practice had the potential for residents and/or their representatives not to be fully informed of the out-of-pocket costs associated with continuing to receive therapy after a Medicare Part A service ended. Findings Include:1. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure incidents of potential resident-to-resident abuse were identified, reported, and investigated per the facility's policy for three of 11 residents (R75, R19, R101) reviewed for abuse. These failures placed the residents at risk for physical and/or psychosocial harm related to continued abuse. Cross Reference F600, F609, and F865.

Inspectors wroteBased on review of record review, document review, interviews, and policy review, the facility failed to ensure timely reporting of allegations of abuse related to three Residents (Resident (R) 101, R75, and R19) out of eleven residents reviewed for abuse. The facility's failure to ensure potential abuse was reported timely created the potential for ongoing abuse of residents in the facility. A total of 34 residents were reviewed in the sample.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement care plans for four residents (Resident (R)2, R5, R24, and R70) of 34 sampled residents. Specifically, care plans were not developed for residents' use of bed rails or oxygen, and resident-to-resident abuse interventions were not included in their comprehensive care plan. This failure had the potential to affect the accuracy and complexity of resident care.

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure an ongoing program of activities was provided for one of five residents reviewed for activities (Resident (R) 28), who was bedbound. This failure placed R28 at risk for isolation or lack of sensory stimulation.

Inspectors wroteBased on record review, observations, staff interviews, review of the Food and Drug Administration (FDA) guidance, and facility policy review, the facility failed to ensure assessments, including alternatives to rail usage, were attempted prior to the installation and use of bed rails for six 34 sampled residents (Resident (R) 2, R5, R24, R28, R33, and R57). This failure had the potential to increase accidental entrapment or injury.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to provide medically-related social services to address potential psychosocial concerns and evaluate the ability to consent in sexual activities for two of three residents (Resident (R) 75 and R19) reviewed for behavioral and emotional needs. These failures had the potential to contribute to ongoing psychosocial distress following an incident of potential sexual abuse.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure a medication error rate was less than five percent during medication administration review. Five errors were identified from 31 opportunities involving three residents (R) (R39, R46, and R49), resulting in a 16.13 percent medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.

Inspectors wroteBased on record review, observation, staff interviews, and policy review, the facility failed to ensure proper storage of refrigerated medications in one of two medication storage rooms in the facility. The facility's failure to ensure medication was appropriately stored created the potential for residents to receive inactive/ineffective medication.

Inspectors wroteBased on documentation review and interview, the facility failed to post daily nurse staffing data that included the total number of licensed and unlicensed staff working each shift responsible for resident care. This deficient practice has the potential to affect all residents and visitors by not informing them of the available nursing staff to care for the residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies, the facility failed to appropriately store medications in three of three medication storage carts (200-300 Hall cart, 400 Hall cart, and 500 Hall cart).

Inspectors wroteBased on observations, staff interviews, record review, and review of the facilities policy, the facility failed to accommodate resident's food allergies, intolerances, and preferences for seven (7) residents that had been identified to have a latex allergy to include sampled residents. [Residents (R) #7, R#13, R#27, R#39, R#49, R#51and R#247]. Specifically, the facility failed to provide an appropriate alternative as evident by dietary staff plating food from the tray line using their hands donning latex gloves. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness were followed and safe food handling for the prevention of foodborne illnesses throughout the facility's food handling processes, and failed to ensure proper hand hygiene or donning (putting on) of a protective apron during meal service tray line. Specifically, two freezers, one walk in refrigerator, three juice coolers, and one front and back ice cream cooler failed to have documentation verifying the temperatures of each. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies, the facility failed to provide services that meet professional standards for one of six residents observed for medication administration (Resident #41). Specifically, blood pressure monitoring was not provided following physician's orders before administering a medication.

Inspectors wroteBased on observations, resident family and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report an incident of sexual abuse for one of three sampled residents (R) (R1). This failure had the potential for abuse to other residents by staff.

Inspectors wroteBased on observation, staff interviews and policy reviews, the facility failed to maintain an effective infection control program related to the unsanitary conditions for three out of three medication carts, failed to ensure that a blood pressure cuff was properly disinfected after each resident use, failed to use barriers with multi-use medications, failed to wash and/or sanitize hands while administering medications to prevent possible cross-contamination, and failed to transport soiled linen in a covered container. The facility census was 93.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure a safe environment related to unsafe employee smoking practices on facility grounds.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of facility policy 'Resident Hydration and Prevention of Dehydration', the facility failed to ensure adequate hydration was provided to three of 40 sampled residents (R) (R#48, R#67, and R#285) and follow the fluid restriction for one of 40 sampled residents (R#26).

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility policy titled Dignity, the facility failed to ensure that 12 of 24 sampled residents (R) (R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, R#18, and R#67) were treated in a dignified manner related to (1) placing medical instruction signage in an area easily viewed by other residents/visitors for R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, and R#18; and (2) an uncovered catheter bag for R#67. Findings Included: 1. A Review of the policy titled Dignity dated 2001 and revised 2/21/22 revealed the policy statement to be: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation section line numbered 10.b. [...]

Inspectors wroteBased on record review, staff interviews, and review of facility policy titled admission Criteria the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for one of 40 sampled residents (R) (R#39) following a new diagnosis of major depressive disorder and mild intellectual disabilities.

Inspectors wroteBased on record review, staff interviews, and review of facility policy 'Care Plan, Comprehensive Person-Centered', the facility failed to develop a person-centered comprehensive care plan related to nutrition/hydration needs for one of 40 sampled residents (R) (R#74).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to document weekly skin assessments in accordance with Physician orders for one of 40 sampled residents (R) (R#77).

Inspectors wroteBased on interviews, record and policy reviews, the facility failed to ensure the safety for one of 40 sampled residents (R) (R#28) related to ensuring safe smoking practices.

Inspectors wroteBased on record review, staff interview, and review of the policy titled Psychotropic Medication Use, the facility failed to ensure that psychotropic medications/antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents (R) (R#66 and R#77) reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and review of the policies titled, Storage of Medications, the facility failed to ensure that one of three medication carts (400 Hall Medication Cart) was locked and secured when the carts were out of view of the nurse. The Deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications.