Accura Healthcare of Carroll

In the surveyor’s words

From the most serious findings on record at Accura Healthcare of Carroll, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 13, 2025

  Based on observation, clinical record review, staff interview and facility policy review, the facility failed to have interventions in place to prevent the development of a pressure ulcer for 1 of 4 residents reviewed (Resident #14). This resulted in harm to Resident #14 when she developed a Stage III pressure ulcer. The facility reported a census of 48 residents. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. […]

• Actual harm, isolatedF692Mar 13, 2025

  Based on clinical record review, staff interviews and policy review the facility failed to conduct appropriate weight monitoring, nutritional assessments, interventions and timely Physician/family notifications for 1 of 2 residents reviewed (Resident #13) for weight loss resulting in severe unplanned weight loss. The facility reported a census of 48 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #13 was independent with eating and was on a therapeutic diet. The MDS documented Resident #13 did not have a 5% weight loss in the last month or 10 % weight loss in the last 6 months. […]

• No harm, potential for more than minimal, widespreadF851Apr 2, 2026

  Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 48 residents.Findings include:Review of the PBJ Staffing Data Report with a run date of 3/25/26 revealed the facility triggered for excessively low weekend staffing. Further review of the document revealed that the submitted weekend staffing data was excessively low. […]

• No harm, potential for more than minimal, widespreadF865Apr 2, 2026

  Based on document review, staff interviews, and facility policy review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies during the current survey process in 1 area and corrections that remained incomplete in a reasonable time frame. The facility reported a census of 48 residents.Findings include:Review of Federal Centers for Medicaid and Medicare Services (CMS) form 2567 for the survey results with correction dates of 10/16/25, and 1/31/26 indicated that the facility had received deficiency F725 related to insufficient nursing staff.Interview on 4/02/26 at 11:13 AM with the Administrator and Staff B Registered Nurse (RN) revealed the facility is currently working on call light audits. […]

• No harm, potential for more than minimal, patternF584Apr 2, 2026

  Based on observations, cleaning schedule review, and staff and resident interviews, the facility failed to ensure residents had housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 4 residents reviewed (Resident #21, #11, #25 and #24). The facility reported a census of 48 residents.Findings include:The Resident Council notes dated 3/19/26 had none circled, indicating the rooms were not clean, and 1 resident citing a need to sweep under the bed.1.An Assessment Scoring report documented Resident #21 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.On 3/30/26 at 11:11 a.m. Resident #21 stated sometimes they didn't make her bed. In subsequent interview on 3/31/26 at 2:49 p.m. […]