Ascension Living Carroll Manor

In the surveyor’s words

From the most serious findings on record at Ascension Living Carroll Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF584Jun 16, 2026

  Based on observations and resident interviews, the facility staff failed to maintain a safe and comfortable environment by not ensuring facility temperatures ranged from 71 to 81 Fahrenheit. As evidenced by four (4) of four residents who had respiratory diagnoses and/or were prescribed oxygen therapy, whose room temperatures ranged from 82 - 90 Fahrenheit after the facility staff turned off the HVAC system for repair. (Residents #1, #4, #196, and #199) The findings included: According to the Weather Channel, on June 10, 2026, the temperature in the District of Columbia ranged between 73 and 90 Fahrenheit. https://weather.com/weather/monthly/l/c4025fdf0177c872b7fc2e0d09e7c523995ef49e21145e2d2438fe08649ca9e81. Resident#1 was admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF689Mar 24, 2026

  Based on observations, record reviews, resident and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to ensure that adequate supervision was provided, in accordance with Resident #1's person-centered plan of care, to prevent her from eloping from a safe area, without authorization. Subsequently, Resident #1 eloped from the secure Memory Care unit on 02/21/26 at 11:45 AM. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervision/Devices on 03/18/26 at 1:12 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on 03/18/26 at 5:27 PM. […]

• Immediate jeopardy, isolatedF689Sep 25, 2024

  Based on observation, record review, video footage, staff interviews, and the resident's interview, for two (2) of 50 sampled residents, the facility staff failed to: adequately supervise Resident #165 while the resident sat in the nurse's station on the evening of 06/28/24. Subsequently, the resident eloped through the loading dock door in the facility's basement. On 06/29/24, the police located the resident near a police station (approximately 5.1 miles from the facility). After being evaluated at a hospital, the resident returned to the facility that same day; and (2) ensure Resident #48 was adequately supervised while wearing facility-provided oversize non-skid socks. […]

• Actual harm, patternF686Jun 16, 2026

  Based on observation, record review, and staff interviews, the facility staff failed to provide the necessary treatment and services to prevent the development and progression of pressure ulcers (bedsores) for two (2) of two residents who developed pressure ulcers that were first observed at advanced stages Residents # 150 and #87. 1. Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Fracture of First Lumbar Vertebra, Abnormalities of Gait Mobility, Generalized Muscle Weakness, Severe Protein-Calorie Malnutrition, and Need for Assistance with Personal Care. An admission nursing progress note dated 04/09/26 at 6:06 PM documented in part, Resident is alert, oriented and verbally responsive. She's able to make his [her] needs known. […]

• Actual harm, isolatedF686Nov 16, 2022

  Based on record reviews and staff interviews, for one (1) of 19 sampled residents, the facility's staff failed to provide care consistent with professional standards of practice to promote healing of Resident #2's Moisture Associated Skin Disorder (MASD). Subsequently, Resident #2's sacrum MASD declined to a Stage III pressure ulcer/injury. These failures resulted in actual harm to Resident #2 when it was determined that the resident's Moisture Associated Skin Disorder to the sacrum, first observed on (04/20/2022) was not treated in accordance with the Nurse Practitioners recommendation. […]