BHM Carrollton Opco LLC

In the surveyor’s words

From the most serious findings on record at BHM Carrollton Opco LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 20, 2025

  Based on record review and interviews, the facility failed to act upon a change of condition for one of 28 sampled residents (R) (263) related to low blood sugar, which resulted in being transferred to the hospital for treatment. This failure to provide quick intervention led to harm being identified on 12/29/2023, when R263's blood sugar went so low, to the point where the resident was unresponsive and slow to respond to the emergency use of Glucagon intramuscular when administered at the facility. R263 had to be transferred to the emergency room (ER). Findings included: 1. […]

• Actual harm, isolatedF686Mar 31, 2022

  Based on observation, interview, record review, review of Centers for Medicare and Medicaid (CMS) guidance, and policy review, the facility failed to ensure that one resident (R) (R#48) of three residents reviewed for pressure sores who was at risk for pressure ulcer development did not develop a pressure ulcer and received the treatment needed to promote healing. R#48 was readmitted to the facility post hospitalization on [DATE] with skin issues which deteriorated to a Stage III pressure ulcer with signs of infection. The facility failed to conduct weekly assessments, change treatments when the pressure ulcer did not respond, and did not provide treatment in a manner designed to promote healing. […]

• Actual harm, isolatedF689Mar 31, 2022

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents and/or an environment free of hazards was provided for five residents (R) (R#8, R#10, R#21, R#30, and R#48) of nine sampled residents reviewed for accidents. This failure caused actual harm, when R#8 sustained a fracture while being transported in her Broda chair. In addition, fall interventions such as non-skid strips designed to prevent accidents were not in place. Staff failed to provide the sufficient amount of supervision/assistance during a transfer. Hazardous substances were left within access of a confused resident. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  Based on observations, staff interviews, and review of the facility's policy titled, Food Safety Requirements, the facility failed to store, handle, and serve food in a safe and sanitary manner by failing to: ensure expired food items were discarded; ensure food items were properly labeled and dated; properly store raw meat to prevent cross-contamination; maintain food storage areas in a clean condition; properly store food off the floor; ensure equipment and surfaces were maintained in a sanitary condition; and ensure meal tray carts were covered during transport. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, large manual can opener, and the main dining room's ice machine and microwave oven clean and sanitized. Additionally, the dietary staff failed to label, date, and/or cover food and beverages stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses, which could affect 101 residents who consumed food prepared from the facility's kitchen. Findings included: A review of the facility's policy titled Sanitation dated October 2008 indicated Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. […]