Carroll Healthcare Center Inc

In the surveyor’s words

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

• Actual harm, isolatedF684Jan 2, 2025

  Based on observation, record review, review of physician office visit notes and hospital records and interview, the facility failed to ensure Resident #24, who had an unstable burst fracture of the first lumbar vertebrae with spinal fusion on 10/18/24 and was admitted to the facility for post-operative care and therapy was provided timely, adequate and necessary wound care monitoring and treatment and antibiotic treatment as ordered by the resident's surgeon/physician for management of a surgical wound, to promote optimal healing and to prevent complications post-operatively. Actual harm occurred on 11/17/24 when Resident #24 was discharged home without evidence the surgical wound to his back was stable and without sign of infection and that wound care had been provided as ordered. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2023

  Based on observation, interviews and facility policy review, the facility failed to ensure the kitchen was clean and sanitary and items were dated. This had the potential to affect all residents except Resident #33, who was identified as receiving nothing by mouth. The facility census was 40. Findings include: Observation on 05/01/23 from 8:12 A.M. to 8:30 A.M. with Dietary Manager #144 of the kitchen and outside area where the walk-in cooler and freezer were located revealed the following concerns: In the three door reach-in in freezer was observed one gallon storage bag of six breadsticks undated, one half of an opened and resealed factory bag of peas and carrots undated, one half of an opened and resealed factory bag of spinach undated, four individual servings of sauerkraut wrapped… […]

• No harm, potential for more than minimal, isolatedF557Sep 15, 2025

  Based on record review, interview, and review of the facility Quality Assurance plan, the facility failed to ensure resident possessions were maintained securely and treated with respect. This affected three residents (#41, #42 and #43) of three closed resident records reviewed.Findings Include:Review of the complaint log revealed the facility lockbox was misplaced affecting Resident's #41 and #42. The result stated it was believed facility lock box was thrown away when the office was cleaned. The resident's families were notified. The Police were notified. The residents' families did not state they felt anything was stolen.The facility was asked for an investigation into the missing lockbox. The paperwork provided included a progress note from Resident #41's record. […]

• No harm, potential for more than minimal, isolatedF880Sep 15, 2025

  Based on observation, interview and policy review, the facility failed to ensure infection control protocols were maintained when performing incontinence care. This affected one resident (#28) of one resident observed for incontinence care The facility identified nine always incontinent residents.Findings Include:Observation on 09/10/25 at 11:02 A.M. of incontinence care for Resident #28 with Certified Nurse Aide (CNA) #50 revealed the CNA washed her hands, and put a barrier on the overbed table. The CNA placed a basin of warm water on the table with towels, washcloths, shampoo and body wash, barrier cream and plastic trash bags. The CNA provided privacy with the use of a bath blanket to cover the resident's pelvic area. […]

• No harm, potential for more than minimal, isolatedF684May 8, 2025

  Based on record review, interview, and policy review, the facility failed to ensure a resident received a clear, liquid diet, as ordered by the physician, prior to a scheduled colonoscopy (a medical procedure used to examine the rectum and colon for abnormalities). This affected one resident (#44) of two residents reviewed for discharge. The facility census was 40. Findings include: Review of the closed medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of sigmoid colon, dementia, weakness, and diabetes mellitus. […]