Carrollton Manor, Incorporated

In the surveyor’s words

From the most serious findings on record at Carrollton Manor, Incorporated, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 25, 2026

  Based 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. Findings include: 1. Review of R101's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease. […]

• Actual harm, isolatedF686Apr 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF628Apr 25, 2026

  Based 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.Findings include:1. Review of R1's admission Record from the electronic medical record (EMR) Profile tab revealed an admission date of 08/09/2024, readmission on [DATE], with medical diagnoses that included paroxysmal atrial fibrillation, acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes,… […]

• No harm, potential for more than minimal, widespreadF803Apr 25, 2026

  Based 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.Findings include: Review of the weekly menu, provided on paper by the Dietary Supervisor (DS), revealed it contained a mix of typed and handwritten entries for breakfast, lunch, and dinner, with instructions such as no bread for the soft/bite-sized diet and omit bacon/sausage for the NAS [no added salt] diet, with no substitutions listed of similar nutritive value. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2026

  Based 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.Findings include: During initial observations of the kitchen on 04/21/2026 at 9:30 AM, along with the Dietary Supervisor (DS), the following was observed:1. […]