The Carrolton of Plymouth

In the surveyor’s words

From the most serious findings on record at The Carrolton of Plymouth, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 16, 2023

  Based on record review, staff and Physician interviews the facility failed to protect a cognitively impaired resident (Resident #82) from physical abuse from an employee when a Nursing Assistant (NA) #2 was witnessed by another employee (Restorative Aide) grab Resident #82 forcibly by the arm once when assisting the resident out of her wheelchair and another time when Resident #82 began walking away from the bathroom and then NA #2 pushed Resident #82 into the resident bathroom. Resident #82 did not have the cognitive capacity to express an adverse outcome. A reasonable person would have been traumatized by being physically abused by their caregiver in their home environment. The facility failed to protect Resident #28 from mistreatment by NA # 1. […]

• Immediate jeopardy, isolatedF607Feb 16, 2023

  Based on record review and staff interviews the facility failed to protect Resident #82 when the Restorative Aide had not intervened when she witnessed Nursing Assistant (NA) #2 forcibly grab Resident #82's arm twice and push the resident into the bathroom, the Restorative Aide left Resident #82 in the care of NA #2 and did not report the abuse immediately. The facility also failed to protect all residents from further potential physical abuse following allegations of staff to resident abuse (Resident #82 and Resident #28) by allowing NA #2 and NA #1 to continue to provide resident care for the remainder of their shifts. This occurred for 2 of 3 residents reviewed for abuse. […]

• No harm, potential for more than minimal, patternF584Mar 27, 2025

  Based on observations and interviews with residents, staff, plumbers, Medical Director, and the [NAME] President of Property Management the facility failed to maintain repair or replace corroded sewage pipes, that caused sewage to back up onto the hallway floors for 2 of 4 hallways (200, 500) reviewed for maintaining a safe, clean, comfortable, and homelike environment. The findings included: a. On 3/26/25 at 9:40 am on the 200 hall Housekeeper #1 was observed mopping up clear colored, odorless water from the hallway floor, which consisted of square non-porous composite tiles, outside of room [ROOM NUMBER]. The floor in 207 was noted to be wet with small puddles of water scattered across the floor. […]

• No harm, potential for more than minimal, patternF689Mar 27, 2025

  Based on observations and interviews with residents and staff, the facility failed to maintain repair or replace corroded sewage pipes, that caused sewage to back up on the hallways and create an accident hazard for 2 of 4 hallways (200 hall and 500 hall) reviewed accident hazards. The findings included: On 3/26/25 at 9:40 am on 200 hallway Housekeeper #1 was observed mopping water up in the hallway outside of room [ROOM NUMBER]. The floor was observed to have non-porous square composite tiles. The floor in 207 was noted to be wet with small puddles of water scattered across the floor. […]

• No harm, potential for more than minimal, patternF837Mar 27, 2025

  Based on observation, record review, and staff, [NAME] President of Property Management, and plumber interviews, the governing body failed to ensure the replacement of aged, malfunctioning, and corroded sewer lines. Due to the state of disrepair of the sewer lines, sewage backed up on multiple occasions each month through sewer cleanout access ports to the point where the replacement of the sewer lines was required to stop the sewer lines from overflowing. When the sewer lines would overflow, several facility toilets on the same hall could not be flushed because they would start to overflow. […]