Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ascension Living Carroll Manor during CMS and state inspections, most recent first.
A resident with dementia and documented high elopement risk, including orders for a wander guard and care plan interventions requiring staff to know her whereabouts at all times, was able to leave a secure Memory Care unit after a pantry door near the exit was left open by dietary staff. Video showed the resident moving from the dining area into the pantry and then out through the open pantry door to an unsecured area, passing security staff and exiting the building without staff awareness. The resident had previously cut off her wander guard bracelet using scissors she had obtained and concealed in her belongings. Nursing leadership later acknowledged that the care plan directive to know the resident’s whereabouts "at all times" had been operationalized as hourly checks, and staff did not maintain continuous awareness of the resident’s location, resulting in an elopement and an Immediate Jeopardy finding under F689.
Staff did not follow a physician’s order that, per a resident’s request, no male CNA be assigned on any shift. The resident had dementia, CHF, HTN, and age-related macular degeneration and required supervision or touching assistance with personal hygiene. Review of assignment sheets and CNA documentation over several weeks showed that a male CNA was repeatedly assigned and documented as providing care on multiple shifts, despite the standing order and staff awareness of the restriction.
Facility staff failed to follow a resident’s documented shellfish allergy and nutritional care plan when a shrimp entrée from the posted dinner menu was plated and delivered despite clear allergy notation and an allergy indicator on the meal ticket. A pantry worker reported relying mainly on diet texture information and cited difficulty seeing allergy information on a new ticket format, while a CNA acknowledged not following her usual practice of verifying the meal against the ticket before the family member took the tray. The resident’s family identified the shrimp on the plate, prompting the tray’s return, and the complainant later reported that the replacement items offered were limited to sandwiches, chips, small pieces of chicken, and cold spinach, which they considered nutritionally inadequate, leading them to obtain another meal for the resident.
A resident with multiple medical conditions and a documented shellfish allergy was not provided a nourishing, palatable, well-balanced meal at a safe and appetizing temperature when the scheduled dinner entrée contained shrimp. Instead, the resident was first offered a peanut butter and jelly sandwich, a ham sandwich, and potato chips, followed by three small pieces of chicken in a plastic container and later a container of cold spinach. The resident’s care plan called for honoring food preferences and providing a prescribed diet while noting the shellfish allergy, and the facility had an always-available menu intended to provide made-to-order alternatives served on plates, but the Dietary Director acknowledged that the alternative food provided was cold and not served as intended.
Elopement from Memory Care Unit Due to Inadequate Supervision and Open Pantry Door
Penalty
Summary
Facility staff failed to ensure adequate supervision and adherence to a person-centered care plan for a resident identified as an elopement risk, resulting in the resident eloping from a secure Memory Care unit. The resident had multiple diagnoses including dementia, congestive heart failure, hypertension, and age-related macular degeneration, and had physician orders for behavioral monitoring related to elopement and for use of a wander guard (code alert) with checks for placement and functioning every shift. An elopement risk screening showed a high-risk score, and the care plan documented that the resident was at risk for elopement related to poor safety awareness, hoovered around the main exit door with a friend waiting for someone to allow them to leave, and was on high alert for elopement. Care plan interventions included following the community elopement evaluation and monitoring process, keeping the resident safe on the locked unit, replacing the wander guard bracelet as soon as it was known the resident had removed it, and that nursing would check and know the whereabouts of the resident at all times. On the day of the incident, documentation showed that the wander guard system had been checked and passed, and a safety checklist entry indicated that the resident was observed in her room at 11:00 AM. However, video recordings later showed that at approximately 11:40 AM, a food service manager entered the first-floor pantry near the Memory Care unit entry/exit doors and left the pantry door wide open. Shortly thereafter, the resident approached the dining room doors near the main entry/exit doors of the unit and hovered there while a food pantry worker was inside the pantry. The pantry worker exited through the dining room side pantry door, and the resident then opened the dining room doors, entered the dining room, and proceeded into the pantry. The video further showed that the resident exited the still-open pantry door located outside of the Memory Care unit, pushing her rolling walker, without staff knowledge. The resident then walked past two security officers in the main lobby, now without a walker and holding a jacket and a bag, and proceeded outside the facility’s main entry/exit doors. A nurse supervisor was later called by security to identify a person outside with a bag and recognized the individual as the resident from the Memory Care unit. The resident was resisting returning inside and was brought back with assistance from nursing staff, after which a head-to-toe assessment was completed with no abnormalities noted. Interviews revealed that an LPN had previously placed and tested a wander guard bracelet on the resident, but after the incident staff discovered that the resident had obtained scissors and used them to cut off the bracelet, hiding the scissors and cut bracelet in her pocketbook. The DON acknowledged that the care plan intervention stating that nursing would check and know the whereabouts of the resident at all times had been interpreted as hourly checks, and could not clearly explain what “at all times” meant beyond stating that staff frequently had eyes on the resident. The evidence showed that staff did not check and know the resident’s whereabouts at all times, and that the resident was able to elope from the secured unit without staff awareness, leading to identification of an Immediate Jeopardy at F689. An Immediate Jeopardy (IJ-J) to resident health and safety was identified at 42 CFR 483.25, F689, on 03/18/26 at 1:12 PM based on these failures in supervision and implementation of the care plan, including failure to ensure the resident’s whereabouts were known at all times and failure to prevent elopement from a secure area.
Removal Plan
- Resident #1 was brought safely back into the facility by the Supervisor and first floor staff after being observed outside unsupervised.
- Upon re-entering the first floor, Resident #1 received a head-to-toe assessment by the charge nurse and supervisor and no abnormalities were noted.
- Resident #1's care plan was revised to increase monitoring of her location/whereabouts to every 30 minutes.
- Resident #1 is utilizing a wanderguard bracelet that will trigger both doors to the memory care unit.
- Resident #1 no longer has access to scissors used to remove the wanderguard; scissors were removed.
- The charge nurse notified Resident #1's legal guardian about the incident and that the resident cannot have access to scissors.
- Dining staff were educated by the Dining Manager on the importance of locking the pantry door when no one is in the pantry.
- Maintenance made the pantry door used for elopement inoperable so no one could enter/exit through that door; pantry access remained available via the dining room door for emergencies.
- Keypads were installed on both pantry doors so they cannot be opened unless the code is entered.
- A 100% audit of all residents at risk for elopement was conducted to ensure behavior monitoring for wandering/exit-seeking was in place.
- All residents identified as elopement risk and exit-seeking were to have care plans updated to reflect increased monitoring every 30 minutes.
- All residents identified as elopement risk were to have a wanderguard applied with an order to check placement and functioning every shift.
- All residents identified as elopement risk were to have a care plan identifying elopement risk and person-centered interventions to prevent unaccompanied leaving.
- All residents identified as elopement risk were to have orders in place to check wanderguards for placement and functioning every shift.
- All employees were to be re-educated on ensuring doors that should not be left open/unlocked are properly closed and locked after entry/exit.
- All charge nurses were to be re-educated on checking wanderguard placement and functioning, including methods to verify function.
- All nursing staff were to be educated on increasing monitoring for residents at risk for elopement from every hour to every 30 minutes.
- All charge nurses were to be educated on documenting the location of the resident's wanderguard when checking placement and functioning.
- Facility implemented a systemic change to increase monitoring for residents at risk for elopement and exit-seeking from every 1 hour to every 30 minutes.
Failure to Follow Physician Order Regarding CNA Gender Assignment
Penalty
Summary
Facility staff failed to follow a physician’s order specifying that Resident #1, who had dementia, congestive heart failure, hypertension, and age-related macular degeneration, was not to be assigned a male CNA on any shift per the resident’s request. The physician’s order, dated 07/28/24, directed that every shift the resident was to have no male CNA, and a quarterly MDS assessment documented a BIMS score of 10, indicating moderately impaired cognition, and a need for supervision or touching assistance with personal hygiene. Review of nursing assignment sheets and CNA documentation from 02/01/26 to 03/18/26 showed that, despite this order, a male CNA was assigned to and documented as providing care to the resident on multiple dates and shifts, totaling 15 shifts during this period. During a face-to-face interview on 03/19/26 at 9:40 AM, the surveyor presented these findings to the Assistant Director of Nursing and the 1st floor Unit Manager, and the Unit Manager acknowledged that staff were aware that a male should not be assigned to this resident.
Failure to Follow Allergy-Specific Diet Order and Provide Adequate Meal Replacement
Penalty
Summary
Facility staff failed to ensure that a resident’s menu and meal service met her nutritional needs and documented food allergy, resulting in a shellfish-containing entrée being served to a resident with a known shellfish allergy. The resident was admitted with multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and had a clearly documented shellfish allergy in the Physician’s Order Reconciliation and History and Physical. An admission MDS showed the resident was cognitively intact, and the care plan identified risk for altered nutritional status with interventions to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On the date of the incident, the facility’s dinner menu included penne pasta with spinach and shrimp. The resident’s meal ticket, as later observed by the surveyor, listed multiple shellfish-related allergies and had a red circular sticker indicating an allergy. Despite this, the pantry worker plated the shrimp entrée for the resident. The pantry worker reported that she based plating on the diet type listed on the ticket (e.g., regular or mechanical) and stated that on the new ticket format the allergy information was printed much smaller, and that she had not received sufficient training, which she believed contributed to her error. The Chef Manager stated that pantry workers are supposed to read the ticket and only plate food specific to the resident, and that nurses are supposed to read the ticket and ensure the food is correct before giving it to the resident. A CNA delivered the tray containing shrimp to the resident’s room. The CNA stated that her usual practice is to place the tray on the table and then remove the dome cover to check the meal against the ticket, but on this occasion she did not do so because the resident’s daughter assisted and immediately took the tray. The daughter opened the cover, saw the shrimp, and stated that the resident was allergic, at which point the CNA apologized and returned the tray to the kitchen. The complaint submitted to the State Agency reported that the replacement food initially offered consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips, which was described as not nutritionally appropriate for an elderly patient, and that subsequent attempts to remedy the situation included three small pieces of chicken in a plastic container and later a container of cold spinach, leading the complainant to reorder a meal on the resident’s behalf.
Failure to Provide Palatable, Nutritious, and Proper-Temperature Meal to Resident With Shellfish Allergy
Penalty
Summary
Facility staff failed to provide a cognitively intact resident with a nourishing, palatable, well-balanced, attractive meal at a safe and appetizing temperature, as required by facility policy. The resident had multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and a documented shellfish allergy. The resident’s care plan identified risk for altered nutritional status and directed staff to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On a dinner menu that included penne with spinach and shrimp, the resident, who could not receive shellfish, required an alternative meal. According to the complaint intake, the replacement food offered for dinner consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips, which was described as not nutritionally appropriate for an elderly patient. Subsequent attempts to remedy the situation included three small pieces of chicken served in a plastic container, followed later by a container of cold spinach at approximately 7:03 PM. The Dietary Director acknowledged that an “Always Available Menu” existed with hot and cold items that could be ordered without a cut-off time and that such items should be served on a plate and logged as a special request. The Dietary Director also acknowledged awareness that the alternative food item served to the resident was cold, but was not aware of how the resident would have received it in a to-go container.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jeanne Jugan Residence | 0.6 mi | ★★★★★ | 0 | 0 |
| The Hsc Pediatric Skilled Nursing Facility | 0.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At Hyattsville | 1.1 mi | ★★★★★ | 57 | 0 |
| White Oak Rehabilitation And Nursing Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Washington Ctr For Aging Svcs | 1.9 mi | ★★★★★ | 2 | 0 |
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