Ascension Living Carroll Manor

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe and comfortable environment by allowing resident room temperatures to rise above the regulatory range of 71 to 81 degrees Fahrenheit after the HVAC system was turned off for repair. Surveyors observed that the ambient temperatures in the rooms of four residents with respiratory diagnoses and/or oxygen therapy ranged from 85 to 90 degrees Fahrenheit during the day, while the weather in the District of Columbia was also hot, ranging between 73 and 90 degrees Fahrenheit. One resident with a history of pulmonary embolism and oxygen use was observed lying in bed and stated that her room was hot; her room temperature was measured at 90 degrees Fahrenheit. Another resident with COPD, cardiac defibrillator, and generalized weakness was also observed in bed and stated that she was not comfortable because it was hot in her room; her room temperature was measured at 88.2 degrees Fahrenheit. A third resident with chronic respiratory failure with hypoxia, obstructive sleep apnea, asthma, paraplegia, and morbid obesity was observed sweating and stated that it was very hot in the room and that she could not sleep the night before; her room temperature was measured at 88.2 degrees Fahrenheit. A fourth resident with COPD, chronic respiratory failure with hypoxia, and oxygen therapy was observed in bed and stated, "I'm hot." Her room temperature was measured at 85 degrees Fahrenheit. During interviews, maintenance staff stated that contractors were on-site working on the HVAC system and that the system had been turned off that morning to repair a leaking pipe. The administrator stated she was not aware the HVAC system had been turned off or that resident rooms had excessive temperatures.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide necessary treatment and services to prevent the development and progression of pressure ulcers for two residents who developed wounds that were first identified at advanced stages. One resident was admitted with multiple diagnoses including fracture of the first lumbar vertebra, gait and mobility abnormalities, generalized muscle weakness, severe protein-calorie malnutrition, and need for assistance with personal care. On admission, nursing documentation described redness and dryness in the perineal, right groin, and sacral areas, and the resident had a Braden score of 14, indicating moderate risk for pressure ulcer development. The record also included conflicting skin documentation, with one admission skin evaluation noting a sacral ulcer with redness/moisture-associated skin damage and stage 2 pressure injury, while later staff interviews stated the resident had no open areas and that the stage 2 entry was documented in error. The resident’s record later showed a history and physical documenting a stage 1 pressure ulcer in the sacral region with an offloading protocol, barrier cream, wound consult, and repositioning every 2 hours. However, the medical record lacked documented evidence of the resident’s left buttock wound before a skin evaluation on 04/23/26 that identified a left buttock deep tissue injury that was unstageable, measuring 8.0 cm by 2.0 cm, with slough and dermis tissue. A wound care physician later stated that 04/23/26 was the first time he assessed the resident’s wounds and that staff told him the resident had been admitted with three wounds, including an unstageable sacral pressure ulcer and a left buttock pressure ulcer. The DON stated staff did not make her aware of the left buttock unstageable wound. A second resident was admitted from home with dementia, diabetes mellitus type 2, and hypertension. Admission documentation stated the skin was intact and no pressure injuries were noted, although the resident had pink scar tissue on the coccyx and right lateral ankle and was at risk due to unsteady gait, incontinence, and limited mobility. On 04/28/26, nursing documented a sacral opening measuring 0.2 cm by 0.3 cm, and the wound was later evaluated as a stage 3 pressure wound of the sacrum. The resident’s care plan was updated to reflect the open sacral area related to limited mobility and incontinence, and wound treatment orders were entered after the opening was identified.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify Resident #195 and the resident representative in writing, and in a manner they understood, at least 30 days before discharge. Resident #195 was admitted with diagnoses including arthritis, osteoporosis, deep vein thrombosis, urinary tract infection, and a history of falls. A complaint intake received by the State Agency alleged that the facility was performing an unsafe discharge and that a discharge meeting was never held. During interviews, the Assistant Director of Nursing stated that staff did not know about the discharge until the afternoon of the discharge day, when the resident's son said he needed a wheelchair to take his mother home and reported that she had already been discharged. She stated the social worker did not follow the usual discharge process, including listing residents to be discharged and obtaining discharge orders in advance, and noted there was no documented physician discharge order in the resident's record. The Social Services Manager stated she did the discharge planning meeting with the resident, the son, and physical therapy on the day of discharge, but was unsure what information had been communicated earlier about the discharge plan or barriers to discharge, and acknowledged that the discharge planning meeting was not complete if other departments were unavailable.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's PASARR II referral was completed within 30 days of admission for Resident #150, who was admitted with diagnoses including Unspecified Psychosis, Anxiety Disorder, and Major Depressive Disorder. The resident's PASARR I form dated 04/09/26 did not capture a history of serious mental illness, was incomplete, and did not document whether a PASARR II referral was needed. A care plan dated 04/09/26 stated that Level II PASARR was not needed. During interview on 06/01/26, the Director of Social Work stated that the PASARR I form had been completed incorrectly and that she would complete another PASARR I and submit a PASARR II referral because of the resident's mental health diagnoses.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to fully implement the care plan interventions for a resident who had an unwitnessed fall and failed to develop a care plan for another resident’s unstageable pressure ulcer. The report identified two residents involved: one resident with dementia, chronic kidney disease stage 4, COPD, urinary retention, edema, unsteadiness on feet, and an indwelling urinary catheter; and another resident admitted with multiple diagnoses including a lumbar fracture, gait abnormalities, generalized weakness, severe protein-calorie malnutrition, and need for assistance with personal care. For the resident with the pressure ulcer, a skin evaluation form documented a left buttocks deep tissue injury/unstageable wound with slough and dermis involvement, and a physician order directed cleansing and dressing treatment. During wound care observation, the dressing was removed and the wound had a moderate amount of dark drainage, dark and yellow tissue in the wound bed, and no redness, swelling, or maceration around the wound. The DON stated that staff should have developed a care plan for the resident’s left buttocks pressure ulcer. For the resident who fell, a nursing progress note documented that the resident was found on the floor, was alert and responsive, had no apparent injury, and was assisted back to bed. Physician orders required 72-hour monitoring for bruising, mental status changes, pain, or other injuries, PT consult, and neuro checks on a specified schedule. The care plan included a bariatric bed, floor mats on both sides of the bed, and neurological assessment for 72 hours. Survey review found no documented evidence that the neuro checks were completed as ordered, no dates or signatures on the assessments, no TAR documentation showing the checks were performed, and no documented evidence that floor mats were placed on both sides of the bed. Staff interviews indicated the nurses were still learning the eHR system and that floor mats were sometimes removed for care and not replaced.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow up with a resident's physician to schedule cataract surgery for Resident #157, who was admitted with diagnoses including cataracts of the right and left eye, dry eyes, and hypertensive retinopathy. Records showed that after an ophthalmology follow-up, the physician recommended cataract evaluation at a local hospital, and later recommended eye surgery at the hospital. A care plan meeting note documented that the resident had an upcoming cataract surgery, that all recommended clearances were complete, and that the facility was awaiting a call back from the eye doctor for an available surgery date. During interview, the ADON stated the resident had completed all pre-op tests for cataract surgery and that it was an oversight that staff did not call the physician to schedule the surgery.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to wash and sanitize chinaware plates and silverware properly during the dishwashing process in the main kitchen, as six of 21 chinaware plates, three of three forks, three of 25 spoons, and one of 10 knives still had food particles remaining on the eating surfaces after they had been washed and sanitized. In a separate observation of the second-floor medication storage room, an opened case of Ensure supplement drinks was found with a use-by date of 05/01/2026, and only 17 of 24 eight-ounce supplement drinks remained, with seven drinks unaccounted for. The Dietary Manager stated the plates and utensils would be rew washed and sanitized, and the RN Unit Manager acknowledged the supplement findings.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to evaluate a resident for occupational therapy services as required by a physician’s order. Resident #146 was admitted with diagnoses including unspecified dementia, chronic kidney disease stage 4, chronic embolism and thrombosis, COPD, shortness of breath, retention of urine, localized edema, and unsteadiness on feet. A quarterly MDS documented severely impaired cognition with a BIMS score of 3, maximal assistance needed for eating, oral hygiene, upper body dressing, and footwear, dependence for toileting, bathing, and personal hygiene, an indwelling urinary catheter, frequent bowel incontinence, and recent anticoagulant use. After the resident’s family member and legal guardian raised concerns about communication with the medical team and the resident’s ability to feed herself, the facility documented that an order was placed for OT to evaluate her ability to feed herself. The physician’s order directed OT to evaluate for decreased ability to feed self, but the record contained no documented evidence that OT completed the evaluation after the family meeting and order. The DON emailed OT requesting the evaluation, and the Director of Rehabilitation Services later stated the resident was placed on a list for OT evaluation but was pushed down behind new admissions and the family, Administrator, and DON were not informed.

Penalty

Inspection fine: $137,333

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Accurate resident record documentation was not maintained for two sampled residents. Resident #150 was admitted with multiple diagnoses including fracture of the first lumbar vertebra, abnormalities of gait and mobility, generalized muscle weakness, severe protein-calorie malnutrition, and need for assistance with personal care. On admission, nursing documentation described redness and dryness to the perineal, right groin, and sacral areas, and a skin evaluation form later documented a sacral ulcer with redness/moisture acquired skin damage and identified it as a Stage 2 pressure injury. During interview, an RN stated she had documented in error that the resident had a Stage 2 sacral pressure ulcer and said that on admission the resident had a Stage 1 sacral injury with red skin and no open areas. Resident #179 was admitted with diagnoses including dementia, acute respiratory distress, and need for assistance with personal care. A complaint intake referenced a reported bedsore in August 2024 that remained present and caused discomfort. During record review, the medical record lacked documented evidence of shower sheets for August 2024. Staff later provided recreated CNA Bath and Shower Documentation Sheets for several August dates, and the sheets did not document any skin concerns. An RN stated the original shower sheets could not be found and that staff had recreated them based on the schedule; a CNA who signed the recreated sheets stated she had been asked to complete them that day and could not verify whether the information was accurate.

Penalty

Inspection fine: $13,260

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $13,260

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.