Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caroleton Healthcare Center during CMS and state inspections, most recent first.
A resident with pneumonia had incomplete McGeer criteria documentation for IV ceftriaxone use, and two other residents had refusals of care that were not accurately charted. One cognitively impaired resident refused heel boots during an observation, but the behavior log did not reflect the refusal, and another resident with stroke and alcohol-induced dementia frequently refused nail care, yet the behavior record showed only one refusal despite staff reporting repeated refusals.
A resident with urinary retention and an indwelling catheter had catheter care provided while a size 22 Fr catheter was in place, even though the physician’s order specified a size 20 Fr catheter. An LPN reviewed the order, confirmed the mismatch, and stated the needed catheter size was not available in facility supplies.
A resident who was cognitively intact and required substantial to maximal staff assistance with personal hygiene was observed with a full beard, long fingernails, and black substance under both hands' nails on multiple occasions. The resident stated he preferred to be clean shaven and said staff had not offered to shave him since admission, while the DON stated CNA staff were responsible for trimming and cleaning fingernails and shaving facial hair.
Failure to apply ordered tubi grip to a resident’s bilateral arms for edema. The resident was observed with swollen lower arms and at times did not have the tubular sleeves in place, despite a physician order and care plan directing tubi grip to both arms in the morning and off at bedtime. The resident stated he had never refused the sleeves and that they provided some relief from the swelling; the DON stated the nurse was responsible for applying them.
A resident with diabetes-related nerve damage, impaired mobility, and foot wounds developed an unstageable pressure injury to the heel after the facility did not consistently implement ordered heel boots and documented betadine treatment that staff later said could not have been applied because the heel was not visible under non-removable dressings. The resident’s care plan and physician orders called for pressure relief and heel suspension boots, but the treatment record did not reflect heel boot use and the heel wound was first identified after the dressing was removed.
Failure to perform hand hygiene and change gloves during catheter care: A resident with an indwelling catheter and a history of UTIs was observed receiving catheter and incontinent care from a QMA and CNA who put on gloves without hand hygiene, cleaned the genital area and catheter tubing, and later drained the catheter bag without performing hand hygiene after changing gloves. The staff stated they normally would complete hand hygiene and change gloves during catheter care, but they were nervous and did not do it.
A resident with a Foley catheter and another resident with multiple wounds were observed receiving care without required infection control practices. Staff did not perform hand hygiene before or during catheter care, did not wear gowns for EBP, and drained the catheter bag without hand hygiene. During wound care, an LPN used unclean scissors, did not change gloves or perform hand hygiene between wound treatments, and reapplied dressings without following standard precautions.
Survey results were not posted in a location readily accessible to residents, family members, or legal representatives for all residents. During a resident council meeting, residents said they did not know where the most recent survey results were located. An observation showed the survey binder and posted notice were placed above wheelchair level near the entrance, and a resident in a wheelchair could not reach the binder or read the sign without assistance.
Incomplete infection documentation and missed refusal-of-care charting
Penalty
Summary
The facility failed to maintain complete and accurate documentation related to antibiotic use for Resident 1, who had pneumonia and was ordered ceftriaxone 1 gram IV every 24 hours. The infection surveillance criteria report for the resident indicated the facility used McGeer criteria to determine whether antibiotic treatment was supported, but the report was incomplete because criterion 1c was not marked. During interview, the infection control nurse stated she forgot to document the mental status change and decline in activities of daily living criterion for the resident on the infection control criteria report. The facility also failed to accurately document refusals of care for Resident 3 and Resident 32. Resident 3, who was cognitively impaired, dependent for hygiene, turning, and transferring, and had delirium, confusion, skin impairments, surgical wounds, and a non-removable dressing, refused pressure-reducing heel boots during an observation and asked to float his heels with a pillow instead, but behavior monitoring documentation for that day did not show any refusals of care. Resident 32, who had stroke and alcohol-induced dementia and was cognitively impaired and dependent for grooming and hygiene, was observed with long, jagged fingernails, and staff stated the resident refused nail care frequently; however, the behavior management log documented only one episode of refusal for the review period, despite staff and leadership stating refusals occurred often.
Incorrect Foley Catheter Size
Penalty
Summary
The facility failed to follow the physician’s order for the correct size indwelling catheter for one resident. During an observation, QMA 3 and CNA 7 provided catheter care to the resident, and the catheter in place was size 22 French. When LPN 6 reviewed the physician’s order, the resident was supposed to have a size 20 French catheter. LPN 6 also stated the resident’s catheter had last been changed on 4/19/26 and later indicated she could not find a size 20 French catheter in the facility’s medical supplies. The resident’s record showed diagnoses including urinary tract infection and urinary retention. The care plan identified the resident as at risk for urinary complications related to urinary retention and an indwelling catheter, with an intervention to change the catheter as ordered by the physician. The physician’s order dated 4/15/26 specified a catheter size 20 with continuous drain. The quarterly MDS dated 1/6/26 indicated the resident was cognitively intact for daily decision making and had an indwelling catheter.
Failure to Provide Personal Grooming Assistance
Penalty
Summary
The facility failed to assist a dependent resident with fingernail care and facial hair removal. During observation and interview, the resident had a full beard and long fingernails with black substance underneath on both hands. The resident stated he did not prefer to have a beard, liked to be clean shaven, and said no staff had offered to shave him since admission. He also stated that when he was at home, he used an electric razor to trim his facial hair and then a disposable razor to cut his facial hair, and that staff sometimes trimmed his fingernails. Additional observations over the next two days showed the resident repeatedly sitting in common areas and eating lunch with moderately long fingernails on both hands, black substances under the nails, and a full long beard. The record showed diagnoses including Parkinson disease, muscle weakness, and need for assistance with personal care. The admission MDS indicated the resident was cognitively intact for daily decision making, had no behaviors of rejecting care, and required substantial to maximal staff assistance with personal hygiene. The care plan also indicated the resident required substantial to maximal staff assistance with personal hygiene. The DON stated it was the CNA's responsibility to ensure the resident's fingernails were trimmed and cleaned and his facial hair was shaven, and the routine resident care policy stated resident care was intended to promote dignity and honor resident lifestyle preferences.
Failure to Apply Ordered Tubular Compression to Resident’s Arms
Penalty
Summary
The facility failed to implement the physician-ordered tubular compression bandages to both arms for a resident with bilateral arm edema. The resident was observed with swelling of the lower arms on 4/21/2026 and again on 4/23/2026, when the tubular sleeves were not in place on either arm. The resident stated he did not know what caused the swelling and reported that he had never refused to wear the tubular sleeves. He also stated the sleeves provided some relief from the swelling. The resident’s record identified bilateral arm edema, and the physician recapitulation dated April 2026 ordered tubi grip to both arms every day and evening shift for edema, to be applied in the morning and removed at bedtime. The care plan also directed tubi grip to both arms in the morning and off at bedtime. The resident was cognitively intact, had no behavior of refusal of care, and required substantial to maximal staff assistance with upper body dressing. The DON stated the nurse was responsible for applying the resident’s tubular sleeves, and the facility policy stated the licensed nurse was responsible for executing physician orders.
Failure to Implement Heel Boots and Follow Wound Treatment Orders
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with partial traumatic amputation of two or more toes, diabetic nerve damage, and impaired mobility and gait. The resident’s admission MDS indicated cognitive impairment and dependence on staff for hygiene, turning, and transferring. The care plan included pressure ulcer interventions, and an intervention added on 3/17/2026 directed the use of heel boots to both feet while in bed. Hospital discharge orders also directed betadine to the left heel twice daily and pressure relief to both heels with heel suspension boots. However, the treatment record showed betadine was documented as applied to the left heel only from 3/9/2026 through 3/11/2026, and the treatment record and care plan did not reflect heel boot use between 3/8/2026 and 3/11/2026. The resident’s admission nursing assessment did not identify skin impairment to the left heel, but the resident had non-removable dressings to both feet. A wound care report later identified an unstageable pressure injury to the left heel measuring 2 cm by 5 cm, with no depth, and noted it was first measured after removal of the non-removable dressing. At that time, additional wounds were also found, including diabetic foot ulcers, a deep tissue injury to the left lateral foot, and a Stage 1 pressure injury to the right lateral foot. The ADON stated the resident’s heels were not visible on admission because of the non-removable dressings and that the left heel was not visible until the first dressing change on 3/25/2026. The ADON also stated staff would not have been able to apply betadine to the left heel as signed on the treatment record and that direct floor staff were responsible for wound care and implementing interventions, including bilateral heel boots.
Failure to Perform Hand Hygiene and Change Gloves During Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene and change gloves during catheter care for a resident with an indwelling catheter. During an observation, the resident stated he had the catheter before admission and reported having been diagnosed with a urinary tract infection a few times since being at the facility. The resident had an indwelling catheter bag hanging on the side of the bed, and during care the QMA and CNA entered the room, applied gloves, and began care without hand hygiene first. The QMA lowered the bed, removed the resident’s incontinent brief, cleaned the genital area with a wet soapy washcloth, rinsed and dried the area, and then used the same soapy washcloth to clean the catheter tubing. The QMA and CNA applied a clean brief and pad, the CNA removed soiled linen, and then the QMA removed gloves, donned another pair, and drained the catheter bag into a urinal without performing hand hygiene. The QMA and CNA stated they normally would complete hand hygiene and change gloves during catheter care, but they were nervous and did not do it. The resident’s record showed diagnoses including UTI and urinary retention, a quarterly MDS indicating cognitive intactness and an indwelling catheter, and a physician order for an antibiotic for a UTI.
Failure to Follow EBP and Wound Care Infection Control Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling Foley catheter and a diagnosis that included a UTI. The resident had an EBP sign at the doorway and EBP gowns and gloves hanging on the door, and the care plan dated 1/7/26 indicated EBP was required for the indwelling medical device. During observed catheter care, a QMA and CNA entered the room and applied gloves without hand hygiene, did not wear gowns, and provided personal care and catheter care while the resident’s incontinent brief was removed and the catheter tubing was cleaned. The QMA later drained the catheter bag into a urinal without performing hand hygiene, and both staff indicated they only kind of remembered training on wearing a gown during catheter care. The facility also failed to follow infection control practices during wound care for another resident with multiple wounds, including a blister to the left knee, diabetic foot ulcers, and pressure injuries to the left heel and both lateral feet. During observed wound care, an LPN had scissors removed from her pocket by the ADON, and the scissors were not cleaned before being used to cut xeroform for the left knee wound. The LPN did not change gloves or perform hand hygiene between removing and cleaning the left knee wound and applying a clean dressing, and then repeated the same process for the left heel wound without hand hygiene when changing gloves. The resident’s record identified cognitive impairment and a pressure care plan with wound care interventions, and the ADON stated hand hygiene was expected before the procedure, each time gloves were changed, and after the procedure, with scissors cleaned before use.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives for 46 of 46 residents. During a resident council meeting, residents stated they were unaware of the location of the most recent survey results. An observation of the survey binder showed it was placed in a bin attached to the wall by the facility entrance, with a sign above it indicating survey results availability, but neither the binder nor the sign were at wheelchair level. When the binder and posting were observed with Resident 18, the co-president of resident council, and the Executive Director, Resident 18 required assistance in her wheelchair to reach the binder and stated she could not read the posting above it.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Connersville | 0.2 mi | ★★★★★ | 3 | 0 |
| Majestic Care Of Connersville | 1.9 mi | ★★★★★ | 4 | 0 |
| Heritage House Rehabilitation & Health Care Center | 2.6 mi | ★★★★★ | 7 | 0 |
| Envive Of Liberty | 11 mi | ★★★★★ | 11 | 0 |
| Ambassador Healthcare | 13.3 mi | ★★★★★ | 19 | 0 |
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