Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Arbors At Carroll during CMS and state inspections, most recent first.
Failure to use PPE during a mechanical lift transfer under EBP. A cognitively intact resident with a feeding tube, wounds, and multiple chronic conditions required two-person mechanical lift transfers and EBP for high-contact care. During the transfer, CNAs initially donned gowns and gloves but removed them, then completed the lift transfer and moved the resident into the hallway without wearing new PPE. Both CNAs confirmed PPE was not worn, and the IP RN confirmed PPE should have been worn during the in-room transfer.
A resident with an indwelling urinary catheter was observed multiple times with the drainage bag hanging uncovered and urine visible from the hallway. The resident was cognitively intact, and the care plan included a privacy cover for the catheter bag. A CNA confirmed the bag did not have a privacy cover, and the facility policy states privacy bags are used to cover catheter drainage bags while in use.
Failure to Provide Privacy During Incontinence Care: An LPN provided incontinence care to a resident with bowel and bladder incontinence while the window blind was left open, allowing potential visibility from other resident rooms. The resident had multiple chronic conditions, was dependent on staff for toileting, and the facility policy required privacy during direct care.
Failure to Off-Load a Stage III Heel Pressure Ulcer: A resident with multiple chronic conditions, including PVD and neuropathy, had a stage III pressure ulcer on the left heel that was present on readmission and remained open during repeated wound assessments. Staff observed the resident sitting in a wheelchair with the affected heel resting on the floor and no off-loading in place, and the DON verified the lack of off-loading. The wound nurse practitioner documented that staff were educated on the importance of off-loading to support wound healing.
Delayed Podiatry Nail Care: Two residents dependent on staff for personal hygiene were observed with overgrown toenails, and one had an ingrown toenail with pain when wearing shoes. One resident had not been seen by podiatry since the prior visit months earlier, and the SSD and DON confirmed podiatry had not returned to trim toenails during that extended interval despite the facility nail care policy calling for routine and as-needed nail care.
A resident with multiple chronic conditions, including COPD, CHF, CKD, dysphagia, and dependence on O2, had no natural teeth and reported mouth discomfort and difficulty chewing. Dental records showed dentures had previously fit well, but later documentation only noted a prior auth for full dentures with no follow-up. The resident was observed without upper or lower dentures and reported the lower dentures were lost; the SS director confirmed the dentures were lost and that the next fitting was scheduled about a year later, which was not timely.
A nurse was found to have pre-pulled and stored medications for eight residents in unlabeled medicine cups in the top drawer of a medication cart, rather than pulling and administering medications at the time of use as required. This practice, confirmed by both the nurse and the DON, did not comply with professional standards for medication storage and labeling, affecting residents with various chronic conditions.
A facility failed to reposition and transfer a resident with cerebral palsy and cognitive impairments as ordered by the physician. The resident was observed in the same position for several hours, contrary to orders for repositioning every two hours and placement in a chair daily. Staff interviews revealed confusion over responsibilities, and the medical record lacked documentation of compliance with the care plan.
A resident with multiple health conditions, including diabetes and myasthenia gravis, did not receive a necessary referral for cataract surgery despite a recommendation from an eye care group. The facility's policy required assistance in making appointments, which was not followed, as confirmed by the resident and the DON.
A resident with mild cognitive impairment and multiple diagnoses experienced two falls while attempting to use the bathroom independently. The facility's interventions, which included replacing non-skid strips and educating the resident to use the call light, were insufficient to prevent further falls. Staff were instructed to check on the resident every two hours, but no additional measures were implemented to prevent independent bathroom use.
The facility failed to implement dietician recommendations and follow physician orders for two residents, leading to deficiencies in nutritional care. One resident did not have weights recorded as ordered, and another experienced significant weight loss without proper adjustment of nutritional supplements. These actions were not in line with the facility's weight monitoring policy.
The facility failed to provide trauma-informed care for two residents with PTSD, as their care plans did not identify or address their triggers. One resident, who witnessed a family suicide, was not involved in care planning, and her triggers were not documented. Another resident with multiple psychiatric diagnoses exhibited behavioral symptoms, but her care plan lacked mention of PTSD triggers. The facility's policy on trauma-informed care was not reflected in the care plans, leading to inadequate management of PTSD symptoms.
A facility failed to document all administrations of a controlled medication on the MAR for a resident with multiple health conditions, leading to discrepancies between the CDRR and MAR. The resident was prescribed Oxycodone for pain management, but the number of doses signed out often exceeded those recorded on the MAR. The DON confirmed the documentation lapses.
The facility failed to ensure medication parameters were in place and followed for three residents receiving blood pressure medication. A resident's Metoprolol was held multiple times due to low blood pressure without notifying the physician. Another resident's carvedilol was not held as ordered before dialysis. A third resident received antihypertensive medications without hold parameters, and low blood pressure readings were not reported to the physician. The DON confirmed that parameters should have been in place and the physician notified.
A resident with multiple health conditions, including diabetes and high potassium levels, did not receive timely laboratory testing as ordered by a CNP. The repeat lab test was delayed by five days, as confirmed by the DON.
Failure to Use PPE During Mechanical Lift Transfer Under EBP
Penalty
Summary
The facility failed to wear appropriate personal protective equipment during a mechanical lift transfer of a resident who was on enhanced barrier precautions. Resident #17 was admitted and later readmitted with diagnoses including heart failure, chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, chronic kidney disease stage 3, chronic kidney disease stage 3, polyneuropathy, peripheral vascular disease, dysphagia, and lymphedema. The resident’s care plan directed staff to transfer the resident with two-person assist and use of a mechanical lift, and also required enhanced barrier precautions because of a feeding tube and wounds. The resident’s MDS indicated the resident was cognitively intact. During observation, the resident’s door displayed a sign for enhanced barrier precautions with guidance to wear PPE during transfers. CNAs #147 and #165 performed hand hygiene, donned gloves, entered the room, and then obtained gowns before placing the mechanical lift pad under the resident. After removing gown and gloves and performing hand hygiene, one CNA returned with clean linens while the other returned with the mechanical lift without applying new gown or gloves. The resident was then transferred from the bed to a specialized wheelchair, including movement into the hallway, without PPE being worn during the transfer. Both CNAs confirmed PPE was not worn during the transfer, and the Infection Preventionist confirmed PPE should have been worn during the resident’s transfer in the room.
Uncovered catheter bag visible from hallway
Penalty
Summary
The facility failed to ensure Resident #3 was treated with dignity when the resident’s indwelling urinary catheter collection bag was left uncovered and visible from the hallway. Resident #3 was initially admitted to the facility and later re-admitted on 12/23/25. The resident’s diagnoses included morbid obesity with alveolar hypoventilation, obstructive and reflux uropathy, major depressive disorder, retention of urine, hydronephrosis with ureteral stricture, and overactive bladder. The quarterly MDS assessment identified the resident as cognitively intact and having an indwelling catheter, and the care plan dated 08/25/25 included a privacy cover for the catheter drainage bag. Observations on 03/02/26 at 11:40 A.M., 03/03/26 at 7:41 A.M., and 03/03/26 at 5:28 P.M. showed the indwelling urinary catheter bag hanging on the left side of the bed without a privacy cover, with urine visible in the collection bag from the hallway. During the 03/03/26 5:28 P.M. observation, CNA #147 confirmed the catheter bag did not have a privacy cover and urine was visible from the hallway. The facility policy titled Catheter Care Procedure - Urinary states that privacy bags are used to cover catheter drainage bags while in use.
Failure to Provide Privacy During Incontinence Care
Penalty
Summary
The facility failed to provide privacy while incontinence care was being provided to one resident. Resident #22 was admitted on 01/06/23 and had diagnoses including cerebrovascular accident with left sided hemiplegia, dementia, convulsions, diabetes mellitus, chronic kidney disease, dysphagia, seizures, peripheral vascular disease, celiac artery compression syndrome, hypertension, insomnia, and anxiety disorder. The resident’s care plan identified bowel and bladder incontinence related to impaired mobility and physical limitations, with interventions to assist with toileting, check at regular intervals, change as needed, and provide perineal care after each incontinent episode with barrier cream. The resident’s MDS indicated no cognitive deficit and dependence on staff for toileting, with bladder incontinence always and bowel incontinence frequently. During an observation, an LPN provided incontinence care with the window blind open, facing another wing of the facility and within view of other residents’ windows with open blinds. The LPN confirmed the blind was not closed for privacy during the care, allowing adjacent hallway resident rooms to potentially view into the resident’s room. Facility policy required the room entrance door to be closed and the resident’s privacy to be provided during direct care.
Failure to Off-Load a Stage III Heel Pressure Ulcer
Penalty
Summary
The facility failed to provide off-loading for a stage III pressure ulcer on the left heel of Resident #21. The resident was admitted with multiple diagnoses including COPD, chronic respiratory failure, CHF, peripheral vascular disease, morbid obesity, neuropathy, edema, anemia, and other chronic conditions. The care plan identified impaired skin integrity and included interventions such as turning and repositioning, heel elevation off the mattress as tolerated, pressure redistribution devices, and wound care monitoring. The resident’s wound documentation showed a stage III pressure ulcer on the left lateral heel that was present on readmission and later described by the wound nurse practitioner as a reopened, healing stage III pressure ulcer. The wound measurements remained small but persistent across multiple assessments, with pink wound base and varying amounts of serosanguinous drainage. The wound nurse practitioner documented that staff were educated on the importance of off-loading to promote wound healing. During observations on multiple days, the resident was seen sitting in a wheelchair with the left heel resting on the floor and no off-loading in place for the heel wound. The DON verified that the resident had no off-loading to the stage III pressure ulcer while sitting in the wheelchair. The facility policy stated that wound treatment management was intended to promote wound healing using evidence-based treatments in accordance with current standards of practice and physician orders.
Delayed Podiatry Nail Care
Penalty
Summary
The facility failed to provide timely podiatry care for two residents who were dependent on staff for personal hygiene. Resident #30, who had diagnoses including spinal stenosis, diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis, muscle weakness, cognitive communication deficit, and major depressive disorder, was last seen by podiatry in the facility on 10/21/25. During observation and interview on 03/02/26, the resident had long toenails hanging over the skin and stated she wanted her toenails cut; she also said she had previously told an unknown staff member that her toenails needed to be cut. Resident #51, who had diagnoses including acute respiratory failure with hypoxia, Crohn's disease, end stage renal disease, muscle weakness, generalized anxiety, osteoarthritis, and congestive heart failure, was also observed on 03/02/26 with an ingrown toenail and toenails so long they were hanging over the skin. The resident stated the toenails were causing pain when wearing shoes. The SSD confirmed on 03/04/26 that podiatry had not visited the facility since 10/21/25, so Resident #51 had not yet been seen, and that both residents were to have their toenails clipped by podiatry services. The DON confirmed podiatry would typically trim toenails for residents and agreed it had been an extended period since the last toenail trims occurred. The facility policy stated routine nail care would be provided on a regularly and as needed basis.
Delayed Dental Follow-Up for Lost Dentures
Penalty
Summary
The facility failed to ensure timely dental services for a resident with no natural teeth and problems related to dentures. Resident #3 was admitted and later re-admitted to the facility, had multiple chronic conditions including chronic respiratory failure, COPD, type 2 diabetes, CHF, CKD stage 3, morbid obesity with alveolar hypoventilation, dysphagia, and dependence on supplemental oxygen, and was documented as cognitively intact. The resident’s MDS noted mouth or facial pain and discomfort or difficulty with chewing. The care plan identified the resident as at risk for dental problems related to no natural teeth and included referral to dental services as needed. Dental records showed impressions were obtained for dentures and later that upper and lower dentures were seated and fit well. A later dental note showed prior authorization for full dentures was submitted, but there was no further documentation or follow-up on that authorization. When observed, the resident was not wearing upper or lower dentures and reported being unable to find the lower dentures and having difficulty chewing at times. The Social Services Director confirmed the resident’s bottom dentures were lost, that the resident had last been seen by the dentist at the prior visit, and that the next fitting was scheduled about a year later, which was not considered timely.
Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to the improper storage and labeling of medications on the South Long Hall medication cart. During an observation, it was found that a registered nurse had pre-pulled morning medications for eight residents and placed them in individual medicine cups labeled with initials, storing them in the top drawer of the medication cart. The nurse admitted to pre-pulling the medications and acknowledged that this practice was not permitted. The Director of Nursing confirmed that medications should only be pulled at the time of administration and that pre-pulling is not allowed. The residents affected had a range of medical conditions, including diabetes, hypertension, chronic pain, dementia, epilepsy, and other chronic illnesses. Their care plans and physician orders required the administration of various medications, including controlled substances and medications for pain, blood pressure, anxiety, and other conditions. The medication administration records indicated that the medications were signed out as administered as ordered. However, the practice of pre-pulling and storing medications in cups outside of their original packaging and outside of locked compartments did not comply with accepted professional principles for medication storage and labeling. The deficiency was identified through record reviews, observations, and interviews with both the nurse involved and the Director of Nursing. The surveyors found that the medications for eight residents were not stored in accordance with regulations, as they were not kept in locked compartments and were not properly labeled. This practice affected eight out of 29 residents who received medications from the South Long Hall medication cart, in a facility with a census of 95.
Failure to Reposition and Transfer Resident as Ordered
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for assistance received the necessary turning, repositioning, and transferring to a chair as ordered by the physician. The resident, who had multiple medical diagnoses including cerebral palsy and cognitive impairments, was supposed to be placed in a chair from 10 A.M. to 2 P.M. daily and repositioned every two hours to prevent skin integrity issues. However, observations on a specific day revealed that the resident remained in the same position in bed for several hours, contrary to the physician's orders. Interviews with staff members, including a CNA and an LPN, confirmed that the resident required assistance with turning and repositioning. The CNA stated that she did not perform these tasks because the resident had a tube feed, indicating that the responsibility fell to the nurse. The LPN acknowledged the physician's orders and the need for regular repositioning but could not recall when the resident was last turned. Additionally, the facility's policy required all nursing staff to assist with turning and repositioning residents at risk of pressure injuries every two to four hours. Further review of the resident's medical record showed a lack of documentation to support that the resident was repositioned every two hours or placed in the chair as ordered. The facility's turning and repositioning policy emphasized the importance of alternating positions to prevent pressure injuries, yet the resident's care did not align with these guidelines. The Administrator and DON confirmed the absence of evidence in the medical record to indicate compliance with the physician's orders.
Failure to Facilitate Ophthalmology Referral for Cataract Surgery
Penalty
Summary
The facility failed to ensure a referral to an ophthalmologist for cataract surgery was made for a resident. The resident, who had intact cognition, was admitted with multiple diagnoses including type two diabetes mellitus, depression, anxiety, myasthenia gravis, dysphagia, personality disorder, and chronic respiratory failure. Her plan of care indicated she was at risk for visual impairment and included interventions such as arranging consultations with an eye care provider as needed. Despite a recommendation from an eye care group for cataract surgery through an ophthalmology consult, no referral was made from July to December. The deficiency was confirmed during an interview with the resident, who stated that the eye doctor informed her that the facility was supposed to follow up for her cataract surgery. The Director of Nursing verified that there had been a recommendation for a referral that was not completed. The facility's policy on 'Hearing and Vision Services' required that once vision services were identified, the resident should be assisted in making appointments and arranging transportation if needed, which was not adhered to in this case.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement timely interventions after a resident fall, affecting one resident out of three reviewed for falls. The resident, who had a mild cognitive impairment and multiple diagnoses including conversion disorder, intellectual disabilities, and dementia, experienced two falls while attempting to go to the bathroom independently. The first fall occurred on 09/30/24, and the intervention implemented was replacing non-skid strips in the bathroom and providing continued reminders and education on unassisted transfers and toileting. The second fall occurred on 11/08/24, and the intervention was to educate the resident to use the call light before and after using the toilet. Despite these interventions, the facility did not implement additional measures to prevent the resident from going to the bathroom independently or performing tasks in the bathroom without staff assistance. The only strategy to prevent the resident from going to the bathroom independently was educating her about asking for assistance. Interviews with the Director of Nursing and a Certified Nursing Aide confirmed that staff were instructed to check on the resident every two hours and to remind her to use the call light. However, these measures were not sufficient to prevent the resident from attempting to go to the bathroom on her own, leading to repeated falls.
Failure to Implement Dietician Recommendations and Follow Orders
Penalty
Summary
The facility failed to implement dietician recommendations and follow physician orders for two residents, leading to deficiencies in nutritional care. Resident #12, who had multiple medical diagnoses including chronic kidney disease and dysphasia, was on a mechanically altered and therapeutic diet. Despite having an order for weekly weight monitoring, the facility did not record weights on several occasions, as confirmed by the Director of Nursing (DON). This lack of adherence to the weight monitoring schedule was a significant oversight in the resident's care plan, which aimed to maintain the resident's weight and nutritional status. Similarly, Resident #74, with diagnoses including schizophrenia and chronic kidney disease, experienced a 6.9% weight loss in one month. The interdisciplinary team recommended increasing the Med Pass supplement and implementing weekly weight monitoring. However, the facility failed to adjust the Med Pass supplement as ordered and missed a scheduled weight check, resulting in a 15-day gap in weight tracking. These actions were not in line with the facility's policy on weight monitoring, which requires regular assessment and adjustment of interventions based on the resident's needs.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents, leading to deficiencies in addressing their PTSD triggers. Resident #73, who had a history of witnessing a family suicide, was not involved in care planning related to her PTSD diagnosis. Despite having intact cognition and being aware of her triggers, such as gunshots and loud noises, these were not documented or addressed in her care plan. The Social Services Director was unaware of the nature and source of her PTSD, and the care plan lacked specific interventions to manage her condition effectively. Similarly, Resident #43, who had multiple psychiatric diagnoses including PTSD, was not provided with a care plan that identified or addressed her triggers. Despite exhibiting verbal behavioral symptoms and rejection of care, her care plan did not include any mention of PTSD triggers. The Social Services Director confirmed that there was no attempt to identify or document triggers in the care plan, which hindered the effective management of her PTSD symptoms. The facility's policy on trauma-informed care emphasized the need for culturally competent care that accounts for residents' experiences and preferences to prevent re-traumatization. However, the care plans for both residents did not reflect this policy, as they lacked individualized approaches and interventions to address their PTSD triggers. This oversight resulted in a failure to provide adequate trauma-informed care for the affected residents.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that as-needed controlled medications were accurately recorded on the Medication Administration Record (MAR) when administered to a resident. This deficiency was identified through interviews, record reviews, and policy reviews, affecting one resident who was being managed for pain. The resident, who had intact cognition, was admitted with multiple diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. The resident's care plan included administering medications as ordered and attempting non-pharmacological interventions prior to medication administration. Discrepancies were found between the Controlled Drug Receipt Record (CDRR) and the MAR for the administration of Oxycodone, a controlled narcotic analgesic prescribed for the resident's pain management. On multiple occasions, the number of doses signed out on the CDRR did not match the doses recorded on the MAR. For example, on several dates in November and December, more doses were signed out on the CDRR than were documented on the MAR. The Director of Nursing confirmed that the nursing staff had not documented all administrations of the resident's Oxycodone on the MAR.
Failure to Follow Medication Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to ensure that medication parameters were in place and followed for three residents receiving blood pressure medication. Resident #69, who had diagnoses including hypertension and intact cognition, was administered Metoprolol Tartrate without specific parameters for holding the medication. The medication was held multiple times due to low blood pressure readings, but there was no documentation that the physician was notified of these actions. The Director of Nursing (DON) confirmed that parameters should have been in place and that the physician should have been informed. Resident #34, with diagnoses including end-stage renal disease and intact cognition, was prescribed carvedilol to be held prior to dialysis sessions. However, the medication was not held as ordered on several occasions. The DON verified that the medication was not held according to the physician's orders, indicating a failure in following the prescribed medication regimen. Resident #79, who had diagnoses including hypertension and was cognitively intact, was receiving multiple antihypertensive medications without hold parameters. The resident's blood pressure readings were sometimes below the threshold that would require holding the medication, yet the medications were administered without notifying the physician. The DON confirmed that parameters should have been in place and that the physician should have been notified of low blood pressure readings and held medications.
Failure to Timely Conduct Ordered Lab Tests
Penalty
Summary
The facility failed to complete laboratory testing as ordered by the physician for a resident, affecting one of two residents reviewed for hydration. The resident, who had intact cognition, was admitted with multiple diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. A review of the resident's laboratory results revealed a high potassium level of 5.6 mEq/L. Following this, a Certified Nurse Practitioner (CNP) ordered Kayexalate and a repeat lab test to be conducted the next day. However, the repeat lab test was not conducted until five days later, as confirmed by the Director of Nursing (DON).
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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 Carroll
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luxe Rehabilitation And Care Center | 2.4 mi | ★★★★★ | 3 | 0 |
| The Springs At Wyandot Trail | 4.5 mi | ★★★★★ | 9 | 0 |
| Lanfair Center For Rehab & Nsg Care Inc | 5.8 mi | ★★★★★ | 0 | 0 |
| Main Street Terrace Care Center | 5.8 mi | ★★★★★ | 14 | 0 |
| Buckeye Care And Rehabilitation | 6.6 mi | ★★★★★ | 23 | 0 |
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