F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews, observations and interviews, the facility failed to ensure safe storage and labeling of
medications. This affected eight residents (#49, #56, #57, #58, #62, #63, #68 and #70) of 29 who received
medications for the medication cart on South Long Hall. The facility census was 95.Findings include: 1.
Review of Resident # 49's medical record revealed she was admitted on [DATE] with diagnoses including
lumbar spinal stenosis, diabetes type two, low back pain, idiopathic neuropathy, and hypertension. Review
of the care plan dated 02/06/25 revealed Resident #49 had an impaired musculoskeletal status related to
spinal stenosis and osteoarthritis with interventions including administering medications as ordered. In
addition, Resident #49 was at risk for pain related to limited mobility, comorbidities with interventions
including administering medications per orders and observing for side effects and effectiveness.Review of
Resident #49's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The
resident was dependent on staff for toileting and required set-up assistance for eating.Review of Resident
#49's physicians orders dated 09/25/25 revealed orders for Aspirin Low Dose Oral Tablet Chewable 81
milligrams (mg) (blood thinner); give one tablet by mouth in the morning, Cyanocobalamin (Vitamin B)
Tablet 500 micrograms (mcg); give one tablet by mouth in the morning, Lisinopril (medication for high blood
pressure) Oral Tablet 40 mg; give one tablet by mouth in the morning, Meloxicam (medication for pain and
inflammation) Oral Tablet 7.5 mg; give one by mouth in the morning, Metformin HCL (hydrochloride)
(medication to control high blood sugars) Oral Tablet 500 mg; give one tablet by mouth every morning and
at bedtime, Metoprolol Tartrate (medication for high blood pressure) Oral Tablet 50 mg; give one tablet by
mouth every morning and at bedtime and Oxycodone HCL (Opioid analgesic used to treat moderate to
severe pain) Oral Tablet 5 mg; give 5 mg by mouth every morning and at bedtime.Review of Resident # 49‘s
Medication Administration Record (MAR) dated 09/25/25 revealed, Registered Nurse (RN) #521 signed the
following medications were administered as ordered; Aspirin 81mg, Cyanocobalamin 500 mcg, Lisinopril 40
mg, Meloxicam 7.5 mg, Metformin 500 mg, Metoprolol Tartrate 50 mg and Oxycodone HCL 5 mg.2. Review
of Resident #56's medical record revealed she was admitted on [DATE] with diagnoses including
hypertension, anxiety, chronic pain, bipolar disorder, depression, and rheumatoid arthritisReview of the
care plan dated 03/11/25 revealed the following care plans: Resident #56 was at risk for impaired cognitive
function related to bipolar disorder with an intervention to administer medications as ordered. Resident #56
had an impaired metabolic status related to diabetes with an intervention to administer medications and
treatments as ordered. Resident #56 had anxiety/restless, delusions with an intervention to administer
medications as ordered, and Resident #56 had an impaired musculoskeletal status related to rheumatoid
arthritis with an intervention to administer
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
365474
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365474
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Carroll
3680 Dolson Court NW
Carroll, OH 43112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
medications as ordered.Review of Resident #56's MDS 3.0 assessment dated [DATE] revealed a BIMS
score of 15 out of 15, indicating the resident was cognitively intact. The resident was assessed to require
assistance with showers and bathing and set up assistance for eating.Review of Resident #56's physicians
orders dated 09/25/25 revealed orders for Alprazolam (medication for anxiety) Tablet 0.25 mg; give one
tablet by mouth three times a day for anxiety, Amlodipine (medication for high blood pressure) Oral Tablet 5
mg; give 5 mg by mouth in the morning, Baclofen (medication for muscle relaxant) Oral Tablet 5 mg; give 5
mg by mouth three times a day, Buspirone HCL (used for anxiety) Oral Tablet 30 mg; give one tablet by
mouth every morning and at bedtime, Cholecalciferol ( Vitamin D) Oral Capsule; give 125 mcg by mouth in
the morning, Lamictal (medication for seizures and mood stabilizer) Oral Tablet 100 mg; give one tablet by
mouth every morning and at bedtime, Metoprolol Succinate ER (used for high blood pressure) Oral Tablet
25 mg; give two tablets by mouth in the morning, Plaquenil ( medication for rheumatoid arthritis) 200 mg;
give two tablets by mouth in the morning, Senna Plus ( medication for constipation) Oral Tablet 8.6/50 mg;
give one tablet by mouth in the morning and Venlafaxine HCL ER (medication for depression) Oral Tablet
150 mg; give one tablet by mouth one time a day.Review of Resident #56's MAR dated 09/25/25 revealed
RN #521 signed the following medications were administered as ordered; Alprazolam 0.25 mg, Amlodipine
5 mg, Baclofen 5 mg, Buspirone HCL 30 mg, Cholecalciferol 125 mcg, Lamictal 100mg, Metoprolol
Succinate 25 mg, Plaquenil 200 mg, Senna Plus 8.6/50 mg and Venlafaxine HCL ER 150 mg.3. Review of
Resident #57's medical record revealed she was admitted on [DATE] with diagnoses including
hypertension, dementia, anxiety, and muscle weakness.Review of the care plan dated 07/10/25 revealed
the following care plans: Resident #57 had behaviors related to dementia with an intervention to administer
medications as ordered, and Resident #57 had impaired cognitive function with an intervention to
administer medications as ordered.Review of Resident #57's MDS 3.0 assessment dated [DATE] revealed
a BIMS of 3 of 15, indicating severe cognitive impairment. The resident was assessed to require dependent
assistance with toileting, dressing and personal hygiene and set up assistance for eating.Review of
Resident #57's physicians orders dated 09/25/25 revealed orders for Amlodipine Besylate (medication for
high blood pressure) Oral Tablet 5 mg; give one tablet by mouth in the morning, Cimetidine ( medication to
reduce stomach acid) Oral Tablet 200 mg; give 200 mg by mouth in the morning, Lisinopril ( medication for
high blood pressure) Oral Tablet 20 mg; give one tablet by mouth in the morning and Tizanidine HCL
(muscle relaxant) Oral Tablet 2 mg; give 2 mg by mouth every morning.Review of Resident # 57‘s MAR
dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered;
Amlodipine 5mg, Cimetidine 200 mg, Lisinopril 20 mg and Tizanidine HCL 2 mg.4. Review of Resident
#58's medical record revealed she was admitted on [DATE] with diagnoses including congestive heart
failure, anxiety, depression, bladder disorder, hypertension, epilepsy and gastro-esophageal reflux
disease.Review of Resident #58's MDS 3.0 assessment dated [DATE] revealed the resident was assessed
to require assistance with toileting and personal hygiene. She was identified as cognitively impaired by
staff.Review of the care plan 09/25/25 revealed the following care plans: Resident #58 had an impaired
neurological status related to epilepsy, with an intervention to administer medications as ordered, and
Resident #58 had impaired cognitive function related to fluctuations in cognition at times, with an
intervention to administer medications per order, and observe for side effects and effectiveness.Review of
Resident #58's physicians orders dated 09/25/25 revealed orders for Aspirin Oral Tablet Chewable 81mg;
give one tablet by mouth in the morning, Buspirone HCL (medication for anxiety) Oral Tablet 10 mg; give
one tablet by mouth three times a day, Cholecalciferol (Vitamin D) Tablet 1000 mg; give one tablet by mouth
in the morning, Famotidine (medication for stomach acid) Oral Tablet 20 mg; give two tablets by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365474
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365474
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Carroll
3680 Dolson Court NW
Carroll, OH 43112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
mouth in the morning, Ferrous Sulfate (Iron Supplement) Oral Tablet 325 mg; give one tablet by mouth
three times a day, Furosemide (medication used for fluid retention and high blood pressure) Oral Tablet 20
mg; give one tablet by mouth in the morning, Guaifenesin ( medication for congestion) ER 600 mg tablet;
give one tablet by mouth every morning, Lactobacillus ( Probiotic) Oral Tablet; give one capsule by mouth in
the morning, Metoprolol Tartrate (medication for high blood pressure) Oral Tablet 25 mg give one tablet by
mouth in the morning and at bedtime, Oxybutynin ( medication for overactive bladder) Chloride Oral Tablet
5 mg; give one tablet by mouth in the morning, Potassium Chloride Crys ER Oral Tablet 10 MEQ (
milliequivalents); give 10 MEQ by mouth in the morning and Sertraline ( medication for depression) HCl
Oral 100 mg; give one tablet by mouth in the morning.Review of Resident #58's MAR dated 09/25/25
revealed RN #521 signed the following medications were administered as ordered; Aspirin 81mg,
Buspirone HCL 10 mg, Cholecalciferol 1000 mg, Famotidine 20 mg, Ferrous Sulfate 325 mg, Furosemide
20 mg, Guaifenesin ER 600 mg, Lactobacillus, Metoprolol Tartrate, Oxybutynin Chloride, Potassium
Chloride ER 10 MEQ and Sertraline 100 mg.5. Review of Resident #62's medical record revealed she was
admitted on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary
disease, gastro-esophageal reflux disease, depression and hypertension.Review of the care plan dated
06/25/25 revealed the following care plans: Resident #62 had an impaired metabolic status with an
intervention to administer medications and treatments as ordered, and Resident #62 was at risk for fluid
volume deficit with an intervention to administer medications as ordered.Review of Resident #62's MDS 3.0
assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively
intact. The resident was assessed to require assistance with bathing and dressing and set up assistance for
eating.Review of Resident #62‘s physicians orders dated 09/25/25 revealed orders for Cyanocobalamin
(Vitamin B12) Tablet 500 mcg; give one tablet by mouth in the morning, Famotidine (medication for stomach
acid) Oral Tablet 20 mg; give one tablet in the morning, Folic Acid Oral Tablet 1 mg; give one tablet by
mouth in the morning, Furosemide (medication used for fluid retention and high blood pressure) Oral Tablet
40 mg; give one tablet by mouth in the morning and Vitamin D3 Oral Tablet 25 mcg; give one tablet by
mouth in the morning.Review of Resident #62's MAR dated 09/25/25 revealed RN #521 signed the
following medications were administered as ordered; Cyanocobalamin 500 mcg, Furosemide 40 mg,
Famotidine 20 mg, Folic Acid 1 mg and Vitamin D3 25 mcg.6. Review of Resident #63's medical record
revealed she was admitted on [DATE] with diagnoses including diabetes mellitus, malignant neoplasm of
left breast, anxiety, osteoarthritis, dementia, Alzheimer's disease, depression, hypertension and cerebral
infarction with left hemiplegia.Review of the care plan dated 03/31/25 revealed the following care plans:
Resident #63 had an impaired neurological status with an intervention to administer medications and
treatments as indicated by orders, and Resident #63 had an impaired mood/psychiatric status with an
intervention to administer medications and treatments as ordered.Review of Resident #63's MDS 3.0
assessment dated [DATE] revealed a BIMS score of 08 out of 15, indicating moderate cognitive impairment.
The resident was assessed to require dependent assistance with toileting, dressing and personal hygiene
and set up assistance for eating.Review of Resident #63's physicians orders dated 09/25/25 revealed
orders for Aspirin Tablet Chewable 81 mg; give one tablet by mouth in the morning, Actos (medication to
control blood sugars) Tablet 45 mg; give one tablet by mouth in the morning, Anastrozole (medication for
breast cancer) Tablet 1 mg; give one tablet by mouth in the morning, Buspirone HCL (medication for
anxiety)Tablet 15 mg; give one tablet by mouth three times a day, Calcium Carbonate Tablet Chewable 500
mg; give one tablet by mouth three times a day, Dailyvite Vitamin D 125 mcg Capsule. Give one capsule by
mouth in the morning, Famotidine (medication used for stomach acid) Oral Tablet 20 mg; give one tablet by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365474
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365474
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Carroll
3680 Dolson Court NW
Carroll, OH 43112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
mouth in the morning every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday, Galantamine
Hydrobromide (medication used for Alzheimer's disease) Oral Tablet 4 mg; give one tablet by mouth two
times a day, Januvia ( medication used for high blood sugars) Tablet 100 mg; give one tablet by mouth in
the morning, Lactobacillus Rhamnosus (Probiotic) Tablet Chewable; give one unit by mouth every morning
and at bedtime, Lamictal (medication used for seizures and mood stabilizer) Oral Tablet 100 mg; give 100
mg by mouth in the morning, Lorazepam (medication used for anxiety) Tablet 1 mg; give one tablet by
mouth three times a day, Meloxicam (medication used for inflammation) Tablet 7.5 mg; give one tablet by
mouth in the morning, Metformin (medication used for high blood sugars) HCL Tablet 1000 mg; give one
tablet by mouth two times a day, Multiple Vitamin Tablet; give one tablet by mouth in the morning, Norvasc
(medication used for high blood pressure) Tablet 5 mg; give one tablet by mouth in the morning,
Oxycodone- Acetaminophen (medication used for moderate to severe pain) Tablet 5-325 mg; give one
tablet by mouth three times a day and Venlafaxine (medication used for depression) HCL Oral Tablet 75 mg;
give 75 mg by mouth every morning and at bedtime.Review of Resident # 63's MAR dated 09/25/25
revealed RN #521 signed the following medications were administered as ordered; Actos 45mg,
Anastrozole 1 mg, Aspirin 81 mg, Buspirone 15 mg, Calcium Carbonate 500 mg, Dailyvite 5000 mcg,
Famotidine 20 mg, Galantamine Hydrobromide 4 mg, Januvia 100 mg, Lactobacillus Rhamnosus, Lamictal
100 mg, Lorazepam 1 mg, Meloxicam 7.5 mg, Metformin 1000 mg, Multiple Vitamin, Norvasc 5 mg,
Oxycodone- Acetaminophen 5-325 mg and Venlafaxine 75 mg.7. Review of Resident #68's medical record
revealed she was admitted on [DATE] with diagnoses including Parkinsonism, hyperlipidemia,
gastro-esophageal reflux disease and asthma.Review of the care plan dated 05/19/25 revealed the
following care plans: Resident #68 had an impaired metabolic status with an intervention to administer
medications and treatments as ordered, and Resident #68 had an impaired neurological status with an
intervention to administer medications and treatments as indicated by orders.Review of Resident #68's
MDS 3.0 assessment dated [DATE] revealed a BIMS of 13 out of 15, indicating the resident was cognitively
intact. The resident was assessed to require assistance with dressing and personal hygiene and set up
assistance for eating.Review of Resident #68's physicians orders dated 09/25/25 revealed orders for
Carbidopa- Levodopa (medication used for Parkinson's symptoms) Oral Tablet 25-100 mg; give three
tablets by mouth in the morning, Docusate Sodium (stool softener) Oral Tablet 100 mg; give one tablet by
mouth in the morning, Multivitamin Oral Tablet; give one tablet by mouth in the morning; Omeprazole
(medication used for stomach acid) Oral Tablet Delayed Release 20 mg; give one tablet by mouth every
morning and at bedtime, Potassium Chloride Crys ER Oral Tablet 10 MEQ; give one tablet by mouth in the
morning, Rosuvastatin (medication used for high cholesterol) Calcium Oral Tablet 20 mg; give one tablet by
mouth in the morning and Zyrtec Allergy Oral Tablet; give 10 mg by mouth in the morning.Review of
Resident #68's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered
as ordered; Carbidopa- Levodopa 25-100mg, Calcium 20 mg, Zyrtec 10 mg, Potassium Chloride 10 MEQ,
Docusate Sodium 100 mg, Multivitamin, Omeprazole 20 mg and Rosuvastin 20 mg.8. Review of Resident
#70's medical record revealed she was admitted on [DATE] with diagnoses including anemia, epilepsy,
chronic kidney disease and depression.Review of the care plan dated 08/15/25 revealed the following care
plans: Resident #70 had behaviors with an intervention to administer medications as ordered, and Resident
#70 was at risk for pain with an intervention to administer medications per orders and observe for side
effects and effectiveness.Review of Resident #70's MDS 3.0 assessment dated [DATE] revealed a BIMS
score of 08 out of 15, indicating moderate cognitive impairment. The resident was assessed to require
dependent assistance with toileting, dressing and bathing. Review of Resident #70's physicians orders
dated 09/25/25 revealed orders for Cholecalciferol (Vitamin D) Tablet
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365474
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365474
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arbors at Carroll
3680 Dolson Court NW
Carroll, OH 43112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
1000 units; give two tables by mouth in the morning, Ferrous Sulfate Oral Tablet 325 mg; give one tablet by
mouth one time a day, Folic Acid Oral Tablet 400 mcg; give one tablet by mouth in the morning, Gabapentin
(medication used to treat seizures and nerve pain) Oral Capsule 300 mg; give one capsule by mouth three
times a day, Levetiracetam (medication used to treat seizures) Oral Tablet 750 mg; give one tablet by mouth
every morning and at bedtime, Magnesium Oxide Oral Tablet 400 mg; give one tablet by mouth in the
morning, Pristiq (medication used to treat depression) Oral Tablet Extended Release 50 mg; give one tablet
by mouth in the morning and Tylenol Extra Strength (ES) Oral Tablet 500 mg; give 1000 mg by mouth every
morning and at bedtime.Review of Resident #70's MAR dated 09/25/25 revealed RN #521 signed the
following medication were administered as ordered; Pristiq 50 mg, Tylenol ES 500 mg, Cholecalciferol 1000
units, Ferrous Sulfate 325 mg, Folic Acid 400 mcg, Gabapentin 300 mg, Levetiracetam 750 mg and
Magnesium Oxide 400 mg.Observation on 09/25/25 at 8:18 A.M of South Long Hall nursing medication cart
with RN #521 revealed eight medicine cups in the top drawer with initials on them. RN #521 revealed the
filled medicine cups belonged to Residents #49, #56, #57, #58, #62, #63, #68 and # 70. Interview on
09/25/25 at 8:20 A.M. with RN #521 revealed she had pre-pulled the morning medications for the eight
residents and placed the medicine cups in the top drawer to dispense later. Further interview with RN #521
revealed she was not allowed to have pre-pulled medicine. RN stated, I know I'm not allowed to pre pull
meds like that, I'm really not supposed to do that. RN #521 also verified all the medications in each
medicine cup for each of the eight residents.Interview on 09/29/25 at 11:30 A.M. with the Director of
Nursing (DON) revealed nurses should pull medications at the time they are administering them to the
resident, they are not allowed to pre pull medications.This deficiency represents non-compliance
investigated under Complaint Number 2614688.
Event ID:
Facility ID:
365474
If continuation sheet
Page 5 of 5