Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview, and policy review, the facility failed to ensure a resident received a clear, liquid
diet, as ordered by the physician, prior to a scheduled colonoscopy (a medical procedure used to examine
the rectum and colon for abnormalities). This affected one resident (#44) of two residents reviewed for
discharge. The facility census was 40.
Residents Affected - Few
Findings include:
Review of the closed medical record revealed Resident #44 was admitted to the facility on [DATE] with
diagnoses including malignant neoplasm of sigmoid colon, dementia, weakness, and diabetes mellitus. The
resident was discharged on 03/24/25 after leaving the facility against medical advice (AMA).
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/18/24, revealed Resident #44
had moderately impaired cognition. The resident required set-up staff assistance for eating.
Review of a physician order, dated 03/11/25, revealed the order for a clear liquid diet only on 03/24/25 for
colonoscopy scheduled on 03/25/25.
Review of nursing progress note, dated 03/24/25 at 9:30 A.M., revealed a message was left for the
physician regarding Resident #44 to be on a clear liquid diet on this date, however, resident had three bites
of a breakfast sandwich at 7:30 A.M., 24 hours prior to colonoscopy. Asking if colonoscopy should be
rescheduled or if this will be okay due to it being 24 hours prior to colonoscopy. Awaiting a return call.
Review of nursing progress note, dated 03/24/25 at 10:09 A.M., revealed Resident #44's daughter stated
she had spoken with the surgeon, and he said the colonoscopy could not be done due to the resident
eating bites of a sandwich. This nurse notified the nurse practitioner that the resident's daughter was taking
her home against medical advice (AMA). The resident and daughter refused to sign any discharge
paperwork.
Interview on 05/06/25 at 11:56 A.M. with the Director of Nursing (DON) revealed an activities aide gave
Resident #44 a sandwich in the dining room after she requested food. The DON stated the activities aide
should have made sure the resident was allowed food prior to giving her any. The DON stated following the
incident, the dietary staff were educated on the policy and procedures that are needed when there is a
dietary order in place for clear liquids. If a staff member asks for a resident to have food or drink, they
should immediately call a member of the administrative nursing staff to ensure that an order is still in place
or has it changed.
(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 6
Event ID:
365579
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
365579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carroll Healthcare Center Inc
648 Longhorn Street
Carrollton, OH 44615
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 0684
Review of the facility's policy titled, Clear Liquid and Full Liquid Diet Supplies, undated, revealed individuals
will be provided with a liquid diet when needed. A physician order is required.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365579
If continuation sheet
Page 2 of 6
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
365579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carroll Healthcare Center Inc
648 Longhorn Street
Carrollton, OH 44615
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record and interview with staff the facility failed to ensure new nutritional interventions
were attempted for a resident with altered nutrition. This affected one resident (#5) of two reviewed for
nutrition.
Residents Affected - Few
Findings included:
Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses
included major depressive disorder, dementia, Alzheimer's disease, pre-glaucoma, macular degeneration,
cystic mastopathy of the breast, hyperlipidemia, and intermittent explosive disorder.
Review of the plan of care dated 07/04/24 revealed Resident #5 had a potential risk for altered nutrition
related to declining meals, makes meal selections meal to meal, snack requests and purchases with poor
dietary lifestyle, counsel possibly related to irreversible cognitive deficit that denies educational reward or
benefits given her inability to comprehend, process and retain information, history of food group refusals
and can be easily agitated with attempts to discuss weight and nutrition, history of dementia, Alzheimer's
disease, diabetes, anemias, declines to be weighed at times, declines medications, declines meals and
menu service yet will submit order on her terms and get food from out of the facility deliveries and snack
shop. Her usual body weight was 143 to 152 pounds. She fluctuates loss with rebounding gains which have
kept her stable despite intakes recorded a choice of dietary lifestyle. Interventions included diet, education,
gentle reminders, denture adhesive strips for her lower dentures, encourage adequate oral intake, educate
and encourage need for nutritional supplement, encourage oral intake at meals, cater to known preferences
at meals and snacks to promote consumption at the resident's level of ability and choice, food and fluid
preferences updated and on tray card as needed, honor food preferences and dietary lifestyles of her
choosing, medical nutritional therapy orders, monitor acceptance of diet order, monitor weight loss and gain
every month, notify the physician of changes as needed, observe and document daily meal intakes, and
offer substitutions.
Review of the Nutritional Note dated 01/09/25 revealed Resident #5 did show a loss trend which was
unplanned but was not a significant change. Resident #5 had a bout of illness with suboptimal intakes but
was rebounding.
Review of the February 2025 Meal Intake documentation revealed Resident #5 ate 76 to 100 percent of all
meals with two refusals.
Review of the March 2025 Meal Intake documentation revealed Resident #5 ate 76 to 100 percent of all
meals with two refusals.
Review of the April 2025 Meal Intakes documentation revealed Resident #5 ate 76 to 100 percent of all
meals with five refusals.
Review of the nutritional assessment dated [DATE] revealed the current body weight for Resident #5 was
132 pounds for a loss of three percent in three months and seven percent in six months. Summary included
the dietitian would monitor as needed her nutrient intake, skin condition and laboratory results. Her oral
intake was 88 percent.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365579
If continuation sheet
Page 3 of 6
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
365579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carroll Healthcare Center Inc
648 Longhorn Street
Carrollton, OH 44615
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #5 had intact cognition with
behaviors. Resident #5 was independent with eating and weighed 132 pounds with no loss or gain of
weight.
Review of the Nutritional Note dated 04/17/25 at 2:28 P.M. revealed Resident #5 was on a regular diet with
an oral intake of 88 percent, current body weight was 132 with her ideal body weight being 110, and body
mass index was 22.6. She was down a negative 7.04 percent in six months.
Review of the weights in the medical record revealed Resident #5 weighed 142.2 pounds on 11/02/24, 140
pounds on 12/04/24, 135.8 pounds on 01/01/25, 132.2 pounds on 02/02/25, 132.4 pounds on 03/02/25,
132.4 pounds on 04/02/25 and 129.6 pounds on 05/05/25 for a weight loss of negative 8.9 percent in six
months with no new nutritional intervention in place.
Review of the May 2025 physicians' orders revealed Resident #5 had a regular diet and the staff were to
encourage fluids dated 04/25/25. However, she had no new nutritional interventions in place.
On 05/07/25 at 2:10 P.M. an interview with Dietitian #215 revealed she came to the facility every Thursday.
She stated she received resident weights from the electronic record. She stated the computer will trigger a
warning if someone was a weight loss of more than three percent. She stated the weight for Resident #5
cycles up and down. She stated she did not have any clinical reason to have concerns with the resident's
weight loss. She verified Resident #5 had lost weight from 140.0 on 12/04/24 to 132.2 on 02/02/25 with no
new nutritional interventions put into place. She stated Resident #5 had a history of her weight going up
and down so she did not feel there was a need for an intervention. She stated Resident #5's weight was
stable from 02/02/25 through 04/02/25. She stated Resident #5 refused meals and snacks however she
verified she documented the resident ate 88 percent of her meals which was good. She stated she received
food from outside the facility, and she would buy snacks from the activity department. She stated she had
spoken to the dietary staff, and they attempt to cater to the resident's wants and what she wants to eat. She
stated she has been following Resident #5 for years and she was unique case, and she may have gotten
lackadaisical with her documentation. She verified that 129 pounds was the lowest weight Resident #5 had
been, but she was also up walking around more.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365579
If continuation sheet
Page 4 of 6
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
365579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carroll Healthcare Center Inc
648 Longhorn Street
Carrollton, OH 44615
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, medical record review, policy review and staff interview the facility failed to ensure
infection control protocols were implemented when a urinary drainage collection device was kept off the
floor. This affected one resident (#98) of one residents reviewed for indwelling urinary catheter use.
Residents Affected - Few
Findings include:
Observations on 05/05/25 at 11:50 A.M. revealed Resident #98 sitting in a wheelchair in his room, a urinary
collection bag was observed attached underneath the wheelchair and was touching the floor.
Additional observation on 05/06/25 at 8:21 A.M. and again at 10:19 A.M. again revealed the resident sitting
in a wheelchair with the urinary collection bag under the wheelchair and touching the floor.
Review of Resident #98's medical record revealed an admission date of 05/04/25 with diagnoses that
included urinary retention, flaccid neuropathic bladder, obstructive and reflux uropathy and benign prostate
hypertrophy.
Review of physician's orders revealed on 05/05/25 revealed the use of a indwelling urinary catheter to
continuous gravity due to urinary obstruction.
Review of the facility policy Catheter Care, Urinary revised September 2014 indicated to keep catheter
tubing and drainage bag off the floor.
On 05/06/25 at 10:28 A.M. interview with Certified Nurse Aide (CNA) #211 verified the urinary collection
bag was touching the floor and should be kept off of the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365579
If continuation sheet
Page 5 of 6
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
365579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carroll Healthcare Center Inc
648 Longhorn Street
Carrollton, OH 44615
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, hospital record review, policy review and staff interview the facility failed to
ensure appropriate indications for use of an antibiotic for Resident #101. This affected one resident (#101)
of six residents reviewed for antibiotic use.
Residents Affected - Few
Findings include:
Review of Resident #101's medical record revealed an admission date of 04/27/25 with diagnoses that
included fall with left tibia fracture, diabetes mellitus, congestive heart failure and atrial fibrillation.
Further review of the medical record including an admission minimum data set (MDS) 3.0 assessment with
a reference date of 05/03/25 revealed the resident had an independent and intact cognition level. Additional
review of the medical record including physician's orders revealed on 04/29/25 cefdinir (antibiotic) 300
milligrams (mg) twice daily was initiated due to leukocytosis (elevated white blood cell level). Additionally, on
05/01/25 the resident was prescribed cipro 250 mg twice daily for a urinary tract infection. The cefdinir was
discontinued when started on cipro.
Review of the Certified Nurse Practitioner (CNP) #266 evaluation on 04/29/25 revealed an evaluation for an
elevated white blood cell level of 14.1 k/uL (kilo per microliter) from admission bloodwork. No evidence of
any signs or symptoms of infection were reported by Resident #101. CNP #266 initiated the use of cefdinir
300 mg twice daily and ordered a urinalysis with culture and sensitivity to be obtained.
Review of the hospital admission information for Resident #101 revealed white blood cell levels of 13.4 k/uL
on 04/26/25 and 14.9 k/uL on 04/25/25.
Review of the urinalysis with culture and sensitivity results obtained on 05/01/25 revealed a positive urine
culture of Enterobacter cloacae complex >100,000 colony-forming units per milliliter (cfu/ml).
Review of the infection screening evaluation completed on 04/30/25 revealed no evidence of any signs or
symptoms of fever, pain, confusion or other symptoms of active infection. The infection screening evaluation
did not indicate if met or did not meet criteria for use of an antibiotic. There was no evidence of an infection
screening evaluation completed for the use of cipro on 05/02/25.
On 05/07/25 at 2:30 P.M. interview with the Director of Nursing and Registered Nurse (RN) #224 verified
Resident #101 did not meet criteria for use of antibiotics prescribed on 04/29/25 and 05/01/25.
Review of the facility policy Antibiotic Stewardship - Orders for Antibiotics revised December 2016 indicated
antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic
Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and
Prescribing. Appropriate indications for use of antibiotics include: criteria met for clinical definition of active
infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365579
If continuation sheet
Page 6 of 6
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0241GeneralS&S Epotential for harm
Have correct number of accessible exits for each story.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
FAQ · About this visit
Common questions about this visit
What happened during the May 8, 2025 survey of CARROLL HEALTHCARE CENTER INC?
This was a inspection survey of CARROLL HEALTHCARE CENTER INC on May 8, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARROLL HEALTHCARE CENTER INC on May 8, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.