Ascension Living Carroll Manor

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Rule F0584. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Rule F0686. H: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

Rule F0628. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Assist a resident in gaining access to vision and hearing services.

Rule F0685. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Provide or get specialized rehabilitative services as required for a resident.

Rule F0825. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 16, 2026.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Rule F0803. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 28, 2026.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Rule F0804. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 28, 2026.

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Rule F0836. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 11, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Jan 11, 2025.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Rule F0607. D: no actual harm, potential for more than minimal harm. From a complaint.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Rule F0623. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 11, 2025.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Rule F0625. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 11, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Assist a resident in gaining access to vision and hearing services.

Rule F0685. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide safe, appropriate pain management for a resident who requires such services.

Rule F0697. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Rule F0725. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being.

Rule F0726. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 11, 2025.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Rule F0756. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide routine and 24-hour emergency dental care for each resident.

Rule F0790. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status.

Rule F0887. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.

Keep all essential equipment working safely.

Rule F0908. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 15, 2024.