Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 1 | 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 | — | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.