Caroleton Healthcare Center
CAROLETON HEALTHCARE CENTER in CONNERSVILLE, IN — inspection on April 24, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the meeting the council indicated they were unaware of the location of the most recent survey results. On 4/22/26 at 10:14 a.m., an observation of the facility survey binder was made.
The binder was located in a bin attached to the wall by the entrance to the facility.
There was a sign, informing survey results availability posted above the survey binder.
Neither the binder nor the sign were at wheelchair level. On 4/22/26 at 12:40 p.m., an observation of the survey binder and posting were made with Resident 18, the co-president of resident council, and the Executive Director (ED).
The ED assisted Resident 18 in her wheelchair to the location of the survey binder. Resident 18 was unable to reach the binder without assistance and indicated she could not read the posting above it. An interview was conducted with the ED on 4/22/26 at 12:40 a.m., immediately after the above observation.
She indicated she would have maintenance staff to move the survey binder and posting to a location more accessible to the residents. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(b)(1)
During an interview with Licensed Practical Nurse (LPN) 6 on 4/22/2026 at 12:50 p.m., the LPN indicated the nurse was responsible to ensure Resident 4 had the correct catheter size in place. LPN 6 reviewed Resident 4's physician order and indicated he was supposed to have a size 20 French catheter in place (medium to large diameter medical tube measuring approximately 6.66 millimeters in external diameter). LPN 6 indicated Resident 4's catheter was last changed on 4/19/26.
During an interview with LPN 6 on 4/22/2026 at 1:11 p.m., the LPN indicated she was unable to find a size 20 French catheter in the facility's medical supplies.
Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection and urinary retention (inability to fully or partially empty the bladder, causing urine to accumulate).
The plan of care for Resident 4, dated 1/6/26, indicated the resident was at risk for urinary complications related to urinary retention and an indwelling catheter.
The interventions included, but were not limited to, change the indwelling catheter as ordered by the physician.
The physician's order for Resident 4, dated 4/15/26, indicated the resident was to have a catheter size 20 with continuous drain.
The quarterly Minimum Data Set (MDS) assessment for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making.
The resident had an indwelling catheter.
According to the American Urology Association 2024, Catheters come in sizes that measure the outside circumference in millimeters (mm), which is called the French (Fr) size.
The larger the French size, the greater the catheter circumference.
The French size as well as the recommended filling volume of the catheter's retention balloon (in cc or mL) is listed on the plastic cuff of the cathetersidearm (the arm of the Foley where the balloon is inflated).
Make sure you have the right type and size Foley catheter kit, then open it up. 410 IAC (Indiana Administrative Code) 3.1-35(g)(1)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
During an observation on 4/22/2026 at 12:10 p.m., Resident 47 was eating lunch in the main dining room.
The resident had moderately long fingernails on both hands, with black substances under the nails and had a full long beard.
During an observation on 4/23/2026 10:24 a.m., Resident 47 was sitting in his wheelchair by the dining room.
The resident had moderately long fingernails on both hands, with black substances and had a full long beard.
Review of the record for Resident 47 on 4/23/2026 at 10:26 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson disease (a chronic, progressive neurological disorder that occurs when nerve cells in the brain die or become impaired), muscle weakness, and need for assistance with personal care.
The admission Minimum Data Set (MDS) assessment for Resident 47, dated 3/20/26, indicated the resident was cognitively intact for daily decision making. Resident 47 had no behaviors of rejecting care.
The resident required substantial to maximal staff assistance with personal hygiene.
The plan of care for Resident 47, dated 4/7/26, indicated the resident required assistance with ADL Self Care Performance related to weakness, pain to left knee with activity tolerance limitations, and Parkinson's disease process.
The interventions included, but were not limited to, the resident required substantial to maximal staff assistance with personal hygiene.
During an interview with the Director of Nursing (DON) on 04/23/2026 at 1:55 p.m., the DON indicated it was the responsibility of the Certified Nursing Assistant's (CNA's) to ensure Resident 47's fingernails were trimmed and cleaned and his facial hair was shaven.
The routine resident care policy, provided by the DON on 4/23/26 at 1:57 p.m., indicated resident care was not necessarily medically or clinically based but was necessary for quality of life to promote dignity.
The facility would promote resident centered care by attending to the total medical, nursing, physical, emotional, mental and social needs and honor resident lifestyle preferences while in the care of the facility.
The routine care provided by the CNA would provide assistance with personal care. 410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(D)410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(E)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
During an observation and interview with Resident 4 on 4/22/2026 at 12:15 p.m., the resident had tubular sleeves on both arms. Resident 4 indicated staff were supposed to take the tubular sleeves off at night and put them on in the morning.
During an observation and interview with Resident 4 on 4/23/2026 at 10:21 a.m., the resident's tubular sleeves were not in place on either arm. Resident 4 indicated he had never refused to wear the tubular sleeves and the tubular sleeves gave him some relief from his arms swelling. Resident 4's bilateral lower arms were swollen (abnormally enlarged, rounded, or puffed up due to fluid accumulation).
During an observation on 4/23/26 at 11:45 a.m., Resident 4 was eating lunch in his room. Resident 4 did not have his tubular sleeves in place; the resident's lower bilateral arms were swollen.
Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnosis included, but were not limited to, bilateral arm edema.
The physician recapitulation for Resident 4, dated April 2026, indicated the resident was ordered tubi grip to bilateral arms every day and evening shift for edema to be applied in the morning and off at bedtime (original order date 1/21/26).
The quarterly Minimum Data Set assessment (MDS) for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making.
The resident had no behavior of refusal of care.
The resident required substantial to maximal staff assistance with upper body dressing.
The plan of care for Resident 4, dated 1/22/26, indicated the resident was to have tubi grip to bilateral arms every day and evening shift for edema, to be applied in the morning and off at bedtime.
During an interview with the Director of Nursing (DON) on 4/23/26 at 1:56 p.m., the DON indicated the nurse was responsible for applying Resident 4's tubular sleeves.
The physician order policy provided by the DON on 4/23/26 at 12:17 p.m., indicated the facility would provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident.
The licensed nurse would accurately document physician and provider orders as determined by the licensee's scope of practice.
The nurse would be responsible for executing the physician's order. 410 IAC (Indiana Administrative Code) 3.1-37(a)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
and follow physician orders for treatment of a pressure area for 1 of 3 residents reviewed for
4/24/2026 at 12:48 PM.
The medical diagnoses included, but were not limited to, partial traumatic amputation (sudden, unexpected [NAME] of a body part) of two or more toes, damage to the nerves from complications of diabetes (nerve damage caused by chronically high blood sugar levels), and abnormalities of mobility and gait.The admission Minimum Data Set (MDS) Assessment, dated 3/10/2026, indicated Resident 3 was cognitively impaired. the resident was dependent on staff for his hygiene needs, turning, and transferring. Resident 3 had a non-removable dressing, surgical wounds and dressings to areas other than feet.A pressure care plan, dated 3/9/2026 and reviewed 4/17/2026, indicated Resident 3 had pressure ulcers. An intervention, dated 3/17/2026, indicated for Resident 3 to utilize heel boots to bilateral feet while in bed.Hospital discharge orders, dated 3/8/2026, indicated Resident 3 to receive betadine to the left heel twice daily and to alleviate pressure at all times to bilateral heels with heel suspension boots.The nursing assessment for Resident 3's admission to the facility, dated 3/8/2026, did not indicate any skin impairment to the left heel but did indicate non-removable dressing to bilateral feet. A physician's order for Resident 3, dated 3/9/2026, indicated staff were to use betadine (broad-spectrum antiseptic used to treat and prevent infections) to the resident's left heel twice a day. A physician's order for Resident 3, dated 3/11/2026, indicated staff were to use bilateral heel boots for the resident while in bed.
The March 2026 treatment administration record for Resident 3 indicated betadine had been applied to the resident's left heel twice a day from 3/9/2026 to 3/11/2026.The March 2026 treatment administration record and care plan for Resident 3 did not reflect the use of heel boots between 3/8/2026 and 3/11/2026.A wound care report, dated 3/25/2026, indicated Resident 3 had an unstageable pressure injury to the left heel.
The measurements for Resident 3's pressure injury to the left heel were 2 centimeters (cm) by 5 cm with no depth.
These were the first measurements of the resident's wound to the left heel. A wound care progress note, dated 3/25/2026, indicated the left heel pressure injury was discovered after removal of a non-removal dressing.
Additional wounds to the bilateral feet were discovered at this time, including diabetic foot ulcers, a deep tissue injury to left lateral foot, and a Stage 1 pressure to the right lateral foot.
During an interview, on 4/23/2026 at 3:00 PM, Assistant Director of Nursing (ADON) indicated Resident 3 admitted for rehabilitation, nursing services, and wound care after surgical intervention. Resident 3 admitted with a surgical wound to the left lateral knee and bilateral feet. At admission Resident 3 had non-removable dressing to bilateral feet covering the toes up to the mid-shin to knee on both legs.
Due to the non-removable dressing, Resident 3's heels were not visible when admitted to the facility.
The left heel was not visible until 3/25/2026 at the first dressing change.
During an interview, on 4/24/2026 at 11:00 AM, ADON indicated staff would not have been able to apply betadine to Resident 3's left heel as signed on the treatment record between 3/9/2026 through 3/11/2026.
Direct floor staff were responsible for providing care to Resident 3's wounds and implementing intervention, including the use of bilateral heel boots. It was the expectation of the facility to follow physicians order unless contraindicated. A policy entitled, Wound Care, was provided by the DON, on 4/23/2026 at 1:57 PM.
The policy indicated residents will receive treatment as indicated for management and prevention of skin integrity issues.410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
During an observation and interview on 4/22/26 at 12:34 p.m., Qualified Medication Aide (QMA) 3 and Certified Nursing Assistant (CNA) 7 went into Resident 4's room and applied gloves.
There was no hand hygiene prior to the staff putting on their gloves. QMA 3 obtained a wash basin and wash clothes, lowered the head of the resident's bed down and raised the bed up with the bed remote control and removed Resident 4's incontinent brief that had a small amount of red substance on it. QMA 3 exposed the resident's genital area and used a wet soapy washcloth to clean the area and then rinsed and dried the area. QMA 3 then took the soapy washcloth and cleaned the catheter tubing. QMA 3 and CNA 7 applied a clean incontinent brief and incontinent pad. CNA 7 took off her gloves and took the soiled linen in a plastic bag out of the room. QMA 3 removed her gloves and donned another pair of gloves on and drained the resident's catheter bag into a urinal without preforming hand hygiene. QMA 3 and CNA 7 indicated they normally would complete hand hygiene and change their gloves during catheter care, but they were nervous and did not do it.
Review of the record for Resident 4 on 4/22/26 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection (UTI) and urinary retention (the inability to fully or partially empty the bladder, causing urine to remain in the bladder even when one feels the need to urinate).
The quarterly Minimum Data Set (MDS) assessment for Resident 4, dated 1/6/26, indicated the resident was cognitively intact for daily decision making.
The resident had an indwelling catheter.
The physician's order for Resident 4, dated 4/21/26, indicated the resident was ordered Sulfamethoxazole-Trimethoprim (antibiotic) 1 tablet by mouth every 12 hours for a UTI for 10 days.
The catheter care policy provided by the Director of Nursing (DON) on 4/23/26 at 12:17 p.m., indicated catheter associated urinary tract infections was the most common adverse event associated with indwelling urinary catheters.
The risk of bacteremia in residents with indwelling catheters was 3 to 36 times more likely that residents without an indwelling catheter.
Catheter care at the bedside was performed to promote cleanliness and dignity.
Catheter care included, but were not limited to, raise the residents bed to waist level before providing care, perform hand hygiene and apply gloves.
Remove your gloves and perform hand hygiene. 410 IAC (Indiana Administrative Code) 3.1-4(a)(2)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
During an observation on 4/21/2026 at 10:56 AM, Resident 32 was sitting in the dining room. Resident 32's fingernails were long, jagged, and cracked on both hands.
During an interview and observation, on 4/22/2026 at 12:05 PM, Resident 32's care was observed with Certified Nursing Assistant (CNA) 4. Resident 32 had long, jagged nails on both hands with brown debris underneath the fingernails on the left hand. CNA 4 touched Resident 32's hand and he immediately swatted at her. CNA 4 indicated Resident 32 refused nail care on almost every shower day, including every time CNA 4 gave Resident 32 a bed bath that month.
When Resident 32 refused, CNA 4 would pass it on in report so staff could reapproach.
During an interview, on 4/22/2026 at 2:00 PM, Director of Nursing (DON) indicated Resident 32 refused care, including nail care, often.
During an interview, on 4/23/2026 at 2:20 PM, Assistant Director of Nursing (ADON) indicated resident behaviors should be documented on their behavior management logs within the electronic medical record.
A policy entitled, Behavior Management, was provided by the DON, on 4/23/2026 at 1:57 PM.
The policy indicated to document behaviors within the clinical record. 410 IAC (Indiana Administrative Code) 16.2-3.1.50(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1.50(a)(2)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
During an interview, on 4/23/2026 at 2:20 PM, ADON indicated she would expect hand hygiene to be
expected scissors to be cleaned before being used on a clean dressing procedure.
A policy entitled, Standard Precautions, was provided by the DON, on 4/23/2026 at 1:57 PM.
The policy indicated hand hygiene should be performed after glove removal and after contact with residents' wound dressings. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a) 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)
155387 04/24/2026
Caroleton Healthcare Center 2500 Iowa Ave Connersville, IN 47331
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.