Ascension Living Carroll Manor
Washington, The District County, District of Columbia · CCN 095034 · Non-profit (Corporation) · part of Ascension Living (12 facilities, chain average 2.8 stars)
CMS rates Ascension Living Carroll Manor 2 of 5 overall as of August 2026. 252 certified beds, 164 residents a day on average. 67 citations on record from the current inspection cycles, 3 at immediate jeopardy; 3 fines totalling $167,394 and 1 payment denial.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 4 / 5 of 5 |
Staffing
| Total nurse staffing | 5.26784 hours per resident per day |
|---|---|
| Registered nurses | 1.2375 hours per resident per day |
| Weekend total | 4.72041 hours per resident per day |
| Nursing staff turnover | 29.8% (registered nurses 39.5%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-16 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
H Actual harm that is not immediate jeopardy; pattern | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-16 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-03-24 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2026-05-16 |
| 2026-03-24 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-16 |
| 2026-01-05 complaint survey |
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. Nutrition and Dietary Deficiencies · tag F0803 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-28 |
| 2026-01-05 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-28 |
| 2024-09-25 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-01-11 |
| 2024-09-25 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
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. Nursing and Physician Services Deficiencies · tag F0726 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-01-11 |
| 2024-09-25 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2024-09-25 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2024-09-25 complaint survey |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-11 |
| 2024-09-25 complaint survey |
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. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-11 |
| 2024-09-25 complaint survey |
Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · tag F0790 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 | 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. Administration Deficiencies · tag F0836 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-11 |
| 2024-09-25 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2024-09-25 complaint survey |
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. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-15 |
| 2023-05-30 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | 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. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · tag F0711 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2023-05-30 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-07 |
| 2021-07-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · tag F0622 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
| 2021-07-28 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-09-17 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-06-16 | Fine | $137,333 |
| 2026-03-24 | Fine | $13,260 |
| 2024-09-25 | Payment denial for 76 days from 2024-10-27 | — |
| 2024-09-25 | Fine | $16,801 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ascension Health Senior Care Organization | 5% or greater direct ownership interest | 100% | 2014-07-01 |
| Ascension Health Senior Care Organization | adp of the snf | — | 2015-07-01 |
| Hannah George Organization | adp of the snf | — | 2024-06-24 |
| Health Dimensions Consulting Inc. Organization | adp of the snf | — | 2019-08-02 |
| House Healthcare Solutions LLC Organization | adp of the snf | — | 2025-06-10 |
| Medical Solutions LLC Organization | adp of the snf | — | 2017-06-14 |
| Dale, Keysha Individual | adp of the snf | — | 2024-07-01 |
| Joseph, Bindu Individual | adp of the snf | — | 2017-11-29 |
| Musgrave, Lisa Individual | adp of the snf | — | 2024-01-01 |
| Shadbolt, Erin Individual | adp of the snf | — | 2025-05-22 |
| Smoot, Kenneth Individual | adp of the snf | — | 2024-01-01 |
| Musgrave, Lisa Individual | corporate director | — | 2024-01-01 |
| Smoot, Kenneth Individual | corporate director | — | 2024-01-01 |
| Shadbolt, Erin Individual | corporate officer | — | 2023-02-28 |
| Dale, Keysha Individual | operational/managerial control | — | 2024-07-01 |
| Joseph, Bindu Individual | operational/managerial control | — | 2017-11-29 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Ascension Living Carroll Manor.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in The District County.