Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carolton Chronic & Convalescent Hospital Inc during CMS and state inspections, most recent first.
The facility did not accurately submit required PBJ staffing data, resulting in a report that incorrectly showed no licensed nurses present for several days. Although schedules confirmed licensed staff were on duty, the staff member responsible for PBJ data entry could not be reached to clarify the error, and leadership was unaware of the cause.
The facility did not promptly report multiple allegations of abuse involving residents with cognitive and physical impairments to the Administrator, State Agency, or Police as required by policy. Incidents included resident-to-resident aggression and a claim of a staff member pushing a resident, with delays or failures in documentation, notification, and escalation by staff and resident representatives.
The facility did not promptly investigate or report multiple allegations of abuse involving residents with cognitive impairments and behavioral concerns. Staff failed to document incidents, notify administration, or remove involved personnel as required by policy, resulting in delayed reporting to the State Agency and incomplete investigations.
Surveyors found that personal care items such as bedpans and urinals were left unlabeled and uncovered in shared bathrooms, contrary to facility policy, with staff unable to explain the lapse. Additionally, a resident with significant health needs experienced consistently inadequate hot water in their bathroom due to a longstanding plumbing issue that had not been addressed, requiring staff to bring in warm water from other rooms for care.
Licensed staff failed to document the administration and effectiveness of controlled pain medications for several residents, with medications being signed out and administered but not recorded in the MAR or nurse's notes. Staff also borrowed controlled medications from other residents' supplies without proper authorization or documentation, and medications were left unsupervised at the bedside for a resident who was not authorized to self-administer, contrary to facility policy.
Multiple residents with respiratory conditions did not have their oxygen and nebulizer tubing labeled or dated to indicate when they were last changed, and staff were unclear about who was responsible for this task. Some residents received oxygen at flow rates lower than prescribed by their physicians, and care plans did not always address oxygen therapy management. Facility policy did not specify the frequency or responsibility for tubing changes, contributing to these deficiencies.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including staff plating food without beard restraints, food being prepared next to an open garbage can, and numerous opened and undated food items in storage areas. The kitchenette refrigerator/freezer was found soiled and contained expired and unlabeled food, with missing temperature logs and inconsistent cleaning practices. These findings reflect failures to follow facility policies and professional standards for food safety.
Surveyors observed multiple failures in infection control practices, including staff not wearing required PPE during high-contact care, not performing hand hygiene before and after glove changes or when exiting rooms, improper posting of transmission-based precaution signage, and incorrect handling of soiled linen. These deficiencies were noted during care of residents with indwelling devices, pressure ulcers, and active infections, and were confirmed through staff interviews and review of facility policies.
The facility did not appoint a qualified Infection Preventionist, as the designated LPN had not completed the required infection prevention training and did not meet the job qualifications, including holding an RN license and relevant experience. The IP began the training months after assuming the role, and only partially completed the required modules, contrary to facility policy.
A resident with a history of a left tibia fracture and chronic pain was given a 50mg dose of Morphine Sulfate Oral Solution instead of the prescribed 5mg dose, due to administration of the wrong concentration. The error occurred when an RN supervisor provided the medication from a locked cabinet, bypassing standard verification procedures, and an LPN administered it without checking the label against the order. No adverse effects were observed in the resident at the time.
A resident with anxiety, CHF, and IBS, who was cognitively intact and dependent on staff, repeatedly reported concerns about staff interactions and care to nursing staff. Despite these ongoing complaints, there was no documentation in the grievance log, no updates to the care plan, and no formal investigation or notification to the grievance officer, contrary to facility policy. Staff interviews confirmed a lack of awareness and follow-up on the resident's grievances.
Two residents did not have comprehensive care plans addressing their specific needs: one with frequent urinary and occasional bowel incontinence was not assessed or provided a toileting program, and another with severe dysphagia and tube feeding did not have NPO status documented in the care plan or nurse aide assignments, despite facility policy requiring this information.
Staff did not consistently provide required fingernail care for two residents dependent on assistance, resulting in long and dirty nails despite care plans and policies mandating weekly nail care. Additionally, a resident with severe physical impairments and incontinence was left without timely assistance after soiling, despite repeated calls for help and facility policy requiring regular incontinence care. Staff interviews confirmed these lapses in care and communication.
A resident with multiple diagnoses and a documented interest in activities such as bingo, reading, and music was not provided with opportunities to participate in these activities as outlined in their care plan. Staff did not ensure the resident was prepared for activities, failed to escalate issues when the resident was not ready, and did not document refusals or provide alternative engagement, resulting in the resident not participating in preferred activities.
A resident with severe cognitive impairment and a pressure ulcer required an air mattress set at a specific setting per physician order, but staff failed to ensure the mattress was set and monitored correctly. The air mattress was found set at a lower setting than ordered, and nursing staff had signed off on checks without verifying the correct setting, resulting in a deficiency in pressure ulcer care.
A resident with Parkinson's disease and other conditions experienced frequent urinary and some bowel incontinence, but did not receive a required assessment or individualized care plan to address continence. Despite being cognitively intact and aware of toileting needs, the resident was not offered a toileting program and had to wear incontinence briefs due to delays in staff assistance. Facility documentation and staff interviews confirmed that necessary assessments and care planning were not completed as required by policy.
A resident receiving nutrition via g-tube was observed lying flat in bed while tube feeding was infusing, despite orders and policy requiring the head of bed to be elevated to prevent aspiration. An agency nurse aide, who had not received facility orientation, lowered the bed without pausing the feeding, and staff interviews revealed a lack of specific instruction and training for agency personnel regarding this care requirement.
Controlled medications were repeatedly borrowed from one resident's supply to administer to others when needed medications were unavailable, as confirmed by multiple staff interviews and documentation reviews. Limited staff access to the automated medication dispensing system and late admissions contributed to this practice, which was also noted by the pharmacy consultant.
Failure to Accurately Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit accurate Payroll-Based Journal (PBJ) staffing data for four specific days, as required by CMS. The PBJ report for the second quarter indicated that there were no licensed nurses present 24 hours a day on those dates. During interviews, the Administrator was unaware of the issue and deferred responsibility to the Director of Nursing Services (DNS), who stated that another staff member was responsible for PBJ data entry but could not explain the discrepancy. The DNS later provided staff schedules confirming that licensed nursing staff were present on all shifts for the days in question. Attempts to interview the staff member responsible for PBJ data entry were unsuccessful. Facility documentation and interviews confirmed that the required staffing information was not accurately reported, despite the presence of licensed staff.
Failure to Timely Report Alleged Abuse and Incidents to Authorities
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft to the Administrator, State Agency, and Police as required by facility policy for three residents reviewed. In one case, a resident with cerebral palsy and adjustment disorder reported that another resident with Alzheimer's disease grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or reported to the appropriate authorities until the surveyor brought it to the attention of the Director of Nursing Services (DNS). The DNS admitted to delaying the report to the State Agency and not notifying the police, contrary to facility policy, and was unaware of the incident until informed by the surveyor. Interviews revealed that the social worker and charge nurse were also unaware or did not report the incident, and the resident's representative had not been informed. Another resident with dementia and depression alleged that a nurse aide pushed them into the bathroom, but was unable to identify the aide. The resident reported the incident to their representative, who did not escalate the concern, believing it may have been a misunderstanding. The charge nurse was aware of the resident's ongoing complaints about a mean and bossy aide but did not report these concerns to administration. When the resident later told an RN about being pushed, the RN conducted an informal investigation but did not report the incident to the DNS, nor did she document the event or collect staff statements. The DNS only became aware of the allegation when notified by the surveyor and subsequently delayed reporting to the State Agency. A review of facility documentation, including care plans and nursing notes, failed to show any record of the alleged incidents for the residents involved. The facility's abuse policy requires immediate reporting of any alleged or witnessed abuse to the nursing supervisor, department heads, administrator, police, and state authorities within two hours. The failure to follow these procedures resulted in delayed or absent reporting and documentation of abuse allegations, as well as a lack of timely notification to the appropriate authorities.
Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse involving three residents. In the first case, a resident with cerebral palsy and anxiety reported that another resident with Alzheimer's disease and agitation had grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or nursing notes, and the Director of Nursing Services (DNS) was unaware of the event until informed by a surveyor. The incident was not reported to the State Agency immediately, and the investigation summary was delayed. Additionally, the involved residents' representatives were not notified, and staff members who were aware of the incident did not escalate it to administration as required by policy. In another instance, a resident with dementia and depression alleged that a nurse aide had pushed them into the bathroom. The resident was unable to identify the aide, but consistently described the aide as mean and bossy. The allegation was not reported to the DNS or administration by the staff who were aware of the resident's concerns. The resident's representative also failed to report the concern, believing it may have been a misunderstanding. When the DNS was finally informed by a surveyor, the incident had not been documented in the care plan or nursing notes, and the staff member involved was not identified or removed from duty as required by facility policy. Across both cases, the facility did not follow its abuse policy, which requires immediate initiation of a thorough investigation, removal of the involved staff member, and timely reporting to the State Agency. Documentation was lacking, and there were delays in both internal and external reporting. Statements from involved staff were incomplete or missing, and the required investigation steps were not followed promptly or thoroughly.
Improper Storage of Personal Care Items and Inadequate Hot Water in Resident Bathroom
Penalty
Summary
Surveyors observed that personal care items, including bedpans, urinals, and toilet hats, were not stored in accordance with facility policy in multiple shared bathrooms. These items were found unlabeled, uncovered, and wedged inside metal racks or railings, sometimes in contact with walls or with other objects such as clothing. Staff interviews revealed that nurse aides were responsible for labeling, covering, and storing these items, but could not explain why the policy was not followed. The infection prevention nurse and the director of nursing both confirmed the expectation for proper storage and labeling, but were unable to account for the observed lapses. Additionally, a resident with a diagnosis of malignant neoplasm of the bladder and blindness was found to have inadequate hot water in their bathroom sink. Multiple temperature checks over several days showed the hot water was consistently far below acceptable levels, requiring staff to bring in warm water from other rooms for bathing. Interviews with maintenance staff and the administrator revealed a longstanding issue with the hot water supply to this room, stemming from an improper connection made during a renovation years prior. The problem had persisted because a repair was never scheduled, and the water would only become hot after running for an extended period or by manipulating water flow in other areas. The facility's failure to ensure proper storage of personal care items and to maintain safe and comfortable water temperatures in resident bathrooms resulted in an environment that did not meet standards for cleanliness, comfort, and safety. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and records.
Failure to Document Controlled Medication Administration and Improper Medication Handling
Penalty
Summary
Licensed nursing staff failed to document the administration of controlled pain medications, including the resident's pain level and the effectiveness of the medication, as required by professional standards. For multiple residents with chronic pain and cognitive impairments, controlled substances such as Oxycodone and Tramadol were signed out on the controlled substance disposition record and administered, but these administrations were not recorded on the Medication Administration Record (MAR) or in the nurse's notes. Pain assessments often indicated a pain level of zero prior to administration, and there was no documentation of complaints of pain, the administration itself, or the medication's effectiveness in the clinical record. Interviews with the LPN responsible for these administrations revealed that omissions in documentation were oversights, and the EMR system was designed to prompt for effectiveness documentation, which was not completed. Additionally, the facility failed to ensure that controlled medications for pain and anxiety were available for residents as ordered, resulting in staff borrowing medications from other residents' supplies. Controlled Substance Disposition Records showed multiple instances where medications were removed from one resident's supply and given to another, without documentation of physician orders authorizing this practice. Interviews with nursing staff and the DNS confirmed that borrowing medications occurred due to limited access to the automated medication dispensing system and staffing limitations, and that this practice was recognized as poor and not in line with facility policy or pharmacy consultant recommendations. Furthermore, a resident who did not wish to self-administer medications was observed with unsupervised medications left at the bedside by an LPN, who admitted to leaving medications with the resident upon request and without a physician's order. The facility's policy prohibits leaving medications unattended and requires staff to observe residents consuming their medications. The DNS confirmed that leaving medications at the bedside for unsupervised self-administration is unacceptable practice.
Failure to Ensure Proper Respiratory Care and Tubing Management
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents requiring oxygen and nebulizer therapy. For multiple residents with diagnoses such as acute respiratory failure, hypoxia, COPD, and congestive heart failure, observations revealed that oxygen and nebulizer tubing were not labeled or dated to indicate when they were last changed. Staff interviews indicated a misunderstanding of responsibility, with some believing the oxygen vendor was responsible for changing and labeling tubing weekly, while the vendor clarified that the facility was responsible for this task. Review of facility policy and the vendor contract confirmed that the facility, not the vendor, was responsible for changing and labeling respiratory supplies, but the policy did not specify the required frequency or responsible party for tubing changes. Additionally, the facility failed to administer oxygen therapy according to physician orders. In several cases, residents were observed receiving oxygen at flow rates lower than those prescribed by their physicians. For example, one resident with a physician order for 2-3 liters per minute was found receiving only 1.5 liters per minute, and staff had to adjust the setting after this was identified. Another resident with a titration order to maintain oxygen saturation above 92% was also observed on a lower flow rate, though their saturation was within the target range at the time of observation. Care plans for some residents did not include interventions or focus areas related to the administration and management of oxygen therapy, despite active physician orders for such care. The facility's oxygen policy was reviewed and found lacking in guidance regarding the frequency of tubing changes and assignment of responsibility for this task. These deficiencies were identified through observations, record reviews, and interviews with staff, the DNS, and the oxygen vendor.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's main kitchen and a kitchenette. Dietary aides were seen plating food without wearing required beard restraints, contrary to facility policy. Additionally, a dietary aide was cooking fish fillets on a stove grill directly adjacent to an open, uncovered, and full industrial-sized garbage can. These actions were acknowledged by the Director of Food Services as violations of established procedures for maintaining sanitary conditions during food preparation and service. Further inspection of the dry storage, refrigerator, and freezer areas revealed several opened and undated food items, including various types of pasta, rice, fish fillets, broccoli, and orange juice. The Director of Food Services confirmed that all opened food items should have been labeled with the date they were opened, as per facility policy. The ice cream freezers were found to be missing thermometers, despite temperature logs being maintained, and the Director of Food Services could not explain how temperatures were recorded without thermometers present. In the kitchenette of the main dining room, the refrigerator/freezer unit was found to be soiled, malodorous, and contained expired and unlabeled food items, including milk cartons, eggnog, pitchers, and a bottle with an unknown liquid. The microwave and coffee maker were also dirty, and the floor was stained and littered with debris. The temperature log for the refrigerator/freezer was missing, and staff interviews revealed inconsistent practices regarding temperature monitoring and responsibility for maintaining cleanliness and food safety in the kitchenette.
Infection Control Deficiencies: PPE Use, Hand Hygiene, and Precaution Signage
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified during observations and record reviews for several residents. Staff failed to consistently wear required personal protective equipment (PPE), such as gowns and gloves, when providing high-contact care to residents on Enhanced Barrier Precautions (EBP) or contact precautions. In one instance, a nurse aide provided incontinent care to a resident with a gastrostomy tube without donning an isolation gown, despite clear signage and available supplies. Additionally, signage for transmission-based precautions was not always correctly posted, as seen with a resident on contact precautions for Clostridium difficile, where only EBP signage was displayed instead of the required contact precautions signage. Hand hygiene practices were not followed according to facility policy and standard precautions. During wound care and dressing changes for residents with pressure ulcers, staff failed to perform hand hygiene before donning gloves, between glove changes, and after glove removal. In several cases, staff reapplied gloves multiple times without hand hygiene, and in one instance, left the resident's room without performing hand hygiene. These lapses were acknowledged by the staff involved and confirmed by interviews with the infection preventionist and director of nursing, who stated that hand hygiene should have been performed at each required step. Improper handling of soiled linen was also observed. A nurse aide was seen carrying visibly soiled linen and a soiled brief in the hallway, then removing gloves and accessing clean linen without performing hand hygiene. Facility policy requires hand hygiene after handling soiled materials and before handling clean items. These failures to adhere to infection control protocols were observed across multiple staff members and resident care situations, as documented in the facility's own policies and confirmed through staff interviews.
Failure to Appoint Qualified Infection Preventionist with Required Training
Penalty
Summary
The facility failed to hire a qualified Infection Preventionist (IP) in accordance with its own policy and regulatory requirements. The IP, an LPN, assumed the role over four months prior to the survey but had not completed the required specialized infection prevention training at the time of the survey. The IP only began the mandatory training several months after starting the position, completing a portion of the required modules online, but had not finished the full curriculum. The delay in obtaining the necessary training was attributed to a misunderstanding about the training format and the demands of the position. Review of the facility's job description for the Infection Preventionist Nurse revealed that the position required a current RN license, two years of professional nursing experience in LTC, and at least three years in nursing administration or a comparable management role with infection control training and APIC interaction. The IP in the role did not meet these qualifications, as she was an LPN and had not completed the required training. The Director of Nursing Service (DNS), who oversaw the IP, held an infection prevention certificate but was not the designated IP according to facility policy.
Significant Medication Error Due to Incorrect Morphine Sulfate Dose
Penalty
Summary
A significant medication error occurred when a resident with a history of a displaced spiral fracture of the left tibia and chronic pain was administered an incorrect dose of Morphine Sulfate Oral Solution. The physician's order specified Morphine Sulfate 10mg/5ml, with a dose of 2.5 ml by mouth every 4 hours as needed for moderate pain. However, the resident was given a 50mg dose instead of the ordered 5mg dose, due to the administration of Morphine Sulfate 100mg/5ml solution rather than the prescribed concentration. This error was identified after the medication was administered, and the resident was closely monitored, with no apparent adverse effects noted at the time of evaluation. The error was facilitated by a breakdown in medication storage and verification procedures. The Morphine Sulfate 100mg/5ml was not stored in the Omnicell automated dispensing cabinet due to a barcode issue, and was instead kept in a locked cabinet in the nursing supervisor's office. On the day of the incident, the RN supervisor removed the medication from the locked cabinet and provided it to an LPN without verifying the medication order or the concentration of the medication. The LPN, in turn, did not check the label on the medication against the physician's order before administration, assuming it was correct. Facility policy required a three-way check to compare the medication to the medication administration record and the prescription label, as well as verification of the correct medication and dose prior to administration. Both the RN supervisor and the LPN failed to follow these procedures, resulting in the administration of the incorrect dose. The incident was documented as a medication administration error, as the resident received a different dosage than specified by the original order.
Failure to Promptly Address and Resolve Resident Grievances
Penalty
Summary
A deficiency occurred when the facility failed to promptly address and resolve a resident's grievances regarding care and staff interactions. The resident, who was cognitively intact and dependent on staff for transfers, bed mobility, and toileting, reported to a nurse that certain evening shift employees spoke to them in a mean tone and acted independently without involving the resident. Despite these concerns being communicated, there was no documentation of grievances for this resident in the facility's grievance log, and the care plan did not reflect the resident's accusatory behaviors or interventions to address them. Nurses' notes over several days documented accusatory statements by the resident about staff and care, but these were not followed up with investigations or reported to the grievance officer as required by facility policy. Interviews with facility staff, including the Director of Nursing Services (DNS), LPN, and Social Worker (SW), revealed a lack of awareness and follow-up regarding the resident's repeated complaints. The DNS acknowledged that although the resident had previously reported complaints about staff behavior, no formal investigation was initiated, and nothing was documented. The SW, who served as the grievance officer, was unaware of the resident's ongoing concerns and stated that he would have followed up if informed. Facility policy required that all grievances be reported, investigated, and resolved in writing, but this process was not followed for the resident's repeated allegations, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Develop Comprehensive Care Plans for Incontinence and NPO Status
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with Parkinson's disease, bipolar disorder, and major depressive disorder, the clinical record and nurse aide documentation showed frequent urinary incontinence and occasional bowel incontinence. Despite this, the care plan did not address the resident's incontinence, and no assessment for incontinence was found in the medical record. Interviews with nursing staff confirmed that an assessment and care plan should have been completed, and a toileting program should have been considered, but these actions were not taken. The resident reported being aware of the need to urinate or have a bowel movement but required staff assistance for toileting due to mobility limitations. The resident wore an adult incontinence brief at all times because of delays in receiving help from staff and indicated that a toileting program had not been offered. Facility policy required a thorough assessment and care planning for residents with incontinence, but this was not followed in this case. For another resident with severe dysphagia, gastrostomy status, and a history of pneumonitis due to aspiration, the care plan failed to specify the resident's NPO (nothing by mouth) status, despite physician orders and nutrition evaluations indicating tube feeding as the sole source of nutrition. The written nurse aide assignment also did not indicate the NPO status, and staff interviews revealed that nurse aides relied on these assignments for care information. Facility policy required clear communication and documentation of NPO status, but this was not reflected in the care plan or assignment sheets at the time of the survey.
Failure to Provide Timely Nail and Incontinence Care
Penalty
Summary
Staff failed to provide adequate fingernail care for two residents who were dependent on staff for personal hygiene. One resident with dementia and chronic medical conditions was observed on multiple occasions to have very long fingernails with dark debris underneath, despite physician orders and care plans directing weekly nail assessments and care on shower days. Interviews with staff confirmed that nail care was their responsibility and there was no directive from the family to restrict staff from performing this care. Similarly, another resident with Alzheimer's disease and limited mobility was observed to have long, dirty fingernails, and reported having requested nail care from staff without receiving it. Staff interviews confirmed that nail care should be performed on shower days or as needed, and facility policy supported this expectation. In a separate incident, a resident with cerebellar ataxia, epilepsy, functional quadriplegia, and a feeding tube, who was fully dependent on staff for all ADLs and incontinent, was left without timely assistance after being incontinent. The resident was observed calling for help for approximately an hour, using the call bell multiple times, and communicating the need for incontinence care. Staff responded through the intercom but did not enter the room or provide assistance for an extended period, with one staff member stating the resident would need to wait due to other duties. When care was finally provided, the resident was found to have a wet brief. Interviews with staff revealed a lack of communication and follow-through to ensure the resident's needs were met, despite care plans and policy requiring incontinence care every 2-3 hours and as needed. These deficiencies were identified through direct observation, review of clinical records, facility documentation, and staff interviews. The facility's own policies and care plans outlined the required standards for nail and incontinence care, but these were not consistently followed, resulting in unmet care needs for the residents involved.
Failure to Provide Activities of Interest to Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide activities of interest to a resident with diagnoses including cerebellar ataxia, epilepsy, mild anxiety, and depression. The resident, who was dependent on staff for mobility and personal care, had a care plan specifying enjoyment of activities such as bingo, reading, music, and pet therapy, with interventions to offer these activities and ensure access to an activity calendar and activity cart. Despite these documented preferences and interventions, observations showed the resident was often in bed, either awake in a dark room or watching TV, and had not attended bingo in a long time. Interviews revealed that the resident liked bingo but was not consistently prepared in time to attend, and staff did not escalate the issue or provide alternative activities as outlined in the care plan. Further review indicated that the recreational staff did not routinely offer activities to the resident, often due to the resident's closed door, and there was a lack of documentation regarding activity refusals or efforts to engage the resident. The recreation therapist acknowledged not escalating the issue when the resident was not ready for activities, and 1:1 interactions were infrequent and not well-documented. Facility records confirmed the resident had not participated in or refused bingo during the review period, and the facility's policy required meaningful activities to support residents' social, emotional, and physical needs, which was not met in this case.
Failure to Monitor and Set Air Mattress as Ordered for Pressure Ulcer Care
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, and a pressure ulcer to the left buttocks was identified as requiring a pressure-reducing air mattress set at a specific setting of 280, as ordered by the physician and outlined in the care plan. Despite these orders, observations revealed that the air mattress was set at 160 instead of the required 280. Nursing staff, including an LPN, had signed off on the Treatment Administration Record (TAR) indicating the mattress was checked, but were unaware of the correct setting and had not verified it against the physician's order. The discrepancy was only discovered after the LPN reviewed the order and adjusted the setting accordingly. Further interviews with nursing staff and the Director of Nursing Services confirmed that the air mattress should have been set and monitored at the correct setting every shift, as per facility policy and physician orders. The facility's policies required pressure relief mattresses to be checked for proper function every shift, but this was not consistently done. The failure to maintain the correct air mattress setting and to verify compliance with physician orders contributed to the deficiency in pressure ulcer care for the resident.
Failure to Assess and Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore or maintain bowel and bladder continence for a resident with diagnoses including Parkinson's disease, bipolar disorder, and major depressive disorder. The resident was identified as having intact cognition, required substantial assistance with mobility and transfers, and was dependent on staff for toileting. Despite frequent urinary incontinence and some episodes of bowel incontinence documented over a 30-day period, there was no evidence that a toileting program had been attempted or that a comprehensive assessment for incontinence had been completed. The resident reported awareness of the need to urinate or have a bowel movement but had to wear an adult incontinence brief at all times due to delays in staff assistance, and indicated that a toileting program had not been offered. Review of facility documentation and interviews with nursing staff and the DNS confirmed that an incontinence assessment should have been completed upon admission or with changes in continence status, and that a care plan and toileting program should have been developed based on the assessment. The care plan did not address the resident's incontinence, and the required assessments were missing from the medical record. Facility policies directed that residents with incontinence should receive thorough assessments and individualized care plans, but these steps were not followed for this resident.
Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
A resident with diagnoses including cerebellar ataxia, COPD, severe malnutrition, and a gastrostomy tube (g-tube) was observed receiving tube feeding while lying flat in bed, contrary to physician orders and facility policy. The care plan and physician's order required the head of the bed to be elevated to 45 degrees during and after tube feedings to prevent aspiration, and the facility's aspiration policy directed that the head of bed should be up 30-45 degrees at all times during tube feeding. During observation, a nurse aide from an agency lowered the resident's bed to a flat position while the tube feeding was infusing, and only stopped when prompted by the surveyor. The nurse aide admitted to not having received a facility orientation and was unaware of the specific requirement to keep the head of bed elevated during tube feeding. Interviews with facility staff revealed that agency nurse aides were assumed to be competent and were not provided with formal facility training, relying instead on agency verification and brief unit tours. The LPN on duty acknowledged that she did not specifically instruct the agency nurse aide to pause the tube feeding before lowering the bed. The Director of Nursing Services (DNS) stated that agency staff were expected to follow facility policies, but the facility did not provide formal training for them. The failure to ensure the head of bed was elevated during tube feeding represented a lack of appropriate care to prevent complications for the resident.
Failure to Maintain Adequate Medication Availability and Secure Dispensing Practices
Penalty
Summary
The facility failed to ensure that medications, specifically controlled substances, were available to meet the needs of each resident. Documentation review revealed multiple instances where controlled medications such as Lorazepam, Oxycodone, and Tramadol were borrowed from one resident's supply to administer to another resident. These borrowings were recorded on Controlled Substance Disposition Records, with some entries lacking clear identification of the recipient. Interviews with nursing staff confirmed that when a medication was needed immediately and not available, the nursing supervisor would obtain the medication from another resident's supply. Additionally, it was noted that not all shifts had staff authorized to access the after-hours automated medication dispensing system (Pyxis), which further contributed to the practice of borrowing medications. The Director of Nursing Services (DNS) acknowledged awareness of this practice and identified limited access to the Pyxis system and late-day admissions as contributing factors. The facility's pharmacy consultant also observed and reported the borrowing of controlled medications during routine inspections, emphasizing that first doses should not be obtained from other residents. Facility policy requires only authorized and trained nursing personnel to access the automated medication dispensing system, but gaps in staff authorization and access were identified as root causes for the deficiency.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southport Center For Nursing & Rehabilitation Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| Cambridge Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Springs At 3030 Park, The | 4.4 mi | ★★★★★ | 3 | 0 |
| Mozaic Senior Life | 4.9 mi | ★★★★★ | 34 | 0 |
| Civita Care Northbridge | 5 mi | ★★★★★ | 22 | 0 |
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