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 Carrollton Manor, Incorporated during CMS and state inspections, most recent first.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Surveyors found that the facility did not implement its antibiotic stewardship program as outlined in policy. Infection tracking documents for several months lacked required elements such as whether infections met defined criteria, whether antibiotics were appropriate, and whether they were effective for identified organisms. The IP reported not receiving antibiotic use reports, not using national criteria like McGeer’s to determine infections, and not having a place on tracking tools to document antibiotic appropriateness, while the Administrator stated the program was expected to be in place for all residents.
Surveyors found that multiple medication carts contained loose pills of various types mixed with sealed and labeled medication blister packets. Staff interviews revealed inconsistent cleaning practices and a lack of routine checks, despite facility policy requiring medications to be stored in their original packaging and storage areas to be kept clean and sanitary.
Dietary staff served food using latex gloves, despite several residents having documented latex allergies. Staff and management were unaware of both the residents' allergies and the use of latex gloves in food service. Facility policies did not specifically address latex allergies or restrict latex glove use, leading to a failure to provide appropriate alternatives and ensure resident safety.
Staff failed to document required temperatures for multiple refrigeration and freezer units and did not consistently record food temperatures during meal service. Additionally, staff did not follow proper hand hygiene and glove use protocols while serving food, as observed during meal service. These actions were not in accordance with facility policy and were confirmed by interviews with the Dietary Manager, DON, and Administrator.
A nurse administered furosemide to a resident without checking blood pressure as required by the physician's order and facility policy. The LPN acknowledged the omission, and both the DON and the resident's physician confirmed that blood pressure should have been checked before giving the medication, especially given the resident's medical history of diabetes, depression, cerebrovascular disease, and edema.
A resident with significant cognitive impairment was involved in an alleged sexual abuse incident that was not reported to all required authorities, including police, Adult Protective Services, and the ombudsman, as mandated by facility policy. Staff and administration limited their response to internal investigation and state notification, citing family wishes, and did not involve external agencies or follow full reporting protocols.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
Failure to Implement Antibiotic Stewardship Program and Document Infection Criteria
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program as required by its own policy. Review of the last three months of infection tracking and trending documents showed there was no documentation indicating whether identified infections met any defined criteria for infection and antibiotic treatment, nor whether prescribed antibiotics were effective for the identified organisms. The facility’s policy required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist (IP) or designee, that antibiotic utilization be reviewed for appropriateness, and that all antibiotic regimens be documented on a facility-approved surveillance tracking form with specific data elements such as date of symptoms, antibiotic name, culture results, pathogen, days of therapy, outcome, and adverse events. These required elements were not present on the tracking/trending documents reviewed. During interview, the IP stated he was in charge of the antibiotic stewardship program but did not receive a monthly report of antibiotic use and had only recently learned that McGeer’s criteria should be used to determine infections. He reported that, up to that point, determinations of infection were not based on any national criteria, but rather on nurses’ narrative documentation such as foul-smelling urine, confusion, and dysuria or frequency. When asked about the antibiotic stewardship program, the IP described monitoring residents with confusion to ensure they were being changed every two hours, and acknowledged he did not know where to document that a resident was on an appropriate antibiotic. He confirmed there was no place on the tracking/trending forms to note whether the antibiotic was appropriate or whether an infection met any criteria for infection. The Administrator stated the expectation was that the antibiotic stewardship program had been instituted, but the evidence showed it was not being implemented as outlined in the facility’s policy for all 86 residents.
Improper Storage of Medications in Multiple Medication Carts
Penalty
Summary
Surveyors observed that medications were not properly stored in three medication carts located in different halls of the facility. Specifically, the 500 Hall medication cart contained five loose pills in the second drawer and four loose pills in the third drawer, all of various sizes, shapes, and colors, mixed among sealed and labeled resident medication blister packets. The 400 Hall medication cart had two loose pills in the second drawer, and the 200-300 Hall medication cart had fourteen and a half loose pills in the third drawer, also among sealed and labeled blister packets. These observations were made during medication storage checks with LPNs present. Interviews with staff revealed that there was no consistent process for cleaning out the medication carts, with the nurse supervisor indicating that night nurses might clean the drawers but not necessarily every night, and that all nurses are responsible for keeping the carts clean. The DON confirmed that medication carts should be cleaned routinely and that all nurses are responsible for checking them, but acknowledged that finding several loose pills in each drawer was not acceptable. The facility's policy requires medications to be stored in their original packaging and for storage areas to be kept clean, safe, and sanitary, which was not followed in these instances.
Failure to Accommodate Resident Latex Allergies in Food Service
Penalty
Summary
The facility failed to accommodate the food allergies, intolerances, and preferences of seven residents who had documented latex allergies. Despite these allergies being recorded in the electronic medical records at admission, dietary staff were observed plating food using latex gloves, which is a direct source of latex exposure. The dietary staff member involved stated a preference for latex gloves over vinyl or nitrile alternatives and was unaware of any residents with latex allergies. The dietary manager confirmed that staff could choose their glove type and was also unaware of the presence of residents with latex allergies. Facility policies reviewed did not specifically address latex allergies or restrict the use of latex gloves in food service. The policies generally required the use of clean barriers, such as single-use gloves or utensils, when handling food, but did not specify glove material. During interviews, the dietary manager, DON, infection control nurse, and administrator all indicated a lack of awareness regarding both the use of latex gloves in dietary services and the presence of residents with latex allergies. The DON and administrator acknowledged the risk of anaphylactic reactions in residents with latex allergies if exposed to latex products. The deficiency was identified during a tray line observation where a staff member served food to residents using latex gloves, despite the presence of multiple residents with documented latex allergies. The lack of communication and policy specificity regarding latex allergies contributed to the failure to provide appropriate alternatives and ensure resident safety during food service.
Failure to Document Food Storage Temperatures and Maintain Proper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices throughout its food service operations, as evidenced by a lack of required temperature documentation for multiple refrigeration and freezer units, as well as failures in hand hygiene and glove use during meal service. Observations revealed that two freezers, a walk-in refrigerator, three juice coolers, and two ice cream coolers did not have documented temperature checks as required by facility policy. Temperature logs for these units showed repeated and extended periods with no recorded temperatures on both AM and PM shifts, spanning several months. Additionally, food temperature logs were incomplete, with multiple instances where food temperatures were not documented prior to service or after half of the meal service, as required by policy. During meal service observations, staff were seen failing to follow proper hand hygiene protocols. One staff member was observed leaving the steamtable area with gloves and apron on, returning without changing gloves or performing hand hygiene, and then continuing to serve food. Another dietary aide picked up items from the floor with gloved hands and continued to serve food without changing gloves or performing hand hygiene. These actions were in direct violation of the facility's policies on employee hygiene and food safety, which require handwashing before handling food and the use of utensils to avoid bare hand contact. Interviews with the Dietary Manager, DON, and Administrator confirmed that staff were expected to check and document temperatures of all cold and hot units, as well as follow proper hand hygiene and food safety protocols. The Dietary Manager acknowledged ongoing in-services on temperature checks but stated that staff were not following policy. The DON and Administrator both expressed expectations that dietary staff adhere to established procedures to prevent foodborne illness, but the documented failures in temperature monitoring and hand hygiene practices were not addressed at the time of the survey.
Failure to Monitor Blood Pressure Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to check a resident's blood pressure prior to administering furosemide, as required by the physician's order. The facility's policy and the physician's order both specified that blood pressure should be monitored before giving the medication, with instructions to hold the dose if the systolic blood pressure was below 100 or diastolic below 60. During a medication pass, the LPN prepared and administered the resident's medications, including furosemide, without obtaining a current blood pressure reading. The last recorded blood pressure in the resident's chart was from several days prior, and the nurse acknowledged during an interview that the check should have been performed immediately before administration. The resident involved had a medical history including diabetes, major depressive disorder, cerebrovascular disease, and edema, and was receiving furosemide for edema management. Both the DON and the resident's physician confirmed that blood pressure monitoring was expected before administering the medication, in accordance with the physician's order and facility policy. The physician noted that while the resident's blood pressures had been stable and no recent low readings had been reported, the standard practice should have been followed.
Failure to Report Alleged Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an incident of alleged sexual abuse involving a resident with significant cognitive impairment, as required by both facility policy and regulatory guidelines. The resident, who had diagnoses including Alzheimer's dementia, anxiety, depression, and a vertebral fracture, was unable to be interviewed due to cognitive limitations. The incident was brought to attention when the resident's stepdaughter observed the resident becoming upset with a CNA, mistaking the CNA for the stepdaughter's husband. The spouse of the resident did not express concern about the incident, but the facility's investigation was limited to internal review without notifying all required external authorities. Despite the facility's policy mandating immediate reporting of suspected abuse to the administrator, state agencies, ombudsman, Adult Protective Services, law enforcement, the resident's representative, and medical professionals, the facility did not notify the police, Adult Protective Services, or the ombudsman. Staff interviews revealed confusion about reporting requirements, with some believing that internal investigation and state notification were sufficient. The administrator and DON deferred to the family's wishes not to involve police or send the resident for a hospital evaluation, contrary to policy. The ombudsman and other staff expressed concern about not being informed or involved in the process.
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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.
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Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carrollton Crossing Of Journey Llc | 1.2 mi | ★★★★★ | 14 | 0 |
| Pruitthealth - Carrollton | 4.7 mi | ★★★★★ | 4 | 0 |
| Pine Knoll Path Of Journey Llc | 5.3 mi | ★★★★★ | 0 | 0 |
| Haralson Nsg & Rehab Center | 14.2 mi | ★★★★★ | 12 | 0 |
| Pruitthealth - Franklin | 16.7 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.