Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Failure to protect residents from abuse occurred when one resident with severe cognitive impairment repeatedly assaulted multiple residents, causing scratches, a skin tear, broken glasses, and other injuries, while another resident with dementia and intermittent explosive disorder hit a resident during an agitation-related incident. Facility investigations substantiated the abuse events, but the record showed no documented ongoing monitoring, supervision, or care plan changes for the abusive residents after the incidents.
Failure to Prevent and Treat a Sacral Pressure Ulcer: A resident with dementia, anoxic brain injury, immobility, and incontinence was admitted with fragile skin and redness to the heels and buttocks, but no baseline pressure injury care plan was in place. Staff observed the resident lying on her back for prolonged periods on a regular mattress, with no formal repositioning schedule or documentation. A stage III sacral pressure ulcer was later identified, the wound order was delayed, and the ulcer increased in size before specialty support surfaces and care planning were implemented.
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.
Missing Written Transfer and Bed-Hold Notices: The facility did not document providing required written transfer/discharge notices or bed-hold notices for four residents who were sent to the hospital. Records showed emergent transfers for residents with significant medical conditions, including respiratory failure, dementia, malnutrition, chest pain, and septic shock, and staff/family interviews confirmed calls were made to representatives, but no written paperwork was found for the transfers or bed-hold information.
Menus Lacked Portion Sizes and Food Substitutions: Surveyors found the weekly menu did not include portion sizes for any residents and did not list substitutions for omitted foods. The DS stated she had no menu with portion sizes or documentation for how much of each item to serve, the Administrator said the facility had no recipes for most meals because foods were pre-packaged or pre-made, and the RD confirmed staff had no clear way to know serving amounts to meet the calculated nutritive value of meals.
Food storage and kitchen sanitation deficiencies were identified when surveyors found thawed nutritional beverages, prepared beverages, pickles, chicken patties, pasta, Watergate salad, and pie slices that were undated or improperly covered, along with a milk refrigerator missing a thermometer. Surveyors also observed dust and debris on stove hood vents, ceiling lights, air vents, and a standing fan in the dish room, and the Maintenance Director stated there was no routine cleaning schedule for the hood vents.
QAPI Program Lacked Data-Driven Performance Improvement: The facility failed to maintain an effective, ongoing QAPI program with data trending, root cause analysis, measurable PIPs, or sustained improvements. QAPI meetings were held quarterly, but issues were mainly identified through morning meetings and informal staff input, and the Administrator could not provide any completed PIPs from the past year or evidence of tracked action plans for concerns such as declining dining room attendance and UTIs.
A facility failed to inspect and maintain bed frames, mattresses, and bed rails per MIFU for multiple residents with bed rails in use. Observations showed several residents with bilateral or mixed bed rail setups, including quarter-length and one-third-length rails in raised or down positions. The MS said he did not perform routine bed or rail inspections unless a problem was reported and had no written inspection records, and the Administrator confirmed there was no assessment of one resident’s bed or rail fit. The facility policy called for routine inspection of beds and related equipment, and the bed manual required periodic inspection and maintenance of bed components.
Failure to provide required QAPI training to CNAs. Review of five CNA personnel files and training transcripts showed no annual education on the facility’s QAPI program elements and goals or the staff role in QAPI. The DON believed the topic was included in computerized in-service training, but no such training was offered, and one CNA stated she did not know what QAPI was and could not describe the program or her role. The facility policy required all staff to receive in-service education on the elements and goals of the QAPI program.
The facility failed to complete annual performance reviews for four CNAs reviewed who had been employed for more than one year. Personnel file review showed no documentation of performance reviews for any of the four CNAs, and the DON stated he was responsible for ensuring annual reviews were completed but had not monitored or administered the annual competency exams.
Dignity not maintained during assisted dining: A resident with Alzheimer's disease and severe cognitive impairment required partial to moderate help with eating, but was lined up outside the dining room, kept in a buckled seat belt during meals, and served with her tray and utensils left on the tray. Staff scraped dishes and dumped food and liquids into a trash bin within her view and hearing, left a visible clipboard with resident assistance information near the dining room entrance, and did not promptly clean a spill or replace the resident's food and beverage. An LPN later assisted the resident with dessert while standing over her rather than at eye level.
Failure to Document Informed Consent for Restraints and Psychotropic Medications: The facility did not show that residents or their representatives were informed of the risks, benefits, and alternatives before restraints were started for two residents or before psychotropic meds were started for four residents. Records showed general restraint consents, wheelchair seatbelts/alarms, and multiple psychotropic orders, but the charts lacked documentation of specific consent discussions. Interviews with the DON and an LPN showed staff were unaware of informed consent requirements for psychotropic meds, despite facility policy requiring review of alternatives, rationale, risks/benefits, and the right to accept or decline treatment.
SNF ABNs Missing Estimated Cost of Continued Therapy: Two residents reviewed for beneficiary notices did not receive properly completed CMS-10055 SNF ABNs with the estimated cost of continued therapy after Medicare Part A coverage ended. One resident with spinal stenosis, PVD, low back pain, altered mental status, acute pulmonary edema, and acute respiratory failure signed the NOMNC and SNF ABN, but the ABN lacked cost information. Another resident with hearing loss, dementia, and cerebrovascular disease had an unsigned NOMNC with a spouse note of understanding, and the SNF ABN for ongoing ST also lacked estimated cost information.
Failure to Report and Investigate Resident-to-Resident Abuse: The facility did not identify, report, or investigate multiple resident-to-resident abuse incidents involving residents with severe cognitive impairment. One resident was observed kissing another resident, but the interaction was not reported or investigated as potential sexual abuse, and the DON stated no capacity-to-consent assessment had been done. In separate incidents, another resident made repeated verbal threats and physical assaults toward other residents, yet the records showed no timely reporting to admin or the SA and no investigation.
Failure to Timely Report Allegations of Abuse: A resident with Alzheimer’s disease and behavioral symptoms was documented threatening, grabbing, pushing, and attempting to be physical with other residents on multiple occasions, but the incidents were not timely reported to the DON, SA, or local Ombudsman. In another event, two severely cognitively impaired residents were documented as engaging in a mutual sexual encounter, yet the facility had no incident report or SA report and had not assessed consent capacity. Interviews confirmed leadership was unaware of several incidents and acknowledged the reporting failures.
Failure to update care plans for bed rail use, oxygen therapy, and resident-to-resident abuse. A resident with respiratory and renal diagnoses, another resident with stroke and dementia, and a third resident with spinal and respiratory conditions were observed using bed rails, and one was also using oxygen, but their care plans did not address those needs. A fourth resident with severe cognitive impairment and behavioral symptoms toward others had repeated agitation documented, yet the care plan was not updated after confirmed incidents of aggression or abuse, and no new interventions were documented.
Failure to Provide Ongoing Activities for a Bedbound Resident: A resident with vascular dementia and anoxic brain damage was bedbound, unresponsive to verbal or tactile stimuli, and observed in bed or in a reclining wheelchair with no meaningful auditory stimulation in the room. Her care plan called for staff conversation, 1:1 bedside/in-room activities, and assistance to activity functions, but the activity calendar documented only a few room visits and no other participation. The AD stated the resident needed music, conversation, or other stimulation and did not have a radio in her room.
Bed rails were used for multiple residents without the required resident-specific assessment, review of alternatives, informed consent, or documentation of risks and benefits. Residents with diagnoses including dementia, stroke, spinal conditions, respiratory illness, and failure to thrive were observed with bilateral or partial bed rails in place, while records showed no bed rail assessments, orders, or care plans. Staff interviews confirmed the facility did not consistently evaluate bed rail need or track which residents required rails and in what position.
Failure to assess consent and psychosocial needs after resident-to-resident sexual incident: Two residents with severely impaired cognition were observed embracing and kissing, and one resident became upset after being told she had kissed a female resident while believing she was kissing a man. The DON did not initiate an incident report or investigation, capacity to consent was not assessed, social services was not notified, and both care plans were left unchanged.
Medication administration errors exceeded the allowed rate when surveyors found five errors in 31 opportunities. An LPN gave a medication even though the expiration date could not be read, administered amlodipine despite the resident’s BP being below the hold parameter, another LPN failed to give ordered gabapentin and guaifenesin because they were not available, and an LPN held scheduled insulin based on nursing judgment even though no hold order existed. The DON confirmed medications were expected to be available, not expired, and not held without a physician order.
In the main med storage room, a refrigerator used for resident meds and vaccine vials was found at 34 degrees Fahrenheit, below the facility’s stated range for refrigerated meds. The temp log had multiple missing entries over several days, and an LPN and the DON confirmed the refrigerator was supposed to be checked and documented at least daily but had not been monitored consistently.
Incomplete Daily Nurse Staffing Posting: The facility failed to post daily nurse staffing data that included the total number of licensed and unlicensed staff on duty for each shift. The posted information showed the facility name, date, census, and actual hours worked, but it did not list the total staff counts. The DON stated he was responsible for the posting and was unaware that the total number of staff members had to be included.
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 Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by two residents, including one resident with Alzheimer’s disease and severe cognitive impairment and another resident with severe cognitive impairment and dementia-related diagnoses. The report documents repeated resident-to-resident abuse events involving the first resident, who was admitted with Alzheimer’s disease and later had a BIMS score of 1 out of 15, indicating severe cognitive impairment. The incidents included slapping, hitting, scratching, grabbing, shoving, and other aggressive behavior toward multiple residents, with injuries documented to the face, eye, neck, arm, and glasses of the affected residents. The first resident was involved in multiple substantiated abuse incidents with different residents. On one occasion, the resident slapped another resident who entered her room, causing a scratch to the nose area. On another occasion, she hit a resident in the eye, scratched the resident’s neck and arm, and broke the resident’s glasses. Additional incidents included slapping a resident in the face and knocking off glasses, grabbing another resident’s arm in the dining room, pushing a resident in a wheelchair, and striking another resident in the face, resulting in a skin tear. The facility’s investigations substantiated these incidents as abuse, but the record repeatedly showed no documented ongoing monitoring or interventions tied to the resident’s abusive behavior after the incidents. The second resident had diagnoses including major depressive disorder, unspecified dementia, intermittent explosive disorder, restlessness and agitation, vascular dementia, moderate agitation, and depression, with a BIMS score of 0 out of 15. Nursing notes documented multiple episodes of anger and agitation toward others, especially related to keeping others away from his wife. The facility later reported an additional incident in which this resident hit another resident on the arm and told the resident to stay away from his wife, which was considered resident-to-resident abuse with no injury. The investigation showed no documentation that the alleged perpetrator was separated from other residents, monitored and supervised after the incident, or that changes were made to his care plan or interventions to prevent further resident-to-resident abuse.
Failure to Prevent and Timely Treat a Sacral Pressure Ulcer
Penalty
Summary
The facility failed to implement pressure ulcer prevention measures and timely treatment for a resident with vascular dementia and anoxic brain damage who was admitted with poor skin turgor, edema, red and purplish discolorations to the extremities, red heels, and skin peeling and redness to the buttocks. The admission skin note did not identify any sacral skin issue, and the record contained no baseline care plan addressing pressure ulcer risk on admission. The resident was totally dependent on staff for bed mobility and all activities of daily living, and staff interviews indicated she was at risk for pressure injury because of immobility, incontinence, fragile skin, and disease processes. On observation, the resident was repeatedly found lying on her back in bed on a regular mattress without changes in position, including while unresponsive to verbal or tactile stimuli. She was also observed seated in a reclining wheelchair and lying on her back for an extended period before being transferred back to bed in the same position. Staff interviews revealed there was no formal repositioning schedule or documentation of repositioning, and the unit manager and administrator stated the resident was initially on a regular mattress and that turning/repositioning was not scheduled or monitored when she first came to the facility. A stage III pressure ulcer to the sacrum was identified, measuring 3.6 cm by 3.6 cm by 0.3 cm with beefy red tissue and moderate drainage. The wound treatment order was not entered until two days later, and the care plan addressing pressure injury risk was not developed until after the wound was identified. The wound later increased in size to 5.32 cm by 5.56 cm by 0.5 cm. Interviews with nursing staff and the medical director indicated the resident had not been seen by the wound physician at the time of the wound discovery, that an alternating air overlay mattress was not implemented until later, and that more could have been done to prevent the pressure ulcer.
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.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that a written notice of transfer and/or a written bed-hold notice was initiated for four residents who were sent to the hospital from the facility. Record review, staff interviews, family interviews, and policy review showed that for each of the four residents, staff documented the emergent transfer or hospitalization and notified the resident representative by phone, but the records did not show that the required written transfer/discharge notice or written bed-hold notice was provided or documented. For one resident with diagnoses including atrial fibrillation, respiratory failure, COPD, diabetes, heart failure, Alzheimer's disease, CKD, CHF, and pancreatitis, the record showed multiple episodes of emesis, decreased oxygen saturation, lethargy, and non-responsiveness before the floor nurse decided to send the resident out and notified the MD and POA. The record did not show a transfer/discharge notice or bed-hold notice, and the family member stated nothing had been provided in writing. For another resident with severe protein calorie malnutrition, pneumonia, Alzheimer's disease, aortic valve disorder, hypertension, and dementia, the record showed abdominal distention, fever, grimacing, physician contact, and transfer to the hospital, but the written transfer/discharge notice and bed-hold documentation were incomplete and the family member stated there was no paperwork. For a third resident with Alzheimer's disease and emphysema, the record showed chest pain unrelieved by nitro, physician direction to send the resident to the hospital, and EMS transport, with the resident remaining out of the facility until later that day; the record did not show a written notice to the resident's daughter explaining the transfer. For a fourth resident with type 2 diabetes and CKD, the record showed hospitalization for septic shock and a severe cognitive impairment score on MDS, but the record did not show a written reason for transfer or bed-hold notice provided to the resident's son. The facility policy stated that written transfer notices and written bed-hold information were to be provided, including at the time of transfer or within 24 hours for emergencies, but the records reviewed did not show that this occurred for the four residents.
Menus Lacked Portion Sizes and Food Substitutions
Penalty
Summary
Menus were not developed to meet residents’ nutritional needs because the weekly menu reviewed by surveyors did not include portion sizes for any of the 86 facility residents and did not list substitutions for omitted foods. The menu contained a mix of typed and handwritten entries for breakfast, lunch, and dinner, with directions such as no bread for the soft/bite-sized diet and omit bacon/sausage for the NAS diet, but it did not identify any substitute foods of similar nutritive value. There were also no serving instructions on the menu. During interviews, the Dietary Supervisor stated she did not have a menu that included portion sizes or any documentation showing how much of each food item to serve or how to adapt meals for mechanically altered texture or therapeutic diets, and she said she had never had a menu with portion sizes before. The Administrator stated the facility did not have recipes for the meals served because most foods were pre-packaged or pre-made and only heated and served. The Registered Dietitian stated kitchen staff should have a general guideline for portions, but confirmed the staff would have no way of knowing how much to serve each food item to ensure the calculated nutritional value of the meal was met. Review of the facility policy titled Menus stated menus meet residents’ nutritional needs and indicate standard portions at each meal.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food stored in the kitchen pantry, refrigerators, and freezer was appropriately labeled and dated, covered, and maintained at proper temperature. During an initial kitchen observation with the Dietary Supervisor, surveyors found three large boxes of thawed nutritional beverages in the juice cooler without a thaw date, a tray of beverages prepared for lunch in a small refrigerator that was open, uncovered, and undated, a five-gallon jug of pickles that was partially used without an open date, a plastic bag of chicken patties in the walk-in freezer without a label or date, an open bag of pasta in the pantry without an open date, and an open refrigerator for milk with no thermometer present. The Dietary Supervisor acknowledged several of these items were undated or improperly stored and stated staff would not have a way of knowing how long some of the foods had been thawed or opened. Surveyors also observed sanitation concerns in the kitchen area. The vents above the stove contained accumulated lint, dust, and debris, and ceiling lights, air vents, and a standing fan in the dish room were covered with dust and debris. On a later observation, the fans remained dirty, the ceiling lights and vents still had visible dust and debris, and the walk-in refrigerator contained an open container of Watergate salad and three individually wrapped slices of pie without dates. The Dietary Supervisor stated she had not been aware of the dust on the lights, ceiling vents, and fans, and the Maintenance Director stated there was no routine cleaning schedule for the hood vents, which were cleaned on an as-needed basis. Review of the facility policy required containers to be labeled and dated, foods to be covered, and every refrigerator to have an internal thermometer.
QAPI Program Lacked Data-Driven Performance Improvement
Penalty
Summary
The facility failed to maintain an effective, ongoing QAPI program that identified issues before they were found by the survey team and that used data, trending, root cause analysis, and measurable performance improvement projects. Review of facility documentation showed QAPI meetings were held, but there was no data trending, no root cause analysis for identified problems, no interventions started, no sustained improvements, and no meaningful action. The facility also could not provide any completed PIPs from the last year, and documentation was not provided for systems and tools used to identify, collect, and evaluate data from all departments, including self-assessment tools, data collection tools, and feedback from staff, residents, and families. During interview, the Administrator and DON stated QAPI meetings were held quarterly and attended by the Administrator, DON, Infection Preventionist, Medical Director, and department managers. The DON said issues were usually identified during morning meetings when staff were asked if they had concerns, and the Administrator and DON said staff input was solicited on a personal level with open-door access. The Administrator said they were working on a PIP for declining attendance in the dining room for the evening meal and another for UTIs, but he could not provide development or implementation of any action plans with measured success or performance tracking of at least one PIP in the past year. The facility policy stated the QAPI program was to be data driven and include performance improvement projects and monitoring of corrective actions.
Failure to Inspect and Maintain Bed Rails and Beds
Penalty
Summary
The facility failed to ensure bed frames, mattresses, and bed rails were inspected and maintained according to the manufacturer’s instructions for use for six residents who were reviewed for bed rail use. Observations showed that R2 had bilateral upper bed rails, R5 had bilateral upper bed rails, and R24 had one rail in the middle section of the bed and one rail toward the head of the bed. R28 was observed lying in bed and unresponsive to questions and verbal or tactile stimuli, with quarter-length bed rails positioned on each side of the bed; at one observation both rails were in the down position and used as side rails, and at another observation one rail was down forming a side rail while the other was up forming a grab bar. R33 was observed multiple times lying in bed with bilateral one-third-length side rails in the raised position. R57 was observed multiple times in the room, either lying or sitting on the bed or transferring between the wheelchair and bed, with one one-third-length bed rail and one quarter-length bed rail in the raised position during each observation. The Maintenance Supervisor stated he did not conduct bed and bed rail inspections or assessments unless a problem was brought to his attention and had no written documentation of bed inspections for the past year. He also stated beds were not physically assessed for safety related to bed rail use and he was not aware of the requirements for safe installation of rails. The Administrator stated there was no assessment of R28’s bed or the fit of the rails on the bed, and the facility policy and manufacturer’s instructions both described periodic inspection and maintenance of bed components and routine inspection of beds and related equipment.
Failure to Provide Required QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure five of five Certified Nurse Aides reviewed for training received annual education on the facility’s QAPI program. Review of CNA1, CNA2, CNA3, CNA4, and CNA5 personnel files and User Learning transcripts showed no training on the facility’s QAPI program elements and goals or on the staff’s role in QAPI. The records reviewed included CNA1’s hire date of 03/16/23, CNA2’s hire date of 01/13/22, CNA3’s hire date of 03/19/20, CNA4’s hire date of 06/17/98, and CNA5’s hire date of 08/29/24, and none of the transcripts provided by the DON documented the required QAPI training. During interview, the DON stated he thought training on the facility’s QAPI program elements and goals and the staff’s role in QAPI was included in the annual computerized in-service training for CNAs, but there was no training offered to staff on the topic. During interview, CNA4 stated she completed the required computerized in-service training annually but was unsure whether QAPI was included, asked what QAPI was, and was unable to describe the QAPI program or her role. Review of the facility’s In-Service Training, All Staff policy stated that all staff are required to participate in regular in-service education and that required topics include the elements and goals of the facility’s QAPI program.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for four of four Certified Nurse Aides reviewed who had been employed for more than one year. Review of the personnel files for CNA2, CNA3, CNA4, and CNA5 showed hire dates of 01/13/22, 03/19/20, 06/17/98, and 08/29/24, respectively, and the Director of Nursing’s documentation did not include performance reviews for any of them. During interview, the DON stated he was responsible for ensuring nurse aides received performance reviews at least once every 12 months and said he had started some required training in Relias but had not monitored and administered their annual competency exams.
Dignity not maintained during assisted dining
Penalty
Summary
The facility failed to ensure a dignified dining experience for one resident with severe cognitive impairment. The resident had diagnoses including Alzheimer's disease, anxiety disorder, depression, and adjustment disorder, and her MDS showed a BIMS score of two, frequent wandering and physical behaviors toward others, and a need for partial to moderate assistance with eating. Her care plan also noted that dementia impaired her ability to consume meals consistently. During dining observations, the resident was seated in her wheelchair with an alarm and seat belt in place, and she was lined up with other wheelchairs outside the dining room before meals. When she was brought into the dining room, her seat belt remained buckled throughout the meal even though staff were present. Her meal tray was placed on the table with the plate, cups, and utensils still on the tray, and a clipboard listing resident names and assistance needs was visible near the dining room entrance. Behind the resident, staff were scraping food off plates into a large trash bin, pounding dishes on the side of the trash can, and placing empty dishes in the dish room window, all within the resident's direct line of sight and hearing. On another observation, the resident spilled tea onto her tray and over her food, but she was not offered help to clean the spill or given a new plate of food. She began scooping food off her plate onto the tray and mixing it with the tea, and no cuing or encouragement to eat was provided. An LPN later assisted her with dessert while standing over her rather than at eye level, and the soiled tray remained in front of her during the assistance. Staff continued scraping dishes and discarding food into the trash container during the meal service. Interviews confirmed staff expected residents to be lined up outside the dining room, that the clipboard contained protected health information, that staff should assist residents at eye level, and that spilled food and beverages should be replaced or cleaned promptly.
Failure to Document Informed Consent for Restraints and Psychotropic Medications
Penalty
Summary
The facility failed to provide evidence that residents and/or their representatives were informed of the risks, benefits, and available treatment options before restraints were initiated for two residents and before psychotropic medications were initiated for four residents. The report states that this deficient practice involved residents who were receiving wheelchair restraints or psychotropic medications without documentation that informed consent had been obtained or that the required discussions occurred before treatment began. For one resident with diagnoses including Alzheimer’s disease with behavioral disturbance, restlessness, and agitation, the record showed a general restraint consent signed on admission, a care plan for a push-button seatbelt in the wheelchair, and later a physician order for an alarming seatbelt restraint. The restraint evaluation documented agitation, frequent falls, and attempts to self-transfer, and noted that alternatives had been tried. However, the assessment only stated that the representative was notified and did not include documentation of consent or discussion of the risks and benefits of the specific restraint being used. During observation, the resident was in a wheelchair with an alarmed seatbelt and tab alarm in place and was unable to respond to questioning. For a second resident with diagnoses including Alzheimer’s disease, anxiety disorder, history of falling, depression, adjustment disorder, and stroke, the record showed a general restraint consent on admission, a care plan for a Velcro seatbelt in the wheelchair, and physician orders for bed and chair alarms and later a Velcro alarming seatbelt. The restraint evaluation documented that the resident forgot she could not walk and was at risk for falls, and that alternatives such as one-to-one activities and alarms had been tried. As with the first resident, the assessment stated that the representative was notified but did not document consent or discussion of the risks and benefits of the restraint. During observation, the resident was in a wheelchair with an alarm and seatbelt in place and was unable to respond to questioning. The report also identified four residents who received psychotropic medications without documentation of informed consent. One cognitively intact resident with vascular dementia, insomnia, anxiety, and major depression was receiving Abilify, Celexa, trazodone, temazepam, and desvenlafaxine, and the record contained nothing showing informed consent for any of these medications. Three other residents with severe cognitive impairment were receiving psychotropic medications as ordered: one received Cymbalta, haloperidol, and escitalopram; another received Risperdal for delusions in dementia; and the third also received Risperdal for delusions in dementia. Their records likewise contained nothing to indicate informed consent had been obtained. Staff interviews showed the DON and unit manager were unaware of informed consent requirements for psychotropic medications, and the facility policy required review of non-pharmacological alternatives, indications, risks and benefits, and the resident’s or representative’s right to accept or decline treatment before initiating or changing psychotropic medication.
SNF ABNs Missing Estimated Cost of Continued Therapy
Penalty
Summary
The facility failed to ensure that two residents reviewed for beneficiary notices received a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) that included the estimated cost of continued therapy services after Medicare Part A coverage ended. For one resident with diagnoses including spinal stenosis, peripheral vascular disease, low back pain, altered mental status, acute pulmonary edema, and acute respiratory failure, the record showed a Medicare Part A benefit period with a last covered day, and the resident signed both the NOMNC and SNF ABN; however, the SNF ABN did not include the estimated cost of continued therapy services to support an informed financial decision. For another resident with diagnoses including hearing loss, dementia, and cerebrovascular disease, the NOMNC was unsigned but contained a handwritten note indicating the spouse understood, and the unsigned SNF ABN showed speech therapy services continuing after the last covered date; however, the form did not include the estimated cost the resident would incur if services continued. During interview, the Business Office Manager stated she does not enter any amount on the SNF ABN notices, while the Administrator stated the expectation was for the SNF ABN to be completed correctly, including the estimated cost of continued services.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, and investigate potential resident-to-resident abuse incidents involving three residents. One resident with dementia and severely impaired cognition was documented as being found kissing another resident from a different hall. The progress note stated the interaction was mutual, but the resident became upset when told she had kissed a female resident. The record contained no incident report or investigation, and the DON stated he did not know one was needed. The DON also stated the facility had not assessed either resident’s capacity to consent or understand their actions, and he could not explain how the interaction was determined to be consensual. Review of the security camera footage showed the two residents embracing and kissing in the hallway. The Administrator stated he was not aware of the incident and had not reviewed the footage or investigated it until the survey. A PT stated she witnessed the interaction, asked the resident if she knew what she was doing and who she was kissing, and then notified a CNA and an LPN. The CNA stated the residents were already separated when she saw them, one resident said, “She kissed me,” and the other denied kissing her. The facility’s documentation did not show that the incident was reported or investigated as potential sexual abuse. The facility also failed to report or investigate multiple resident-to-resident aggression incidents involving another resident with Alzheimer’s disease and severely impaired cognition. Progress notes documented threats such as “I will kill you,” “I’m going to kill you,” and physical altercations including grabbing another resident’s arm, pushing a resident back in a wheelchair, and putting fingers in another resident’s face. The documentation showed staff separated residents, administered PRN medications, and notified the resident representative, but there was nothing to indicate timely reporting to facility administration or the State Agency, or that an investigation was completed for any of the incidents. During interview, the DON and Administrator stated they were not aware of these incidents and therefore they were never reported or investigated.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse involving multiple residents. Review of records showed several incidents involving a resident with Alzheimer’s disease and behavioral disturbances, including threats toward roommates and physical altercations with other residents. In one incident, the resident was documented as arguing with a roommate and voicing violent threats, and in other incidents she was observed yelling, threatening, grabbing, pushing, and attempting to be physical with other residents. The documentation showed staff intervened, separated residents, and in some cases notified the MD, DON, or resident representative, but there was nothing to indicate the allegations were reported timely to facility administration, the State Agency, or the local Ombudsman. The record also showed an incident involving two residents, both with severely impaired cognition, in which staff were alerted that they were “caught making out” and were separated. The resident’s representative was notified, but the facility had no documentation of an incident report or report to the State Agency. The DON stated he did not know a report was needed in this instance and later stated that any allegation involving abuse should be reported immediately to him and to the State Agency within two hours. He also stated the facility had not assessed either resident’s capacity to consent or understand their actions and could not explain how the interaction was determined to be consensual. During interviews, the DON and Administrator stated they were not aware of several of the incidents involving the resident who made threats and became physical with others, and they acknowledged the incidents should have been reported timely to the State Agency and local Ombudsman. The facility’s abuse reporting policy stated suspected abuse must be reported immediately to the administrator and other officials according to state law, with immediately defined as within two hours for abuse allegations or serious bodily injury, or within 24 hours for allegations not involving abuse or serious bodily injury. The documentation and interviews showed the facility did not timely report the allegations described in the record.
Failure to Update Care Plans for Bed Rails, Oxygen, and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents. For one resident with pneumonia, asthma, protein-calorie malnutrition, chronic respiratory failure, and chronic kidney disease, bilateral upper bed rails were observed during two separate observations, but the care plan only addressed dependence on staff for bed mobility and did not include the bed rails. For another resident with cerebral infarction, dementia, hearing loss, and peripheral vascular disease, bilateral upper bed rails were observed and the resident stated she did not use them, yet the care plan addressed only dependence for bed mobility and refusal to turn and reposition, with no care plan entry for bed rail use. A third resident with spinal stenosis, peripheral vascular disease, low back pain, altered mental status, acute pulmonary edema, and acute respiratory failure was observed with bed rails and using oxygen at 3 liters per minute via nasal cannula from an oxygen concentrator, and stated that 3 LPM was normal but sometimes 4 LPM was used. The care plan addressed bed mobility only and did not include the use of bed rails or oxygen. The Administrator stated that the expectation was that care plans would include oxygen use and mobility assistance. A fourth resident with major depressive disorder, unspecified dementia, intermittent explosive disorder, restlessness and agitation, vascular dementia with agitation, and depression had a BIMS score of 0 and exhibited verbal behavioral symptoms toward others, including threatening, screaming, and cursing. Nursing progress notes documented multiple observations of agitation toward other residents, and the investigation file for a reported abuse allegation showed no measures were implemented to protect other residents from the resident's abusive behavior. The care plan was not updated after confirmed occurrences of resident agitation or the reported resident-to-resident abuse incident, and no new interventions were documented after 11/19/2025.
Failure to Provide Ongoing Activities for a Bedbound Resident
Penalty
Summary
The facility failed to ensure an ongoing program of activities was provided for one resident who was bedbound and reviewed for activities. The resident was admitted with diagnoses including vascular dementia and anoxic brain damage. During observations, the resident was lying in bed or seated in a reclining wheelchair with eyes closed and was unresponsive to verbal or tactile stimuli. In the room, there was no radio, and at times the TV was off or on without volume. The resident's care plan stated she was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, and included approaches for staff to converse with her during care, provide 1:1 bedside/in-room visits and activities if she could not attend out-of-room events, and assist or escort her to activity functions. The activity participation calendar showed room visits on only five dates in April 2026, with no other activity participation documented. The Activity Director stated the resident was unable to respond to staff or participate in activities, was bedbound, and would need room visits with music, conversation, or other auditory or tactile stimulation; the resident did not have a radio in her room.
Bed rails used without required assessment, consent, or documentation
Penalty
Summary
The facility failed to ensure that assessments, including attempts at alternatives to bed rail use, were completed before bed rails were installed and used for six sampled residents. The report states that the facility did not ensure resident-specific evaluation, informed consent, or documentation of risks and benefits before bed rails were in place for residents R2, R5, R24, R28, R33, and R57. The deficiency was identified through record review, observations, staff interviews, review of FDA guidance, and review of the facility’s Bed Safety and Bed Rails policy. R2 was admitted with diagnoses including pneumonia, asthma, protein calorie malnutrition, chronic respiratory failure, and CKD. During observations, R2’s bed had bilateral upper bed rails in place. The medical record did not show a bed rail assessment, evaluation, or informed consent discussing risks and benefits. R2’s care plan noted dependence on staff for all bed mobility. R5 was admitted with diagnoses including cerebral infarction, dementia, hearing loss, and peripheral vascular disease, and had a BIMS score of 12, indicating moderate cognitive impairment. R5 was observed with bilateral upper bed rails, and stated the facility had not discussed the risks or benefits of bed rails. The record did not contain a bed rail assessment, evaluation, or informed consent. R24, who had diagnoses including spinal stenosis, PVD, low back pain, altered mental status, acute pulmonary edema, and acute respiratory failure, was observed with bed rails in place and stated the rails were used for positioning and that he had rolled out of bed before. The record did not show a bed rail assessment or informed consent, and the DON confirmed there were no bed rail assessments for R2, R5, or R24. R28, who had vascular dementia and anoxic brain damage, was observed lying in bed without response to stimuli and had quarter-length bed rails positioned on both sides of the bed in different positions during observations. The record showed no assessment, no order, and no indication of the reason for bed rail use, and the care plan did not address bed rails. The Administrator stated there was no assessment of R28’s need for or ability to use the rails. LPN2 stated the facility had no orders, care plans, or assessments for bed rails unless they were used as a restraint, and that CNAs made their own judgment about whether rails were needed and whether they should be up or down. R33, who had vascular dementia and type 2 diabetes and a BIMS score of 15, was repeatedly observed with bilateral one-third length side rails raised. The record contained no bed rail care plan, no order, no assessment, and no informed consent. LPN2 stated the rails were probably raised because R33 requested them, while R33 stated she thought the rails were useful when turning in bed but did not remember requesting them or giving informed consent. R57, who had adult failure to thrive and a BIMS score of 5, was observed with one one-third length rail and one quarter-length rail raised during multiple observations. The record contained no bed rail care plan, no order, no assessment, and no informed consent. LPN2 stated the quarter-length rail was not considered raised and that orders, consent, and a care plan were only obtained when rails were raised on both sides of a resident’s bed. The UM stated she was not aware of any assessment for any resident’s use of bed rails, and the DON and Administrator confirmed that no assessments, orders, care plans, or informed consent were obtained for the use of bed rails.
Failure to Assess Consent and Address Psychosocial Needs After Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to provide medically-related social services to address psychosocial concerns and to evaluate the ability of two residents to consent to sexual activity after an incident involving R75 and R19. R75 had a diagnosis of dementia with psychotic disturbance and an annual BIMS score of 3 out of 15, indicating severely impaired cognition. R19 had a diagnosis of Alzheimer's disease and a quarterly BIMS score of 3 out of 15, also indicating severely impaired cognition. The incident occurred when staff observed the two residents embracing and kissing, and R75 later became upset when told she had been kissing a female resident and stated she thought she was kissing a man. The facility did not document an incident report or conduct an investigation of the event, and the DON stated he did not know one was needed because he believed it was a mutual act. The DON also stated the facility had not assessed either resident's capacity to consent or to understand their actions and could not explain how the interaction was determined to be consensual. Video review showed the residents embracing and kissing in the hallway while a staff member watched, then approached another staff member after the residents had already separated. The residents' care plans were not updated after the incident. R75's care plan had last been revised before the event, and R19's care plan was also not updated after the interaction. Social services staff stated they were unaware of the incident and would have expected to be notified right away to assess both residents for psychosocial effects and to evaluate their ability to consent. The facility policy stated that sexual contact is nonconsensual if a resident lacks the cognitive ability to consent and that staff should evaluate capacity to consent when there is reason to suspect it may be lacking.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent during a medication administration review. Surveyors identified five errors out of 31 opportunities involving three residents, resulting in a 16.13 percent medication error rate. The report states the deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes. For one resident with hypertension, the record showed orders for ferrous sulfate 325 mg daily and amlodipine 2.5 mg daily, with instructions to hold amlodipine if systolic blood pressure was less than 110 or diastolic blood pressure was less than 60. During observation, an LPN administered the ferrous sulfate even though the expiration date on the container had been rubbed out and could not be determined. The resident’s blood pressure was 146/48, but the LPN administered amlodipine despite the diastolic pressure being below the hold parameter. The LPN stated she was not sure what to do when a medication expiration date could not be clearly seen and said she gave the amlodipine based on her nursing judgment. For another resident with osteoarthritis, orders were in place for guaifenesin ER 600 mg every 12 hours and gabapentin 600 mg three times daily. An LPN could not locate either medication in the cart and did not administer them during the observation. For a third resident with type 2 diabetes, orders required blood sugar checks before meals and routine insulin aspart 10 units before meals, with no hold parameters. An LPN obtained a blood sugar of 174 and then held the scheduled insulin because she believed it should be held if the blood sugar was less than 200. The DON confirmed medications were expected to be available, expired medications were not to be administered, and medications were not to be held unless a physician’s order was obtained.
Inconsistent Monitoring of Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper storage of refrigerated medications in the main medication storage room. During observation, the refrigerator was being used to store multiple residents’ medications, including insulin, suppositories, eye drops, and vaccine vials. At the time of the observation, the refrigerator temperature was 34 degrees Fahrenheit, which was cooler than the facility’s policy range for refrigerated medications. Review of the Medication Refrigerator Temperature Log showed missing temperature entries on multiple days between 04/01/2026 and 04/25/2026. An LPN who served as Unit Manager stated the refrigerator temperature was to be monitored at least daily on the evening shift and recorded in the log, and she confirmed the temperatures had not been monitored consistently as required. The DON also stated he expected at least daily monitoring and recording of temperatures for any refrigerator in the facility containing resident medications or immunizations.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post daily nurse staffing data that included the total number of licensed and unlicensed staff working each shift responsible for resident care. Review of the posted staffing information showed the facility name, date, census, and actual hours worked per shift for licensed and unlicensed staff, but it did not include the total number of licensed and unlicensed staff members on duty for each shift. During interview, the Administrator and DON confirmed that the DON was responsible for calculating and posting the daily nurse staffing information and all required components, and the DON stated he was unaware that the total number of staff members needed to be included in the posting. A policy related to daily nurse staffing reports was not provided during the survey.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 9 | 0 |
| Haralson Nsg & Rehab Center | 14.2 mi | ★★★★★ | 3 | 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 August 2026) and official state health department websites.