Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Childserve Habilitation Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for multiple residents with MDROs and indwelling medical devices, including tracheostomies and gastrostomy tubes. During high-contact care such as suctioning, chest percussion, peri care, transfers with a mechanical lift, and medication administration via feeding tubes, staff often wore only gloves or a mask and did not don gowns as required. Care plans identified MDROs and indicated that EBP was needed, but documentation of EBP use was missing for a resident on a ventilator, and staff interviews showed confusion about when EBP applied, with some believing that wounds, trachs, and G-tubes did not require EBP. The IP acknowledged that these residents should have been on regular EBP, while the facility’s EBP risk assessment and signage practices did not align with CDC guidance for residents with MDROs and indwelling devices.
The facility failed to notify the LTC ombudsman about the transfer of six residents to an acute care hospital. The residents were documented to have been discharged with the anticipation of return on multiple occasions, but the facility's discharge template did not reflect these transfers. The Administrator acknowledged issues with tracking due to a change in the EHR system and confirmed the absence of a policy for ombudsman notifications.
The facility failed to follow infection prevention practices during care for two residents. An RN set up enteral tube feeding and suctioned mucus without gloves for a resident with a tracheostomy, while a CNA performed tracheostomy suctioning without gloves for another resident. Both actions violated the residents' care plans and the facility's infection control guidelines.
Failure to Implement Enhanced Barrier Precautions for Residents With MDROs and Indwelling Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and/or MDROs, as required by CDC guidance and the facility’s own policies. Resident #2 had diagnoses including an MDRO (Pseudomonas aeruginosa), cerebral palsy, severe hypoxic ischemic encephalopathy, and required tracheostomy care and a gastrostomy tube. His care plan directed staff to follow EBP for MDRO, but observations showed staff inconsistently using gowns during high-contact care activities. During suctioning and chest percussion, one respiratory therapist wore a gown and gloves, but a CNA providing cares in the room did not wear a gown, and an RN administering liquid medication via the gastrostomy tube also did not wear a gown, despite leaning against the resident’s bedding. Resident #3 had diagnoses of MDRO and respiratory failure, a feeding tube, tracheostomy care, and required an invasive mechanical ventilator. Her care plan documented MDRO: Pseudomonas aeruginosa but lacked documentation of EBP use. During observation, a respiratory therapist performed multiple high-contact respiratory procedures, including applying a chest percussion vest, disconnecting and reconnecting ventilator tubing, administering albuterol via a PDI adaptor through the trach, and suctioning the trach, while only wearing a surgical mask and gloves and not donning a gown. Resident #4 had diagnoses of MDRO and cerebral palsy and required a feeding tube; his care plan indicated MDRO: Pseudomonas aeruginosa and stated that EBP would be indicated. However, during observation, a CNA provided peri care and transferred him with a mechanical lift while he had a gastrostomy tube with feeding attached, and did not wear a gown. Staff interviews revealed confusion and incorrect understanding of when EBP was required. A respiratory therapist stated that a gold shield on the standard precautions sign indicated MDRO but was unsure about EBP requirements and believed other staff in the room did not need gowns if they were not handling tracheostomy care or urine. A CNA stated that one resident was on standard precautions and not EBP, indicating that EBP would have a separate sign. Two RNs reported that residents with MDROs had a gold shield on their standard precautions sign and did not think that wounds, tracheostomies, or gastrostomy tubes counted for EBP. The infection preventionist stated the facility followed EBP and a modified EBP for pediatric residents based on CDC FAQs, and acknowledged during the interview that Residents #2 and #4 should be on regular EBP due to MDROs and that Resident #3, who was 26 years old and had an MDRO, should also be on regular EBP with staff wearing gowns for cares. The facility’s EBP risk assessment document indicated EBP for residents colonized with targeted MDROs and modified EBP for residents with no targeted MDRO colonization and/or indwelling devices, which did not align with CDC guidance that EBP should be considered for residents with wounds or indwelling medical devices regardless of MDRO status.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the long-term care ombudsman regarding the transfer of six residents to an acute care hospital. The residents involved were documented to have been discharged with the anticipation of return on multiple occasions, as recorded in their Minimum Data Set (MDS). The facility's document titled 'Monthly Discharge Template, Ombudsman Notify' did not reflect any of these hospital transfers. During an interview, the Administrator acknowledged that the facility had changed to a different electronic health record (EHR) system in November 2023, and both the old and new systems were being used for different purposes. This transition led to incorrect tracking of transfer outs. Additionally, the Administrator confirmed via email that the facility did not have a policy regarding ombudsman notifications.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices during the care of two residents, leading to deficiencies in infection control. In the first instance, a registered nurse (RN) was observed setting up enteral tube feeding for a 10-month-old resident with chronic respiratory failure and a tracheostomy, without wearing gloves. The RN also suctioned mucus from the resident's nose without gloves, using a nasal cannula attached to a suction machine. This was contrary to the resident's care plan, which required adherence to CDC guidelines and the facility's infection control processes, including the use of gloves. In the second instance, a certified nursing assistant (CNA) was observed providing tracheostomy suctioning for another resident, who was nonverbal and fully dependent, without wearing gloves. This resident also had a tracheostomy and was on a mechanical ventilator. The care plan for this resident similarly required following CDC guidelines and the facility's infection control processes, which include wearing gloves. The facility's Infection Prevention & Control Handbook and Hand Hygiene Education Session both emphasized the importance of wearing gloves when contact with potentially infectious materials is anticipated.
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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 Johnston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bishop Drumm Retirement Center | 0.5 mi | ★★★★★ | 18 | 0 |
| Royal Oaks Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 15 | 1 |
| Karen Acres Care Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Brio Of Johnston, Llc | 2.9 mi | ★★★★★ | 12 | 0 |
| Calvin Community | 3.5 mi | ★★★★★ | 12 | 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.