Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Wheelchairs were left unlocked during mechanical lift transfers for two residents who were dependent for all ADLs and mobility and used wheelchairs. One resident had spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis; the other had cerebral palsy, seizure disorder, and asthma. Staff observed transferring both residents with a mechanical lift while the wheelchair brakes were not locked, and staff later stated the wheelchairs should have been locked during the transfers.
Infection prevention and control practices were not followed for two residents. A resident with a gastric feeding tube had the tubing connector left uncapped between feedings, and staff gave conflicting accounts about whether the cap should be used. For another resident with a trach, J-tube, and MDRO precautions, an LPN provided tube feeding and trach care while other staff performed hygiene care, but hand hygiene was not done between glove changes and no PPE gowns were worn during the care activities.
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.
Wheelchairs Left Unlocked During Mechanical Lift Transfers
Penalty
Summary
The facility failed to lock wheelchair brakes during mechanical lift transfers for 2 of 58 residents dependent on lift transfers. Resident #57’s MDS documented diagnoses including spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis, and indicated the resident was dependent for all ADLs and mobility and used a wheelchair. The care plan directed staff to use a 2-person side-by-side mechanical lift for wheelchair transfers. During observation, Staff F, a CNA, and Staff G, a CMA, transferred Resident #57 from bed to wheelchair with a mechanical lift while Staff H, an LPN, was present, and the wheelchair was left unlocked when the resident was lowered and seated. Resident #4’s MDS documented diagnoses of cerebral palsy, seizure disorder, and asthma, and indicated the resident was dependent for all ADLs and mobility and used a wheelchair. The care plan directed staff to use a mechanical lift for wheelchair transfers. During observation, Staff F, a CNA, transferred Resident #4 from wheelchair to bed with a mechanical lift, and the wheelchair was not locked during the transfer. Staff F stated the wheelchairs should have been locked but were left unlocked because it made it easier to move the wheelchair out of the way once residents were raised on the mechanical lift. Staff G, a CMA, stated the wheelchair should have been locked and said multiple staff in the room may have assumed someone else locked it. The mechanical lift user manual stated the wheels on a mobile lift must not be locked during transfers, while the Administrator stated the facility did not have a policy specific to locking wheelchairs during mechanical lift transfers and the Clinical Director stated staff should have locked the wheelchair when transferring residents in and out of them.
Infection Prevention and Control Failures During Tube Feeding and Resident Care
Penalty
Summary
The facility failed to implement infection prevention and control practices for a resident with a gastric feeding tube when the tube feeding connector was left uncapped between feedings. Resident #26 had diagnoses including cerebral palsy with spastic quadriplegia, epilepsy, and asthma, was dependent for all ADLs and mobility, and had an abdominal feeding tube. The care plan directed staff to follow CDC guidelines, and the physician ordered bolus tube feedings four times daily via gastric tube. During observation, the tube feeding tubing tip was disconnected from the resident’s gastric tube and the transition tip was uncapped and hanging from a pole when the feeding was not in use. The same issue was observed again the following day when the resident’s tube feeding tubing was uncapped and dangling from a pole. Staff interviews showed conflicting understanding of the tubing cap requirement: one RN stated the facility usually did not have a cap on the tubing tip and that the tip was cleaned if contaminated, while another staff member stated staff should be using the tube feed tubing caps as a protective device and should not use the tubing if the cap had not been used between feedings. The QA nurse stated the caps come with the tubing transition tip and that staff should not use the tubing if the tip cover had not been used between feedings. The facility also failed to use appropriate PPE and perform hand hygiene during resident care for another resident with invasive devices and MDRO precautions. Resident #57 had diagnoses including spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis, was dependent for all ADLs and mobility, used a wheelchair, and received most calories and fluids by tube feeding. She also had tracheostomy care orders and a care plan noting MDRO isolation as needed. During care, an LPN administered Beneprotein via J-tube and performed tracheostomy care while CNA and CMA staff provided hygiene care in the room; gloves were changed, but hand hygiene was not performed between glove changes, and no staff wore PPE gowns during the resident care activities. The LPN later stated she forgot to perform hand hygiene between changing gloves.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 454 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 16 | 0 |
| Royal Oaks Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 19 | 0 |
| Karen Acres Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Brio Of Johnston, Llc | 2.9 mi | ★★★★★ | 12 | 0 |
| Calvin Community | 3.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Childserve Habilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.