Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Carnegie Village Rehabilitation & Health Care Cent during CMS and state inspections, most recent first.
Food items were found improperly stored in the kitchen, including undated cut cantaloupe, open hot dogs in freezer K, chicken tenders in a container with the lid not fully closed, undated fries and tater tots, and opened dry goods that were not dated. The Dietary Manager stated opened items should be covered and dated, and the Administrator stated opened food should be covered and dated.
Damaged commode seats in multiple resident rooms were observed with numerous indentations and scratches, leaving them not easily cleanable. The Maintenance Director said housekeepers had not reported the damage, and a Housekeeper stated he/she did not know to notify maintenance. The Housekeeping Supervisor said staff were supposed to use the maintenance log for such issues, but housekeeping employees were not informed that damaged commode seats were something they needed to look for.
Oxygen and respiratory equipment were not kept in sanitary condition for three residents, and one resident’s oxygen was set incorrectly. Oxygen tubing was observed hanging over chairs or sitting on the floor instead of being stored in a clean bag when not in use, and a resident with trach-related respiratory needs had uncapped suction tubing in a drawer, a suction machine on the floor, and opened distilled water without a date. The same resident’s oxygen was also found set at 7 liters per minute instead of the ordered 5 liters, and staff identified the nurse as responsible for the equipment and oxygen settings.
The facility failed to follow its infection prevention and control program by not completing TB screening correctly for several employees and a resident, by allowing a resident’s Foley bag to touch the floor, and by not using the PPE required for a resident on EBP. Staff interviews confirmed the TB timing was handled incorrectly, the resident’s TB documentation was incomplete or inaccurate, and care was provided without the gown required by the EBP sign despite the resident’s MRSA, wounds, trach, G-tube, and urinary catheter.
Call light signals at the west and east nurse's stations were not loud enough to be heard over televisions and conversations. Observations showed activated room call lights producing soft, repeated beeps, and in one instance no audible sound was heard at the nurse's station. An LPN and CNA stated the signals could be hard to hear when TVs were loud or staff were talking, and another LPN said the tones from room and door activations eventually sounded the same.
Open Dumpster Lids: Surveyors observed the dumpster lids open on multiple occasions in the dumpster area. The DM said staff from other departments and dietary had to be reminded to keep the lids closed, and the Administrator stated that facility staff should shut the dumpster lid.
A resident with Parkinson's disease, Alzheimer's disease, and reduced mobility was not properly supervised during nighttime hours. Staff failed to physically check the resident during required rounds and did not include the courtyard in their safety checks. As a result, the resident exited to the courtyard unobserved and fell from a wheelchair, leading to a medical incident.
A facility failed to prevent the misappropriation of 30 tablets of Hydrocodone belonging to a resident. The incident involved two LPNs, with one being the primary suspect. The discrepancy was discovered during a shift change when a narcotic card was found missing. Despite protocols for controlled substances, the missing medication was not accounted for, and the investigation suggested that the LPN responsible for the night shift was involved.
Food items were left undated and improperly covered in the kitchen
Penalty
Summary
The facility failed to store food appropriately in the kitchen. During an initial kitchen observation, surveyors found cut cantaloupe in the refrigerator that was not dated, a large package of hot dogs in freezer K left open to air and not dated, chicken tenders in a plastic storage container with the lid not closed all the way and not dated, and containers of tater tots and fries that were not dated. On a dry storage shelf, opened bags of cheerios and bran flakes were wrapped in plastic wrap but were not dated. The facility census was 68 residents. During a later kitchen observation, the cantaloupe and tater tots were no longer present. The hot dogs in freezer K were wrapped in cellophane and dated 7/22/25, the chicken tenders remained in a plastic storage container with the lid not closed all the way and were dated 7/21/25, the fries were dated 7/17/25, and the opened bags of cheerios and bran flakes were dated July 2025. The Dietary Manager stated that anyone in dietary who opens items should cover and date them, and that all opened packages should be in a container or wrapped in cellophane. The Administrator stated that opened food should be covered and dated.
Damaged Commode Seats Not Reported or Maintained
Penalty
Summary
The facility failed to maintain commodes in resident rooms 107, 100, 167, 162, 140, 132, and 124 free of numerous indentations and scratches, leaving the commode seats not easily cleanable. Observations with the Maintenance Director on 7/21/25 and 7/22/25 documented numerous indentations on commode seats in multiple resident rooms, and one commode seat also had numerous scratches. This affected 7 residents who lived in those rooms, and the facility census was 68 residents. During interviews, the Maintenance Director stated that none of the housekeepers had informed him/her about the damaged commode seats. A Housekeeper stated that he/she had not notified the Maintenance Director about the scratches and indentations in the past because he/she did not know that was required. The Housekeeping Supervisor stated that housekeepers were supposed to notify the maintenance department through the maintenance log if they found anything wrong with commode seats, but housekeeping employees were not informed that damaged commode seats were something they needed to look for.
Oxygen and Respiratory Equipment Not Kept Sanitary and One Resident’s Oxygen Set Incorrectly
Penalty
Summary
The facility failed to ensure oxygen and respiratory equipment were kept in a sanitary condition when not in use for three residents and failed to ensure one resident’s oxygen was set at the ordered rate. Resident #7 had chronic respiratory failure with hypoxia, was cognitively intact, and had an order for oxygen one to three liters per nasal cannula as needed to maintain oxygen above 90%. Observations showed the resident’s oxygen tubing hanging over the back of a chair, not placed in the storage bag, and later sitting on the floor while oxygen was running when the resident was not in the room. The resident stated oxygen was only worn at night and staff put it on and took it off. Resident #8 had chronic respiratory failure, was cognitively intact, and had an order for oxygen two liters per nasal cannula at night. Observations showed the resident’s oxygen tubing hanging off the back of a chair and not in the oxygen bag when the resident was not using oxygen. Later observations again showed the oxygen running with the tubing sitting on the floor while the resident was not in the room. The resident stated oxygen was worn at night and staff applied and removed it. Resident #33 had COPD, acute respiratory failure, tracheostomy status, and dependence on supplemental oxygen. Orders included oxygen at five liters via trach continuously, humidified oxygen, suction setup at bedside, and disposal of suction catheter tubing after each use. Observations showed suction tubing stored in a drawer without a cap, the suction machine sitting on the floor, and an opened distilled water container without a date written on it. On a later observation, the resident’s oxygen was set at seven liters per minute instead of the ordered five liters. Staff interviews confirmed the tubing should have been capped, the suction machine should not have been on the floor, the distilled water should have been dated when opened, and the oxygen setting was incorrect.
Infection Control Failures With TB Screening, Foley Bag Placement, and PPE Use
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not following its TB screening policy for employees and residents. Four of ten sampled employees did not have TB testing completed in accordance with the facility’s process: one employee’s second TST was administered one day early, another employee’s second TST was administered two days early, a third employee’s second TST was documented with incorrect administration and read dates, and a fourth employee’s first TST was not completed prior to hire and the second TST was administered one day early. Interviews with the Infection Preventionist and DON showed the facility was using the administration date rather than the read date to determine timing for the second TST, and that one employee’s dates were entered incorrectly. One sampled resident also did not have TB screening completed as documented and timed per the facility’s process. The resident’s record showed the first TST was documented as administered 10 days after admission instead of on the day of admission, with no read date on the immunization page, and the second TST was pending. The TAR showed the first TST was administered and read in less than 48 hours, with no results documented, and the second TST was also read in less than 48 hours with no results documented. Staff interviews indicated the admitting nurse or Infection Preventionist was responsible for ordering, administering, reading, and documenting the resident’s TB testing. The facility also failed to maintain sanitary catheter care and to follow Enhanced Barrier Precautions for a resident with multiple infection-related conditions. The resident had MRSA, open wounds, a tracheostomy, a gastrostomy tube, and a urinary catheter. During observation, the resident’s Foley bag was touching the floor, and staff were observed providing care and medication administration without a gown despite an EBP sign on the door directing gown and glove use for care activities. Staff interviews confirmed the Foley bag should not have touched the floor and that gown and glove use was required during care for the resident under EBP.
Call Light Signals Not Audible Over Background Noise
Penalty
Summary
The facility failed to ensure that the audible signal from the call light system at the west and east nurse's stations was loud enough to be heard over ambient noise from televisions in adjacent day rooms and resident rooms, as well as conversations at the nurse's stations. During observation, call lights from resident rooms 116, 208, 200, 201, and 205 were activated and produced two quick beeps that repeated every 30 seconds in a soft tone at the west nurse's station, while televisions and other noise were present. During a later observation, call lights from resident rooms 145, 154, 158, 162, and 143 were activated, and there was no audible sound at the nurse's station. During interviews, an LPN stated that if televisions were on in resident rooms and the day room and there were conversations at the nurse's station, the call light could be hard to hear. A CNA stated that when residents kept televisions loud, staff sometimes could not hear the call light signal above the television volume. The DON said nursing staff had not mentioned that the call light signal was too low in volume, and the Administrator stated the volume had been at that level since the system was installed. Another LPN stated it was difficult to hear the call light signal when televisions were on and conversations were occurring at the east nurse's station, and that the tones from room call lights and door activations eventually sounded the same.
Open Dumpster Lids
Penalty
Summary
The facility failed to ensure the lids of the dumpsters were closed. On 7/22/25 at 11:09 A.M. and 3:48 P.M., surveyors observed the dumpsters in the dumpster area with the lids open. On 7/23/25 at 11:46 A.M. and 12:49 P.M., the dumpsters were again observed with the lids open. During interview, the Dietary Manager stated that he/she had to constantly remind personnel from other departments and dietary staff to keep the lids closed, and expected any staff member who dumped trash to close the lids. The Administrator later stated that facility staff should shut the dumpster lid.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with Parkinson's disease, Alzheimer's disease, reduced mobility, and insomnia. The resident, who was cognitively intact according to the most recent MDS, had a care plan that included monitoring for fall risk, poor balance, and insomnia, as well as a preference for outdoor activities such as gardening. Despite these documented needs and risks, staff did not properly visualize the resident during required safety rounds at night. Specifically, the LPN responsible for the midnight census did not physically check the resident, and the CNA performing two-hour rounds relied on seeing the resident's feet from the doorway rather than entering the room to confirm the resident's presence. On the night of the incident, the resident left his room and accessed the facility's courtyard without staff awareness. The resident was later found lying face down on the concrete walkway in the courtyard, having fallen from his wheelchair. Staff interviews revealed that it was not standard practice to check the courtyard during nightly rounds, and staff were unaware that the resident had previously attempted to go outside at night. The CNA stated that rounds were performed every two hours but did not include the courtyard, and the LPN confirmed that the charge nurse did not perform room-to-room checks at midnight as expected by facility policy. Interviews with other residents and staff indicated that the resident was known to be active at night and had a history of going outside or attempting to do so. However, this behavior was not consistently monitored or addressed by staff during their rounds. The lack of direct visualization and failure to include the courtyard in safety checks resulted in the resident being unsupervised outside for an undetermined period, leading to a fall and subsequent medical evaluation.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of 30 tablets of 2 mg Hydrocodone, an opioid pain medication, belonging to a resident. The incident involved two LPNs, with one LPN, referred to as LPN A, being the primary suspect. The deficiency was identified when LPN B noticed a discrepancy in the narcotic card count during a shift change. LPN B reported that a card of Hydromorphone was missing, which was confirmed after a recount with RN A. LPN A, who had just completed orientation and was working their first shift alone, was the only person with access to the medication cart during the night shift when the discrepancy occurred. The facility's Controlled Substance Policy required that controlled substances be stored under double-lock conditions and that a physical inventory be conducted at each shift change. Despite these protocols, the missing medication was not accounted for, and LPN A was unable to provide a satisfactory explanation for the missing card. LPN A claimed not to have given the keys to anyone else and stated that the medication cart was visible in the hallway at all times. However, the investigation revealed that LPN A made multiple trips to their car during the shift, which was not typical behavior for a nurse. Interviews with staff indicated that the facility's system for counting and securing narcotics was in place, but the incident highlighted a failure in execution. LPN B followed protocol by reporting the discrepancy to the DON immediately, and the DON initiated an investigation. However, LPN A's actions and the subsequent investigation suggested that they were responsible for the missing medication. The resident involved was unaware of the missing medication and reported receiving all their pain medication as prescribed.
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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 Belton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beautiful Savior Home | 1.2 mi | ★★★★★ | 2 | 0 |
| Foxwood Springs Living Center | 2 mi | ★★★★★ | 1 | 0 |
| Sunrise Nursing & Rehabilitation | 4.2 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Grandview | 5.8 mi | ★★★★★ | 23 | 0 |
| Raintree Village | 7.3 mi | — | 1 | 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.