Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate PBJ staffing data to CMS for a quarterly reporting period. HR, the DON, and the ADMIN described a process where staffing hours were gathered from invoices, adjusted, entered into Workday, and then pulled by the Home Office service center for CMS submission. Record review showed the submission failed because one employee did not match after a software change, creating a fatal coding error in the file, and the issue was not discovered until after the deadline had passed.
A facility failed to maintain privacy during resident care when an RN performed blood sugar checks for two residents without closing the door or pulling the privacy curtain, and two CNAs provided incontinent care to another resident without pulling the curtain between the resident and roommate. The affected residents included individuals with diabetes and cognitive impairment, and one resident had severe cognitive impairment with bowel and bladder incontinence. Staff acknowledged the privacy barriers were not used during the observed care.
Failure to follow ordered wound and skin care. A resident with MASD was transferred after a shower without a brief or barrier covering the gerichair seat, leaving the bare perineal area in direct contact with a wet seat. Another resident with edema and weeping feet had wet kerlix dressings despite orders for daily and PRN changes. A third resident’s right shin wound was cleansed using the same gauze on the wound bed after the surrounding skin, instead of following the facility’s wound care technique from the center outward.
Late Medication Administration: During medication pass observations, an MA administered scheduled morning meds late for three residents, including a resident with dementia and DM, a resident with DM, cellulitis, and dysphagia, and a resident with GERD and dysphagia. The eMARs were red, the residents were observed eating, sleeping, or resting, and the MA stated the meds were scheduled for 6:30 a.m. Interviews with the MA, RN, and DON confirmed that late administration was outside the expected time frame and required nurse notification and documentation.
Late Administration of Scheduled Morning Medications: Surveyors found an 11.11% med error rate after an MA gave three residents their 6:30 a.m. meds well after the scheduled time. One resident with dementia and DM received metformin late and initially refused it, while two other residents with GERD or indigestion-related orders received Protonix or omeprazole late while one was sleeping and another was resting in bed. Interviews with the MA, RN, and DON confirmed late administration was considered a med error and should be reported to nursing.
A facility failed to keep several drugs and biologicals secured and out of resident rooms. One cognitively intact resident had zinc oxide on her side table, another had Vicks Vapor Stick on her overbed table, and a third resident with moderate cognitive impairment had peri-care wipes and a calmoseptine/nystatin mixture on her bedside table. Records did not show assessments or authorization for self-administration or room storage, and staff stated these items should not have been left accessible.
Kitchen Food Storage and Labeling Deficiency: Surveyors found multiple food items in the kitchen that were not properly labeled, dated, sealed, or discarded before use-by dates, including noodles, cake mix, cheese, purred fruit, and carrots with brownish spots. The DM stated all staff were responsible for labeling and that opened items should be properly sealed and dated, while the ADMIN stated she expected the kitchen to follow facility policy requiring foods to be labeled and dated before storage.
Multiple infection control failures were observed during resident care, including a CNA feeding two residents at once without hand hygiene between them, a resident being transferred after a shower with bare perineal skin directly touching a geri-chair seat, wet kerlix dressings touching the floor, catheter care and transfers performed without required gowns, incontinent care and transfers for a resident on EBP without gown use or proper hand hygiene, a personal lunch bag stored in the med room refrigerator, and an RN failing to sanitize hands between dirty and clean glove changes during wound care.
Call Light Not Kept Within Reach: A resident with dementia, a history of falls, and need for assistance with personal care was observed in bed with his call light on the floor under the bedside table and out of reach. Staff, including a housekeeper, CNA, LVN, DON, and Administrator, stated the call bell should always be within reach so the resident can call for assistance.
A resident with COPD and severe cognitive impairment had an MDS assessment that did not indicate oxygen therapy, even though a physician order required O2 at 2 L/min continuously via nasal cannula and the resident was observed on oxygen. The MDS Nurse later acknowledged the omission as an oversight after reviewing the order and the MDS, and the DON and Administrator stated the MDS should reflect the resident’s current status and diagnoses.
A resident with COPD and severe cognitive impairment had a physician order for continuous O2 at 2 L/min via nasal cannula, and she was observed on oxygen therapy during the survey. However, her comprehensive care plan did not include oxygen use, and the MDS did not indicate she was receiving oxygen. The MDS Nurse stated that continuous oxygen use should have been care planned so staff would know how to manage it, and the facility policy required an interdisciplinary comprehensive care plan for each resident.
Hazardous Items Found in Resident Rooms: Staff observed germicidal wipes in one resident’s room and scissors in another resident’s possession. Both residents had dementia and required assistance with care and supervision, and staff interviews confirmed that such items should not be kept in resident rooms. The Administrator removed the scissors after the resident said his daughter had given them to him, and the facility policy stated that medications, chemicals, cleaning supplies, and other hazardous materials must be kept locked or secure.
A resident with a suprapubic catheter and cognitive impairment had the catheter bag placed on top of her during a mechanical lift transfer, and it remained there while staff adjusted her wheelchair. A CNA observed the bag in that position but did not intervene, and later acknowledged the bag should stay below the bladder to prevent backflow and UTI risk; the DON confirmed catheter bags should always be kept below the bladder.
Improper Storage of Oxygen Tubing and Spirometer: A resident with COPD, chronic respiratory failure, and CHF had an oxygen nasal cannula left exposed when not in use, despite staff stating it should be bagged per policy. Another resident with atelectasis and asthma had an unbagged spirometer left on a dresser with the mouthpiece touching the wall, and staff confirmed it should have been bagged to keep it clean.
Pest Control Program Failed to Keep a Resident Room Free of Gnats. A resident with dementia and DM had a gnat observed on her breakfast tray while she was eating. Staff confirmed pests had been reported in the building, used a logbook and verbal reporting process, and said the facility had monthly pest service and spot treatment as needed, but gnats were still present in the environment and on the resident’s tray.
A cognitively impaired resident with multiple comorbidities independently obtained ice from an ice cooler after a nurse opened the lid on her cup, without staff assistance or intervention. Staff interviews revealed that this resident sometimes got her own ice, even though residents were not supposed to access the ice cooler due to cross-contamination and infection control concerns. Nursing and CNA staff acknowledged that they attempted to assist and redirect the resident, but she was still able to reach the cooler and serve herself ice, contrary to the facility’s infection prevention expectations.
Surveyors identified that staff failed to consistently follow required procedures for controlled medication disposal and documentation. One med aide reported she would waste refused controlled meds directly into a sharps container, with or without a witness, and was unsure of the associated risks, despite facility expectations for witnessed wasting using a drug buster. On another cart, a discrepancy was found between the Lorazepam blister card and the controlled drug count sheet for a resident after a med aide administered a dose but did not immediately update the count sheet, resulting in a one‑tablet variance. Other nursing staff and the DON described policies requiring two licensed or registered personnel to document destruction and immediate updating of count sheets when controlled meds are removed.
Surveyors found that three cognitively impaired residents with dementia and depression-related diagnoses were not protected from environmental hazards. One resident had a can of Lysol spray stored on a chest in his room, and another had an aerosol air freshener can on her nightstand; an RN acknowledged residents were not supposed to have these items because they were dangerous. A third resident, who had dementia and conduct disorder, was observed in bed after inserting a phone charging cord directly into an electrical outlet without the plug attached, despite a posted sign asking staff to assist with plugging in her phone. Staff, including an RN and CNA, stated they should have connected the phone for the resident, and the DON confirmed that staff should have plugged in the charger and that the resident could have harmed herself by doing it independently, contrary to the facility’s Resident Rights policy requiring a safe environment.
Surveyors found that nebulizer masks and nasal cannulas for four cognitively impaired residents with COPD, chronic respiratory failure, or chronic kidney disease were left unbagged on nightstands, oxygen concentrators, and an oxygen tank between uses, despite physician orders for PRN or continuous O2 and staff acknowledgment that such equipment should be stored in plastic bags when not in use to prevent contamination. The facility’s oxygen administration policy did not address bagging respiratory devices.
Surveyors found that three cognitively impaired, high-fall-risk residents with diagnoses such as lack of coordination, muscle weakness, and unsteadiness on feet did not have accessible call systems as required by their care plans and facility policy. One resident in bed had no call light and instead relied on a bell attached to a bedside table placed across the room, while two other residents had call lights either on the floor behind the bed or hanging from the head of the bed, all out of reach. Staff, including a CNA, RN, DON, and an LVN, acknowledged that call lights should be within residents’ reach so they can call for assistance, and that residents sometimes pulled out or knocked off the call lights.
A resident with severe cognitive impairment and a right heel wound did not receive wound care as ordered on two scheduled days. Nursing staff reported being too busy to complete the treatments and failed to notify the DON or oncoming nurses, contrary to facility policy. This resulted in a lapse in following professional standards for pressure ulcer prevention and care.
A nurse failed to close the door or pull the privacy curtain while changing a resident's feeding tube supplies, leaving the resident's abdomen exposed to the hallway. The resident, who is non-verbal and severely cognitively impaired, attempted to cover himself and later indicated a preference for privacy during care. The nurse acknowledged forgetting to provide privacy, and facility policy requires maintaining resident dignity and privacy during personal care.
A resident with severe cognitive impairment and a history of falls was found on the floor by a CNA, who failed to notify a nurse and moved the resident without a licensed assessment, contrary to facility policy. The incident was only reported after the responsible party observed it on video and contacted the facility, resulting in a delayed assessment and documentation.
A medication cup containing calmoseptine ointment was left unsecured and unattended in a resident's room, despite the resident's severe cognitive impairment and lack of orders to self-administer medications. Nursing and CNA staff were either unaware of the ointment's presence or did not secure it, and facility policy required all medications and treatments to be locked and accessible only to authorized personnel.
Staff failed to follow infection control protocols during care for two residents, including not changing soiled gloves or performing hand hygiene during incontinent care and feeding tube supply replacement. Supplies were improperly stored on a dirty linen cart, and staff moved between contaminated and clean tasks without proper glove changes or handwashing, despite recent in-service training on infection control procedures.
Three residents with mobility needs were observed using wheelchairs with cracked right armrests and exposed foam, despite having care plans that included wheelchair mobility. Staff interviews revealed inconsistent reporting of needed repairs, with CNAs and RNs relying on verbal communication rather than the required electronic maintenance system. The Maintenance Director and Administrator confirmed that no repair requests had been entered and that there was no policy or procedure for equipment repair.
A nurse failed to administer medications as ordered for a resident with a G-tube, including giving a chewable aspirin instead of a capsule, substituting an over-the-counter calcium supplement, and administering Geritol instead of Maalox. The nurse did not check for the correct medications or consult with other staff, leading to multiple medication errors during a single medication pass.
A resident with significant medical needs did not receive medications as ordered when an RN administered incorrect forms and substitutes of prescribed drugs via G-tube, resulting in a medication error rate of ten percent. The RN failed to follow proper medication administration protocols, including giving a chewable aspirin instead of a capsule, crushing a tablet that should not have been crushed, and substituting Geritol for Maalox, without notifying the DON or obtaining physician approval.
A resident with multiple health conditions experienced a delay in diagnosis and treatment of pneumonia due to the facility's failure to obtain a chest X-ray and results in a timely manner. The X-ray was ordered as routine, leading to delays by the contracted provider, and the facility lacked a specific policy for managing X-ray orders and results, contributing to the deficiency.
A registered nurse failed to disinfect a blood pressure cuff between uses on multiple residents and did not perform hand hygiene after stoma care or before administering G-tube medications to a resident with significant medical needs. The nurse also inadequately cleaned reusable equipment, contrary to facility policy and prior training, resulting in a breakdown of infection prevention and control procedures.
A resident with severe cognitive impairment was hit by a CNA in response to the resident's aggressive behavior, resulting in a red handprint on the resident's thigh. The CNA admitted to the action, which violated the facility's abuse and neglect policy. The incident was reported to the DON and ADM, and the facility had addressed the issue before the state's investigation.
The facility failed to ensure the proper administration of parenteral fluids for two residents, as their IV dressings were not changed according to physician orders. This oversight placed the residents at risk of infection.
A resident's call light was found out of reach on two separate occasions, despite facility policy and staff acknowledgment that it should always be accessible. The resident has significant medical conditions, and staff interviews confirmed the oversight.
A resident with a gastrostomy tube was found in unsanitary conditions, with dried formula spills and trash in their room. Interviews revealed a lack of proper cleaning and communication among staff, leading to a failure in maintaining cleanliness and infection control.
A facility failed to ensure accurate MDS assessments, leading to a resident being incorrectly documented as having a wound infection. The error was due to prepopulated data from a previous assessment and a lack of review for accuracy, as confirmed by interviews with staff and a review of the resident's records.
The facility failed to act on the Pharmacist Consultant's recommendation to update a resident's Lidocaine patch order to include 12 hours on and 12 hours off. The resident continued to receive the patch daily without removal instructions, and the DON was unaware of the oversight. The facility lacked a policy for Drug Regimen Review.
The facility failed to ensure that a resident was free from significant medication errors by administering Losartan Potassium outside of physician-recommended parameters on four occasions. Despite the resident's blood pressure being below the safe range, medication aides administered the drug, contrary to the care plan and medication administration policy.
A resident with severe cognitive impairment was found with an unsupervised medication cup in her room, indicating a failure in proper medication storage and administration. Staff acknowledged the issue, and the DON confirmed the responsible nurse was an agency nurse.
A facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had a history of elopement, left the building without staff being aware and was found approximately 2/10ths of a mile away. Despite previous incidents, there were no current special supervision precautions in place, and staff were unaware of the resident's potential to elope.
PBJ Staffing Data Not Submitted
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2026, including agency and contract staff, using payroll and other verifiable and auditable data in the required uniform format. Review of the CMS PBJ report showed the facility did not submit staffing data for the quarter. The report identified that the submission failure was tied to the facility’s PBJ reporting process and the quarter ending December 31, 2025. During interviews, HR stated staffing hours were gathered from invoices, adjusted through time adjustment forms, entered into the Workday payroll tracking system, and then pulled by the Home Office service center for submission to CMS. The DON gave a similar account, stating nursing hour reports were received from HR, verified, entered into Workday, and then submitted by the service center. The ADMIN also stated that nursing hours were compiled through HR and DON review, entered into Workday, and submitted by the service center. The ADMIN said the report would be pulled to determine whether any nursing hours were missing. Record review of the facility’s internal investigation showed the PBJ data was submitted by the facility payroll vendor, but CMS loaded a report showing a failed submission. The investigation stated that one employee did not match due to new software that went live on 1/1/26, causing a fatal error. The facility identified a coding error attached to employee positions in the file, and the contracted service did not discover the issue until after the submission deadline had passed. CMS later denied the facility’s appeal to resubmit the PBJ data. The ADMIN stated the facility did not have a PBJ policy other than following CMS guidelines, and the CMS policy manual required quarterly direct care staffing and census data to be timely and accurate.
Failure to Maintain Privacy During Blood Sugar Checks and Incontinent Care
Penalty
Summary
The facility failed to ensure resident privacy during medical treatment and personal care for three residents. Resident #46, a male with diabetes mellitus and moderate cognitive impairment, was observed during a blood sugar check by RN B on 06/24/2026. RN B sanitized her hands, put on gloves, entered the room, and performed the blood sugar check without closing the door or pulling the privacy curtain, and the treatment could be seen from the hallway. Resident #70, a female with diabetes mellitus and moderate cognitive impairment, was also observed on 06/24/2026 during a blood sugar check by RN B. RN B again sanitized her hands, put on gloves, entered the room, and completed the blood sugar check without closing the door or pulling the privacy curtain, allowing the treatment to be seen from the hallway. During an interview later that day, RN B stated the door should have been closed or the privacy curtain should have been pulled during any treatment to provide privacy and prevent embarrassment. Resident #81, a 74-year-old male with hemiplegia, hemiparesis, severe cognitive impairment, and bowel and bladder incontinence, was observed on 06/23/2026 during incontinent care by CNA F and CNA G. The CNAs washed their hands, put on gloves, and proceeded with care without pulling the privacy curtain between the resident and his roommate. The roommate was in the room, and the care could be seen from the roommate's side. CNA F stated he forgot to pull the curtain, and CNA G stated she did not notice it had not been pulled. The DON and Administrator stated staff must provide privacy during care and treatment, and the facility policy reflected that residents have the right to privacy.
Failure to follow ordered wound and skin care
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice for three residents reviewed for quality of care. One resident had moisture associated skin damage (MASD) and a care plan intervention to keep the skin clean and dry, with an order for Calmoseptine every shift and as needed for soiling. During observation, a CNA was transferring the resident after a shower while the resident’s pants were only halfway on, the resident had no brief on, no towel or blanket covered the gerichair seat, and the resident’s bare perineal area was directly touching the seat. After the transfer, the gerichair seat was observed to be wet and the resident’s bottom had scratches. The CNA stated she had just finished the shower and would raise the resident’s pants after transfer, and she did not explain why the resident had no brief or why the seat was uncovered. Another resident had fluid overload, edema, and weeping areas to both feet, with care plan interventions and physician orders to cleanse and change the kerlix dressings daily and as needed when leaking. During observation, both feet were wrapped in wet, white dressings while the resident was sitting in a wheelchair in the hallway. The RN stated the dressings had already been changed but were wet because of the resident’s weeping edema, and she did not know how long they had been wet. She acknowledged that if the dressings were wet and saturated, they could impair healing and further irritate the skin. A third resident had diabetes, cellulitis of the right lower limb, moderate cognitive impairment, and a right shin wound with an order to cleanse the wound with wound cleanser, pat dry, apply Iododorb to calcium alginate, and cover with a dry dressing. During wound care observation, the RN cleansed the inside of the wound after cleaning the surrounding skin with the same gauze. The RN stated the proper technique was to clean from the inside of the wound to the outside, from least contaminated to most contaminated area. The DON also stated that wound care should go from the center to the periphery of the wound to keep a healthy wound bed and promote wound healing. The facility policy reviewed stated to cleanse the wound with the ordered solution, use no-touch technique, and wash from the center of the wound to the periphery.
Late Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for three residents reviewed during medication pass observations. On 06/24/26, Resident #69, a female with dementia and Type 2 diabetes with hyperglycemia, had an order for Metformin HCL 500 mg scheduled for 6:30 a.m., but during an observation at 7:56 a.m. the medication was still due on the eMAR and the resident was eating breakfast in her room. MA C stated the medication was scheduled for 6:30 a.m. and attempted to administer it using the Korean language line, but the resident refused and RN C was notified. Resident #40, a female with Type 2 diabetes, cellulitis of the right lower limb, and dysphagia, had an order for Protonix 40 mg scheduled for 6:30 a.m. During an observation at 8:12 a.m., MA C was passing medications in hall 200, the resident’s eMAR was red, and the resident was in her room sleeping with her breakfast tray untouched. MA C stated the medication was scheduled for 6:30 a.m., and after the resident said she could take it then, MA C administered the medication. Resident #38, a female with GERD and dysphagia with severe cognitive impairment, had an order for Omeprazole 20 mg scheduled for 6:30 a.m. During an observation at 8:34 a.m., MA C was still passing medications, the eMAR was red, and the resident was resting in bed. MA C stated the medication was scheduled for 6:30 a.m. and then administered it. During interviews, MA C stated the facility policy was that medications should be given within one hour before or after the scheduled time and that doctors’ orders should be followed. RN C stated that when a medication was late, the MA had to notify the nurse, and if the medication was late it was a medication error. The DON stated medications should be given within the correct time frame, that the MA should notify the nurse and DON to call the doctor for direction, and that medications should be on time to have their full effects. The facility policy stated medications must be administered in accordance with the written orders of the attending physician and that if a drug was withheld, refused, or given other than at the scheduled time, the reason must be documented on the MAR or eMAR.
Late Administration of Scheduled Morning Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors found an 11.11% medication error rate, based on 3 errors out of 27 opportunities, involving three residents and one medication aide. The errors involved late administration of scheduled 6:30 a.m. medications for three residents on the same morning, and each medication was given after the scheduled time while the eMAR was marked red. Resident #69 was an older female with dementia and Type 2 diabetes with hyperglycemia. Her physician ordered Metformin HCL 500 mg twice daily for diabetes, scheduled for 6:30 a.m. and 4:30 p.m. During observation, she was in her room eating breakfast when the medication aide attempted to administer the 6:30 a.m. dose at 7:56 a.m. The aide stated the medication was scheduled for 6:30 a.m., attempted to give it using the language line, and the resident refused. The aide then notified the RN, who notified the physician. Resident #40 had diagnoses including Type 2 diabetes, cellulitis of the right lower limb, and dysphagia. She had an order for Protonix 40 mg in the morning for heartburn/indigestion, scheduled for 6:30 a.m. During observation, she was in her room sleeping with her breakfast tray untouched when the medication aide administered the dose at 8:04 a.m. Resident #38 had diagnoses including GERD and dysphagia, with an order for Omeprazole 20 mg in the morning for GERD, scheduled for 6:30 a.m. During observation, she was resting in bed when the medication aide administered the dose at 8:12 a.m. Interviews with the medication aide, RN, and DON confirmed that medications were expected to be given within an hour before or after the scheduled time, that late medications were to be reported to nursing, and that giving a medication late was considered a medication error.
Medication and topical products left accessible in resident rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and kept out of resident rooms for three residents reviewed for medication storage. During observation, Resident #29, who was cognitively intact with a BIMS score of 15 and incontinent of bladder and bowel, had a tube of zinc oxide on top of the side table in plain view. Her care plan addressed incontinent care, but the record did not show an assessment for self-administration of medications, competency to apply barrier cream, or permission to store medications in her room. The resident stated staff used the cream when changing her brief and that it had always been kept at her bedside. Resident #9, who was cognitively intact with a BIMS score of 15 and dependent for ADLs, was observed lying in bed with a bottle of Vicks Vapor Stick on top of the overbed table. Her care plan included an intervention to evaluate whether she could follow directions, tell time, and store medication safely and securely, but the record did not show an assessment for self-administration of medications, competency to apply barrier cream, or permission to store medications in her room. The resident stated she used the Vicks to clear her sinuses and that staff knew she used it and had not told her she was not allowed to keep it. Resident #40, who had a BIMS score of 11 and diagnoses including Type 2 diabetes and cellulitis of the right lower limb, had a physician order for peri-area and inner groin care with calmoseptine/nystatin mixture three times daily and as needed for MASD. During observation, a peri-guard wipe and a container of pink paste were on her bedside table. She stated staff used the items when performing peri-care and that they were left on the bedside table after she was cleaned. Staff interviews stated these items should not be in resident rooms and that residents were not supposed to have unauthorized items in their rooms unless carefully assessed and care planned to self-administer medications.
Kitchen Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation in the kitchen, several food items were found in gallon bags or containers without visible expiration dates, including pasta egg noodles dated 06/12/2026, spaghetti noodles dated 05/11/2026, white cake mix dated 05/12/2026, sliced cheese dated 06/21/2026, shredded cheese dated 06/21/2026, and purred fruit dated 06/18/2026. A gallon bag of shredded carrots also had brownish spots. The report stated these items were not properly dated, discarded prior to use-by date, or properly sealed. During interview, the DM stated all staff were responsible for labeling and that the items would be corrected. The DM stated that serving foods past the use-by date or not labeled or dated could cause food borne illness, and that once items were opened they should be properly sealed and dated. The ADMIN stated she oversaw all departments and was made aware of the kitchen concerns by the DM. She stated expired, unlabeled, or improperly dated food could cause food contamination and residents getting sick, and that she expected the DM to ensure the kitchen followed facility policies and procedures. The facility's Food Storage Policy stated that food storage areas shall be maintained in a clean, safe, and sanitary manner and that all foods shall be labeled and dated prior to being stored.
Infection Control Failures During Resident Care and Staff Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program during multiple observed care activities involving residents with feeding tubes, catheters, wounds, and incontinence care. Resident #39, who had weakness, muscle wasting, and required staff assistance with meals and transfers, was observed being fed at the same time as another resident by CNA J without hand hygiene between residents. The same CNA later transferred Resident #39 after a shower while the resident had no brief on, no clean towel or blanket covering the geri-chair seat, and the resident’s bare perineal area touched the chair seat directly. Resident #46, who had fluid overload, edema, and weeping lower-extremity skin impairment, was observed sitting in a wheelchair with wet kerlix dressings on both feet that were touching the floor. Resident #70, who had neuromuscular dysfunction, moderate cognitive impairment, and an indwelling suprapubic catheter, was observed having her catheter bag emptied by CNA H without a gown, despite a sign on the door indicating gown use for catheter care. The same resident was later transferred to a motorized wheelchair by CNA H and CNA I without gowns, even though the door sign also indicated a gown was required for catheter transfers. Resident #81, who had severe cognitive impairment, dysphagia, a feeding tube, and an order for enhanced barrier precautions, was observed receiving incontinent care from CNA F without a gown and without hand hygiene when changing gloves. CNA F also repositioned the resident while in direct contact with the resident’s upper body. Later, CNA F and CNA G transferred the resident to a wheelchair without gowns, and CNA G stripped the resident’s bedding without a gown, despite signage in the room requiring gowns for these high-contact activities. In addition, LVN E placed a personal lunch bag inside the medication room refrigerator, and RN S did not sanitize her hands after removing dirty gloves and before putting on clean gloves multiple times while performing wound care on Resident #40, who had diabetes, cellulitis, and a right shin wound requiring daily dressing changes.
Call Light Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of Resident #12’s needs and preferences when the call light in his room was not kept within his reach. Resident #12 was a male resident admitted to the facility with diagnoses including dementia, history of falling, need for assistance with personal care, and age-related physical debility. His MDS assessment showed a BIMS score of 99, indicating he was unable to complete the assessment, and his care plan identified him as a fall risk with an intervention to ensure the call light was within reach and to encourage him to use it. During observations, Resident #12 was lying in bed while his call light was found on the floor under his bedside table and out of reach. Staff interviews confirmed that the call bell should be within reach at all times and that everyone was responsible for ensuring it remained accessible. The housekeeper stated the call bell should not have been left on the floor, the CNA and LVN stated it should always be within reach, and the DON and Administrator stated the expectation was that it remain within reach for the resident to call for assistance.
MDS Did Not Reflect Resident’s Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident #8’s Comprehensive MDS Assessment accurately reflected the resident’s status for oxygen therapy. Resident #8 was a [AGE]-year-old female admitted to the facility with a diagnosis of chronic obstructive pulmonary disease and had a BIMS score of 07, indicating severe cognitive impairment. The Comprehensive MDS Assessment dated 03/24/2026 did not indicate that the resident was receiving oxygen, and the Comprehensive Care Plan dated 06/22/2026 also did not include a care plan for oxygen use. Record review showed a physician order dated 02/17/2026 for oxygen at 2 L/min continuously via nasal cannula every shift for shortness of breath related to COPD. During an observation on 06/23/2026, the resident was in bed with eyes closed and was observed on oxygen therapy. During an observation and interview on 06/24/2026, the MDS Nurse stated that if Resident #8 was using oxygen continuously, the resident should be coded for oxygen therapy, and after reviewing the physician order and the MDS, she noted the resident had not been coded for oxygen therapy. She then changed the code and stated it was an oversight. The DON and Administrator later stated that the MDS should reflect the resident’s current status and diagnoses.
Failure to Care Plan Continuous Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #8 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #8 was a female admitted to the facility with a diagnosis of COPD and a BIMS score of 07 indicating severe cognitive impairment. Her physician ordered oxygen at 2 L/min continuously via nasal cannula every shift for shortness of breath related to COPD, and she was observed on oxygen therapy during the survey. Record review showed that Resident #8’s comprehensive care plan dated 06/22/2026 did not include a care plan for oxygen use, and the MDS assessment dated 03/24/2026 did not indicate that she was receiving oxygen. During interview, the MDS Nurse stated that if the resident was using oxygen continuously, there should be a care plan for oxygen use so staff would know how to manage it, and she updated the care plan to reflect that the resident was using oxygen. The DON and Administrator stated that residents should be care planned according to their needs so staff providing care would be on the same page, and the facility policy stated that the interdisciplinary team shall develop a comprehensive care plan for each resident.
Hazardous Items Found in Resident Rooms
Penalty
Summary
The facility failed to keep resident rooms free of hazardous items when a can of Sani-cloth germicidal disposable wipes was observed on the shelf in a resident’s room. The resident was a female with dementia and metabolic encephalopathy who required substantial to maximal assistance with eating and was dependent for oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. Her care plan identified her as at risk for impaired cognitive function and thought processes related to dementia and noted that she needed supervision and assistance with all decision making. During the observation, the wipes were present in the room, and staff interviews confirmed that such items should not be in residents’ rooms. An LVN stated that the wipes should not be in resident rooms per facility policy and that nurses and care staff were responsible for ensuring they were not present. A MA and CNA also stated that the wipes should not be in residents’ rooms and should be reported if found. The DON stated that residents are not supposed to have Sani-wipes in their rooms and that staff had started in-servicing right away. The facility also failed to keep a resident’s room free of sharp objects when scissors were observed in the hands of a male resident. He had dementia, a history of falling, and needed assistance with personal care; his MDS indicated a BIMS score of 99, meaning he was unable to complete the assessment. His care plan stated that he was at risk for impaired cognitive function or thought processes related to dementia and needed redirection and assistance to find his room and time-related activities. The Administrator removed the scissors after the resident stated that his daughter had given them to him. Staff interviews and the facility policy reflected that sharp or hazardous items should not be in residents’ rooms and that room searches should be conducted if unsafe items are suspected.
Improper catheter bag positioning during transfer
Penalty
Summary
The facility failed to ensure appropriate catheter care and services to prevent urinary tract infection for one resident with an indwelling suprapubic catheter. Resident #70 was a 67-year-old female with neuromuscular dysfunction of the bladder, moderate cognitive impairment with a BIMS score of 08, and a care plan intervention directing staff to position the catheter bag and tubing below the bladder. During an observation, the resident was in bed with the catheter bag hanging at the side of the bed and stated she had the catheter because her bladder was not working. During a transfer from bed to a motorized wheelchair using a mechanical lift, CNA H placed the catheter bag on top of the resident before the resident was lowered into the wheelchair. The catheter bag remained on top of the resident while CNA H adjusted the wheelchair leg rest, and CNA I observed the bag in that position but did not remind CNA H that it should remain below the bladder. CNA H later stated she forgot to hook the catheter bag at the side of the wheelchair and acknowledged that the bag should always be below the bladder to prevent backflow of urine that could cause a UTI. The DON stated catheter bags should always be below the bladder to prevent backflow of urine from the catheter bag to the bladder.
Improper Storage of Oxygen Tubing and Spirometer
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD, chronic respiratory failure, and CHF when the resident’s oxygen nasal cannula was left exposed and not bagged when it was not in use. The resident’s care plan called for oxygen therapy at 2 LPM per nasal cannula, and the physician order directed continuous oxygen at 2-4 L/min with routine tubing and humidifier care. During observation after the resident was transferred from a wheelchair to bed, the CNA removed the nasal cannula from the wheelchair oxygen tank and left it exposed rather than bagged. The resident stated the CNA did not know whether the cannula should be bagged. During interviews, the LVN stated the facility policy required oxygen tubing to be bagged when not in use to prevent bacteria from contaminating the tubing and potentially causing infection or worsening the resident’s condition. The CNA stated the tubing should be bagged when not in use and acknowledged that leaving it exposed could contaminate it and require replacement. The DON also stated the tubing should be bagged after the resident was transferred to bed if oxygen was not in use, and that all care staff were responsible for ensuring it was bagged per facility policy. The facility also failed to ensure a resident’s spirometer was properly stored when not in use. The resident had diagnoses of atelectasis and asthma and severe cognitive impairment. During observation, an unbagged spirometer was found on top of the resident’s dresser with the mouthpiece touching the wall. RN A stated she was not sure whether the resident was using the spirometer or had an order for it, but said it should be bagged because it was still in the room and should be kept clean. The DON and Administrator later stated the spirometer should be bagged to keep it clean, and the facility policy required the mouthpiece to be placed in a plastic storage bag between exercises.
Pest Control Program Failed to Keep Resident Room Free of Gnats
Penalty
Summary
The facility failed to maintain an effective pest control program to keep one resident room free of pests and rodents when a gnat was observed flying and perching on Resident #69’s breakfast tray while she was eating. Resident #69 was an elderly female admitted to the facility with diagnoses of dementia and Type 2 diabetes with hyperglycemia. Her MDS assessment documented severe cognitive impairment with a BIMS score of 06, and her care plan addressed altered endocrine status related to diabetes mellitus with monitoring for side effects and effectiveness of medication. During the observation, MA C noticed the gnat on the resident’s breakfast tray and stated the resident should not have gnats on her breakfast tray while eating. Interviews with MA C, CNA M, RN C, Housekeeper A, the Maintenance Director, the DON, and the Administrator confirmed that pests had been reported in the building, that staff used a logbook and verbal reporting process, and that the facility had a pest control company that came monthly and as needed. The Maintenance Director and DON stated gnats were present in the building, and the DON and Administrator stated family members sometimes brought in kimchi or uncovered food, which was associated with the gnat problem.
Resident Self-Access to Ice Cooler in Violation of Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from independently accessing ice from an ice cooler, contrary to infection control expectations. The resident was an adult woman with epilepsy, Down syndrome, major depressive disorder, and mild intellectual disabilities, and had a BIMS score of 07, indicating severe cognitive impairment. On the observed date, the ADON assisted the resident by opening the lid on her cup, after which the resident walked toward the area near the dining room, poured a can of soda into her cup, and placed the cup and lid on top of the ice cooler. The resident stated she obtained ice for her cup herself, indicating staff did not assist her with getting ice from the cooler. Staff interviews confirmed that this resident sometimes got ice from the cooler on her own and that other residents did not. RN A stated that staff tried to assist the resident with getting ice when they saw her walking around, as she might be going to the cooler, but acknowledged that the resident did sometimes get ice herself. CNA B also indicated that the resident often got her own ice, despite residents not being supposed to do so. The ADON confirmed she had opened the resident’s cup but did not anticipate the resident would go to get ice, and acknowledged that the resident would forget staff instructions to ask for help. Staff, including RN A, CNA B, the DON, and the ADM, all identified that residents were not supposed to get their own ice due to concerns about contamination and infection control, yet the resident was still able to access the ice cooler independently.
Failure to Accurately Account for and Properly Dispose of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate system for disposition and accounting of controlled medications and to ensure staff competency in these processes. During medication pass on one hall, a medication aide (MA A) reported she had never experienced a resident refusing narcotics or controlled medications, but stated that if a resident refused, she would waste the medication directly into the sharps container on her cart, with or without a witness. She stated she did not think a witness was needed and was unsure of the risk of wasting without a witness. MA A also stated that the controlled medication count sheet should always be documented immediately after administration to prevent forgetting and causing a discrepancy, and reported she had not received in‑service training on controlled medication counting and disposal since starting work in September 2025. On another hall, observation of a medication cart managed by a second medication aide (MA B) revealed a discrepancy between the Lorazepam card and the controlled drug count sheet for one resident: the medication card showed 18 tablets while the count sheet showed 19. MA B stated he had administered Lorazepam to the resident earlier that morning but forgot to document the count sheet immediately because he became busy, and acknowledged that failure to document right away could lead to suspicion of drug diversion. The resident confirmed receiving all medications that morning and did not notice any missed dose, and the MAR reflected Lorazepam administration at 0700. Other staff, including an LVN and the DON, described facility expectations that controlled medications be wasted only with a witness, using a drug buster rather than a sharps container, and that count sheets be updated as soon as a controlled medication is removed from the cart. Facility policy required two licensed or registered personnel to document destruction of medications and to dispose of medications in a manner that renders them unusable.
Failure to Maintain Resident Rooms Free of Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ environments free from accident hazards to the extent possible for three residents with cognitive impairment and mental health diagnoses. One male resident with dementia, severe cognitive impairment, and depression was observed with a can of Lysol spray sitting on top of a 5‑drawer chest in his room. A female resident with major depressive disorder, moderate cognitive impairment, and an impaired cognitive function care plan was observed with a can of aerosol air freshener spray on top of her nightstand. When shown these items, RN A stated that residents were not supposed to have these cans in their rooms because they were a biohazard and dangerous for the residents. Another female resident with dementia, conduct disorder, and severe cognitive impairment, who also had a care plan for impaired cognitive function, was observed lying in bed while pointing to a phone charger cord that she had inserted directly into an electrical outlet without the charging plug attached; the plug was observed separately on top of her 5‑drawer chest. A sign above the outlet requested that staff assist the resident by ensuring her phone was plugged in and turned on. During an interview and observation, RN A and CNA L acknowledged that staff should have connected the resident’s phone to the charger after placing her in bed, and stated the resident could injure herself if she attempted to charge the phone on her own. The Administrator and DON were informed of the situation, and the DON stated staff should have plugged in the charger for the resident and that the resident could have harmed herself by plugging the charging cord directly into the outlet. The facility’s Resident Rights policy stated that residents have a right to a safe, clean, comfortable, and homelike environment and that the facility must ensure residents can receive care and services safely and that the physical layout does not pose a safety risk.
Improper Storage of Respiratory Equipment Between Uses
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice and residents’ care plans by not properly storing nebulizer masks and nasal cannulas when not in use. For one resident with COPD and severe cognitive impairment, surveyors observed a nebulizer mask ordered for PRN Ipratropium-Albuterol treatments sitting unbagged on the nightstand. For another resident with COPD, chronic respiratory failure, and severe cognitive impairment, a breathing treatment mask ordered for PRN Ipratropium-Albuterol was also observed unbagged on the nightstand. Both instances occurred despite physician orders for respiratory treatments and the residents’ need for respiratory equipment. Two additional residents with severe cognitive impairment were observed with nasal cannulas not stored in bags when not in use. One male resident with COPD had a nasal cannula hanging unbagged on his oxygen concentrator, and he reported that he had not used the oxygen device in a few days and did not use it much. Another male resident with chronic kidney disease and an order for continuous oxygen at 2 L/min via nasal cannula had his nasal cannula hanging unbagged on an oxygen tank attached to his wheelchair. Nursing staff, including an RN and an LVN, acknowledged during interviews that nebulizer masks and nasal cannulas should be placed in plastic bags when not in use to prevent contamination and infection, and the DON similarly stated that these items needed to be bagged to avoid residents getting an infection. The facility’s written oxygen administration policy did not address bagging respiratory devices when not in use.
Inaccessible Call Systems for Multiple Cognitively Impaired, High-Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to a functioning call system from their beds and bathrooms/bathing areas, as required by facility policy. For three residents with severe cognitive impairment and documented fall risk, surveyors found that call systems were not within reach. One resident, an elderly female with lack of coordination, history of falling, and a care plan intervention specifying that the call system be within reach, was observed lying in bed without a call light. Instead, she had a bell attached to a bedside table that was placed across the room near a chest of drawers, out of her reach. Staff, including an RN and a CNA, acknowledged that the resident used the bell to contact staff, that she was unable to self-transfer and required staff assistance, and that staff should have placed the bedside table near her. The RN stated the resident had a history of yanking the call light cord out of the wall and destroying it. Two additional residents, both elderly males with severe cognitive impairment, muscle weakness or lack of coordination, unsteadiness on feet, and care plans identifying them as fall risks with interventions to keep call lights within reach, were also found without accessible call lights. One resident’s call light was observed on the floor behind the bed, and the other’s was hanging down from the head of the bed, both out of reach. A CNA observed that these residents often knocked the call lights off the bed and stated she would use a clip to secure them, acknowledging that call lights needed to be within reach so residents could call for assistance. The DON confirmed that all staff were responsible for ensuring call lights were within residents’ reach, and an LVN covering the hall also stated that call lights should be within reach so residents could call for help. The facility’s written policy required that each resident be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Provide Scheduled Wound Care and Communicate Missed Treatments
Penalty
Summary
A resident with multiple diagnoses, including hypertension, dementia, and muscle weakness, was admitted with an open lesion on the right heel. The care plan specified that wound care was to be administered to the right heel on Monday, Wednesday, and Friday, as ordered by the physician. Documentation and observation revealed that wound care was not provided as scheduled on two occasions, with dressings on the heel dated several days prior to the surveyor's observation. The resident was noted to have severe cognitive impairment and required assistance with personal care. Interviews with nursing staff revealed that wound care was missed on the scheduled days because the responsible RNs were too busy and failed to complete the treatments. Both RNs admitted they did not inform the oncoming nurse or the DON about the missed wound care, as required by facility protocol. The DON confirmed she was not made aware of the missed treatments and stated that the expectation was for nurses to report and ensure completion of wound care if unable to perform it themselves. Facility policy required that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, with nursing staff responsible for administering treatments as ordered. The failure to provide wound care as scheduled and to communicate missed treatments to supervisory staff constituted a lapse in following professional standards of practice and facility policy, resulting in a deficiency related to the prevention and treatment of pressure ulcers.
Failure to Provide Privacy During Wound Care
Penalty
Summary
A registered nurse (RN) failed to provide privacy and maintain the dignity of a resident during a routine change of gastroenterology (feeding tube) supplies. The RN entered the resident's room, did not close the door, and did not pull the privacy curtain, resulting in the resident's abdomen being exposed and visible from the hallway throughout the procedure. The resident, who is non-verbal due to severe cognitive impairment and a history of cerebral vascular disease, aphasia, and dysphagia, attempted to cover himself by pulling up the sheet and adjusting his gown. The resident later indicated through non-verbal communication that he did not like having the door open during care and preferred it to be closed. During interviews, the RN acknowledged forgetting to ensure privacy and admitted awareness of the facility's policy and training regarding residents' rights to privacy, dignity, and respect. The Director of Nursing confirmed that privacy and dignity should be maintained during all nursing care, including closing the door and pulling the privacy curtain. Facility policy requires that residents be treated with dignity and that their bodies be shielded from view during personal care activities.
Failure to Follow Fall Reporting and Assessment Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow facility policy and procedure after finding a resident on the floor in her room. The CNA did not report the incident to the nurse in charge and instead assisted the resident up from the floor, placed her in a wheelchair, and took her to the dining room for breakfast. The resident was not assessed by a licensed nurse prior to being moved, contrary to facility policy which requires a nurse assessment before moving any resident found on the floor. The resident involved was an elderly female with a history of hypertension, non-Alzheimer's dementia, cerebrovascular accident, and repeated falls. She had severe cognitive impairment, used a wheelchair for mobility, and required assistance with transfers and activities of daily living. Her care plan specified that she was at risk for falls and required one-person assistance for transfers, use of a gait belt, and immediate nurse notification if a fall or injury occurred. Despite these interventions, the CNA did not follow the care plan or facility policy when the resident was found on the floor. Interviews and record reviews confirmed that the CNA was aware of the policy to leave residents in place and notify a nurse if found on the floor, but did not comply. The incident was only discovered when the resident's responsible party observed the event on a camera and notified the facility. The nurse was not informed until after the responsible party's call, at which point the resident was assessed and appropriate documentation was completed. The failure to follow established procedures resulted in the resident not being assessed for injuries in a timely manner.
Unsecured Medication Ointment Left in Resident Room
Penalty
Summary
A deficiency occurred when a medication cup containing a pink ointment, identified as calmoseptine ointment, was found unsecured and unattended on top of a dresser in a resident's room. The resident had severe cognitive impairment, was unable to make decisions, and required staff assistance for activities of daily living. There were no physician orders for the resident to self-administer medications. During observations and interviews, nursing staff acknowledged the ointment was likely used for the resident's skin care, but did not remove it from the room or secure it. Certified nursing assistants interviewed were unaware of the ointment's presence or use, and one stated she did not use any cream during care. Further interviews with licensed nursing staff and the Director of Nursing confirmed that all treatments, including ointments, were supposed to be stored in a locked treatment cart and only accessed by authorized personnel. The facility's policy required drugs and treatments to be administered only upon a licensed provider's order and to be securely stored. The failure to secure the ointment and restrict access to authorized personnel constituted a breach of the facility's medication storage protocols.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by direct observations of staff not following established protocols during resident care. One certified nursing assistant (CNA) did not perform hand hygiene or change soiled gloves during incontinent care for a female resident with severe cognitive impairment, hypertension, diabetes, and dementia. The CNA also used supplies stored on a dirty linen cart and failed to wash hands or use sanitizer after completing care, returning contaminated items to the cart. The CNA acknowledged awareness of proper procedures but attributed the lapse to nervousness during survey observation. Additionally, a registered nurse (RN) did not change gloves or perform hand hygiene while replacing feeding tube supplies for a male resident with cerebral vascular disease, aphasia, dysphagia, and hypertension. The RN wore personal protective equipment but moved between contaminated and clean tasks without changing gloves or sanitizing hands, and left the room without performing hand hygiene. The facility's infection control policy requires handwashing after direct resident contact, after removing gloves, and after handling potentially contaminated items, but these procedures were not followed during the observed care. Interviews with staff and the Director of Nursing (DON), who also serves as the infection control preventionist, confirmed that staff had recently received in-service training on infection control, including glove changes and hand hygiene. Despite this training, staff did not adhere to the required protocols during care, as observed by surveyors. The DON acknowledged the importance of these practices and that failure to follow them could result in the spread of germs.
Failure to Maintain Wheelchairs and Ensure Hazard-Free Equipment
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were properly maintained and free of hazards for three residents reviewed for essential equipment. Observations revealed that each of these residents was using a wheelchair with a cracked right armrest and exposed foam while seated in the dining room. All three residents had care plans that included wheelchair mobility, and their medical histories included conditions such as dementia, cerebral vascular accident, heart failure, hypertension, weakness, and unsteadiness. At the time of observation, none of the residents had skin problems or tears on their arms. Interviews with staff indicated that the process for reporting wheelchair repairs was inconsistent. CNAs typically reported needed repairs verbally to the nurse in charge, while RNs stated that staff were supposed to inform the maintenance department. The Maintenance Director explained that repairs should be entered into the electronic maintenance system, but acknowledged that staff often failed to do so, making it difficult to track and address needed repairs. A review of the electronic maintenance system showed no entries for wheelchair armrest repairs during the relevant period, and the Administrator confirmed that there was no policy or procedure in place for equipment repair at the facility.
Failure to Administer Medications as Ordered via G-Tube
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to accurately administer medications to a resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion, who required assistance for activities of daily living and received medications via G-tube. The RN did not follow physician orders for three separate medications during a medication pass. Specifically, the RN administered a chewable aspirin (ASA) 81 mg via G-tube instead of the ordered ASA 81 mg capsule, without checking the medication room or consulting other staff for the correct form of the medication. Additionally, the RN administered an over-the-counter Calcium D supplement instead of the prescribed Calcium D oral tablet 600-400 mg, and did not mix the medication properly before administering it through the G-tube. The RN also failed to administer the ordered Maalox (aluminum/magnesium suspension) and instead gave Geritol 5 ml. These actions were observed during the medication pass, and the RN acknowledged not following the correct procedures, citing being busy and running behind as reasons for the errors. Interviews with the RN and the Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered as prescribed and that staff should notify the DON if medications are unavailable. The RN admitted to not following the established medication administration process, including verifying medication availability and consulting with the DON or physician before substituting medications.
Medication Error Rate Exceeds Five Percent Due to Incorrect Administration and Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass, resulting in a ten percent error rate for one resident. Specifically, a registered nurse (RN) did not administer medications as ordered for a male resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion. The resident required assistance with activities of daily living and received medications via G-tube. During observation, the RN did not have the prescribed ASA (aspirin) 81 mg capsules available and instead administered a chewable form of ASA through the G-tube. The RN also incorrectly crushed and administered a Calcium D oral tablet that was not intended to be crushed, and substituted Geritol for the prescribed Maalox suspension. These actions were not in accordance with the physician's orders or facility policy, which requires medications to be administered as prescribed. Interviews with the RN revealed a lack of adherence to medication administration protocols, including failure to notify the DON when medications were unavailable and administering substitute medications without physician approval. The RN acknowledged being busy and running behind, which contributed to the errors. The resident was able to respond to some questions and indicated feeling safe and cared for at the facility.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide or obtain timely radiology services as ordered by a physician for a resident who was admitted with multiple diagnoses, including coronary artery disease, hypertension, and pneumonia. The resident, who was cognitively alert but experienced short periods of confusion and required assistance with activities of daily living, had a chest X-ray ordered due to a new onset cough. Despite the physician's order, the chest X-ray was not completed on the same day, and there was a delay in both obtaining the X-ray and receiving the results. Nursing documentation showed that the X-ray was ordered as routine, which allowed the contracted X-ray company to delay the service. Staff interviews revealed that the X-ray company often did not prioritize routine orders and sometimes refused to come on weekends, resulting in further delays. The nurse responsible for ordering the X-ray continued to follow up, but the company cited being too busy as a reason for the delay. The physician assistant and DON were both aware of the delay, and the physician assistant attempted to change the order to STAT, but the X-ray company did not process the change in a timely manner. The delay in obtaining the chest X-ray led to a delay in diagnosing and treating the resident's pneumonia. The facility did not have a specific policy or procedure in place for managing X-ray orders and test results, which contributed to the lack of timely follow-up and coordination with the X-ray provider. The deficiency was identified through record review and staff interviews, which confirmed that the facility did not ensure prompt diagnostic services as required.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during the care of a resident with multiple medical conditions, including a history of stroke, hemiplegia, and muscle weakness. The RN did not disinfect the blood pressure cuff between uses on different residents and failed to perform hand hygiene after providing stoma care and before administering medications via a G-tube. The RN was observed using the same blood pressure machine on multiple residents without cleaning it and did not wash her hands or use hand sanitizer after removing gloves and gown following direct care contact. Additionally, the RN used tweezers to clean the resident's stoma and returned them to a cup on the bedside table after only cleaning them with normal saline, rather than disinfecting them as required. The facility's policies and the infection control preventionist confirmed that equipment should be disinfected between residents and that hand hygiene should be performed before and after resident contact and medication administration. Despite having received prior in-service training on these procedures, the RN did not follow established infection control protocols during the observed care.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who hit a resident on the outer left thigh, leaving a red handprint. The incident occurred when the resident, who had severe cognitive impairment and was known to be resistive to care, reportedly hit the CNA, prompting the CNA to retaliate by hitting the resident. This action was contrary to the facility's policy and training on abuse and neglect, which the CNA had received. The resident involved was an elderly male with a history of dementia, stroke, and aphasia, and had a care plan that included interventions for being resistive to care. The care plan advised staff to leave the room, approach the resident later, or seek assistance from another staff member when the resident was resistive. Despite these guidelines, the CNA reacted physically to the resident's behavior, resulting in the abuse incident. Interviews with staff revealed that the CNA reported the incident to a Medication Aide (MA), who then informed the Director of Nursing (DON) and the Administrator (ADM). The CNA admitted to hitting the resident as a reaction to being hit first. The facility's policy on abuse and neglect was clear that any form of abuse, including physical retaliation, was unacceptable. The incident was identified as past noncompliance, and the facility had addressed the issue before the state's investigation began.
Failure to Change IV Dressings as Per Physician Orders
Penalty
Summary
The facility failed to ensure the proper administration of parenteral fluids consistent with professional standards of practice and physician orders for two residents. Resident #52, a [AGE] year-old female with a history of joint replacement surgery and infection, had a PICC line dressing that was not changed as per the physician's order. The dressing was last changed on 03/29/24, but it was not changed on 04/05/24 as required. During an interview, Resident #52 confirmed that her dressing had not been changed in the last week, and the nurse assigned to her was unaware of the missed dressing change. Similarly, Resident #3, a [AGE] year-old female with a history of a pelvic fracture and elevated white blood cell count, had a mid-line dressing that was not changed as per the physician's order. The dressing was last changed on 03/31/24, but it was not changed on 04/03/24 as required. During an interview, Resident #3 confirmed that her dressing had not been changed recently, and the nurse assigned to her was also unaware of the missed dressing change. The Director of Nursing (DON) stated that the expectation was for nurses to check PICC lines every shift, flush before and after medication, and change the dressing every 7 days or as needed if soiled. However, the DON was unaware of when the dressings for Resident #3 and Resident #52 were last changed. The facility's failure to follow physician orders for dressing changes placed the residents at risk of developing an infection.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a critical aspect of accommodating resident needs and preferences. Specifically, Resident #45, a [AGE] year-old female with diagnoses including metabolic encephalopathy, acute kidney failure, and adjustment disorder with anxiety, was found on two separate occasions with her call light placed out of reach on top of the light above her bed. This was observed on 04/09/24 and 04/10/24 while the resident was sleeping in her room. Interviews with staff, including an LVN and the DON, confirmed that the call light should always be within the resident's reach to ensure they can call for assistance when needed. The LVN admitted to not noticing the call light's placement during her morning check, and the DON stated that it was the responsibility of the assigned Angel, CNAs, or nurses to ensure the call light was accessible. The facility's policy, revised on 08/03/21, also mandates that the call device be placed within the resident's reach before leaving the room.
Failure to Maintain Clean and Homelike Environment for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with a gastrostomy tube. The resident's feeding pump and surrounding area were observed to be dirty, with dried formula spills on the floor and pole, and trash behind the oxygen tank and under the bed. The resident, who has severe cognitive impairment and relies on a feeding tube, was found in these unsanitary conditions during multiple observations. Interviews with the assigned nurse, housekeeper, and housekeeping director revealed a lack of proper cleaning and communication. The nurse admitted to not noticing the dirty g-tube poles and floor, while the housekeeper acknowledged the difficulty in removing dried formula and not cleaning under the bed regularly. The housekeeping director was unaware of the trash accumulation and expected his staff to clean thoroughly and report any issues. The Director of Nursing confirmed that nurses were responsible for cleaning the g-tube poles and housekeepers for the floors, highlighting a failure in maintaining cleanliness and infection control.
Inaccurate MDS Assessment for Wound Infection
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one resident reviewed for MDS assessment accuracy. Specifically, a quarterly MDS assessment for a resident was incorrectly coded to indicate a wound infection when no such infection was present. This error was identified through a review of the resident's face sheet, physician's orders, and interviews with the resident, the Director of Nursing (DON), an LVN, and two MDS Coordinators. The resident's face sheet and physician's orders did not show any indication of a wound infection, and interviews confirmed that the resident did not have any wounds or infected wounds during the relevant period. The error occurred because the MDS assessment section for wound infection was automatically prepopulated from a previous assessment and was not corrected before completion. The MDS Coordinator responsible for the assessment admitted to not catching the error. The facility's policy requires that each individual who completes a portion of the assessment certify its accuracy, but there was no process in place to review completed MDS assessments for accuracy. This lack of oversight led to the inaccurate documentation of the resident's condition, which could potentially affect the level of care provided.
Failure to Act on Pharmacist Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon for a resident reviewed for unnecessary medications and medication regimen review. The Pharmacist Consultant recommended updating the Lidocaine External Patch 4% order to include instructions to wear the patch for 12 hours on and then 12 hours off. However, this recommendation was not implemented, and the resident continued to receive the patch daily without an order for removal. The Director of Nursing (DON) was unaware that the recommendation had not been acted upon and admitted that reviewing the Pharmacist Consultant's recommendations was primarily her responsibility. The facility did not have a policy for Drug Regimen Review, and the DON could not provide any guidance being used. The resident involved was a [AGE] year-old female with diagnoses including a disorder of muscles and multiple sclerosis. Her comprehensive MDS indicated moderate cognitive impairment. The resident's physician's orders and Medication Administration Record (MAR) reflected the use of the Lidocaine patch daily without removal instructions. The failure to act on the Pharmacist Consultant's recommendation could place residents at risk for possible adverse side effects and decreased quality of life. The DON assumed that when pharmacy reviews were placed in the binder, they were completed, but this was not the case for the resident in question.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for one resident who was administered Losartan Potassium outside of the physician-recommended parameters. Resident #45, a [AGE] year-old female with diagnoses including unspecified dementia and essential hypertension, was given Losartan Potassium on four occasions when her blood pressure readings were below the prescribed thresholds. These instances occurred on 03/05/24, 03/10/24, 03/20/24, and 03/21/24, with different medication aides administering the medication despite the resident's blood pressure being out of the safe range specified by the physician's orders. The resident's care plan and medication administration records indicated that the medication should be held if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60, but these guidelines were not followed in the noted instances. Interviews with the medication aides and the Director of Nursing (DON) revealed a lack of adherence to the medication administration policy. One medication aide stated that he always checked the parameters before administering the medication and would notify the nurse if the vitals were out of range, but could not recall the documentation code for not administering the medication. The DON acknowledged that two medication aides had administered the medication out of parameters and that one aide was terminated for this reason. The DON also admitted that she was responsible for monitoring the residents' Medication Administration Records (MARs) but was unable to review all of them due to the high number of residents. The facility's Medication Administration policy, dated May 2007, mandates that medications must be administered according to the written orders of the attending physician, which was not adhered to in this case.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and administered properly, as evidenced by an incident involving a resident with severe cognitive impairment. The resident was found with a medication cup containing a white pill on her bedside table, which she stated she would take when she was ready. This medication was supposed to be administered by the nursing staff, but it was left unsupervised in the resident's room, contrary to the facility's policy and standard medication administration practices. Multiple staff members, including a medication aide, a licensed vocational nurse, and a certified nursing assistant, observed the pill in the resident's room and acknowledged that medications should not be left unsupervised. The Director of Nursing confirmed that the nurse responsible was an agency nurse and reiterated that all nurses, including agency staff, are oriented to the facility's procedures. However, the facility's Medication Administration policy did not address the need for resident supervision until the medication is taken, contributing to the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had a history of elopement, was able to leave the building without staff being aware and was found approximately 2/10ths of a mile away from the facility early in the morning. The resident had a diagnosis of schizophrenia, cerebral infarction, PTSD, aphasia, and required assistance with personal care. Despite being placed on 15-minute checks after a previous elopement incident, there were no current special supervision precautions in place at the time of the incident. The resident's elopement assessment completed after the incident scored him as high risk for elopement, but prior assessments had scored him as low risk. Interviews with staff revealed that they were unaware of the resident's potential to elope and had not observed any exit-seeking behavior prior to the incident. The facility's failure to maintain adequate supervision and implement effective elopement precautions led to the resident's unsupervised departure from the facility, placing him at risk for harm or serious injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Gardens Rehabilitation And Healthcare | 1.9 mi | ★★★★★ | 10 | 0 |
| Brentwood Place Three | 2.9 mi | ★★★★★ | 14 | 1 |
| South Dallas Nursing & Rehabilitation | 2.9 mi | ★★★★★ | 38 | 0 |
| Brentwood Place One | 2.9 mi | ★★★★★ | 3 | 0 |
| Brentwood Place Two | 2.9 mi | ★★★★★ | 11 | 0 |
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