Calhoun Convalescent Center

Inspectors wroteBased on review of facility policy, interviews and record review, the facility failed to protect one of four residents (Resident (R) 1) from verbal and mental abuse, which resulted in the patient's psychological harm (fear) and mental anguish at the time of the abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure that two of two contracted Certified Nursing Assistants (CNA) AA and BB were trained and competent in abuse prevention protocols established by the facility prior to providing direct resident care. This deficient practice was evidenced by the facility permitting a contracted CNA AA to provide direct care despite having failed the mandatory abuse training examination, resulting in the verbal and mental abuse of Resident (R)1 (who verbalized being afraid). This failure had the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to report abuse for one resident (Resident (R)1) and injury of unknown origin for one resident (R2) in a sample of four residents sampled for abuse.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to ensure that Resident (R)1 received appropriate supervision to prevent a successful elopement from the facility on 03/22/26. On 03/30/26 at 2:37 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/30/26 at 2:37 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/22/26. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices. On 03/30/26 at 4:07 PM, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on review of facility policy and interviews, the facility failed to ensure resident's received their mail in a timely manner and unopened. This deficient practice had the potential to effect all residents in the facility that received mail.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure unlabeled, outdated and expired medications were removed from 4 of 4 medication carts, and not stored with the current medications in use for residents.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to perform Abnormal Involuntary Movement Scale (AIMS) assessments every three months as ordered by the provider for 3 out of 3 residents reviewed for psychotropic medications (Resident (R)41, R92, R97). This failure to complete AIMS assessments as ordered put residents at risk for harm due to the potential of adverse effects from psychotropic medications not being recognized in a timely manner.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 began receiving Hospice care on 01/09/26, and a Significant Change MDS assessment was not completed as required. This failure had the potential for harm due to the Resident not being comprehensively assessed at the time of the significant change in her status.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to update the Care Plan for Resident (R)2, who changed from a Full Code status to a Do Not Resuscitate (DNR) status, for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 changed from a Full Code status to a DNR status on 11/24/25, and her Care Plan was not updated to reflect this change until 02/24/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R)7 and R37 were offered and/or assisted with hand hygiene prior to meal service for 2 of 2 residents observed during meal service.

Inspectors wroteBased on review of the facility policy, record review and interview, the facility failed to report allegations of sexual abuse, to the State Agency (SA), involving Resident (R)1, R2 and R3, for 3 of 3 residents reviewed for allegations of sexual abuse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement Care Plan interventions related to fall prevention for Resident (R)4, for 1 of 2 residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow manufacturer's guidelines to ensure that blood glucose glucometers were sanitized/cleaned properly. On 03/25/25 at 12:10 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/25/25 at 12:15 PM, the Administrator was notified that the facility's failure to have systems in place to monitor for blood glucose glucometers constituted Immediate Jeopardy (IJ) at F880. On 03/26/25 at 3:00 PM, the facility provided an acceptable IJ Removal Plan. On 03/26/25 at 4:10 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F880 at a lower scope and severity of D.

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure medications and biological were not expired for 2 of 2 units reviewed.

Inspectors wroteBased on review of the facility policy, observation, record review and interviews, the facility failed to ensure a room was clean and sanitary for 1 of 1 Residents (R) 80 reviewed for environment.

Inspectors wroteBased on review of the facility policy, record review, observation and interviews, the facility failed to ensure residents right to be free from neglect by failing to provide Resident (R)107 Activities of Daily Living (ADL) care in a timely manner. 1 of 3 reviewed for abuse/neglect.

Inspectors wroteBased on review of the facility policy, record review, observation and interview, the facility failed to revise/implement Care Plan interventions for Resident (R)41 to reflect his need for assistance with dining/feeding after an injury to the residents' dominant hand for 1 of 3 residents reviewed for nutritional care plans.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure that a medication was administered according to physician orders for 1 of 2 residents reviewed for tube feeding. Resident (R) 85 was admitted to the facility on [DATE] with diagnoses including, but not limited to severe intellectual disabilities, gastrostomy, schizophrenia and anxiety, The facility policy on Physician Orders, revised May 5, 2023, states The qualified nurse will obtain and transcribe orders according to Facility Practice Guidelines, .PRN (as needed) medications: Transcribe or electronically enter all PRN Medication/Treatment Orders to properly identified area of MAR (medication administration record).

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. On 06/14/24 at 1:28 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 06/14/24 at 1:28 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/11/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/14/24 at approximately 2:18 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. [...]

Inspectors wroteBased on review of the facility policy titled, Catheter- Urinary Catheter, Cleaning and Maintenance, observations, and interviews, the facility failed to follow a procedure during catheter care for Resident (R)1 to prevent the likelihood of infection for 1 of 1 residents observed for Foley catheter care.

Inspectors wroteBased on a review of the facility policy, record reviews, and interviews, the facility failed to protect 1 of 1 residents from sexual abuse. Resident (R)1 inappropriately touched R2 on 08/28/2023 at approximately 5:20 p.m. This was observed by staff members. On 09/01/2023 at 05:30 pm, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/01/2023 at 05:30 pm, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to protect R2 from sexual abuse by R1 constituted IJ at F600 with the start date of 08/28/2023. The facility presented an acceptable removal plan for F600 on 09/01/2023 via email. [...]

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide and document sufficient preparation and orientation to a resident to ensure safe and orderly discharge from the facility for 1 of 1 residents reviewed for discharge. Specifically, Resident (R)1, nor his representative was adequately prepared or informed of R1's discharge from the facility. On 09/01/23 at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/01/23 at 5:30 PM, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to ensure a proper and safe discharge for R1 constituted IJ at F624 with a start date of 08/29/23. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to notify Resident (R)5's Resident Representative of a hospitalization in a timely manner as required by federal regulation, for 1 of 2 residents reviewed for transfer/discharge.

Inspectors wroteBased on review of facility policy, observations, record reviews, interviews, and manufacturer labeling/package inserts, the facility failed to ensure that expired medications were removed from active storage, that opened and in-use medications were properly dated, that unattended medication carts were locked, that unsecured and unattended medications were not left atop medication cart and that sterile/single-use products were removed from active storage in 6 of 6 medication carts. (Refer to F755)

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the walk-in refrigerator and freezer, dry storage, emergency storage and resident dietary rooms were properly labeled and discarded by the manufacturer's expiration date. Findings Include: Review of the facility policy titled, Food Safety in Receiving and Storage, with a complete revision date of 06/20/23, revealed, Food will be received and stored by methods to minimize contamination and bacterial growth. Receiving Guidelines: 5. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents to that the food is not exposed to adulteration or potential contaminants. A. [...]

Inspectors wroteBased on the facility policy, observations, and interviews, the facility failed to ensure that a Schedule III controlled substance was double locked and a lock box for controlled substances in the refrigerator was secured inside the refrigerator for 1 of 2 medication rooms. (Refer to F761)

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)354's catheter bag for 1 of 1 resident reviewed. Findings Include: Review of the facility's policy titled, Patient/Resident Rights, with a complete revision date of 10/01/20, revealed, The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities . The Facility treats each resident with respect and dignity . The facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. [...]

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to ensure the administration of medication for 2 of 25 residents reviewed for medication administration. Specifically, Resident (R)46 and R94 did not receive their medication as ordered by the physician. Findings Include: Review of the facility's policy titled Medication Management program, dated 05/05/23, revealed The facility will ensure the schedules for administrating medications : 1) maximize the effectiveness of the medications .Authorized staff must understand: effectiveness for achieving the therapeutic goal .The authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements .If a medication is unavailable, contact the pharmacy and document accordingly. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide 2 of 2 residents with Activities of Daily Living (ADL) care. Specifically, Resident (R)16 and R354 did not receive routine bathing, incontinent care, and linen changes. Resulting in the potential for skin irritation, infection, and complications with pressure ulcers. Findings Include: Review of the facility policy titled, Activities of Daily Living, Optimal Function, with a complete revision date of May 5, 2023, documented, The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. [...]

Inspectors wroteBased on review of facility policy, observations, interviews, and record review, the facility failed to properly label and date the oxygen tubing for 1 of 2 residents reviewed for respiratory care, Resident (R)49.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to follow a procedure during wound care for Resident (R)28 to promote healing and to prevent or decrease the likelihood of infection for 1 of 5 residents reviewed with pressure ulcers.