Carillon Nursing and Rehabilitation Center

Inspectors wroteBased on record review and interviews during the Recertification initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. This was identified for three (Unit 1, Unit 6, and Unit 7) of six nursing units reviewed for the Sufficient Staffing Task. Specifically, the facility was triggered for excessively low weekend staffing on the Payroll-Based Journal Staffing Data Report for the Fiscal Year Quarter 1 2025 (October 1-December 31). A review of the daily staffing sheets indicated that Unit 1, Unit 6, and Unit 7 did not have sufficient nursing staff available to care for residents during the weekends in October 2024, November 2024, December 2024, and 5/18/2025. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for one (Resident #240) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #240's five-day Minimum Data Set Assessment was not transmitted within 14 days of the resident assessment completion date. Additionally, the resident was discharged from the facility in December 2024; however, the Minimum Data Set discharge assessment was not completed and transmitted until May 2025. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on, 5/20/2025 the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #230) of one resident reviewed for Activities of Daily Living. Specifically, Resident #230's care plan included the use of a right-resting hand splint for positioning and a left-hand palm grip to be worn at all times; however, the resident refused the right arm splint and left palm grip. There was no documented evidence that the resident's care plan was revised to reflect the resident's preferences or refusals. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that each resident received care consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for one (Resident #44) of four residents reviewed for Pressure Ulcers. Specifically, Resident #44 with a history of a pressure ulcer to the sacrum utilized an air mattress for pressure relief. During two separate observations, the weight setting for the air mattress was not calibrated to the resident's actual weight. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #335) of four residents reviewed for Pressure Ulcers. Specifically, Resident #335 complained of discomfort during the wound care treatment of their Coccyx (tailbone) Stage 2 pressure ulcer. Registered Nurse #4 (the nurse administering the wound treatment) continued the treatment without assessing and addressing the resident's pain. The finding is: The facility's policy titled Pain Management, dated 1/22/2025, documented the facility is committed to providing optimal pain management to the residents. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey, initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that an infection prevention and control program was implemented to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Unit 2) of six nursing units reviewed during the Medication Administration Task. Specifically, during a medication pass observation for Resident #188, who was on Enhanced Barrier Precautions, Registered Nurse #8 handled Resident #188's used meal tray after administering medications to the resident. Registered Nurse #8 did not perform hand hygiene. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prevent abuse for one of three residents reviewed for physical abuse. Specifically, on 12/27/2023 at approximately 5:00 AM, Resident #1 reported to Registered Nurse #1 that Certified Nursing Assistant #1 physically assaulted them. The same day at approximately 7:00 AM, Resident #1 again reported to Registered Nurse Manager #2 that Certified Nursing Assistant #1 physically assaulted Resident #1. Subsequently, the Facility's Accident and Incident investigation determined that Resident #1 sustained bruising and pain from the encounter and there was reasonable conclusion that Certified Nursing Assistant #1 physically assaulted Resident #1. This resulted in actual harm to Resident #1 that is not immediate jeopardy.

Inspectors wroteBased on observations, interviews, record review during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure an infection prevention and control program was established to help prevent the development and transmission of communicable diseases and infections. This was identified for 1) one (Resident #141) of five of residents reviewed during a medication administration task; and 2) for one (unit 3) of six units observed on 10/23/2023. Specifically, 1) Resident #141 was on contact and droplet precautions for COVID-19 exposure and contact precautions for Vancomycin-Resistant Enterococci (VRE) infection. During the medication pass observation 1 a) the medication nurse did not follow instructions for proper Personal Protective Equipment (PPE) use as indicated on the signage outside the resident's room; [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were thoroughly investigated. This was identified for one (Resident #113) of four residents reviewed for accidents. Specifically, on 9/7/2023 Resident #113 was observed by Certified Nursing Assistant (CNA) #3 sitting on the toilet in their (Resident #113) room. The resident required extensive assistance of one staff member for toileting; however, CNA #3 did not stay with the resident. The resident subsequently was found on the floor in their room and complained of left hip pain upon assessment. Resident #113 was transferred to the hospital and was diagnosed with a hip fracture. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure each resident received adequate supervision to prevent avoidable accidents. This was identified for two (Resident #113 and Resident 31) of four residents reviewed for accidents. Specifically, 1) Resident #113, who required extensive assistance of one staff member for toileting, was left unattended in the bathroom. Subsequently Resident #113 was found on the floor in their room, was transferred to the hospital and diagnosed with a hip fracture. 2) Resident #31 required extensive assistance with personal hygiene, including shaving. A used disposable razor was observed in the resident's room with no staff in the vicinity.