Carrollton Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 1 2026 (October 1 - December 31) reviewed for administration. The facility failed to submit staffing data to CMS for FY Quarter 1 2026 (October 1 - December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care for three of twenty residents (Residents #46, #70, and #81) reviewed for privacy. 1. The facility failed to ensure RN B pulled the privacy curtain or closed the door during Resident #46's blood sugar check on 06/24/2026. 2. The facility failed to ensure RN B pulled the privacy curtain or closed the door during Resident #70's blood sugar check on 06/24/2026. 3. The facility failed to ensure CNA F and CNA G closed pulled the privacy curtain during Resident #81's incontinent care on 06/23/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided that could result to embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for three of four residents (Resident #39, #46, and #40) reviewed for quality of care. 1. The facility failed to ensure that CNA J would dry up Resident #39's bottom, who had MASD, on 06/23/2026. 2. The facility failed to ensure that Resident #46's kerlix dressings to both feet were changed, as ordered, when they were wet due to the resident's weeping edema on 06/23/2026. 3. The facility failed to ensure that Resident #40's non-pressure right shin wound was cleansed in accord with the facility's wound care policy on 06/24/26. These failures could place the residents at risk for worsening non-pressure injuries and could result in a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for three of six residents (Resident #69, Resident #40 and Resident # 38) reviewed for medication administration. The facility failed to ensure MA D did not give Resident #69's 6:30 a.m. medications at 7:56 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #40's 6:30 a.m. medications at 8:04 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #38's 6:30 a.m. medications at 8:12 a.m. on 06/24/2026. [...]

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11.11%, based on 3 errors out of 27 opportunities, which involved three of six residents (Resident #69, Resident #40, and Resident #38) and one of one staff (MA D) reviewed for medication errors. The facility failed to ensure MA D did not give Resident #69's 6:30 a.m. medications at 7:56 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #40's 6:30 a.m. medications at 8:04 a.m. on 06/24/2026. The facility failed to ensure MA D did not give Resident #38's 6:30 a.m. medications at 8:12 a.m. on 06/24/2026. These failures could place residents at risk for treatment failure, disease progression, reduced effectiveness, and adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of eighteen residents (Residents #9, #29, and #40) reviewed for medication storage. 1. The facility failed to ensure Resident #29's zinc oxide was not on top of the resident's side table on 06/23/2026. 2. The facility failed to ensure Resident #9 did not have a Vicks Vapor Stick on her bedside table on 06/23/26 3. The facility failed to ensure Resident # 40 did not have peri-guard wipes and a container of calmoseptine / nystatin mixture on her bedside table on 06/23/26. These failures could place residents at risk of misuse of medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated, discarded prior to their use-by date and were properly sealed. This failure could place residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of eighteen residents (Residents #39, #40, #46, #50, #70 and #81) and for six of ten direct care staff (LVN E, CNA F, CNA G, CNA H, CNA I, and CNA J) reviewed for infection control. 1. The facility failed to ensure CNA J would not assist Resident #39 and Resident #50 at the same time during lunchtime on 06/23/2026. 2. The facility failed to ensure CNA J did not place Resident #39 in her geri-chair without any brief on, with the perineal area touching the seat of the geri-chair directly, after a shower on 06/23/2026. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of eight (Resident #12) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #12's room was in a position that was accessible to the resident on 06/23/26. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of eight residents (Residents #8) reviewed for accuracy of assessments. The facility failed to ensure Resident #8's Comprehensive MDS Assessment, dated 03/24/2026, accurately reflected that the resident was receiving oxygen therapy. This failure could place the residents at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Record review of Resident #8's Face Sheet, dated 06/24/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of eight residents (Resident #8) reviewed for care plans. The facility failed to ensure that Resident #8 had a care plan for her oxygen use on 06/23/2026. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for two of eight Residents (Resident #65 and #12) reviewed for accident hazard. The facility failed to ensure that Resident #65 did not have a container of germicidal wipes on her shelf on 06/23/2026. The facility failed to ensure that Resident #12 did not have scissors in his room on 06/23/26. These deficient practices placed the residents at risk for accidental injury, exposure to hazardous chemicals and misuse of sharp objects.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #70) reviewed for incontinent care. The facility failed to ensure that CNA H did not place Resident #70's catheter bag on top of the resident, rendering the catheter bag and its tubing to above the bladder during transfer on 06/24/2026 This failure could place the residents at risk of urinary tract infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #1 and Resident #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's oxygen nasal canula was properly stored on 06/23/26. 2. The facility failed to ensure Resident #14's spirometer was properly stored when not in use on 06/23/2026. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met. Findings Include 1. Record review of Resident #1's face sheet, dated 06/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for one of 8 residents' rooms (Resident #69) reviewed for pest control. The facility failed to ensure Resident #69's room was free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents did not get ice from the ice cooler used for 1 of 1 (Resident #1) resident reviewed for infection control. Resident #1 got ice for her cup from an ice cooler, without the help of staff. This failure could result in contaminated ice that could transmit organisms to other residents, resulting in waterborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of disposition of controlled drugs to enable an accurate reconciliation and failed to maintain account of controlled drugs for 1 of 5 residents reviewed for pharmacy services. MA A was unaware of how to dispose controlled medication. MA B failed to update count sheet for Resident #1 after administering controlled medication to the resident, causing discrepancy between medication card and count sheet. These failures could lead to suspected drug diversion and medication error.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 6 residents (Resident #5, #6, and #7) reviewed for accident prevention. The facility failed to ensure Resident #5 did not have a can of Lysol spray in his room on 01/30/2026. The facility failed to ensure Resident #6 did not have a can of aerosol air freshener spray in her room on 01/30/2026. The facility failed to ensure Resident #7's cell phone charging cord was plugged correctly into the outlet in her room on 01/30/2026. These failures could prevent the residents from having an environment that was free from hazards.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of six residents (Resident #1, #2, #3 and #4) reviewed for respiratory care. The facility failed to ensure Resident #1 and #2's breathing treatment mask was properly stored in a bag when not in use on 01/30/26. The facility failed to ensure Resident #3 and #4's nasal canula was properly stored in a bag when not in use on 01/30/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were adequately equipped to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from three of six residents (Resident #7, #8, and #9) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #7, #8, and #9's rooms were in a position that was accessible to the residents on 01/30/26. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers. The facility failed to provide appropriate treatment to Resident #1's skin issues. This failure placed residents at risk for the decline in quality of life and the wounds being infected or deteriorating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity during wound care for 1 of 4 residents (Resident #2) reviewed for respect and dignity in that: The facility failed to ensure RN B provided privacy by leaving the door open and not pulling privacy curtain, exposing Resident #2's abdomen when providing Resident #2 while changing gastroenterology tube (feeding tube) supplies. This failure could place residents at risk of emotional distress and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensured each resident received adequate supervision for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was free of injury from accident hazards when CNA D failed to follow policy and procedure and report to the nurse in charge, when CNA D found Resident #1 was on the floor in her room. CNA D picked the resident up from the floor and placed her in wheelchair taking the resident to the dining room for breakfast. The LVN did not assess Resident #1 before she was moved by CNA D. These failures could place residents at risk for harm, pain, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #2) of 4 reviewed for storage of drugs, in that: The facility failed to ensure Resident #2's calmoseptine ointment (ointment applied to the bottom to treat and prevent redness) was secured. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (CNA A and RN B) staff members and 2 of 2 residents (Residents #3, and #2) reviewed for infection control procedures. CNA A failed to change their soiled gloves and perform hand hygiene during incontinent care on Residents #3. RN B failed to change her soiled gloves and perform hand hygiene during replacement of gastroenterology tube (feeding Tube) supplies for Residents #2. These failures could place residents at risk for cross contamination and infectionsFindings included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all assistive devices, wheelchairs were maintained and free of hazards for three (Residents #4, #40, and #55) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #4, #40, and #55. The failure could place residents at risk for equipment that is in unsafe operating condition, that could cause injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquitting, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 (Resident #56) for medication pass 1. RN D failed to follow physician orders to administer Resident #56's ASA (aspirin) capsule 81 mg per G-tube (feeding tube), and instead administered chewable ASA 81 mg per G-tube. RN D failed to check the medication room and to inquire of the other nursing staff if the staff had the appropriate ASA on their medication carts. 2. RN D failed to follow physician order to administer Resident #56's Calcium D (vitamin supplement) oral tables 600-400 mg and administered Over the counter Calcium D. RN D did not mix the Calcium D completely prior to administering the medication per G-tube. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 3 of 30 opportunities during medication pass resulting in a 10 percent (10%) error rate for one (Residents #13) of 4 residents observed for medication pass. 1. RN D failed to administer Resident #56's ASA (aspirin) capsule 81 mg per G-tube (feeding tube), and instead administered chewable ASA 81 mg, as RN D had no ASA capsules 81 mg on her medication cart. 2. RN D failed to administer Resident #56's Calcium D (vitamin supplement) oral tables 600-400 mg correctly. RN D crushed the incorrect Calcium D (that was not supposed to be crushed) and delivered by G-tube. 3. RN D failed to administer Resident #56's Maalox (anti-acid) (aluminum/magnesium) Suspension, Suspension 200-200-20 5 ml 30 cc per G-tube. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Promptly obtain the Chest X-ray per the ordering physician's orders for one (Resident #39) of five residents reviewed for radiology services. The facility failed to obtain the chest X-ray and the results for Resident #39's chest in a timely manner, resulting in a delay to diagnosis Resident #39. The routine X-ray should be completed on the same day as ordered. This failure could place residents at risk of injury, pain and a delay in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (RN D) staff members and 1 of 5 residents (Residents #56) reviewed for infection control procedures. RN D failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #56 and was observed using blood pressure cuffs on two other unknown residents. RN D failed to cleanse her hands following stoma care and prior to administering G-tube medications for Resident #56. The failures could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the right to be free from abuse was provided for one (Resident #1) of seven residents reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 5/18/2024 at 2:10 p.m., CNA A hit Resident #1 with an open hand on the outer left thigh causing a red handprint. The noncompliance was identified as past noncompliance (PNC). The past noncompliance began on 05/18/24 and ended on 05/20/24. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for abuse and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 2 of 4 resident (Resident #52 and Resident #3) reviewed for peripheral intravenous care. The facility did not ensure Residents #52's and #3's PICC line dressings were changed per the physician's order. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #45) of five residents reviewed for call lights. The facility failed to ensure Resident #45's call light was accessible. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 2 residents (Resident #46) reviewed for physical environment. The facility failed to ensure Resident #46's gastronomy tube (a tube placed through the abdominal wall with the aid of an endoscope into the stomach used for feeding patients unable to swallow food) pole and floor was clean. These failures could place the residents at risk for the spread of infection and disease, a diminished quality of life and a diminished clean, homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #63) reviewed for MDS assessment accuracy in that: Resident #63's quarterly MDS assessment dated [DATE] was coded incorrectly in that it indicated she had a wound infection when she did not. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 1 resident (Resident #49) reviewed for unnecessary medications, and medication regimen review. The facility's Pharmacist Consultant recommended Residents #49's Lidocaine External Patch 4 % (Lidocaine) required to be updated to read wear 12 hours and then off 12 hours. This failure could place residents on lidocaine patch at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of any significant medication errors for 1 of 3 residents (Resident #45) reviewed for medication administration. The facility failed to prevent Resident #45 from being provided Losartan Potassium, a medication designed to lower a person's blood pressure, while Resident #45 was assessed with blood pressure lower than the physician recommended parameters for providing the medication. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, they stored all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 4 residents (Residents #36) reviewed for pharmacy services. The facility failed to ensure Resident #36 took her medications when they were administered, which resulted in the resident saving the medication in her room. This failure could place residents at risk of not receiving the therapy needed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) resident of five residents reviewed for elopement. The facility failed to provide Resident#1 with adequate supervision to prevent him from eloping from the facility on 01/04/24. Resident #1 was able to leave the building without staff being aware that he left the building early morning on 01/04/24 and made it down the street, approximately 2/10ths of a mile from the facility. It was determined a past non-compliance Immediate Jeopardy existed from 01/04/24 to 01/05/24. The Immediate Jeopardy was determined to have been removed on 01/05/24 due to the facility's implemented actions that corrected the non-compliance. [...]