Deficiency Records for Carrollton Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Carrollton Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-04-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-02 | 2023-04-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-02 | 2023-04-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-02 | 2023-04-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-02 | 2023-04-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-02 | 2023-04-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-02 | 2023-04-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-02 | 2023-04-02 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-02 | 2023-04-02 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-02 | 2023-04-02 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-02 | 2023-04-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-04-02 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-03-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-03-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-02 | 2023-03-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-02 | 2023-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-29 | 2022-09-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-14 | 2022-08-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-27 | 2022-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-27 | 2022-08-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-27 | 2022-08-08 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-27 | 2022-08-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-22 | 2022-04-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-22 | 2022-04-11 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-09 | 2022-01-21 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-09 | 2022-01-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-09 | 2022-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-09 | 2022-01-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-09 | 2022-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-09 | 2022-01-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-09 | 2022-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-14 | 2022-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-19 | 2020-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-19 | 2020-02-01 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-12-19 | 2020-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-02-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-12-18 | 2020-01-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-18 | 2020-01-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-18 | 2020-01-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-18 | 2020-01-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-18 | 2020-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-18 | 2020-01-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-14 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-18 | Not Fixed | N |
