Inspection Reports for
Carrollton Nursing & Rehab Ctr
2327 NORTH HIGHWAY 27, CARROLLTON, GA, 30117
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
107 residents
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Carrollton Nursing & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
A revisit survey was conducted on 6/17/2025 - 6/18/2025 to verify correction of deficiencies cited in the recertification survey completed on 3/20/2025.
Findings
All deficiencies cited as a result of the recertification survey completed on 3/20/2025 were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 112
Capacity: 159
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to deficiencies including a non-operable exit sign near smoke doors in Hall B, a missing self-closing device on the oxygen storage room door in Hall C, and obstructed electrical breaker panels with exposed wiring in the kitchen area.
Deficiencies (3)
Exit sign near the smoke doors in Hall B is not illuminated and inoperable.
Door closing device is missing from the oxygen storage room door, failing to ensure it is self-closing.
Electrical breaker panels in the kitchen were obstructed by plate tops and exposed wiring was present.
Report Facts
Census: 112
Total Capacity: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Mar 20, 2025
Visit Reason
A State Licensure survey was conducted from March 16, 2025 through March 20, 2025 to assess compliance with state health regulations and facility policies.
Findings
The inspection revealed multiple deficiencies including failure to provide snacks to diabetic residents as ordered, inadequate pharmaceutical management for psychoactive medications, medication administration errors, incomplete care plans for residents, failure to complete dialysis communication forms, poor environmental sanitation in laundry and kitchen areas, and improper food storage and sanitation practices in the kitchen.
Deficiencies (6)
Failed to offer snacks between meals for three diabetic residents, risking unmet nutritional needs.
Failed to implement policies and procedures to monitor response to psychoactive medications for two residents.
Medication error rate of 8% due to incorrect dosing for one resident.
Failed to develop and implement comprehensive care plans for three residents and incomplete dialysis communication forms for one resident.
Laundry room in disrepair with gaps, broken wallboard, debris buildup, and uncleanable surfaces risking contamination.
Kitchen equipment including ovens, fryer, steamer, can opener, ice machine, and microwave were unclean; food items were unlabeled, undated, uncovered, or improperly stored.
Report Facts
Medication error rate: 8
Residents affected by snack deficiency: 3
Residents sample size for nursing care deficiency: 28
Residents affected by pharmaceutical service deficiency: 2
Residents affected by medication errors: 1
Residents affected by environmental sanitation issues: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Named in medication error finding for incorrect medication dosing. |
| LPN5 | Licensed Practical Nurse | Confirmed lack of dementia care plan for resident R44 and care plan omissions for R263. |
| CNA3 | Certified Nursing Assistant | Reported limited snacks provided to residents and lack of labeled snacks for diabetic residents. |
| CNA2 | Certified Nursing Assistant | Reported kitchen did not always provide bedtime snacks for residents. |
| Dietary Manager | Dietary Manager | Confirmed unclean kitchen equipment and improper food storage; stated dietary staff responsibilities. |
| Medical Director | Medical Director | Confirmed lack of resident-specific behavior monitoring and care plans for psychoactive medication use. |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed nursing documentation practices and dialysis communication form expectations. |
| Director of Nursing | Director of Nursing | Confirmed expectations for dialysis communication form completion and nursing documentation. |
| Laundry Supervisor | Laundry Supervisor | Confirmed laundry area in need of repair and cleaning. |
| Interim Director of Nursing | Interim Director of Nursing | Stated monitoring practices for residents on psychotropic medications. |
| Registered Nurse Consultant | Registered Nurse Consultant | Confirmed dialysis communication forms were not completed as required. |
| Administrator | Administrator | Confirmed unclean ice machine and microwave oven. |
Inspection Report
Routine
Census: 103
Deficiencies: 14
Date: Mar 20, 2025
Visit Reason
A standard survey was conducted from March 16, 2025, through March 20, 2025, including investigation of multiple complaint intake numbers to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Numbers GA00246829, GA00250380, GA00249815, GA00248276, GA00253240, GA00249721, GA00249324, GA00251690, GA00253930, GA00253313, GA00243681, GA00253588 were investigated with no deficiencies issued. Complaint intakes GA00243434, GA00246549, and GA00250515 were substantiated.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to assess resident self-administration of medication, failure to notify responsible parties of new medication orders, failure to prevent resident abuse, failure to develop comprehensive care plans, failure to act on change of condition leading to harm, failure to investigate falls, failure to complete dialysis communication forms, failure to monitor psychoactive medication responses, medication administration errors, failure to follow menus, failure to serve palatable and hot food, failure to provide bedtime snacks for diabetic residents, unsanitary kitchen and food storage conditions, and laundry area maintenance issues.
Deficiencies (14)
Failed to ensure one resident (R89) was assessed for self-administration of medications before medications were left at bedside.
Failed to notify one resident's (R89) responsible party of a new medication order before administration.
Failed to ensure one resident (R33) was free from abuse by another resident and failed to promptly report allegations of abuse for one resident (R62).
Failed to develop and implement comprehensive care plans for two residents (R44 and R263).
Failed to act upon a change of condition for one resident (R263) related to low blood sugar, resulting in harm and hospital transfer.
Failed to investigate a fall for one resident (R70).
Failed to complete dialysis communication forms for one resident (R77) for multiple dialysis treatments.
Failed to implement policies and procedures to monitor response to psychoactive medications for two residents (R62 and R44).
Medication administration errors for one resident (R5) with incorrect doses given.
Failed to ensure menus were followed as planned for one resident (R105), including failure to serve cereal as ordered.
Failed to serve food that was palatable and hot to four residents (R22, R77, R83, and R105).
Failed to provide a bedtime snack each night for three diabetic residents (R76, R77, and R83).
Failed to keep kitchen equipment and food storage areas clean and sanitized, and failed to label, date, and cover stored food and beverages.
Failed to maintain laundry room in good repair and clean, including gaps under doors, broken wallboard with exposed insulation, unclean air vents, unfinished molding, debris buildup, and unclean fan.
Report Facts
Complaint Intake Numbers Investigated: 15
Residents sampled: 28
Medication error rate: 8
Blood sugar reading: 45
Blood sugar reading: 39
Blood sugar reading: 30
Blood sugar reading: 67
Resident census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Named in medication error finding for giving incorrect doses to resident R5. |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple findings including medication administration, abuse investigations, and care plan deficiencies. |
| IDON | Interim Director of Nursing | Interviewed regarding notification of responsible parties for new medications. |
| NP1 | Nurse Practitioner | Documented and interviewed regarding resident R263's hypoglycemia event. |
| DM | Dietary Manager | Interviewed regarding food service deficiencies including meal temperature, menu adherence, and snack provision. |
| Laundry Supervisor | Interviewed regarding laundry room maintenance and cleanliness deficiencies. | |
| Medical Director | Confirmed lack of behavior monitoring and care plans for psychoactive medication use. | |
| RNC | Registered Nurse Consultant | Confirmed dialysis communication form deficiencies. |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Carrollton Nursing and Rehab Center to investigate Complaint Intake Number GA00253759.
Complaint Details
Complaint Intake Number GA00253759 was investigated and found unsubstantiated.
Findings
The complaint was found unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Carrollton Nursing & Rehab Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A revisit survey was conducted on 2/2/2024 to investigate Complaint Intake Numbers GA00242308 and GA00242269 and to verify correction of deficiencies cited in the 12/7/2023 Recertification Survey.
Complaint Details
Complaint Intake Numbers GA00242308 and GA00242269 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 12/7/2023 Recertification Survey were found to be corrected. The complaint investigations for GA00242308 and GA00242269 were found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A revisit survey was conducted on 2/2/2024 to investigate Complaint Intake Numbers GA00242308 and GA00242269 and to verify correction of deficiencies cited in the 12/7/2023 Recertification Survey.
Complaint Details
Complaint Intake Numbers GA00242308 and GA00242269 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 12/7/2023 Recertification Survey were found to be corrected. The complaint investigation found the complaints GA00242308 and GA00242269 to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of previously cited deficiencies at Carrollton Nursing & Rehab Center.
Findings
The survey found that all previously cited deficiencies had been corrected except for the sprinkler system gauges, which had not been changed since 2017 as required by code. The gauges in the sprinkler system riser room need to be checked and changed every five years.
Deficiencies (1)
Sprinkler system gauges had not been changed since 2017, violating NFPA 101 and NFPA 25 standards requiring gauges to be checked and changed every five years.
Report Facts
Years since gauges changed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system gauges during facility tour |
Inspection Report
Life Safety
Census: 120
Capacity: 159
Deficiencies: 6
Date: Dec 7, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety code requirements, including issues with non-automatic horizontal sliding doors, unlit exit signs, outdated sprinkler system gauges, sprinkler system maintenance and testing deficiencies, non-compliant smoke door gaps, and improper use of an extension cord as wiring.
Deficiencies (6)
Horizontal sliding doors at entrance did not function automatically; activation required pressing a handicap button.
Two exit signs were not lighted, located in overflow dining room and Hall D.
Gauges on sprinkler system had not been changed since 2017; gauges should be checked and changed every 5 years.
Sprinkler system was yellow tagged; some sprinkler heads were due for testing.
A gap in smoke doors on Hall B was greater than 1/8 inch, not compliant with smoke compartment requirements.
An extension cord was being used as wiring above the ceiling near the nurse's station to power a TV in the hallway.
Report Facts
Census: 120
Total Capacity: 159
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
A State Licensure survey was conducted at Carrollton Nursing and Rehabilitation Center from December 4, 2023 through December 7, 2023 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including restrictions on residents' access to personal funds exceeding $20 per day, failure to follow infection control procedures regarding PPE use and hand hygiene, and environmental sanitation issues such as damaged walls, doors, and caulking in resident rooms.
Deficiencies (3)
Facility failed to allow two residents with personal funds accounts to withdraw more than $20.00 a day, potentially restricting purchases for 74 residents.
Facility staff failed to wear PPE prior to entering isolation room and failed to perform hand hygiene after glove removal during pressure ulcer treatment.
Facility failed to maintain residents' rooms in good repair, with issues including black substance near air conditioning unit, bathroom doors not closing, holes in drywall, and dirty caulking.
Report Facts
Residents affected by personal funds restriction: 74
Resident rooms with environmental issues: 5
Residents involved in PPE deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Notified Unit Manager of critical lab result and confirmed PPE noncompliance |
| LPN2 | Wound Nurse | Observed failing to perform hand hygiene during pressure ulcer treatment |
| DON | Director of Nursing | Observed failing to perform hand hygiene during pressure ulcer treatment |
| Business Office Manager | Explained $20 daily withdrawal limit policy for residents' personal funds | |
| Regional Nurse Consultant | RNC | Provided expectations regarding PPE use and hand hygiene |
| Administrator | Provided explanation of petty cash policy and withdrawal limits | |
| Maintenance Director | Interviewed about maintenance issues and unaware of observed deficiencies | |
| LPN7 | Licensed Practical Nurse | Described maintenance reporting process |
Inspection Report
Routine
Census: 118
Deficiencies: 4
Date: Dec 7, 2023
Visit Reason
A Standard survey was conducted from December 4 through December 7, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Carrollton Nursing and Rehabilitation Center.
Complaint Details
Multiple complaint intake numbers were investigated; most were found unsubstantiated except one which was substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including restrictions on residents' access to personal funds, unsafe and unmaintained resident rooms, inadequate respiratory equipment maintenance, and failure to follow infection prevention protocols including PPE use and hand hygiene.
Deficiencies (4)
Facility failed to allow two residents with personal funds accounts to withdraw more than $20.00 a day, limiting their ability to make purchases.
Facility failed to maintain residents' rooms in good repair, with issues such as black substance near air conditioning, bathroom doors not closing, holes in bathroom drywall, and dirty caulking.
Facility failed to ensure clean filters were in the CPAP machine for one resident, risking respiratory infections.
Facility staff failed to wear PPE properly and perform hand hygiene during care of residents in isolation and with pressure ulcers.
Report Facts
Resident census: 118
Residents with personal funds accounts: 74
Rooms with repair issues: 5
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R74 | Resident | Interviewed regarding personal funds withdrawal limitation |
| R59 | Resident | Interviewed regarding personal funds withdrawal limitation and respiratory care |
| Business Office Manager | Explained $20 daily withdrawal limit policy | |
| Nurse Consultant | Former Director of Nursing | Interviewed about personal funds accounts and CPAP maintenance |
| Administrator | Interviewed about personal funds withdrawal policy and room maintenance | |
| Maintenance Director | Interviewed about room repair issues and maintenance reporting | |
| Licensed Practical Nurse 7 | LPN | Described maintenance reporting process |
| Licensed Practical Nurse 3 | LPN | Interviewed about CPAP machine maintenance |
| Interim Director of Nursing | DON | Interviewed about CPAP filter maintenance |
| Licensed Practical Nurse 1 | LPN | Notified about resident isolation and PPE requirements |
| Certified Nurse Aide 4 | CNA | Observed entering isolation room without PPE |
| Infection Preventionist | IP | Observed entering isolation room without PPE and discussed PPE policy |
| Regional Nurse Consultant | RNC | Discussed expectations for staff education and hand hygiene |
| Licensed Practical Nurse 2 | LPN | Observed failing to perform hand hygiene during pressure ulcer care |
| Director of Nursing | DON | Observed failing to perform hand hygiene during pressure ulcer care |
| Wound Nurse | Observed assisting with pressure ulcer care |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
An Abbreviated Survey was conducted to investigate complaints #GA00228852, #GA00228296, and #GA00224033 at Carrollton Nursing & Rehab Center from March 8, 2023 through March 9, 2023.
Complaint Details
Complaints #GA00228852, #GA00228296, and #GA00224033 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
The inspection was conducted to review the facility's reporting of COVID-19 data to the CDC's National Healthcare Safety Network (NHSN) as required by regulation.
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period between 11/28/2022 and 12/04/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Jul 6, 2022
Visit Reason
A revisit survey was conducted on 7/5/22 through 7/6/22 to verify correction of deficiencies cited during the 3/31/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 3/31/22 Recertification Survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Jul 6, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Carrollton Nursing & Rehab Center following a survey completed on July 6, 2022.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Life Safety
Census: 84
Capacity: 159
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the requirements set forth in 42 CFR 483.73.
Inspection Report
Renewal
Deficiencies: 7
Date: Mar 31, 2022
Visit Reason
A Licensure Survey was conducted from 3/28/22 through 3/31/22 to assess compliance with state regulations and facility licensure requirements.
Findings
The survey identified multiple deficiencies including failure to provide required written transfer/discharge notices, inadequate pharmacy management and monitoring of antipsychotic medication, improper infection control practices, incomplete care plan implementation, inadequate wound care and documentation, unsafe dietary equipment conditions, failure to ensure proper dishwashing sanitization, and failure to offer pneumococcal vaccinations according to current CDC guidelines.
Deficiencies (7)
Failure to provide written notice to residents, representatives, and ombudsman for emergent hospital transfers.
Failure to act on pharmacy recommendations and monitor antipsychotic medication use and side effects for one resident.
Failure to implement infection control measures including improper glove use and sharps disposal.
Failure to implement all care plan interventions and inadequate wound care and documentation for residents at risk for pressure ulcers.
Failure to maintain dietary department equipment in safe working condition; walk-in freezer had ice buildup due to structural issues.
Failure to monitor dish machine temperatures and chemical sanitizer levels, risking inadequate sanitization of dishware.
Failure to offer pneumococcal vaccinations to residents according to updated CDC recommendations and facility policy.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for infection control: 5
Residents reviewed for pressure sores: 3
Residents affected by dietary equipment failure: 78
Residents receiving food from dietary services: 78
Residents reviewed for flu/pneumonia vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failure to monitor antipsychotic medication and infection control issues; provided interviews regarding wound care and vaccination practices. |
| Wound Care Nurse | Wound Care Nurse (WCN) | Performed wound care and provided wound documentation; acknowledged deficiencies in wound treatment and documentation. |
| Dietary Manager | Dietary Manager (DM) | Observed and reported issues with walk-in freezer and dishwashing sanitization. |
| Maintenance Assistant | Maintenance Assistant (MA) | Reported ice buildup in walk-in freezer and maintenance actions. |
| Psychiatrist | Psychiatrist | Provided information on resident behavior and antipsychotic treatment. |
| Nurse Practitioner | Nurse Practitioner (NP) | Provided clinical information on resident and vaccination practices. |
Inspection Report
Routine
Census: 80
Deficiencies: 14
Date: Mar 31, 2022
Visit Reason
A standard survey was conducted including complaint investigations related to allegations of abuse, neglect, and compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA00220769, GA00215764, GA00215271, GA00214967, and GA00214219 were investigated in conjunction with this standard survey. Actual harm occurred when R#48 sustained a Stage III pressure ulcer with infection and R#8 sustained a fracture during transport in a Broda chair.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to report and investigate abuse allegations, failure to implement care plans, inadequate pressure ulcer treatment, failure to provide foot care, unsafe environment and equipment issues, and deficiencies in infection control and immunization practices.
Deficiencies (14)
Failure to report an allegation of potential neglect/abuse related to a resident's fracture and delayed assessment.
Failure to complete a thorough investigation of an abuse allegation including failure to assess resident injury timely and failure to investigate all relevant factors.
Failure to provide written notice of transfer to hospital to residents and ombudsman.
Failure to implement care plan interventions for fall prevention including non-skid strips.
Failure to include resident or representative in care plan meetings and failure to revise care plan after change in resident condition.
Failure to provide treatment to promote healing of a Stage III pressure ulcer and failure to conduct weekly wound assessments.
Failure to provide foot care as needed for a diabetic resident resulting in long, thick toenails.
Failure to ensure supervision to prevent accidents and maintain a hazard-free environment including failure to use leg rests on wheelchair, failure to provide non-skid strips, and hazardous substances accessible to confused resident.
Failure to monitor dish machine temperatures and sanitizer levels, and failure to assure dishware was clean and sanitized.
Failure to assure infection control measures related to hand hygiene, glove use, and sharps disposal.
Failure to offer pneumococcal vaccination according to current CDC guidelines to residents and/or their representatives.
Failure to maintain dietary freezer in safe operating condition due to ice buildup and improper leveling.
Failure to act on pharmacist's recommendation for AIMS testing for resident on antipsychotic medication and failure to monitor for target behavior and adverse effects.
Failure to ensure psychotropic medication was used only as clinically indicated and failure to monitor for effectiveness and side effects.
Report Facts
Resident census: 80
Pressure ulcer size: 5.5
Fracture displacement: 11
Insulin dose: 28
Antipsychotic dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA2 | Activities Aide | Named in fracture and abuse neglect findings related to transport of R#8 |
| LPN1 | Licensed Practical Nurse | Performed wound care and insulin administration for R#48 |
| DON | Director of Nursing | Named in multiple findings including wound care, care plan, and infection control |
| MDS2 | MDS Coordinator | Named in care plan and investigation findings |
| Wound Physician | Physician | Named in wound care findings |
| Wound Care Nurse | Nurse | Named in wound care findings |
| Administrator | Administrator | Named in abuse and care plan findings |
| Dietary Manager | Dietary Manager | Named in dish machine and freezer findings |
| LPN2 | Licensed Practical Nurse | Named in foot care findings |
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
Date: May 4, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints GA00203511, GA00206102, GA00210176 were unsubstantiated with no deficiencies. Complaints GA00213595, GA00212384, GA00211413 were substantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices. Several complaints were investigated; some were substantiated but no deficiencies were cited.
Report Facts
Complaints investigated: 6
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 96
Deficiencies: 0
Date: Nov 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 109
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health on August 5, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations.
Inspection Report
Abbreviated Survey
Census: 108
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at Carrollton Nursing and Rehabilitation Center on July 2, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 0
Date: Jan 13, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00202084, GA00200406, GA00199673, and GA00199320 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was complaint-related, investigating four complaints which were all found to be unsubstantiated.
Findings
The complaints investigated during the survey were unsubstantiated, indicating no violations were found related to the complaints.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 2, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
A revisit survey was conducted on 12/26/18 and 12/27/18 to verify correction of deficiencies cited in the 11/8/18 Standard Survey and to investigate Complaint Intake Number GA00193063.
Complaint Details
Complaint Intake Number GA00193063 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 11/8/18 Standard Survey were found to be corrected. The complaint investigation GA00193063 was unsubstantiated.
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
A revisit survey was conducted on 12/26/18 and 12/27/18 to investigate Complaint Intake Number GA00193063 and to verify correction of deficiencies cited in the 11/8/18 Standard Survey.
Complaint Details
Complaint Intake Number GA00193063 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 11/8/18 Standard Survey were found to be corrected and the facility was in substantial compliance as of 12/23/18. The complaint investigation GA00193063 was unsubstantiated.
Report Facts
Facility census: 119
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 4
Date: Nov 8, 2018
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and long term care requirements.
Findings
The facility was found not in substantial compliance with regulations due to failures in developing and revising comprehensive care plans for residents, failure to provide appropriate treatment and care related to a resident's wrist fracture, failure to address positioning needs of another resident, and failure to properly dispose of garbage and maintain the dumpster area.
Deficiencies (4)
Failed to develop care plan interventions to address positioning needs of resident #99, who was observed leaning with unsupported head/neck in a chair.
Failed to revise care plan for resident #84 following a fall with wrist fracture, including failure to identify fracture, treatment, and decreased ability to ambulate and perform ADLs.
Failed to ensure residents received treatment and care in accordance with professional standards and care plans, including delayed second x-ray for wrist fracture and failure to address positioning needs.
Failed to properly dispose of garbage and refuse, with dumpster doors left open and garbage strewn around the dumpster area, creating potential for disease transmission.
Report Facts
Resident census: 126
Deficiency severity count: 3
Deficiency severity count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Unit Manager | Named in relation to resident #84 fall and care plan deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and treatment deficiencies for residents #84 and #99 |
| CNA LL | Certified Nursing Assistant | Observed and interviewed regarding resident #99 positioning |
| Physical Therapist | Physical Therapist | Interviewed regarding resident #84 therapy and fracture care |
| Physical Therapy Assistant | Physical Therapy Assistant | Interviewed regarding resident #84 therapy and fracture care |
| Dietary Manager | Dietary Manager | Interviewed regarding dumpster area responsibility and observations |
| Assistant Dietary Manager | Assistant Dietary Manager | Interviewed regarding dumpster area responsibility and observations |
| Maintenance Director | Maintenance Director | Interviewed regarding dumpster area maintenance and observations |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 8, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nursing care, physical plant standards, and overall facility operations at Carrollton Nursing & Rehab Center.
Findings
The facility failed to develop adequate care plan interventions for residents with positioning deficits and failed to ensure timely and thorough assessment and documentation of a resident's wrist injury following a fall. Additionally, the outdoor garbage/refuse area was found to be littered with garbage and dumpster doors were frequently left open, creating potential health hazards.
Deficiencies (3)
Failure to develop care plan interventions addressing positioning needs of resident R#99, resulting in improper positioning and lack of staff guidance.
Failure to thoroughly assess and document resident R#84's decline in mobility and pain related to wrist injury after a fall, including delays in obtaining a second x-ray.
Failure to maintain outdoor garbage/refuse area free of garbage and to keep dumpster doors closed, creating potential for disease transmission.
Report Facts
Residents sampled: 25
Dates of dumpster emptying: 3
Dates of observations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (Unit Manager) | Named in relation to resident R#84 fall and positioning issues with R#99 |
| LL | Certified Nursing Assistant | Assisted with repositioning resident R#99 |
| Director of Nursing (DON) | Interviewed regarding care plan deficiencies and resident positioning | |
| Physical Therapist (PT) | Interviewed regarding resident R#84 therapy and injury | |
| Physical Therapy Assistant (PTA) | Interviewed regarding resident R#84 therapy and injury | |
| Dietary Manager | Interviewed regarding dumpster area responsibility and observations | |
| Assistant Dietary Manager | Interviewed regarding dumpster area responsibility and observations | |
| Regional Registered Dietitian (RD) | Interviewed regarding dumpster area responsibility and observations | |
| Maintenance Director | Interviewed regarding grounds maintenance and dumpster area |
Inspection Report
Life Safety
Census: 126
Capacity: 159
Deficiencies: 4
Date: Nov 6, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including emergency lighting failures, fire alarm system maintenance deficiencies, smoke barrier construction issues, and electrical system hazards that could place residents at risk.
Deficiencies (4)
Failed to maintain required emergency lighting in corridors and exterior walkways leading to the public way.
Failed to maintain the fire alarm system; three smoke detectors failed sensitivity tests and lacked recalibration or replacement records.
Failed to maintain smoke barriers to a ½ hour fire resistant rating; gaps and penetrations not properly fire stopped.
Failed to maintain electrical system; junction box above ceiling with no cover exposing wires.
Report Facts
Emergency lights not operating: 3
Smoke detectors failed sensitivity test: 3
Smoke compartments at risk: 3
Smoke compartments at risk: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M and Staff A confirmed findings during the tour and discovery |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
A complaint survey was conducted on 10/9/2018 to investigate complaint GA00191887 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00191887 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 26, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this Follow-Up Survey.
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 0
Date: Feb 1, 2018
Visit Reason
A standard survey was conducted at Carrollton Nursing and Rehabilitation Center from January 29, 2018 through February 1, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 110
Capacity: 159
Deficiencies: 4
Date: Jan 30, 2018
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements, including deficiencies in emergency power system compliance, sprinkler system supervisory signals, corridor door functionality, and smoking area safety provisions.
Deficiencies (4)
Emergency Preparedness Plan was not in substantial compliance with Appendix Z requirements, including lack of a proper connection point for the portable emergency generator.
Automatic sprinkler system supervisory attachments for OS&Y valves in the valve pit were not provided.
Facility failed to maintain corridor doors protecting openings so there is no impediment to door closing, with specific doors scrubbing on floor or striker plates.
Facility failed to provide metal containers with self-closing cover devices for ashtrays at the designated smoking area.
Report Facts
Census: 110
Total Capacity: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, sprinkler system supervisory attachments, corridor door impediments, and smoking area deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 20, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/2/17 recertification survey.
Findings
All deficiencies cited as a result of the 2/2/17 recertification survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during this follow-up visit.
Inspection Report
Life Safety
Census: 112
Capacity: 159
Deficiencies: 3
Date: Feb 2, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including blocked access to a fire alarm pull station, sprinkler heads loaded improperly, and smoke barriers with penetrations that could allow smoke passage. These deficiencies placed residents at risk in the event of fire.
Deficiencies (3)
Fire alarm box (Pull Station) at the front door was blocked/obstructed by a floor plant restricting access.
Sprinkler heads throughout the facility were loaded, failing to assure maximum capable sprinkler protection.
Smoke and fire wall barriers had penetrations that would not resist the passage of smoke in multiple locations.
Report Facts
Residents at risk due to blocked fire alarm box: 50
Residents at risk due to sprinkler protection failure: 30
Residents at risk due to smoke barrier penetrations: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
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