Inspection Reports for
Life Care Center of Carrollton
300 LIFE CARE LN, CARROLLTON, MO, 64633-1861
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
18.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
238% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
48% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The inspection was conducted due to resident-to-resident altercations involving physical abuse where Resident #1 held Resident #2 down and squeezed their jaw, and pushed Resident #3 against a wall. The facility was investigating these incidents and the facility's response to ensure resident safety.
Complaint Details
The complaint involved substantiated resident-to-resident abuse incidents where Resident #1 physically restrained and squeezed Resident #2's jaw and pushed Resident #3 against a wall. The facility investigated, notified families and providers, and implemented corrective actions including psychiatric evaluation and staff training.
Findings
The facility failed to protect residents from physical abuse by another resident. Resident #1 exhibited aggressive behaviors resulting in physical altercations with Residents #2 and #3. The facility initiated immediate interventions including one-on-one monitoring, emergency room evaluations, psychiatric hospitalization referral, and staff education on abuse prevention and reporting.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident.
Report Facts
Residents affected: 3
Medication dosage: 50
Medication dosage: 150
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Interviewed regarding Resident #1's behavior and facility response |
| Certified Medication Technician A | CMT | Interviewed about Resident #1 pushing Resident #2 and staff training |
| Certified Nursing Assistant A | CNA | Interviewed about resident altercation and staff response |
| Director of Nursing | DON | Provided information on incidents, interventions, and staff training |
| Social Services Director | Interviewed about resident rights and abuse incidents | |
| Senior Executive Director | Acting Administrator | Interviewed about resident incidents and facility placement plans |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged financial exploitation of Resident #1 by a certified nursing assistant (CNA B).
Complaint Details
The complaint investigation substantiated that CNA B financially exploited Resident #1 by coercing and accepting money totaling approximately $220. The resident was cognitively intact but vulnerable to exploitation. CNA B was suspended on 8/17/25 and terminated on 9/18/25. Police were involved but did not pursue criminal charges. The facility reimbursed the resident $220.
Findings
The facility failed to protect Resident #1 from financial exploitation by CNA B, who requested and accepted money from the resident, violating facility policy. The investigation confirmed CNA B borrowed approximately $220 from the resident and was suspended and later terminated. The resident was reimbursed $220 by the facility.
Deficiencies (1)
Failure to protect a resident from misappropriation of resident property when a staff member accepted money from the resident.
Report Facts
Amount of money taken: 220
Facility census: 57
Additional money given to CNA B by other employees: 217
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in financial exploitation finding involving Resident #1 |
| LPN A | Licensed Practical Nurse | Notified Administrator of financial exploitation situation |
| Administrator | Conducted investigation, notified police, suspended and terminated CNA B | |
| Regional Director of Clinical Services | Provided information on investigation and reimbursement receipt | |
| Director of Nursing | Director of Nursing | Interviewed regarding resident's decision-making and vulnerability |
| Account Specialist | Notified about incident and reassured resident |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 15
Date: Apr 25, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Life Care Center of Carrollton.
Findings
The facility was found deficient in several areas including reasonable accommodations for residents, personal funds management, safe and homelike environment, trauma-informed care, and food safety. Multiple residents' care plans and documentation were incomplete or inaccurate, and the facility failed to maintain a safe and comfortable environment.
Deficiencies (15)
F558 Reasonable Accommodations Needs/Preferences. The facility failed to provide acceptable sink accommodations and transfer assistance for residents, affecting two of 15 sampled residents. The resident could not independently use hot water due to lack of accommodations.
F569 Notice and Conveyance of Personal Funds. The facility failed to provide personal funds and final accounting within 30 days upon discharge for two residents. Refunds were delayed and not processed timely.
F578 Request/Refuse/Discontinue Treatment. The facility failed to provide timely refunds to discharged residents and did not ensure proper handling of resident funds.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a clean and comfortable environment, including housekeeping and maintenance, affecting all residents.
F699 Trauma Informed Care. The facility failed to provide trauma-informed care for one resident with PTSD, lacking appropriate care plans and staff training.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to store, prepare, and serve food in accordance with professional food safety standards, including improper temperature controls and expired food items.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met.
A4086 Infection Control/Communicable Disease. The facility failed to use acceptable infection control procedures to prevent spread of infection. This regulation was not met.
A4093 Bedpans, Commodes, Urinals Clean/Covered. Staff failed to ensure bedpans, commodes, and urinals were covered and cleaned promptly after use.
A4100 Social Service Program. The facility failed to designate a qualified staff member responsible for the social services program as required.
A4108 Clinical Records - assessment/interventions. The facility failed to maintain clinical records with sufficient information on assessments and interventions.
A7015 Food-Protected, Temp, Need to Contact DHSS. The facility failed to maintain proper food protection and temperature controls as required.
A7019 Food Stored in Identifying Containers. The facility failed to store food in containers properly labeled with common names.
A7028 Hazardous Food Cooking Temperatures. The facility failed to cook potentially hazardous foods to required temperatures.
A9010 Discharge Requirement Within 5 Days. The facility failed to provide timely accounting and return of resident funds and possessions within five days of discharge.
Report Facts
Facility census: 58
Sampled residents: 15
Residents affected by F558: 2
Residents affected by F699: 1
Residents affected by F569: 2
Inspection Report
Routine
Census: 58
Deficiencies: 6
Date: Apr 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, rights, food service, and facility environment at Life Care Center of Carrollton.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, improper handling of resident funds, incorrect documentation of Do Not Resuscitate orders, inadequate housekeeping resulting in unclean environments, failure to provide trauma-informed care for a resident with PTSD, and unsafe food storage and handling practices.
Deficiencies (6)
Failed to provide acceptable sink accommodation for hot water and transfer assistance for eating for two residents.
Failed to provide personal funds and final accounting within 30 days upon discharge for two residents.
Do Not Resuscitate orders had guardian's name printed instead of resident's name for two residents.
Failed to maintain a clean and comfortable homelike environment; dirt, food debris, and dead bugs observed in resident rooms and common areas.
Failed to provide trauma informed care for a resident with PTSD; care plan lacked PTSD diagnosis and interventions.
Failed to store, prepare, and serve food in accordance with professional standards; food items were unlabeled, expired items not discarded, and temperature checks not consistently performed.
Report Facts
Residents affected: 15
Facility census: 58
Resident refund balance: 803
Resident refund balance: 5618.32
Temperature: 108
Temperature: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant A | COTA | Discussed sink accommodation for Resident #14 |
| Business Office Manager | BOM | Discussed resident fund refunds |
| Certified Nurses Aide A | CNA | Provided information on DNR orders and resident care |
| Licensed Practical Nurse A | LPN | Provided information on DNR orders and resident care |
| Social Services Designee | SSD | Reviewed and discussed DNR orders |
| Director of Nursing | DON | Discussed expectations for DNR orders and PTSD care planning |
| Administrator | Discussed facility policies and expectations for resident care and food safety | |
| Housekeeper A | Housekeeper | Discussed housekeeping practices |
| Dietary Manager | DM | Discussed food safety and temperature checks |
| Dietician | Discussed food safety and temperature checks | |
| Certified Nurses Aide B | CNA | Discussed resident PTSD care |
Inspection Report
Life Safety
Deficiencies: 2
Date: Apr 23, 2025
Visit Reason
An emergency preparedness survey and life safety code inspection were conducted to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in substantial compliance with emergency preparedness regulations. However, deficiencies were cited related to egress doors not meeting NFPA 101 Life Safety Code requirements and emergency lighting not provided in one medication room.
Deficiencies (2)
K222 Egress Doors: Facility staff failed to maintain a door in the path of egress in compliance with NFPA 101. The door lacked proper signage and documentation for unlocking delayed-egress exit doors, potentially delaying evacuation.
K291 Emergency Lighting: Facility staff failed to provide emergency lighting inside one medication room, which could prevent proper illumination during power loss.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding emergency lighting requirements for the medication room. | |
| Maintenance Supervisor | Interviewed regarding signage requirements on egress doors. | |
| Executive Director | Signed the deficiency statement on 21 May 2025. |
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 2
Date: Sep 24, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding comprehensive care plans and medication administration for residents.
Findings
The facility failed to meet professional standards of care by not ensuring staff obtained physician orders to check blood sugars and did not ensure medications were administered properly for a new admission. Documentation and completion of assessments and care plans were also deficient.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff obtained physician orders to check blood sugars and did not ensure medications for a new admission were administered properly. Documentation of blood sugar monitoring and baseline care plans was incomplete.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiencies cited in F658.
Report Facts
Facility census: 62
Days for corrective action completion: 51
Audit frequency days per week: 5
Audit frequency days per week: 3
Audit frequency per week: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jocelyn Pointer | Infection Preventionist (IP) | Interviewed regarding medication delays and physician orders |
| Jocelyn Pointer | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiencies and plan of correction |
| Unnamed Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed about resident admission and medication orders |
| Unnamed Director of Nursing | Director of Nursing (DON) | Interviewed about medication orders and blood sugar monitoring |
Inspection Report
Routine
Census: 62
Deficiencies: 3
Date: Sep 24, 2024
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality of care, specifically regarding medication administration and blood sugar monitoring for a new admission.
Findings
The facility failed to ensure staff obtained a physician's order to check blood sugars and failed to ensure medications for a new admission were obtained and administered timely. This affected one of five sampled residents, Resident #3, with minimal harm or potential for actual harm.
Deficiencies (3)
Failure to obtain a physician's order to check blood sugars for a diabetic resident.
Failure to ensure medications for a new admission were obtained and administered as ordered.
Failure to complete the admission Minimum Data Set (MDS) and baseline care plan for Resident #3.
Report Facts
Facility census: 62
Medication doses: 20
Dates: Aug 30, 2024
Dates: Sep 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Admitted the resident and provided information about medication receipt and orders |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding the need for physician orders and medication administration |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed regarding medication delays and physician orders for blood sugar monitoring |
Inspection Report
Census: 59
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing care and assistance for activities of daily living to residents unable to perform these tasks independently.
Findings
The facility failed to ensure that staff provided necessary care and services to three of 15 sampled residents who were unable to complete their own activities of daily living, specifically failing to reposition or provide incontinent care in a timely manner.
Deficiencies (1)
Failure to provide care and assistance to perform activities of daily living for residents unable to do so independently, including timely repositioning and incontinent care.
Report Facts
Residents sampled: 15
Residents affected: 3
Facility census: 59
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 14
Date: Jan 6, 2024
Visit Reason
The inspection was the annual survey of Life Care Center of Carrollton to assess compliance with federal regulations and state requirements.
Findings
The facility was found to have multiple deficiencies related to resident rights, safe environment, medication management, nutrition, infection control, and care planning. Several deficiencies were classified as Class II, indicating a moderate level of severity.
Deficiencies (14)
F561 Self-determination: The facility failed to promote residents' rights to make choices regarding food served and other personal preferences for 15 sampled residents.
F584 Safe/Comfortable/Homelike Environment: The facility failed to maintain floors, doors, and handrails in good repair, with multiple areas of missing floor tile and damaged handrails.
F623 Notice before transfer/discharge: The facility failed to provide timely and complete notice of transfer or discharge to residents and their representatives.
F658 Professional Standards of Quality: The facility failed to ensure staff followed professional standards in insulin pen use and medication administration for 15 sampled residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary assistance with activities of daily living to maintain good personal hygiene and prevent skin breakdown for 15 sampled residents.
F679 Activities, Supervision: The facility failed to provide adequate activities and supervision to meet residents' needs and interests for 15 sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and assistance to prevent accidents during meals for 15 sampled residents.
F690 Incontinence: The facility failed to provide appropriate care and assessment for residents with urinary and bowel incontinence, including catheter care and infection prevention.
F692 Nutrition/Hydration: The facility failed to provide adequate nutrition and hydration, including proper meal assistance and monitoring of weight loss for 15 sampled residents.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility failed to prevent medication errors, including insulin administration errors, for 15 sampled residents.
F760 Labeling of Drugs and Biologicals: The facility failed to properly label and store medications and biologicals, including insulin pens and expired medications.
F761 Storage of Drugs and Biologicals: The facility failed to ensure medications were stored securely and properly, including expired and opened medications.
F801 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain food safety, including proper storage, sanitation, and labeling of food items.
F812 Infection Control: The facility failed to maintain an effective infection prevention and control program, including hand hygiene and sanitizing procedures.
Report Facts
Facility census: 59
Sampled residents: 15
Inspection Report
Routine
Census: 59
Deficiencies: 14
Date: Jan 5, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, safety, care, medication administration, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to promote resident choice in meals, inadequate maintenance of floors and handrails, failure to provide timely transfer/discharge notices, medication administration errors, inadequate infection control practices, insufficient dietary management qualifications, unsanitary kitchen conditions, failure to provide adequate activities, inadequate supervision during meals, improper catheter care, failure to assist residents with eating, and improper medication storage and labeling.
Deficiencies (14)
Failure to promote residents' right to make choices regarding foods served to sampled residents.
Failure to keep floors, doors, and handrails in good repair causing unsafe surfaces.
Failure to provide written notice of transfer or discharge to residents or responsible parties including appeal rights.
Failure to follow professional standards in medication administration including not cleaning insulin pen ports and vial ports and improper use of nasal spray.
Failure to properly use and maintain the Arivo 2 Nasal High Flow oxygen delivery system including lack of staff education and improper cleaning.
Failure to provide necessary care and assistance with activities of daily living including personal hygiene and positioning for dependent residents.
Failure to provide adequate activities to meet residents' needs including lack of individualized activities and failure to assist residents to activities.
Failure to provide adequate supervision during meals and failure to monitor safety and choking risks of a resident on a mechanically altered diet.
Failure to provide appropriate catheter care including cleaning drainage spout and use of dignity covers, and failure to clean perineal areas properly.
Failure to provide enough food/fluids and assistance to a resident with significant weight loss and failure to encourage meal consumption.
Medication administration errors including failure to clean insulin pen ports, failure to prime insulin pens, and crushing medications that should not be crushed.
Failure to ensure medications and biologicals are properly labeled, stored, and discarded including expired medications and undated insulin pens, and failure to have physician orders for medications kept at bedside.
Failure to maintain sanitary kitchen conditions including dirty vents, peeling paint, missing baseboards, expired food items, improper storage of food, lack of paper towels, and expired sanitizer test strips.
Failure to maintain effective infection prevention and control program including failure of staff to perform hand hygiene when passing food trays, assisting residents to eat, and administering eye drops.
Report Facts
Medication errors: 7
Resident census: 59
Weight loss: 16.6
Weight loss percentage: 10.3
Sanitizer test strip expiration: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in insulin administration errors and medication handling. |
| CNA C | Certified Nurse Aide | Named in catheter care deficiencies. |
| CNA H | Certified Nurse Aide | Named in infection control and feeding assistance deficiencies. |
| Dietary Manager | Dietary Manager | Named in dietary management and kitchen sanitation deficiencies. |
| Registered Dietitian | Registered Dietitian | Named in dietary management and kitchen sanitation deficiencies. |
| Administrator | Facility Administrator | Named in dietary management and kitchen sanitation deficiencies. |
| LPN B | Licensed Practical Nurse | Named in medication crushing and medication knowledge deficiencies. |
| LPN E | Licensed Practical Nurse | Named in infection control deficiency during eye drop administration. |
| CNA G | Certified Nurse Aide | Named in infection control deficiencies. |
| Dietary Aide A | Dietary Aide | Named in dishwasher sanitizer testing deficiencies. |
| Maintenance Director | Maintenance Director | Named in kitchen maintenance deficiencies. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Jan 5, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide necessary care and assistance to residents unable to perform activities of daily living, failure to assist a resident with eating despite significant weight loss, and failure to maintain kitchen sanitation.
Complaint Details
The visit was complaint-related due to allegations of inadequate care for residents unable to perform activities of daily living, failure to assist a resident with eating despite weight loss, and unsanitary kitchen conditions. The report documents observations, interviews, and record reviews supporting these complaints.
Findings
The facility failed to provide adequate personal hygiene care and assistance with activities of daily living to two residents, failed to assist one resident with eating despite significant weight loss, and failed to maintain the kitchen in a sanitary manner including improper food storage, unclean vents, expired sanitizer test strips, and inadequate dishwasher sanitization.
Deficiencies (3)
Failure to provide necessary care and assistance with activities of daily living to residents unable to complete their own care, including hygiene and repositioning.
Failure to assist a resident with eating despite significant weight loss and cognitive impairment.
Failure to maintain kitchen sanitation including dirty vents, peeling paint, missing baseboards, uncovered food containers, expired sanitizer test strips, and improper dishwasher sanitizer levels.
Report Facts
Weight loss: 16.6
Census: 59
Sanitizer level: 50
Sanitizer level: 100
Sanitizer test strip expiration date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in findings related to failure to provide timely incontinent care and improper application of splints. |
| CNA E | Certified Nurse Aide | Named in findings related to improper transfer and positioning of resident. |
| CNA B | Certified Nurse Aide | Named in findings related to failure to provide oral care to resident. |
| CNA C | Certified Nurse Aide | Named in findings related to failure to provide oral care to resident. |
| LPN A | Licensed Practical Nurse | Charge nurse who acknowledged staffing limitations affecting care. |
| Director of Nursing | Director of Nursing | Provided expectations for resident care and staff responsibilities. |
| Dietary Aide A | Dietary Aide | Observed using expired sanitizer test strips and unaware of sanitizer levels in dishwasher. |
| Dietary Aide B | Dietary Aide | Observed failing to wash hands after picking up bowl from floor before serving food. |
| Dishwasher Service Technician | Provided information on dishwasher sanitizer requirements. | |
| Maintenance Director | Maintenance Director | Responsible for HVAC vent cleaning and kitchen ceiling maintenance. |
| Registered Dietitian | Registered Dietitian | Provided expectations for kitchen sanitation and staff training. |
| Administrator | Administrator | Provided expectations for kitchen cleanliness and staff hygiene. |
Inspection Report
Life Safety
Census: 59
Capacity: 120
Deficiencies: 13
Date: Jan 5, 2024
Visit Reason
The inspection was an emergency preparedness and life safety code survey conducted on January 5, 2024, to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements with no deficiencies cited. However, multiple life safety code deficiencies were identified related to hazardous areas, sprinkler system maintenance, corridor wall construction, corridor doors, utilities, and electrical equipment.
Deficiencies (13)
K321 Hazardous Areas - Enclosure: The facility failed to ensure propane tanks were not stored in smoking areas or inside the building, and hazardous areas lacked proper self-closing doors and fire-resistant corridor walls.
K353 Sprinkler System - Maintenance and Testing: Sprinkler heads were loaded and had unsealed penetrations around them, affecting four of eight smoke sections and potentially impacting residents in multiple halls.
K362 Corridors - Construction of Walls: The facility failed to maintain fire-resistive ratings of corridor walls due to unfilled penetrations, affecting four of eight smoke sections.
K363 Corridor - Doors: Corridor doors did not latch properly into frames, affecting two of eight smoke sections, and doors were not closing due to moisture and heat.
K511 Utilities - Gas and Electric: Items were stored within inches of breaker panels, violating clearance requirements and posing a fire hazard.
K920 Electrical Equipment - Power Cords and Extension Cords: Extension cords were used improperly as permanent wiring and were plugged into other extension cords, affecting multiple smoke sections.
A1088 Door No Louvre/Transom, Solid-Core Wood/Metal: Doors between rooms and corridors lacked required louvers or transoms and did not meet fire-resistance standards.
A2003 No Fire Hazard: The building presented fire hazards contrary to regulations, as referenced in K321.
A2008 Hazardous Areas: Hazardous areas were not properly separated by fire-resistant construction and lacked self-closing or automatic closing doors.
A2034 Sprinkler System-Test/Maintain: The sprinkler system was not properly inspected, maintained, or tested as required by regulations.
A3001 Substantially Constructed/Maintained: The building was not maintained in good repair, including physical plant deficiencies affecting fire safety.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained according to NFPA standards, posing safety risks.
A3037 Extension Cords/Duplex Receptacles: Extension cords were used improperly and posed physical damage risks, violating electrical safety standards.
Report Facts
Facility capacity: 120
Resident census: 59
Inspection Report
Abbreviated Survey
Census: 54
Deficiencies: 2
Date: Mar 31, 2022
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted from 3/29/22 to 3/31/22 to assess compliance with emergency preparedness regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness. However, deficiencies were cited related to activities of daily living (ADL) care, specifically failure to provide necessary oral care and personal hygiene to dependent residents.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2). The facility failed to ensure dependent residents received necessary services to maintain good personal hygiene and oral care, affecting four of ten sampled residents.
A4076 19 CSR 30-85.042(67) Clean, Dry, Odor Free. Each resident shall be clean, dry, and free of offensive body and mouth odor. This regulation was not met as evidenced by the referenced F677 deficiency.
Report Facts
Facility census: 54
Sampled residents: 10
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Haynes | Executive Director | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Routine
Census: 60
Deficiencies: 7
Date: Dec 9, 2021
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations including proper use of beneficiary notices, restraint use, care planning, medication administration, catheter care, nutritional intake documentation, food safety, and medication error rates.
Findings
The facility failed to use updated beneficiary notice forms, maintain proper restraint documentation and consent, implement comprehensive care plans including nutritional intake documentation, ensure proper medication administration timing, provide adequate catheter care and documentation, prepare pureed meals according to recipes, and maintain safe food storage and labeling practices. Medication error rate exceeded 5% due to improper inhaler administration timing.
Deficiencies (7)
Failed to use the most updated SNFABN form for beneficiary notifications for five residents.
Failed to maintain proper documentation and monitoring for physical restraint use and assessments for one resident.
Failed to implement comprehensive care plans including documentation of meal intakes and restraint use for sampled residents.
Failed to ensure medication administration followed professional standards, specifically timing between inhaled medications.
Failed to provide and document catheter care and timely emptying of catheter bags as ordered.
Failed to follow provided recipes when preparing pureed meals, risking alteration of nutritional value.
Failed to store and prepare food in a safe and sanitary manner, including unlabeled and expired food items and unsanitary kitchen conditions.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication error rate: 7.69
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist A | Provided expert opinion on medication administration timing for inhalers | |
| Certified Medication Technician C | Observed administering inhaled medications improperly | |
| Director of Nursing | Director of Nursing | Provided expectations on restraint assessments, medication administration, and catheter care documentation |
| Certified Nurse Aide B | Certified Nurse Aide | Provided information on restraint use and care plan knowledge |
| MDS Coordinator | Provided information on restraint care plan and corporate instructions | |
| Dietary Manager | Discussed pureed food preparation and food safety practices | |
| Registered Dietician | Provided expectations on pureed meal recipe use | |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided information on catheter care and output documentation |
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 7
Date: Dec 9, 2021
Visit Reason
The document is a Plan of Correction submitted by Life Care Center of Carrollton following a survey conducted on December 9, 2021. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including Medicaid/Medicare coverage notices, use of physical restraints, comprehensive care plans, medication administration, and food safety. Specific issues included failure to use updated forms, inadequate documentation and monitoring of restraints, incomplete care plans for residents, medication errors, and unsafe food storage practices.
Deficiencies (7)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to use the correct SNFABN form for Medicaid-eligible residents and did not provide updated notices as required.
F604 Right to be Free from Physical Restraints: The facility failed to maintain proper documentation and monitoring for the use of physical restraints for one resident.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement comprehensive care plans for two of fifteen sampled residents, including failure to document meal intakes and restraint use.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff provided and documented catheter care and medication administration according to physician orders for several residents.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure a medication error rate of less than 5%, with a 7.69% error rate observed.
F800 Provided Diet Meets Needs of Each Resident: The facility failed to provide a diet meeting residents' nutritional and special dietary needs, including failure to follow recipes for pureed food.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to store and prepare food in a safe and sanitary manner, including improper labeling and disposal of food items.
Report Facts
Resident census: 60
Medication error rate: 7.69
Number of sampled residents with deficient care plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Hayes | Executive Director | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Life Safety
Census: 60
Capacity: 120
Deficiencies: 10
Date: Dec 9, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations for the Life Care Center of Carrollton.
Findings
The facility failed to meet several Life Safety Code requirements including maintaining fire-rated ceilings without unsealed penetrations, proper delayed egress door signage and function, emergency lighting testing and maintenance, exit signage illumination, fire alarm system testing and maintenance, sprinkler system maintenance, corridor door integrity, and electrical system testing. Multiple deficiencies were identified related to fire safety and emergency preparedness.
Deficiencies (10)
K161 Building Construction Type and Height: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations such as holes and pipes in various rooms. The facility had a capacity of 120 with a census of 60 at the time of the survey.
K222 Egress Doors: The facility failed to ensure delayed egress doors were maintained in working order and lacked appropriate signage. Observations included delayed egress doors without proper signage and doors that did not release when pushed for 15 seconds.
K291 Emergency Lighting: The facility failed to conduct required monthly and annual emergency lighting tests. An emergency light with battery backup did not operate correctly during testing.
K293 Exit Signage: The facility failed to maintain illuminated exit signs in several locations, including outside room #104 and egress doors to the memory care unit.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the fire alarm system, including missing semi-annual inspections and failure to perform sensitivity tests on smoke detectors.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler heads were free of corrosion and paint, and failed to replace corroded sprinkler heads in multiple locations.
K363 Corridor Doors: The facility failed to maintain corridor doors to resist passage of smoke, with issues including doors not latching properly and gaps at the top of doors exceeding allowed limits.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to conduct annual visual and functional fire door assessments and failed to inspect all fire doors annually.
K918 Electrical Systems - Essential Electric System: The facility failed to test the generator's fuel annually and failed to maintain records of such testing.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to assure safe use of power strips and extension cords, including use of non-UL approved cords and improper plugging of appliances.
Report Facts
Facility capacity: 120
Resident census: 60
Inspection date: Dec 8, 2021
Plan of correction completion date: Jan 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Byrne Hayes | Executive Director | Named in relation to education on ceiling penetrations, exit signage, emergency lighting, and fire alarm system maintenance in the plan of correction |
| Maintenance Director | Named in relation to assessment and correction of ceiling penetrations, exit signage, emergency lighting, fire alarm system, sprinkler heads, and corridor doors |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 2
Date: Nov 2, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding the provision of restorative range of motion exercises as ordered by physicians.
Findings
The facility failed to ensure staff followed physician orders to provide range of motion exercises to one resident. Documentation and interviews revealed inconsistent completion of restorative nursing services and lack of a policy addressing physician orders.
Deficiencies (2)
F658: The facility did not provide a policy that addressed following physician orders for restorative nursing services. Staff failed to consistently perform and document range of motion exercises as ordered for Resident #1.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues referenced in F658.
Report Facts
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Haynes | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 4
Date: May 27, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with professional standards of care and food safety regulations at Life Care Center of Carrollton.
Findings
The facility failed to meet professional standards in comprehensive care plans and food temperature requirements. Deficiencies were identified related to incomplete treatment orders and failure to maintain appropriate food temperatures for residents.
Deficiencies (4)
F658 Comprehensive Care Plans: The facility failed to ensure staff completed care according to professional standards and physician orders, affecting one sampled resident. Treatment orders were incomplete or not followed on specified dates.
F804 Food and Drink: The facility failed to maintain appropriate food temperatures, serving cold meals to residents. Observations and interviews confirmed food was not served hot as required.
A4074 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, referencing F658. Classified as Class II.
A7036 Food Temperature Compliance: Food was not served at required temperatures of 120°F or 45°F or below, referencing F804. Classified as Class II with higher classification due to extent of violation.
Report Facts
Facility census: 54
Date of survey: May 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Hayes | Executive Director | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed regarding treatment completion and plan of correction | |
| Dietary Manager | Interviewed regarding food temperature issues and corrective actions | |
| Registered Nurse | RN | Interviewed about treatment completion for resident |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted on December 28 and 29, 2020 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from September 22 to September 24, 2020 to assess compliance with CDC and CMS recommended practices and regulatory requirements.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted on May 28 and May 29, 2020 to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 2
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to investigate behavioral health services deficiencies related to resident safety and care at Life Care Center of Carrollton.
Findings
The facility failed to ensure the safety of a resident who was physically aggressive toward another resident. Deficiencies included inadequate supervision, failure to keep residents separated, and insufficient staff intervention to prevent aggressive behaviors.
Deficiencies (2)
F740 Behavioral health services. The facility failed to provide necessary behavioral health care and supervision to prevent physical aggression between residents.
A4074 Nursing care per resident condition. The facility failed to provide personal attention and nursing care consistent with acceptable nursing practices.
Report Facts
Facility census: 45
Number of facilities contacted for placement: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Hayes | Executive Director | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed regarding supervision and placement of residents | |
| Social Services Designee | SSD | Interviewed about efforts to find alternative placement for Resident #1 |
| Licensed Practical Nurse | LPN | Interviewed about instructions to keep residents separated |
| Certified Nurse Assistant A | CNA | Interviewed about care provided and knowledge of resident separation |
| Certified Nurse Assistant B | CNA | Interviewed about care provided and knowledge of resident separation |
| Certified Nurse Assistant C | CNA | Interviewed about care provided and instructions to keep residents separated |
| Registered Nurse A | RN | Interviewed about staff assignments and supervision of residents |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 10
Date: Sep 6, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations and ensure the facility meets required standards of care.
Findings
The facility was found to have multiple deficiencies related to resident rights, restraint use, transfer/discharge notices, medication administration, care planning, bed rail use, and medication storage. Several residents were affected by these deficiencies, and the facility failed to provide proper documentation, notification, and care interventions in several areas.
Deficiencies (10)
F604: The facility failed to maintain proper orders, documentation, assessments, and monitoring for physical restraints for two sampled residents. Restraint use was not properly ordered or assessed, and care plans did not address restraint use adequately.
F623: The facility failed to provide timely and adequate written notice of transfer or discharge to residents and their representatives for two sampled residents. Notices did not include required information and were not provided at least 30 days prior to transfer.
F625: The facility failed to inform residents and their representatives of the bed-hold policy at the time of transfer or discharge for two sampled residents. Written notification was not provided as required.
F656: The facility failed to develop comprehensive, individualized care plans addressing the use of side rails for three sampled residents. Care plans did not reflect assessments or interventions related to side rail use.
F689: The facility failed to ensure a safe environment free of accident hazards by not following mechanical lift policies and procedures for one sampled resident. Staff did not properly secure mechanical lift devices during transfers.
F693: The facility failed to ensure proper administration and monitoring of enteral nutrition via PEG tube for one sampled resident. Medication administration and tube feeding procedures were not followed according to policy and physician orders.
F700: The facility failed to assess residents for risk of entrapment from bed rails and did not obtain informed consent or develop appropriate care plans for bed rail use for three sampled residents.
F759: The facility failed to maintain a medication error rate below 5%, with two medication errors out of 32 opportunities for error affecting two sampled residents.
F761: The facility failed to properly store and label medications, including expired medications, and failed to monitor refrigerator temperatures and medication expiration dates for four sampled residents.
F805: The facility failed to prepare smooth pureed foods for one sampled resident with a physician-ordered pureed diet. The pureed food contained visible pieces inconsistent with the diet texture.
Report Facts
Facility census: 44
Medication error rate: 6.25
Deficiencies cited: 10
Inspection Report
Life Safety
Census: 44
Capacity: 120
Deficiencies: 7
Date: Sep 6, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain the Type V protected wood-frame construction standard and smoke barrier walls, and failed to properly test and maintain the fire alarm system and conduct required fire drills. These deficiencies affected multiple smoke compartments and all residents in those areas.
Deficiencies (7)
K161: The facility failed to maintain the Type V protected wood-frame construction standard as staff did not seal openings in ceilings around pipes and vents, affecting two of eight smoke compartments. The facility had a capacity of 120 and a census of 44.
K345: The facility failed to test and maintain the fire alarm system in accordance with NFPA 70, NFPA 72, and NFPA 25, lacking semi-annual inspections and proper maintenance records. This deficiency had the potential to affect all residents.
K372: The facility failed to maintain smoke barrier walls free of penetrations, affecting five of eight smoke compartments and all residents. Observations showed gaps and holes in smoke barrier walls.
K712: The facility failed to maintain documentation and conduct fire drills as required, missing records for several drills and failing to conduct a fire drill on the second shift between 2/26/19 and 8/14/19. This deficiency had the potential to affect staff readiness.
A2019: The facility failed to maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition, as referenced in K345.
A2059: The facility failed to meet fire drill plan requirements including phased response, evacuation instructions, and staff responsibilities, as referenced in K712.
A3001: The facility failed to substantially construct and maintain the building in good repair per NFPA 101, 2000 edition, as referenced in K161 and K372.
Report Facts
Facility capacity: 120
Census: 44
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lynn Hayes | Executive Director | Signed the report and plan of correction |
| Interim Maintenance Director | Named in corrective actions related to sealing penetrations and maintaining smoke barriers and fire drills |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 2
Date: Mar 22, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with respiratory and tracheostomy care regulations at Life Care Center of Carrollton.
Findings
The facility failed to provide respiratory care consistent with professional standards, including failure to administer oxygen according to physician's orders and failure to change residents' oxygen tubing and humidifiers per policy. This affected three residents and was supported by observations, interviews, and record reviews.
Deficiencies (2)
F695 Respiratory care, including tracheostomy care and suctioning, was not provided according to professional standards. Staff failed to administer oxygen per physician's orders and did not change oxygen tubing and humidifiers as required by facility policy, affecting three residents.
A4074 Nursing care per resident condition was not met as evidenced by failure to provide personal attention and nursing care consistent with current acceptable nursing practice, linked to F695.
Report Facts
Facility census: 46
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynn Hayes | Executive Director | Signed the statement of deficiencies and plan of correction |
| RN A | Registered Nurse | Interviewed regarding oxygen care and resident condition |
| CNA A | Certified Nurse Assistant | Interviewed about oxygen tubing disconnection during resident transfers |
| CNA B | Certified Nurse Assistant | Interviewed about oxygen tubing disconnection during resident transfers |
| Administrator | Administrator | Interviewed about oxygen care policies and staff responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 14, 2018
Visit Reason
The inspection was conducted as a licensure inspection and complaint investigation.
Findings
No state licensure deficiencies were cited as a result of this inspection and complaint investigation. The facility met the applicable provisions of the 2012 edition of the Life Safety Code. The Emergency Preparedness survey did not result in deficiencies.
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Jul 27, 2018
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to comprehensive care plans and nursing care practices at Life Care Center of Carrollton.
Findings
The facility failed to follow acceptable standards of practice for one resident regarding tube feeding documentation, blood sugar monitoring, and physician notification. Staff did not document tube feeding supplement and water intake as ordered, nor notify the physician of a high blood sugar reading.
Deficiencies (2)
F658: The facility failed to follow professional standards for comprehensive care plans by not documenting tube feeding supplement and water intake, not checking feeding tube placement as ordered, and not notifying the physician of a blood sugar reading over 300 for one resident.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency referenced in F658.
Report Facts
Facility census: 52
Blood sugar reading: 325
Blood sugar threshold: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Byron Hayes | Executive Director | Signed deficiency statement and plan of correction |
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