Carillon Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Carillon Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 13, 2024

  Based on observation, record review, and interview the facility failed to prevent abuse for one of three residents reviewed for physical abuse. Specifically, on 12/27/2023 at approximately 5:00 AM, Resident #1 reported to Registered Nurse #1 that Certified Nursing Assistant #1 physically assaulted them. The same day at approximately 7:00 AM, Resident #1 again reported to Registered Nurse Manager #2 that Certified Nursing Assistant #1 physically assaulted Resident #1. Subsequently, the Facility's Accident and Incident investigation determined that Resident #1 sustained bruising and pain from the encounter and there was reasonable conclusion that Certified Nursing Assistant #1 physically assaulted Resident #1. […]

• No harm, potential for more than minimal, patternF725May 19, 2025

  Based on record review and interviews during the Recertification initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. This was identified for three (Unit 1, Unit 6, and Unit 7) of six nursing units reviewed for the Sufficient Staffing Task. Specifically, the facility was triggered for excessively low weekend staffing on the Payroll-Based Journal Staffing Data Report for the Fiscal Year Quarter 1 2025 (October 1-December 31). […]

• No harm, potential for more than minimal, patternF880Oct 25, 2023

  Based on observations, interviews, record review during the Recertification Survey initiated on 10/19/2023 and completed on 10/25/2023 the facility did not ensure an infection prevention and control program was established to help prevent the development and transmission of communicable diseases and infections. This was identified for 1) one (Resident #141) of five of residents reviewed during a medication administration task; and 2) for one (unit 3) of six units observed on 10/23/2023. Specifically, 1) Resident #141 was on contact and droplet precautions for COVID-19 exposure and contact precautions for Vancomycin-Resistant Enterococci (VRE) infection. […]

• No harm, potential for more than minimal, isolatedF640May 19, 2025

  Based on record review and interviews during the Recertification Survey initiated on 5/13/2025 and completed on 5/19/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for one (Resident #240) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #240's five-day Minimum Data Set Assessment was not transmitted within 14 days of the resident assessment completion date. […]

• No harm, potential for more than minimal, isolatedF657May 19, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 5/13/2025 and completed on, 5/20/2025 the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #230) of one resident reviewed for Activities of Daily Living. Specifically, Resident #230's care plan included the use of a right-resting hand splint for positioning and a left-hand palm grip to be worn at all times; however, the resident refused the right arm splint and left palm grip. […]