Carrollton Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF755Apr 22, 2022

  Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1(Resident #1) of 7 residents reviewed for anticonvulsant medication. The facility failed to discontinue Resident #1's previous order for [MEDICATION(S)], an anticonvulsant medication, which included 200mg in the morning and 300mg at night prior to administering the updated and correct dose of [MEDICATION(S)] per physician's orders, which included 200mg every 12 hours. As a result, Resident #1 was receiving a total of 900 mg of [MEDICATION(S)] per day for 6 days and had to be transferred to the hospital due to having [CONDITION(S)] like activity and unsteady gait. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. […]

• Immediate jeopardy, patternF760Apr 22, 2022

  Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of 7 residents reviewed for medication administration. The facility failed to discontinue Resident #1's previous order for [MEDICATION(S)], an anticonvulsant medication, which included 200mg in the morning and 300mg at night prior to administering the updated and correct dose of [MEDICATION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident #1 was receiving a total of 900 mg of [MEDICATION(S)] per day for 6 days and had to be transferred to the hospital due to having [CONDITION(S)] like activity and unsteady gait. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. […]

• Immediate jeopardy, isolatedF689Mar 20, 2024

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

• Actual harm, isolatedF600Jan 14, 2025

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

• No harm, potential for more than minimal, widespreadF851Jun 25, 2026

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