Carrollton Manor, Incorporated
CARROLLTON MANOR, INCORPORATED in CARROLLTON, GA — inspection on April 25, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R88's admission MDS with an ARD of 03/23/26 located in the EMR revealed a facility admission date of 03/16/26 with medical diagnoses of atrial fibrillation, renal insufficiency, and respiratory failure.
The resident was discharged from the facility on 04/22/26.
Review of R88's EMR under the Miscellaneous tab revealed a positive urine culture on 04/01/26 and a subsequent positive Clostridium difficile (C. diff/bacterium causing severe, often antibiotic-associated diarrhea) culture on 04/14/26.
During an observation on 04/21/26 at 10:58 AM, R88 was observed lying in bed with his door partially opened.
There was a sign on the door indicating the resident was in isolation.
There was no information to direct visitors on the precautions to take or to seek guidance from a staff member.
During an interview on 04/25/26 at 12:34 PM regarding the lack of EBP for residents with risk, the IP responded, We ordered these caddies [for PPE], only had a certain number - put in room appropriate at the time for EBP, such as an IV [intravenous catheter], peg [gastrostomy] tube, foley [indwelling urinary catheter], urostomies, and wounds. If you're having to go in and change a draining wound, you should have on gowns/gloves. I've told the wound care nurses, Certified Nursing Assistant's (CNAs), and the nurses.
Regarding residents on other isolation, such as contact isolation and how visitors would be advised of the need for personal protective equipment (PPE), the IP confirmed there is nothing for visitors to be directed to the nurse as the State had told us we couldn't have anything like that.
When asked how visitors would know to wear PPE, the IP did not have an answer and confirmed if PPE were in a box in the room or hanging on the door and the door was open, a visitor would have no clue.
115638 04/25/2026
Carrollton Manor, Incorporated 2455 Oak Grove Church Road Carrollton, GA 30117
Review of the last three months of tracking/trending infections document provided by the facility revealed there was no documentation of whether an infection met any defined criteria for infection and antibiotic treatment, or if the antibiotic prescribed was effective for any identified organisms.
During an interview on 04/25/26 at 11:42 AM, the Infection Preventionist (IP) stated he was in charge of the antibiotic stewardship program, but did not receive a monthly report of antibiotic use and just found out last week during a training that the facility should be using McGeers criteria (standardized surveillance definitions used to identify and track infections).
The IP stated, Up until now, that I'm aware of, [determination of] infections were not based on any national criteria, just the nurse documenting [for example] saying foul smelling urine, confusion, and dysuria or frequency.
When asked about if antibiotic stewardship program was being used, the IP responded, We do; when I see someone is being talked about with confusion, I ensure they are being changed every two hours.
Again, I don't know; there is a specific place to document that the resident was on an appropriate antibiotic.
Currently, there is no place on the tracking/trending that notes if the antibiotic was appropriate or if an infection did or did not meet a criteria for infection.
During an interview on 04/25/26 at 1:48 PM, the Administrator stated an expectation is that the antibiotic stewardship program had been instituted.
Review of the facility policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, revealed:Policy StatementAntibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form.
The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.Policy Interpretation and Implementation1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee.2.
The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.a.
Therapy may require further review and possible changes if:(1) the organism is not susceptible to antibiotic chosen;(2) the organism is susceptible to narrower spectrum antibiotic;(3) therapy was ordered for prolonged surgical prophylaxis; or(4) therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.3. At the conclusion of the review, the provider will be notified of the review findings.4.
All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form.
The information gathered will include:a. resident name and medical record number;b. unit and room number;c. date symptoms appeared;d. name of antibiotic (see approved surveillance list);e. start date of antibiotic;f. pathogen identified (see approved surveillance list);g. site of infection;h. date of culture;i. stop date;j. total days of therapy;k. outcome; andl. adverse events.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.