Carrollton Health And Rehabilitation Center
Carrollton Health and Rehabilitation Center in Carrollton, TX — inspection on November 20, 2025.
Found 4 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 facility's policy Resident Rights dignity and respect revised dated 2015, reflected: It is the policy of this facility that all residents be treated with kindness, dignity, and respect.4. residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the residents from passer-by. 5.
Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene. 6.
Violation of the Residents' Rights to dignity and respect should be promptly reported to the Director of Nursing Services and/or Administrator.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Carrollton Health and Rehabilitation Center
1618 Kirby Rd Carrollton, TX 75006
SUMMARY STATEMENT OF DEFICIENCIES
the resident.
Record review of the in-service logs dated 08/2025-10/2025 reflected on 8/10/2025 and on 10/31/2025 an all-staff in-service titled Falls and Fall Management system was conducted. CNA D attended both in-services.
Further review reflected the DON followed-up with the staff once a week for two weeks on reporting and following the policy and procedure for falls and reporting. [NAME] review of the employee file for CNA D reflected the only write-up in the CNA D's file was dated 10/31/2025, concerning, resident was on the floor and did not follow the facility policy and procedure.
Record review of the facility's policy titled Fall Management System revised December 2023, read in part .
Policy: It is the policy of this to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. procedure: 3.When a resident sustains a fall, a physical assessment will be completed by a licensed nurse.a.The attending physician and Resident Representative shall be notified of the fall and the resident status.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Carrollton Health and Rehabilitation Center
1618 Kirby Rd Carrollton, TX 75006
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 11/20/2025 at 12:17 p.m., the DON stated she expected the nurses to know better than to leave medications in any resident's rooms.
The DON stated negative effects could occur to the residents if medications were left in their rooms.
During the interview the DON did not confirm what the cream was.
The DON stated, anybody can get them and have access to them.
The DON stated this could cause harm to another resident or even staff.
Record review of the Facility's Policy titled Pharmacy Services revised dated May 2007 reflected: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments.2.
All drugs and biologicals orders shall be dated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Carrollton Health and Rehabilitation Center
1618 Kirby Rd Carrollton, TX 75006
SUMMARY STATEMENT OF DEFICIENCIES
During which time the RN placed on gloves and the PPE, personal protective equipment (gloves, gown and mask) and began to remove the used tubing and the used water bag.
The RN placed the used supplies in the trash. RN B opened the door to the bathroom, took the cap off the new water bag, and filled it with water. RN B returned to the bedside of Resident #2, replacing the tubing RN B connected the new tubing to the gastronomy tube and hanging the new water bag and a new bottle of formula.
The RN took her gloves off and left the room.
The RN never replaced the gloves or sanitized her hands from the dirty supplies used to the new supplies. An interview with the DON, who was the infection control preventionist on 11/20/2025 at 2:39 p.m., revealed the DON stated that all direct care staff must keep their supplies available for usage, but in a clean supply area.
The DON stated the staff, when performing incontinent care, should be changing gloves from dirty to clean, and washing their hands or using the available hand sanitizer.
The DON stated she had just had an in-service in the past 3 weeks presenting the importance of changing gloves and washing hands during care and incontinent care.
The DON stated that some of the CNAs had spent extra time with them, to make sure they understood.
The DON stated during the in-service, the staff did not ask any questions and appeared to understand and indicated they knew everything.
The DON stated if the staff did not change gloves and clean their hands when they should, they could spread germs to themselves and the residents.
Record review of the Facility's Policy titled Infection Control Guidelines for All Nursing Procedures dated December 2024, reflected: Purpose: to provide guidelines for general infection control while caring for residents . for residents when performing high-contact resident care activities: dressing, grooming, transferring, providing hygiene, changing linens, changing briefs ., 4.
Employees must wash hands for twenty (20) seconds or longer using antimicrobial or non-antimicrobial soap and water under the following conditions: .a. after direct contact with resident, d. after removing gloves, after handling items potentially contaminated with blood, body fluids, or secretions,
Facility ID: