A list of the most recent deficiencies for Carolton Chronic and Conv Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-11 | 2023-05-20 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-01 | 2023-05-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-07 | 2023-03-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-07 | 2023-03-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-07 | 2023-03-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-07 | 2023-03-21 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-07 | 2023-03-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-07 | 2023-03-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-07 | 2023-03-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-03-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-07 | 2023-03-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-07 | 2023-03-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-07 | 2023-03-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-07 | 2023-03-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-07 | 2023-03-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-07 | 2023-03-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-02-07 | 2023-03-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-03-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-07 | 2023-03-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-14 | 2022-11-11 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-25 | 2021-03-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-25 | 2021-03-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-02-25 | 2020-03-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-25 | 2020-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-25 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-25 | 2020-03-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-25 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-25 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-25 | 2020-03-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-25 | 2020-03-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-02 | 2019-03-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-01-08 | 2019-02-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-08 | 2019-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-08 | 2019-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-08 | 2019-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-08 | 2019-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-08 | 2019-01-22 | N |
