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Deficiency Records for Carolton Chronic and Convalescent Hospital Inc

View the most recent health deficiencies and inspection results for Carolton Chronic and Convalescent Hospital Inc. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Carolton Chronic and Convalescent Hospital Inc. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide properly protected cooking facilities. Fire Safety 2025-04-08 2025-06-29 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2025-04-08 2025-06-29 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2025-04-08 2025-06-29 N
Meet requirements for the use of electrical equipment. Fire Safety 2025-04-08 2025-06-29 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2025-04-08 2025-06-29 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2025-04-08 2025-06-29 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-04-08 2025-06-29 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2025-04-08 2025-06-29 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2025-04-08 2025-06-29 N
Have simulated fire drills held at unexpected times. Fire Safety 2025-04-08 2025-06-29 N
Provide a written emergency evacuation plan. Fire Safety 2025-04-08 2025-06-29 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2025-04-08 2025-06-29 N
Install corridor and hallway doors that block smoke. Fire Safety 2025-04-08 2025-06-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-04-08 2025-06-29 N
Install an approved automatic sprinkler system. Fire Safety 2025-04-08 2025-06-29 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2025-04-08 2025-06-29 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2025-04-08 2025-05-18 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-04-08 2025-05-18 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-04-08 2025-05-18 N
Provide activities to meet all resident's needs. Health 2025-04-08 2025-05-18 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2025-04-08 2025-05-18 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-04-08 2025-05-18 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2025-04-08 2025-05-18 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-04-08 2025-05-18 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-04-08 2025-05-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-04-08 2025-05-18 N
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2025-04-08 2025-05-18 N
Provide and implement an infection prevention and control program. Health 2025-04-08 2025-05-18 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2025-04-08 2025-05-18 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-04-08 2025-05-18 Y
Respond appropriately to all alleged violations. Health 2025-04-08 2025-05-18 Y
Ensure that residents are free from significant medication errors. Health 2025-04-08 2025-05-18 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2025-04-08 2025-05-18 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2025-04-08 2025-05-18 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-06-14 2024-07-04 Y
Provide properly protected cooking facilities. Fire Safety 2023-02-07 2023-05-01 N
Establish staff and initial training requirements. Fire Safety 2023-02-07 2023-05-01 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-02-07 2023-05-01 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-02-07 2023-05-01 N
Install an approved automatic sprinkler system. Fire Safety 2023-02-07 2023-05-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-07 2023-05-01 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-02-07 2023-05-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-02-07 2023-05-01 N
Provide a written emergency evacuation plan. Fire Safety 2023-02-07 2023-05-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-02-07 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 2023-02-07 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 2023-02-07 2023-05-01 N
Respond appropriately to all alleged violations. 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
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly 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
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
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
Implement a program that monitors antibiotic use. 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 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
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
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
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
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
Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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
Honor the resident's right to organize and participate in resident/family groups in the facility. 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
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

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