Carolton Chronic & Convalescent Hospital Inc

In the surveyor’s words

From the most serious findings on record at Carolton Chronic & Convalescent Hospital Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 10, 2026

  Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure supervision was provided to prevent an accident when the resident was on a shower bed ,resulting in a fall to the floor with an injury. The findings include: Resident #1 had a diagnosis of dementia, delusional disorders, and anxiety. Quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 0 indicating severely impaired cognition, had physical behaviors, and was dependent on staff for showers and transfers. The Resident Care Plan dated 6/7/26 identified a self-care deficit and risk for falls. […]

• No harm, potential for more than minimal, widespreadF851Apr 8, 2025

  Based on review of facility documentation and staff interview the facility failed to submit accurate PBJ staffing data on 2/26/24, 2/27/24, 2/28/24, and 2/29/24. The findings include: The PBJ 2nd quarter report for January 1, 2024, through March 31, 2024, triggered no licensed nurses 24 hours a day. Interview with the Administrator on 4/8/25 at 3:55 PM identified that he was not aware of what happened and why the report indicated a lack of nursing staff. The Administrator explained that the DNS usually takes care of the scheduling. Interview with DNS on 4/8/25 at 3:57 PM identified that while Person #3 was responsible for inputting PBJ data, she was not aware of why the report triggered no licensed staff 24 hours a day on 2/26/24, 2/27/24, 2/28/24, and 2/29/24. […]

• No harm, potential for more than minimal, patternF584Apr 8, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 6 resident shared bathrooms on 1 of 4 nursing units, the facility failed to ensure personal care items were stored in a manner to maintain a clean, comfortable, and homelike environment, and for 1 resident (Resident #89), the facility failed to maintain safe and comfortable water temperatures in the residents bathroom. The findings include: 1. Observation on 4/1/25 at 11:33 AM and observation and interview with NA #5 on 4/7/25 at 4:15 PM and LPN #13 on 4/7/25 at 4:22 PM identified the following. room [ROOM NUMBER]'s shared bathroom contained four bedpans, all unlabeled and uncovered and wedged inside a metal rack located on the door side wall. […]

• No harm, potential for more than minimal, patternF609Apr 8, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #45, 53 and 4) reviewed for abuse, the facility failed to report allegations of abuse to the Administrator, the State Agency and Police according to facility policy. The findings include: 1. Resident #45's diagnoses included cerebral palsy and adjustment disorder with anxiety. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, required the assistance of 2 via mechanical lift for transfers to the wheelchair, and was independent while in the wheelchair. a. Interview with Resident #45 on 3/31/25 at 11:50 AM identified that Resident #53 had grabbed Resident #45's neck and pushed the back of his/her wheelchair when exiting the dining room. […]

• No harm, potential for more than minimal, patternF610Apr 8, 2025

  51756 Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #45, 53 and 4) reviewed for abuse, the facility failed to immediately initiate a thorough investigation after allegations of abuse were either witnessed or reported, identify and remove the staff member involved, and report the results of the investigation to the administrator and to the State Agency within 5 working days of the incident. The findings include: 1. Resident #45's diagnoses included cerebral palsy and adjustment disorder with anxiety. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, required the assistance of 2 via mechanical lift for transfers to the wheelchair, and was independent while in the wheelchair. a. […]