Safety Report: Carolton Chronic & Convalescent Hospital INC
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
6Abuse, neglect & exploitation
6Infection control
5Medications & pharmacy
3Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (19) than in the cycle before (17).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | August 10, 2026; February 7, 2023; February 25, 2020 |
| Provide and implement an infection prevention and control program. (F880) | 3 | April 8, 2025; February 7, 2023; February 25, 2020 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | April 8, 2025; February 7, 2023; February 25, 2020 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | April 8, 2025; February 25, 2020 |
| Respond appropriately to all alleged violations. (F610) | 2 | April 8, 2025; February 7, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | April 8, 2025; February 7, 2023 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | June 14, 2024; February 25, 2020 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 10, 2026 — 1 citation (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 13, 2026
April 8, 2025 — 18 citations
F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F851 · corrected May 18, 2025
E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F882 · corrected May 18, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected May 18, 2025
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected May 18, 2025
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected May 18, 2025
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · corrected May 18, 2025
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected May 18, 2025
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected May 18, 2025
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected May 18, 2025
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected May 18, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected May 18, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected May 18, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected May 18, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected May 18, 2025
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected May 18, 2025
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected May 18, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected May 18, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected May 18, 2025
June 14, 2024 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected July 4, 2024
February 7, 2023 — 17 citations
E
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F881 · corrected March 21, 2023
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected March 21, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected March 21, 2023
E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F756 · corrected March 21, 2023
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected March 21, 2023
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected March 21, 2023
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected March 21, 2023
D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F868 · corrected March 21, 2023
D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F867 · corrected March 21, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected March 21, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F726 · corrected March 21, 2023
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected March 21, 2023
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected March 21, 2023
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected March 21, 2023
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected March 21, 2023
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected March 21, 2023
D
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F565 · corrected March 21, 2023
February 25, 2020 — 8 citations
E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected March 16, 2020
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 16, 2020
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected March 16, 2020
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected March 16, 2020
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected March 16, 2020
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected March 16, 2020
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected March 16, 2020
B
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
No actual harm, potential for minimal harm · Pattern · Resident Rights Deficiencies · F577 · corrected March 16, 2020
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare