Deficiency Records for Carriage Square Rehab and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Carriage Square Rehab and Healthcare Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-14 | 2023-09-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-14 | 2023-09-20 | N |
| 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 | 2023-07-14 | 2023-09-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-14 | 2023-09-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-14 | 2023-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-14 | 2023-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-14 | 2023-09-20 | 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 | 2023-07-14 | 2023-09-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-14 | 2023-09-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-14 | 2023-09-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-14 | 2023-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-14 | 2023-09-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-14 | 2023-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-14 | 2023-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-09-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-14 | 2023-09-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-14 | 2023-09-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-14 | 2023-09-20 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-14 | 2023-09-06 | 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 | 2023-07-14 | 2023-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-10 | 2023-05-04 | Y |
| 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 | 2023-03-10 | 2023-05-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-06 | 2023-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-06-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-16 | 2022-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-28 | 2022-05-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-28 | 2022-05-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-11-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-05 | 2021-09-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-05 | 2021-09-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-08-05 | 2021-09-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-08-05 | 2021-09-30 | N |
| 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 | 2021-08-05 | 2021-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-05 | 2021-09-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-08-05 | 2021-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-08-05 | 2021-09-30 | N |
| Post nurse staffing information every day. | Health | 2021-08-05 | 2021-09-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-05 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-05 | 2021-09-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-04-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-18 | 2019-12-09 | 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 | 2019-09-18 | 2019-12-09 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-09-18 | 2019-10-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-18 | 2019-10-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-18 | 2019-10-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-18 | 2019-10-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-18 | 2019-10-30 | 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 | 2019-09-18 | 2019-10-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-18 | 2019-10-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-18 | 2019-10-30 | 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 | 2019-09-18 | 2019-10-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-18 | 2019-10-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-18 | 2019-10-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-18 | 2019-10-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-18 | 2019-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-18 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-18 | 2019-10-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-18 | 2019-10-30 | N |
