CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Carriage Square Rehab and Healthcare Center
View the most recent health deficiencies and inspection results for Carriage Square Rehab and Healthcare Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Carriage Square Rehab and Healthcare Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-01-27 | 2026-01-28 | Y |
| 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 | 2025-12-23 | 2025-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-12-23 | 2025-12-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-12-03 | 2025-12-08 | Y |
| 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 | 2025-11-03 | 2025-11-24 | Y |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2025-03-14 | 2025-04-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-14 | 2025-04-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-14 | 2025-04-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-03-14 | 2025-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-14 | 2025-04-17 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2025-03-14 | 2025-04-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-14 | 2025-04-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-03-14 | 2025-04-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-03-14 | 2025-04-17 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2025-03-14 | 2025-04-17 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2025-03-14 | 2025-04-17 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2025-03-14 | 2025-04-17 | N |
| Provide training in compliance and ethics. | Health | 2025-03-14 | 2025-04-17 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2025-03-14 | 2025-04-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-14 | 2025-04-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-14 | 2025-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-14 | 2025-04-17 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2025-03-14 | 2025-04-17 | N |
| Use approved construction type or materials. | Fire Safety | 2025-03-14 | 2025-04-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-03-14 | 2025-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-23 | 2024-05-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-23 | 2024-05-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-23 | 2024-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-14 | 2023-09-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-14 | 2023-09-20 | Y |
| 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 |
| 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 |
| Ensure proper usage of power strips and extension cords. | 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-14 | 2023-09-06 | N |
| Use approved construction type or materials. | 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 restrictions on the use of portable space heaters. | 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 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 |
| Have simulated fire drills held at unexpected times. | 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 |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | 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 |
| Provide properly protected cooking facilities. | 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 |
| Install emergency lighting that can last at least 1 1/2 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-11-30 | 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 |
| 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 |
| 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 |
| 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 manage his or her financial affairs. | 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 |
| Allow residents to self-administer drugs if determined clinically appropriate. | 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 |