A list of the most recent deficiencies for Carriage Inn of Cadiz Inc. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-07 | 2024-03-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-08 | 2024-02-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-08 | 2024-02-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-08 | 2024-02-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-08 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-02-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-08 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-22 | 2023-12-14 | Y |
| Have policies on smoking. | Health | 2023-11-22 | 2023-12-14 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-06-13 | 2023-06-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-13 | 2023-06-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-13 | 2023-06-30 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-06-13 | 2023-06-30 | Y |
| 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 | 2023-06-13 | 2023-06-30 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-06-13 | 2023-06-30 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-14 | 2022-05-05 | 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 | 2022-04-14 | 2022-05-05 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-04-14 | 2022-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-14 | 2022-05-05 | 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 | 2022-04-14 | 2022-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-14 | 2022-05-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-12 | 2022-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-12 | 2022-05-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-12 | 2022-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-12 | 2022-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-12 | 2022-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-06 | 2022-02-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-06 | 2022-02-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-06 | 2022-02-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-27 | 2021-05-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-27 | 2021-05-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-15 | 2019-10-11 | 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 | 2019-08-15 | 2019-10-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-15 | 2019-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-10-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-15 | 2019-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-15 | 2019-10-11 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-15 | 2019-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-15 | 2019-10-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-15 | 2019-10-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-15 | 2019-10-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-08-19 | 2019-10-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-15 | 2019-09-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-19 | 2019-09-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-19 | 2019-09-13 | N |
