Deficiency Records for Carriage Hill Health and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Carriage Hill Health and Rehab 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-07 | 2023-07-22 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-06-07 | 2023-07-22 | 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 | 2023-06-07 | 2023-07-22 | 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 | 2023-06-07 | 2023-07-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-07 | 2023-07-22 | 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 | 2023-06-07 | 2023-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-07 | 2023-07-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-07 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-07 | 2023-07-22 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-07 | 2023-07-22 | Y |
| Meet other general requirements. | Fire Safety | 2022-02-09 | 2022-08-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-02-09 | 2022-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-09 | 2022-05-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-02-09 | 2022-03-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-09 | 2022-03-25 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-27 | 2022-03-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-27 | 2022-03-08 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-27 | 2022-03-08 | 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 | 2022-01-27 | 2022-03-08 | 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 | 2022-01-27 | 2022-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-27 | 2022-03-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-27 | 2022-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-27 | 2022-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-03-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-09 | 2022-03-02 | 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 | 2022-02-09 | 2022-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-09 | 2022-02-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-09 | 2019-11-18 | 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 | 2019-10-09 | 2019-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-09 | 2019-11-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-09 | 2019-11-07 | 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 | 2019-10-09 | 2019-11-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-08 | 2019-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-08 | 2019-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-08 | 2019-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-09-10 | 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 | 2019-08-08 | 2019-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-08 | 2019-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-08 | 2019-09-10 | 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 | 2019-08-08 | 2019-09-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-08 | 2019-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-08 | 2019-09-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-08 | 2019-09-10 | 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 | 2019-08-08 | 2019-09-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-08-08 | 2019-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-08 | 2019-09-10 | N |
