Inspection Reports for
Carriage Square Rehab and Healthcare Center

The facility failed to provide timely access to resident electronic medical records, staff list, and resident matrix from 9:50 A.M. to 12:00 P.M. on the day of the survey, delaying the surveyors' ability to review necessary records. Access was eventually provided after authorization from the regional corporate team.

The facility failed to provide appropriate catheter care and infection control measures, including failure to prevent urinary tract infections and maintain enhanced barrier precautions during wound care. Staff were observed not following proper hand hygiene, glove use, and gowning protocols, and catheter bags and tubing were found touching the floor. These deficiencies affected multiple residents and posed minimal harm or potential for actual harm.

The facility failed to follow its policy for medical record requests by allowing staff to print and give copies of electronic medical records without a formal written request and failed to provide requested medical records in a timely manner for one previous resident.

The facility failed to ensure appropriate incontinent care was provided to three sampled residents, resulting in improper perineal care practices that could lead to urinary tract infections. Staff were observed reusing soiled wipes and gloves during perineal care, contrary to facility policy and best practices.

The complaint investigation focused on Resident 63's change of condition that was not timely reported to the physician, delayed antibiotic administration, and delayed urinalysis collection, leading to sepsis hospitalization. The investigation also included a medication error involving Resident 89 receiving another resident's medications.

The facility failed to notify the physician timely of a resident's change of condition, delayed starting an antibiotic, and delayed obtaining a urinalysis, resulting in hospitalization for sepsis. Another deficiency involved a medication error where a resident was given medications not ordered for her, increasing risk of adverse effects. Corrective actions were implemented during the survey.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, failure to timely notify physicians and administer ordered antibiotics leading to hospitalization, improper respiratory care equipment maintenance, inadequate pain management, medication errors, unsanitary kitchen conditions, incomplete arbitration agreements, ineffective infection prevention and control program, lack of designated infection preventionist, and inadequate staff training programs.

The investigation was complaint-driven based on allegations of sexual assault by two Physical Therapy Assistants against residents. The allegations included inappropriate touching and failure to report and investigate properly. The facility unsubstantiated the allegations but failed to follow proper reporting and investigation protocols.

The facility failed to implement abuse and neglect policies properly, including staff training after alleged sexual assaults, timely reporting to law enforcement and state agencies, and conducting thorough investigations. Allegations against two Physical Therapy Assistants were unsubstantiated due to lack of evidence, but the facility did not follow required procedures for reporting and investigation.

The complaint involved allegations of misappropriation of Resident #37's debit card by CNA F, confirmed by bank records showing unauthorized transactions totaling $563.76. The employee was suspended and later terminated. A police report was filed. Additional complaints involved inadequate personal care for residents #69, #22, #24, and #43.

The facility failed to prevent misappropriation of Resident #37's property by a CNA who used the resident's debit card without authorization, resulting in fraudulent charges totaling $563.76. Additionally, the facility failed to provide adequate personal hygiene care, including incomplete perineal care, insufficient shower frequency, and lack of oral care for multiple residents.

The facility had multiple deficiencies including failure to maintain resident dignity and privacy, inadequate cleaning and pest control, failure to accommodate resident preferences for snacks and showers, medication administration errors, incomplete care plans especially related to trauma informed care, improper use of mechanical lifts, call lights not within reach, and environmental safety issues including water management and building maintenance.

The facility failed to meet professional standards in medication administration, including preparing medications in advance and leaving them unattended, and improper handling of medication tablets leading to contamination. Additionally, narcotics and controlled medications were not properly secured, with medication carts left unlocked and the medication room and refrigerator unlocked.

The facility was found deficient in multiple areas including failure to obtain physician orders for bedside medications, failure to ensure call lights were within reach, improper catheter anchoring, failure to manage resident funds properly, incomplete posting of survey results and nurse staffing, environmental cleanliness issues, failure to provide proper respiratory care, failure to follow medication administration standards, and failure to provide residents with meal choices.