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 facility failed to maintain fire resistance ratings of walls, electronic supervision of sprinkler system valves, electrical wiring compliance, and generator maintenance. Multiple deficiencies were identified that could potentially affect all residents and staff.

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 facility failed to ensure that fire extinguishers were checked monthly as required. Observations showed that fire extinguishers in multiple locations were last checked in June 2024, and this deficiency affected all eleven residents present during the inspection.

The facility failed to ensure residents and staff were properly screened for tuberculosis, lacked a TB policy, did not maintain signed physician statements for employees, and failed to review resident rights annually with residents. The facility census was 13 at the time of the survey.

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 facility failed to implement and train staff on abuse and neglect policies, failed to report allegations of sexual abuse to law enforcement within required timeframes, and failed to conduct thorough investigations of alleged abuse incidents. The facility census was 87 at the time of inspection.

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 maintain fire-rated construction due to water damage affecting smoke compartments, failed to keep means of egress free of obstructions, lacked proper emergency lighting in some areas, and had deficiencies in fire alarm system maintenance and sprinkler system upkeep. Several other fire safety code violations were noted including issues with hazardous areas, cooking facilities, fire drills, and electrical systems.

The facility failed to meet multiple fire safety regulations including annual fire department consultation, semi-annual fire alarm testing, annual fire alarm certification, annual sprinkler system inspection, and prohibition of portable heaters. These deficiencies affected all fifteen residents present during the inspection.

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 failed to meet professional standards in medication administration, including improper handling and preparation of medications by staff. Additionally, narcotics and controlled medications were not properly secured, with medication carts and storage areas left unlocked and unattended.

The facility failed to meet professional standards of quality in care planning and wound management for a resident with a stage two pressure ulcer. Documentation deficiencies included lack of wound measurements, failure to notify appropriate staff, and absence of physician orders for treatment.

The complaint investigation was triggered by an incident on 5/30/22 where a resident requiring two staff for care was found on the floor face down and later pronounced deceased. The investigation substantiated the failure of the facility to provide adequate supervision and care, resulting in an immediate jeopardy level violation that was later lowered.

The facility failed to provide adequate personal attention and nursing care to a resident requiring two staff for assistance, resulting in the resident rolling off the bed and dying. The investigation revealed lapses in staff response, failure to call emergency services, and inadequate monitoring of the resident's condition.

The facility failed to provide documentation for annual fire department consultation, did not conduct required fire drills equally across shifts, failed to provide fire safety training to all employees, did not maintain or test the fire alarm system properly, failed to ensure hazardous areas and laundry room doors met fire safety requirements, did not maintain sprinkler systems, improperly disposed of ashtray contents, had building maintenance issues, and failed to control hot water temperature within required limits. These deficiencies affected all fourteen residents present during the inspection.

The facility failed to notify a resident's physician timely after a wound care consultant's recommendations and did not provide a policy on physician's orders. The resident required extensive assistance and had multiple wounds that were not promptly addressed, leading to hospitalization and altered mental status.

The complaint investigation substantiated that the facility failed to notify the physician of a resident's significant change in condition and failed to provide adequate assistance with activities of daily living, including bathing.

The facility failed to notify a resident's physician promptly about significant changes in the resident's condition, specifically respiratory issues. Additionally, the facility did not ensure dependent residents received necessary assistance with activities of daily living, including bathing, as required by policy.

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.

The facility failed to meet several Life Safety Code requirements including exit signage, sprinkler system maintenance, smoke barrier construction, utilities safety, evacuation and relocation plans, and fire door maintenance. Multiple deficiencies were identified that potentially affected residents, staff, and visitors.

The facility failed to ensure a resident environment free of accident hazards and adequate supervision to prevent falls. Documentation and interventions following resident falls were insufficient, and protective oversight procedures for residents on voluntary leave were not properly followed.

The facility failed to ensure staff compliance with infection prevention protocols including proper use of PPE, social distancing, and isolation procedures. Multiple deficiencies were noted related to infection control and communicable disease regulations.

The complaint investigation substantiated that a resident's Medicare card and two debit cards were used without authorization between 11/4/19 and 11/6/19, with charges totaling $31.25 and an attempted charge of $56.14 declined due to insufficient funds. The facility notified the resident's family, filed a police report, and notified the Department of Health and Senior Services.

The facility failed to prevent the misappropriation of one resident's Medicare card and debit cards, resulting in unauthorized charges. The investigation revealed inadequate staff supervision and delayed reporting of the incident.

The facility failed to properly document all fire drills, specifically lacking the length of time for drills. The facility census was fourteen residents at the time of inspection.

The facility was found to have multiple deficiencies related to employment screening, resident assessments, care planning, medication administration, infection control, and safety measures. Several residents' care plans and assessments were incomplete or inaccurate, and medication errors were noted.

The facility failed to maintain corridor doors and smoke barrier doors to resist the passage of smoke as required by NFPA 101. Several corridor doors and smoke barrier doors did not close properly, exposing gaps that could allow smoke passage.

The facility failed to properly document psychotropic medication gradual dose reduction attempts and ensure proper labeling and storage of medications and biologics. The infection prevention and control program was not fully implemented, resulting in inadequate hand hygiene and infection control practices affecting residents.

The facility failed to implement adequate measures to prevent and treat pressure ulcers for one resident, resulting in unstageable pressure ulcers and lack of proper documentation and interventions. Staff did not complete timely skin assessments or update care plans to address the resident's skin condition.

The facility failed to meet professional standards of care for one resident by not timely contacting the physician for a prescription, failing to follow physician orders, and inadequate documentation of care related to diarrhea and medication administration. The facility also lacked a safe and effective medication system and did not provide personal nursing care consistent with acceptable nursing practice.