Carriage Hill Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Carriage Hill Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 7, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to identify and prevent pressure ulcers/injuries, resulting in harm for two of 41 residents in the survey sample, Residents #47 and #15. The findings include: 1. For Resident #47 (R47), the facility staff failed to identify and prevent pressure injuries until stage three pressure injuries (1) developed on the resident's right buttock and sacrum on 4/12/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/10/23, the resident's cognitive skills for daily decision making were coded as severely impaired. […]

• No harm, potential for more than minimal, widespreadF563Jan 27, 2022

  Based on observation, staff interview, and facility documentation review, the facility staff failed to allow all residents to receive visitors from 7:00 P.M. through 10 A.M. for an undetermined length of time. The findings included: On 01/25/2022 at 12:15 P.M. upon survey entrance, a sign was observed on the front door of the facility which read: Visiting Hours 10AM to 7PM Please wear a face mask, sanitize hands upon entry and departure, and social distance during your visit. If you have any questions or concerns, please ask the Charge Nurse. The sign was also observed on the front door on the morning and afternoon of 01/26/2022. On 01/26/2022 at 2:05 P.M., an interview with Employee G, the front desk receptionist, was conducted. Employee G verified that she worked from 11:00 A.M. […]

• No harm, potential for more than minimal, patternF684Dec 12, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to promote the highest level of well-being for five of eleven residents in the survey sample, Residents #10, #4, #5, #6, and #2. The findings include: 1. For Resident #10 (R10), the facility staff failed to assess a resident identified as having a change in status on 7/31/24. A review of R10's clinical record revealed the following: 7/29/24 6:15 p.m. New Order O2 (oxygen) at 2 liters/min (per minute) via NC (nasal canula) prn (as needed) for SOB (shortness of breath). The resident received oxygen as ordered for her shortness of breath. 7/31/24 8:38 a.m .Pt (patient) noted to be quieter on this shift and appeared lethargic. Vitals wnl (within normal limits). […]

• No harm, potential for more than minimal, patternF656Jun 7, 2023

  Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 41 residents in the survey sample; Residents #121, #4, #76, #29, #130. The findings include: 1. For Resident #121 the facility staff failed to follow the comprehensive care plan for indwelling catheter care. On 6/6/23 at 8:38 AM, Resident #121 was observed sitting on the side of the bed awaiting his breakfast tray. […]

• No harm, potential for more than minimal, patternF698Jun 7, 2023

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services per the comprehensive care plan, for one of 41 residents in the survey sample, Resident #29. The findings include: The facility failed to provide communication to the dialysis facility for 4 out of 20 dialysis center visits in April and May 2023. Resident #29 was admitted to the facility on [DATE] with a diagnosis that included but was not limited to, end stage renal disease (ESRD) with dialysis. […]