Carriage House Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Carriage House Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 6, 2026

  Based on interview and record review, the facility failed to ensure appropriate supervision for one resident (Resident #1) of three residents reviewed for falls, resulting in three unwitnessed falls causing an elbow skin tear and a hand laceration, resulting in a hospital visit for sutures. Finding include:Resident #1:On 4/6/2026, at 12:10 PM, a record review of Resident #1's electronic medical record revealed an admission on [DATE] with diagnoses that included Wedge compression fracture of T7-T8 Vertebra, fracture of first thoracic vertebrae, Vascular Dementia and Anxiety. Resident #1 had a Brief Interview for Mental status (BIM) assessment on 3/26/2026 which resulted the resident had severely impaired cognition. […]

• Actual harm, isolatedF689Mar 6, 2024

  Based on observation, interview and record review, the facility failed to implement timely interventions, provide appropriate supervision and ensure that staff assisted with transfers to prevent recurrent falls for one resident (Resident #5), resulting in a forehead laceration requiring emergency care and neck and rib fractures. Finding include: Resident #5: On 3/4/24, at 11:00 AM, a record review of Resident #5 electronic medical record (EMR) revealed an admission on 12/28/2023 with diagnoses that included Stroke, unsteadiness on feet and Parkinson's disease. Resident #5 required assistance with all activities of daily living (ADL) and had severely impaired cognition. The Fall Assessment, Date 12/28/2023, revealed that Resident #5 was at High Risk for falls. […]

• Actual harm, isolatedF686Dec 21, 2022

  Based on interview and record review, the facility 1) Failed to offer appropriate timely interventions to prevent the development of two unstageable pressure ulcers (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough - yellow, tan, gray, green or brown and/or eschar - tan, brown or black in the wound bed, 2) Failed to prevent the worsening of a left heel pressure ulcer, and 3) Failed to provide a physician's assessment and monitoring of the wounds of one resident (Resident #513) of three residents reviewed for pressure ulcers, resulting in pain, new bilateral Achilles tendon pressure ulcers, Osteomyelitis (bone infection) of left calcaneus and hospitalization . […]

• No harm, potential for more than minimal, widespreadF812May 13, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 05/11/2026 at 5:37am during the initial kitchen tour, shredded lettuce with a best buy date of 5/5/26 was observed in the walk-in cooler. On 05/11/2026 at 5:37am parmesan cheese blend with a use by date of 5/10/26 in walk in cooler was observed. […]

• No harm, potential for more than minimal, widespreadF880May 13, 2026

  Based on observation, interview and record review, the facility failed to follow Infection Control Practices for enhanced barrier precautions (EBP) during high contact cares for two residents (Resident #3, Resident #16) of two residents reviewed for EBP precautions; appropriately transport clean and dirty linen throughout the facility; and to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP); resulting in the likelihood of contamination of the environment and the likelihood to spread multi-drug resistant organisms causing infection and an increased risk of respiratory infection among all residents in the facility. Findings include. […]