Carriage Inn of Cadiz

In the surveyor’s words

From the most serious findings on record at Carriage Inn of Cadiz, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 22, 2023

  Based on review of the medical record, review of the facility investigation, and interviews with staff, the facility failed to ensure Resident #41 was free from accident hazards. Actual harm occurred on 10/16/23 when Resident #41, who was cognitively impaired, at risk for falls, and dependent on two staff for bed mobility, fell out of bed while State tested Nursing Assistant (STNA) #112 was providing incontinence care by himself. Resident #41 sustained a fracture to the right hip and hematoma to the back of her head. Resident #41 was transferred to the hospital and received surgical intervention to her right hip. This affected one resident (Resident #41) of three residents reviewed for accident hazards. […]

• Actual harm, isolatedF688Jun 13, 2023

  Based on observation, record review and interview, the facility failed to ensure therapy recommendations were implemented upon discontinuation of therapy services. Actual harm occurred when Resident #1 had worsening contractures and decline in range of motion when restorative/maintenance programs for application of hand splints, passive range of motion (PROM) exercises and a timed out of bed schedule was not provided as recommended impacting the resident's mobility and skin integrity. This affected two residents (Resident #1 and #40) of three residents reviewed for range of motion. The census was 59. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF761Dec 23, 2025

  Based on observation, record review, and interview, the facility failed to provide safe and secure medication storage, including proper labeling and maintaining temperatures of medication storage refrigerators, of all medications. This had the potential to affect all residents of the facility. The facility census was 51.Findings include:On 12/09/2025 at 9:05 A.M., an observation of the treatment cart in the Kerrozin medication room was performed. The observation revealed Medihoney 1.5-ounce tube which was opened, unlabeled, and undated. The treatment cart observation further revealed a Dermasyn hydrogel wound dressing 3-ounce tube which was opened, unlabeled, and undated. […]

• No harm, potential for more than minimal, widespreadF880Dec 23, 2025

  Based on review of the facility's infection control surveillance logs and interview, the facility failed to adequately monitor for patterns of infection and provide oversight to identify the cause of identified patterns of infection. This had the potential to affect all 51 residents.Findings include:Review of the July 2025 infection surveillance logs revealed six residents had urinary tract infections (UTI), with Resident #7 being treated twice for UTI. The surveillance logs did not contain information regarding what microorganisms were involved. Review of the August 2025 infection surveillance records revealed microorganisms were not monitored. […]

• No harm, potential for more than minimal, widespreadF812Jun 17, 2024

  Based on observation, policy review and interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect 54 of 55 residents residing in the facility. The facility identified Resident #55 not receiving nutrition by mouth. The facility census was 55. Findings include: On 06/17/24 between 9:45 A.M. and 10:01 A.M. observations of the kitchen revealed Dietary Director #69 and Dietary [NAME] #73 were observed to have beards and a mustache. Upon entrance to the kitchen, Dietary [NAME] #73 had his beard net below his chin and when the surveyor approached the dishwashing station, Dietary [NAME] #73 raised the beard net to cover his beard; however, his mustache remained uncovered. […]