Carriage Square Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Carriage Square Rehab and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 14, 2025

  Based on interview, record review, and review of the facility's policy, the facility failed to notify the physician timely when a resident had a change of condition, failed to start an antibiotic that was ordered by the resident's physician, and failed to obtain a physician ordered urinalysis (UA) timely for one resident (Resident (R) 63) of 33 sampled residents. These failures resulted in R63's hospitalization due to sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) related to a urinary tract infection (UTI). The facility census was 93. The facility's Administrator and Director of Clinical and Reimbursement Services were informed on 03/13/25 at 3:23 P.M. […]

• Immediate jeopardy, isolatedF689Jun 22, 2022

  Based on interview and record review, the facility failed to provide adequate personal attention and nursing care for one resident (Resident #1), who the facility assessed and identified as needing the assistance of two staff for cares. On [DATE], one staff member, Nurse Aide (NA) A provided care to the resident without securing assistance from a second staff member. The NA rolled the resident onto his/her side and the resident rolled off the bed onto the floor landing face down. The NA left the room to alert the charge nurse of the accident. The charge nurse, Licensed Practical Nurse (LPN) A and a second nurse, Registered Nurse (RN) A pronounced the resident deceased . The facility census was 68. The administrator was notified on [DATE] at 3:33 P.M. […]

• Actual harm, isolatedF697Mar 14, 2025

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to effectively manage pain for one of one resident (Resident (R) 71) reviewed for pain out of 33 sampled residents. The facility failed to order R71's oxycodone (an opioid pain medication) in a timely manner and the physician ordered pain medication was not administered as ordered. This failure caused R71 to experience terrible pain, was unable to relax enough to sleep, and felt like he was having withdrawals. The facility census was 93. Findings include: Review of the facility's policy titled, Pain Management, dated 10/24/22, revealed, . […]

• No harm, potential for more than minimal, widespreadF847Mar 14, 2025

  Based on interview, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RR) during admission included a clause that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. This failure affected all residents who had signed the Arbitration Agreement and any future residents who might sign the agreement. The facility census was 93. […]

• No harm, potential for more than minimal, widespreadF882Mar 14, 2025

  Based on interview, document review, and policy review, the facility failed to ensure there was a designated Infection Preventionist (IP) that had completed specialized training in infection prevention and control that had sufficient time to assess, develop, implement, monitor, and manage the facility's Infection Prevention and Control Program (IPCP). The failure placed all residents in the facility at risk for acquiring diseases and infections. The facility census was 93. Findings include: Review of the Infection Control Preventionist Job Description, provided by the facility, revealed Position Description Responsible for assuming the responsibility for the Infection Control Program of the facility in accordance with accepted standards of practice, state and federal regulations and… […]