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Inspection visit

Health inspection

CARRIAGE SQUARE REHAB AND HEALTHCARE CENTERCMS #26533618 citations on this visit
18 citations recorded

Citations

18 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0561GeneralS&S Epotential for harm

    F561 - Self-determination

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0623GeneralS&S Epotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625GeneralS&S Epotential for harm

    F625 - Transfer and discharge-

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0699GeneralS&S Epotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0727GeneralS&S Epotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0759GeneralS&S Epotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0921GeneralS&S Fpotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the July 14, 2023 survey of CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER?

This was a inspection survey of CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER on July 14, 2023. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER on July 14, 2023?

Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.