Inspection visit
Health inspection
Citations
15 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.
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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F940 - Training Requirements
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F946 - Compliance and ethics
Provide training in compliance and ethics.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
FAQ · About this visit
Common questions about this visit
What happened during the March 14, 2025 survey of CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER?
This was a inspection survey of CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER on March 14, 2025. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER on March 14, 2025?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
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.
SourceView on CMS Care Compare
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.