Carriage House Nursing and Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and records review, the facility failed to 1) Provide palatable food products for 8 of 10 residents during the dining task, 2) Follow resident preferences in choices in dining for one resident (Resident #13) of 10 residents reviewed for food quality and preferences and, 3) Address food complaints received during resident council meeting, resulting in multiple food/meal complaints of cold food, no condiments with meals, poor taste and appearance of meals and one resident R13 not receiving the meal choice ordered timely.

Inspectors wroteBased on interview and record review, the facility failed to provide Advanced Beneficiary Notice of Non-coverage (ABN) notices for 2 residents (#7 & #87) of 3 residents reviewed, resulting in the lack of disclosure related to Medicare rights and the inability to appeal the discharge in the time frame allotted by Medicare.

Inspectors wroteBased on interview and records review, the facility failed to follow the comprehensive care for post fall interventions for 1 resident (Resident #7) of 2 residents reviewed, resulting in Resident #7's post fall interventions of monitoring every 2 hours and PRN (as needed) with no documentation of the actual monitoring being performed by facility staff. Resident #7:Observation and interview on 05/11/2026 at 9:24 AM of Resident #7 revealed a right wrist with black splint in place. Resident #7 stated that she did fall but does not remember how it happened. In an interview on 05/11/2026 at 9:35 AM, Licensed Practical Nurse (LPN) V stated that Resident #7 had a fall in April 2026 right at shift change. Resident #7 herself transferred and had fallen and fractured her right wrist. The right wrist started to swell so we sent her out to the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate grooming/showers per residents' preferences for three residents (#7, #16, #75) of 6 residents reviewed for Activities of Daily Living (ADL), resulting in resident complaints and unkempt appearances.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the formation of a contracture for one resident (Resident 9) of four residents reviewed for range of motion. Findings Include:Resident #9: On May 12, 2026, at approximately 1:30 PM, a review was conducted of Resident #9's medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Hemiplegia and Hemiparesis, Dysphagia, Acute Respiratory Failure, Aphasia and Hypertension. Further review of the chart yielded the following:There was nothing located in Resident #9's Care Plan, Kardex or Progress Notes that indicated any decline, formation of stiffness or contractures. Room Change:Upon admission Resident #9 was placed in room [ROOM NUMBER]-1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely notify the physician of a positive urine sensitivity result for one resident (Resident #107) of one resident reviewed for Urinary Tract Infections (UTI), resulting in complaints of stomach pain, and a positive urine culture going untreated for approximately 24 hours.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor an ileostomy for one resident (Resident #108) of one resident reviewed for ostomy care, resulting in delayed physician's orders for assessment and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) Label open biologic medications with resident and dates for two residents (Resident #113 and Resident #67) that were refrigerated in two of three medication rooms viewed for medication storage and 2) Secure medications stored in two of three carts reviewed for medication storage, resulting in the potential risk of resident safety, misappropriation and integrity of medications.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility: (1.) Failed to ensure proper labeling of medications in 3 of 3 medication carts, (2.) Failed to ensure properly secure/lock 1 treatment cart with medical supplies and prescription creams/ointments, and (3.) Failed to ensure proper completion of medication refrigerator temperature log, resulting in opened and undated medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the CMS 802 (form utilized by the facility to list all current residents and to note pertinent care categories) was accurate for three residents (#48 #49 and #93) of 10 residents reviewed for matrix accuracy.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff competency for medication administration for one resident (Resident #21) of one resident reviewed, resulting in medication administration without a Health Care Provider's order and inappropriate medication administration per professional standards of practice.

Inspectors wroteBased on interview and record review the facility failed to effectively monitor four residents (#60, #76 #85, #276) of five residents reviewed for unnecessary medications. Resulting in, Residents # #60, #85 and #276) being administered medications without the proper indications for usage and Resident #76 being administered a prophylactic antibiotic without risk versus benefit analysis. Findings Include: Resident #60: On 3/12/2025 at 8:40 AM, a review was conducted of Resident #60's records, and it indicated the resident initially admitted to the facility on [DATE] with diagnoses that included, Acute and Chronic Respiratory Failure with Hypoxia, Anxiety Disorder, Atrial Fibrillation and Major Depressive Disorder. Resident #60 can make her needs known to facility staff and is her own person. Further review yielded the following: Physician Orders: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper administration of medication for one resident (Resident #83), resulting in Resident #83 receiving levothyroxine (thyroid hormone replacement) with med pass supplement and other medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow care plan interventions for dining for one resident (Resident #8) out of five residents reviewed for dining, resulting in a lack of assistive devices provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to transport clean linen and store gloves in a sanitary manner, resulting in contamination of linen and Personal Protective Equipment (gloves).

Inspectors wroteBased on observation, interview and record review, the facility failed to document pain medication administration and complaints of ankle pain for one resident (Resident #1) of three residents reviewed for falls, resulting in a lack of documented left ankle assessments and Tylenol administration.

Inspectors wroteThis citation pertains to intake number MI00147076 Based on observation, interview and record review the facility failed to maintain professional standards and complete comprehensive and safe discharge for one resident (Residednt #808) reviewed for discharge, resulting in Resident #808 being discharged from the facility with a multitude of another resident's (Resident #807) medications in their possession. Findings Include: Resident #808: On 10/22/2024 at 4:30 PM, Resident #808 was observed watching television in her room. She was in good spirits and when asked about her most recent discharge from the facility she stated the nurse gave her another residents medications. Resident #808 explained she was discharged around 5:30 PM (on 9/20/2024) and provided with a lot of medications which she thought was odd as she was only prescribed 2-3 medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in good repair, properly cool cooked potentially hazardous foods, and provide backflow protection for plumbing equipment, resulting in the potential for an increased risk of foodborne illness and contamination of the potable water supply, affecting all residents that consume food from the kitchen.

Inspectors wroteThis Citation pertains to Intake Number MI00143283. Based on observation, interview and record review, the facility failed to (1.) Ensure a comfortable shower room, (2.) Ensure that meal trays were picked up timely, (3.) Ensure that call light tasks were completed and answered in a dignified manner for three residents (Resident #34, Resident #46, Resident #55) and residents at the Resident Council confidential group meeting, resulting in concerns of a cold shower room, meal trays be left in residents' rooms, and call light task/needs to go unmet in a timely manner.

Inspectors wroteThis Citation pertains to Intake Number MI00143283. Based on interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two residents (Resident #55, Resident #60) and residents from the Resident Council confidential group meeting, resulting in residents voicing concerns with not receiving two showers weekly and the likelihood for a negative psychosocial outcome for residents.

Inspectors wroteThis Citation pertains to Intake Number MI00143283. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for a census of 93 residents residing in the facility, resulting in sampled Resident #55 and Confidential Resident Group residents voicing concerns of insufficient staff, long call light wait times, unmet care needs and incontinence due to call lights not answered timely or needs responded to timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) Reconcile narcotics for one resident (Resident #295) and store medications including a narcotic (Lyrica) properly during medication administration task; 2.) Properly dispose of expired medication/medical supplies and ensure proper securement of the [NAME] hall treatment cart; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medication administration times were adjusted to coordinate care when one resident (Resident #3) was out of the facility for dialysis treatments, of two residents reviewed for dialysis, resulting in medications not administered with the potential for the exacerbation of diagnoses for Resident #3.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that side rails were assessed, the results communicated to the resident and a consent and a physician's order were obtained, ensure that maintenance did the appropriate installation and assessed for risk of entrapment for one resident (Resident #27) of one sampled resident from a total sample of 20 residents resulting in the potential for accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer an ulcer medication prior to the breakfast meal for one resident (Resident #30), resulting in late administration and the likelihood of decreased therapeutic effectiveness of the ulcer medication. Finings include: On 3/27/24, at 9:27 AM, During medication pass task, Nurse E prepared medications for Resident #30. It was noted that the Sucralfate ulcer medication was in red. Nurse E was asked why it was highlighted red and Nurse E it is a little late. Resident #30 was lying in their bed and offered they had already eaten their breakfast. A reconciliation was done of the morning medications for Resident #30. The following medications were administered and consumed at 9:33 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow enhanced barrier precautions during a medical treatment and disinfect reusable medical equipment for two residents (Resident #30, Resident #40), resulting in cross contamination of medical equipment and a nurse uniform with the likelihood of further cross contamination and spread of infectious causing bacteria.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the required nurse staffing hours and retain accurate records for required nurse staffing hours, resulting in the potential to affect all 93 residents residing at the facility, resident representatives, staff and visitors to be unable to accurately determine nursing staff who are on duty.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to reconcile admission orders for one resident (Resident #13) of three residents sampled for pressure ulcers resulting in wound care treatment orders not being in place.

Inspectors wroteBased on interview and record review, the facility failed to provide medication timely per physician's orders for one resident (Resident #9), resulting in a delay in medication treatment with the likelihood of increased neurological symptoms.

Inspectors wroteBased on interview and record review the facility failed to administer medications per the physician's order for one resident (Resident #1) of three residents sampled for medication administration, resulting in a physician-ordered intravenous (IV) antifungal (Micafungin) not being administered.