Carriage Inn of Cadiz

Inspectors wroteBased on funds account review, record review, policy review, and interview, the facility failed to ensure accurate accounting of a resident account. This affected one (Resident #54) of three residents reviewed for Personal Fund Accounts. The facility held funds for 31 current and former residents. The facility census was 53.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on review of infection surveillance records, policy review and interview, the facility failed to ensure antibiotic orders were thoroughly researched to determine if residents met the criteria for infections, failed to ensure when criteria was not met the prescriber was informed, and failed to provide education and reports regarding antibiotic use to prescribers in accordance with policies. This affected three (Residents #7, #21 and #61) of four residents reviewed for antibiotic use and had the potential to affect any other residents for whom antibiotics were ordered. During review of the August 2025 infection surveillance reports, the following were identified:1. Review of Resident #7's medical record revealed diagnoses including secondary Parkinsonism, irritable bowel syndrome, and dementia. A nursing note dated 07/21/25 at 11:00 P.M. [...]

Inspectors wroteBased on review of medical records, activity calendars, activity logs, facility policy, and interviews with staff and residents, the facility failed to maintain an activity program specific to meet the individualized needs of Resident #40. This affected one resident (Resident #40) of one resident reviewed for the activities program. The facility census was 51.

Inspectors wroteBased on medical record, policy review, staff and resident interviews, the facility failed to provide routine dental services to one (Resident #53) of two residents reviewed for dental services. The facility census was 51. Findings Include:Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including kidney disease, enlarged prostate, lung disease, anemia, high blood pressure, reflux, Alzheimer's Disease, dementia, anxiety and depression. Record review of Resident #53 most recent Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15/15 meaning the resident was cognitively intact with no impairments. The MDS further noted Resident #53 use of wheelchair for mobility and supervision or minimal assistance with transfers and personal care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #26's medication orders and administration record were accurate. This affected one (Resident #26) of six residents reviewed for medication administration. The facility census was 51.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, incident log review, procedure review and interview, the facility failed to maintain hot water temperatures below 120 degrees Fahrenheit (F). This had the potential to affect 16 residents (#6, #8, #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30) identified by the facility as cognitively impaired and independent with mobility of 34 residents who reside on the 200 and 300 halls. The census was 55.

Inspectors wroteBased on interview and record review the facility failed to ensure that witness authorizations were obtained to manage resident funds. This affected five residents (#1, #6, #24, #26, and #56) of five reviewed for personal funds. This had the potential to affect 33 residents whose funds were managed by the facility. The census was 58.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents disposed of cigarettes in the designated containers and that facility staff supervising residents smoking knew where the fire safety devices were located. This affected four residents (#3, #14, #19, and #20) of four identified by the facility as smokers. The facility census was 58.

Inspectors wroteBased on observation and interview, the facility failed to ensure there was sufficient staff to monitor dining activities on the secure unit. This had the potential to affect all 19 residents who resided on the secure unit. The facility census was 58.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to complete a comprehensive assessment to determine if side rails were used as a restraint or an enabler. This affected one (Resident #56) of 24 residents observed for possible restraints. Te census was 58.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure comprehensive assessments were completed accurately related to hospice services and medication use. This affected two (Resident #18 and #35) of 19 residents reviewed for comprehensive assessments. The facility census was 58.

Inspectors wroteBased on medical record review, observations, policy review and staff interview the facility failed to ensure Resident #21 was turned and repositioned as per the care plan and ordered by the physician. The facility also failed to accurately stage pressure ulcer wounds for Resident #44. This affected two (Residents #21 and #44) of two resident reviewed for pressure ulcer wounds. The facility census was 58.

Inspectors wroteBased 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. The facility census was 57.

Inspectors wroteBased on observations, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility main entrance door. This had the potential to affect all the residents in the facility. The facility census was 57.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident bathrooms were in good repair. This affected four Residents (#12, #28, #31, and #40) of 19 residents reviewed for physical environment . The facility census was 64.

Inspectors wroteBased on interview and record review the facility failed to use the correct form to notify Resident #42 and #112 of a change in their skilled nursing benefits. This affected two Residents ( #42 and #112 ) of three Residents reviewed for skilled nursing facility advanced beneficiary notifications (SNFABN). The facility census was 64.

Inspectors wroteBased on interview and record review the facility failed to accurately complete the Preadmission Screening and Resident Review Result notice (PASRR) for a significant change in status. This affected two (Residents #23 and #52) of two residents reviewed for PASRR. The facility census was 64.

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to ensure a resident, who required an extensive assist of one from staff for personal care, received the assistance needed to keep his fingernails trimmed. This affected one (Resident #57) of four residents reviewed for activities of daily living (ADL's). The facility census was 64.

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to provide joint movement services or splint use for residents identified with limited range of motion. This affected one (Resident #35) of one residents reviewed for range of motion services. The facility census was 64.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure a resident's fall prevention interventions were implemented as per their plan of care. This affected one (Resident #59) of two residents reviewed for falls. The facility census was 64.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #54 received therapeutic dietary interventions to prevent weight loss. This affected one resident (#54) of three residents reviewed for nutrition and weight loss. The facility census was 64.