CARRIAGE SQUARE REHAB AND HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (SAINT JOSEPH, Missouri)

4009 GENE FIELD ROAD, SAINT JOSEPH, Missouri 64506

Phone: 8163641526

CMS Overall:1/5

Overview & Bed Count

Certified Beds

130

Avg Residents/Day

86.9

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Buchanan

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	Missouri Avg	Difference
RN Hours per Resident per Day	0.38	0.46	-0.08
Total Nurse Hours per Resident per Day	3.70	3.40	+0.30
CMS Staffing Rating	1/5	2.2/5	-
Nursing Staff Turnover	72.4%	56.9%	-

Health Citation History

58 health citations on record

Date	Category	Description	Severity
2026-06-04	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2026-06-04	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-01-27	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	B – Minimal Harm Potential
2025-12-23	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	E – Moderate Harm Potential
2025-12-23	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2025-12-03	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2025-11-03	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	E – Moderate Harm Potential
2025-03-14	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	J – Immediate Jeopardy
2025-03-14	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	G – Actual Harm
2025-03-14	Administration Deficiencies	Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.	F – Moderate Harm Potential
2025-03-14	Infection Control Deficiencies	Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.	F – Moderate Harm Potential
2025-03-14	Administration Deficiencies	Develop, implement, and/or maintain an effective training program for all new and existing staff members.	F – Moderate Harm Potential
2025-03-14	Administration Deficiencies	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.	F – Moderate Harm Potential
2025-03-14	Administration Deficiencies	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.	F – Moderate Harm Potential
2025-03-14	Administration Deficiencies	Provide training in compliance and ethics.	F – Moderate Harm Potential
2025-03-14	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	F – Moderate Harm Potential
2025-03-14	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2025-03-14	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-03-14	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2025-03-14	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2025-03-14	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2025-03-14	Infection Control Deficiencies	Implement a program that monitors antibiotic use.	D – Moderate Harm Potential
2024-04-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2024-04-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2024-04-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2023-07-14	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2023-07-14	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	F – Moderate Harm Potential
2023-07-14	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2023-07-14	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	E – Moderate Harm Potential
2023-07-14	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-07-14	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential
2023-07-14	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-07-14	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2023-07-14	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2023-07-14	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2023-07-14	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	E – Moderate Harm Potential
2023-07-14	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2023-07-14	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2023-07-14	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2023-07-14	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2023-07-14	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from the wrongful use of the resident's belongings or money.	D – Moderate Harm Potential
2023-07-14	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2023-07-14	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2021-08-05	Resident Rights Deficiencies	Honor the resident's right to manage his or her financial affairs.	E – Moderate Harm Potential
2021-08-05	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2021-08-05	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	E – Moderate Harm Potential
2021-08-05	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential
2021-08-05	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2021-08-05	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2021-08-05	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential

Showing 50 of 58 citations.

Fire Safety Citation History

30 fire safety citations on record

Date	Category	Description	Severity
2025-03-14	Smoke Deficiencies	Properly install and monitor supervisory attachments on automatic sprinkler systems.	F – Moderate Harm Potential
2025-03-14	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2025-03-14	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	F – Moderate Harm Potential
2025-03-14	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2025-03-14	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	F – Moderate Harm Potential
2023-07-14	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2023-07-14	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	F – Moderate Harm Potential
2023-07-14	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	F – Moderate Harm Potential
2023-07-14	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2023-07-14	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2023-07-14	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-07-14	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	E – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2023-07-14	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2023-07-14	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	E – Moderate Harm Potential
2023-07-14	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2023-07-14	Miscellaneous Deficiencies	Have restrictions on the use of portable space heaters.	E – Moderate Harm Potential
2023-07-14	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2021-08-05	Miscellaneous Deficiencies	Provide a written emergency evacuation plan.	F – Moderate Harm Potential
2021-08-05	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2021-08-05	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2021-08-05	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	E – Moderate Harm Potential
2021-08-05	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	E – Moderate Harm Potential
2021-08-05	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2021-08-05	Egress Deficiencies	Have properly located and lighted "Exit" signs.	D – Moderate Harm Potential
2021-08-05	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential

Total Penalties & Fines

$48,685

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-03-14	Fine	$48,685	-

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