MADISON CARRIAGE COVE SHORT STAY REHABILITATION

Nursing Home Inspector

410 WEST 1ST NORTH
REXBURG, ID 83440
Madison County
Phone: 208-359-7676
Provider Number: 135140
Last Inspection: 04/21/2017

About the Nursing Home

Number of Beds: 35
Number of Residents: 25
Beds Available: 10
Percent Occupancy: 71%
Insurance Accepted: Medicare & Medicaid
Types of Councils: None
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

65

Facility
37

County
28

ID
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

65

2017
12

2016
19

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Minimal 5 9/5/2017
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 5/31/2017
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 5/31/2017
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 5/31/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 5/31/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 5/31/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 9/5/2017
 
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Isolated : Minimal 3 9/5/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/5/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 9/5/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 9/5/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 5/31/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 5/31/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/5/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 5/31/2017
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Minimal 5 5/31/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 9/5/2017
 

10/5/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 11/7/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 11/7/2016
 
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 11/7/2016
 

2/26/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Potential 4 4/23/2015
 
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 4/23/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/23/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 4/23/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/23/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg ID State Avg
Number of Residents 25 34.00 49.22
Registered Nurses 2.15 1.44 0.87
Licensed Practical / Vocational Nurses 0.00 0.32 0.78
Certified Nursing Assistants 3.51 3.21 2.50
Total Staff Hours 5.66 4.97 4.15

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% ID State Avg%
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 1 3
of short-stay residents who had an outpatient emergency department visit 11 98 95
of short-stay residents who made improvements in function 77 100 96
of short-stay residents who newly received an antipsychotic medication 0 2 2
of short-stay residents who self-report moderate to severe pain 34 2 5
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 2 6
of short-stay residents who were rehospitalized after a nursing home admission 8 26 20
of short-stay residents who were successfully discharged to the community 81 8 17
of short-stay residents with pressure ulcers that are new or worsened 2 3 10