Aventura at Carriage Inn

In the surveyor’s words

From the most serious findings on record at Aventura at Carriage Inn, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580May 6, 2021

  Based on closed medical record review, review of the facility policy, interviews with facility staff, and Primary Care Physician/Medical Director #33, the facility failed to notify the physician for one resident (#01), who had a significant change in condition. This resulted in Immediate Jeopardy and potential serious life-threatening harm when the facility failed to notify the physician when Resident #01 experienced diaphoresis, chest discomfort requiring [MEDICATION(S)] (a medication for chest pain), low blood pressure, and decreased oxygen saturation requiring oxygen. The resident had a continual decline throughout the day and there was no evidence the physician had been notified of the decline. […]

• Immediate jeopardy, isolatedF684May 6, 2021

  Based on closed medical record review, review of the facility policy and procedures related to notification of change in condition, interviews with facility staff, and Primary Care Physician/Medical Director #33, the facility failed to seek timely and appropriate care and treatment for one resident (#01), who experienced diaphoresis, chest discomfort requiring [MEDICATION(S)] (a medication for chest pain), low blood pressure, and decreased oxygen saturation requiring oxygen. This resulted in Immediate Jeopardy and potential serious life-threatening harm when the facility failed to notify the physician when Resident #01 developed diaphoresis and chest discomfort, low oxygen saturation, and experienced a continual decline in her blood pressure, became unresponsive and required initiation of… […]

• No harm, potential for more than minimal, widespreadF812Oct 21, 2025

  Based on observation and staff interview, the facility failed to maintain kitchen equipment and furnishings in a clean and sanitary manner. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not consume food by mouth. The facility census was 63 residents.Findings include:1.Observation on 10/20/25 at 9:24 A.M. revealed there were plastic containers on the clean dish rack which had been stacked while wet and were nesting. Interview on 10/20/25 at 9:25 A.M. with Dietary Manager (DM) #21 verified that the containers were wet and were being stored nested together so they couldn't dry properly. 2.Observation on 10/20/25 at 9:28 A.M. […]

• No harm, potential for more than minimal, widespreadF880Aug 10, 2022

  Based on review of the facility's policy, record review, observations, review of online resources for the Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS), and staff interview, the facility failed to ensure staff wore Personal Protective Equipment (PPE) while caring for residents to the prevent the potential spread of COVID-19. In addition, the facility failed to have a Legionella management plan in place. This had the potential to affect all 72 residents residing in the facility. Findings include: 1. Observation on 08/02/22 at 1:26 P.M. revealed there were two staff members supervising five residents smoking. Residents were spaced approximately six feet apart. […]

• No harm, potential for more than minimal, patternF803Dec 10, 2025

  Based on review of the facility menu, observations, staff interview, and policy review, the facility failed to ensure food was served per the facility menu. This affected nine (#28, #32, #33, #34, #35, #36, #40, #41, and #71) resident who did not receive coleslaw on their lunch trays. The facility census 62. Findings include: Review of the facility menu for the lunch meal for 12/10/25 revealed that residents would receive baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. Observation of the lunch service on 12/10/25 at 1:04 P.M. revealed that the kitchen ran out of coleslaw and Resident #28, #32, #33, #34, #35, #36, #40, #41, and #71 did not receive coleslaw on their trays. Interview on 12/10/25 at 1:06 P.M. […]