Carriage House Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 3 of 3 kitchens (Kitchen #1, Kitchen #2, and Kitchen #3) reviewed for dietary services.1. The dietary staff failed to label and date all food items in Kitchen #1.2. The dietary staff failed to effectively reseal, label and date frozen and refrigerated food items in Kitchen #1.3. The dietary staff failed to put separate dented cans from undented cans in Kitchen #1.4. The facility failed to ensure CNA B and CNA C wore their hairnets properly during the lunch meal in Kitchen #2 on 07/21/2025.5. The facility failed to ensure Honey Nut and Crisp [NAME] cereal were not left unsealed in Kitchen #3.6. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2024

  Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility did not label, or date food stored in the kitchen's refrigerator. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on [DATE] at 8:55 a.m., it was observed that a whole pie, a slice of pie, French fries, tater tots, 1 gallon of partially eaten ice cream, and 2 bags of hard-boiled eggs did not have a date or label. […]

• No harm, potential for more than minimal, patternF761Jul 23, 2025

  Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 21 residents (Resident #24) and 2 of 8 medication carts (Building #2 and Building #3 nurse medication carts) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #24's formoterol fumerate (inhaled medication to improve breathing) was properly stored and secured. 2. The facility failed to ensure LVN A did not leave Resident #24's budesonide and formoterol fumerate (inhaled medications) in the chamber of his nebulizer (chamber on the breathing machine that holds the liquid medication to be converted to a mist for inhalation) . 3. […]

• No harm, potential for more than minimal, patternF804Jul 23, 2025

  Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals (7/22/2025 Lunch) and for 5 of 5 residents reviewed for palatability, attractiveness, and appetizing (Resident #'s 63, 33, 10, 54, and 88). The dietary staff failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 7/22/25 (lunch) meal in Kitchen #1.The facility failed to ensure Resident #s 63, 33, 10, 54 and 88 food was not served bland and lacking flavor. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. […]

• No harm, potential for more than minimal, patternF641Jun 26, 2024

  Based on observation , interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 22 residents (Resident #14, Resident 73, Resident #53, and Resident #186) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document Resident #53's chair alarm use. 2.The facility failed to accurately reflect Resident #14 was PASRR positive (identified as having a serious mental illness) on her annual MDS assessment. 3. The facility failed to accurately reflect Resident #73 was receiving hospice services on her significant change MDS assessment. 4. The facility failed to accurately reflect Resident #186 had bed and chair alarms on his quarterly MDS assessment. […]