Coldwater Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 18, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food and nutritional services, when they failed to: A. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings include: In an observation and interview on 6/16/25 at 12:00 pm, [NAME] A was observed in the kitchen with gloved hands serving the noon meal. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2024

  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 for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to discard leftover food by use by date on the label. These failures could place residents at risk of food borne illness. Findings included: An observation on [DATE] at 09:30 AM of shelving in the kitchen revealed the following: A plastic lidded tub of what appeared to be heart-shaped cereal with no label and no date. A plastic lidded container of whipped vanilla frosting with an open date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 17, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure stored food were properly labeled and dated. B. Ensure that frozen foods were properly labeled and dated C. Ensure that expired foods were not in the pantry, refrigerator, and freezer. These failures could place residents who ate the food at risk for food-borne illness. Findings include: Observation of the refrigerator on [DATE] at 10:00AM revealed the following: 1. Thousand Island dressing opened [DATE] with expiration date [DATE]. 2. 1 gallon of vanilla extract with expiration date [DATE]. 3. 1 gallon of BBQ Sauce with expiration date [DATE]. 4. 1 open 8oz Boost nutritional drink which was not dated. 5. […]

• No harm, potential for more than minimal, patternF812Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included:Observation of the freezer on 08/18/26 at 9:39 AM revealed the following:1. (1) bag of meat, not labeled, date unreadable.2. (1) bag of meat, not labeled or dated.3. (2) bags of meat, label and date were unreadable.4. (1) bag frozen vegetables, not labeled.5. (2) bags of breaded meat, not labeled.6. (3) bags of what looked like sweet potatoes, not labeled. 7. […]

• No harm, potential for more than minimal, patternF578Jun 18, 2025

  Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #8, #17, and #18) of 15 residents reviewed for advanced directives. Residents #8, #17, and #18 had a DNR in their records that was missing the date when the notary signed the form. The facility's failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Resident #8: Record review of Resident #8's face sheet printed [DATE] revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). […]