Manor at Carpenters, The

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 17, 2025

  Based on staff interviews, record review and policy and procedure review, the facility failed to protect one (Resident#1) of five residents right to be free from physical abuse (slap) by facility staff. Findings included: Review of the record for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included depression, senile degeneration of the brain, cerebral atherosclerosis, major depressive disorder, and dementia without behaviors. Review of a quarterly Minimum Data Set (MDS) assessment completed 12/13/24 revealed Resident #1 was rarely/never understood and was dependent on staff for upper body dressing, oral care, toileting, bathing, personal hygiene, and lower body dressing. […]

• Actual harm, isolatedF607Mar 17, 2025

  Based on resident record review, staff interview, personnel record review, and review of facility policies and procedures, the facility did not ensure abuse policies and procedures related to screening of potential employees were followed. The facility did not attempt to obtain information from previous or current employers for one staff member (Staff A, Certified Nursing Assistant) out of five staff members reviewed, resulting in harm to Resident #1. Findings included: Review of the record for Resident #1 revealed she was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Jun 11, 2026

  Based on observations, interviews and record review, the facility failed to ensure infection prevention and control practices were followed for the handling and storage of respiratory equipment for one resident (#72) out of four residents sampled and during three out of three medication administration opportunities with Staff A, Licensed Practical Nurse (LPN), and during the handling of soiled laundry in one out of one laundry rooms. These failures created a risk of cross contamination. Findings included: On 06/08/2026 at 10:30 a.m., an oxygen concentrator was observed in Resident #72's room. A long clear tube with a nasal cannula attached was hanging from the concentrator uncovered and unprotected from environmental contamination. […]

• No harm, potential for more than minimal, patternF645Jun 11, 2026

  Based on interview and record review, the facility did not ensure the Preadmission Screening for Resident Review (PASRRs) were completed accurately for four residents (#1, #7, #18, and #39) out of four residents reviewed. Findings included: A review of Resident #39's admission summary showed an admission date of 11/01/24, with diagnosis to include paranoid schizophrenia (onset 2/18/25), major depressive disorder, recurrent, moderate (onset 3/19/25), other specified persistent mood disorders (onset 3/18/25), unspecified dementia, unspecified severity, without behaviors/psychological/ mood, anxiety (onset 10/06/25), and generalized anxiety disorder (onset 10/21/25). A review of Resident #39's Preadmission Screening for Resident Review (PASRR) level I, dated 10/22/25, Section A. […]

• No harm, potential for more than minimal, patternF656Jun 11, 2026

  Based on interviews and record review, the facility did not ensure the development of comprehensive person-centered care plans related to the use of high risk medications for five residents (#1, #5, #7, #18 and #37) out of five residents reviewed. Findings included: A review of Resident #18's Detailed Summary showed an admission date of 3/11/2026 and diagnoses that included mood disorder due to known physiological conditions, unspecified; bipolar disorder, current episode mixed, moderate; major depressive disorder, recurrent, moderate; and unspecified dementia, unspecified severity, with other behavioral disturbances. […]