Carriage House Manor

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 1 of 1 supply storage rooms reviewed for drugs and biologicals in that: The nurse storage room located on the hall identified as Cottage Street was left unlocked and unattended and the refrigerator storage in the storage room was unlocked and unattended. This failure could place residents at risk for loss of control of prescribed medications and essential resident care supplies.

Inspectors wroteBased 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. The facility failed to ensure 2 containers of tea in Kitchen #3 were dated.7. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 21 residents (Resident #43) reviewed for accuracy of assessments. The facility failed to complete Resident #43's admission MDS assessment, with an ARD of 06/03/2025, within 14 days of admission. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care. (Resident #33) The facility failed to administer Resident #33's oxygen as ordered on 07/22/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #35 and Resident #88) and 2 of 2 staff (CNA K and CNA G) reviewed for infection control. 1. The facility failed to ensure CNA K changed her gloves and performed hand hygiene when she provided incontinent care to Resident #35 on 07/22/2025. 2. The facility failed to ensure CNA G followed enhanced barrier precautions related to a wound while assisting Resident #88 with the use of a urinal on 07/23/2025. These failures could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #86) reviewed for discharge MDS assessments. The facility failed to ensure Resident #86's discharge MDS assessment was completed within 14 days of discharge. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased 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.

Inspectors wroteBased 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. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 22 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's diagnosis of Chronic combined systolic and diastolic congestive Heart Failure (heart does not pump blood adequately causing cough, shortness of breath, difficulty breathing, swelling, chest pain, weight gain, tiredness, and weakness). This failure could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 7 residents who were reviewed for quality of care. (Resident #77) 1. The facility failed to ensure Resident #77 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 77 had proper catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 2 of 7 residents (Resident #58 and Resident #73) reviewed for unnecessary medications. The facility failed to ensure Resident #58 and Resident #73 had a stop date or duration for PRN Lorazepam (a medication used to treat anxiety). These failures could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 4 residents reviewed for accidents. (Residents #3) The facility failed to ensure Resident #3 had on a Wanderguard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time) leading him to be able to elope out of the door at the end of the 400 Hall. This failure could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure LVN A followed the facility's Administering Medications policy which resulted in Resident #1 receiving Resident #2's hydrocodone/APAP 7.5 mg/325 mg tablet (opioid analgesic medication used to treat pain) that was not prescribed to her. This failure could place residents at risk of receiving incorrect medications, dosages of medications , and significant adverse effects from medication errors.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 12 resident rooms reviewed on Hall 5 (Room #'s 502, 204, 507, and 510) for resident rights and privacy. The facility failed to ensure Laundry Aide O, HA P, CNA Q and MA R knocked on Room #'s 502, 504, 507, and 510. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 medication carts (nurse cart 5/6) reviewed for controlled medications. The facility did not ensure LVN's B, E, F, G, H, K, L, M, N counted controlled drugs every shift change. This deficient practice could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents reviewed for unnecessary psychotropic medications. (Resident's #9 and #31) The facility failed to ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #9 and #31. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #17) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #17 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #19) reviewed for MDS assessments. The facility did not ensure Resident #19's annual comprehensive MDS assessment was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 22 residents (Resident #2 and Resident #42) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #2's PASRR Evaluation on the MDS assessment. The facility failed to accurately reflect Resident #42's weight on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents reviewed for care plans. (Resident #2 and Resident #17) The facility failed to care plan that Resident #2 and Resident #17 were PASRR positive. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 56) reviewed for dialysis. 1. The facility failed to have a physician's order for dialysis for Resident #56. 2. The facility failed to ensure nursing staff monitored Resident #56's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection. 3. The facility failed to develop a person-centered care plan for Resident #56's dialysis treatments and care. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 2 of 4 meetings (May 2022, and September 2022) reviewed for QAPI. The facility did not ensure the ADON attended QAPI meetings in May 2022, and September 2022. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 1 of 1 facility and 1 of 1 staff (Laundry Aide O) reviewed for transportation of linens. The facility failed to ensure Laundry Aide O covered the clean linen cart while passing out resident's personal laundry. This failure could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life.