Ely Manor

Inspectors wroteBased on interview and record review the facility failed to ensure the Director of Nursing (DON) of record worked full time defined as 40 hours a week and to fulfill DON duties for 3 weeks (from 5/4/2026 to 5/24/2026) resulting in the potential for unmet care needs for all residents who resided in the building during those weeks.

Inspectors wroteThis citation pertains to Intakes #3036506 and #3042881. Based on interview and record review, the facility failed to report within 24 hours to the State Agency 1) an incident of neglect, residents' unadministered medications found in a pharmacy bag with trash in it at the nurses' station on approximately 5/25/26 and 2). Timely report a second incident of neglect of residents' medications not being administered and found unadministered in a dumpster.

Inspectors wroteThis citation pertains to intake numbers 3036506 and 3042881. Based on interview and record review, the facility failed to maintain the highest practicable resident well-being by ensuring facility staff administered resident medications as ordered by the physician in 11 of 18 residents (Resident #8, #11, #6, #12, #13, #10, #16, #17, #18, #14, and #15) reviewed for medication administration, resulting in unmet medical needs and the potential for medical complication for affected residents.

Inspectors wroteThis citation pertains to intake #2988597. Based on interview and record review, the facility issued an against medical advice (AMA) form when transferring a resident to the hospital and failed to permit 1 resident (Resident #3) of 3 residents reviewed for discharges to return to the facility resulting in the guardian having to find placement elsewhere.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 2 (Resident #3 and Resident #51) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility.

Inspectors wroteThis citation contains two deficient practice statements, A & B.Deficient Practice Statement (DPS) A Based on observation, interview, and record review, the facility failed to establish and maintain a system for surveillance of employee infections and effectively implement infection control measures related to Enhanced Barrier Precautions (EBP), Transmission-Based Precautions (TBP), catheter care, and cleanliness of resident equipment in 5 of 18 residents (Resident #1, #37, #69, #5, & #73) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive resident-specific treatment plan for five (R43, R31, R4, R11, and R71) of 18 residents reviewed for care planning, resulting in the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1.) 2 residents (R43 and R69) of 3 residents reviewed for self-administration of medications was assessed to determine if self-administration of medication was clinically appropriate, and 2.) orders were written for 2 residents (R69 and R31) of 3 residents reviewed to be able to self-administer medications, resulting in unsupervised administration of medications (R43 and R69) and the potential for mismanagement of medication and potential for adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident in 2 (Resident #49 and Resident #51) of 2 residents reviewed for abuse resulting in Resident #49 being physically assaulted by Resident #51 and the potential for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 (Resident #49 and Resident #51) of 2 residents reviewed for abuse resulting in an allegation of physical abuse not being thoroughly investigated and the potential for ongoing resident to resident physical abuse to occur.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse and protect residents from further abuse for 2 residents (Resident #49 & #51) of 2 residents reviewed for abuse, resulting in the potential for ongoing abuse due to an incomplete investigation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1(Resident #4) of 1 resident reviewed for Pre-admission Screening and Resident Review (PASARR) was referred for a comprehensive level II PASARR evaluation, resulting in the potential for the resident to not receive the appropriate mental health treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 of 18 residents (Resident #51) reviewed for care plans, resulting in further occurrences of resident-to-resident physical aggression and the potential for unmet care needs and impaired physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to reduce hazards and risks for 2 residents (Resident #71 and Resident #24) of 6 residents reviewed for accidents, resulting in: 1. Resident #71 maintaining possession of smoking paraphernalia while unsupervised. This deficient practice has the potential to impact all 80 residents of the facility due to the increased risk of a potential fire. 2. Resident #24 being transported in a wheelchair without foot pedals in place, resulting in the potential for an avoidable injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the need of a bubbler/humidifier to aid in oxygen therapy for 1 of 1 resident (R69) reviewed for oxygen therapy, resulting in the resident experiencing dryness and sores in her nose resulting in psychosocial and physical distress.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents pain medications as ordered in 1 resident (Resident #7) of 6 residents reviewed for medications, resulting in Resident #7 receiving prescribed opioid (pain reliever) medication at a lower dose than the physician had ordered potentially causing Resident #7 to be at risk for breakthrough pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to attain and maintain the mental and psychosocial health for 3 (Resident #71, Resident #13 and Resident # 4) of 18 residents reviewed for social services resulting in: 1. lack of evaluation of psychosocial needs for Resident #71, 2. expired resident guardianship paperwork for Resident #13, and 3. lack of care planning for Resident #4's psychiatric diagnosis with mood/behavior concerns and the use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely follow up with pharmacy recommendations occurred for 2 residents (Resident #3 and Resident# 51) of 5 residents reviewed for medications resulting in the potential for medication side effects and/or unnecessary medications for residents.

Inspectors wroteBased on observation and interview the facility failed to provide food at a palatable texture for 2 residents (R69 and R73) of 18 residents reviewed for palatable foods and 3 of 14 residents in attendance of a confidential meeting, resulting in the potential for decreased food consumption and the potential for nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 18 residents (Resident #13) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's antibiotic stewardship program protocols for 1 (Resident #51) of 5 residents reviewed for unnecessary medications resulting in resident #51 receiving multiple doses of an unnecessary antibiotic and the potential for adverse effects, and the development of antibiotic-resistant organisms from unnecessary and inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's non-smoking policy for 1 of 1 resident (Resident #71) reviewed for smoking, resulting in the resident possessing smoking paraphernalia while unsupervised in his room.

Inspectors wroteBased on interview, and record review, the facility failed to provide written notification to the resident/representative detailing the reason for a transfer to the hospital in 1 of 2 resident (Resident #83) reviewed for hospitalization, resulting in the potential for the resident/representative to be unaware of the reason for the hospital transfer and their right to appeal.

Inspectors wroteThis citation pertains to intake # 2592873. Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 5 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 8/13/25 between 8:30 PM and 8:45 PM, Resident #101, who was an elopement risk with a prior recent history of elopement, exited the facility, unbeknownst to facility staff, and was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, sitting on the front porch of a residential home. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.

Inspectors wroteThis citation pertains to intake # 2568748. Based on interview, and record review, the facility failed to provide showers/baths per resident preference and plan of care in 1 of 3 residents (Resident #102) reviewed for Activities of Daily Living (ADL) care, resulting in dissatisfaction with care, and the potential for skin complications and infection due to impaired hygiene.

Inspectors wroteThis citation pertains to intake 2575758Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in 1 of 4 residents (Resident #101) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/20/25 between 7:30 p.m. and 7:45 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found by an off duty nurse approximately 0.3 miles away after sustaining a fall. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.

Inspectors wroteThis citation pertains to intake #1234842Based on observation, interview and record review the facility failed to identify signs and symptoms of a stroke for 1 (Resident #112) of 3 residents reviewed for change of condition, resulting in an Immediate Jeopardy when Resident #112 did not receive timely medical intervention for a stroke on 7/15/25 who then suffered significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally.

Inspectors wroteThis citation pertains to intake 2563197. Based on observation, interview, and record review, the facility to ensure safety and prevent a major injury 1 of 3 residents (R108) reviewed for safety, resulting in an Immediate Jeopardy when, on 7/2/25 at 5:04AM, R108 fell from a transferring position onto an exposed metal bracket at the end of her bed impaling her in the soft tissue of her left buttock entering the rectum cutting it and the anal sphincter and also suffering an open fracture of the pubis ramus. The injured tissues required surgical reconstruction and after complications, placement of an ostomy (surgery that creates a new opening in your body for waste to come out).

Inspectors wroteThis citation pertains to intake 2563197. Based on observation, interview and record review, the facility failed to perform routine inspections and maintenance to ensure safety of resident beds for 1 of 1 resident (R108) reviewed for bed safety, resulting in a life-altering injury for R108 and potential for further injury for 9 additional residents who had foot-board brackets on their beds with no foot board.

Inspectors wroteThis citation pertains to intakes 1234839, 1234837, 2563197, 2564473, 1234842, and #1234844 Based on interview and record review, the facility failed to identify quality deficiencies and issues that should have been addressed in quality assurance committee, resulting in systems failure of ensuring resident treatments were completed and documented per physician's orders, change of condition was identified and assessed in a timely manner, facility beds were properly assembled and maintained in safe working condition, infection control practices were implemented, activities were provided to meet each resident's needs, and the facility provided an environment that was free from abuse. This deficient practice has the potential to affect all 89 residents.

Inspectors wroteThis citation pertains to intakes #1234837. Based on interview, and record review, the facility failed to ensure residents were treated with dignity and respect in 1 (Resident #100) of 3 resident reviewed for dignity, resulting in a staff member refusing to assist Resident #100 with care needs

Inspectors wroteThis citation pertains to intake 2563197 and 2564437Based on interview and record review, the facility failed to ensure an incident of neglect (unsafe environment) was reported accurately to the State Agency in 1 of 1 resident (R108) reviewed for reporting, resulting in inaccurate information being reported regarding an incident to the State AgencyFindings include:According to the Minimum Data Set (MDS) dated [DATE], R108 scored 9/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status). R108 was occasionally incontinent and had diagnoses that included right artificial knee joint, cognitive communication deficit, and a history of falling. Section J-Fall History on Admission/Entry or Reentry, indicated R108 had two or more falls since admission or prior assessment with no injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 3 Residents (Resident #104) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, anxiety and boredom.

Inspectors wroteThis citation pertains to intake # 123442Based on interview and record review, the facility failed to assess and monitor resident nutritional status in 1 of 3 residents (Resident #105) reviewed for notifications, resulting in a 12% weight loss for Resident #105.

Inspectors wroteThis citation pertains to intakes #1234844 and #1234842Based on observation, interview and record review the facility failed to ensure facility staff documented resident care in the medical records for 2 residents (Resident #104 and Resident #105) reviewed for records, resulting in the potential for worsening of health conditions in incontinuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standards of infection control practices for one (R112) of one resident reviewed for the use PPE (Personal Protection Equipment) for Enhanced Barrier Precautions (EBP), resulting in the potential of cross-contamination and harborage of bacteria to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to maintain dignity and respond to residents' call lights in a timely manner in 2 (Resident #104 and #105) of 5 residents reviewed for dignity, resulting in feelings of frustration and the potential for overall decline in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to demonstrate evidence of prompt action taken to resolve resident council concerns of lengthy call light wait times in 4 of 6 resident council meetings reviewed for concern resolution, resulting in on-going dissatisfaction with call light response and the potential for feelings of frustration.

Inspectors wroteThis citation pertains to intake MI00150558 Based on interview and record review, the facility failed to inform the resident's emergency contact of a fall in a timely manner for 1 (Resident #101) of 3 residents reviewed for falls resulting in a delay in the time the emergency contact was made aware of the fall.

Inspectors wroteThis citation pertains to Intake: MI00148829, MI00147804, MI00148226 and MI00148227. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from staff to resident and resident to resident verbal and physical abuse for 4 (Resident #107, #101, #102, and #104) of 11 residents reviewed for abuse, resulting in the potential for physical, emotional and psychosocial harm.

Inspectors wroteThis citation pertains to Intake: MI00147804 Based on interview and record review, the facility failed to ensure staff fully implemented the abuse policy for reporting an incident of abuse to the abuse coordinator in 2 out of 13 sampled residents (Resident #101, and #102) reviewed for abuse reporting, resulting in the potential for incidents of abuse going undetected, unreported, or without thorough investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident of 13 (Resident #101) reviewed for care planning resulting in a lack of service for the resident to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure facility nursing staff followed physician orders to obtain urine sample in 1 of 13 residents (Resident #101) reviewed for laboratory orders and standard of practice, resulting in the potential for the worsening of a condition and a delay in treatment.

Inspectors wroteThis citation pertains to Intake: MI00146669 Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 8 residents (Resident #100 and #101) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide consistent, meaningful, person-centered activities for 2 of 2 residents (Resident #102, #104) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of wellbeing, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort.

Inspectors wroteThis citation pertains to Intake: MI00148896 Based on observation, interview and record review, the facility failed to provide adequate supervision, implement care plan interventions, and assistive devices for proper transfer for 1 (Resident #108) of 4 residents, resulting in a fall which had the potential to cause injury and negatively affect the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted the autonomy in 2 of 20 residents (Resident #334 and Resident #333) reviewed for homelike environment, resulting in emotional distress, loss of independence, and feelings of frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 (Resident #34 and Resident #332) of 20 sampled residents reviewed for care plans, resulting in inconsistent application of pressure relieving device (heel protectors) for Resident #34 and an incomplete reflection of care needs for both Resident #34 and Resident #332.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive care plan after a change in resident condition in 1 of 20 residents (Resident #75) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent worsening of contractures (hardening of the muscles, tendons, and other tissues) for 1 of 2 residents (Resident #67) reviewed for range of motion resulting in the potential for worsening of right and left hand contractures.

Inspectors wroteThis citation pertains to intake# MI00145167 Based on interview and record review, the facility failed to ensure that residents received adequate treatment and care for pain management for 1 of 2 residents (Resident #380) reviewed for pain, resulting in increased pain with the potential to affect activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a mechanically altered diet was provided as ordered to meet individual needs in 1 of 13 residents (Resident #75) reviewed for dining and dietary orders, resulting in the potential for aspiration, choking, and harm.

Inspectors wroteBased on observation and interview the facility failed to maintain general cleanliness and repair of the dry storage room as well as provide proper storage for items in central supply. Findings Include: During a tour of the facility, at 10:00 AM on 7/9/24, it was observed that the floor drain in the dry storage room was being used for draining the ice machine and walk in cooler condensers. The floor in this area was found with black lines between the floor tiles and visible water coming up from the gaps in the tiles when walked on. During a tour of the central supply storage room, with Environmental Services H, at 3:04 PM on 7/9/24, it was observed that some storage shelving being used was made from raw wood with no covering to make it smooth and easily cleanable. Further observation found clean and sanitary items stored on the floor and on the raw wood surface. These items were: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide care to meet the resident needs in 1 of 8 sampled residents (Resident #106) reviewed for accomodation of need, resulting in discomfort in activites of daily living care for Resident #106.

Inspectors wroteThis citation pertains to intakes: #MI00139716, MI00139718, MI00139719, MI00140206 & MI141271. Based on observation, interview, and record review the facility failed to ensure adequate supervision to prevent resident to resident physical altercations for 3 Residents (Resident #102, #103, and Resident #104) of 6 residents reviewed for abuse resulting in Resident #102 striking both Resident #103 & Resident #104 on more than one occasion and the potential for further resident to resident altercations to continue for vulnerable residents residing in the facility.

Inspectors wroteThis citation pertains to intake: #MI00138772. Based on interview and record review, the facility failed to ensure the safety and prevent elopement in 1 (Resident #35) of 4 residents reviewed for accidents/hazards, resulting in an Immediate Jeopardy when Resident #35, who had been assessed as an elopement and fall risk on admission and had a Brief Interview for Mental Status (BIMS) of 9, left the facility unbeknownst to facility staff and was found on [DATE] at 7:25 pm approximately 0.25 miles away at a neighbors residence, across a 35 mph road, after another resident notified the nurse that the wheelchair at the facility exit door belonged to R#35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and temperature appropriate food products to 4 residents (Resident #23, #28, #63, and #7) of 4 residents reviewed for food palatability, resulting in dissatisfaction with meals, the potential for decreased food acceptance and nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are treated with dignity and respect for 1 of 2 residents (Resident #386) reviewed for dignity, resulting in episodes of incontinence, causing embarrassment and potential for a decline in self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician orders for use of a continuous positive airway pressure (CPAP) machine for 1 of 1 resident (Resident #52) reviewed for respiratory care resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to identify emotional triggers for 1 of 1 resident (Resident #56) reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma, and the lack of care plan interventions in place.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records regarding advanced directives in 2 (Resident #28 and #84) of 5 residents reviewed for advanced directives, resulting in incomplete medical records and the potential for inappropriate care being provided in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to provide requested immunizations to 1 of 5 residents (Resident #48) reviewed for immunizations, resulting in the potential for acquiring, transmitting, or experiencing complications from communicable diseases.