Manning Gardens Care Center, Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained free from accidents and hazards by not identifying, repairing, or replacing unsecured, lifted, or damaged floor vents in multiple resident rooms in accordance with the facility policy Safety and Supervision of Residents and Quality of Life- Home like environment for one of three sampled residents (Res 1). This failure resulted in Res 1 experiencing a fall and sustaining facial injuries, and placed other residents and staff at risk of injury due to the hazardous floor vents in 7 of 12 rooms that were observed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident (Res) 1), had a safe, clean, comfortable and homelike environment when staff admitted Res 1 to a room that contained a bed side storage and drawer that were not cleaned and contained personal belongings of the previous resident, the flooring had sticky residue and the staff did not clean the bed prior to use. These failures had the potential to cause cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and potentially expose Res 1, who had undergone recent surgery to infections leading to prolonged recovery time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment when the transition strip (a narrow piece of material used to bridge the gap between two different types of flooring) between the residents' room and hallway to room [ROOM NUMBER] was approximately 0.5 inches (unit of measurement) in height and the transition strip to room [ROOM NUMBER], 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were cracked and uneven. This failure had the potential to result in hazardous conditions for four of four sampled residents (Resident 1, 2, 3, and 4) which could lead to falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice, manufacturer instructions, and the facilities medication management policies when: 1. Discontinued medications for three of 51 sampled Residents (Residents 32, 30, and 9) were found in the East Station medication cart, indicating medications without active orders were stored in the cart. These failures had the potential to result in medication errors, including the risk of administering medications that were no longer prescribed, which could result in adverse effects or harm to the residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation practices were followed in the kitchen when the ice machine and food preparation sink did not have an air gap. These failures had the potential for contaminated water to flow back into the sink and ice machine and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (small organism that can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and water served to residents and staff in the facility, causing foodborne illness. During a concurrent observation and interview on 12/16/25 at 8:50 a.m. during the initial tour in the kitchen, observed food preparation sink did not have an air gap and ice machine located in the dining room did not have a functioning air gap. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection prevention and control standards for three of 14 sampled residents (Resident 13, 33, and 64) when:1. Licensed Vocational Nurse (LVN) 3 administered an insulin (medication injected into the body to treat high blood sugar levels) injection to Resident 33 without changing gloves or performing hand hygiene. Immediately afterward, LVN 3 gave Resident 33 a medication by mouth (PO). This failure had the potential to cause pathogens (germs that can enter the body and cause illness) to spread to Resident 33 as a result of cross contamination (unintentional transfer of harmful germs or allergens from one surface or object to another).2. Urinals for Resident 13 and Resident 64 were not labeled with the date they were first used and the room number. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate one of six sampled residents (Resident 45), right to self-determination when the facility denied Resident 45's request to use an iron to press his clothes and refused his request for hot water to make instant coffee in his room. The facility did not complete individualized assessment of Resident 45's ability to safely perform these tasks, nor did the facility attempt to identify or implement alternative interventions or accommodations to incorporate the resident's stated preferences into his care plan. Instead, the requests were denied based on generalized safety concerns without evidence of an interdisciplinary team review, despite Resident 45 identifying these preferences as very important. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on change in condition or status for one of three sampled residents (Resident 17), when Resident 17 was transferred out to general acute care hospital (GACH) on 12/17/25 and there was no documentation the medical doctor was notified and no information in Resident 17's medical record regarding a change in condition. This failure had the potential to place Resident 17 at risk of not meeting significant changes in needs.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 17), when Resident 17 did not have a care plan when she was sent out to the general care hospital (GACH) on 12/17/25 and a paracentesis (medical procedure where a needle is inserted into the abdomen to drain excess fluid [ascites]) procedure was performed. Resident 17 returned to the facility on [DATE] and there was no care plan created to care for the paracentesis procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice for one of three sampled residents (Resident 41), when Resident 41's physician order to check Vitamin D level (blood test result showing how much Vitamin D the body has stored, indicating if body has enough for healthy bones, muscles, and immune functions [fighting off harmful invaders like germs]) ordered on 10/17/25 was not carried out and no follow-up by the nursing staff. This deficient practice placed Resident 41 at risk of developing Vitamin D deficiency and not recognizing the signs and symptoms resulting in not treating the deficiency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with resident preferences for one of three sampled residents (Resident 7), when Resident 7 preferred to receive gravy on his tray and Resident 7 was not served gravy. This failure had the potential for Resident 7 to not consume his preferred food and not to receive the full nutritional benefit of his meal which could lead to weight loss.

Inspectors wroteBased on observation during the survey period of 12/16/25 through 12/19/25, the facility failed to ensure each bedroom accommodated no more than four residents per room for four of 19 rooms (rooms 1, 2, 5, and 6). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review during the survey period of 12/16/25 through 12/19/25, the facility failed to provide the minimum of at least 80 square feet per resident for eight of 19 multiple resident rooms (rooms 1, 2, 5, 6, 9, 10, 11, and 12). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

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 to help prevent the development and transmission of communicable diseases (illnesses that can be spread from one person, animal, or object to another) and infections for five of seven residents (Resident 2, 3, 4, 5, and 6) when: 1. Resident 2, 3, 4, 5, and 6's personal trash bins (a metal or plastic container used for discarding garbage) without lids located at the bedside contained used blue rubber gloves (protective coverings for the hands designed to shield against chemicals, contamination, and other harmful substances). 2. Two of six large yellow barrels (a cylindrical container) with lids labeled soiled linen (gowns, bedsheets, drawsheets, towels etc. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for one of four residents (Resident 1), when a pitcher (a large container with a handle and a lip, used for holding and pouring liquids) filled with hot water by Certified Nursing Assistant (CNA) 1 spilled onto Resident 1's left thigh on 2/3/25. The facility's hot water temperatures were measured in sinks and showers with a digital thermometer (a device that measures temperature using a sensor an electronic display) on 2/6/25. A dining room sink was found to have a hot water temperature of 140 degrees Fahrenheit (F; unit of measurement). The Maintenance Supervisor (MS) who was responsible for maintaining water temperatures was not aware of the dining room sink's temperature of 140 degrees F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 12 residents (Resident 1 and Resident 3) when: 1. Resident 1's care plan was not developed to reflect an assessment and interventions for the use of bed rails. This failure put Resident 1 at risk of harm due to improper use of bed rails. 2. Resident 3's care plan was not developed and implemented to reflect assessments and interventions to address Resident 3's edema (medical term for swelling) to the right and left lower legs, or the use of a brace for Resident 3's right leg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and 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 (Illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air) and infections for 53 of 54 residents when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen food was stored and maintained in a safe and sanitary manner when: 1. The facility failed to store food in Resident 105's room in a safe manner in accordance with the facility's policy and procedure (P&P) Foods Brought by Family/Visitors. 2. An open jar of garlic was stored in the refrigerator without an open labeled date in accordance with the facility's P&P Sanitation and Infection Control. 3. A case of bran muffins was found in the refrigerator missing half of the labeled date identifying the placed in the freezer date per the facility's P&P Sanitation and Infection Control. 4. Two dented tomato sauce cans were stored in the pantry for use and not set aside in a designated area for return to the vendor or disposed of properly per the facility's P&P Sanitation and Infection Control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control when flies were observed in resident rooms and in the common areas of the dinning room and activities room and had the potential for rodents to enter from two holes on the laundry room wall. These failures led to insects being observed in the facility and had the potential to allow rodents to enter the facility from the outside, posing a risk of infection to residents due to cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of six sampled residents (Resident 44) the right to self-administer medications, when Resident 44 stated she wanted to keep her inhaler at bedside and the facility did not allow her to. This failure resulted in Resident 44's right to self-administer medications to be violated and had the potential to cause Resident 44 to experience difficulty breathing as a result of not having her inhaler at the bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for one of one residents (Resident 40), when Resident 40 described her waffle mattress (a pressure relief mattress overlay [on top of mattress] that's designed to be placed on top of an existing mattress to redistribute pressure from bony areas of the body, manufacturer name Air Overlay) as uncomfortable and staff did not know how to adjust the mattress. This failure resulted in Resident 40's discomfort while lying in bed and had the potential to put the resident at risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 Residents (Resident 1) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from the bed side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard [raised] or lowered position), had no consent (form signed by resident or family explaining the risks of side rail use), no physician order, no indication for use, and no care plans prior to the installation and use when Resident 1 had two bed rails one on both sides at the head of the bed in the guard position (a position that is intended to prevent an individual from inadvertently[accidentally] rolling out of bed). This failure had the potential to cause entrapment, serious harm, injury, or death to Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs of one of six residents (Resident 37) when Resident 37's lorazepam (a controlled medication used to help with anxiety, sleep, and maintain calmness) medication was administered and was not documented on the controlled substances count sheet (This document is typically used in a medical setting to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). This failure had the potential for Resident 37's lorazepam to be mistakenly administered to her twice and cause Resident 37 to experience side effects from an additional dose of medication.

Inspectors wroteBased on observation during the survey period of 11/5/24 through 11/8/24, the facility failed to ensure each bedroom accommodated no more than four residents in four of 19 rooms (rooms 1, 2, 5, and 6). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review during the survey period of 11/5/24 through 11/8/24, the facility failed to provide the minimum of at least 80 square feet per resident in eight of 19 multiple resident rooms (rooms 1, 2, 5, 6, 9, 10, 11, and 12). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the recommended diet plan for 1 of 3 residents (Resident 1) when Resident 1 received a swallowing evaluation (a test to visualize the function of the throat and esophagus while swallowing) on 5/2/24 and the facility did not obtain the result of the swallowing evaluation until 5/17/24. This failure was not the standard of practice according to the facility's policy and procedure, titled, Referrals, Social Services, and had the potential to place Resident 1 at risk for inadequate nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. The toaster had a brown substance stuck on the front knobs and a yellow substance on the edge of the toaster opening and the plate warmer had a greasy brown substance and dirt along the bottom edge and there was a clean plate on top of brown flakes of food. 2. There was a plastic bag containing American cheese slices with brown debris on them and placed inside the refrigerator. 3. Two out of two dry food bins in the dry food storage area had a brown substance inside the bottom of the bin. 4. There were no airgaps (A fixture that provides back-flow prevention) under the three compartment sink and the food preparation sink. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 18 sampled residents (Residents 26 and Resident 1) were free from unnecessary psychotropic (drugs that affect brain activity associated with mental processes and behavior) medications, as evidenced by: 1. For Resident 26, there was inadequate Divalproex Sodium side-effect (S/E) monitoring. 2. For Resident 1, Olanzapine was not started at the recommended dose and there was inadequate monitoring of recommended laboratory testing while on psychotropic therapy. These failures resulted in the potential for medication interactions, adverse reactions, and increased risks associated with the use of psychotropic medications that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, memory loss and toxicity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions, and the expiration date as applicable when: Licensed Nurse (LN) staff did not apply adequate labels (discard by date) on inhaler medications for 3 residents (Resident 48, Resident 26 and Resident 261) and LN staff did not ensure adequate storage of discontinued medications for 3 residents (Resident 30, Resident 36, and Resident 9). These failures increased the potential for Resident 48, Resident 26 and Resident 261 to be administered expired medication and inadequately treated for breathing difficulty and for Resident 30, Resident 36, and Resident 9 to be administered unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the privacy of one of six sampled residents (Resident 260), when Registered Nurse (RN) 4 left the privacy curtain and door open while providing care to Resident 260 and exposed Resident 260 to public. This failure resulted in violation of Resident 260's rights to confidentiality and the potential for unauthorized access to Resident 260.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 14) when Resident 14 did not have a care plan for the use of anticoagulant (blood thinner) medication. This failure placed Resident 14 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free of accident hazards when: 1. Resident 11's bed rail was loose and not in good working condition which led to Resident 11's fall on 10/11/23. This failure had the potential to result in additional falls which could have result in serious injury for Resident 11. 2. Multiple handrails in the hallways were found cracked with missing end pieces and exposed sharp edges. This failure had the potential to cause injuries to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 9) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when Resident 9's urinary catheter bag was touching the floor on three separate occasions. This failure had the potential for Resident 9 to develop a urinary tract infection (UTI- infection in any part of the urinary system, kidneys, bladder, or urethra) which could cause sepsis (the body's overwhelming and life-threatening response to infection) and hospitalization if untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one of two sampled residents (Resident 10) when Resident 10's oxygen flow rate was given at a higher rate than the physician ordered. This failure had the potential for Resident 10 to experience difficulty breathing, respiratory distress and lung damage.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the pain management needs of residents consistent with professional standards of practice for one of six sampled resident (Resident 23) when Resident 23's pain was not managed effectively due to unavailability of Resident 23's Percocet (medication used to treat pain) medication from 10/17/23, 10/18/23 and 10/19/23. This failure resulted in Resident 23's experiencing avoidable pain and suffering for prolong periods of time from 10/17 through 10/19/23 which led to her inability to sleep at night and unable to received needed care due to severe pain to the areas of her body affected by pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse according to facility policy and procedures (P&P) when two of four dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional environment for staff members and the public when: 1. The dryer door glass was broken, and the glass was replaced by a circular piece of cardboard covering the opening in the dryer door while the dryer was in use. 2. The handwashing sink's hot water in the kitchen was 163 degrees Fahrenheit (F-unit of measurement). These failures placed staff and the public's safety at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the presence of rodents when rodent excrement was found in the basement dry food storage area. This failure had the potential to lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for residents who eat food prepared in the kitchen.

Inspectors wroteBased on observation during the survey period of 10/16/23 through 10/20/23, the facility failed to ensure each bedroom accommodated no more than four residents in four of 19 rooms (rooms 1, 2, 5, and 6). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview and record review during the survey period of 10/16/23 through 10/20/23, the facility failed to provide the minimum of at least 80 square feet per resident in eight of 19 multiple resident rooms (rooms 1, 2, 5, 6, 9, 10, 11, and 12). This failure had the potential for residents to not have reasonable accomodations for privacy or adequate space for care to be rendered.