The Manor Healthcare Residence

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #6) of three residents reviewed for PASRR Level 1 screenings. The facility failed to refer Resident #6 to the appropriate state designated MH/ID authority for evaluation. Resident #6 was diagnosed with a mental illness prior to admission. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. Upon observation of medication pass on 12/09/2025 beginning at 9:18AM, the medication error rate was 100% based on 31 out of 31 medications being administered late for 2 of 2 residents (15 and #17) by MA #A. The medication error rate was 100% based on 31 out of 31 medications being administered late for 2 of 2 residents (#15 and #17) by MA A. The failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. 1. Record review of Resident #15's face sheet dated 12/09/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for seven of seven anonymous residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In a Resident Council interview on 9/11/24 at 2:00 pm, the AT Director gathered several residents and brought them to the Dining Room. In the Dining Room, there were several residents watching TV and several staff in and about the area attending to their daily duties. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident right for personal privacy for 5 of 5 residents (Resident #3, Resident #17, Resident #19, Resident #21 and Resident #40) reviewed for resident rights. The facility failed to knock on Residents #3, #17, #19, #21 and #40's rooms when going into the residents' rooms. This failure could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food items were sealed and not exposed to air in the freezer and in the dry storage area. This failure placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 1 of 3 residents (Resident #92) reviewed for transfers. The facility failed to ensure Resident #92 was transferred using a gait belt . This failure could place residents at risk for injuries and falls.

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: *The deep roasting pan was clean *The sheet pans were clean *The muffin pans were clean *The roasting pans were clean *The skillets were clean *The stock pot was clean These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 1 of 2 shower chairs (East shower chair) reviewed for cleanliness. The facility failed to ensure the East shower chair was free from slime like pink, brown, and black material. This failure could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 15 residents reviewed for abuse. (Resident #92) The facility failed to follow their policy when they did not report timely to the state agency Resident #92's allegation of neglect on 06/12/2023. This failure could cause residents to have continued neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 15 residents (Resident #92) reviewed for abuse and neglect. The facility failed to follow their policy when they did not report timely to the state agency Resident #92's allegation of neglect on 06/12/2023. This failure could cause residents to have continued neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 Residents (Resident #34) reviewed for transmitting assessments. 1. Resident #34's Annual-5-day MDS assessment had an Assessment Reference date of 03/13/23 and was completed on 03/23/23 but was not transmitted within 14 days of completion 2. Resident #34's Quarterly MDS assessment had an Assessment Reference date of 05/26/23 and was completed on 06/05/23 but was not transmitted within 14 days of completion. This failure could put residents at risk of state and federal monitors having inadequate information about the care residents require and receive.

Inspectors wroteBased on interviews, and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 15 residents (Resident #92) reviewed for MDS assessment accuracy. The facility failed to accurately code Resident #92's PTSD on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observations, 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 3 of 14 residents (Resident #9, Resident #11, and Resident #92) reviewed for care plans. 1. The facility failed to follow the care plan for health shakes on Resident #9 and Resident #11. 2. The facility failed to ensure Resident #92's care plan reflected she had PTSD (post-traumatic stress disorder-a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). These failures could place residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (east nurse/treatment cart) observed for medication storage. The facility failed to ensure the east nurse/treatment cart contained properly labeled medication. These failures could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date.

Inspectors wroteBased on observations, and interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 maintenance building grounds. The facility failed to ensure the maintenance building grounds were free of broken furniture, mop buckets, mattresses, fall mat, window screens, privacy fencing, gutters, televisions, metal sidings, shop vacuum, shower chairs, pvc piping, and pallets. These failures could place residents at risk for a diminished clean, and well-kept environment.