Manor House Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and the facility policy, the facility failed to keep a urinary catheter bag off the floor for 1 of 2 residents reviewed for urinary catheters (Resident #42). The facility reported a census of 43 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident dependent with toileting hygiene and used an indwelling catheter. The MDS revealed medical diagnoses for renal insufficiency and neurogenic bladder. The MDS indicated the resident took a diuretic. The Care Plan revealed a focus area dated 3/5/26 for use of an indwelling catheter related to comfort for end of life and fluid overload. The interventions dated 3/5/26 indicated to ensure dignity bag remained in place, monitor tubing for kinks and leaks, and ensure tubing remains off the floor. The Electronic Medical Record (EMR) revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interviews, resident interviews, and the facility policy, the facility failed to provide a mechanical/ground texture meat to residents prescribed a mechanical soft or ground meat texture diet for 9 of 9 residents; and failed to provide the prescribe diet for 2 of 2 residents prescribed a 2 gram sodium diet ( Resident #20 and Resident #42) during a meal observation. The facility reported a census of 45 residents. Findings include: 1. The Facility Order Listing Report for Dietary Diet dated 5/12/25 at 1:20 PM revealed 7 residents prescribed a mechanical soft diet; 2 residents prescribed a ground meat only diet; and 2 residents (Resident #20 and Resident #42) prescribed a 2 gram sodium diet. The Facility Menu for Week 1 revealed a mechanical soft diet main course was 6 ground honey garlic meatballs, potato casserole, broccoli, frosted peach cake, and milk. The alternate menu for the mechanical soft diet was ham and bean soup, cornbread, and cottage cheese. The Facility Menu for Week 1 revealed the 2 gram sodium diet main course was 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Deficiency Text Not Available

Based on observation, clinical record review, and staff interviews, the facility failed to ensure the Care Plan reflected edema (swelling) for 1 of 2 resident's reviewed for edema (Resident #30). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/1/25, listed diagnoses for Resident #30 which included morbid obesity, high blood pressure, muscle weakness, and osteoarthritis (inflammation of the bone and joints). The MDS listed the resident's Brief Interview of Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility Care Plan Policy, dated 7/2023, stated the facility would complete a Comprehensive Care Plan after the comprehensive assessment of the resident. Provider Encounter Notes on 1/8/25, 2/5/25, 3/4/25, and 3/26/25 stated the resident had bilateral (referred to both sides) lower 1+ edema (swelling where an indentation or pit remained after applied pressure to the area with severity measured on a 1-4 scale with a 1+ grade indicating a barely visible indentation and a 4+ grade…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, resident and staff interview, the facility failed to consistently evidence of including residents in care conference meetings on a quarterly basis for 1 of 1 residents reviewed for Care Conferences (Resident #6). The facility reported a census of 45. Findings include: The Minimum Data Set (MDS) Annual assessment, dated 3/13/25, and Quarterly MDS, 4/14/25, revealed Resident #6 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The facility documentation lacked evidence facility staff invited the resident to participate in a care conference with the Care Plan revision on 3/31/25. On 05/13/25 at 1:48 PM, Resident #6 reported she did want to be included in Care Plan meetings, but had not been included in a long time. She reported she would have liked to get a copy of the Care Plan, but had not received a copy of her current plan. On 05/13/25 at 2:02 PM, the Social Worker reported they usually just touch base with Resident #6 and see if she wants the team to meet with her. The Social Worker explained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, staff interview and policy review, the facility failed to ensure nursing staff followed wound care orders for 1 of 1 residents (Resident #6) with a wound care observation. The facility census was 45. Findings include: The Minimum Data Set (MDS) quarterly assessment, dated 4/14/25, identified the resident had diagnoses of congestive heart failure, hypertension, and diabetes mellitus. The resident was dependent on staff for transfers, toilet use and lower body dressing. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. A Communication with Physician note, dated 4/25/25, included documentation of wound culture results of the left lower leg wound with moderate growth of Staphylococcus Aureus (an infectious organism). (facility) Advanced Registered Nurse Practitioner (ARNP) updated. New orders received to start Bactrim DS (antibiotic) 1 tab every 12 hours for 7 days. Verbal order via (facility) ARNP to discontinue the Doxycycline (antibiotic). The Medication Administration Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and the facility policy, the facility failed to notify the physician after a resident lost over 13 pounds in a month for 1 of 1 residents reviewed for nutrition (Resident #13). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 scored a 1 out of 15 on the (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident needed supervision or touching assistance with eating. The MDS indicated a loss of 5% or more in the last month or loss of 10% or more in the last months. The MDS revealed resident received a mechanically altered diet- require change in texture of food or liquids (example- pureed, thickened liquids). The MDS revealed diagnoses for unspecified dementia, unspecified severity, without behavioral disturbance/psychotic disturbance/mood disturbance/anxiety; and malnutrition (protein, calorie), risk of malnutrition. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interviews, the facility failed to obtain Occupational Therapy(OT) services in a timely manner for 1 of 3 residents reviewed for specialized rehabilitative services(Resident #30). The resident reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/1/25, listed diagnoses for Resident #30 which included morbid obesity, muscle weakness, and osteoarthritis(inflammation of the bone and joints). The MDS listed the resident's Brief Interview of Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Provider Encounter Notes on 1/8/25, 2/5/25, 3/4/25, and 3/26/25 stated the resident had bilateral(referred to both sides) lower 1+ edema(swelling where an indentation or pit remained after applied pressure to the area with severity measured on a 1-4 scale with a 1+ grade indicating a barely visible indentation and a 4+ grade indicating a deep indentation which took a considerable time to fade). A 4/30/25 provider Encounter Note stated the resident had 2-3+ lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, staff interview and policy review, the facility failed to ensure nursing staff followed infection prevention and control policies to help prevent the development and transmission of communicable diseases and infections for 1 of 1 sampled residents (Resident #6) with an observation of wound care. The facility reported a census of 45. Findings include: The Minimum Data Set (MDS) quarterly assessment, dated 4/14/25, identified the resident had diagnoses of congestive heart failure, hypertension, and diabetes mellitus. The resident was dependent on staff for transfers, toilet use and lower body dressing. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. A Communication with Physician note, dated 4/25/25, included documentation of wound culture results of the left lower leg wound with moderate growth of Staphylococcus Aureus (an infectious organism). (facility) Advanced Registered Nurse Practitioner (ARNP) updated. New orders received to start Bactrim DS (antibiotic) 1 tab every 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interviews, the facility failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for pneumococcal vaccinations (Resident #11, #13, #16, #22). The facility reported a census of 39 residents. Findings include: 1. Resident #11's Immunization record stated the resident received the PCV23 (a type of pneumococcal vaccine) on 10/28/10 and the PCV13(a type of pneumococcal vaccine) on 1/27/17. The record stated the resident was [AGE] years old. 2. Resident #13's Immunization record stated the resident received the PCV23 pneumococcal vaccine on 1/23/08 and the PCV13 vaccine on 7/23/15. The record stated the resident was [AGE] years old. 3. Resident #16's Immunization record stated the resident received PCV13 vaccine on 4/20/15 and the PCV23 pneumococcal vaccine on 5/23/16. The record stated the resident was [AGE] years old. 4. Resident #22's Immunization record stated she resident received PCV23 pneumococcal vaccine on 9/6/07 and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and staff interviews, the facility failed to intervene when several days elapsed without a bowel movement (BM) for 1 of 2 residents reviewed for a change in condition (Resident #4). The facility reported a census of 39 residents. Findings: The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/18/24, listed diagnoses for Resident #4 which included schizophrenia, mild intellectual disabilities, and pressure ulcer. The MDS listed a Brief Interview for Mental Status(BIMs) score as 10 out of 15, indicating moderately impaired cognition. 5/6/24 Care Plan entries stated the resident received antipsychotic medication and directed staff to monitor for adverse reactions to antipsychotics including digestive issues and constipation. 7/1/24 Care Plan entries stated the resident received antidepressant medication and directed staff to monitor for adverse reactions to antidepressant therapy including constipation and fecal impaction. The resident's Bowel Movement record lacked documentation the resident had a BM on the following days: 7/1/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and policy review the facility failed to ensure residents were free from neglect when 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) did not receive their scheduled medications including, narcotics, insulin, antibiotics, blood pressure, psychotropic, respiratory and blood thinner medications on 7/4/2022 by Staff A, Licensed Practical Nurse (LPN) who was their nurse from 2:00 PM to 6:00 AM on 7/5/22. The facility reported a census of 51 residents. Findings include: Record review of a document created by the facility titled, Medications Documented as Administered by Staff A on 7/4/2022, documented the following 24 residents failed to receive the following medications on 7/4/22 while Staff A was working. 1. Resident #104 Flomax 0.4 mg Levemir 100 unit/ml 35 units Metformin HCI 500 mg Metoprolol Tartrate 50 mg Cephalexin Capsule 250 mg Citalopram Hydrobromide Tablet 20 mg Colace Capsule 100 mg 2. Resident #105 Donepezil 5 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and policy review the facility failed to ensure 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) were provided with professional standards of nursing care on 7/4/2022 from 2:00 PM to 6:00 AM, by Staff A, Licensed Practical Nurse (LPN) who documented medications were given, but during review of video footage and a facility timeline was found to dispense and dispose of resident medications instead of administering the medications to residents. The facility reported a census of 51 residents. Findings include: Record review of a document created by the facility titled, Medications Documented as Administered by Staff A on 7/4/2022, documented the following 24 residents failed to receive medications on 7/4/22 while Staff A was working: Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14. Record review of an undated document created by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.