The Manor, Inc.

Per interview and record review, the facility failed to ensure that 48 of 48 contracted nursing staff (licensed nursing staff and licensed nursing assistants) obtained through staffing agencies have the specific competencies necessary to care for residents' needs as identified through resident assessments and the plan of care. This has the potential to affect all residents. Findings include: Per review of 2 LNA (Licensed Nursing Assistant) employee records (1 permanent LNA and 1 contracted LNA), required competencies for resident care were missing for the LNA contracted through Clipboard Health (service used to fill staffing gaps).Per interview with the Director of Nursing (DON) on 4/15/2026 at 12:11 PM, she stated that they do not always provide the facility training to new staff especially agency because they don't know how long they are going to stay. It is a challenge to hire new staff, and they have gone back and forth about whether or not to offer the training on hire or wait until later. In regard to the Clipboard staff (staffing agency), they are required to read through 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 observations and interview, the facility failed to ensure a resident's right to privacy was maintained while receiving person care for 2 of 18 sampled residents (Resident #4 and Resident #33). Findings include: Per observations on 4/13/2026 at 1:40 PM, Resident #33 was being assisted with incontinence care by a Licensed Nursing Assistant (LNA) with the door to the hall open. At this time, Resident #4 was also in their bed across the room, the curtain was not drawn between them. Another LNA entered the room and closed the door. Two of Resident #4's family members arrived and entered the room. The privacy curtain was still open, and Resident #33 was visible. On 4/14/2026 at approximately 3:30 PM, Resident #4 was observed in bed receiving personal care with 3 LNAs in the room, the door to the hall was wide open. Resident #4 was exposed on their bed. When one of the LNA's saw the surveyors, she closed the door. Per interview on 4/15/2026 at 12:30 PM, the Director of Nursing (DON) confirmed that LNAs should have provided the residents privacy by drawing the privacy curtain…

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, interview, and record review the facility failed to ensure that a physician supervised and provided consultation or treatment when contacted by the facility for 1 of 18 Residents in the sample (Resident #52). Findings include:During an interview with Resident #52 on 4/13/2026 at 11:30AM, s/he was observed scratching both of their arms. The Resident stated that s/he had been itching for about three weeks, and s/he thinks it is a seasonal thing. The Resident stated that s/he had asked for medication to help. Observation of the Resident's arms revealed deep scratches on both upper and lower arms. Resident #52 has a care plan focus related to skin reflects - 3/27/2026: self-inflicted scratches to right dorsum hand - resolved- 3/27/2026: self-inflicted scratches to right wrist - resolved- 4/5/26: open lesion/self-inflicted scratches to left hand- 4/11/26: self-inflicted scratches to left forearm Interventions include Report abnormalities, failure to heal, [signs and symptoms] of infection, maceration etc. to MD. Per record review a Health Status Note dated 3/27/2026…

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 and staff interview, the facility failed to ensure that physicians reviewed the resident's total program of care at required physician visits for 2 of 18 residents (Resident #6 and Resident #33). Findings include:1.) Per record review Resident #33 has diagnoses that include dementia, anxiety, osteoporosis, cachexia (a complex metabolic syndrome characterized by involuntary weight loss, muscle wasting, and often fat loss associated with chronic or severe illness), gastroesophageal reflux, adult failure to thrive, pressure ulcer of the sacral region, malnutrition, and depression, bipolar disorder, and dysphagia (painful and/of difficult swallowing). Physician/Provider regulatory visit progress notes from 3/25/2025 - 3/24/2026 do not document a total review of care for Resident #33. The Physician documented at each visit that the Resident was currently taking two medications that were not ordered, Vitamin B-12 1000 MCG tablet once daily and Diflucan 100 MG daily. Per review of current Physician's orders neither of the medications were ordered. Per record review,…

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, interview, and record review, the facility failed to ensure that infection control measures regarding hand hygiene were followed during medication administration for 2 of 2 (Resident #26 and Resident #28) residents sampled. Findings include:During observation of medication administration on 4/14/2026 at 8:22 AM, an LPN (Licensed Practical Nurse) did not perform hand hygiene by either using hand sanitizer or soap and water as required before or after wearing gloves, when preparing and administering medications for Resident #26 or before or after administering eye drops and after replacing a medication patch on the back of Resident #28.Per interview on 4/14/2026 at 8:30 AM, the LPN confirmed that she did not perform hand hygiene during medication administration for Resident #26 or Resident #28 and stated that she washes her hands or uses hand sanitizer after every few medications or residents or when she completes direct care.Review of facility policy titled Hand Hygiene Policy, review date 4/2019, states that gloves do not replace hand washing/hand hygiene and…

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 observation and interview, the facility failed to ensure that all food was stored safely and to ensure that sanitary conditions for safe food handling were maintained. This has the potential to impact all residents. Findings include:A kitchen tour was conducted on 11/25/25 at 9:15 AM. Per observation, there was an open and undated package of waffles in freezer. There was a container of rotting lettuce in the walk-in fridge. There was a container of celery uncovered in the walk-in fridge. There was a package of 14 hot dogs that was open to air and not dated. There was a container of raw chicken. There was a container of chicken sitting in chicken juices on the bottom shelf. There was an undated package of American cheese slices. There were (2) 32 ounce Dannon yogurts with an expiration date of 11/14/25. There was a container of pasta salad that expired on 11/24/25. There was an open container of 12 quarts of cream of asparagus dated 11/25/25. An interview with a Kitchen Staff Member on 11/25/25 at 9:30…

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.

Per interview and record review that facility failed to provide abuse training prior to a substantiated sexual assault for one out of six employees sampled. Findings include: Per interview on 11/12/24 at 1:25 PM, the Director of Nursing confirmed that the facility substantiated that LNA #1 sexually assaulted Resident #1 on 11/6/24. A review of all educational materials used to train staff on abuse, neglect, exploitation, misappropriation of resident property was reviewed while investigating the allegations of sexual abuse. The education provided included a PowerPoint titled The Manor C.A.R.E.S. and Incident reporting Requirements (CMS F-609) of Crimes of Abuse, Neglect, Injuries of Unknown Origin, Mistreatment, and Misappropriation of Property [last revised 11/23]. The facility also has an Annual Employee Education packet that contains quizzes based on training for subjects including Incident Reporting Requirements (F-609) and Resident Rights. The facility also supplied a Harassment and Sexual Harassment policy [last revised 10/22] as well as a handout discussing Suspected Physical…

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 upon observation, interview, and record review, the facility failed to implement procedures that assure the accurate acquiring, dispensing and administering drugs to meet the needs of one resident [Res.#45] of 23 sampled residents. Finding include: Review of Res.#45's medical record reveals the resident has diagnoses that include Hypertension [high blood pressure], Hypokalemia [low potassium levels in the blood], Dementia with Behavioral Disturbance, restlessness and agitation, osteoarthritis of the right knee, and an Overactive bladder, Review of Physician Orders for Res.#45 include: Amlodipine tab - related to Essential Hypertension. Potassium Chloride tab- related to Hypokalemia Quetiapine tab- related to Restlessness and Agitation Diclofenac Topical Gel- for Right Knee pain Acetaminophen- for pain Myrbetriq Oral Tablet- for overactive bladder Review of the facility's 'Administering Medications' policy [Version 2.0 Revised Dec. 2021] includes Medications must be administered in accordance with the orders, including any required time frames. Additionally, the policy states…

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 interview and record review the facility failed to ensure the physician documented a duration of use or rational for extending the use for an as needed (prn) psychotropic medication for 2 of 5 sampled residents (Residents #51 and #10 ). Findings include: 1. Per record review Resident #51 has a Physicians order for Mirtazapine (antidepressant) 7.5mg every 24 hours as needed (PRN) related to dementia with psychotic disturbance. The order exceeds the required limit of 14 days with no specified duration or documented rational to exceed 14 days. During interview on 2/7/2024 at 2:30 PM the Director of Nursing (DON) confirmed that there was no documented duration or rational for exceeding the 14 day limitation for the PRN Mirtazapine. 2. Per record review Resident #10 had an order for Lorazepam oral tablet 0.5 mg (an anti-anxiety medication) to be given every 8 hours as needed (PRN) for anxiety without a specified duration of days. This order was noted to have become active on 7/21/23. Per interview with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain contact precautions for 1 resident [Res.# 108] of 23 sampled residents. Findings include: Per record review, Physician Orders for Res.#108 dated 1/26/24 call for Maintain contact precautions due to C-Diff unless otherwise instructed. Every shift. [Clostridioides difficile (C-Diff) is a bacterium that causes an infection of the colon. Symptoms can range from diarrhea to life-threatening damage to the colon. Because C. difficile can live outside the body, the bacteria spread easily. Not washing hands or cleaning well make it easy to spread the bacteria.] (https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691) Per observation, posted on the outside of Res.#108's room is a Centers for Disease Control and Prevention [CDC] sign reading STOP. CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Per observation on 2/5/24 at 9:41 AM, 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.