Antlers Manor

In the surveyor’s words

From the most serious findings on record at Antlers Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF656May 18, 2026

  Based on record review and interview, the facility failed to ensure elopement prevention interventions were implemented on the care plan for 1 (#1) of 3 sampled residents reviewed for elopement.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident had walked to their home. The report showed the resident had a small abrasion to their forehead.Resident #1's care plan did not show wandering and elopement incidents/interventions prior to 11/06/25.The administrator identified 21 residents in the facility at risk for elopement.On 05/13/26, an Immediate Jeopardy (IJ) situation was determined to exist related… […]

• Immediate jeopardy, isolatedF689May 18, 2026

  Based on observation, record review, and interview, the facility failed to provide adequate supervision and maintain a secure environment to prevent elopement of a resident with a known history of wandering and elopement risk for 1 (#1) of 3 sampled residents reviewed for elopement.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement. A quarterly assessment for Resident #1, dated 09/01/25, showed the resident had a diagnosis of dementia and their cognition was severely impaired with a BIMS of 5.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident showed up at their home. […]

• No harm, potential for more than minimal, patternF689Mar 6, 2025

  Based on record review and interview the facility failed to ensure a resident was assessed related to smoking and accident hazards for 1 (#22) of 1 sampled resident reviewed for smoking. The administrator identified three residents were smokers. Findings: A policy titled SMOKING SAFETY, dated 08/03/15, read in part Initiate and complete the Smoking Safety evaluation if the resident requests smoking privileges as follows: 1. On Admission 2. Quarterly .Staff will monitor distribution of smoking material during smoking sessions .Document interventions on the resident's care plan. Resident #22 had diagnoses which included acute upper respiratory infection, chronic atrial fibrillation, shortness of breath, congestive heart failure, and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, patternF758Mar 6, 2025

  Based on record review and interview, the facility failed to ensure: a. a PRN psychotropic medication had a 14 day stop date for 1 (#11], and b. an antipsychotic medication had an appropriate diagnosis for 1 (#5) of 5 residents sampled for unnecessary medications. The administrator reported 32 residents resided in the facility. Findings: 1. Res #5 admitted to the facility with diagnoses of other Alzheimer's disorder, other depressive episodes, and bipolar disorder. A physician order, dated 02/19/24, showed risperidone (antipsychotic medication) tablet 0.5 mg, one tablet by mouth twice a day for a diagnosis of Alzheimer's disease. On 03/06/25 at 8:39 a.m., the DON stated Alzheimer's was not an appropriate diagnosis for an antipsychotic medication. 2. […]

• No harm, potential for more than minimal, patternF812Mar 6, 2025

  Based on observation, record review, and interview, the facility failed to ensure the low temperature dish machine had the appropriate amount of chemical to sanitize dishes for the facility. The administrator identified 32 residents who ate meals prepared by the kitchen. Findings: On [DATE] at 11:38 a.m., the DM obtained a bottle of test strips for testing the sanitizer level for the dish machine. The test strip did not register a result. The container of tests strips documented the strips had expired on ,d+[DATE]. On [DATE] at 1:25 p.m., the DM used new test strips obtained by the facility to check the sanitizer level. The test strip showed 10 parts per million. A undated manufacturers operations guide for the dish machine, read in part, Verify Sanitizer levels regularly. […]