Ely Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 21, 2025

  This citation pertains to intake # 2592873.Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 5 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 8/13/25 between 8:30 PM and 8:45 PM, Resident #101, who was an elopement risk with a prior recent history of elopement, exited the facility, unbeknownst to facility staff, and was found by a Certified Nursing Assistant (CNA) approximately 0.3 miles away from the facility, sitting on the front porch of a residential home. […]

• Immediate jeopardy, isolatedF689Aug 7, 2025

  This citation pertains to intake 2575758Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in 1 of 4 residents (Resident #101) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 7/20/25 between 7:30 p.m. and 7:45 p.m., Resident #101 exited the facility, unbeknownst to facility staff, and was found by an off duty nurse approximately 0.3 miles away after sustaining a fall. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #101, who was an elopement risk. […]

• Immediate jeopardy, isolatedF684Jul 22, 2025

  This citation pertains to intake #1234842Based on observation, interview and record review the facility failed to identify signs and symptoms of a stroke for 1 (Resident #112) of 3 residents reviewed for change of condition, resulting in an Immediate Jeopardy when Resident #112 did not receive timely medical intervention for a stroke on 7/15/25 who then suffered significant loss of function of her left upper extremity, developing unilateral spatial neglect (condition where a person has difficulty noticing or responding to stimuli on one side of their body), facial droop, and decreased ability to communicate verbally.Findings include:The facility failed to accurately assess Resident #112 for a change in condition on 7/15/25 at 12:00pm when Physical Therapist (PT) JJ reported to Director of… […]

• Immediate jeopardy, isolatedF689Jul 22, 2025

  This citation pertains to intake 2563197. Based on observation, interview, and record review, the facility to ensure safety and prevent a major injury 1 of 3 residents (R108) reviewed for safety, resulting in an Immediate Jeopardy when, on 7/2/25 at 5:04AM, R108 fell from a transferring position onto an exposed metal bracket at the end of her bed impaling her in the soft tissue of her left buttock entering the rectum cutting it and the anal sphincter and also suffering an open fracture of the pubis ramus. The injured tissues required surgical reconstruction and after complications, placement of an ostomy (surgery that creates a new opening in your body for waste to come out).Findings include:The Facility failed to identify environmental hazards and risks of an exposed bed frame bracket. […]

• Immediate jeopardy, isolatedF689Aug 23, 2023

  This citation pertains to intake: #MI00138772. Based on interview and record review, the facility failed to ensure the safety and prevent elopement in 1 (Resident #35) of 4 residents reviewed for accidents/hazards, resulting in an Immediate Jeopardy when Resident #35, who had been assessed as an elopement and fall risk on admission and had a Brief Interview for Mental Status (BIMS) of 9, left the facility unbeknownst to facility staff and was found on [DATE] at 7:25 pm approximately 0.25 miles away at a neighbors residence, across a 35 mph road, after another resident notified the nurse that the wheelchair at the facility exit door belonged to R#35. […]