Grand Manor Health Care Center

In the surveyor’s words

From the most serious findings on record at Grand Manor Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 15, 2026

  Based on interview and record review, the facility failed to provide supervision to one resident (Resident #2), when the facility did not initiate a Code Purple (missing resident), per facility policy, when Resident #2 failed to return to the facility for dinner and evening medications and did not return all night. The resident signed out at 8:30 A.M. on the morning of [DATE] with an expected return time of 5:25. The resident did not return to the facility and per the facility policy, staff should have initiated a Code Purple when the resident did not return at the expected time and staff couldn't contact the resident. When the resident did not return for dinner or medications that evening, staff did not initiate a Code Purple. […]

• Immediate jeopardy, isolatedF760Feb 13, 2024

  Based on interview and record review, the facility failed to provide a medication to one of eight sampled residents (Resident #1) whose diagnosis included human immunodeficiency virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and progressive multifocal leukoencephalopathy (PML, a disease of the white matter of the brain, caused by a virus infection (polyomavirus JC) that targets cells that make the myelin sheath-the material that insulates nerve cells) when the resident was admitted to the facility on [DATE] and was not given their Biktarvy (contains three antiviral medications). The resident was discharged to the hospital on [DATE] when he/she was unable to respond. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2023

  Based on observation and interview, the facility failed to store food appropriately by failing to label, date, cover and discard outdated items. The facility also failed to ensure kitchen equipment was clean and in working condition. In addition, staff failed to ensure a leaking pipe under the kitchen sink was repaired in a timely manner. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The census was 62. 1. Observations on [DATE] at 9:15 A.M., [DATE] at 7:30 A.M., [DATE] at 9:30 A.M., showed the following: -Storage room: -A bottle of Apple Ready Care drink mix with an expiration date of [DATE]; -Six (6) packs of V8 original Vegetable Juice with expiration dates of [DATE]. […]

• No harm, potential for more than minimal, patternF803Nov 17, 2025

  Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals. The facility had eight residents on pureed meals. The sample was six. The census was 112. Review of the facility's Dietary Food Preparation Policy, dated 7/5/23, showed the following:-Standardized Recipes: Standardized recipes will be used for all product prepared;-Procedure: -Use standardized recipes provided with menu cycle; -The Dietary Manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added to the recipe file, they must be written, standardized and approved by the Registered Dietitian; -Pureed recipes are found in the recipe binder. […]

• No harm, potential for more than minimal, patternF658Apr 16, 2025

  Based on interview and record review, the facility failed to meet professional standards when staff failed to administer and document medications as order by the physician for three residents. (Resident #10, Resident #12 and Resident #15). The sample was 13. The census was 111. Review of the facility's Transcription of Orders/Following Physician's Order Policy, dated 5/18/24, showed the following: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders. -Procedure: A. […]