Indigo Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 13, 2023

  Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's neglect to provide appropriate services and interventions to prevent elopement after identifying the resident as at risk, permitted Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. […]

• Immediate jeopardy, isolatedF689Apr 13, 2023

  Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to provide supervision and implement interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's failure to provide appropriate supervision and implement identified and/or available interventions, allowed Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2026

  Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service. Proper food handling and sanitation are essential in healthcare environments serving nursing home residents. Failure to adhere to safe food handling practices may expose all residents consuming food prepared in the kitchen to potential pathogenic risks.The findings include:On 8/19/2026 at 10:41 AM, a tour of the facility's kitchen was conducted with the Culinary Director. The following conditions were observed: A double compartment sink was present, with one compartment covered by a large pan, obstructing use. […]

• No harm, potential for more than minimal, widespreadF812Feb 17, 2026

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to maintain sanitary conditions in the cooking area, with significant accumulation of grease buildup, food debris and residue, and heavy soilage on both floor surfaces and equipment. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:A tour of the kitchen was conducted on 2/17/26 at 10:15 am. […]

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  Based on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to log proper temperatures for the dish machine and chemical sanitization for the 3-compartment sink, and clean food buildup stuck on the back handle and under the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 03/10/25 at 11:07 AM. […]