Ingraham Manor Rehab and Nursing

In the surveyor’s words

From the most serious findings on record at Ingraham Manor Rehab and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 20, 2026

  Based on clinical record review, interviews, and facility documentation/policies, for one (1) of three (3) residents (Resident #1) reviewed for cardiopulmonary resuscitation (CPR), the facility failed to initiate CPR and activate Emergency Medical Services (EMS) for a resident identified as a Full Code after the resident was found pulseless and without respirations. The facility's failure to initiate life-saving measures resulted in Immediate Jeopardy. The findings included:Review of the hospital Discharge summary dated [DATE] identified Resident #1 was a Full Code (medical order directing staff to initiate all resuscitative measures, including CPR and advanced life support, if a resident has no pulse or respirations).Resident #1 was admitted to the facility on [DATE] with diagnoses which… […]

• Immediate jeopardy, isolatedF689Sep 6, 2023

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three Residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision for a resident identified at risk for wandering. The resident left the facility and was found wandering 0.4 miles away from the facility. The failures resulted in a finding of Immediate Jeopardy. The findings include: Review of the hospital discharge summary dated 1/19/2023 identified Resident #1 was seen for evaluation of chest pain after Resident #1 eloped from his/her home during the middle of the night and was discharged from the hospital to a skilled nursing facility. […]

• Actual harm, isolatedF689Nov 18, 2025

  Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure assistance was provided safely and in accordance with physician orders to prevent a fall with injury. The findings include:Resident #1 had a diagnosis of difficulty in walking, and osteoarthritis. The significant change Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and required [NAME] assistance for transfers. Physician order dated 10/6/2025 directed to transfer Resident #1 with the assistance of one (1) staff with a rolling walker. […]

• Actual harm, isolatedF689Sep 8, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a resident with known wandering behaviors was not able to leave the unit without staff knowledge, resulting in a fall with injury in the stairwell. The findings include: Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a resident with known wandering behaviors was not able to leave the unit without staff knowledge, resulting in a fall with injury in the stairwell. […]

• No harm, potential for more than minimal, patternF730Jun 17, 2025

  Based on review of facility documentation, facility assessment and interviews for 4 out of 5 nurse aides in the last 2 years, the facility failed to ensure annual evaluations were completed. The findings include: Interview with Human Resources Person (HR #1) on 6/17/25 at 10:38 AM indicated the DNS received the employee annual evaluations via a computer program and she is responsible to complete the evaluations, and the employee signs the evaluation in the computer. HR #1 indicated that the DNS and leadership team are instructed they must meet with the employee and go over the evaluation. HR #1 indicated the employee can go into the computer and sign the evaluation. […]