Manor House Care Center

In the surveyor’s words

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

• Actual harm, isolatedF690May 15, 2025

  Based on observation, record review, resident and staff interview and policy review, the facility failed to notify the resident's provider of a change of condition that required physician intervention, and failed to consistently document the status of a resident for 1 of 3 residents reviewed (Resident #145). The facility staff failed to notify the provider of the blood in Resident #145's catheter for 3 days that required an intervention in a hospital. The facility reported a census of 44 residents. […]

• No harm, potential for more than minimal, patternF803May 15, 2025

  2. The Quarterly Minimum Data Set (MDS) quarterly assessment, dated 2/11/25, identified the resident had diagnoses of hypertension (high blood pressure), edema (fluid retention), lymphedema (tissue swelling in the body's lymphatic system), and chronic obstructive pulmonary disease. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. An Order Entry, dated 3/15/2023, included a physician order for a general, 2 gram sodium diet (low salt diet). […]

• No harm, potential for more than minimal, patternF883Jul 18, 2024

  Based on record review, policy review, and staff interviews, the facility failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for pneumococcal vaccinations (Resident #11, #13, #16, #22). The facility reported a census of 39 residents. Findings include: 1. Resident #11's Immunization record stated the resident received the PCV23 (a type of pneumococcal vaccine) on 10/28/10 and the PCV13(a type of pneumococcal vaccine) on 1/27/17. The record stated the resident was [AGE] years old. 2. Resident #13's Immunization record stated the resident received the PCV23 pneumococcal vaccine on 1/23/08 and the PCV13 vaccine on 7/23/15. The record stated the resident was [AGE] years old. 3. […]

• No harm, potential for more than minimal, patternF600Jul 13, 2023

  Based on record review, staff interviews, and policy review the facility failed to ensure residents were free from neglect when 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) did not receive their scheduled medications including, narcotics, insulin, antibiotics, blood pressure, psychotropic, respiratory and blood thinner medications on 7/4/2022 by Staff A, Licensed Practical Nurse (LPN) who was their nurse from 2:00 PM to 6:00 AM on 7/5/22. The facility reported a census of 51 residents. […]

• No harm, potential for more than minimal, patternF658Jul 13, 2023

  Based on record review, staff interviews, and policy review the facility failed to ensure 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) were provided with professional standards of nursing care on 7/4/2022 from 2:00 PM to 6:00 AM, by Staff A, Licensed Practical Nurse (LPN) who documented medications were given, but during review of video footage and a facility timeline was found to dispense and dispose of resident medications instead of administering the medications to residents. The facility reported a census of 51 residents. […]