Memorial Manor Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, patternF835Mar 12, 2021

  Based on observation, interviews, record review, review of the facility's job descriptions for the Administrator and Director of Nursing (DON), the facility failed to ensure administration was consistent with oversight and monitoring of the Infection Control program, failed to ensure that one of 22 residents was free from neglect, and failed to ensure that the Infection Control program fully implemented the CMS and CDC recommended practices. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, patternF880Mar 12, 2021

  Based on observations, interviews, record review, review of the facility policy's titled, Interim Long-Term Care Setting Guidance for Residents with Suspected Confirmed Coronavirus Disease 2019, and the facility policy titled, Considerations for new Admissions or Readmissions to the Facility review of facility documents, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement an infection control program designed to prevent the spread of infection, including the COVID-19 virus, which affected seven (Resident (R) #4, R#6, R#17, R#18, R#21, R#22, and R#23) of 24 sampled residents. […]

• Immediate jeopardy, isolatedF600Mar 12, 2021

  Based on interviews, record review, and review of the facility policy titled, Abuse Prohibition Policies and Procedures the facility failed to protect one of 24 sampled residents (R#4) from neglect. Specifically, the facility failed to ensure R#4, who was COVID positive, received needed care and services, including monitoring per physician orders after the resident experienced a change in condition requiring continuous oxygen. R#4 who was newly symptomatic was prematurely released R#4 from the COVID unit, licensed staff failed to monitor R#4 in accordance with physician orders from [DATE] through [DATE]. The resident was transferred to the hospital where she subsequently died with [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, patternF550May 1, 2025

  18750 Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Dignity, the facility failed to ensure residents ate in a dignified manor in that the facility supplied plastic utensils during meal service affecting three of 34 sampled Residents (R) (R3, R21, and R35). The plastic utensils were difficult for some of the residents to grip and carry food to their mouth for residents with certain disease processes. Findings include: Review of the facility's undated policy titled Dignity revealed, All Residents are to be treated with dignity, respect, consideration, and in a manner that recognizes their individuality. 1. During an interview on 4/28/2025 at 12:57 pm, R21 stated that she ate all meals in her room. […]

• No harm, potential for more than minimal, patternF690Oct 24, 2024

  Based on observations, staff interviews and review of the facility's policy titled, Care of the Resident with a urinary catheter, the facility failed to ensure that four of six residents (R) (R2, R3, R9, R10) with indwelling catheters were secured and stored properly. Specifically, the facility failed to ensure that R2, R3, and R10's catheter tubing was secured with catheter straps, and R9's catheter drainage bag was not stored on the floor. Findings included: Review of the facility's policy Care of the Resident with a Urinary Catheter with revised date of 10/2014, revealed under Procedure: 5. Maintain tension free catheter by taping securely but still allowing movement. Never allow bag to touch the floor. 1. […]