Northwest Manor Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689May 13, 2026

  Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident was transferred with only one staff and without a lift which resulted in actual harm of a tibia fracture for 1 of 6 residents reviewed for accidents (Resident 64), and the facility failed to prevent potential for accidents when a resident's medications were left at bedside without a self-administration assessment for 1 of 28 residents observed for environments (Resident 45).Findings include:Findings include: 1. On 5/12/26 at 9:20 a.m., Resident 64 was observed reclined in her bed, her right leg uncovered by the bed sheet so that her knee was observed. The knee was significantly swollen. […]

• No harm, potential for more than minimal, patternF880May 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure vital sign equipment was cleaned between residents (Residents 28 and 83), appropriate infection control techniques were used during blood glucose (sugar) checks, glucometers (measures blood sugar) were cleaned between residents (Residents 125 and 31), and enhanced barrier precautions (EBP) (infection control measures requiring staff to wear gowns and gloves during high-contact resident care to prevent the spread of multidrug-resistant organisms) were followed (Resident 93) during 5 of 35 medication observations. Findings include:1. […]

• No harm, potential for more than minimal, patternF689Jun 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place as outlined in the residents' plan of care for 3 of 4 residents reviewed for falls (Residents 88, 96, and 85). Findings include: 1. On 6/5/25 at 2:22 p.m., Resident 88 was observed in the main dining room during a group activity. She was seated in a wheelchair and although she had a personal storage pouch, it was attached to the back of her wheelchair out of reach. She was not observed to have a reacher. On 6/9/25 at 8:35 a.m., Resident 88 was observed. She was seated in her wheelchair in the main dining room, in front of the nurses' station. Her eyes were closed and there was a stack of papers and a word search booklet which rested on her lap. […]

• No harm, potential for more than minimal, patternF812Apr 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure puree food items were properly prepared and mixed according to the recipe and the equipment was thoroughly washed and sanitized. This deficient practice had the potential to affect 8 of 8 residents who received pureed food from the kitchen. Findings include: On 4/4/24 at 9:24 a.m., Cook 13 was observed as he prepared pureed lunch for the afternoon meal service. Cook 13 was not observed to conduct hand hygiene. He indicated he had already measured out the vegetables and added water and a blender was observed full of mixed vegetables submerged in water. Cook 13 turned on the blender and after several minutes, indicated the vegetables were done. He did not add any additional ingredients. […]

• No harm, potential for more than minimal, patternF656Jan 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure comprhensive care plans were initiated and implement for 6 of 19 residents reviewed for comprehensive care planning (Residents 1, 46, 45, 198, 202, and 5). Findings include: 1. Resident 1's medical record was reviewed on 1/9/23 at 2:49 p.m. She was admitted on [DATE]. Her diagnoses included, but were not limited to fracture of right femur, chronic kidney disease, major depressive disorder, chronic heart failure, hypothyroidism, and protein-calorie malnutrition. Resident 1's Minimum Data Set (MDS), dated , 10/2/22 indicated she received extensive assistance with bed mobility. […]