Park Manor Ltd

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF628Sep 10, 2025

  Based on record review and interview, the facility did not provide Notice of Bedhold and Notice of Transfer to a resident or resident representative who were transferred from the facility to a hospital for 4 of 4 residents (R) (R4, R20, R33 and R34). Example 1 R4 was admitted to the facility on [DATE] and has an Activated Power of Attorney (APOA). On 06/11/25, R4 had a change in condition that required being sent to emergency room (ER). The facility contacted R4's APOA and left a voicemail regarding change in condition. The facility was unable to provide documentation to support that the APOA was provided a Notice of Bedhold or Notice of Transfer. On 07/08/25, R4 had a change in condition that required being sent to emergency room (ER) and subsequently admitted to hospital. […]

• No harm, potential for more than minimal, patternF641Jul 18, 2024

  Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R43, R25, R35 and R34) of 18 sampled residents. Findings: The facility's policy titled, COMPREHENSIVE ASSESSMENTS reviewed 4/18/2024, states in part: . 7. A significant error is an error in an assessment where: a. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and b. The error has not been corrected via submission of a more recent assessment. 8. […]

• No harm, potential for more than minimal, patternF880Jul 18, 2023

  Based on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following 5 observations. Staff did not practice appropriate donning of Personal Protective Equipment (PPE) and hand hygiene with the care and services of a resident in Transmission-Based Precautions (TBP) for Clostridium difficile (R55), a very contagious bacterium. Staff did not practice appropriate hand hygiene with a dressing change for R179. Staff did not practice appropriate hand hygiene after incontinence cares with R44. […]

• No harm, potential for more than minimal, isolatedF609Jul 9, 2026

  Based on record review and interviews, the facility did not ensure that an alleged violation involving abuse was reported to the State Survey (SA) and law enforcement. This had the potential to affect 1 of 4 residents (R1) investigated for abuse.The facility reported the incident to the SA within five days following their investigation, but did not report the injury of unknown origin to the SA within 24 hours.Surveyor reviewed the facility's policy titled Abuse and Misconduct, which read in part, The administrator, Director of Social Services, and/or the Director of Nursing determined whether the suspicion/alleged incident is reportable (meets the definition of caregiver misconduct) to the Division of Quality Assurance and other officials.On 06/20/26, the facility submitted an alleged… […]

• No harm, potential for more than minimal, isolatedF609May 6, 2026

  Based on Interview and record review, the facility did not ensure that all alleged violations involving abuse resulting in physical harm, pain or mental anguish are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility (including to the State Survey Agency) and to other officials in accordance with State law through established procedures for 2 (R5, R8) of 6 residents. On 4/16/26 at 8:15 AM, R6 barricaded self in R5's room and threatened to harm R5. The facility did not report this within allotted time frames. On 6/4/25 at approximately 7:40 AM, Certified Nursing Assistant (CNA) D heard Registered Nurse (RN) E yelling at R8. […]