Ross Manor

In the surveyor’s words

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

• Actual harm, isolatedF760Sep 12, 2024

  Based on review of the facility internal investigation, clinical record review, facility Medication Administration Policy and Procedure, and interviews, the facility failed to protect a resident from receiving another residents medications resulting in the resident being transferred to the Acute Care Emergency Department (ED) for evaluation and monitoring of low blood pressure and a drop in hemoglobin and hematocrit for 1 of 1 resident reviewed (Resident #1 [R1]). Finding: On 9/3/24, a review of the facility's internal investigation was completed. […]

• No harm, potential for more than minimal, patternF578Jun 10, 2026

  Based on facility policy review, record reviews, and interviews, the facility failed to ensure that resident(s) and/or resident representative(s) were provided with written information and/or follow-up, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate for 3 of 10 residents reviewed for advanced directives (Resident 98 [R98], R36, and R6). Findings: Review of policy Advance Directives revised 3/25 states .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative,… […]

• No harm, potential for more than minimal, patternF761Jun 10, 2026

  Based on facility policy, record review, observations, and interviews, the facility failed to adequately ensure medications and biologics were stored at appropriate temperatures in 2 of 3 refrigerators observed for 4 of 4 months of medication refrigerator logs reviewed ([NAME] Unit and [NAME] Unit). Additionally, the facility failed to ensure medications were removed from medication cart after discharge for 1 of 7 carts reviewed ([NAME] Unit).Findings:1.Review of the [NAME] Treatment cart with Registered Nurse (RN)#2 on 6/9/26 at 9:02 a.m., revealed the following medications belonging to a resident that was discharged on 5/19/26, available for use: (1 )Multi-use vial of insulin Lispro, (1)Novolin R100 flex pen, and (1) multi-use vial of insulin Lantus. […]

• No harm, potential for more than minimal, patternF812Jun 10, 2026

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety by failing to ensure foods were sealed, labeled, and dated in 2 reach-in refrigerators and a walk-in freezer for 1 of 2 kitchen tours and by failing to ensure staff perform hand hygiene during a breakfast service observation on 1 of 3 days of survey (6/10/26). Additionally, the facility failed to monitor refrigerator and dish machine temperatures for 3 of 4 months reviewed (March, April, and May). Findings: Review of facility policy Food Storage, dated 3/2025 states, .Refrigerated Food Storage. Foods must be maintained at or below 41 degrees F [Fahrenheit]. […]

• No harm, potential for more than minimal, patternF880Jun 10, 2026

  Based on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of bedpans on 2 of 3 days of survey (6/8/26, 6/9/26) and hand hygiene during a dining observation. Findings: 1. Facility policy Handwashing/Hand Hygiene, revised 2/2026 states, .Hand hygiene is indicated. before preparing or handling food.after glove removal. Indications for Gloves. Use single-use disposable gloves: when enhanced barrier precautions are applicable; when contact precautions are applicable; before aseptic procedures; and when anticipating contact with blood or body fluids. […]