The Manor Healthcare Residence

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 12, 2023

  Based on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 1 of 3 residents (Resident #92) reviewed for transfers. The facility failed to ensure Resident #92 was transferred using a gait belt . This failure could place residents at risk for injuries and falls. Findings included: Record review of an undated face sheet indicated Resident #92 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of left sided weakness following a stroke, fracture of the nose, and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). […]

• Actual harm, isolatedF760Jan 29, 2022

  Based on observations, interviews, record review, and facility policy and document review, the facility failed to ensure one (Resident #1) of three residents received medications as prescribed. Specifically, the facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer [MEDICATION(S)] (a compound containing sodium valproate and [MEDICATION(S)] acid; an antiseizure medication and mood stabilizer used primarily to treat [CONDITION(S)] and [CONDITION(S)]) to the resident for five days. This failure resulted in Resident #1 having a subtherapeutic [MEDICATION(S)] level and a post-traumatic [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: *The deep roasting pan was clean *The sheet pans were clean *The muffin pans were clean *The roasting pans were clean *The skillets were clean *The stock pot was clean These failures could place residents at risk for foodborne illness. Findings included: During an observation and interview on 07/10/23 at 08:25 AM, the following items had carbon buildup inside and outside: *one deep roasting pan *four large sheet pans *three muffin pans *one small sheet pan *two small roasting pans *four skillets *one stock pot One of the skillets was on top of the stove… […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2022

  Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen A) reviewed for food storage. The facility did not label or date all foods after it was removed from its original packaging in Kitchen A. This failure could place 38 residents who ate from the 1 kitchen at risk for foodborne illness. Findings include During an observation of Kitchen, A on 6/01/2022 at 9:30 a.m. All foods that were removed from its original packaging did not have labels or dates. Those items were milk, butter, cottage cheese, yellow mustard, relish, cheese, lunch meat, salad, whip cream, tea, and pudding. During an interview on 06/01/2022 at 11:35 a.m. […]

• No harm, potential for more than minimal, patternF565Sep 12, 2024

  Based on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for seven of seven anonymous residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In a Resident Council interview on 9/11/24 at 2:00 pm, the AT Director gathered several residents and brought them to the Dining Room. […]