The Manor, Inc.

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 16, 2024

  Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by staff for 1 of 2 sampled residents (Resident #1). As a result of the deficient practice, Resident #1 was transferred to the hospital and had a sexual assault nurse exam where genital tearing was detected. Using the reasonable person concept, Resident #1 would likely experience severe adverse psychosocial outcomes related to the event. Findings include: Per record review, Resident #1 has diagnoses that include Alzheimer's disease, major depressive disorder, anxiety disorder, and failure to thrive. […]

• Immediate jeopardy, isolatedF607Dec 16, 2024

  Based on interviews and record review the facility failed to develop and implement a policy related to screening of potential employees to include a national background checks for all employees. Findings include: Per interview on 11/12/24 at 1:25 PM, the DON [Director of Nursing] confirmed that the facility substantiated that LNA #1 sexually assaulted Resident #1 on 11/6/24. Per record review of LNA #1's human resource file there was no national background check completed for LNA #1. Per interview with the Human Resources Director and the Administrator on 11/12/24 at 11:30 AM, it was confirmed that the facility did not do a national background check for LNA #1. […]

• Actual harm, isolatedF684Feb 7, 2024

  Based on observation, interview, and record review the facility failed to ensure that residents received care in accordance with professional standards of practice related to the worsening of an arterial ulcer that resulted in a Staphylococcus (Staph) infection (an infection caused by a bacteria commonly found on the skin) for 1 of 23 residents sampled (Resident #35). Findings include: Per record review Resident #35 was admitted to the facility on [DATE] with diagnoses that include venous insufficiency (leg veins become damaged causing blood to pool in your legs. This increased pressure in your leg veins causes symptoms like swelling and ulcers), and chronic venous ulcers of bilateral lower extremities (leg ulcers caused by problems with blood flow in your leg veins. […]

• No harm, potential for more than minimal, widespreadF726Apr 15, 2026

  Per interview and record review, the facility failed to ensure that 48 of 48 contracted nursing staff (licensed nursing staff and licensed nursing assistants) obtained through staffing agencies have the specific competencies necessary to care for residents' needs as identified through resident assessments and the plan of care. This has the potential to affect all residents. Findings include: Per review of 2 LNA (Licensed Nursing Assistant) employee records (1 permanent LNA and 1 contracted LNA), required competencies for resident care were missing for the LNA contracted through Clipboard Health (service used to fill staffing gaps).Per interview with the Director of Nursing (DON) on 4/15/2026 at 12:11 PM, she stated that they do not always provide the facility training to new staff… […]

• No harm, potential for more than minimal, widespreadF812Nov 25, 2025

  Based on observation and interview, the facility failed to ensure that all food was stored safely and to ensure that sanitary conditions for safe food handling were maintained. This has the potential to impact all residents. Findings include:A kitchen tour was conducted on 11/25/25 at 9:15 AM. Per observation, there was an open and undated package of waffles in freezer. There was a container of rotting lettuce in the walk-in fridge. There was a container of celery uncovered in the walk-in fridge. There was a package of 14 hot dogs that was open to air and not dated. There was a container of raw chicken. There was a container of chicken sitting in chicken juices on the bottom shelf. There was an undated package of American cheese slices. […]