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Deficiency Records for The Manor
A list of the most recent deficiencies for The Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-01 | 2024-04-18 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-03-01 | 2024-04-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-01 | 2024-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-01 | 2024-04-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-01 | 2024-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-03-01 | 2024-04-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-01 | 2024-04-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-01 | 2024-04-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-01 | 2024-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-01 | 2024-04-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-01 | 2024-04-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-01 | 2024-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-01 | 2024-04-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-01 | 2024-04-18 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-08-05 | 2022-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-08 | 2022-10-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-08 | 2022-10-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-05 | 2022-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-05 | 2022-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-05 | 2022-09-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-05 | 2022-09-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-05 | 2022-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-09-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-05 | 2022-09-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-08-05 | 2022-09-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-12 | 2022-06-26 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-12 | 2022-06-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-12 | 2022-06-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-06-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-12 | 2022-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-14 | 2020-03-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-14 | 2020-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-14 | 2020-03-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-14 | 2020-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-14 | 2020-03-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-14 | 2020-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-14 | 2020-03-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-14 | 2020-03-27 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-02-14 | 2020-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-14 | 2020-03-27 | N |
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