Inspection Reports for
Grand Manor Nursing & Rehabilitation Center

The facility failed to timely report an injury of unknown source involving Resident #7, reporting it 10 days late. The facility also failed to provide adequate supervision and assistive devices to prevent falls for Resident #88, who was observed without required floor mats and with the bed in the highest position despite a care plan specifying otherwise.

The facility failed to timely convey personal funds of deceased residents to the probate jurisdiction, did not report alleged misappropriation incidents within required timeframes, and failed to thoroughly investigate and respond promptly to an allegation of staff threatening a resident.

Complaint survey with 10 health and 6 life safety citations including deficiencies in accuracy of assessments, care planning, drug regimen review, infection control, and electrical equipment.

Complaint survey with 2 health citations related to notice and conveyance of personal funds and reporting of alleged violations.

The facility had multiple deficiencies including failure to maintain resident privacy during medical treatment, inaccurate Minimum Data Set assessments, incomplete care plans, improper wound care infection control practices, failure to address pharmacy consultant recommendations, missed medication doses, improper medication storage, and lack of specialized training for the Infection Preventionist.

The facility failed to notify the designated representative and medical doctor of Resident #1's change in condition, did not perform a comprehensive clinical assessment, and did not reassess the resident after administering acetaminophen. Resident #1 subsequently expired due to cardiac arrest secondary to coronary artery disease.

Complaint survey with 2 health citations including notification of changes and quality of care with actual harm.

The investigation was initiated based on four complaints submitted to the State Agency regarding loss of heat affecting six residents, and six additional resident grievances filed at the facility about cold room temperatures. The complaints were substantiated with findings of unsafe temperature levels and maintenance failures.

The facility failed to maintain safe and comfortable temperature levels due to malfunctioning boilers and lack of maintenance, resulting in temperatures below regulatory requirements in all sampled resident rooms and common areas. The Administrator lacked awareness and effective oversight of the heating issues and maintenance failures, leading to Immediate Jeopardy to resident health and safety.

Complaint survey with 3 health and 0 life safety citations including administration, essential equipment, and safe/clean environment with immediate jeopardy.

The complaint investigation focused on allegations of resident abuse involving Resident #118 and Resident #151. The investigation confirmed resident-to-resident abuse resulting in actual harm to Resident #118. The facility was found deficient in supervision, care planning, and behavioral health interventions related to this incident.

The facility failed to prevent resident-to-resident abuse resulting in actual harm, did not ensure comprehensive care plans were reviewed and revised after incidents, failed to provide adequate assistance with activities of daily living including showering, and did not maintain sufficient nursing staff to meet residents' needs. Behavioral health care and supervision for a resident with violent behavior were inadequate.

Complaint survey with 16 health and 3 life safety citations including accuracy of assessments, ADL care, administration, behavioral health, care plan, free from abuse, governing body, infection prevention, and label/store drugs.

The complaint investigation revealed substantiated findings of abuse and neglect, including a resident-to-resident altercation causing actual harm, failure to provide care consistent with resident preferences, and inadequate supervision of residents with behavioral issues.

The facility was found deficient in multiple areas including resident rights, abuse prevention, accurate assessments, care planning, assistance with activities of daily living, pressure ulcer prevention, staffing adequacy, nurse aide performance evaluations, medication storage, infection control, and quality assurance oversight. Several deficiencies were repeated from prior surveys.

The complaint investigation found substantiated issues related to missed medication administration and inadequate wound care management for residents, including failure to notify physicians and implement treatment orders.

The facility failed to administer prescribed medications to residents, including missed insulin doses and failure to order or administer intravenous antibiotics. Additionally, the facility did not provide appropriate foot care and treatment for a resident's diabetic foot ulcer, and there was no documented physician review of the resident's wound care treatment recommendations.

Complaint survey with 7 health and 5 life safety citations including disposal of garbage, food procurement, foot care, physician visits, posted nurse staffing, safe environment, sufficient nursing staff, and electrical equipment.

Complaint survey with 1 health citation for quality of care.

The facility had multiple deficiencies including failure to provide appropriate foot care and treatment for a resident's diabetic foot ulcer, insufficient nursing staff levels below facility-assessed minimums, failure to post nurse staffing information daily, improper food service hygiene practices, improper garbage disposal, lack of consistent hot water supply, and failure to ensure physician review of resident care and orders.

Covid-19 survey with 1 health citation related to reporting to national health safety network.

Covid-19 survey with 1 health citation related to reporting to national health safety network.

The facility failed to ensure that Resident #1 was free from physical abuse when Security Guard #1 pushed the resident to the wall and towards the elevator to prevent them from leaving the facility. The facility investigated the incident, found no injuries, and acknowledged the abuse based on video surveillance and staff interviews.

The complaint investigation involved Resident #201's personal belongings being discarded without notification and Resident #121's loose bowel movements not being properly managed. The complaint was substantiated with findings of minimal harm.

The facility failed to ensure Resident #201 was treated with respect and dignity, including improper handling and disposal of personal belongings without notification. Additionally, the facility did not provide appropriate care for Resident #121 who had loose bowel movements that were not identified or treated as ordered.

The facility failed to ensure that laboratory blood work ordered for Resident #1 on 04/07/22 was completed. Documentation and interviews revealed no evidence that the blood was drawn or lab work completed, and no documentation supported resident refusal.