27 Reports
Inspection Report — Jun 10, 2026
Plan of Correction
Date: Jun 10, 2026
Visit Reason
Plan of Correction submitted for the Statement of Deficiencies issued on June 24, 2026, following the survey visit on June 10, 2026.
Findings
This document is the facility's plan of correction for the survey conducted on June 10, 2026, addressing deficiencies cited under rules F0578, F0761, F0812, F0880, F0641, F0644, F0655, F0695, F0790, and F0842.
Report Facts
: Jul 17, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Jun 9, 2026
Plan of Correction
Date: Jun 9, 2026
Visit Reason
This document is the facility's plan of correction related to the June 9, 2026 Life Safety Code and Emergency Preparedness survey of Ross Manor.
Findings
This plan of correction addresses the deficiency cited regarding means of egress and general fire safety compliance as identified in the June 9, 2026 survey.
Report Facts
: 232286-L1
: 1912
Inspection Report — Jun 6, 2026
Date: Jun 6, 2026
Visit Reason
Federal Recertification Survey with a revisit date of 06/09/2026.
Findings
Ross Manor is in substantial compliance with Long Term Care Facilities Emergency Preparedness regulations. However, it is not in substantial compliance with the National Fire Protection Association 101 Life Safety Code 2012 Edition due to obstructions in the service wing corridor.
Deficiencies (1)
K0211: Means of egress corridors are obstructed by drying racks with rags stored in the service wing corridor next to the main laundry room, violating NFPA 101 Life Safety Code 2012 Edition.
Report Facts
: Jun 9, 2026
Inspection Report — Jun 10, 2025
Follow-Up
Date: Jun 10, 2025
Visit Reason
An unannounced on-site revisit was conducted to complete a follow-up to the annual Long Term Care Survey Process for Federal Recertification dated 4/17/25.
Findings
Ross Manor is in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Inspection Report — May 19, 2025
Annual Inspection
Date: May 19, 2025
Visit Reason
Annual federal recertification survey and fire safety inspection.
Findings
Ross Manor was found not in substantial compliance with NFPA 101 Life Safety Code and NFPA 72 National Fire Alarm and Signaling Code due to improperly installed fire alarm pull stations and incomplete generator maintenance.
Deficiencies (2)
Fire Alarm System - Installation: Multiple manually actuated alarm-initiating devices (pull stations) throughout the facility had operable parts higher than 48 inches above the floor, violating NFPA 101, Life Safety Code, 2012 edition, sections 19.3.4.2.1 and 9.6.2.5, and NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Section 17.14.4.
Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain the essential electric system generator per NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, sections 5.6.5.6, and NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.4.4.1.1.3, as the shut-off device was not installed and weekly inspections were incomplete.
Report Facts
: Jun 27, 2025
Inspection Report — Apr 16, 2025
Follow-Up
Date: Apr 16, 2025
Visit Reason
On 4/16/25, an on-site re-visit was conducted at Ross Manor for the purpose of following up on the survey of 2/5/25 (complaints #ME00050290 and #ME00050288).
Findings
Ross Manor is in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities for the survey of 2/5/25.
Report Facts
: ME00050290
: ME00050288
Inspection Report — Apr 15, 2025
Biennial Survey
Date: Apr 15, 2025
Visit Reason
The survey was conducted as a Federal Recertification Survey to assess compliance with applicable regulations and codes.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements including exit discharge conditions, hazardous area enclosures, fire alarm system installation, sprinkler system installation and maintenance, portable fire extinguisher placement, corridor door integrity, fire door inspection, electrical system maintenance, essential electric system generator maintenance, and improper use of power strips in patient care areas.
Deficiencies (11)
K271: Exit discharge surfaces were uneven, cracked, and obstructed by water, creating trip hazards and non-slip resistant conditions.
K321: Hazardous areas such as soiled linen storage and storage rooms had unsealed penetrations compromising smoke resistance.
K341: Manually actuated fire alarm pull stations throughout the facility were installed higher than the required 48 inches above the floor.
K351: Sprinklers were not installed under exterior projections exceeding four feet, including roofs and canopies at multiple building locations.
K353: Sprinkler system maintenance was deficient; dry head sprinklers required testing after 50 years and a damaged quick opening device was scheduled for replacement.
K355: Portable fire extinguishers lacked required placards near class K extinguishers and some extinguishers were mounted less than 4 inches above the floor.
K363: Corridor door frame in resident room 504 was damaged, creating a gap that compromised smoke resistance.
K761: The facility lacked documentation of annual fire door inspections by trained personnel as required by NFPA 80.
K914: The facility failed to document annual testing of non-hospital grade electrical receptacles at resident bed locations, risking electrical hazards.
K918: Essential electric system generator inspections were incomplete; weekly inspections were not conducted, monthly inspection sheets lacked key information, no annual fuel quality test documentation was available, and no labeled remote manual stop device was installed outside the generator housing.
K920: Power strips not listed as hospital-grade were used in patient care vicinities as substitutes for fixed wiring, violating electrical safety codes.
Report Facts
: 2
: 2
: 2
: 3
: 3
: 50.25
: 50.5
: 50
: 49.5
: 50.5
: 52.5
: 50.75
: 50.75
: 50.5
: 50.5
: 50.5
: 52.3125
: 49
: 49
: 49
: 49
: 3
: 3
: 0.6875
Inspection Report — Apr 14, 2025
Annual Inspection
Date: Apr 14, 2025
Visit Reason
The survey was conducted for the annual Long Term Care Survey Process for Federal Recertification and to investigate complaints #ME00048261, #ME00049345, and #ME00050495.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including baseline care planning, ADL care, quality of care, respiratory care, psychotropic medication management, food safety, resident records, and infection prevention and control.
Deficiencies (8)
F 655: The facility failed to develop and implement a baseline care plan within 48 hours that included instructions needed to provide minimum healthcare information for 1 of 2 sampled residents admitted for skilled care services.
F 677: The facility failed to consistently provide Activities of Daily Living care in oral hygiene for 1 resident, with documentation showing oral hygiene was not completed after the evening meal for 13 out of 31 days in March.
F 684: The facility failed to follow physician orders for 2 residents, including administering Levofloxacin doses too close together and failing to recheck blood sugar as ordered after insulin administration.
F 695: The facility failed to provide physician-ordered respiratory services for 1 resident with a CPAP machine due to failure to obtain missing tubing, resulting in multiple hospital readmissions.
F 758: The facility failed to ensure a physician-ordered renewal for an as needed psychotropic medication without a stop date, making it available for administration beyond the 14-day limit for 1 resident.
F 812: The facility failed to ensure plumbing fixtures were properly installed to prevent backflow, with improper air gaps on drain lines of ice machines observed on all days of survey.
F 842: The facility failed to maintain complete and accurate clinical records for 2 residents, including inaccurate documentation of CPAP use and medication indications.
F 880: The facility failed to maintain an infection prevention and control program, with multiple observations of unsanitary conditions including soiled commode seats, unlabeled and soiled bed pans, blood on bed frames, and improper handling of gloves and linens.
Report Facts
: Dose given on 4/2/25 and again on 4/3/25, not 48 hours apart
: 13
: 50 days from admission (2/20/25) to receipt of tubing (4/11/25)
: 2/12/25
: 4/14/25 to 4/17/25
Inspection Report — Dec 6, 2024
Complaint Investigation
Date: Dec 6, 2024
Visit Reason
Investigation of a reported incident of physical abuse at Ross Manor.
Findings
The facility failed to ensure staff reported an allegation of physical abuse immediately, as required by policy and regulations.
Deficiencies (1)
F609: The facility failed to ensure staff reported an allegation of physical abuse immediately for one resident during a complaint investigation.
Report Facts
: ME00049550
: Nov 11, 2024
: 15:24
Inspection Report — Jul 1, 2024
Complaint Investigation
Date: Jul 1, 2024
Visit Reason
Investigation for facility reported event #ME00047874.
Findings
Ross Manor was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Report Facts
: ME00047874
Inspection Report — May 16, 2024
Annual Inspection
Date: May 16, 2024
Visit Reason
The survey was conducted to complete the annual Long Term Care Survey Process for Federal Recertification and to investigate multiple complaints.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. Deficiencies were identified related to resident rights, advance beneficiary notices, advance directives, resident assessments, coordination of PASARR and assessments, activities of daily living, quality of care, free of accident hazards, and physician visits.
Deficiencies (11)
483.10(b)(2): The facility failed to ensure that a resident requiring feeding assistance was fed in a dignified manner, as evidenced by a Certified Nursing Assistant feeding a resident while facing away and talking to another staff member.
483.10(b)(7): The facility failed to review an Advance Beneficiary Notice with a resident's legal guardian, potentially preventing the resident's right to appeal discharge.
483.10(c)(6)(8)(g)(12)(i)-(v): The facility failed to ensure residents' rights to request, refuse, or discontinue treatment and to participate in or refuse experimental research, as evidenced by inaccurate code status documentation for residents.
483.20(f)(1)-(4): The facility failed to transmit electronically accurate and complete Minimum Data Set assessments within required timeframes for residents.
483.20(e)(1)(2): The facility failed to coordinate assessments with PASARR requirements and follow up on Level II recommendations for residents.
483.20(e)(2): The facility failed to incorporate recommendations from the Preadmission Screening Resident Review for a resident with serious mental illness.
483.24(a)(1)(b)(1)-(5): The facility failed to provide restorative nursing services and maintain residents' highest level of functional mobility for a resident, including a restorative nursing program and passive range of motion exercises.
483.25: The facility failed to ensure physicians' orders for sliding scale insulin were followed for residents, resulting in unnecessary medications and inconsistent blood sugar management.
483.25(d)(1)(2): The facility failed to provide adequate supervision and assistance devices to prevent accidents, as evidenced by a resident being sent out to an appointment without proper supervision.
483.30(b)(1)-(3): The facility failed to ensure timely review, signing, and dating of physician orders and progress notes for residents, including missing signatures and late orders.
483.80(a)(1)(2)(4)(e)(f): The facility failed to establish and maintain an effective infection prevention and control program, including failure to follow wound care policy and procedures during dressing changes, resulting in a pressure ulcer not being properly managed.
Report Facts
: Array
: Array
: Array
: 34
Inspection Report — May 1, 2024
Follow-Up
Date: May 1, 2024
Visit Reason
On 5/1/24, an on-site visit was conducted at Ross Manor for the purpose of following up on complaints #ME00044693, #ME00046610, and #ME00046661.
Findings
Ross Manor was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00044693
: ME00046610
: ME00046661
Inspection Report — Mar 11, 2024
Plan of Correction
Date: Mar 11, 2024
Visit Reason
Investigation of complaints #ME00044693, #ME00046610, and #ME00046661 at Ross Manor.
Findings
This document is the facility's plan of correction for the survey completed on 2024-03-11 addressing deficiencies related to resident rights, abuse and neglect, and activities of daily living.
Report Facts
: 44693
: 46610
: 46661
: Mar 11, 2024
: Apr 22, 2024
: Mar 28, 2024
Inspection Report — Nov 6, 2023
Complaint Investigation
Date: Nov 6, 2023
Visit Reason
Investigation of complaints #ME00042681 and #ME00045330.
Findings
Ross Manor was found to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; no deficiencies were cited.
Report Facts
: ME00042681
: ME00045330
Inspection Report — NU7S23 SOD
Date: NU7S23 SOD
Visit Reason
Federal Recertification survey
Findings
Ross Manor, a long term care facility, is in substantial compliance with 42 Code of Federal Regulations Part 483.73 Requirement for Long Term Care Facilities Emergency Preparedness and the National Fire Protection Association 101 Life Safety Code 2012 Edition as referenced on 42 CFR 483.90 (a-d) physical environment.
Document — PEXN12 SOD
Date: PEXN12 SOD
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