Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manila Healthcare Center during CMS and state inspections, most recent first.
A resident with a PEG tube and active EBP order did not have EBP signage or PPE posted outside the room, and an RN performed PEG tube care without using a gown despite the facility’s EBP policy requiring gown and gloves for device care. In a separate observation, a CNA provided peri-care to a severely cognitively impaired resident who was incontinent of bowel and urine without changing gloves or performing hand hygiene while moving between contaminated and clean tasks, and the CNA acknowledged the lapse.
A resident with COPD, CHF, pneumonia, vitamin deficiency, dizziness, and GERD was not given the opportunity to choose when morning meds were administered. The resident said the meds were brought too early and asked to wait until after breakfast, but staff told the resident meds had to be taken within a set time window and later documented the meds as refused. The NP stated the resident should have been accommodated, and the antibiotic was missed on the scheduled day.
A resident with epilepsy, restless leg syndrome, hemiplegia/hemiparesis, and severe cognitive impairment had a care plan requiring 2 staff for bed mobility and repositioning. During a briefs change, a CNA moved the resident without help and did not check the bed wheels before smoothing the drawsheet, causing the resident to roll out of bed and land on the floor; no injury was identified. The LPN confirmed 2 CNAs were required, and the DON stated staff were expected to follow the care plan every time care was provided.
Failure to Trim Diabetic Resident’s Toenails: A resident with DM and dementia was dependent on staff for personal hygiene and had an order for diabetic nail care. Surveyors observed long, curved toenails, including a big toenail overlapping the second toe and another nail severely curved under the toe. Staff gave conflicting accounts about who was responsible for nail care, and the treatment nurse confirmed signing off that nail care had been completed despite the observed condition. The DON described the nails as very long and jagged, and the resident was not listed for podiatry review.
A resident with pneumonia, SOB, OSA, and acute bronchitis did not have oxygen added to the active physician orders or care plan despite a standing NP order for oxygen PRN for SOB or low pulse oximetry. The resident reported difficulty breathing and needing oxygen, was observed crying and later had an O2 saturation of 90%, and oxygen was not started until later that day at 3 L/min by NC.
Delayed PRN Pain Medication Administration: A resident with osteoporosis and a back fracture had an order for PRN opioid pain medication and a care plan calling for immediate response to pain complaints. The resident reported back pain and requested the medication in the morning, but the LPN did not assess pain or give the medication during the medication pass, stating she was busy and could not recall the request. The resident later received the medication about 45 minutes after the surveyor spoke with the resident and reported pain at 8/10.
A resident with dementia, chronic pain, and severe cognitive impairment missed doses of an NSAID and a topical anti-inflammatory gel when the meds were unavailable during med pass. An LPN documented the meds were on order, but the MD/NP was not notified, and the resident did not receive the missed doses until later. The ADON and MD confirmed provider notification should have occurred, and the Administrator stated nurses were expected to call the physician and pharmacy immediately when meds were not in the facility.
The facility failed to consistently post complete nurse staffing information on the Daily Staffing Log. Surveyors observed logs missing dates, resident census, staff names, shift details, and work locations, and review of multiple logs showed undated entries, missing census information, and incomplete documentation for RNs, LPNs, MAs, and CNAs. HR confirmed the logs were incomplete, and the Administrator stated the logs were used so visitors and families could see who was working in residents’ areas and how many residents were in the building.
The facility failed to maintain a clean and sanitary environment in the secured unit, affecting 20 residents. Observations revealed cobwebs, peeling paint, debris, and inadequate lighting. Housekeeping practices were inadequate, with staff understaffed and unable to maintain cleanliness. The shower room was in poor condition, with black and gray spots, dirty vents, and walls and floors covered in brown matter. The Infection Preventionist acknowledged the importance of cleanliness for infection control, but staffing constraints hindered efforts.
A facility failed to implement infection control measures for a smoking assistive device used by a resident with cerebral palsy and Parkinson's disease. The device was left unattended and not cleaned before use, contrary to facility policy. The DON confirmed it should have been stored and cleaned properly, highlighting a lapse in infection control procedures.
Failure to Implement EBP and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with a PEG tube and failed to ensure hand hygiene was consistently performed during incontinence care for another resident. For the resident with the PEG tube, the physician’s orders showed all medications were to be given via PEG tube, and the resident had an active EBP order related to indwelling devices. The resident’s MDS showed severe cognitive impairment and a feeding tube, and the care plan directed staff to follow EBP for tube feedings. Despite this, observations on two separate days showed no EBP signage or PPE outside the resident’s room, and staff later confirmed the signage had not been posted. During a concurrent observation, an RN entered the resident’s room to change PEG tube tubing. The RN sanitized her hands and donned gloves, but did not bring or use a gown while disconnecting and reconnecting enteral feeding bags and tubing and while checking PEG placement with a syringe. The RN stated she had never worn a gown for hooking up a PEG tube and said she had not been informed that a gown was to be used when changing PEG tube lines. The EBP policy in effect required gown and gloves before high-contact resident care activities, including device care such as a feeding tube. The RN had completed an EBP competency checklist that included feeding tubes as a condition requiring EBP. For the resident who was incontinent of bowel and urine, the MDS showed severe cognitive impairment and dependence for toileting and personal hygiene. During observed peri-care, a CNA sanitized her hands and donned gloves, but when more wipes were needed, she received the package from another aide without changing gloves or sanitizing her hands. She then used the same gloves to handle clean wipes, the perineum wash bottle, and to cleanse both the anterior and posterior peri-area, including fecal material, without changing gloves or performing hand hygiene during the care. After completing care, she placed clean items in the resident’s drawer before removing and discarding her soiled gloves. The CNA acknowledged she should have sanitized her hands and changed gloves during peri-care, but said she moved too fast and had not completed skills checkoffs before caring for residents on her own.
Failure to Honor Resident Choice for Medication Timing
Penalty
Summary
The facility failed to ensure that Resident #95 had the opportunity to exercise autonomy in choosing when to have medications administered. Resident #95 was admitted with diagnoses including COPD with acute exacerbation, CHF, pneumonia, vitamin deficiency, dizziness, and GERD. On 03/16/2026, the MAR showed the resident refused multiple scheduled morning medications, including an antibiotic, blood pressure medication, allergy medication, vitamin, iron supplement, anticholinergic, probiotic, blood thinner, antacid, oral steroid, antitussive, diuretic, and antivertigo medication. During interview, Resident #95 stated the medications were brought around 7:30 AM and that it was too early to take 11 pills, so the resident asked that they be brought back after breakfast, around 9:00 AM to 9:30 AM. Staff interviews showed the resident’s preference was not accommodated. LPN #8 stated Med Tech #9 attempted to give the medications at 8:30 AM, that the resident wanted to wait until 9:00 AM after breakfast, and that the resident was told medications had to be taken between 7:00 AM and 9:00 AM. The NP later stated the resident should have been accommodated if choosing to take medications later than scheduled and that the scheduled antibiotic was not given on 03/16/2026, with the last dose instead administered on 03/17/2026. The DON and Administrator both stated the resident’s preference for medication timing should be accommodated, and the policy stated medication times are determined by resident need and benefit, not staff convenience, with resident choices and preferences considered.
Failure to Follow Resident Care Plan During Bed Mobility
Penalty
Summary
The facility failed to ensure a Comprehensive Care Plan was consistently implemented for a resident with epilepsy, restless leg syndrome, hemiplegia and hemiparesis affecting the right dominant side, severe cognitive impairment, and dependence on staff for rolling left and right. The resident’s care plan required extensive assistance by 2 staff for bed mobility, including repositioning and turning in bed every 2 hours and as necessary, and also noted the resident had an actual fall with minor injury on 02/05/2026 with one-on-one education provided to staff to ensure two-person assistance with bed mobility and care. Despite these care plan requirements, the resident was found on the floor after rolling out of bed during a briefs change. The incident report stated the resident rolled out of bed while a CNA was trying to smooth out the drawsheet and that no injuries were identified. During interviews, the LPN stated 2 CNAs were required to turn and reposition the resident in bed, and the CNA admitted moving the resident in bed without help and not checking the bed wheels before reaching under the resident to smooth the drawsheet. The DON stated staff were expected to follow the care plan every time care was provided and to check bed wheels before providing care and before exiting the room.
Failure to Trim Diabetic Resident’s Toenails
Penalty
Summary
The facility failed to ensure that Resident #4’s nails were trimmed. Resident #4 was admitted with type 2 diabetes with hyperglycemia and was dependent on staff for personal hygiene. The resident’s care plan identified an ADL self-care performance deficit related to dementia and indicated total dependence on one staff member for personal hygiene. An order was in place for diabetic nail care to be provided by a licensed nurse as needed, and the facility policy stated that nail care included daily cleaning and regular trimming, with nails to be trimmed and smooth and the nail condition documented in the medical record. During observation, Resident #4’s toenails were noted to be long and curved, with the right big toenail overlapping the second toe and another toenail severely curved under the toe. Staff interviews showed conflicting understanding of who was responsible for the nail care: a nurse aide stated she did not clip the resident’s toenails because she was not certified to perform nail care for diabetic residents, while the treatment nurse stated nurses and CNAs were responsible and confirmed signing the treatment record indicating nail care had been completed. The DON observed the nails and described them as very long, jagged, and probably having fungus, and stated the resident’s toenails should be trimmed weekly. The podiatrist had last come to the facility in February 2026, but Resident #4 was not on the list to be seen, and review of podiatry referral lists for September 2025, October 2025, and February 2026 did not show a referral for the resident.
Oxygen Order Not Added to Resident’s Physician Orders
Penalty
Summary
The facility failed to add oxygen to Resident #40’s physician orders. Resident #40 was admitted with diagnoses including pneumonia, shortness of breath, obstructive sleep apnea, and acute bronchitis. The record showed no active physician order for oxygen administration, and the care plan also did not indicate that the resident was on oxygen. However, a standing order signed by the NP directed oxygen at 2-4 liters per minute as needed for shortness of breath and/or a pulse oximetry less than 90%. During observations and interviews, Resident #40 stated they were supposed to have oxygen and reported difficulty breathing. On 03/16/2026, the resident was observed in a medical reclining chair in the dining room, later crying with their head covered, and then had an oxygen saturation of 90% when checked by CNA #7. LPN #2 was informed, and oxygen was not administered until 1:27 PM, when it was started at 3 liters per minute by nasal cannula. Subsequent interviews showed the NP, DON, and MDS Coordinator all acknowledged that standing oxygen orders needed to be added to the active physician orders and care plan, and the DON stated the oxygen dosage should also be added. The facility policy stated oxygen should be administered under physician orders except in an emergency, with the order obtained immediately after the crisis was under control.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident who had an order for an opioid pain medication to be given every eight hours as needed for pain. The resident was admitted with diagnoses including age-related osteoporosis with a current pathological fracture, and the care plan identified acute pain related to a back fracture and osteoporosis. The care plan directed staff to anticipate the resident’s need for pain relief and respond immediately to any complaint of pain. The resident was cognitively intact and reported back pain during the survey interview, stating that the pain medication was usually needed in the morning and had not yet been received. During the morning medication pass, the resident asked a CNA to inform the LPN that pain medication was needed, and the CNA reported that the LPN was told. The LPN stated she had finished passing morning medications, could not remember whether staff informed her of the request, and did not assess the resident’s pain because another staff member was assigned to pass medications to the resident. The LPN confirmed the resident was not assessed for pain during the medication pass and did not receive pain medication at that time. Later the resident stated the medication was received about 45 minutes after the surveyor spoke with the resident, and the resident reported a pain level of 8 out of 10. Interviews with the NP, DON, and Administrator indicated that PRN pain medication should be given as soon as possible, within an hour of request, and immediately after receiving the request if another medication pass was in progress.
Medication Not Available Without Provider Notification
Penalty
Summary
The facility failed to ensure the MD or NP were contacted when two medications were unavailable for one resident during medication pass, resulting in a medication error rate of 5.41% based on 2 of 37 opportunities. The resident had diagnoses including dementia, fibromyalgia, and polyneuropathy, and the MDS indicated severe cognitive impairment, scheduled pain management, and use of a wheelchair. The care plan identified chronic pain and risk related to a topical nonsteroid anti-inflammatory gel, with interventions to monitor for signs of heart attack, stroke, and gastrointestinal reactions. During medication administration, an LPN observed that the resident’s NSAID and anti-inflammatory gel were not available. Progress notes documented that the gel was on order and later that the gel was not available, but there was no documentation that the MD, NP, or ADON was notified at the time the medications were missing. The pharmacy later delivered both medications to the facility, and the LPN stated the doctor was not notified that the resident had not received the ordered doses and that the missed dose was not given because the resident would receive it at the next dose period. The ADON confirmed the resident missed a dose of NSAID and two doses of the anti-inflammatory gel and stated the MD or NP should have been notified. The MD stated the NP should have been notified that the medications were not available. The Administrator stated nurses were expected to call the physician and pharmacy immediately when medication was not in the facility, and that the physician should be notified when a resident does not have medication. The resident stated the pain cream would have helped with discomfort and pain, and staff were not notified about the resident’s discomfort because there was nothing they could do without the prescribed medication.
Incomplete Daily Staffing Logs
Penalty
Summary
The facility failed to ensure required nurse staffing information was consistently posted on the Daily Staffing Log, including staff names, resident census, date, shift, and work location. During observation and concurrent interview, Human Resources provided Daily Staffing Logs from 02/15/2026 through 03/15/2026, and the surveyor observed that some logs were missing dates, resident census, staff names, and work locations. Human Resources stated the logs were posted on a whiteboard opposite the time clock for visitors and staff, and that HR was responsible for dating the log, posting it, recording the census, and writing total work hours, while staff were responsible for entering their names and work locations. Review of the logs showed multiple examples of missing required information. Entries included shifts that were undated, had no resident census, and lacked documented LPN/RN hours or specific units worked for CNAs and other nursing staff. Some logs listed a census but still omitted shift information, dates, or work locations for multiple staff members. Human Resources confirmed that all of the Daily Staffing Log sheets reviewed were missing required nurse staffing information. The Administrator later confirmed that HR was responsible for ensuring the logs were completed and stated that the DON should check the daily log sheet to make sure staff names, resident census, shift, and date were filled out.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the secured unit, affecting the homelike atmosphere for all 20 residents residing there. Observations revealed cobwebs, peeling paint, and debris in various areas, including behind the television, above the air conditioner unit, and in the hallway. The lighting in the hallway was inadequate due to a non-functional light, and light covers in the dining room were dirty and contained dead insects. The handrails and vents in the hallway were covered in debris and fine brown particles, and the tiles were discolored with gray and black matter. Housekeeping practices were inadequate, as observed with a housekeeper changing gloves without washing hands and failing to clean certain areas, such as the splatter on the hallway floor and the bathroom floor in a resident's room. Interviews with housekeeping staff revealed that the facility was understaffed, with only two housekeepers on duty instead of the three needed to manage floor tech duties. The staff expressed difficulty in maintaining cleanliness due to the staffing constraints and the lack of a dedicated floor tech. The shower room in the unit was also found to be in poor condition, with black and gray spots on the ceiling, a vent covered in brown particles, and walls and floors covered in brown matter. The Infection Preventionist acknowledged the importance of a clean environment for infection control but noted the challenge of filling the floor tech position due to its temporary nature. Maintenance staff were unaware of the issues in the shower room until the surveyor's observation, indicating a lapse in the reporting and addressing of maintenance issues.
Infection Control Lapse in Smoking Device Handling
Penalty
Summary
The facility failed to implement proper infection control measures concerning the storage and cleaning of a smoking assistive device used by a resident with cerebral palsy and Parkinson's disease. The resident, who was moderately impaired according to a recent assessment, was observed using a special ashtray device that was left exposed and unattended in the smoking area. This device was not cleaned before being handed to the resident by a Restorative Certified Nursing Assistant (RCNA), who admitted to not cleaning it despite acknowledging that it should have been cleaned. The Director of Nursing confirmed that the device should have been stored in a plastic bag at the nurse's station and cleaned before and after use. The failure to adhere to these procedures was observed over multiple days, indicating a lapse in following the facility's policy on cleaning and disinfection of resident-care items and equipment. This oversight in infection control measures posed a risk of potential infection and/or the spread of infections among residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Manila
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harris Health And Rehab | 9.6 mi | ★★★★★ | 0 | 0 |
| Monette Manor, Llc | 10.9 mi | ★★★★★ | 11 | 0 |
| Gosnell Health And Rehab | 11.9 mi | ★★★★★ | 6 | 0 |
| Heritage Square Healthcare Center | 13.9 mi | ★★★★★ | 0 | 0 |
| Lakeside Health And Rehab | 16.5 mi | ★★★★★ | 5 | 0 |
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