Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Manning Gardens Care Center, Inc during CMS and state inspections, most recent first.
A resident with significant comorbidities and recent MCA stroke fell and sustained facial injuries when his sock became caught on a lifted floor vent while ambulating to the bathroom. He reported that the vent had been raised for some time and that prior concerns to maintenance had not led to correction. Nursing documentation confirmed the fall, associated facial abrasion, bruising, and nosebleed, and recorded the resident’s statement that his sock got stuck in the vent. The maintenance supervisor later acknowledged that the vent in that room had a lifted corner and that other room vents could lift, move, or crack. A subsequent observation identified multiple rooms with lifted, broken, sharp-edged, or unsecured floor vents, despite facility policies requiring an environment free from accident hazards and a safe, clean, homelike environment.
A resident admitted for short‑term rehab after multiple pelvic and lumbar fractures and recent pelvic fixation surgery was placed in a bed that she reported still had used linens, a blanket, and a pillow with used tissues from a prior occupant, with the bedside drawer and closet containing that prior resident’s belongings and the floor visibly dirty with sticky residue. Another resident in the room stated the bed, closet, and drawer still held the previous resident’s items, and a housekeeper later observed sticky material on the floor and cleaned the room only after the new resident complained. The DSD and other staff acknowledged that the closet and bedside drawer had not been emptied after the prior resident’s discharge and that the bed had been on hold until shortly before the new admission, while facility policies required a clean, sanitary, and orderly environment with clean bed linens and respect for residents’ private space and property.
The facility failed to maintain safe, even doorway transition strips between resident rooms and the hallway, resulting in cracked, uneven, and in one case over-height strips that impeded wheelchair and walker movement. A resident with muscle weakness reported falling and injuring his back when his wheelchair could not clear the raised strip and he attempted to stand and push it backward. Other residents with COPD, dementia, fibromyalgia, sepsis, DM2, and lumbar discitis described difficulty crossing the strips, including wheelchairs spinning or turning and needing staff assistance to enter or exit rooms. CNAs reported that the bumpy strips made it hard to push residents in wheelchairs and shower chairs, especially heavier residents, and that the uneven surfaces could cause falls. The DOM and DSD acknowledged the strips were cracked, uneven, and potentially hazardous, while facility policies and ADA standards required surfaces to be maintained in good repair, free of hazards, and with vertical changes in level not exceeding 1/4 inch.
Discontinued ondansetron for multiple residents was found stored in the med cart even though there were no active orders, and staff stated these meds should have been removed when discontinued. An opened bottle of sterile sodium chloride irrigation labeled DO NOT REUSE was also kept in the treatment cart after opening, despite staff acknowledging it was no longer sterile and should not be reused.
Failure to maintain air gaps at the food prep sink and ice machine was observed when the sink lacked an air gap and the ice machine drain was pushed down into a dirty drain basin. Dietary staff and the CDM stated the sink had not had an air gap for years, the ice machine air gap was not functioning, and there was no facility P&P specific to an air gap.
An LVN gave an insulin injection to a resident and then immediately administered a PO medication without changing gloves or performing hand hygiene. In addition, two residents had unlabeled urinals at bedside that were not marked with the date, room, or bed number, despite facility practice and policy requiring single-resident use and labeling.
A resident with no cognitive impairment and documented preferences for personal appearance and routine was denied access to an iron and hot water for bedside coffee based on generalized safety concerns. Staff said the resident was alert and independent, but there was no individualized assessment of his ability to safely iron or handle hot water, no direct discussion with the resident by the SSD, and no IDT review or care plan documentation addressing his stated preferences.
Failure to document and notify physician during hospital transfer. A resident with alcoholic cirrhosis, ascites, hepatomegaly, and a subdural hematoma was observed with abdominal distention and discomfort, then later transferred to the hospital. The LVN and CS could not find documentation of a head-to-toe assessment, significant change of condition, MD notification, or family notification, despite facility policy requiring physician notification and documentation of changes in condition when a resident is sent to a hospital.
Missing Care Plan After Paracentesis: A resident with alcoholic cirrhosis and ascites was sent to the ED for worsening abdominal discomfort and had 3.7 L removed during a paracentesis, then returned to the facility the same day. Staff confirmed no care plan was initiated for the procedure, and the DON stated care plans should be individualized and created promptly when there is a change of condition.
Vitamin D Lab Order Not Completed: A resident with thyroid cancer, multiple myeloma, aplastic anemia, and Vitamin D deficiency had a physician order for a Vitamin D level that was not completed. The note to the prescriber requested monitoring of Vitamin D therapy, but the LVN, CS, and DON all confirmed no lab result was found and the order was not followed through with the lab.
Failure to Provide Ordered Gravy on a Resident’s Meal Tray A resident with ID and schizoaffective disorder, and no cognitive impairment per BIMS, was served lunch without the 4-oz gravy listed on his meal ticket. CNA did not check the tray before serving, the LVN was unsure the missing gravy was noticed, and the CDM and RD stated the gravy was a documented preference meant to improve moisture and palatability and encourage intake. Facility policy required staff to verify the correct tray and follow resident food preferences.
Excess Residents in Multiple Bedrooms: Surveyors observed that four bedrooms each housed more than four residents, exceeding the room occupancy limit. The report noted that the rooms otherwise had adequate closet and storage space, accessible wheelchair and toilet facilities, sufficient room for nursing care and ambulation, and bedside stands for each resident.
A facility failed to provide at least 80 square feet per resident in eight of 19 multiple resident rooms. During an environmental tour with the MS, the rooms were measured and found not to meet the required minimum square footage, although the MS stated there was sufficient room for nursing care and resident ambulation, and that wheelchairs, toilet facilities, closets, storage space, and bedside stands were available.
Surveyors found that staff improperly disposed of used blue rubber gloves in open personal trash bins at the bedside and mixed them with soiled linen in designated barrels, contrary to facility policy. These actions resulted in contaminated PPE being placed in containers not intended for such waste, exposing residents and staff to potential infection risks. Staff and leadership interviews confirmed that these practices were unacceptable and not in line with infection control protocols.
A resident suffered second-degree burns on her thigh when a CNA spilled hot water from a pitcher obtained from a coffee machine set at 165°F. The resident, who required assistance for transfers and personal hygiene, experienced severe pain and needed hydrocodone for relief. The facility's video surveillance confirmed the CNA's actions, and the incident was recognized as physical abuse due to the unsafe water temperature.
A resident suffered second-degree burns when a CNA provided hot water from a coffee machine, measured at 165°F, which spilled onto the resident's thigh. The facility failed to monitor water temperatures, with the dining room sink also reaching 140°F. Staff were unaware of safe temperature ranges, contributing to the incident.
Two residents in an LTC facility experienced deficiencies in their care plans. One resident's plan lacked assessment and interventions for bed rail use, posing a safety risk. Another resident's plan failed to address edema and brace use, leading to wounds and pain. Staff interviews revealed missing physician orders and inadequate training, resulting in improper care and potential harm.
The facility failed to maintain an effective infection prevention and control program, leading to multiple deficiencies. Staff stored personal items on the ice machine, risking cross-contamination. A resident's feeding tube bottle lacked a start date, and an LVN did not follow proper PPE and hand hygiene protocols. Another LVN failed to sanitize a glucometer properly. Dirty decorations and improper catheter bag placement further increased infection risks.
The facility failed to ensure safe food storage and handling, with perishable food left in a resident's room without proper labeling or refrigeration, an open jar of garlic without an open date, bran muffins missing a labeled date, and dented tomato sauce cans stored for use. These actions violated the facility's policies and posed potential health risks to residents.
The facility failed to maintain an environment free from insects and potential rodent entry, with flies observed in resident rooms, dining areas, and activity rooms, and holes in the laundry room wall. Staff confirmed the persistent issue of flies, posing infection risks to residents. The pest control program was deemed ineffective, with fly traps often unplugged or not working.
A resident with asthma was denied the right to keep her albuterol inhaler at bedside for self-administration, despite having no cognitive impairment and expressing the need due to her condition. The facility staff failed to obtain a doctor's order or assess the resident's ability to self-administer, as required by policy. Interviews revealed a lack of understanding and training among staff regarding the policy on self-administration of medications.
A resident experienced discomfort due to a waffle mattress set to its firmest setting, and staff were not trained to adjust it. Despite the resident's clear complaints, the nursing staff incorrectly relied on maintenance for adjustments, contrary to the facility's expectations and the manufacturer's instructions. This oversight resulted in the resident's discomfort and posed a risk for skin breakdown.
A resident with severe cognitive impairment had bed rails installed without proper assessment, physician order, or consent, posing a risk of entrapment. The facility's policy requiring interdisciplinary assessment and informed consent was not followed, and regular bed rail checks were not conducted.
A facility failed to document the administration of lorazepam, a controlled medication, for a resident with major depressive disorder and adjustment disorder. The LVN responsible admitted to forgetting to record the administration in the Narcotic Binder, which is crucial for ensuring accurate medication dispensing and preventing errors. The oversight was confirmed by another LVN and the DON, highlighting the importance of accurate documentation for controlled substances.
The facility was found to have four rooms with more than the allowed number of residents, each accommodating five residents instead of the maximum four. Despite this, the rooms met the residents' needs, with adequate space and facilities, and did not adversely affect their health and safety.
A facility failed to provide the minimum required square footage per resident in eight multiple resident rooms. During a survey, it was found that rooms did not meet the regulatory requirement of at least 80 square feet per resident. Despite this, the facility maintained that there was sufficient room for nursing care and resident ambulation, with accessible wheelchairs and toilet facilities, adequate closets and storage space, and available bedside stands. The facility requested a waiver to continue, asserting no adverse effects on residents' health and safety.
A resident with a history of hemiplegia and hemiparesis underwent a swallowing evaluation, but the LTC facility failed to obtain the results in a timely manner. The resident, who had a PEG tube, pulled it out and was transferred to the hospital, where it was revealed that a puree diet was recommended. The delay in obtaining the evaluation results was due to a lack of communication and follow-up among staff, placing the resident at risk for inadequate nutritional intake.
Failure to Maintain Safe Flooring Vents Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by not identifying, repairing, or replacing unsecured, lifted, or damaged floor vents in multiple resident rooms. One resident, an older male with complex medical problems and multiple comorbidities, had been admitted for short-term and long-term rehabilitation following a large middle cerebral artery (MCA) stroke that resulted in contralateral paralysis, facial drooping, and speech deficits. On the day of the incident, the resident was observed with a bruise under the left eye and an abrasion on the left cheek and reported that he had fallen in his room when his sock became caught on a lifted floor vent as he attempted to walk to the bathroom. According to the resident, the floor vent in his room had been lifted prior to his fall, and he had previously notified maintenance personnel about the issue, but no action had been taken. He stated that his sock got stuck in the vent, causing him to fall forward and hit his face, resulting in a nosebleed, bruising under the eye, and fear for his safety and eye. The resident reported that after the fall, the maintenance staff entered the room and repaired the vent, and that while staff offered help after the fall, he felt that staff had not cared about his earlier safety concerns when the vent was lifted. He also stated that other rooms in the facility had broken and lifted vents that could lead to injuries to other residents. Nursing documentation for the incident indicated that a nurse entered the resident’s room during the early morning hours to change his G-tube feeding and observed him attempting to use the restroom. The nurse noted the resident falling and found him lying face down on the floor, with a light nosebleed and a 0.5 cm by 0.5 cm abrasion and bruise under the left eye on the cheek. The resident told the nurse that his sock had gotten stuck in the floor vent as he tried to go to the bathroom, and the nurse documented that maintenance was notified to check the vent and that a slip was placed in the maintenance box. The maintenance supervisor later stated that the corner piece of the vent in the resident’s room had lifted and fallen inside the vent and acknowledged that vents on the floor had the potential to lift, move, or crack, creating safety hazards. During a facility-wide observation of rooms, seven rooms were identified with floor vents that were lifted, had broken pieces, sharp corners or edges, or were not secured in place. The director of staff development agreed that these vents could pose safety hazards for residents and staff and stated that, to her knowledge, the vents had been in this condition for a long time and that no residents or staff had previously expressed safety concerns. She also stated that some rooms had solid, secured vent pieces while others did not and was unable to explain the discrepancy. The facility’s policies on Safety and Supervision of Residents and Quality of Life–Home like environment stated that the facility strives to make the environment as free from accident hazards as possible, that safety risks and environmental hazards are to be identified on an ongoing basis through training, monitoring, reporting, and QAPI review, and that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions of the floor vents and the resulting fall demonstrated a failure to adhere to these policies.
Failure to Provide Clean, Prepared Room for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a newly admitted resident. The resident, an adult female admitted for short‑term rehabilitation after a traumatic fall with multiple pelvic and lumbar fractures and recent pelvic fixation surgery, arrived at the facility by medical transport after an eight‑hour ambulance ride. She reported that, despite the facility having more than 24 hours’ notice of her admission, she was placed in a bed that still had used linens and a blanket from the prior resident, with a pillow containing used tissues underneath. She also reported that the bedside drawer and closet contained the previous resident’s personal belongings and that the room’s floor was dirty with sticky residue. The resident stated she was transferred into this bed and remained there for a couple of hours before clean linens were provided and housekeeping cleaned the room. Interviews and observations by multiple staff and another resident corroborated key aspects of these concerns. The Director of Staffing Development acknowledged that the closet and bedside drawer had not been emptied after the prior resident’s discharge and that the floor cleanliness issue was addressed only after the new resident complained. The DSD explained that the bed had been on hold for the previous resident until midnight and that the new resident was admitted to that bed around 6:20 a.m., but she could not verify whether the bed and linens were dirty at the time of admission. The Infection Prevention Nurse stated that she learned the resident was very upset about the dirty bed and sticky floor and confirmed that having dirty floors and beds was not acceptable and could be a potential source of infection. The Business Manager confirmed seeing sticky residue on the floor later that morning and acknowledged that the resident reported belongings from the previous resident in the bedside drawer, though he did not personally inspect the storage areas. Additional interviews further supported that the room and storage areas were not properly prepared before the resident’s admission. A roommate stated she witnessed the new resident being placed in a dirty bed that still contained the prior resident’s belongings and that the closet, drawer, and bed all had items from the previous resident, whose bed was being held. Housekeeping staff described the facility’s usual room turnover process, in which CNAs are expected to strip the bed and remove personal belongings so housekeeping can disinfect the bed, clean the floor, and clean storage areas once emptied. One housekeeper, who worked the morning of the admission, stated that when she entered the room after the resident’s arrival, the resident complained about a dirty bed, dirty floor, and belongings in the closet and drawer; the housekeeper observed sticky material on the floor and then cleaned the room. Another RN acknowledged seeing items in the closet and directing a CNA to empty it for the new resident’s use. The administrator later stated that if a bed was on hold, personal belongings and drawers would not be cleared and housekeeping would not clean those areas, but the bed itself should still be cleaned after transfer or discharge, and he conceded that this admission was an unusual circumstance and that staff may not have realized the previous resident’s belongings needed to be removed before admitting the new resident. The facility’s own policies required a safe, clean, sanitary, and homelike environment, including clean bed and bath linens, and emphasized resident dignity, respect for private space and property, and maintenance of a safe, sanitary, and comfortable environment to prevent and manage transmission of infections. Despite these policies, the resident was admitted to a room where the bed, linens, floor, and storage areas were not confirmed to have been cleaned or cleared between residents, and multiple interviews confirmed that personal belongings from the prior resident remained in the closet and bedside drawer at the time of admission. These actions and inactions led to the cited deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment and to receiving treatment and supports for daily living safely.
Cracked, Uneven Doorway Transition Strips Create Mobility Hazards
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple transition strips between resident rooms and the hallway were cracked, uneven, and in at least one case higher than the ADA standard. Observations showed that the transition strip at one room entrance was approximately 0.5 inches high and made of wood, exceeding the 0.25-inch maximum vertical change allowed by ADA standards, while other strips were cracked and uneven. The Director of Maintenance confirmed that the transition strips to rooms 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were high, uneven, cracked, and could be difficult for residents to pass safely. The facility’s own policies required the environment to be free from accident hazards and the building to be maintained in good repair and free from hazards, but these conditions persisted. One resident reported a fall that occurred approximately one month prior while attempting to exit his room in a wheelchair. This resident, who had diagnoses including Hepatitis C, Coccidioidomycosis, and muscle weakness and a BIMS score of 15, stated he could not push his wheelchair over the “lip” at the doorway. He described turning and attempting to stand to push the wheelchair backward over the transition strip, at which point the wheelchair moved and he lost his balance, falling onto his bottom and injuring his back. He indicated that he routinely propelled himself backward in the wheelchair to get over the transition strip because the larger back wheels made it easier to cross the uneven surface, and he pointed out that the strip at his doorway was cracked and uneven. Other residents and staff corroborated that the transition strips created difficulty and potential for loss of control when moving in and out of rooms. One resident with COPD, hypertensive heart disease, dorsalgia, dementia, and a BIMS score of 11 stated that the transition strip at his room made it difficult to enter and exit and sometimes caused his wheelchair to spin or turn as he crossed it. Another resident, who used a wheelchair for seven years due to fibromyalgia and had diagnoses including sepsis, type 2 diabetes, cellulitis, and hypertensive heart disease, stated that while she could manage the strip herself, she had observed other residents going backward in their wheelchairs to cross the strips, which she believed could cause a fall, and noted that shuffling residents could trip on cracked, uneven strips. A fourth resident, with diagnoses including lumbar discitis, sepsis, type 2 diabetes, and a cutaneous abscess of the back and a BIMS score of 13, reported being unable to get past the transition strip at her doorway with a walker or wheelchair and having to call staff for assistance. Staff interviews further described the impact of the defective transition strips on resident mobility and safety. A CNA stated that pushing residents in wheelchairs over the bumpy transition strips was difficult and that some strips were more cracked and uneven than others and could cause a fall. Another CNA reported that the strips made it difficult to push residents in both wheelchairs and shower chairs, noting that the small, hard wheels of shower chairs made crossing the strips more difficult and that going backward in a wheelchair could cause it to tilt backward. This CNA also stated that the uneven strips could cause a fall when moving forward in a wheelchair or shower chair and that assisting heavier residents over the strips was more difficult and carried a higher risk of falling. The Director of Staff Development, after observing the strips to the identified rooms, stated that they were cracked and uneven, could be a fall hazard, and that the strips should be flat, smooth, and even so residents and staff could pass without difficulty. Despite these observations and statements, the Administrator asserted that the transition strips were not hazardous and attributed the reported fall to the resident’s choice to go backward in his wheelchair, while also acknowledging that the facility should provide a safe, functional, sanitary, and comfortable environment. The facility’s written policies on Safety and Supervision of Residents and Maintenance Service required ongoing identification of safety risks and environmental hazards, QAPI review of safety and incident data, and maintenance of the building in good repair and free from hazards. The ADA standards referenced in the report required floor surfaces to be stable, firm, slip resistant, and limited vertical changes in level to a maximum of 1/4 inch. The presence of cracked, uneven, and in at least one case over-height transition strips at multiple room entrances, combined with resident and staff reports of difficulty, loss of control, and a documented fall associated with these strips, demonstrate that the facility did not adhere to these standards and policies in maintaining the environment.
Discontinued Medications Left in Cart and Opened Sodium Chloride Reused
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted standards when discontinued ondansetron tablets for three residents were found in the East Station medication cart despite no active orders. During observation of the cart, individually packaged ondansetron ODT 4 mg bubble packs labeled for specific residents were present. Review of the electronic health records and MARs showed that one resident’s ondansetron had been discontinued on 12/2/25, and two other residents did not have active orders for the medication. The LVN stated the medications should have been removed from the cart as soon as the orders were discontinued and acknowledged that keeping them there created a risk of medication error. The facility’s records also showed that one resident’s ondansetron had been received from the pharmacy after the resident refused it, and the physician later ordered it to be discarded. The DON stated discontinued medications should not remain in medication carts. Facility policies titled Storage of Medications and Discontinued Medications stated discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. An opened 100 mL bottle of sterile sodium chloride irrigation solution labeled DO NOT REUSE was observed stored in the [NAME] Treatment Cart after it had been opened. The treatment nurse stated she opened the bottle, poured the needed amount into a medication cup, recapped it, and kept it for up to 24 hours, even though she acknowledged the bottle was no longer sterile once opened and that reuse could lead to contamination. The infection preventionist and DON both stated the bottle should not be reused if the label said do not reuse. The package insert stated that after opening, the contents should be used promptly and unused portions discarded because the solution contains no preservatives.
Failure to Maintain Air Gaps at Food Prep Sink and Ice Machine
Penalty
Summary
The facility failed to ensure safe, sanitary food preparation practices were followed in the kitchen when the food preparation sink did not have an air gap and the ice machine in the dining room did not have a functioning air gap. During the initial kitchen tour, the food preparation sink was observed without an air gap, and the ice machine’s drain basin was observed to be dirty. Dietary staff stated she was not aware the ice machine did not have a functioning air gap and said the Certified Dietary Manager was responsible for cleaning the ice machine, but she was unsure whether the drain basin was also cleaned. During a later observation, the Certified Dietary Manager stated the food preparation sink had not had an air gap since she assumed her position four years earlier and said the facility had been working on it for almost two years. She also stated she was responsible for deep cleaning the ice machine monthly and had not noticed that the drain tube had been pushed down past the grill covering the drain basin. The Maintenance Supervisor confirmed the drain from the ice machine was pushed down at least four inches past the grill and stated there should have been at least a two-inch gap between the drain pipe and the drain basin. The facility had no specific policy and procedure for an air gap.
Infection Control Lapses During Medication Administration and Urinal Labeling
Penalty
Summary
LVN 3 administered an insulin injection into Resident 33’s abdomen and then immediately prepared and gave the resident a PO gabapentin medication without changing gloves or performing hand hygiene. The observation occurred during a medication pass, and the LVN later stated he should not have given the insulin injection first and should have changed gloves or done hand hygiene after the injection because the abdomen was considered a dirty area and there was a possibility of contact with the resident’s blood. During interview, the Infection Preventionist stated the LVN should have changed gloves or performed hand hygiene when moving from an injection to a PO medication, and that the insulin injection site in the abdomen was considered a dirty area. The Infection Preventionist stated pathogens could have traveled to the resident’s mouth during administration of the PO medication and that nurses should never go from a dirty to clean area because it could cause cross contamination. The DON also stated nurses should know when to perform hand hygiene or change gloves when giving medications and that following proper infection control standards was important to stop cross contamination. Urinals for Resident 13 and Resident 64 were observed hanging on the side of bedside garbage cans with urine in them and no lids, and neither urinal had a label with the date, room, or bed number. Both residents had BIMS scores of 15 out of 15, indicating no cognitive deficit. Staff interviews confirmed the urinals should have been labeled with the date, room number, and bed number and changed every seven days or as needed. The facility’s policy stated bedpans and urinals are for single resident use only, must be discarded every seven days or when damaged, and must be labeled with room number and date.
Resident Preferences for Ironing and Hot Water Denied Without Individualized Assessment
Penalty
Summary
The facility failed to promote and facilitate one resident’s right to self-determination when it denied his requests to use an iron to press his clothes and to receive hot water in his room to make instant coffee. The resident had diagnoses of protein-calorie malnutrition and esophageal obstruction, and his MDS showed a BIMS score of 15, indicating no cognitive impairment. He told surveyors that he woke around 5:00 a.m., wanted coffee at that time, and felt frustrated and punished when he could not get it. He also stated that personal appearance was important to him and that he had previously been allowed to iron his clothes during an earlier stay at the facility. The resident reported that after his readmission, staff removed the iron from his closet and told him he could no longer have one. He said he asked to iron his clothes in the laundry room, but that request was denied because of liability concerns. He also reported that hot water had previously been available but was later discontinued, and that when he requested hot water before 7:00 a.m., staff told him he would have to wait until 7:00 a.m. He stated the water provided was barely warm and did not dissolve powdered creamer well. Staff interviews showed that the resident was described as alert and independent, with staff acknowledging that he attempted to complete his own care. CNA and LVN staff stated residents were not permitted to have an iron at bedside and that hot water could not be provided because of safety concerns and kitchen timing. The SSD stated the resident’s family had been told he would not be permitted to iron due to safety concerns, but she did not discuss the issue directly with the resident. She also stated there was no documentation in the record of the resident’s preference for ironing or of the incident involving the iron. The CS and DON stated the resident had not been assessed for his ability to iron or for safely handling hot water, that such requests should have been reviewed by the IDT, and that there were no IDT notes or care plan entries addressing these preferences. The resident’s MDS preferences indicated that choosing what clothes to wear was very important to him, and his MDS functional assessment showed no impairment or functional limitation in upper or lower extremity range of motion.
Failure to Document and Notify Physician During Hospital Transfer
Penalty
Summary
The facility failed to follow its policy on change in a resident's condition or status for Resident 17 when the resident was transferred to a general acute care hospital on 12/17/25. Resident 17's admission record showed diagnoses including alcoholic cirrhosis of the liver with ascites, hepatomegaly, and subdural hematoma. During an observation and interview on 12/16/25, Resident 17 was noted to have a rounded abdominal area and appeared uncomfortable while sitting at the edge of the bed. The resident stated she was uncomfortable because of her abdomen, said the hospital had not been able to drain fluid when she was sent out on 12/13/25, and reported that her abdomen was becoming uncomfortable and it was hard to sleep at night. During record review and interviews on 12/19/25, the assigned LVN stated she could not find documentation of Resident 17's assessment or physician notification and said the usual practice was to document a complete head-to-toe assessment, MD notification, and the reason for transfer. The CS also stated there was no nursing progress note, no documented significant change of condition assessment, and no documentation that the MD or family were notified of the transfer to the hospital. The DON stated her expectation was that the nurse document the resident's condition and vital signs at the time of transfer and notify the family and MD when sending a resident to the hospital. The facility policy required the nurse to notify the attending physician or physician on call when there was a need to transfer the resident to a hospital or treatment center and to record information related to changes in the resident's medical or mental condition or status.
Missing Care Plan After Paracentesis
Penalty
Summary
A comprehensive, person-centered care plan was not developed and implemented for Resident 17 to address the needs related to a paracentesis procedure performed at the general care hospital. Resident 17 was admitted to the facility with diagnoses including alcoholic cirrhosis of the liver with ascites, hepatomegaly, and subdural hematoma. Her MDS assessment showed a BIMS score of 15 out of 15, indicating no cognitive deficit. On 12/17/25, Resident 17 was sent to the emergency department for further evaluation and treatment because her abdomen was becoming too uncomfortable, and 3.7 liters of fluid were removed during the paracentesis. She returned to the facility the same day. During record review and staff interviews, Licensed Vocational Nurse 5 stated there was no care plan initiated for Resident 17's paracentesis procedure. Licensed Vocational Nurse 3 also confirmed the clinical record showed no care plan had been created when Resident 17 was sent out and had the procedure performed. The Director of Nursing stated charge nurses were expected to create care plans and that care plans should be individualized and created as soon as possible when there was a change of condition. The facility policy for comprehensive, person-centered care plans stated they should include measurable objectives and timeframes, describe services to be furnished, incorporate identified problem areas and risk factors, and reflect treatment goals, timetables, and objectives.
Vitamin D Lab Order Not Completed
Penalty
Summary
The facility failed to meet professional standards of practice for one sampled resident when a physician order to check a Vitamin D level was not carried out and nursing staff did not follow up. Resident 41 was admitted with diagnoses including malignant neoplasm of the thyroid gland, multiple myeloma, aplastic anemia, and Vitamin D deficiency. The resident’s order summary showed an oral Vitamin D medication order for 2 tablets daily related to Vitamin D deficiency, and the resident’s MDS indicated a BIMS score of 15 out of 15, showing no cognitive deficit. A note to the attending physician/prescriber documented that the resident was receiving Vitamin D and that a Vitamin D level should be ordered on the next lab day to monitor therapy. During interview and record review, the LVN stated the nurse supervisor was responsible for carrying out pharmacy recommendations and could not find a Vitamin D lab result, while the CS stated there was an order to check the Vitamin D level but no laboratory result was found. The CS stated the order should have been completed because lab draws were available in the facility three times a week, and the DON stated the Vitamin D level was not done and should have been. The DON also stated the order had been entered but the laboratory was not contacted.
Failure to Provide Ordered Gravy on Resident Meal Tray
Penalty
Summary
The facility failed to provide food in accordance with a resident’s preferences when Resident 7 was served lunch without the four-ounce gravy that was listed on his meal ticket. Resident 7 had diagnoses including intellectual disability, schizoaffective disorder, and dysphagia, and his MDS showed a BIMS score of 14, indicating no cognitive impairment. During observation in the dining room, he was served minced meat, minced green vegetables, minced bread, and drinks, but no gravy was present, and he began eating without responding to questions. During interview and record review, CNA 2 stated the gravy should have been included on Resident 7’s tray but was not, and she had not checked the tray before serving it. LVN 4 stated she checked meal trays before service but was not sure she noticed the missing gravy, and said gravy should have been included if listed on the diet slip. The CDM stated Resident 7 was supposed to receive gravy as a preference to add moisture and improve palatability, but it was missed by dietary staff and not noticed by the nurse or CNA. The RD stated gravy was ordered to encourage residents to eat and that Resident 7’s food preference should have been followed. Facility policy required nursing personnel to ensure residents were served the correct tray and to check the tray card before serving, and also required staff to identify and document resident food preferences.
Excess Residents in Multiple Bedrooms
Penalty
Summary
The facility failed to ensure each bedroom accommodated no more than four residents per room for four of 19 rooms, specifically rooms 1, 2, 5, and 6. During the initial tour on 12/19/25 at 9:13 a.m., surveyors observed that these bedrooms each had more than four residents. The report states that although the rooms housed more than four residents, each room met the particular needs of each resident, with adequate closet and storage space, accessible wheelchair and toilet facilities, sufficient room for nursing care and resident ambulation, and bedside stands available for each resident. The report also states that the health and safety of residents would not be adversely affected by the continuance of the waiver.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in eight of 19 multiple resident rooms, specifically rooms 1, 2, 5, 6, 9, 10, 11, and 12. During a concurrent observation and interview with the Maintenance Supervisor, an environmental tour was conducted and the rooms were measured. The Maintenance Supervisor stated that the rooms did not meet the minimum square footage of 80 square feet per resident required by regulation. The report also noted that there was sufficient room for nursing care and resident ambulation, wheelchairs and toilet facilities were accessible, closets and storage space were adequate, and bedside stands were available.
Improper Disposal of Used PPE and Soiled Linen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper disposal of used blue rubber gloves and mixing of soiled linen with waste products. Surveyors observed that personal trash bins without lids, located at the bedsides of five residents, contained used blue rubber gloves. These bins were intended for residents' personal use and not for the disposal of contaminated personal protective equipment (PPE). Staff members, including CNAs, were observed or reported to have discarded used gloves in these open bins after providing care, despite facility policy requiring such items to be disposed of in lidded bins or designated containers. Further observations revealed that two of six large yellow barrels labeled for soiled linen in the east hall also contained used blue rubber gloves, sometimes mixed directly with soiled linen and without proper containment. Staff interviews confirmed that soiled linen barrels were dedicated for linen only, and that used PPE should be contained in plastic bags and discarded in gray bins with lids. Laundry staff reported having to separate trash from soiled linen, increasing their exposure to contamination. The improper disposal practices were acknowledged as unacceptable by the Infection Preventionist, Director of Maintenance, DON, and Administrator during interviews. The report included specific details about a resident who was admitted after back surgery and later transferred to the hospital with an infection. This resident witnessed a CNA discarding used gloves with stool into her personal trash bin, which did not have a lid, resulting in direct contact with contaminated material. The facility's policies and procedures, as well as CDC guidelines, were reviewed and found to require proper containment and disposal of infectious waste, which was not followed in these instances.
Resident Suffers Burns Due to Hot Water Spill
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) spilled hot water onto the resident's left thigh, resulting in second-degree burns. The incident occurred when the resident requested hot water to wash her face, and the CNA brought a pitcher filled with hot water from the kitchen's coffee machine, which was set at 165 degrees Fahrenheit. The CNA placed the pitcher on the bedside table without a lid, and when the table was moved, the pitcher tipped over, spilling the hot water onto the resident's thigh. The resident, who had a history of a right femur fracture and an unspecified open wound on the left lower leg, experienced severe pain and required hydrocodone for pain management. The resident's cognitive status was assessed as minimally impaired, with a Brief Interview for Mental Status (BIMS) score of 15. The resident was dependent on assistance for transfers and personal hygiene, which contributed to her vulnerability during the incident. The facility's video surveillance confirmed that the CNA obtained the hot water from the coffee machine, contrary to her initial statement that it was from the dining room sink. The dining room sink's hot water was also found to be out of the acceptable temperature range, reaching 140 degrees Fahrenheit. The Director of Nursing and the Administrator acknowledged that the water temperatures exceeded the safe limit of 120 degrees Fahrenheit, which could cause skin injury, and recognized the incident as physical abuse due to the exposure to scalding hot water.
Unsafe Water Temperatures Lead to Resident Burn Injury
Penalty
Summary
The facility failed to maintain a safe environment for residents by not ensuring that water temperatures were within a safe range, leading to an accident involving a resident. A Certified Nursing Assistant (CNA) provided a resident with hot water from a coffee machine, which was measured at 165 degrees Fahrenheit, significantly above the safe limit of 120 degrees Fahrenheit. This hot water was placed in a pitcher without a lid on the resident's bedside table, and when the table was moved, the pitcher tipped over, spilling the scalding water onto the resident's left thigh, resulting in second-degree burns. The Maintenance Supervisor was unaware of the unsafe water temperatures in the dining room sink, which was measured at 140 degrees Fahrenheit. The facility's policy did not specify how often water temperatures should be monitored and documented, leading to a lack of oversight and control over water temperature safety. Staff members, including CNAs and Licensed Vocational Nurses (LVNs), were not aware of the acceptable water temperature range and the potential for burns, indicating a gap in training and communication regarding safety protocols. The resident involved in the incident had a history of a right femur fracture and an unspecified open wound on the left lower leg. At the time of the incident, the resident was dependent on assistance for transfers and personal hygiene. The resident experienced severe pain from the burns, requiring the administration of hydrocodone. The facility's failure to monitor and control water temperatures, combined with inadequate staff training, directly contributed to the resident's injury.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to significant deficiencies in their care. For Resident 1, the care plan did not include an assessment or interventions for the use of bed rails, which are considered a restrictive device. This oversight was identified during an observation where bed rails were raised on both sides of the resident's bed without any documented physician orders, consent, or a care plan addressing their use. The Licensed Vocational Nurse (LVN) acknowledged the absence of necessary documentation and stated that bed rails could be unsafe if not properly assessed, potentially putting the resident at risk of harm. Resident 3's care plan was also found lacking, as it did not address the resident's edema or the use of a brace for the right leg. This deficiency was highlighted during observations and interviews where the resident reported pain and wounds caused by the brace. The Certified Nursing Assistant/Rehabilitation Nurse Assistant (CNA/RNA) and Clinical Supervisor Nurse (CSN) noted the improper application of the brace and inadequate wound care, which led to a bleeding wound on the resident's ankle. The Treatment Nurse (TN) was unaware of the resident's wounds until the issue was brought to attention, indicating a lack of communication and monitoring. Interviews with various staff members, including the Director of Nursing (DON) and the Physical Therapist (PT), revealed that there were no physician orders or care plans in place for the use of the brace, and nurses had not received training on its application. The DON confirmed that the wound was avoidable and emphasized the importance of having a care plan to monitor the resident's condition and ensure proper care. The facility's policies and procedures were not followed, resulting in inadequate care and potential harm to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies. Staff were observed storing personal lunch bags and a drink canister on top of the dining room ice machine, contrary to the facility's policy. This practice posed a risk of cross-contamination and exposure to foodborne illnesses for residents, staff, and visitors. Additionally, a resident's feeding tube bottle was not labeled with a start date, which could lead to the administration of expired nutrition, increasing the risk of infection. In another instance, an LVN did not adhere to proper procedures for donning PPE and performing hand hygiene while providing care to a resident on enhanced barrier precautions. The LVN also placed supplies on an unclean windowsill and failed to clean a feeding pump, which could lead to cross-contamination and infection. Furthermore, another LVN did not follow hand hygiene protocols before checking blood sugar levels for two residents and did not properly sanitize the glucometer, risking cross-contamination. Additional observations included dirty Halloween decorations on a dining table where a resident was eating, and a resident's urine catheter bag placed on their lap during a meal, both of which were against infection control practices. These actions increased the risk of infection due to cross-contamination. The facility's policies and procedures were not followed, leading to potential health risks for the residents.
Food Storage and Labeling Deficiencies in Facility
Penalty
Summary
The facility failed to ensure the safe storage and handling of food in several instances, leading to potential health risks for residents. In Resident 105's room, perishable food brought by family members was left on the bedside table without proper labeling or refrigeration, contrary to the facility's policy. The food, which included stew and a bread product, was brought in hot but had become cold, and there was no indication of when it was brought in or when it should be consumed by. Interviews with staff, including a Registered Nurse, Licensed Vocational Nurse, Interim Dietary Manager/Registered Dietician, Director of Nursing, and Infection Preventionist, revealed that the facility's policy for handling food brought by family members was not followed, posing a risk of foodborne illness to the resident. In the kitchen, an open jar of garlic was found without an open labeled date, which is required to track the shelf-life and ensure it is not used beyond its expiration. The Dietary Manager and Interim Dietary Manager/Registered Dietician acknowledged that the lack of labeling could lead to the use of expired food, increasing the risk of foodborne illness and cross-contamination. The facility's policy on sanitation and infection control mandates that all perishable food items be properly labeled and dated, which was not adhered to in this case. Additionally, a case of bran muffins was found in the refrigerator with a missing labeled date, and two dented tomato sauce cans were stored in the pantry for use instead of being set aside for return or disposal. The absence of proper labeling on the bran muffins could lead to serving expired items, while the dented cans pose a risk of bacterial contamination, including botulism. The facility's policy requires that frozen foods be labeled with the date they were placed in the freezer and that canned goods be inspected for damage and set aside if compromised, which was not done, further endangering resident safety.
Insect and Rodent Control Deficiencies
Penalty
Summary
The facility failed to maintain an environment free from insects and potential rodent entry, as evidenced by the presence of flies in resident rooms, dining areas, and activity rooms, as well as holes in the laundry room wall that could allow rodents to enter. Observations revealed flies in Resident 40's room, who was unable to move due to a tumor on her leg, and in the dining room where an inoperable fly trap was noted. Interviews with staff, including CNAs and the Director of Nursing, confirmed the persistent issue of flies, which posed a risk of infection to residents. Resident 23, who was moderately cognitively impaired, also experienced flies in his room, with a fly swatter present on his nightstand. Staff interviews indicated that flies were a common problem, particularly during the summer, and that fly traps and fans were used to mitigate the issue. However, the pest control program was deemed ineffective, as confirmed by the Maintenance Supervisor, who noted that fly traps were often unplugged or not working. In the activities room, flies were observed landing on residents' food and on the residents themselves during restorative dining. The Maintenance Assistant confirmed that the bug light in the room was not functioning. Additionally, holes in the laundry room wall were identified as a potential entry point for rodents, which could lead to cross-contamination and infection risks. The Maintenance Supervisor acknowledged the need for repairs and the inadequacy of the current pest control measures.
Failure to Allow Self-Administration of Medication
Penalty
Summary
The facility failed to uphold a resident's right to self-administer medications, specifically an albuterol inhaler, which the resident wanted to keep at her bedside. The resident, who had been diagnosed with asthma and traumatic pneumothorax, expressed her desire to have the inhaler nearby due to her condition that made breathing difficult at times. Despite having no cognitive impairment, as indicated by a BIMS score of 15, the resident's request was denied by the nursing staff, who informed her that she was not allowed to keep medications in her room. This decision was made without obtaining a doctor's order or assessing the resident's ability to self-administer the medication, as required by the facility's policy. Interviews with staff revealed a lack of understanding and training regarding the facility's policy on self-administration of medications. A CNA confirmed hearing the resident's request and the subsequent denial by nurses, while an LVN admitted to being unaware of the policy allowing residents to keep medications at bedside. The Director of Nursing acknowledged that residents could store medications at bedside if deemed clinically appropriate and safe by the interdisciplinary team, which had not been done in this case. The facility's policy outlined the need for a comprehensive assessment by the interdisciplinary team to determine a resident's capability to self-administer medications, which was not conducted for this resident.
Failure to Adjust Pressure Relief Mattress Leads to Resident Discomfort
Penalty
Summary
The facility failed to meet professional standards of practice for a resident, identified as Resident 40, who reported discomfort with her waffle mattress, a pressure relief mattress overlay. The mattress was set to its firmest setting, which made the resident feel hot and uncomfortable. Despite the resident's complaints, the staff, including a CNA, RN, and LVN, were unaware of how to adjust the mattress to improve comfort, as they had not been trained on its use. The resident, who was admitted with a diagnosis of a mass/lump on her right lower limb and morbid obesity, was cognitively intact and expressed her discomfort clearly. The physician had ordered an alternating pressure mattress to prevent skin breakdown, but the staff did not follow the instructions provided in the owner's manual for adjusting the mattress. The manual outlined a method for checking and adjusting the mattress firmness to ensure optimal pressure redistribution and resident comfort. Interviews with various staff members, including the Maintenance Supervisor, Director of Staff Development, and Director of Nursing, revealed a lack of training and understanding regarding the operation of the waffle mattress. The nursing staff incorrectly relied on maintenance for adjustments, contrary to the facility's expectations and the manufacturer's instructions. This oversight resulted in the resident's discomfort and posed a risk for skin breakdown.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the risk of entrapment from bed side rails. The resident, who was severely cognitively impaired with a BIMS score of 3, had bed rails installed without a documented assessment, physician order, or consent. The resident's medical records lacked a care plan for the use of bed rails, and there was no indication for their use. This oversight had the potential to cause serious harm, injury, or death to the resident. During an observation, the resident was found sleeping with bed rails raised at the head of the bed, and fall mats were placed on both sides. However, the facility's policy required an interdisciplinary assessment and informed consent before the use of bed rails, which was not followed. The Licensed Vocational Nurse confirmed that there were no orders, care plans, or assessments documented for the use of bed rails, and acknowledged that bed rails are considered a restrictive device that could be unsafe if not properly assessed. The Maintenance Supervisor admitted that no regular bed rail checks were conducted, and there was no log of such checks. The maintenance department relied on CNAs or nurses to report any issues with bed rails, which were then addressed. The facility's policy emphasized the need for regular inspections and assessments to prevent injuries from bed-related equipment, but these procedures were not implemented, leading to the deficiency.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident when a controlled medication, lorazepam, was administered but not documented on the controlled substances count sheet. This oversight occurred during an observation where it was noted that the lorazepam administration at 8:00 a.m. was not recorded in the Narcotic Binder. The Licensed Vocational Nurse (LVN) responsible admitted to forgetting to document the administration, which is a critical step to ensure accurate dispensing and prevent potential medication errors. The resident involved had been admitted with diagnoses of major depressive disorder and adjustment disorder. The failure to document the administration of lorazepam, a medication used to manage anxiety and maintain calmness, posed a risk of double dosing and potential side effects. Interviews with another LVN and the Director of Nursing confirmed the importance of maintaining accurate records for controlled substances to prevent theft and ensure proper medication administration.
Excessive Resident Occupancy in Rooms
Penalty
Summary
The facility failed to ensure that each bedroom accommodated no more than four residents in four of the 19 rooms surveyed. Specifically, rooms 1, 2, 5, and 6 each contained five residents, exceeding the maximum allowed occupancy. This was observed during the survey conducted from November 5 to November 8, 2024. Despite the excess number of residents, the report notes that each room met the particular needs of the residents, providing adequate closet and storage space, accessible wheelchair and toilet facilities, sufficient room for nursing care, and space for residents to ambulate. Bedside stands were available for each resident, and the health and safety of residents were not adversely affected by the continuance of this waiver.
Deficiency in Room Square Footage
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in eight of 19 multiple resident rooms during a survey conducted from 11/5/24 through 11/8/24. Specifically, rooms 1, 2, 5, 6, 9, 10, 11, and 12 did not meet the regulatory requirement of at least 80 square feet per resident. This deficiency was identified during an observation and interview with the Maintenance Supervisor, who confirmed that the rooms did not meet the minimum square footage per resident. Despite this, the facility maintained that there was sufficient room for nursing care and resident ambulation, with accessible wheelchairs and toilet facilities, adequate closets and storage space, and available bedside stands. The facility requested that a waiver continue in effect, asserting that the waiver would not adversely affect the health and safety of residents.
Failure to Implement Recommended Diet Plan
Penalty
Summary
The facility failed to implement the recommended diet plan for a resident who underwent a swallowing evaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with a PEG tube for nutritional intake. Despite undergoing a swallowing evaluation on May 2, 2024, the facility did not obtain the results until May 17, 2024, after the resident had pulled out the PEG tube and was transferred to the hospital. The hospital informed the resident's responsible party that the resident had passed the evaluation and recommended a puree diet. The delay in obtaining the swallowing evaluation results was attributed to a lack of communication and follow-up among the facility's staff. The RN assigned to the resident on the day of the evaluation informed the Director of Social Services that the hospital would fax the results, but no follow-up was conducted to ensure the results were received. The Director of Medical Records was not aware of the evaluation, and the facility's policy required the charge nurse to communicate with Medical Records to obtain necessary documents. The Director of Nursing and the Administrator acknowledged the failure to follow up on the evaluation results, which was against the facility's policy. The resident's condition at the time of the deficiency included severe cognitive impairment, requiring extensive assistance with daily activities, and the need for a puree diet as recommended by the swallowing evaluation. The facility's failure to obtain and implement the evaluation results in a timely manner placed the resident at risk for inadequate nutritional intake and potential aspiration. The facility's policy and procedure required obtaining follow-up paperwork for residents returning from appointments, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 359 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyards At Fowler | 4.7 mi | ★★★★★ | 25 | 0 |
| Fowler Care Center | 6.4 mi | ★★★★★ | 2 | 0 |
| Grace Healthcare Center | 6.4 mi | ★★★★★ | 33 | 0 |
| Rolling Hills Care Center | 8.1 mi | ★★★★★ | 21 | 0 |
| Sierra Vista Healthcare | 8.3 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Manning Gardens Care Center, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.