Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Grace Manor Care Center during CMS and state inspections, most recent first.
Infection control failures occurred when a housekeeper sprayed disinfectant on a sink and bedside tables without allowing the required dwell time and while resident personal items remained on the sink, then another housekeeper moved between rooms and between dirty and clean tasks without proper hand hygiene or glove changes. An LPN also cleaned a resident’s wound and then applied a dressing without changing gloves or performing hand hygiene between the dirty wound care and the clean dressing application.
Failure to assess and secure self-administered medications: A cognitively intact resident with diabetes, CHF, and CKD had multiple medications at the bedside, including eye drops, dry mouth spray, and antibiotic cream, but the chart had no assessment, no provider order, and no care plan for self-administration. The resident said she had been approved to use the medications, while the DON stated the provider had not ordered self-administration and that over-the-counter medications had been brought in and confiscated.
Failure to Consistently Implement Fall Interventions: A resident with dementia, vision loss, weakness, and unsteadiness had repeated unwitnessed falls, yet planned fall interventions were not consistently followed. Observations showed the resident was left without water in the locations specified by the care plan and was not offered toileting around the scheduled time, while staff described the resident as confused and at high fall risk. Record review showed multiple prior falls and changing interventions, but the resident later reported crawling to reach water, and only one water cup was observed instead of the two directed by the care plan.
The facility failed to ensure proper storage and labeling of medications in two medication carts and one medication room. Loose medication tablets were found in the carts, and expired Tylenol suppositories were found in the medication room. The DON confirmed that there was no formal cleaning schedule, and nurses were responsible for maintaining cleanliness and checking for expired medications.
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not having a wound care order in place prior to treatment. The resident, who had a history of falling and other medical conditions, sustained an abrasion to his right elbow following an unwitnessed fall. Despite the injury, there were no treatment orders documented, and the dressing on the wound had not been changed since the fall. Staff interviews confirmed the absence of a physician's order for treating the wound and monitoring for infection.
Infection Control Failures During Room Cleaning and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program on two units when housekeeping staff did not follow the correct disinfectant dwell time and did not protect resident personal items during room cleaning. During observation, a housekeeper placed cleaning supplies outside a resident room, donned gloves, entered the room, removed trash from the bathroom and bedside trash cans, and then sprayed disinfectant on the sink and bedside tables while a stack of clean washcloths and a toothbrush remained on the sink. The housekeeper immediately wiped the surfaces instead of allowing the disinfectant to remain wet for the required dwell time. Facility staff interviews confirmed that the disinfectant was intended to be sprayed on surfaces and left wet for the required time before wiping, and that personal items should be removed before spraying because residue could get in a resident’s mouth. The housekeeping supervisor stated the product had a three-minute dwell time and that all personal items should be removed before spraying chemicals. The DON also stated resident belongings should be removed before spraying so the chemical did not get in the resident’s mouth or on their face. The facility also failed to ensure housekeeping staff performed hand hygiene and changed gloves appropriately while cleaning resident rooms. During observation, a housekeeper finished one room, moved to another room without performing hand hygiene, donned clean gloves, cleaned the bathroom, then continued into the bedroom without changing gloves or performing hand hygiene after cleaning the dirty bathroom area. The housekeeper handled personal items and cleaned linen areas after working in the bathroom, and later removed soiled gloves without performing hand hygiene. The housekeeping supervisor stated staff should perform hand hygiene after each room and change gloves and wash hands between cleaning areas to prevent cross contamination. The facility further failed to ensure proper hand hygiene and glove changes during wound care. An LPN washed her hands, donned clean gloves, and cleaned a resident’s wound area while the resident was receiving perineal care from two CNAs. After cleaning the dirty wound area, the LPN applied betadine, calcium alginate, and a foam dressing without changing gloves or performing hand hygiene between the dirty wound cleansing and the clean dressing application. The DON stated gloves should be changed and hand hygiene completed after removing the soiled dressing and after the wound is cleansed.
Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for one resident who was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including type 2 diabetes, chronic heart failure, and chronic kidney disease. The facility policy stated that residents may self-administer medications only after the interdisciplinary team determines it is clinically appropriate and safe, with the decision documented in the medical record and care plan, and that self-administered medications must be stored in a safe and secure place not accessible by other residents. For this resident, surveyors observed multiple medications at the bedside, including a bottle of eye drops, dry mouth spray, and triple antibiotic cream, and the resident stated she had been approved by the doctor and nurses to use them because of dry eyes, nose, and mouth. Record review showed no assessment for self-administration, no physician order for self-administration, and no care plan addressing it. The DON stated the resident had over-the-counter medications in the room on admission, that the provider did not order self-administration, and that the medications were confiscated; she also stated the resident’s son later brought in more over-the-counter medications, which were again confiscated.
Failure to Consistently Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and consistent implementation of person-centered fall interventions for one resident who had repeated falls. The resident was over age 65 and had diagnoses including Friedreich ataxia, muscle weakness, unsteadiness on feet, dementia, and macular degeneration. The resident’s MDS showed moderate cognitive impairment, a brief interview for mental status score of 7 out of 15, and the resident required maximal assistance with toileting, dressing, bathing, and transfers. The fall care plan included interventions such as assisting the resident to the bathroom at approximately 3:00 p.m. daily and placing two water cups in the room, one on the bedside table and one on the night stand. During observation, the resident was seen sitting in a wheelchair and later in a recliner with the call light within reach, but the water cup was not placed where the care plan directed. At one point the resident stated she did not know how to call for help, and staff did not offer toileting around the 3:00 p.m. time identified in the care plan. Instead, the water cup remained on the night stand across the room until later in the observation, when a CNA placed the water pitcher on the bedside table. The observations showed that the planned interventions were not consistently in place as written. Record review showed multiple unwitnessed falls in January, March, and April 2026. After each fall, different interventions were added, including pillows to define the bed edges, removing the wheelchair from reach, keeping the bed in the lowest position, offering assistance with evening cares, and placing water cups by the chair and on the night stand. However, the resident later reported crawling out of the bedside chair and around the bed because she was thirsty and needed water, and the record and observations showed only one water cup on the night stand rather than two cups as planned. Staff interviews described the resident as confused, a fall risk, and in need of frequent checks and assistance, while the DON stated staff were responsible for ensuring interventions were in place.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly in two medication carts and one medication room. Specifically, medication cart #1 contained 28 whole medication tablets and one half medication tablet loose in the drawers, while medication cart #2 had 16 whole medication tablets loose in the drawers. The Licensed Practical Nurse (LPN) interviewed stated that there was no formal cleaning schedule, and it was the nurses' responsibility to keep the medication carts clean to prevent contamination and aid in medication stocking. Additionally, the medication room contained two boxes of 50 Tylenol 650 mg suppositories that had expired in February 2024, which should have been removed for destruction. The Director of Nursing (DON) confirmed that medication carts were to be cleaned daily by the charge nurse and that the pharmacy consultant performed monthly inspections. However, the facility did not have a specific schedule for cleaning the medication carts, and nurses were expected to check for expired medications and cleanliness daily. The DON also mentioned that the nurse manager was responsible for checking the medication room for expired medications every two weeks. The failure to properly store and label medications and biologicals, as well as the presence of expired medications, created a potential for medication errors and compromised the effectiveness of the medications.
Failure to Obtain Physician's Order for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #19 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not have a wound care order in place prior to treatment being provided for the resident. Resident #19, who had a history of falling and other medical conditions such as chronic kidney disease and hypertension, sustained an abrasion to his right elbow following an unwitnessed fall. Despite the injury, there were no treatment orders documented in the resident's computerized physician orders (CPO) for March and April 2024. The resident was observed with a soiled dressing on his elbow, which had not been changed since the fall, and later with the wound open to air and scabbed over. The resident confirmed that the dressing had not been changed and that he had removed it himself. Interviews with staff revealed that there was no physician's order in place for the treatment of the wound. Licensed Practical Nurse (LPN) #1 acknowledged that there should have been a physician's order for treating the wound and monitoring for infection. The Director of Nursing (DON) also confirmed that the nurse should have called the physician for an order to treat the abrasion and to monitor for infection. The facility's policy on the care of skin tears, abrasions, and minor breaks in the skin, which requires obtaining a physician's order, was not followed in this case.
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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 Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Topside Manor Inc | 29.1 mi | ★★★★★ | 0 | 0 |
| Cheyenne Manor | 33.7 mi | ★★★★★ | 12 | 0 |
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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.