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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Manor during CMS and state inspections, most recent first.
Delayed Response to Resident’s GI Bleed Symptoms: A resident with severe cognitive impairment and tube feeding dependence developed nausea followed by a large amount of coffee ground emesis. The nurse gave Zofran, held the TF briefly, and left a message for the physician, but there was no documented assessment or VS at the time of the change in condition. The second physician call was not made until over 6.5 hours later, after which the resident was transferred to the hospital for an upper GI bleed.
The facility failed to follow physician orders for ventilator settings for two ventilator-dependent residents and for O2 therapy for two residents. One resident’s vent settings were observed above the ordered rate, and another resident’s vent settings and O2 were repeatedly different from the physician order. Two residents’ O2 flow meters were observed set above the ordered liters per minute, and one resident’s nebulizer treatment was not continuously monitored when the RT left the room and the tubing disconnected during treatment.
Missing Hand Hygiene Equipment in Soiled Linen Area: The facility failed to implement its infection control program in the laundry soiled linen area by not providing proper hand hygiene equipment. Observation found a sink without a paper towel dispenser or trash bin, and staff described improper hand hygiene practices, including air drying hands and turning off the faucet with a wet hand. The Facilities Director stated he was responsible for ensuring the equipment was available, but did not know why the paper towel dispenser was not replaced or that no trash bin was present.
A resident with a history of hypertension had blood pressure medications withheld for three consecutive days due to low BP and elevated HR, but the physician was not notified as required by facility policy. Nursing staff recognized the abnormal vital signs and deviation from baseline, yet failed to document physician notification or consult with supervisors. The DON confirmed there was no evidence of physician notification regarding the resident's condition or the held medications.
The facility failed to monitor the behaviors of residents on psychotropic medications, as evidenced by the lack of documentation for four residents. Despite care plans requiring behavior monitoring, staff interviews revealed inconsistencies in documentation practices, with some staff unaware of behavior monitoring flow sheets and others using them only when behaviors were present. This resulted in significant gaps in monitoring, particularly for residents with severe cognitive impairments and those on multiple psychotropic medications.
A resident with Alzheimer's and other conditions was served meals that did not meet the IDDSI guidelines for a pureed diet, as they contained lumps and lacked uniform consistency. The Speech-Language Pathologist and Food Service Director confirmed the deficiency, noting that pureed bread, made in-house, did not meet the required standards, affecting ten residents.
Delayed Response to Resident’s GI Bleed Symptoms
Penalty
Summary
The facility failed to respond in a timely manner to a resident’s change in condition when the resident developed nausea and then a large amount of coffee ground emesis, which is indicative of a gastrointestinal bleed. The resident had severe cognitive impairment, was dependent for activities of daily living, and received tube feedings for nutritional support. After the resident was noted with nausea, Zofran was given and the tube feeding was held for 30 minutes. When the resident later had a large amount of coffee ground vomitus, the note documented that the Zofran was ineffective, the feedings were off, and the physician was called with a message left, but there was no documented assessment or vital signs at that time. Further review showed no vital signs documented until several hours after the change in condition, and the second call to the physician service was not placed until over 6.5 hours later. The physician then ordered transfer to the hospital for evaluation and treatment, and the resident was admitted for an upper GI bleed. The DON stated that with a change in condition the nurse is expected to assess the resident, including vital signs, and call the physician, and acknowledged there was no evidence of an assessment or vital signs at the time of the change and no documentation that a supervisor was notified during the delay in physician response.
Failure to Follow Ordered Ventilator and Oxygen Therapy, and Incomplete Nebulizer Monitoring
Penalty
Summary
The facility failed to follow physician orders for ventilator settings for two residents who were tracheostomy and ventilator dependent. One resident had a physician order dated 04/10/26 for a ventilator rate of 20, but during trach care the ventilator was observed at a rate of 22, and the RT confirmed the resident was not receiving the ordered settings. Another resident had physician orders for vent settings of rate 24, tidal volume 450, and oxygen at 35%, but observations on two separate days showed settings of rate 22, tidal volume 400, and oxygen at 40%. The RT confirmed the resident was not receiving the ordered vent settings and stated the resident had returned from the hospital on hospital vent settings, while the DON acknowledged the resident’s vent settings should match the physician’s orders. The facility also failed to follow physician orders for oxygen therapy for two residents. One resident had an order for continuous oxygen via nasal cannula at 3 L/min with oxygen saturation to remain above 90%, but the oxygen concentrator was observed set at 4.5 L/min, then 3.75 L/min, and later a portable tank was observed at 4.0 L/min during therapy. The resident stated he could not reach the concentrator and denied adjusting it. Staff interviews showed the RT stated the concentrator flow meter should be set to the ordered amount and that oxygen would only be increased temporarily if the resident had signs or symptoms of respiratory distress or low oxygen saturation. Another resident had physician orders for oxygen at 2 L/min via nasal cannula, but repeated observations showed the oxygen concentrator set at 3 L/min and 3.5 L/min. The resident stated no one had touched the machine, and the record review showed the documented oxygen flow rate remained at 2 L/min. Staff interviews indicated that only RTs adjust oxygen flow meters and that nurses check and document the ordered oxygen delivery during shifts. In addition, during nebulizer therapy for this same resident, the RT did not read and check the medication label or expiration date, placed the mask on the resident, and left the room for about 3 minutes while the tubing disconnected from the mask. The resident attempted to reconnect the tubing while the RT was absent, and the RT returned afterward and reattached it.
Missing Hand Hygiene Equipment in Soiled Linen Area
Penalty
Summary
The facility failed to ensure its infection control program was implemented by providing equipment for proper hand hygiene in the soiled linen area of the laundry room. A review of the facility policy titled, Laundry PH 180-886, stated that the laundry area will provide hand washing facilities and products as well as PPE, and the policy Handling Soiled Linen documented that hands are to be washed after contact with soiled linen. During observation, the hand-washing station in the soiled linen area had a sink, but there was no trash bin underneath or next to it and no paper towel dispenser for hand drying. Staff D stated there was a soap dispenser but no paper towel dispenser and no trash collection in the room. Staff D also stated she did not remember how long soiled linen had been sorted without proper hand hygiene equipment and did not respond when asked whether the issue had been reported to the Facilities Director. Staff E demonstrated hand hygiene by turning off the faucet with a wet hand and air drying, and stated this was not proper hand hygiene technique. The Facilities Director stated he was responsible for ensuring equipment was available for proper hand hygiene, but he did not know why the paper towel dispenser had not been put back after a new soap dispenser system was installed and did not know there was no trash bin inside the soiled linen area. The Infection Control Nurse stated laundry staff had attended hand hygiene in-service training.
Failure to Notify Physician of Held Blood Pressure Medications and Abnormal Vital Signs
Penalty
Summary
The facility failed to notify a resident's physician after blood pressure medications were held for three consecutive days due to low blood pressure. According to the facility's policies, the physician should be notified of significant changes in a resident's condition, including abnormal vital signs and when medications are held. Review of the clinical record for a resident with a history of hypertension, hypokalemia, and anemia showed that blood pressure readings were significantly lower than the resident's baseline, and heart rates were elevated over several days. Despite these findings, there was no documentation that the physician was notified about the low blood pressure, elevated heart rate, or the decision to withhold blood pressure medications. Nursing notes indicated that the resident experienced low blood pressure readings and elevated heart rates on multiple occasions, with the resident also exhibiting poor appetite and weakness. The medications Irbesartan, Metoprolol, and Nifedipine were not administered for three consecutive days due to these low readings. Staff interviews revealed that nurses recognized the abnormal vital signs and the deviation from the resident's baseline, but did not notify the physician or supervisor as required by facility policy. One nurse stated she rechecked the blood pressure and found it acceptable, but there was no evidence that the elevated heart rate was rechecked or that the physician was informed. Further interviews with the Director of Nursing confirmed that there was no written evidence of physician notification regarding the resident's low blood pressure, elevated heart rate, or the held medications. The DON acknowledged that the standard of practice is to notify the physician in such cases, and that sustained low blood pressure is a reason to contact the physician. The lack of documentation and failure to notify the physician constituted a deficiency in following the facility's policies and procedures for changes in resident condition and medication administration.
Failure to Monitor Behaviors of Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of residents receiving psychotropic medications, as evidenced by the lack of documentation and behavior monitoring for four out of five sampled residents. Resident #94, who was admitted with diagnoses including Mild Dementia and Major Depressive Disorder, was prescribed Zoloft but had no behavior monitoring documented since admission. Interviews with staff revealed inconsistencies in the use of behavior monitoring flow sheets, with some staff unaware of their existence and others indicating they were only used when behaviors were present. Resident #79, admitted with diagnoses such as Paraplegia and Major Depressive Disorder, was prescribed Mirtazapine but also had no behavior monitoring documented. The Director of Nursing acknowledged the absence of behavior monitoring flow sheets and progress notes specific to behaviors, despite the facility's policy requiring such documentation. The consultant pharmacist assumed that the absence of documentation indicated no behaviors, highlighting a lack of clarity in the facility's monitoring practices. Resident #73, with diagnoses including Depression and Adjustment Disorder with Anxiety, was on antidepressants but had no documented behavior monitoring or side effects monitoring. The Director of Nursing stated that behavior monitoring was only documented if behaviors were observed, leading to gaps in monitoring. Similarly, Resident #1, with severe cognitive impairment and multiple psychotropic medications, had numerous days without documented behavior monitoring, despite care plans indicating the need for such monitoring. These deficiencies indicate a systemic issue in the facility's approach to monitoring residents on psychotropic medications.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for a resident on a pureed diet, as observed during two separate meal times. The resident, who has Alzheimer's Disease, Bipolar Disorder, and Depression, was served meals that did not meet the International Dysphagia Standardization Initiative (IDDSI) guidelines for a pureed diet. The meals included pureed chicken, mashed potatoes, broccoli, bread, and cobbler, which were noted to have lumpy pieces and lacked a uniform consistency. This inconsistency was documented with photographic evidence. Interviews with the Speech-Language Pathologist and the Food Service Director revealed that the pureed diet should be smooth and creamy without any lumps or solid particles. It was noted that most pureed foods are purchased from an outside company, except for pureed bread, which is made in-house. The Food Service Director acknowledged that the pureed bread did not meet the required consistency guidelines, affecting ten residents on a pureed diet.
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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.