Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Memorial Manor Nursing Home during CMS and state inspections, most recent first.
Several residents were consistently provided with plastic utensils during meals, making it difficult for some to eat due to physical limitations. Despite requests for regular silverware and acknowledgment from staff that the practice was undignified, the facility continued to supply only plastic utensils, citing issues such as missing silverware and dishwashing problems.
An allegation of verbal abuse by an LPN toward a resident was not reported to the State Agency within the required time frame. The facility only became aware of the incident after being notified by surveyors, and the Administrator was unclear about the reporting requirements and process, resulting in a delayed report.
The facility did not follow its abuse policy when an LPN accused of verbal abuse was allowed to work during an active investigation, despite the DON confirming the investigation was ongoing. The Administrator was unsure if suspension was required when the allegation came from a survey team, resulting in the LPN remaining in the building while the investigation was still in progress.
A resident with multiple chronic conditions and dependent for mobility was not regularly turned or repositioned by staff, despite being incontinent and at risk for skin breakdown. Staff interviews and observations confirmed that the resident remained in the same position for extended periods, and care was not provided as ordered.
Two residents received incomplete and improper incontinent and perineal care, including failure to use correct cleaning techniques, not drying the area, not retracting the foreskin for cleaning, and improper glove use, as observed and confirmed by staff interviews.
A resident with end stage renal disease receiving regular dialysis treatments did not have ongoing assessments or documented communication between the facility and the dialysis center before and after treatments. Staff interviews and record reviews confirmed the absence of a system or documentation for monitoring the resident's condition related to dialysis.
Staff did not follow infection control protocols during perineal care, including failing to change gloves and perform hand hygiene after contact with soiled materials. CNAs were observed touching clean surfaces, resident clothing, and equipment with soiled gloves, and in some cases, leaving resident rooms and handling common area items without removing gloves or performing hand hygiene, contrary to facility policy.
The facility failed to properly secure and manage indwelling catheters for several residents, resulting in unsecured catheter tubing and a drainage bag on the floor. Observations showed incomplete catheter care documentation and improper attachment of secure devices. Staff interviews revealed a lack of recent training and inconsistent adherence to facility policy on catheter care.
Failure to Provide Dignified Dining Utensils
Penalty
Summary
The facility failed to ensure that residents were provided with appropriate dining utensils, resulting in the use of plastic utensils for meal service. Multiple residents reported receiving only plastic utensils with their meal trays, which made eating difficult, especially for those with physical limitations such as arm injuries or tremors. Observations confirmed that residents were served meals with plastic utensils, and some residents resorted to eating with their hands due to the difficulty of using the provided utensils. Resident Council meeting minutes also documented that residents had previously requested regular silverware, indicating ongoing dissatisfaction with the use of plastic utensils. Staff interviews revealed that the continued use of plastic utensils was attributed to issues such as silverware being thrown away, going missing, or problems with the dishwashing machine. The facility's own policy emphasized treating residents with dignity and respect, yet the practice of providing only plastic utensils did not align with this standard. Several cognitively intact residents expressed frustration and difficulty with the plastic utensils, and staff acknowledged the problem, noting that some residents could not eat properly with them.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the State Agency (SA) within the required time frame. The incident involved an LPN allegedly verbally abusing a resident. The facility's policy requires immediate or prompt notification of all abuse allegations to the appropriate authorities. However, the report of the alleged abuse was not made by the facility, but instead was received by the SA from an anonymous source. The Administrator and DON were only made aware of the allegation when notified by surveyors, and the facility subsequently reported the incident to the SA later that same day. Interviews revealed that the Administrator was unclear about the required reporting time frames for verbal abuse and was unfamiliar with the process when allegations are brought to their attention by the survey team rather than staff, residents, or family members. The Administrator also indicated a misunderstanding regarding the facility's responsibility to investigate and report such allegations when notified by the state, believing that the state would handle the investigation and reporting process. This lack of timely reporting and misunderstanding of procedures resulted in a delay in notifying the SA of the alleged abuse.
Failure to Protect Residents During Active Abuse Investigation
Penalty
Summary
The facility failed to protect residents during an active investigation of an alleged staff-to-resident verbal abuse incident involving an LPN. According to the facility's Abuse Prohibition Policies and Procedures, the safety of residents should be immediately secured by the first employee aware of the alleged abuse. Despite this policy, after the facility was notified of the allegation by the State Agency, the LPN accused of verbal abuse was allowed to remain on the work schedule and was observed working in the facility while the investigation was still ongoing. The Director of Nursing confirmed that the investigation was still active at the time the LPN was present in the building. The Administrator stated uncertainty about whether the same process for investigating allegations of abuse applied when the allegation was reported by a survey team rather than a resident, employee, or family member. The Administrator acknowledged that, under normal circumstances, the accused employee would be suspended pending the outcome of the investigation and not permitted to return to work until the investigation was complete. However, in this instance, the LPN was not immediately suspended, and residents were not protected according to facility policy during the investigation.
Failure to Reposition Dependent Resident as Ordered
Penalty
Summary
A deficiency was identified when staff failed to assist a resident with turning and repositioning as required by her care plan and medical needs. The resident, who was admitted with diagnoses including venous insufficiency, diabetes, and peripheral vascular disease, was documented as being dependent for mobility and repositioning. Multiple observations throughout the day showed the resident lying on her back in bed for extended periods without being turned or repositioned by staff. Staff interviews confirmed that the resident was not routinely turned, with one CNA stating she only checked on the resident when she had time, despite the resident being incontinent and requiring checks every two to three hours. The resident was cognitively intact and able to communicate her needs, but staff reported that she refused to get out of bed or be moved. Despite these refusals, there was no evidence that staff made consistent efforts to turn or reposition her according to her care needs and orders. The lack of regular repositioning placed the resident at risk for skin breakdown, as noted in the report.
Inadequate Incontinent and Perineal Care Provided to Two Residents
Penalty
Summary
Two residents were found to have received inadequate incontinent care, as observed and documented by surveyors. One resident, who was cognitively intact and fully dependent on staff for toileting, was left without incontinent care from the morning until the afternoon. When care was provided, the certified nurse aide (CNA) used improper technique, including using a single wet washcloth without soap for multiple wipes, not cleaning the perineal area in the correct direction, failing to dry the area, and not changing gloves between tasks. The CNA also touched various surfaces and equipment in the room and hallway while wearing soiled gloves, increasing the risk of cross-contamination. The resident was experiencing a bowel movement during care, and the CNA did not follow proper infection control or perineal care procedures as outlined in the facility's protocols. Another resident, who was always incontinent of bowel and bladder and required substantial assistance, did not receive complete perineal care during toileting. The CNA failed to retract and clean under the foreskin while performing peri care, a step acknowledged as necessary by the staff involved. Both incidents were confirmed through interviews with the CNAs and the Clinical Care Coordinator, who stated that staff are expected to follow the facility's established procedures for perineal care and infection control.
Lack of Ongoing Assessment and Communication for Dialysis Care
Penalty
Summary
The facility failed to establish and implement a system for ongoing assessment and monitoring of a resident with end stage renal disease who required regular dialysis treatments. Review of the resident's medical record showed that there was no documented communication between the facility and the dialysis center before and after dialysis sessions, including assessments of the resident's health status. The resident was readmitted with a diagnosis of end stage renal disease and was scheduled for dialysis three times per week, as indicated in the physician's orders. Interviews with facility staff, including the Unit Clerk, Infection Preventionist, and DON, revealed that there was no specific process or documentation system in place for communication with the dialysis center. Staff were unable to locate any records of pre- or post-dialysis communication or assessments in either the electronic medical record or the hard chart. The facility did not have a documented policy or procedure for dialysis communication until after the deficiency was identified.
Failure to Follow Infection Control Practices During Perineal Care
Penalty
Summary
Staff failed to adhere to infection control practices during perineal care for three out of 34 sampled residents. Certified Nurse Aides (CNAs) were observed not changing gloves or performing hand hygiene after contact with soiled materials and before touching clean items or other surfaces. In one instance, a CNA performed peri care on a resident who was having a bowel movement, used the same gloves to touch the resident’s bedside table, nightstand, nasal cannula, and to dispose of trash, and then exited the room and walked down the hallway still wearing the soiled gloves. In other cases, CNAs were observed pulling up residents’ clothing, adjusting blankets, moving walkers, and handling dirty linens and doorknobs while still wearing soiled gloves, and in some instances, only partially removing gloves before performing hand hygiene. The facility’s own Nursing Assistant Clinical Skills Checklist and Perineal Care procedures require staff to remove and discard gloves and perform hand hygiene after contact with soiled materials. Interviews with the involved CNAs confirmed awareness of the improper practices, and the Clinical Care Coordinator stated that staff are expected to follow established protocols, including hand hygiene and not touching items around the room or leaving the room with soiled gloves.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to ensure proper care and management of indwelling catheters for four residents, leading to deficiencies in catheter security and storage. Specifically, residents with indwelling catheters did not have their catheter tubing secured with straps, and one resident's catheter drainage bag was found on the floor. Observations revealed that catheter tubing was not secured, leading to potential tension and pulling on the catheter, as seen with one resident whose tubing was caught on the bed frame. Additionally, catheter care documentation was incomplete, with several instances of missing records for catheter care tasks. The facility's policy on catheter care, which mandates securing catheter tubing and preventing drainage bags from touching the floor, was not adhered to. Interviews with staff confirmed the absence of catheter straps and a lack of recent inservice training on catheter care. One resident's catheter secure device was observed to be peeling off, indicating improper attachment. The Director of Nursing acknowledged that CNAs should report missing catheter straps to nurses, who are responsible for securing them, but this protocol was not consistently followed.
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Illustrative
What surveyors actually found near you
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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 Bainbridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bainbridge Landing Of Journey Llc | 2.3 mi | ★★★★★ | 5 | 0 |
| Pinewood Health And Rehabilitation | 13.7 mi | ★★★★★ | 8 | 7 |
| Archbold Living Cairo | 21.1 mi | ★★★★★ | 2 | 0 |
| Miller Nursing Home | 21.6 mi | ★★★★★ | 2 | 0 |
| Seminole Manor Nursing Home | 21.8 mi | ★★★★★ | 6 | 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.