Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hospital Ltcu (village Manor) during CMS and state inspections, most recent first.
The facility failed to submit accurate PBJ data, indicating a lack of 24/7 licensed nurse coverage on multiple days, despite evidence of continuous coverage. Administrative Staff A acknowledged missing data input and the absence of a Payroll Based Journaling policy contributed to this deficiency, risking inadequate staffing.
A resident with a history of dementia, bipolar disorder, and suicidal ideation expressed self-harm thoughts on multiple occasions. The facility failed to promptly notify the physician, delaying potential treatment. Despite the facility's policy requiring immediate physician notification for life-threatening conditions, the administrative nurse admitted to not documenting the communication with the doctor.
A resident with bipolar and major depressive disorders reported missing clothing items, but the facility failed to log and resolve the grievance according to policy. Despite staff being informed, the grievance was not documented, and the issue was not formally investigated, leading to unresolved grievances and decreased quality of life.
A resident with severe cognitive impairment was found with bilateral upper arm bruises, but the facility failed to identify and report the injury as potential abuse. Despite the care plan's directive to observe and report skin abnormalities, the EMR lacked documentation of further assessment. Staff interviews revealed a lack of awareness and reporting, contrary to the facility's policy requiring prompt reporting of suspected neglect or abuse.
A facility failed to provide timely written notification to a resident with severe cognitive impairment or his representatives regarding multiple hospital transfers due to medical conditions. The facility also did not notify the LTCO about the discharges, violating their Bed-Holds and Returns Policy and placing the resident at risk for impaired rights and uninformed care choices.
A resident with severe cognitive impairment was not provided with the facility's bed hold policy upon transfer to the hospital, as required by the facility's policy. Staff interviews revealed a lack of awareness about the need to provide this information during transfers, which placed the resident at risk for impaired ability to return to the facility.
A facility failed to complete a recapitulation post-discharge for a resident with multiple health issues, including dementia and diabetes. The resident required significant assistance and had a care plan for discharge to their home with family support. However, the clinical record lacked a summary of the resident's stay, and the administrative nurse was unaware of the requirement for such documentation, placing the resident at risk of unmet care needs.
A resident with a history of dementia, bipolar disorder, and depression exhibited suicidal ideation, but the LTC facility failed to provide adequate social services and timely physician notification. Despite care plan directives, the facility did not consistently monitor or document the resident's mental health needs, placing the resident at risk for further emotional decline.
A facility failed to ensure appropriate documentation and rationale for the continued use of an antipsychotic medication for a resident with various diagnoses, including depression. The resident's care plan lacked interventions related to antipsychotic use, and staff observations indicated no behaviors or hallucinations justifying the medication. The facility's policy required a care plan with specific documentation for psychotropic medication use, which was not followed, placing the resident at risk for unnecessary medication and adverse effects.
A facility failed to label and store insulin pens properly for a resident, as observed during a medication cart check. The insulin pens, Admelog Solostar and Tresiba, lacked open and discard dates, which are necessary to ensure their effectiveness within 28 days. A nurse confirmed the oversight, and the facility did not provide an insulin storage policy, risking the resident receiving an expired dose.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2024 Quarters 1, 2, and 3 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. Specifically, there were 18 dates in Quarter 1, 19 dates in Quarter 2, and 13 dates in Quarter 3 where coverage was lacking. However, a review of the facility's licensed nurse data for the dates listed on the PBJ revealed that a licensed nurse was indeed on duty for 24 hours a day, seven days a week. On a specific date, an observation confirmed the presence of a licensed nurse on duty in the facility. Administrative Staff A stated that the schedule was input into the computer and that he submitted the PBJ, assuming it was correct since no error report was received. Upon further review, he noted that some licensed nurse hours were not input into the computer and acknowledged the need to verify the data before submission. The facility did not provide a policy for Payroll Based Journaling, which contributed to the inaccurate PBJ data submission, placing residents at risk for unidentified and ongoing inadequate staffing.
Failure to Notify Physician of Resident's Self-Harm Statements
Penalty
Summary
The facility failed to notify the physician of a resident's statements of self-harm, which placed the resident at risk for delayed treatment due to a delay in physician involvement. The resident, identified as R168, had a history of dementia, bipolar disorder, traumatic brain injury, depression, and suicidal ideation. Despite these conditions, the facility did not promptly inform the physician of the resident's self-harm statements made on multiple occasions. On 08/25/24, the resident expressed suicidal ideation, stating he wanted to be dead and made a gesture of shooting himself in the head. The nursing staff placed the resident on 15-minute checks and monitored him throughout the shift but failed to notify the physician immediately. It was not until 08/27/24 that the physician was informed of the resident's suicidal ideation from two days prior. Additionally, on 09/02/24, the resident again made comments about wanting to hurt himself, but there was no documentation that the physician was notified of these statements. The facility's policy required licensed nurses to report any clinical issues requiring physician notification, especially in life-threatening situations. However, the administrative nurse admitted to seeing the note about the resident's self-harm verbalizations the day after they occurred and possibly calling the doctor but did not document it. This lack of timely communication with the physician regarding the resident's self-harm statements was a significant deficiency in the facility's care process.
Failure to Log and Resolve Resident Grievance on Missing Clothing
Penalty
Summary
The facility failed to properly log and resolve a grievance reported by a resident, identified as R18, regarding missing clothing items. R18, who has diagnoses of bipolar disorder and major depressive disorder, reported missing several clothing items since February 2024. Despite having intact cognition and being independent with most activities of daily living, R18's grievance was not documented in the facility's grievance log, nor was it recorded in her clinical record. Interviews with staff revealed that although the issue was communicated to various personnel, including a Certified Nurse Aide, a Licensed Nurse, and Social Services, the grievance was not formally logged or investigated as per the facility's policy. The facility's policy requires all grievances to be recorded and investigated, but in this case, the staff did not adhere to these procedures. Social Services X did not log the grievance, considering it a complaint rather than a formal grievance, and did not fill out a grievance form unless the issue was deemed severe or the resident explicitly requested it. Additionally, the facility had a new laundry staff, which contributed to the mix-up of residents' clothing, and some of R18's items were reportedly replaced or given away without proper documentation. This oversight placed R18 at risk for unresolved grievances and decreased quality of life.
Failure to Report Injury of Unknown Origin as Potential Abuse
Penalty
Summary
The facility failed to identify and report an injury of unknown origin as potential abuse for a resident with severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety, neurocognitive disorder with Lewy body, depression, and PTSD, was found to have bilateral upper arm bruises. Despite the care plan directing staff to observe and report any abnormal skin findings, the electronic medical record lacked documentation of further assessment or investigation into the bruises. The resident required partial assistance with personal care but was independent with mobility, transfers, and ambulation. Interviews with facility staff revealed a lack of awareness and reporting of the bruises. A CNA was unaware of the bruises and stated she would notify a nurse if any skin issues were found. A licensed nurse acknowledged the resident's cognitive impairment and the need to report unknown injuries to administration. However, both the administrative nurse and administrative staff were unaware of the bruises until informed during the survey. The facility's policy required prompt reporting of any suspected neglect or abuse, including injuries of unknown origin, to management, which was not followed in this case.
Failure to Notify Resident and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to a resident, identified as R42, or his representatives regarding multiple facility-initiated transfers to the hospital. R42, who had severe cognitive impairment and required varying levels of assistance with daily activities, was transferred to the hospital on several occasions due to medical conditions such as pancreatitis and gastrointestinal bleeding. Despite these transfers, the facility did not provide the required written notices to R42 or his representatives, nor did they notify the Office of the Long-Term Care Ombudsman (LTCO) about the discharges. The facility's Bed-Holds and Returns Policy, which mandates providing written information to residents and their representatives before a transfer, was not adhered to in R42's case. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide written notices and notify the LTCO. This oversight placed R42 at risk for impaired rights and uninformed care choices, as the necessary communication regarding his hospital transfers was not conducted as per regulatory requirements.
Failure to Provide Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a resident, identified as R42, or his representative with written information regarding the facility's bed hold policy when the resident was transferred to the hospital. This deficiency was identified during a review of R42's clinical records, which lacked evidence of the bed hold policy being provided on multiple hospital transfer dates. R42 had severe cognitive impairment and required varying levels of assistance with daily activities, as documented in his medical records. Despite these needs, the facility did not adhere to its policy of informing residents or their representatives about bed hold rights and limitations before transfers. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide the bed hold policy upon hospital transfers. Administrative Nurse D and Social Service X both stated they were unaware of the need to provide this information at the time of transfer, believing it was only necessary upon admission. The facility's policy, revised in March 2017, clearly stated that residents or their representatives should be informed in writing about the bed hold policy before transfers. This oversight placed R42 at risk for impaired ability to return and resume residence in the nursing facility.
Failure to Complete Post-Discharge Recapitulation
Penalty
Summary
The facility failed to complete a recapitulation post-discharge for a resident who had a self-initiated discharge. The resident had multiple diagnoses, including infection and inflammatory reaction to an indwelling catheter, atherosclerotic heart disease, chronic pain, dementia, muscle weakness, diabetes mellitus, reduced mobility, and mixed receptive-expressive language disorder. The resident required substantial assistance with personal hygiene and mobility, had an indwelling urinary catheter, and was incontinent of bowel. The care plan included discharge planning to the resident's home with family members, with instructions to ensure continuity of care by providing a detailed summary of care needed upon discharge. Despite these plans, the resident's clinical record lacked evidence of a recapitulation of the stay in the facility. The administrative nurse reported being unaware of the need for such a recapitulation following the resident's discharge. Additionally, the facility did not provide a policy for recapitulation for discharged residents. This oversight placed the resident at risk of unidentified and unmet care needs.
Failure to Provide Adequate Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R168, who exhibited signs of self-harm and suicidal ideation. R168 had a complex medical history, including dementia, bipolar disorder, traumatic brain injury, and depression. Despite these conditions, the facility did not adequately address the resident's mental health needs. The resident's electronic medical record documented several instances of suicidal ideation and self-harm gestures, yet there was a lack of timely notification to the physician and insufficient follow-up by social services. The resident's care plan included directives for staff to monitor for mood swings and suicidal ideation, and to notify the physician immediately if such behaviors were observed. However, the documentation revealed that the physician was not promptly informed of the resident's suicidal ideation on multiple occasions. Additionally, the social services department did not engage with the resident to address his verbalizations of self-harm and feelings of sadness, nor did they document any follow-up actions taken to support the resident's mental well-being. Observations and interviews with staff indicated that while some efforts were made to engage the resident in activities and provide one-on-one support, these actions were not consistently documented or followed through with appropriate medical oversight. The facility's policy on behavioral health services emphasized the importance of monitoring residents for suicidal issues and ensuring their safety, yet these protocols were not effectively implemented for R168, placing him at risk for further emotional and mental decline.
Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure an appropriate indication of use or a documented physician rationale for the continued use of an antipsychotic medication for a resident, identified as R43. The resident's electronic medical record documented various diagnoses, including diabetes mellitus, hypertension, and depression, but lacked documentation of any history of hallucinations or behaviors that would justify the use of an antipsychotic. Despite this, the resident was prescribed Zyprexa, an antipsychotic, after a physician visit noted decreased confusion and possible hallucinations, although these were not distressing to the resident. The care plan for R43 did not include interventions related to the use of antipsychotics, nor did it provide information on behavioral interventions or drug side effects and warnings. Observations and interviews with facility staff revealed that R43 had not exhibited behaviors or reported hallucinations, and the care plan lacked documentation of the use of antipsychotic medication. The facility's policy required that residents on psychotropic medication have a care plan with interventions, diagnosis, medication list, and other relevant information, which was not adhered to in this case. The facility's failure to document an appropriate CMS-approved indication or the required physician documentation for the continued use of R43's antipsychotic medication placed the resident at risk for unnecessary psychotropic medications and adverse side effects. The consultant pharmacist review highlighted the risks associated with antipsychotic use for conditions other than those specifically indicated, and the lack of documentation and monitoring in the resident's care plan further contributed to the deficiency.
Failure to Label and Store Insulin Pens Properly
Penalty
Summary
The facility failed to properly label and store insulin pens for a resident, specifically Admelog Solostar and Tresiba, which are fast-acting and long-acting insulins, respectively. During an observation of the medication cart, it was found that these insulin pens did not have an open date or discard date, which is necessary to ensure the insulin is used within the effective period of 28 days as documented by Medlineplus.gov. A licensed nurse confirmed the finding and acknowledged that the insulin should have been labeled with an open date. The facility did not provide an insulin storage policy upon request, indicating a lack of proper procedures for labeling and storing insulin, which placed the resident at risk of receiving an expired or ineffective dose.
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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 Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Enterprise Estates Nuring Center | 5.3 mi | ★★★★★ | 20 | 0 |
| Chapman Valley Manor | 10.7 mi | ★★★★★ | 0 | 0 |
| Holiday Resort Of Salina | 19.9 mi | ★★★★★ | 18 | 0 |
| Tallgrass Healthcare Campus | 19.9 mi | ★★★★★ | 8 | 1 |
| Salina Presbyterian Manor | 20.4 mi | ★★★★★ | 7 | 3 |
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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.