Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Imperial Manor Nursing Home during CMS and state inspections, most recent first.
Failure to perform hand hygiene during food prep. A cook was observed handling thawing potatoes, raw chicken, baking pans, and steam table pans while wearing torn or soiled gloves, using bare hands on food and pan liners, rinsing gloved hands in a food prep sink, and putting on new gloves without washing hands first. The Dietary Mgr and Admin confirmed handwashing is required after glove removal and before donning new gloves, and the facility policy states hands must be cleaned in an approved handwashing sink.
A Dietary Aide was observed serving drinks in the dining room while wearing the same gloves after wiping a soiled counter with a rag and without performing hand hygiene. The aide also used drinking glasses and small cups to scoop ice from an ice chest instead of using an ice scoop, then poured juice and served it to residents. Facility policy required handwashing and clean scoop use for ice handling, and the DM confirmed the gloves should have been changed and hands washed after touching the rag.
The facility failed to employ a qualified infection preventionist for the infection prevention and control program. The administrator identified an LPN as the Infection Preventionist, but record review found no evidence of specialized infection control and prevention training. The administrator later confirmed the LPN had not completed the required training and that the DON had been covering those duties in addition to DON responsibilities.
A resident was discharged to another nursing facility, but the facility had no evidence that the ombudsman was notified. The DON confirmed the discharge and said the SSD was responsible for the notification, while the SSD stated she only understood the requirement for emergency transfers, so no notice was sent.
The facility failed to develop comprehensive care plans for two residents. One resident had chronic severe pain related to migraine and polyneuropathy, with MDS assessments showing frequent to almost constant pain affecting sleep and daily activities, but the care plan did not address the pain or related interventions. Another resident had Myasthenia Gravis with weakness, falls history, and gait abnormalities, yet the care plan did not include the condition, associated risks, or treatment interventions. The DON confirmed both care plans were incomplete.
The facility failed to adhere to proper food storage and handling practices, as observed in the walk-in refrigerator and freezer. Boxes of lettuce and other food items were stored on the floor, and chicken was thawing above ready-to-eat lettuce. Interviews with dietary staff revealed that food deliveries had not been properly stored due to time constraints, and some items had been on the floor for over five days.
A survey found deficiencies in food safety and sanitation at a facility, including outdated food items, improper hand hygiene, and lack of sanitizer testing. Staff failed to use pasteurized eggs and did not follow food preparation directions, affecting 32 residents.
The facility failed to ensure nurse aides completed the required 12 hours of continuing education, including dementia and abuse training. Four nurse aides did not meet the training requirements, potentially affecting all 32 residents. Record reviews showed deficiencies in training hours, confirmed by the Administrator.
The facility failed to prevent elopement for a resident with dementia, as no new interventions were implemented after elopement incidents. Additionally, two residents at risk for falls did not have necessary interventions in place, such as keeping a walker and call light within reach. Another resident with severe cognitive impairment had their call light consistently out of reach, contrary to facility policy.
A facility failed to report a resident's elopement to the State Agency within the required 5 working days. The policy required reporting to the administrator and State Survey Agency but lacked a specific timeframe. A resident eloped after breakfast and was redirected by staff, attempting to leave again an hour later. The Administrator confirmed the report was not completed on time.
A facility failed to complete a significant change in status MDS assessment within the required 14-day timeframe for a resident admitted to hospice care. The assessment was delayed beyond the mandated period, as confirmed by the MDS Coordinator, despite the facility's adherence to the RAI Manual's guidelines.
A facility failed to complete an accurate PASRR for a resident with schizoaffective disorder. The PASRR form incorrectly indicated no suspected mental illness, despite the resident's diagnosis and use of psychotropic medications. The Social Service Director confirmed the facility's responsibility to complete the PASRR for residents admitted from home and acknowledged the need for a level two PASRR.
A facility failed to develop a comprehensive baseline care plan for a resident admitted with COPD and dementia. The care plan lacked essential components such as physician's orders, dietary orders, and social services, as confirmed by the MDS Coordinator. This omission was contrary to the facility's policy requiring such information in baseline care plans.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies. One resident with COPD had their nasal cannula tubing improperly stored and oxygen concentrator set at an incorrect rate. Another resident with multiple diagnoses, including COPD, was found with an unplugged CPAP device and incorrect oxygen settings. Staff interviews confirmed these issues, highlighting a failure to adhere to the facility's oxygen administration policy.
A resident was prescribed Doxycycline for a chronic knee infection without a stop date, contrary to the facility's Antibiotic Stewardship Program policy. The Infection Preventionist confirmed no attempts were made to discontinue the antibiotic, highlighting a deficiency in medication management.
A resident with moderate cognitive impairment and dysphagia was improperly administered Metoprolol Succinate extended-release in a crushed form, contrary to manufacturer instructions. The RN confirmed the error, and the DON acknowledged the practice of crushing medications for residents who refuse whole pills, despite lacking documentation to support this decision.
A facility failed to follow infection control protocols for a resident with a urinary catheter and MRSA. Staff did not don gowns during care and neglected hand hygiene between glove changes, contrary to the facility's policies.
The facility did not submit the required PBJ data for the third quarter of 2024, as mandated by CMS. The policy required submission by August 14th, but the data for April 1 to June 30, 2024, was not submitted. The Administrator confirmed the business manager's failure to report on time, potentially affecting all 32 residents.
Failure to Perform Hand Hygiene During Food Preparation
Penalty
Summary
Food handling practices during meal preparation failed to follow hand hygiene requirements. On 10/01/2025 at 9:17 AM, three bags of half frozen potatoes were observed defrosting in a sink. Cook-B, while wearing gloves, opened the bags with a knife, poured the potatoes into a colander, spooned frozen chunks into a bowl, chopped at the potatoes to separate them, used bare hands to break apart a large chunk, rinsed gloved hands in the same sink where the potatoes were sitting, and then poured the potatoes into a pan on the stove while still wearing the same gloves. Later that morning, Cook-B was observed while wearing gloves moving two bowls of raw chicken from the refrigerator to the counter, handling baking pans and baking sheets, spraying pans with cooking oil, and continuing to work with torn gloves until removing them. New gloves were then put on without first performing hand hygiene. Cook-B then breaded the chicken, removed soiled gloves, and continued cleaning counters and collecting dishes. At 11:40 AM, Cook-B removed pans of chicken from the oven, placed them on a cart, sprayed steam table pans with oil, used tongs to press baking paper into the pans, and used a bare hand to smooth the paper into the pan before using tongs to place the chicken into the steam table pans. The Dietary Manager and Administrator confirmed hands are to be washed each time gloves are removed and before putting on new gloves, and the facility policy states handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses.
Improper Hand Hygiene and Ice Handling During Hydration Service
Penalty
Summary
The facility failed to prevent cross contamination during hydration preparation in the dining room. A Dietary Aide was observed serving juice from a cart with bins sitting on ice while wearing gloves. After noticing a soiled spot on the counter, the aide grabbed a rag and wiped the counter, then resumed serving drinks to residents without changing gloves or performing hand hygiene. The aide continued using the same gloves while serving drinks from the cart. The aide also used drinking glasses and small drinking cups to scoop ice from a blue ice chest sitting on a chair in the dining room instead of using an ice scoop. The aide poured juice into the glasses and cups and served them to residents while still wearing the same gloves. Facility policy required handwashing to prevent the spread of bacteria and stated that ice must be handled only with a clean scoop and that scoops may not be stored in ice. The Dietary Manager confirmed that staff were to use an ice scoop and that gloves should have been changed and hands washed after touching the cleaning rag.
Unqualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection preventionist for its infection prevention and control program. During an interview, the administrator identified LPN-C as the facility's Infection Preventionist, but a review of facility documents found no evidence that LPN-C had completed specialized training in infection control and prevention. In a later interview, the administrator confirmed that LPN-C had not completed the required specialized training and stated that the DON had been covering the Infection Preventionist duties in addition to DON responsibilities. The facility census was 30.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the ombudsman of Resident 35’s discharge from the facility. Record review showed the resident was admitted on [DATE] and later discharged to another nursing facility on 8/19/2025. Review of the resident’s electronic medical record found no evidence that the ombudsman was notified of the discharge. During interview, the DON confirmed the resident had been discharged and stated the SSD was responsible for ombudsman notifications. The SSD stated she only knew of the requirement to notify the ombudsman for emergency transfers, so no notification was sent regarding Resident 35’s discharge.
Incomplete Care Plans for Pain and Myasthenia Gravis
Penalty
Summary
The facility failed to ensure that the care plans for 2 residents were comprehensive and included measurable objectives and timeframes to meet identified needs. The facility’s policy stated that each resident should have a comprehensive person-centered care plan consistent with the resident’s assessed medical, nursing, and psychological needs. Record review showed Resident 17 was admitted with diagnoses of migraine and polyneuropathy, and MDS assessments documented frequent to almost constant pain that frequently or almost constantly affected sleep and day-to-day activities, with the resident rating the pain as severe. Physician orders included ibuprofen as needed for pain/headaches, pregabalin for neuropathy, and Tylenol as needed, but the undated care plan contained no evidence of care planning related to chronic pain. The DON confirmed the care plan did not reflect the resident’s chronic pain or the interventions in place to address it. Record review also showed Resident 26 was admitted with Myasthenia Gravis without acute exacerbation, and MDS assessments documented Myasthenia Gravis, weakness, a history of falling, and unspecified abnormalities of gait and mobility. Physician orders included azaTHIOprine and pyridostigmine bromide for Myasthenia Gravis. The undated care plan contained no evidence of care planning related to the resident’s Myasthenia Gravis condition, potential risks, or interventions related to the condition. The DON confirmed the resident had Myasthenia Gravis and that the care plan did not address the disease process, medications, or interventions required to treat it.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a survey. In the walk-in refrigerator, two boxes of lettuce were stored on the floor, and a non-drip container of chicken was thawing on a shelf above a box of ready-to-consume lettuce. Additionally, a bowl of ground meat was stored above a bowl of potato salad. The walk-in freezer door was left open into the refrigeration area, and several boxes of food, including desserts, ice cream, fine ground beef, potato triangles, and dinner roll dough, were stored on the floor. A plastic bag of sliced apples and a large container of ice cream were also found on the floor, along with two non-drip containers of frozen produce holding sliced apples. The black plastic floor mats in the freezer area had small bits of yellow and brown debris. Interviews with the dietary staff revealed that the delivery truck had arrived, and the food in the freezer was to be put away by the end of the shift. However, due to meal preparation, there was no time to do so immediately. The Dietary Supervisor confirmed that food deliveries occur on Mondays, Thursdays, and Fridays, and no deliveries had been made since the previous Friday. It was confirmed that food had been stored on the floor for over five days, indicating a failure to adhere to the facility's policy and procedure for food receiving and storage, which mandates that food be stored in a manner that complies with safe food handling practices.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food safety and sanitation during a survey. Observations revealed that the kitchen had outdated food items, including undated and expired products such as baking soda, granola, and cottage cheese. The kitchen surfaces, including shelves and carts, were covered with dust, grime, and food particles, posing a risk of contamination. Additionally, the facility failed to use pasteurized eggs when serving over-easy eggs, increasing the risk of foodborne illness among residents. The survey also identified issues with hand hygiene and sanitization practices. Staff members were observed not performing proper hand hygiene between tasks, such as changing gloves without washing hands. The sanitizer solution used for cleaning surfaces was not tested for effectiveness, as the facility had run out of test strips. This lack of testing and improper hand hygiene practices could lead to cross-contamination and the spread of foodborne illnesses. Furthermore, the facility did not follow package directions when preparing food, such as stuffing, which resulted in improperly cooked meals. The dietary staff was uncertain about the sanitization process of the dishwasher, and the chemicals used were not tested due to a lack of test strips. These deficiencies in food preparation and sanitation practices had the potential to affect all 32 residents served by the kitchen, compromising their health and safety.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of continuing education, including training in dementia care and abuse prevention, as mandated by Licensure Reference 175 NAC 12-00604(B)(ii). This deficiency was identified through record reviews and interviews, affecting four out of five sampled nurse aides. Specifically, Nurse Aide G, F, D, and H did not meet the continuing education requirements, which had the potential to impact all 32 residents residing in the facility. The record review revealed that Nurse Aide G had not completed any training hours for the year, including dementia or abuse training. Nurse Aide F had completed only 9.05 hours, Nurse Aide D had completed 11.3 hours, and Nurse Aide H had completed 11.55 hours of training for the year. An interview with the Administrator confirmed these findings, indicating that the facility did not comply with the required training hours for these nurse aides.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to implement necessary interventions to prevent elopement for Resident 26, who was admitted with dementia, agitation, and anxiety. Despite being identified as an elopement risk with a history of wandering into unsafe spaces, Resident 26 managed to elope through the front door and later through a rear door on the same day. The care plan included interventions such as documenting wandering behavior, providing structured activities, and using a Wander Guard. However, no new interventions were implemented after the elopement incidents, as confirmed by RN-E. The facility also failed to ensure fall prevention interventions were in place for Resident 3 and Resident 22. Resident 3, who had severe cognitive impairment and a history of falls, was observed without their walker within reach on multiple occasions, contrary to their care plan. NA-D was unaware of the intervention to keep the walker within reach. Similarly, Resident 22, with severe cognitive impairment and at risk for falls, was observed with their call light inaccessible, despite the care plan intervention to remind them to use it when needing to transfer. NA-C confirmed the call light was not within reach. Additionally, the facility did not ensure a call light was within reach for Resident 15, who had severe cognitive impairment. Observations revealed the call light was consistently across the room, not within reach, and Resident 15 confirmed they had to walk to the wall to use it. NA-J and the MDS Coordinator confirmed that Resident 15 did not have a pendant and should have had the call light within reach. The DON confirmed the expectation for call lights to be near residents, but this was not adhered to for Resident 15.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the State Agency within the required timeframe of 5 working days. The facility's policy on reporting alleged violations, dated February 22, 2023, mandates that such incidents be reported to the administrator and the State Survey Agency, but it does not specify a timeframe for reporting. On January 27, 2024, a registered nurse documented in the progress notes that a resident had eloped out the front door after breakfast and was subsequently redirected by staff. The resident attempted to leave the facility again about an hour later. An interview with the Administrator on October 10, 2024, confirmed that the report to the State Agency regarding this elopement had not been completed within the required timeframe.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. According to the Long-Term Care Facility Resident Assessment Instrument Manual, a significant change of status assessment is required when a terminally ill resident enrolls in a hospice program, and the Assessment Reference Date (ARD) must be no later than the 14th calendar day after the determination of the significant change. However, the MDS assessment for the resident was completed beyond this required timeframe. The resident in question was admitted to the facility and later had an active physician's order dated June 5, 2024, to admit them to hospice services. The MDS assessment, which was supposed to reflect this significant change, was dated July 4, 2024, indicating a delay in compliance with the mandated assessment period. An interview with the MDS Coordinator confirmed that the assessment was not completed within the required timeframe, despite the facility's adherence to the RAI Manual's guidelines for completing and submitting MDS assessments.
Failure to Complete Accurate PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed prior to the admission of a resident diagnosed with schizoaffective disorder. Upon reviewing the resident's records, it was found that the PASRR form, dated the day of admission, incorrectly indicated that the resident did not have a suspected mental illness, despite the diagnosis of schizoaffective disorder. Additionally, the form failed to acknowledge other diagnoses such as psychotic disturbance and mood disturbance, as well as the use of psychotropic medications. The Social Service Director confirmed that the facility was responsible for completing the PASRR for residents admitted from home and acknowledged that the diagnosis should have triggered a level two PASRR.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan for a resident, identified as Resident 30, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and dementia. The baseline care plan, which is a written strategy for how nursing home staff will help a resident receive the care they need, was missing essential components such as physician's orders, dietary orders, and social services. This deficiency was confirmed during an interview with the Minimum Data Set (MDS) Coordinator, who acknowledged that the required information was not included in the baseline care plan for Resident 30. The facility's policy, implemented on 10/7/2022, mandates that baseline care plans must include initial goals, physician's orders, dietary orders, therapy services, and social services, but these were not present in the interim care plan dated 3/29/2024.
Deficiencies in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to maintain sanitary conditions and adhere to prescribed oxygen settings for two residents, leading to deficiencies in respiratory care. Resident 30, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had an order for oxygen at 2 Liters Per Minute (LPM) at bedtime and as needed. However, observations revealed that the nasal cannula tubing was improperly stored on the floor, and the oxygen concentrator was set at 4 LPM instead of the prescribed 2 LPM. Interviews with nursing staff confirmed these discrepancies, indicating a failure to follow the facility's policy on oxygen administration, which requires oxygen delivery devices to be kept in plastic bags when not in use and administered under a physician's orders. Resident 8, with diagnoses including COPD, Essential Hypertension, and Chronic Systolic Heart Failure, had a physician's order for oxygen at 2 LPM to maintain oxygen saturation levels above 90%. During an observation, it was found that the resident's CPAP device was unplugged, resulting in the resident not receiving oxygen. After the device was plugged in, the oxygen concentrator was set at 0.5 LPM, contrary to the prescribed 2 LPM. An interview with a registered nurse revealed that the staff responsible for the medication cart should have been monitoring the oxygen machine and saturation levels, but this was not done, leading to the deficiency.
Antibiotic Prescription Lacks Stop Date
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of antibiotics. A review of the facility's Antibiotic Stewardship Program policy, last revised on 10/8/2024, indicated that all antibiotic prescriptions should specify the dose, duration, and indication for use. However, upon admission on 8/1/2023, a resident was prescribed Doxycycline for a chronic knee infection without a specified stop date. This oversight was confirmed during an interview with the Infection Preventionist on 10/9/2024, who acknowledged that no attempts had been made to discontinue the antibiotic, resulting in a deficiency in the facility's medication management practices.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that a resident received an extended-release medication according to the manufacturer's directions, resulting in a significant medication error. The resident, identified as having moderate cognitive impairment and diagnosed with non-Alzheimer's dementia and dysphagia, was administered Metoprolol Succinate extended-release in a crushed form, contrary to the manufacturer's instructions. The medication administration was observed when a registered nurse (RN) prepared and crushed all oral medications, including the extended-release Metoprolol, and mixed them with applesauce for the resident to consume. The RN confirmed that Metoprolol ER should not be crushed and acknowledged the absence of any special order or instructions permitting this action. The Director of Nursing (DON) stated that while some medications should not be crushed, they continue to do so for residents who refuse to swallow whole pills, with the Medical Director's agreement. However, there was no documentation in the resident's medical record to support the decision to crush the medication. This oversight led to the improper administration of the medication, violating the manufacturer's guidelines.
Infection Control Deficiency: PPE and Hand Hygiene Lapses
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during the care of a resident with a urinary catheter and a history of Methicillin-resistant Staphylococcus aureus (MRSA) infection. Specifically, the facility did not ensure that staff donned appropriate Personal Protective Equipment (PPE), such as gowns, during high-contact care activities. This was observed when a nurse aide began providing care to a resident without wearing a gown, despite the resident's care plan indicating the necessity of wearing gowns and gloves during physical contact due to the resident's medical condition. Additionally, the facility did not comply with hand hygiene protocols between glove changes. Observations revealed that two nurse aides changed gloves without performing hand hygiene before applying new gloves. Interviews with the nurse aides confirmed that they did not perform hand hygiene between glove changes, acknowledging that they should have done so. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene before donning gloves and immediately after removing them.
Failure to Submit PBJ Data for Q3 2024
Penalty
Summary
The facility failed to submit the required Payroll Based Journal (PBJ) data for the third quarter of 2024, which is a mandatory requirement for all long-term care facilities as per the Centers for Medicare and Medicaid Services (CMS). The facility's policy, last reviewed on August 31, 2024, mandates that this data be submitted no later than the specified deadline for each quarter, with the deadline for the third quarter being August 14th. A review of the PBJ report from CMS confirmed that the facility did not submit the data for the period of April 1 to June 30, 2024. During an interview, the Administrator acknowledged that the business manager did not report the third quarter PBJ on time, as required. This oversight had the potential to affect all 32 residents residing within the facility.
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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 Imperial
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wauneta Care And Therapy Center | 16 mi | ★★★★★ | 0 | 0 |
| Western Sky Community Care Center Inc | 23.2 mi | — | 0 | 0 |
| Sarah Ann Hester Memorial Home | 33.1 mi | ★★★★★ | 7 | 0 |
| Regent Park Care Center | 34.4 mi | ★★★★★ | 2 | 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.