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 The Manor, Inc. during CMS and state inspections, most recent first.
The facility did not verify or document required competencies for a large number of contracted nursing staff, including licensed nurses and LNAs obtained through staffing agencies. Record review showed missing resident-care competencies for a contracted LNA, despite the facility assessment requiring skills such as wound management, dementia care training, behavioral interventions, infection prevention, safe lift/transfer, and emergency response preparedness. The DON reported that new and agency staff often did not receive facility training, that agency staff were only required to read policies through the agency system, and that competency was informally monitored after assignment rather than verified beforehand. A contracted LNA described starting work by going directly to the nurse’s station, receiving an assignment, and beginning work without task-specific orientation.
Two residents’ rights to privacy were not maintained during personal and incontinence care. In one instance, a resident received incontinence care from an LNA with the hall door open and the privacy curtain between beds not drawn, while a roommate and visiting family members were present and the resident remained visible. In another instance, a resident was exposed in bed while three LNAs provided personal care with the hall door wide open, and the door was only closed after staff noticed surveyors. The DON later confirmed that LNAs were expected to ensure privacy by using the curtain and/or closing the door.
A resident with several weeks of itching and self-inflicted scratches to the arms and hands was observed actively scratching with deep scratches present, while documentation showed repeated episodes of pruritus and open skin areas. Nursing staff had previously obtained a short course of Triamcinolone cream and later left messages for the physician requesting systemic medication (cetirizine) and reporting continued scratching and inflamed areas, but no new orders or documented physician response were received despite multiple calls and faxes. This resulted in the resident not being under timely physician supervision or receiving updated treatment in response to ongoing symptoms.
Surveyors found that physicians did not complete required total program of care reviews for two residents. One resident with multiple complex conditions, including dementia, cachexia, pressure ulcers, malnutrition, and dysphagia, had regulatory visit notes over an extended period that lacked documentation of a comprehensive care review, listed two medications that were not actually ordered, and failed to reflect documented MASD and pressure injuries noted in nursing progress notes. The DON confirmed the absence of a total care review and reported difficulty obtaining such documentation from some providers. Another resident admitted earlier in the year had no provider visit notes that met the definition of a total program of care review, including review of all current meds, treatments, and the comprehensive care plan.
An LPN failed to follow hand hygiene requirements while preparing and administering medications to two residents, including not using hand sanitizer or soap and water before or after wearing gloves, administering eye drops, and replacing a medication patch. The LPN later acknowledged not performing hand hygiene and described a practice of cleaning hands only after several medications or residents or after completing direct care. Review of facility policies showed that hand hygiene is required before handling medications, before and after resident contact, after glove removal, and before and after administering ophthalmic and topical preparations, and the DON confirmed the nurse did not follow these policies.
Surveyors identified multiple deficiencies in food storage and sanitation, including expired and undated food items, uncovered and improperly stored food, and widespread debris and unclean equipment throughout the kitchen. A kitchen staff member confirmed the presence of expired, undated, and improperly stored items, as well as unsanitary conditions, in violation of facility policy.
A resident with severe cognitive impairment and a history of abuse was sexually assaulted by a staff member, as witnessed by an LPN. The resident required hospital care, where a genital injury was confirmed. The facility failed to screen all residents for abuse after the incident and did not ensure the staff member had a national background check or abuse prevention training, as confirmed by the DON and Administrator.
The facility did not conduct required national background checks for most employees, including an LNA who sexually assaulted a resident. Review of staff files showed that the majority of employees lacked this screening, and the facility's policy did not address state requirements for national background checks. Leadership confirmed a lack of understanding and implementation of these requirements.
A facility failed to provide required abuse prevention training to an LNA who subsequently committed a substantiated sexual assault against a resident. Despite policies mandating abuse education upon hire, the LNA worked for over two months without completing any such training, as confirmed by both the DON and HR Director.
Lack of Verified Competencies for Contracted Nursing Staff
Penalty
Summary
The facility failed to ensure that contracted nursing staff, including licensed nurses and LNAs obtained through staffing agencies, had documented competencies matching residents' assessed needs and care plans. Review of two LNA employee records, one permanent and one contracted through Clipboard Health, showed that required competencies for resident care were missing for the contracted LNA. The facility assessment dated 3/9/26 identified required nursing staff competencies such as wound management skills, dementia care training, behavioral intervention training, infection prevention practices, safe lift and transfer training, and emergency response preparedness, but these were not verified for agency staff. A staffing list showed 48 nursing staff identified as contract/agency, and the DON confirmed that agency staff made up a large part of the nursing workforce. In interviews, the DON stated that the facility did not always provide facility training to new staff, especially agency staff, because of uncertainty about how long they would stay and challenges in hiring new staff. The DON explained that Clipboard Health staff were required to read facility policies in the agency system before picking up a shift, and that facility staff would monitor them, but there was no verification of competency before they worked with residents and no documentation of competencies by the facility. A contracted LNA reported that upon starting work, the process was to enter through the front door, go to the nurse's station, receive an assignment, and "jump right in" without orientation to new tasks. The DON confirmed that the listed competencies in the facility assessment were not verified for contracted nursing staff.
Failure to Maintain Privacy During Personal and Incontinence Care
Penalty
Summary
The deficiency involves failure to maintain residents’ privacy and confidentiality during provision of personal and incontinence care for two sampled residents. On 4/13/2026 at 1:40 PM, one resident (Resident #33) was observed receiving incontinence care from an LNA with the door to the hallway open and the privacy curtain between beds not drawn, while their roommate (Resident #4) was in the other bed. Another LNA entered and closed the door, but when two family members of the roommate entered the room, the privacy curtain remained open and Resident #33 was visible. On 4/14/2026 at approximately 3:30 PM, Resident #4 was observed in bed receiving personal care from three LNAs with the door to the hallway wide open and the resident exposed on the bed until one LNA noticed the surveyors and closed the door. Per interview on 4/15/2026 at 12:30 PM, the DON confirmed that LNAs should have provided privacy to the residents by drawing the privacy curtain and/or closing the door, indicating that the observed practices did not align with the facility’s expectations for maintaining resident privacy during personal care.
Failure to Obtain Timely Physician Response for Ongoing Pruritus and Skin Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician supervised and provided consultation or treatment after being contacted regarding a resident with ongoing pruritus and self-inflicted skin injuries. During an interview and observation, the resident reported itching for about three weeks, stated they had requested medication to help, and was observed scratching both arms, which showed deep scratches on the upper and lower arms. The resident’s care plan documented multiple episodes of self-inflicted scratches to the hands and forearm over several weeks, with interventions directing staff to report abnormalities, failure to heal, and signs and symptoms of infection or maceration to the physician. Record review showed that on 3/27/2026 a verbal order was received to restart scheduled Triamcinolone cream to the right arm and left shin daily for 14 days. A skin/wound note dated 4/5/2026 documented that the resident continued to have pruritus to all extremities, with one open area on the left hand and no signs of infection, and that a message was left for the provider questioning the need for systemic medication (cetirizine) to ease the pruritic issue and assist with sleep. A communication note dated 4/11/2026 documented a call to update the physician that there were no changes to the areas on the arms and legs and that the resident continued to scratch and areas remained inflamed, with staff “waiting on updated orders,” but no physician response or new orders were documented. In interviews, an RN and the DON confirmed there had been a delay in physician response despite multiple calls and faxes and that the physician had not yet responded to the request for treatment for this resident’s ongoing scratching and skin issues.
Failure to Complete Required Total Program of Care Reviews
Penalty
Summary
Surveyors identified that physicians failed to complete required total program of care reviews for two residents. One resident with multiple complex diagnoses, including dementia, anxiety, osteoporosis, cachexia, GERD, adult failure to thrive, sacral pressure ulcer, malnutrition, depression, bipolar disorder, and dysphagia, had physician/provider regulatory visit progress notes over a one-year period that did not document a total review of care. At each visit, the physician documented that the resident was taking Vitamin B-12 1000 mcg daily and Diflucan 100 mg daily, even though these medications were not present in the current physician orders. Additionally, nursing progress notes documented the development and treatment of MASD on specific dates, but the physician’s regulatory visit note during that same period did not reflect that the resident was being treated for MASD. Nursing progress notes for the same resident also documented a stage 2 pressure ulcer on the coccyx and bilateral blanchable erythema on the heels, but the corresponding physician/provider regulatory visit note did not document the presence of these wounds or the care needed to treat them. The DON confirmed that the physician had not documented a total review of care for this resident and reported difficulty getting certain providers to complete such reviews. For another resident admitted in January 2025, review of physician/provider notes from admission through the survey date showed no provider visit notes that met the definition of a total program of care review, including a review of all current medications, treatments, and all aspects of the resident’s comprehensive plan of care.
Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to hand hygiene during medication administration for two residents. On 4/14/2026 at 8:22 AM, an LPN was observed preparing and administering medications to Resident #26 without performing hand hygiene with either hand sanitizer or soap and water before or after wearing gloves. During the same medication pass, the LPN also failed to perform hand hygiene before or after administering eye drops and after replacing a medication patch on the back of Resident #28. In an interview shortly after the observation, the LPN acknowledged not performing hand hygiene for these residents and stated that she typically washes her hands or uses hand sanitizer only after every few medications or residents or when she completes direct care. Review of the facility’s Hand Hygiene Policy (reviewed 4/2019) showed that gloves do not replace hand hygiene and that alcohol-based hand sanitizer or soap and water must be used before preparing or handling medications, before and after direct resident contact, and after glove removal. Review of the Medication Administration-General Guidelines Policy (reviewed 8/2025) indicated that staff administering medications must adhere to good hand hygiene before and after administration of ophthalmic and topical preparations. The DON confirmed that the nurse’s actions did not follow facility policies and practices for hand hygiene.
Deficient Food Storage and Sanitation Practices Identified in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and sanitation practices within the facility's kitchen. An open and undated package of waffles was found in the freezer, and a container of rotting lettuce was present in the walk-in refrigerator. Additional issues included uncovered celery, an open and undated package of hot dogs, a container of raw chicken sitting in its own juices, and an undated package of American cheese slices. Expired food items, such as two large containers of yogurt and a container of pasta salad, were also found. A kitchen staff member confirmed that items were expired, undated, and improperly stored, and admitted to not knowing how long items should remain in the refrigerator. The staff member repackaged and dated the hot dogs instead of discarding them and acknowledged that rotting and uncovered items should have been discarded or covered according to facility policy. Further inspection revealed unsanitary conditions throughout the kitchen. Debris was found under the steam table, on the cart holding serving trays, and in the spooning tray. Sticky substances were present on shelves holding food items, and the microwave contained debris and had not been cleaned. Dirty muffin containers were found on the clean dish rack, and storage containers for oats and fry mix were coated with dust and debris. Fans in the dish room were also coated with dust and debris. A kitchen staff member confirmed these observations and stated that floors are supposed to be cleaned at night. These findings demonstrate a failure to maintain safe food storage and sanitary conditions as required by facility policy.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
A resident with Alzheimer's disease, major depressive disorder, anxiety disorder, and a history of domestic abuse, who was severely cognitively impaired and required assistance from two staff for bed mobility, personal hygiene, and toileting, was not protected from sexual abuse by staff. On the night of the incident, an LPN entered the resident's room after hearing a call for help and witnessed a staff member (LNA) in the act of sexually assaulting the resident. The LNA was found with pants and underwear down, positioned between the resident's legs, and was observed engaging in sexual activity. The resident was subsequently transferred to the hospital, where a sexual assault nurse exam revealed a genital tear and trace blood, and the resident was given antibiotics for STI prophylaxis. The facility's investigation revealed several failures in protocol. Only a portion of the residents were screened for abuse following the incident, with no males or residents with severe cognitive impairment included in the sample. Additionally, the LNA involved did not have a national background check or documented abuse education in their employee file. The Director of Nursing and Administrator confirmed these lapses, and the facility's own policy required such screenings and training to prevent abuse.
Failure to Implement National Background Checks for Employees
Penalty
Summary
The facility failed to develop and implement a policy requiring national background checks for all employees, as evidenced by interviews and record reviews. Specifically, a licensed nursing assistant (LNA) was employed and worked for 73 days without a national background check, during which time the LNA sexually assaulted a resident. Review of employee files revealed that 4 out of 5 sampled employees did not have national background checks, and overall, 77 out of 103 staff members lacked this screening. The Human Resources Director confirmed that national background checks were only being conducted for agency staff, not for full-time, volunteer, or contracted staff. Despite state and federal requirements communicated to the facility in memos, which mandate national background checks prior to employment and at least annually, the facility's policy did not address these requirements. The Director of Nursing and the Administrator both confirmed a lack of understanding and implementation of these requirements. The facility's existing abuse prevention policy referenced several screening measures but did not specifically address the need for national background checks for all employees, nor did it reflect current state requirements.
Failure to Provide Abuse Training Prior to Substantiated Sexual Assault
Penalty
Summary
The facility failed to provide required abuse prevention training to an employee prior to a substantiated incident of sexual assault. Specifically, one Licensed Nursing Assistant (LNA) worked at the facility for 73 days without any documented education or training on abuse, neglect, or exploitation, as confirmed by a review of the employee's human resources file and by the Human Resources Director. The facility's own policy requires that all staff and volunteers receive training on abuse policy and procedures upon hire and annually thereafter, but this was not followed in the case of this employee. The deficiency was identified after the facility substantiated that the LNA sexually assaulted a resident. During the investigation, surveyors reviewed the facility's educational materials and policies, which included training modules and handouts on abuse, neglect, exploitation, and reporting requirements. However, there was no evidence that the LNA in question had completed any of this required training prior to the incident. The Director of Nursing and Human Resources Director both confirmed the lack of abuse education for this employee.
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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 Morrisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greensboro Nursing Home | 15 mi | ★★★★★ | 10 | 0 |
| Union House Nursing Home | 19.9 mi | ★★★★★ | 11 | 0 |
| Premier Rehab And Healthcare At Berlin | 23.3 mi | ★★★★★ | 2 | 0 |
| Barre Gardens Nursing And Rehab, Llc | 25 mi | ★★★★★ | 13 | 3 |
| Maple Lane Nursing Home | 25.4 mi | ★★★★★ | 3 | 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.