Below 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 Manawa Com Nur Ctr during CMS and state inspections, most recent first.
The facility assigned a food and nutrition services director who had not completed the required certification or education and had only recently begun a certified dietary manager course, with facility leadership mistakenly believing that course enrollment alone met regulatory requirements. This affected all 23 residents.
Surveyors found that menus did not specify portion sizes or differentiate between diet types such as NAS or NCS. Dietary staff relied on memory for serving sizes, and meal cards lacked detailed instructions. Pureed meals were divided without standardized scoops, and the menu used for all residents did not reflect individual dietary needs, potentially affecting all residents.
A registered nurse left a medication cart unlocked and unattended in a hallway while administering medications to a resident, with bottles of aspirin and Lactobacillus left on top of the cart. Facility policy requires medication carts to be locked or attended at all times, and only authorized staff to have access to medications. The DON confirmed these actions were not in compliance with policy.
Surveyors identified multiple failures in the infection prevention and control program, including incomplete infection control line lists for staff and residents, missing documentation of symptom resolution, and lack of required COVID-19 testing records. Observations revealed improper linen handling, such as placing a sheet from the floor back onto a resident's bed and using soiled washcloths without barriers during peri-care. Staff also failed to follow proper procedures for hand hygiene and glove changes, and placed washcloths in unsanitized sinks during catheter care.
A resident with severe cognitive impairment and a history of stroke did not receive routine nail care as required by their care plan and facility policy. Staff and documentation confirmed that the resident's nails had not been trimmed for over a month, and scheduled nail care was missed when a shower was not provided. The DON verified the lapse in nail care, resulting in a deficiency related to assistance with activities of daily living.
A resident with chronic health conditions was not provided with appropriate respiratory care, as there was no care plan or maintenance order for oxygen therapy despite ongoing use. Facility policy requiring weekly tubing changes and regular care plan updates was not followed, and the deficiency was confirmed by the DON during the survey.
A facility failed to prevent falls for two residents due to inadequate staff training. A CNA transferred a resident without a gait belt, resulting in a fall and injury, and later transferred another resident without a mechanical lift. The CNA returned to work without receiving necessary education on proper transfer techniques, despite a history of not following care plan interventions.
The facility did not have a qualified director of food and nutrition services, as the current Dietary Manager (DM-D) lacked necessary certifications and education. DM-D, hired in March 2024, was not enrolled in a Certified Dietary Manager program, despite intentions to do so. This deficiency could impact all 23 residents, as the facility was not seeking a new manager.
The facility failed to maintain complete medical records for four residents, as physician visit notes were missing. The issue arose after a provider switch in December 2023, which left the facility without access to the new provider's electronic portal. The DON confirmed the deficiency, and the ADON later received most of the missing notes from the physician's office.
A facility failed to thoroughly investigate an alleged neglect incident where a CNA transferred a resident without a gait belt, resulting in a fall and injury. The CNA returned to work without receiving necessary education, and was involved in another improper transfer. The investigation was not completed or submitted timely.
The facility did not ensure that two CNAs received mandatory QAPI training as part of their onboarding process. Despite being listed as a required training, records for CNA-I and CNA-J, hired in 2017 and 2015 respectively, showed no evidence of QAPI training. The Business Office Manager confirmed the lack of documentation, highlighting a gap in the facility's training records.
The facility failed to maintain a safe and clean environment after heavy rains caused water damage in several rooms, leading to mold-like growth and a mildew smell. Despite concerns from residents and family members, the facility did not immediately relocate affected residents or complete necessary repairs, leaving them in potentially unsafe conditions.
The facility failed to report abuse allegations involving four residents to the appropriate authorities in a timely manner. Incidents of verbal and alleged sexual abuse were not promptly reported, despite the facility's policy requiring immediate action. Staff interviews revealed delays in reporting due to the frequency of such incidents, and the Director of Nursing was unaware of some incidents until the surveyor's review.
The facility failed to investigate abuse allegations involving four residents. One resident verbally abused two others on separate occasions, and another resident allegedly sexually abused a second resident. The facility did not conduct thorough investigations into these incidents, and the DON was unaware of them until informed by the surveyor. The facility's policy requires immediate investigation of abuse allegations, but this was not followed, leading to a deficiency in addressing and investigating these incidents.
The facility failed to ensure timely reporting of allegations of abuse and misappropriation for four residents. An LPN administered lorazepam to a resident without a physician's order or consent, and this incident was not reported promptly. Additionally, a Hospitality Aide alleged that a CNA physically abused another resident with a hot washcloth, and a CNA alleged that the same LPN misappropriated lorazepam from another resident. These incidents were not reported to administration or the State Agency in a timely manner, resulting in a deficiency in the facility's compliance with regulations.
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving four residents. Incidents included unauthorized administration of medication, physical abuse with a hot washcloth, and misappropriation of lorazepam. The investigations were incomplete, lacking interviews with all relevant staff and residents, and missing documentation in nursing notes.
A resident with severe cognitive impairment was administered lorazepam by an LPN without a physician's order or consent from the resident's POAHC. The LPN gave the medication to calm the resident, which was against the facility's policy. The incident was reported by a staff member, and an investigation confirmed the unauthorized administration.
The facility failed to ensure an RN worked for at least eight consecutive hours per day on multiple dates in November 2023, December 2023, and January 2024. The DON was aware of the requirement but was only on-call during the days without RN coverage.
The facility did not designate a qualified person to serve as the director of food and nutrition services. The Dietary Manager, who started as a dietary aide, did not complete an approved certification course and only received training from the non-accredited ServSafe program. The Registered Dietitian's feedback was not well received, and the Business Office Manager recognized the need for higher education for kitchen staff.
The facility did not ensure food was prepared and served under sanitary conditions, lacking an internal surface temperature monitoring device for the dishwasher. The Dietary Manager was unaware of the food code followed and did not know if the facility had logs or a process for monitoring the dishwasher's internal surface temperature. Observations showed inconsistent temperature readings, and the facility lacked additional temperature logs or a policy for monitoring.
The facility failed to monitor high-risk medications for three residents, specifically for potential side effects or adverse reactions of opioid medications such as fentanyl and morphine. The care plans and physician orders for these residents did not include necessary monitoring interventions, which was confirmed by the DON.
The facility failed to review vaccination history or offer the PCV20 vaccine to three residents. The DON indicated that new residents are offered the PCV20 vaccine, but existing residents were not audited or offered the vaccine due to the focus on COVID-19 and influenza vaccines. The ADON confirmed that only PCV13 and PPSV23 vaccines were audited.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the food and nutrition services director, as required by regulations. The person assigned to this role, identified as DM-H, had not completed an approved dietary manager or food service manager certification course, nor did they possess a national certification or an associate's or higher degree in food service management or hospitality. DM-H was hired in March 2024 and, although enrolled in a certified dietary manager (CDM) course, had only started the course approximately one month prior to the survey. Interviews with DM-H and the Director of Nursing (DON) confirmed that DM-H had delayed starting the course due to personal and staffing issues, and that facility leadership believed enrollment in the course was sufficient to meet requirements. This deficiency had the potential to affect all 23 residents residing in the facility.
Menus Lacked Portion Sizes and Diet Differentiation
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents in accordance with established national guidelines. Observations revealed that the menu did not specify portion sizes or differentiate between diet types such as No Added Salt (NAS) or No Concentrated Sweets (NCS). Dietary staff confirmed that there were no written instructions on the menu regarding portion sizes or specific dietary modifications for different resident needs. Instead, staff relied on their own knowledge of which scoops to use for serving, and meal cards did not contain portion sizes or indicate changes between diets. During meal service, pureed meals were divided evenly among residents without the use of standardized scoops, and any leftover food was given to a resident known to eat more, further indicating a lack of standardized portion control. Interviews with the Dietary Manager and the recently hired Registered Dietitian confirmed that the facility used a single menu for all residents, which lacked delineation between different diet types and did not specify portion sizes. The dietitian acknowledged that menus should be standardized for all diets and that the current system did not meet this requirement. The absence of an extended menu that clearly outlined differences between diet types and portion sizes had the potential to affect all 23 residents in the facility.
Unattended and Unsecured Medication Cart During Medication Pass
Penalty
Summary
Surveyors observed that medication storage and security protocols were not followed during a medication pass. A bottle of aspirin 81 mg and a bottle of Lactobacillus 100 mg, both intended for a specific resident, were left on top of an unlocked medication cart. The cart was left unattended in the hallway by a registered nurse while the nurse administered medications in residents' rooms, at times with the door closed. During this period, both staff and residents passed by the unattended cart. The nurse later confirmed that the medications should have been secured and that the cart should have been locked when not attended. Facility policies require that only authorized personnel have access to medications and that medication carts are locked or attended at all times. The policies also specify that the cart must be locked before entering a resident's room and that medications should never be left on top of the cart. The Director of Nursing acknowledged awareness of the incident and confirmed that the observed practices did not align with facility policy.
Infection Control Program Deficiencies and Improper Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by incomplete and inaccurate infection control line lists for both residents and staff. The line lists were missing critical information such as last symptom dates, times, and return-to-work dates, which are required by facility policy and CDC guidance. Additionally, the facility did not provide requested COVID-19 testing results for staff on day 5 and day 7, and several entries for residents and staff lacked documentation of symptom resolution or removal from precautions. The Director of Nursing confirmed these omissions and acknowledged that the facility used the test date as day one instead of day zero, contrary to standard protocols. Direct care observations revealed lapses in infection control practices during resident care and linen handling. For one resident with multiple comorbidities, including diabetes and chronic kidney disease, an Assistant Director of Nursing placed a sheet that had been on the floor back onto the resident's bed and later covered the resident with it, despite the resident indicating it was saturated with urine. During peri-care, a CNA used only two washcloths for both the front and back areas, placed soiled washcloths directly on the bed without a barrier, and failed to change gloves or perform hand hygiene before handling clean items and assisting with a lift. Both the CNA and the Director of Nursing confirmed these practices, which were inconsistent with facility policy and training materials. Further, improper linen handling was observed during catheter care for another resident, where a CNA placed washcloths in a sink without sanitizing it first, instead of using a basin as required. The CNA and the staff development nurse both acknowledged that this was not in accordance with facility procedures. These observed actions and documentation failures demonstrate a lack of adherence to established infection control protocols, increasing the potential for transmission of communicable diseases among residents and staff.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, a history of Marfan syndrome, dementia, and stroke, was not provided with routine nail care as required by facility policy. The resident's care plan specified that nail length should be checked and nails trimmed and cleaned on bath days and as necessary. Despite this, documentation and staff interviews revealed that the resident's nails had not been trimmed since a documented activity on 3/18/25, and on observation, the resident's fingernails were found to be clean but approximately 1/4 inch long. The resident required substantial to maximal assistance with activities of daily living, including bathing and nail care, due to their medical conditions and cognitive status. Further review showed that the resident was scheduled to receive a shower and associated care, including nail care, on a specific day, but the shower was not provided due to a missing key to the shower room. Documentation for that day did not indicate whether nail care was performed. Staff interviews confirmed that nail care should have been provided regardless of whether the shower occurred, and the DON verified that the last documented nail trimming was over a month prior. This failure to provide routine nail care as outlined in the care plan and facility policy constituted the deficiency.
Failure to Provide Necessary Respiratory Care and Services
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including type 2 diabetes mellitus with neuropathy, traumatic amputation, and chronic kidney disease, was not provided with the necessary respiratory care and services as required. The resident had an order for oxygen therapy to be administered as needed via nasal cannula for respiratory distress or discomfort, with instructions to titrate to maintain oxygen saturation above 90%. Despite this, there was no order in place for changing or maintaining the resident's oxygen equipment, nor was there a care plan for respiratory therapy documented at the time the resident was observed using oxygen. The facility's policy required weekly tubing changes and regular updates to the care plan by licensed nursing staff, but these were not followed. Surveyor observations and record reviews revealed that the resident was using oxygen for significant periods each day, yet the Treatment Administration Record did not include a maintenance order for oxygen tubing, and a care plan for oxygen therapy was not present until after the survey began. The Director of Nursing confirmed that a care plan should have been developed when the resident started using oxygen consistently and acknowledged the absence of an order for weekly tubing changes as required by facility policy.
Failure to Prevent Falls Due to Inadequate Staff Training
Penalty
Summary
The facility failed to provide adequate assistance to prevent falls for two residents, R3 and R5, as per their care plans. On August 19, 2024, a Certified Nursing Assistant (CNA-E) transferred R3 without using a gait belt, which was required according to R3's care plan. This resulted in R3 falling and sustaining a 4 cm forehead laceration and a subdural hematoma. Despite the incident, CNA-E was allowed to return to work on August 24, 2024, without receiving the necessary education on proper transfer techniques. On August 24, 2024, CNA-E was observed transferring R5 without using a mechanical lift, which was required by R5's care plan. This incident occurred before the facility completed its investigation into the previous incident involving R3. The facility's policies required that staff be educated as necessary during an investigation, but this was not adhered to in CNA-E's case. Interviews with staff revealed that CNA-E had a history of not following care plan interventions related to transfers, and management had been informed of this behavior previously. The facility's failure to educate CNA-E on following care plan interventions for transfers and allowing CNA-E to return to work without this education created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy. The facility's policies on abuse, neglect, and transfer procedures were not followed, contributing to the incidents involving R3 and R5.
Removal Plan
- Educate direct care/nursing staff on following care cards/care plan interventions related to transfer status.
- Update a binder to be kept at the nurses' station with care cards and individual service plans for residents.
- Conduct audits to ensure accuracy of transfer status.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which is a requirement for ensuring proper management and safety in food service operations. The Dietary Manager (DM-D) was identified as the lead cook and had been hired in March 2024. However, DM-D had not completed an approved dietary manager or food service manager certification course, nor did they possess any related education or national certification for food service management and safety. This deficiency was identified during a surveyor's visit to the kitchen, where DM-D confirmed their role as the Dietary Manager and mentioned plans to enroll in a Certified Dietary Manager (CDM) program. Interviews with the Director of Nursing (DON-B) and the Business Office Manager (BOM-C) revealed that DM-D was rehired in April 2024 to be the Dietary Manager after the previous manager left. Both DON-B and BOM-C acknowledged that DM-D was not currently enrolled in the CDM course, although there were intentions for DM-D to complete the course. The lack of a qualified director of food and nutrition services had the potential to affect all 23 residents residing in the facility, as the facility was not actively seeking a new Dietary Manager and relied on DM-D, who was not yet certified.
Incomplete Medical Records Due to Missing Physician Visit Notes
Penalty
Summary
The facility failed to ensure that medical records contained complete information for four residents, as physician visit notes were not readily accessible and available in their medical records. The surveyor reviewed the medical records of four residents, each with various diagnoses such as Alzheimer's disease, dementia, hypertension, anxiety, hypothyroidism, and arthritis. It was found that the physician visit notes were missing from the records of these residents, which is a requirement according to the facility's Long Term Facilities Retention Plan. The Director of Nursing (DON) acknowledged the issue, indicating that the facility had switched providers in December 2023 and had not yet set up access to the new provider's electronic portal system. This lack of access resulted in the unavailability of the physician visit notes. The Assistant Director of Nursing (ADON) later confirmed that the physician's office had sent most of the missing notes, except for one resident's notes, which were received later. This deficiency highlights the facility's failure to maintain complete and accessible medical records for its residents, as required by professional standards.
Failure to Investigate Alleged Neglect Thoroughly
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged neglect incident involving a resident, R3, who was transferred without a gait belt by a Certified Nursing Assistant (CNA-E). This incident resulted in R3 falling and sustaining a forehead laceration and hematoma. The facility's policy mandates that staff receive education on resident mistreatment and neglect, and that alleged perpetrators be removed pending investigation. However, CNA-E returned to work before the investigation was completed and without receiving the necessary education. The investigation revealed that CNA-E was involved in another improper transfer of a different resident, R5, who required a sit-to-stand lift for transfers. This transfer was conducted without the required equipment, further indicating a lapse in adherence to care plans. The Director of Nursing confirmed that staff education on falls and care plan interventions began only after CNA-E had returned to work, and the final investigation report was not submitted to the State Agency until after CNA-E's return.
Deficiency in QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNA-I and CNA-J) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of staff education requirements. The facility provided a list of trainings that new employees are supposed to receive on their first day, which included QAPI training. However, upon reviewing one year of electronic and paper training records for CNA-I and CNA-J, the surveyor found no documentation of QAPI training for these staff members. CNA-I was hired on 5/16/17 and CNA-J on 7/22/15, indicating a long-standing oversight. The Business Office Manager, responsible for training and onboarding, confirmed the absence of QAPI training records for these CNAs, despite the facility's policy that such training should occur during orientation.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for several residents, specifically those residing in rooms affected by water damage from heavy rains. On July 5, 2024, water from heavy rains penetrated the exterior walls of certain rooms, leading to the presence of a black and/or dark green, damp, and smudgeable substance on the baseboards and drywall surfaces. Additionally, a white fuzzy growth and a mildew-like smell were noted in some rooms. The 100 wing lounge was also affected, containing remodeling supplies and a bed stored in the center of the room, which contributed to the unclean environment. The surveyor's observations on July 26, 2024, confirmed the presence of these substances in the affected rooms, with varying degrees of growth noted on the baseboards and drywall. Family members and residents expressed concerns about the mold-like smell, with one family member indicating sensitivity due to asthma. Despite these concerns, the facility did not block off the lounge during repairs, and the affected residents continued to reside in their rooms without immediate relocation. The Nursing Home Administrator acknowledged the presence of the substances and indicated plans to repair the affected rooms within a few days to a week. However, at the time of the survey, the facility had not yet completed the necessary repairs or relocated the residents to unaffected rooms. The County Public Health Department and the facility's Medical Director provided guidance on testing and monitoring for respiratory symptoms, but the deficiency remained unaddressed at the time of the survey.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse involving four residents to the Nursing Home Administrator, the State Agency, and local law enforcement in a timely manner. Specifically, incidents of verbal abuse by one resident towards two other residents were not reported promptly. Additionally, an incident involving alleged sexual abuse by another resident was not reported to the appropriate authorities. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed. The residents involved had varying levels of cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident, who was involved in multiple incidents of verbal aggression, had a severe cognitive impairment, while the other residents had moderate to no cognitive impairment. Despite the facility's policy to monitor and report aggressive behaviors, staff failed to report these incidents immediately, citing the frequency of such occurrences as a reason for the delay. Interviews with staff revealed that incidents were often reported the day after they occurred, which is against the facility's policy. The Director of Nursing was unaware of some incidents until the surveyor's review, indicating a breakdown in communication and reporting procedures. The facility's failure to report these incidents in a timely manner represents a significant deficiency in adhering to established protocols for handling and reporting abuse allegations.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations involving four residents. On two occasions, one resident verbally abused another, and the facility did not conduct a comprehensive investigation into these incidents. Additionally, the same resident verbally abused a third resident, and again, the facility did not thoroughly investigate the matter. The Director of Nursing (DON) was unaware of these incidents until informed by the surveyor, indicating a lack of proper reporting and investigation procedures. Another incident involved a resident allegedly sexually abusing a second resident. The facility did not thoroughly investigate this allegation either. The resident accused of the abuse had a history of inappropriate sexual behavior, as noted in their care plan, but no updates were made to address the behavior towards other residents. The DON was also unaware of this incident, further highlighting the facility's failure to document and investigate reported incidents of abuse. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property requires immediate investigation of such allegations. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and investigation into the reported incidents. The DON's lack of awareness of these incidents suggests a breakdown in communication and reporting within the facility, leading to the deficiency in addressing and investigating abuse allegations.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and misappropriation for four residents. On 4/9/24, an LPN administered a dose of lorazepam, a sedative medication, to a resident without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). This incident was not reported to administration or local law enforcement in a timely manner. Additionally, on 4/10/24, a Hospitality Aide alleged that a CNA physically abused another resident with a hot washcloth, but this incident was also not reported to administration or the State Agency (SA) in a timely manner. Furthermore, on 4/25/24, a CNA alleged that the same LPN misappropriated a dose of lorazepam from another resident on 7/17/23, and this incident was not reported to administration or the SA in a timely manner either. The facility's policy on abuse, neglect, and exploitation was not followed, and staff were not adequately educated on timely reporting of such incidents. The Director of Nursing (DON) confirmed that the incidents were not reported promptly and that staff education on timely reporting was insufficient. The facility's investigation revealed that the incidents were eventually reported to law enforcement and the SA, but not in a timely manner as required by the facility's policy. The failure to report these incidents promptly resulted in a deficiency in the facility's compliance with regulations regarding the reporting of abuse, neglect, and misappropriation. The facility's policy on abuse, neglect, and exploitation was not followed, and staff were not adequately educated on timely reporting of such incidents. The Director of Nursing (DON) confirmed that the incidents were not reported promptly and that staff education on timely reporting was insufficient. The facility's investigation revealed that the incidents were eventually reported to law enforcement and the SA, but not in a timely manner as required by the facility's policy. The failure to report these incidents promptly resulted in a deficiency in the facility's compliance with regulations regarding the reporting of abuse, neglect, and misappropriation.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility did not ensure all allegations of abuse and misappropriation were thoroughly investigated for four residents. On one occasion, an LPN administered a dose of another resident's lorazepam to a resident without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). The facility's investigation was incomplete, as not all staff and residents were interviewed, and there was no documentation of the incident in the resident's nursing notes for the day in question. In another incident, a Hospitality Aide alleged that a CNA physically abused a resident with a hot washcloth. The facility's investigation included a statement from the aide and water temperature audits but failed to document an interview with the accused CNA or other staff members who worked with the CNA. Additionally, the facility did not interview other residents to determine if they were affected. A third incident involved an allegation of misappropriation of a resident's lorazepam by an LPN. The facility's investigation included a statement from a CNA but did not interview other staff members, including night shift nurses who conducted controlled substance counts with the LPN. The facility also failed to document the incident in the resident's nursing notes and did not thoroughly investigate the timeline and events surrounding the alleged misappropriation.
Unauthorized Administration of Lorazepam to Resident
Penalty
Summary
The facility did not ensure that a resident (R2) was free from chemical restraints, as a Licensed Practical Nurse (LPN-C) administered lorazepam to R2 without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). R2, who had severe cognitive impairment and was not prescribed lorazepam, was given the medication to stop pacing and calm down. This action was against the facility's policy, which requires written authorization from a physician for any chemical restraint. The incident was reported by a Hospitality Aide (HA-E) who witnessed LPN-C administering lorazepam to R2 and later observed R2 becoming unusually calm and relaxed. The facility's investigation confirmed that lorazepam was detected in R2's urine, and LPN-C had admitted to giving the medication to R2 because they were busy and could not handle the situation. The investigation also revealed that R2's medical record did not contain any documentation or physician's order for lorazepam on the day of the incident. Further review of the facility's records and interviews with staff corroborated the findings. The Director of Nursing (DON-B) verified that LPN-C's actions constituted a chemical restraint, which was against the facility's policy. The Police Chief (PC-G) also confirmed that the POAHC did not give consent for the administration of lorazepam to R2. The facility's investigation included statements from staff and drug panel results, which provided evidence of the unauthorized administration of lorazepam to R2.
RN Coverage Deficiency
Penalty
Summary
The facility did not ensure a Registered Nurse (RN) worked for at least eight consecutive hours per day seven days per week on multiple dates in November 2023, December 2023, and January 2024. This deficiency was identified through a review of the facility's nurse staffing schedules from October 2023 through January 2024, which revealed that the facility lacked RN coverage for at least 8 consecutive hours on nine specific dates. Interviews with the Business Office Manager (BOM) and the Director of Nurses (DON) confirmed awareness of the regulatory requirement but indicated that the DON was only on-call during the days without RN coverage, rather than physically present for the required hours.
Unqualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the required qualifications. The Dietary Manager (DM) hired on 9/20/23 did not complete an approved dietary manager or food service manager certification course or other related education. The DM, who started as a dietary aide, functioned more as a glorified cook and oversaw food ordering, cooking, and instruction for kitchen staff. The DM only received training from the ServSafe program, which is not an accredited food service program. The Registered Dietitian (RD) visited the facility once per month and was available by email when not on-site. The RD worked with the DM on kitchen processes but felt that their feedback and collaboration were not well received. The Business Office Manager (BOM) was under the impression that ServSafe was an approved course and indicated a need to implement a higher level of education and understanding for all kitchen staff.
Sanitary Conditions and Temperature Monitoring Deficiency
Penalty
Summary
The facility did not ensure food was prepared and served under sanitary conditions, potentially affecting all 23 residents. The facility lacked an internal surface temperature monitoring device to routinely monitor and ensure the warewashing machine (dishwasher) was functioning correctly. The Dietary Manager (DM) was unsure of the food code the facility followed and did not know if the facility had logs or a process for monitoring the internal surface temperature of the dishwashing machine. The Business Office Manager (BOM) confirmed that the facility used ServSafe, based on the FDA Food Code, as its standard of practice. The DM was not aware of internal surface temperature monitoring and did not know if the dishwashing machine used chemical or heat sanitization, deferring to the BOM for this information. The BOM confirmed that the dishwashing machine was a hot water sanitization machine, but the DM could not provide internal temperature monitoring logs. The surveyor observed the DM washing dishes in the dishwashing machine, noting that the temperature dials displayed a bouncing needle between 135-148 degrees F for the wash cycle and 186 degrees F for the rinse cycle. Despite this, the DM did not re-wash the dishes. The company that leases the machine verified it was working properly. Further observations showed the temperature dial displaying 140 degrees F for the wash cycle and 182 degrees F for the rinse cycle. After the machine's temperature was increased by the service company, the external temperature dial for the wash cycle reached 150 degrees F and the rinse cycle reached 190 degrees F, with the internal surface temperature of the cups measuring 160 degrees F. The DM verified the facility had one temperature monitoring log, which did not contain a month but was stated to be for February 2024. The log showed wash cycles documented as 168, 169, or 170 degrees F, and the DM stated staff averaged the reading when the needle bounced. The BOM confirmed the facility did not have additional temperature logs or a policy for internal or external temperature log monitoring.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility did not ensure high-risk medications were monitored for three residents (R2, R7, and R14) of five residents reviewed for unnecessary medications. Specifically, the facility failed to monitor these residents for potential side effects or adverse reactions of opioid medications such as fentanyl and morphine. The facility's Pain policy aims to recognize and manage pain to help residents attain or maintain their highest practicable level of well-being and to prevent or manage pain. However, the medical records and care plans for R2, R7, and R14 did not contain monitoring interventions for potential side effects or adverse reactions related to their opioid medications. For R2, the medical record showed an order for a fentanyl patch, but the care plan and physician orders lacked monitoring interventions for side effects or adverse reactions. Similarly, R7 had an order for morphine sulfate tablets, and R14 had an order for morphine sulfate oral solution, but neither of their care plans nor physician orders included monitoring interventions for potential side effects or adverse reactions. The Director of Nursing (DON) confirmed that monitoring was an expectation and verified the absence of these interventions in the residents' care plans and physician orders.
Failure to Administer PCV20 Vaccine to Residents
Penalty
Summary
The facility did not ensure that vaccinations were reviewed, offered, and administered for three residents (R14, R10, and R4) out of five residents reviewed for vaccines. Specifically, the facility failed to review the vaccination history or offer the PCV20 (Prevnar 20) vaccine to these residents. R14, who was admitted with diagnoses including Parkinson's disease, dementia, and hemiplegia, had received a PPSV23 vaccine in 2014 and a PCV13 vaccine in 2016 but was not offered the PCV20 vaccine. Similarly, R10, admitted with diagnoses including COVID-19, chronic kidney disease stage 3, dementia, hemiplegia, and diabetes, had received a PPSV23 vaccine in 2016 and a PCV13 vaccine in 2015 but was not offered the PCV20 vaccine. R4, admitted with diagnoses including Alzheimer's disease, COVID-19, and dementia, had received a PPSV23 vaccine in 2004 and a PCV13 vaccine in 2015 but was also not offered the PCV20 vaccine. The Director of Nursing (DON), who also served as the facility's Infection Preventionist, indicated that new residents are offered the PCV20 vaccine upon admission. However, the facility had not audited or offered the PCV20 vaccine to existing residents. The DON stated that the facility was focused on administering COVID-19 and influenza vaccines, which led to the oversight. The Assistant Director of Nursing (ADON) confirmed that they were assisting with follow-up on vaccines but had only audited residents for the PCV13 and PPSV23 vaccines, not the PCV20 vaccine.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Weyauwega | 9.7 mi | ★★★★★ | 6 | 0 |
| St Joseph Residence | 10.7 mi | ★★★★★ | 7 | 0 |
| Bethany Home | 11.5 mi | ★★★★★ | 2 | 0 |
| Wi Veterans Home Moses Hall | 12.3 mi | ★★★★★ | 3 | 1 |
| Wi Veterans Hm Ainsworth Hall | 12.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.