Deficiency Records for Grand Manor Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Grand Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-13 | 2023-10-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-13 | 2023-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-13 | 2023-09-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-07 | 2023-09-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-13 | 2023-09-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-13 | 2023-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-13 | 2023-09-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-13 | 2023-09-08 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-13 | 2023-09-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-07-13 | 2023-09-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-13 | 2023-09-08 | N |
| Post nurse staffing information every day. | Health | 2023-07-13 | 2023-09-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-07-13 | 2023-09-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-13 | 2023-09-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-13 | 2023-09-08 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-13 | 2023-09-08 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-07-13 | 2023-09-08 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-07-13 | 2023-09-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-13 | 2023-09-04 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-07-13 | 2023-09-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-13 | 2023-09-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-07-13 | 2023-08-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-05 | 2023-08-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-13 | 2023-08-29 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-07-13 | 2023-08-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-13 | 2023-08-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-13 | 2023-08-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-27 | 2023-06-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-15 | 2023-01-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-03 | 2022-09-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-03 | 2022-09-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-03 | 2022-09-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-03 | 2022-09-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-03 | 2022-09-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-03 | 2022-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-03 | 2022-09-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-03 | 2022-09-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-08-03 | 2022-09-28 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-08-03 | 2022-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-03 | 2022-09-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-03 | 2022-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-03 | 2022-09-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-03 | 2022-09-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-03 | 2022-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-09-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-03 | 2022-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-03 | 2022-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-09-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-03 | 2022-09-28 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-14 | 2022-07-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-20 | 2022-07-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-31 | 2022-03-28 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-11-19 | 2022-01-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-19 | 2022-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2022-01-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-11 | 2021-06-30 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-08-30 | 2019-10-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-30 | 2019-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-10-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-08-30 | 2019-10-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-30 | 2019-10-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-30 | 2019-10-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-30 | 2019-10-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-30 | 2019-10-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-30 | 2019-10-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-30 | 2019-10-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-30 | 2019-10-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-30 | 2019-10-21 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-08-30 | Not Fixed | N |
