All citations for Elizabeth Church Manor Nursing Home

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Elizabeth Church Manor Nursing Home

Last standard health inspection on record

August 1, 2025

Showing 1 to 22 of 22 citations

  1. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 21, 2024).

  2. No harm, with potential for more than minimal harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  3. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  4. No harm, with potential for more than minimal harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of August 22, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  5. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  6. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  7. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 28, 2024).

  8. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  9. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 21, 2024).

  10. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 21, 2024).

  11. No harm, with potential for more than minimal harm

    Ensure that testing and maintenance of electrical equipment is performed.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 21, 2024).

  12. No harm, with potential for more than minimal harm

    Allow residents to self-administer drugs if determined clinically appropriate.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0554, Resident Rights Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  13. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  14. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of August 22, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  15. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  16. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  17. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  18. No harm, with potential for more than minimal harm

    Address subsistence needs for staff and patients.

    Isolated (one or a few residents). CMS level D.

    Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 10, 2024).

  19. No harm, with potential for more than minimal harm

    Have an enclosure around a vertical opening shaft.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0311, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  20. No harm, with potential for more than minimal harm

    Have restrictions on the use of portable space heaters.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0781, Miscellaneous Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

  21. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 26, 2024).

  22. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 21, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.