Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grace Manor Care Center during CMS and state inspections, most recent first.
The facility failed to ensure proper storage and labeling of medications in two medication carts and one medication room. Loose medication tablets were found in the carts, and expired Tylenol suppositories were found in the medication room. The DON confirmed that there was no formal cleaning schedule, and nurses were responsible for maintaining cleanliness and checking for expired medications.
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not having a wound care order in place prior to treatment. The resident, who had a history of falling and other medical conditions, sustained an abrasion to his right elbow following an unwitnessed fall. Despite the injury, there were no treatment orders documented, and the dressing on the wound had not been changed since the fall. Staff interviews confirmed the absence of a physician's order for treating the wound and monitoring for infection.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly in two medication carts and one medication room. Specifically, medication cart #1 contained 28 whole medication tablets and one half medication tablet loose in the drawers, while medication cart #2 had 16 whole medication tablets loose in the drawers. The Licensed Practical Nurse (LPN) interviewed stated that there was no formal cleaning schedule, and it was the nurses' responsibility to keep the medication carts clean to prevent contamination and aid in medication stocking. Additionally, the medication room contained two boxes of 50 Tylenol 650 mg suppositories that had expired in February 2024, which should have been removed for destruction. The Director of Nursing (DON) confirmed that medication carts were to be cleaned daily by the charge nurse and that the pharmacy consultant performed monthly inspections. However, the facility did not have a specific schedule for cleaning the medication carts, and nurses were expected to check for expired medications and cleanliness daily. The DON also mentioned that the nurse manager was responsible for checking the medication room for expired medications every two weeks. The failure to properly store and label medications and biologicals, as well as the presence of expired medications, created a potential for medication errors and compromised the effectiveness of the medications.
Failure to Obtain Physician's Order for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #19 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not have a wound care order in place prior to treatment being provided for the resident. Resident #19, who had a history of falling and other medical conditions such as chronic kidney disease and hypertension, sustained an abrasion to his right elbow following an unwitnessed fall. Despite the injury, there were no treatment orders documented in the resident's computerized physician orders (CPO) for March and April 2024. The resident was observed with a soiled dressing on his elbow, which had not been changed since the fall, and later with the wound open to air and scabbed over. The resident confirmed that the dressing had not been changed and that he had removed it himself. Interviews with staff revealed that there was no physician's order in place for the treatment of the wound. Licensed Practical Nurse (LPN) #1 acknowledged that there should have been a physician's order for treating the wound and monitoring for infection. The Director of Nursing (DON) also confirmed that the nurse should have called the physician for an order to treat the abrasion and to monitor for infection. The facility's policy on the care of skin tears, abrasions, and minor breaks in the skin, which requires obtaining a physician's order, was not followed in this case.
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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 Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Topside Manor Inc | 29.1 mi | — | 0 | 0 |
| Cheyenne Manor | 33.7 mi | — | 12 | 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 August 2026) and official state health department websites.