Deficiency Records for Manchester Rehab and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Manchester Rehab and Healthcare 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? |
|---|---|---|---|---|
| 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 | 2023-12-05 | 2024-02-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-05 | 2024-01-18 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-12-05 | 2024-01-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-05 | 2024-01-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-05 | 2024-01-18 | N |
| 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. | Health | 2023-12-05 | 2024-01-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-05 | 2024-01-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2024-01-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-05 | 2024-01-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-05 | 2024-01-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-05 | 2024-01-18 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-05 | 2024-01-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-05 | 2024-01-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-05 | 2024-01-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Develop a communication plan. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-05 | 2024-01-18 | 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 | 2023-12-05 | 2024-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-05 | 2023-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-15 | 2023-03-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-15 | 2023-03-07 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-01 | 2023-03-07 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-01 | 2023-03-07 | 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 | 2023-01-25 | 2023-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-25 | 2023-02-15 | Y |
| 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 | 2022-11-15 | 2023-02-15 | 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 | 2022-11-15 | 2023-02-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2023-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2023-02-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-15 | 2023-02-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-13 | 2022-10-03 | Y |
| 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 | 2022-09-13 | 2022-10-03 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-13 | 2022-10-03 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-17 | 2022-07-06 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-10 | 2022-04-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-10 | 2022-04-05 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-03-10 | 2022-04-05 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-03-10 | 2022-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-10 | 2021-06-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-10 | 2021-06-05 | Y |
| 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 | 2020-02-25 | 2020-06-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-25 | 2020-06-05 | 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 | 2020-02-25 | 2020-06-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-02-25 | 2020-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-25 | 2020-06-05 | 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 | 2020-02-25 | 2020-06-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-25 | 2020-06-05 | N |
| Post nurse staffing information every day. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-25 | 2020-06-05 | 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 | 2020-02-25 | 2020-06-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-25 | 2020-06-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-25 | 2020-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-25 | 2020-06-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-25 | 2020-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-25 | 2020-06-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-25 | 2020-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-24 | 2019-08-07 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-24 | 2019-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-24 | 2019-06-24 | 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 | 2019-05-24 | 2019-06-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-05-24 | 2019-06-24 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-24 | 2019-06-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-24 | 2019-06-24 | 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 | 2019-05-24 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-24 | 2019-06-24 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-01 | Not Fixed | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-01 | Not Fixed | Y |
