A list of the most recent deficiencies for Manchester Manor Conv Hospital. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-20 | 2024-01-20 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-13 | 2023-07-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-13 | 2023-07-13 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-04-25 | 2023-05-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-11 | 2023-05-11 | Y |
| 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 | 2023-04-11 | 2023-05-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-16 | 2022-10-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-16 | 2022-10-16 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-11-03 | 2021-12-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-03 | 2021-12-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-03 | 2021-12-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-03 | 2021-12-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-11-03 | 2021-12-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-03 | 2021-12-10 | N |
| Post nurse staffing information every day. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-03 | 2021-12-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-11-03 | 2021-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-03 | 2021-12-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-03 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-03 | 2021-12-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-03 | 2021-12-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-14 | 2021-10-28 | 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 | 2021-04-02 | 2021-05-12 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-04-02 | 2021-05-12 | 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 | 2019-04-24 | 2019-06-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-24 | 2019-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-24 | 2019-06-07 | 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 | 2019-04-24 | 2019-06-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-24 | 2019-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-24 | 2019-06-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-24 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-24 | 2019-06-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-19 | 2019-05-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-19 | 2019-05-14 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Develop a communication plan. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-15 | 2018-05-31 | 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 | 2018-05-06 | 2018-05-29 | 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 | 2018-05-06 | 2018-05-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-05-06 | 2018-05-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-06 | 2018-05-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-06 | 2018-05-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-06 | 2018-05-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-06 | 2018-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-06 | 2018-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-06 | 2018-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-06 | 2018-05-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-05-06 | 2018-05-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-06 | 2018-05-29 | 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 | 2018-05-06 | 2018-05-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-06 | 2018-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-06 | 2018-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-06 | 2018-05-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-06 | 2018-05-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-05-06 | 2018-05-29 | N |
