Manchester Center For Rehabilitation And Healing L

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to perform an assessment for the use of a seatbelt for 2 residents (Resident #34 and #67) of 3 residents reviewed for physical restraints.The findings include: Review of the facility's policy dated 4/2017 titled Use of Restraints, revealed .individuals shall be reviewed regularly (at least quarterly) . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the comprehensive Care Plan initiated 4/26/2026 and revised 4/30/2026, revealed .Resident is at risk for falls r/t [related to] impaired mobility .use of proper assistive device . and .Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement the care plan for the use of a lap belt for 2 residents (Resident #34 and #67) and for falls for 1 resident (Resident #107) of 15 residents reviewed for care plans. The findings include: Review of the facility's policy dated 4/2017 titled Use of Restraints, revealed .care plans for residents in restraints . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes. Review of an admission MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive Care Plan initiated 4/26/2026, revealed .Resident is at risk for falls r/t [related to] impaired mobility .use of proper assistive device . and .Resident requires PT/OT [physical therapy/occupational therapy] due to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interviews, the facility failed to revise the care plan for 1 resident (Resident #107) of 15 residents reviewed for care plans.The findings include:Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Age-Related Physical Disability, and Repeated Falls (added on 3/13/2026).Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #107 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed the resident required partial/moderate assistance with transfers, and substantial/maximal assistance with toileting.Review of the comprehensive care plan revised 6/2/2026, revealed Resident #107's care plan did not reflect bed in lowest position, floor mat to right side of bed, or nightlight. During an observation on 6/1/2026 at 11:54 AM, in Resident #107's room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations and interviews, the facility failed to ensure proper infection control practices during medication administration for 1 resident (Resident #18) of 5 residents reviewed for medication administration.The findings include: Review of the facility policy titled, Administering Medications, dated 4/2019, revealed .Staff follows established facility infection control procedures .for the administration of medications . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Diabetes Mellitus, and Chronic Pain Syndrome. Review of the current physician's recapitulation orders for Resident #18 revealed, .Eliquis [medication to thin blood] 5 mg [milligram] .twice a day .Benzonate [medication for cough] 200 mg .every 8 hours .Duloxetine [medication for depression] 40mg .one time a day .Farxiga [medication for diabetes] 10 mg .one time a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on job description review, facility policy review, facility investigation documentation review, and interview, the facility failed to ensure 1 resident (Resident #1) was returned to her room after transportation to a medical appointment for 1 of 3 residents reviewed for accident hazards. The facility failure occurred on 5/8/2024 when Resident #1 was taken to a medical appointment by the Transportation Coordinator and returned to the facility at approximately 4:30 PM. The facility was under a code black at the time for serious weather conditions. The Transportation Coordinator failed to unload Resident #1 from the facility van and Resident #1 was locked inside the facility van for an unknown amount of time, estimated to be 3 to 4 hours. Licensed Practical Nurse (LPN) A became concerned about Resident #1 and the Transportation Coordinator due to the serious weather conditions around 7:00 PM shift change on 5/8/2024 and called the Nurse Practitioner (NP) to inquire about their location. The NP was present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Kitchen 12/06/22 11:10 AM Steam table set up in dining room, vertical barrier hung between food station and the rest of dining room, as ceiling was being worked on. 12/06/22 09:58 AM Observation of plating station showed dining area back to normal, with no repairs being done and barrier gone. 12/07/22 8:30 AM Observation of kitchen workers showed appropriate hand sanitation and hair nets in place. During an interview on 12/5/22 at 8:42 AM, [NAME] O'Keefe, Dietary Manager the facility has a full-time qualified with ServSafe Certification that expires 5/18/23, with 14 years experience in healthcare foodservice. Menu was reviewed and the mechanical consistency of the meal is followed per orders from Speech therapy, RD and physician. Alternatives are offered for any meal. Copy of menu reviewed with DM. A tour of the kitchen followed. Brief tour of kitchen included temperature checks on all refrigerators and freezers, and all food products were properly stored at proper temperatures. Dry stored food products…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, the facility's documentation, and interviews, the facility failed to provide evidence that the allegations of abuse were thoroughly investigated for 2 residents (Residents #40 and #96) of 4 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Policy, dated 4/26/2022, showed .It is the policy of the facility that acts of physical .abuse .against residents are absolutely prohibited .DEFINITIONS .Physical Abuse is the inappropriate physical contact with a resident .This includes .slapping .Upon receiving .suspected incident of resident abuse .the Administrator/DON [Director of Nursing]/Designee will conduct an investigation .Witness reports will be in writing. Witnesses will be required to sign and date such reports .copy of .must be attached to the Abuse Investigation Report . Review of the facility's policy titled, Abuse Reporting & Investigating Policy dated 10/27/2022, showed .All reports of resident abuse .are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #21 was admitted to the facility on [DATE] and had diagnoses including Dementia, Generalized Anxiety Disorder, Schizophrenia, Morbid Obesity, Cognitive Communication Deficit, Bipolar Disorder, Major Depressive Disorder, and Obsessive Compulsive Disorder. The diagnosis of Impulse Disorder was added on 9/19/2019 and the diagnosis of Psychotic Disorder was added 10/12/2021. Review of a PASARR dated 6/11/2012 showed a level 1 PASARR was completed and included the diagnosis of Schizophrenia. Resident #21 was not referred for level 2 services due to the resident not requiring specialized services. Review of the medical record showed a new PASARR had not been submitted to the stated designated authority after the diagnosis of Impulse Disorder was added on 9/19/2019 or the diagnosis of Psychotic Disorder was added on 10/12/2021. During an interview on 12/6/2022 at 10:25 AM, MDS Coordinator #2 confirmed a new PASARR had not been submitted to the state designated authority after the new mental health diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview the facility failed to ensure appropriate infection control practices were maintained for 1 resident (#115) of 5 residents reviewed for transmission-based precautions which had the potential to affect 11 of 116 residents. The findings include: Review of the facility's policy titled, Clostridium Difficile (an infection spread by bacterial spores found within the feces), revised on 10/2018, showed Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C.difficile [CDI] to prevent transmission to others residents .placed on contact precautions . Review of the facility's policy titled, Isolation, Cohorting, And Transmission Based Precautions, dated 9/28/2021, showed .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to immediately report an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARD revised 11/2017, revealed .Report allegations or suspected abuse .immediately to: Administrator, Other Officials in accordance with State Law .Reporting-All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation .of resident abuse .investigation can be undertaken promptly .The Director of Nursing Services, Administrator, or designee will .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus Type 2, Alzheimer's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to initiate an immediate investigation of an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARDS, revised 11/2017, revealed .This facility will conduct a comprehensive investigation of any employee suspected of abuse .of residents and will implement disciplinary action according to company policy. Any employee, who is accused of resident abuse .will be suspended at the time of allegation, pending further investigation .INVESTIGATION: OF ALLEGED ABUSE .When .reports of abuse .occur, an investigation is immediately warranted .All alleged violations involving .abuse .will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Medical record review revealed Resident #33 was admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, and interview, the facility failed to perform proper hand hygiene after providing direct resident care for 1 resident (#32) of 3 residents during resident care of 17 sampled residents. The findings include: Review of the facility policy Hand Hygiene, revised 2011, revealed .Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .waterless handwashing products. If hands are not visibly soiled, use an alcohol based hand tub for routinely decontaminating hands in all clinical situations . Observation of Certified Nursing Assistant (CNA) #3 on 8/6/19 at 2:58 PM, in the resident's room, revealed after CNA #3 donned gloves to provide peri-care (personal hygiene care) to Resident #32. Continued observation revealed the CNA then assisted the resident to bed, adjusted the resident's call light, removed the contaminated gloves, and without washing the hands, took a lift device out of the resident's room, and placed it into the 200 hall bathroom. Interview with CNA #3 on 8/6/19 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.