Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manchester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and existing stage 4 pressure ulcers had a care plan calling for turning, a low air-loss mattress, and heel offloading, but there was no physician order for offloading boots or for skin checks under the boots. Over several months, documentation did not show any directive to assess skin beneath the boots each shift, and a weekly skin check noted no new issues. Subsequently, an APRN and the ADON identified a new open area on the dorsal left foot, attributed by the ADON to rubbing from the boot strap, and a wound physician documented a full-thickness wound with 100% slough requiring ongoing treatment. Interviews with the APRN, the wound physician, and the ADON indicated the wound was not identified timely and that, had the boots been removed and the skin assessed every shift, the area could have been detected earlier and the wound’s progression potentially limited.
A resident with severe cognitive impairment, multiple chronic conditions, poor oral hygiene, and documented oral/dental problems was seen by a dental provider who found devastated dentition with cavities on every tooth, likely infection, and recommended full-mouth x‑rays, extractions, and frequent cleanings. The findings were not documented in the clinical record as progress notes, and the provider was not notified. Over the next several months, the resident repeatedly missed scheduled dental hygienist visits due to scheduling issues and hospitalizations, without evidence of nursing or provider notification or alternative follow-up. The social services director acknowledged seeing the dental note but did not inform nursing, the DON was unaware of the visit and missed appointments despite schedules addressed to her, and the APRN was not informed of the dental findings, contrary to the facility’s own notification-of-changes policy.
Lack of Controlled Medication Reconciliation Process: The facility failed to maintain a process for controlled med audits and reconciliation. The ADNS said bi-weekly audits were done by counting meds at the carts and matching white and yellow CSDRs later, but she did not bring the yellow CSDR binders to the audits and could not identify a policy for the process. Surveyors found yellow CSDRs dating back over time, 23 records flagged for reconciliation, and the facility leadership stated there was no policy directing the audits. The ADNS reconciled 22 records but could not account for Tramadol HCL 50 mg half tablets received earlier.
Infection Control Program Deficiencies: The facility lacked a laundry room cleaning schedule, and the laundry area was observed with heavy dust on washers, filters, lights, a wall unit, and a ceiling fan over clean linens. The facility also had missing monthly infection surveillance and trend analysis documentation, an incomplete infection surveillance report, an inaccurate MDRO tracking sheet that did not reflect all residents with MDRO history or current status, and an influenza outbreak that was not fully tracked with exposure investigation because additional positive staff cases were not communicated to infection control staff.
The facility failed to maintain a consistent designated IP with the required specialized infection control training to oversee the infection control program. Interviews and record review showed gaps when no IP nurse was in place, incomplete or unavailable IP certification documentation, and missing infection surveillance, MDRO tracking, and antibiotic stewardship records for multiple periods. The Administrator acknowledged the facility had no IP nurse during some of the timeframe, and no policy for a designated IP with specialized training was provided.
Failure to protect a resident from inappropriate sexual contact occurred when one resident touched another resident's breast in the recreation room. The affected resident had dementia with severe cognitive impairment and needed extensive assistance with ADLs, while the other resident admitted to the touching and said he thought the interaction was mutual. Staff observed the incident, but the weekend nursing supervisor did not escalate it or start an investigation, and the Administrator later stated the facility had not investigated because the affected resident had a history of seeking physical contact with other residents.
Failure to Report Alleged Resident-to-Resident Sexual Abuse: A recreation aide observed one resident touching another resident’s breast, and the resident admitted to the contact. The touched resident had dementia and severe cognitive impairment and was documented as unable to consent, while the other resident had intact cognition but a behavioral history. Although nursing, SW, and the family were notified, the facility did not report the allegation to the state survey agency within the required timeframe and did not file the event in the reporting portal.
Failure to Investigate Inappropriate Sexual Contact Between Residents: Staff observed one resident touching another resident’s breast in the recreation room, and the resident admitted to the contact. The affected resident had dementia with severe cognitive impairment and could not consent, yet the facility did not promptly initiate a full abuse investigation as required by policy, did not complete interviews and documentation, and did not update the other resident’s care plan to address the new behavior or protect other residents.
Failure to complete pressure injury assessments, repositioning documentation, and timely wound documentation. Two residents with significant cognitive and mobility impairments developed skin breakdown/pressure injuries. The record showed missed Braden Scale assessments, no documented RN assessment when new skin impairment was first identified, incomplete initial wound documentation without measurements or staging, delayed wound treatment documentation, and no documentation showing the ordered q2h turning/repositioning program was implemented.
Expired medications were found in active use areas on medication carts and in the medication room, including Meclizine, Ondansetron, and Duoneb. An LPN stated expired or discontinued meds should be removed from carts, another LPN said they should be taken out of active use and sent to pharmacy or destroyed, and the ADNS said expired meds should be removed from carts and returned to pharmacy. The facility policy required meds to be stored per manufacturer and regulatory requirements, with expiration based on the label unless otherwise specified.
Failure to Provide Dental Services: A resident with intact cognition, who had been edentulous since admission and repeatedly requested dentures, was not seen by dental for about 2 years. The record showed no clear enrollment in the facility’s contracted dental provider, and staff interviews confirmed the resident’s requests were not followed through because a family member handling finances said dentures would not be paid for. Staff also did not clarify coverage or costs with the dental provider, and the resident was not on the upcoming dental schedule.
A resident with Parkinson's disease, AFib, and dementia was ordered erythromycin ophthalmic ointment for an eye infection, but the record did not show an antibiotic time out within 48 to 72 hours or provider feedback on whether the antibiotic was working or needed to continue. The facility also lacked completed antibiotic stewardship documentation showing antibiotic usage, patterns, and resistant trends, and staff stated the tracking reports had not been completed.
MDS assessments were inaccurately coded for a resident with bipolar disorder and schizophrenia and for another resident with multiple pressure injuries. The PASRR section failed to reflect a positive level II assessment, and the skin section failed to show a resident’s suspected deep tissue injury and stage 2 pressure injuries documented in wound records. An LPN responsible for the MDSs acknowledged the coding should have reflected the clinical record.
A resident with multiple diagnoses experienced an unwitnessed fall and was hospitalized. Upon return, required neurological monitoring was not completed or documented for several hours, and staff failed to follow the expected monitoring schedule. The facility did not have a clear policy guiding post-fall neurological checks, leading to missed assessments and inaccurate documentation.
A facility failed to honor a resident's advanced directive choices due to severe cognitive impairment. Despite a hospital directive for DNR status, the resident incorrectly signed as full code without a witness or physician's signature. The facility did not contact the resident's representative within 24 hours to confirm wishes, and no progress notes indicated attempts to reach them. The DNS acknowledged the need for representative involvement, and the case manager confirmed no legal forms were signed by the representative, despite daily visits.
A resident with a history of falls and hip replacement was not consistently ambulated as per physician orders, despite the care plan requiring ambulation twice daily with a walker. Nursing staff failed to document or provide rationale for missed ambulation opportunities, and the resident expressed concerns about not being walked regularly. Interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's mobility.
The facility failed to conduct annual performance reviews for two nurse aides, as required by their policy. The Director of HR admitted that a process change led to missed evaluations, and the DNS, who was not in her role at the time, has since been completing evaluations as expected.
A facility failed to conduct behavior monitoring for a resident on Seroquel, an antipsychotic medication prescribed for dementia with insomnia. Despite recommendations to update the medication order with specific behaviors for monitoring, the resident's representative did not want changes. The APRN and DNS acknowledged that behavior monitoring was not implemented as required by the facility's policy, which mandates targeted behavior monitoring and non-pharmacological interventions for residents on psychotropic medications.
A malfunctioning call bell system in two units caused continuous ringing, disturbing residents and staff. The issue began several days prior, and attempts to fix it with an adapter failed. The Maintenance Director tried to contact the vendor, but the problem persisted over the weekend. The Administrator acknowledged the malfunction, which violated the facility's noise control policy.
Failure to Monitor Offloading Boots and Prevent New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and monitoring for a dependent resident at high risk for skin breakdown. The resident had multiple diagnoses including dementia, Parkinson’s disease, CKD stage 3, hypothyroidism, protein-calorie malnutrition, and type 2 diabetes, and was dependent on staff for personal hygiene, bed mobility, and transfers. A quarterly MDS documented severely impaired cognition and three unhealed stage 4 pressure ulcers present on admission, and the care plan identified impaired skin integrity with interventions such as turning and repositioning every two hours, use of a low air-loss mattress, and offloading heels as tolerated. A Braden Scale assessment identified the resident as high risk for pressure injuries, and a wound care note documented that a prior left medial foot wound had resolved. Despite these identified risks and care plan interventions, the clinical record from mid-May through late September did not contain any physician order to utilize offloading boots or to check the skin under the boots every shift. A weekly skin check on 9/21/25 documented no new skin issues. On 9/23/25, an APRN was asked to evaluate a wound on the resident’s left foot and documented a left dorsal foot wound requiring daily cleansing and silver alginate dressing. Later that day, the ADON documented discovering an open area on the left dorsal foot, approximately 3 cm by 0.5 cm, and attributed it to the resident’s skin rubbing against the strap of the offloading booties. The ADON noted that the offloading boots were removed and replaced, and that new dressing orders were obtained, but there was no prior order directing use of the boots or skin checks under them. On 9/25/25, the wound care physician documented a new full-thickness wound on the left dorsal foot measuring 1.1 cm by 0.9 cm by 0 cm with 100% slough and moderate serosanguinous drainage, and recommended offloading heels per facility protocol. A later note on 3/19/26 showed the left dorsal foot wound persisted as a stage 4 pressure ulcer. Interviews with the APRN, the wound care physician, and the ADON indicated that the wound was not identified timely, that the resident should have had an order to offload both heels while in bed, and that offloading boots, once used, should have been removed every shift to assess the underlying skin. They stated that if the skin under the boots had been assessed every shift, the area could have been identified earlier and the progression to a full-thickness wound might have been prevented or less severe. The facility’s pressure injury policy referenced systematic prevention and management based on risk factors such as impaired mobility, comorbidities, cognitive impairment, and malnutrition, but there was no available policy specific to offloading boots.
Failure to Notify Provider and Follow Up on Significant Dental Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s provider and nursing staff of significant dental findings and to follow up on recommended dental care. A resident with dementia, Parkinson’s disease, stage 3 chronic kidney disease, hypothyroidism, protein-calorie malnutrition, type 2 diabetes mellitus, and three unhealed stage 4 pressure ulcers was care planned for oral/dental health problems, including poor oral hygiene and the need to monitor and report signs and symptoms of oral/dental issues. A dental visit on 9/25/25 documented that the resident had cavities on every tooth, devastated dentition likely infected or a great source of bacteria, and that the resident would be healthier without the remaining teeth. The dentist recommended an FMX to determine the best referral for further intervention and dental cleanings every three months due to poor oral health. However, from 9/25/25 through 3/25/26, the clinical record contained no progress notes about this dental visit, the need for x‑rays, the condition of the dentition, or any notification to the provider about these issues. Subsequent dental hygienist schedules showed that the resident was not treated on multiple dates over approximately six months, with reasons including not being on the hygienist’s list and the resident being at the hospital, and there was no evidence that these missed visits were communicated to nursing or the provider. The Director of Social Services, who managed outside providers, acknowledged seeing the 9/25/25 dental note but did not ensure nursing was aware of the findings or arrange additional follow-up, and confirmed the resident was repeatedly on the list but not seen. The DON stated she was unaware of the 9/25/25 dental visit and the missed hygienist visits, despite schedules being addressed to her, and indicated that the Director of Social Services should have notified nursing and a provider of the missed visits. The APRN reported she was unaware of the dental findings and would have evaluated and treated the resident if notified, and that alternative arrangements should have been made after missed appointments due to hospitalization. The facility’s Notification of Changes policy required informing and consulting with the provider and notifying the resident or representative when there is a significant change requiring alteration of treatment, but there was no policy available for outside consults and follow-up.
Lack of Controlled Medication Reconciliation Process
Penalty
Summary
The facility failed to ensure there was a process for reconciliation of controlled medications. The ADNS stated she completed bi-weekly controlled medication audits by counting controlled medications at each medication cart with another nurse for verification. She explained that when a controlled medication was received, the white CSDR was kept with the medication at the cart and the yellow copy was filed in a binder in the ADNS office, and that she did not bring the yellow CSDR binders with her during audits. She also stated she matched the white and yellow CSDRs when medications were completed or destroyed, and she could not identify a facility policy addressing the reconciliation process. Observation of the yellow CSDR binders showed records dating back to 11/21/23, and 23 yellow CSDRs dated from November 2023 through January 2026 were flagged for reconciliation. The DNS stated she was responsible for controlled medication audits but that the process had been delegated to the ADNS and she was not aware of the process being followed. The Corporate Representative for Clinical Services and the Administrator stated the facility did not have a policy for controlled medication audits or reconciliation. The ADNS later reconciled 22 of the 23 flagged controlled medications but could not determine what happened to Tramadol HCL 50 mg half tablets, quantity 15, received on 11/23/23.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain a laundry room cleaning schedule and the laundry area was observed with heavy dust accumulation on multiple surfaces. During a tour of the laundry room, three washers were in use and were noted to have greyish dust-like matter on the tops and sides, with dust also covering the walls, pipes, plumbing fixtures, detergent system area, washer filters, ceiling lights, a wall-mounted heating/cooling unit, and a ceiling fan. Clean linens were observed in the clean area beneath dust-covered ceiling lights and near the dust-covered wall unit and fan. Laundry staff stated they did not have a cleaning schedule for the laundry room, and the Laundry Supervisor stated there was no actual cleaning schedule in place and that she had not developed one since becoming supervisor three months earlier. The facility also failed to document monthly infection surveillance reports and monthly analysis of infection trends and rates for multiple time periods. Review of the infection control program with the Infection Preventionist in training, the ADNS, and another RN showed that monthly surveillance documentation was not available for several months, and monthly trend analysis documentation was also missing for multiple months. One RN described that surveillance reports were supposed to be generated from the electronic medical record, reviewed for accuracy, and used to create monthly infection rate reports and graphs showing trends, but the ADNS and the Infection Preventionist in training stated that what was described was not actually being done. An incomplete infection surveillance report was also reviewed and was found to contain missing information in several columns, including signs and symptoms, infection, pharmacy order, and comments. The facility further failed to ensure the MDRO tracking sheet accurately reflected residents’ MDRO status. The tracking sheet reviewed by the facility only listed three residents with MDROs for 2026, and the ADNS stated that at least two additional residents with a history of MDRO should have been included. The ADNS also stated the tracking sheet needed to include residents with both active and colonized MDRO infections and be updated when status changed, but the facility could not locate a 2024 MDRO tracking sheet. In addition, the facility failed to track an influenza outbreak and complete exposure investigations per policy. The State Survey Agency reporting system showed an influenza outbreak with multiple resident and staff cases, but the Infection Preventionist in training and the ADNS were unaware of the staff cases, and the DNS stated she had continued adding cases to the outbreak report without informing them. The facility acknowledged that contact tracing or an exposure investigation should have been initiated, but it was not completed because the additional positive staff cases were not communicated to the infection control staff.
Missing Designated Infection Preventionist With Required Training
Penalty
Summary
The facility failed to have a consistent designated Infection Preventionist (IP) with the required specialized infection control training responsible for the Infection Control Program during 2024, 2025, and 2026. Interview with the ADNS and RN #4 identified RN #4 was hired as the full-time IP nurse and was still completing the specialized Infection Preventionist training course, while the ADNS stated she had only overseen infection control for one month and had completed the IP training modules in 2020 but did not have the certificate available. The facility also provided a list of IP nurses showing LPN #11, RN #8, and RN #9 had each worked as the IP nurse during different periods and had certificates for the training course, but the documentation did not identify an IP nurse with specialized training in place for some periods from one date through April 2025 and from another date through another date. Review of the infection control program with the ADNS and RN #4 failed to identify an MDRO tracking list for 2024 and failed to provide documentation showing monthly infection surveillance and analysis of infections and antibiotic stewardship surveillance were completed for the period from one date through another date, for complete documentation in one year, and for the period from another date to February 2026. The ADNS stated the IP nurse was responsible for ensuring surveillance and analysis were completed, but the facility had nobody working in the IP role during some of that timeframe. The Administrator acknowledged there were gaps when the facility had no Infection Preventionist nurse and stated they were unable to find someone to fill the position. The facility also failed to provide a policy regarding having a designated Infection Preventionist with specialized training, and documentation showed RN #9 did not receive IP certification until a later date even though she had been working as DNS before and after that time.
Failure to Protect Resident from Inappropriate Sexual Contact
Penalty
Summary
The facility failed to ensure a resident was free from inappropriate sexual conduct when Resident #31 touched Resident #119's breast in the recreation room. Resident #119 had diagnoses including dementia without behavioral disturbances, anxiety, and depression, and the quarterly MDS identified severe cognitive impairment with extensive assistance needed for toileting, personal hygiene, dressing, and transfers. The care plan noted the resident had expressed a desire to be intimate with a partner and included interventions for psychiatric consultation, privacy for intimacy, and social work visits as needed. On 3/1/26, a recreation aide observed Resident #31 touching Resident #119's breast while the two residents were seated together in the recreation room. The aide immediately removed Resident #119 from the area and reported the incident. Nursing documentation later noted that Resident #31 confirmed touching Resident #119's breast and stated he was "just an old man" and laughed it off. Social work documentation stated Resident #31 believed the interaction was mutual and that education was provided regarding boundaries, consent, and respecting other residents' rights and personal space. The facility did not initiate an investigation or file an A&I report at the time of the incident. A weekend nursing supervisor was notified but did not notify nursing administration or begin an investigation because she did not want to escalate the matter. The Administrator later stated the facility had not investigated the alleged sexual contact because Resident #119 had a history of seeking physical contact and relationships with other residents and had a care plan addressing that behavior, although she also stated she was unsure whether Resident #119 had been evaluated to determine capacity to consent to sexual activity.
Failure to Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexually inappropriate behavior between two residents to the state survey agency within the required timeframe. The incident involved one resident with dementia, severe cognitive impairment, and dependence for multiple activities of daily living, and another resident with intact cognition who required extensive assistance for care needs and had a history of behavioral issues. The facility’s abuse, neglect, and exploitation policy required alleged violations to be reported immediately, with abuse reports made no later than 2 hours after the allegation. According to the record, a recreation aide observed one resident touching the other resident’s breast while both were seated in the recreation room. The aide immediately removed the resident from the area and reported the incident to nursing. The resident who made the contact acknowledged touching the other resident’s breast and stated that the interaction was mutual. Staff documented that the resident who was touched had impaired cognition and lacked the capacity to consent. Although nursing, social work, and the family were informed, the facility did not submit a reportable event through the state reporting portal. The administrator later stated the incident was not considered reportable and confirmed that no report had been filed even after surveyor inquiry. The facility also did not initiate an incident report at the time of the event, and the weekend nursing supervisor stated she did not escalate the matter because she did not want to do so.
Failure to Investigate Inappropriate Sexual Contact Between Residents
Penalty
Summary
The facility failed to conduct a timely and comprehensive investigation after an inappropriate sexual contact occurred between two residents, one of whom had severe cognitive impairment and a documented history of seeking physical contact with others. Resident #119 had diagnoses including dementia without behavioral disturbances, anxiety, and depression, and the quarterly MDS identified severe cognitive impairment, extensive assistance needs for toileting, personal hygiene, dressing, and transfers, and use of a rolling walker and wheelchair. The resident’s care plan noted a desire to be intimate with a partner and included interventions for psychiatric consultation, reporting changes to the physician, providing a safe/private area for intimacy, and social work visits as needed. On 3/1/26, staff observed Resident #31 touching Resident #119’s breast while both residents were seated together in the recreation room. The recreation aide immediately removed Resident #119 from the area and reported the incident. Resident #31 admitted to touching Resident #119 and stated he/she was “just an old man” and laughed it off. Staff documented that Resident #119 was assessed afterward and did not show distress at that time, and social services documented reinforcement of boundaries and resident rights. Resident #119’s responsible party later reported that nursing staff called to say another resident had touched Resident #119’s chest, and stated that Resident #119 had impaired cognition and did not give permission for inappropriate touching. The facility did not initiate or begin an investigation into the reportable event when it occurred, despite its abuse policy requiring an immediate investigation of any report or suspicion of sexual abuse. The policy required interviews with the alleged victim, alleged perpetrator, witnesses, and others with relevant information, along with complete documentation of findings and actions taken. Review of the facility’s investigation records showed that a reportable event investigation was not requested until 3/10/26, and the facility still did not initiate an investigation into the incident that occurred on 3/1/26. Resident #31’s care plan was also not updated to address the newly developed behavior or to identify measures to protect other residents from inappropriate touching. The Administrator and DNS could not identify what measures had been put in place to prevent recurrence with Resident #119 or to protect other residents from similar behavior.
Failure to complete pressure injury assessments, repositioning documentation, and timely wound documentation
Penalty
Summary
The facility failed to complete Braden Scale assessments in accordance with its policy, failed to document turning and repositioning, failed to complete a comprehensive pressure ulcer assessment when new skin breakdown was identified, and failed to put timely treatment orders in place for two residents reviewed for facility-acquired pressure ulcers. The facility policy required Braden Scale risk assessments on admission or readmission, weekly for four weeks, quarterly, and with any significant change in condition, and required a thorough wound assessment with measurements and description of the wound. The policy also required licensed nurses to conduct full skin assessments and document wound characteristics such as measurements, tissue type, drainage, odor, pain, and other findings. One resident was readmitted with diagnoses including peripheral venous insufficiency, pneumonia, anemia, and chronic venous hypertension. The resident had a Braden score of 16, indicating low risk, and orders were entered for heel skin prep, turning and repositioning every two hours, and a pressure-reducing mattress. The quarterly MDS identified severe cognitive impairment, extensive assistance needs, non-ambulatory status, bowel incontinence, an indwelling catheter, and risk for pressure ulcers, but the required quarterly Braden Scale assessment had not been completed before the quarterly MDS. When an open wound on the left heel was later noted, the initial wound assessment failed to include wound measurements, wound bed description, or staging. The wound was later evaluated by the wound physician and identified as a Stage 3 pressure injury, then later reclassified as an unstageable pressure injury and later as an arterial full-thickness wound. The wound nurse acknowledged she forgot to measure and describe the wound when it was first reported and stated she did not stage open wounds until the wound specialist evaluated them. The second resident had severe cognitive impairment, was incontinent of bowel and bladder, non-ambulatory, on hospice, and at risk for pressure ulcers. Weekly skin check documentation identified a new skin impairment on the left gluteal fold, but the record did not show that a registered nurse assessed the new wound when it was first noted. The physician later ordered Triad for a left buttock open area, and the care plan identified a left buttock Stage 2 pressure injury with interventions for incontinent care and repositioning every two hours. Wound documentation later described the area as MASD with a measured open area, and the wound physician noted the resident had a new Stage 2 pressure ulcer to the left buttock. The record also failed to identify documentation of implementation of turning and repositioning, and observations showed the resident seated in the same position in the dining room/lounge during repeated checks.
Expired Medications Left in Active Medication Storage Areas
Penalty
Summary
Expired medications were found in active use areas during observations of the North 1 medication cart, the North 2 medication cart, and the North unit medication room. On the North 1 medication cart, Meclizine 12.5 mg was observed with an expiration date of 12/31/25 and 29 tablets remaining in the bubble pack. On the North 2 medication cart, two blister packs of Ondansetron 4 mg with an expiration date of 1/12/26 and Meclizine 12.5 mg with an expiration date of 12/30/25 were observed. In the North unit medication room, a box of Duoneb solution containing 3 sealed multi packs and 3 single-use vials with an expiration date of January 2026 was observed on a shelf containing active use overflow medications. During interviews, an LPN stated that expired or discontinued medications should be removed from medication carts and that all nurses are responsible for ensuring carts do not contain expired or discontinued medications. Another LPN stated that expired or discontinued medications should be removed from active use areas, placed in a bag, and sent to pharmacy or destroyed. The ADNS stated that expired medications should be removed from medication carts and returned to pharmacy, and that all nurses are responsible for the medication carts, with night shift nurses usually checking them. The facility policy stated medications must be stored in accordance with manufacturer specifications and applicable state and federal requirements, and that medications expire on the date specified by the manufacturer unless a shorter expiration is indicated on the label.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided for a resident who had been edentulous since admission and wanted dentures. The resident was admitted in July 2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, hypertension, and GERD without esophagitis. The quarterly MDS identified intact cognition, and the care plan noted an oral/dental problem with interventions including annual/as-needed dental consultation and monitoring for signs or symptoms of dental problems needing attention. The record and interviews showed the resident had not been seen by dental for the past two years and there was no documentation that the resident elected to receive dental services through the facility’s contracted dental provider. An APRN note documented that the resident reported wanting to be seen by the dentist and evaluated for dentures, and nursing staff were asked to place the resident in the Health Drive book for evaluation, but no evaluation was found. The resident stated that dentures had been planned before admission, but the family member handling finances canceled the order after admission, and the resident reported no one had contacted a dentist or dental service to determine whether there would be any out-of-pocket cost. Interviews with the Administrator, social workers, scheduler, APRN, and Health Drive staff showed the resident had repeatedly expressed a desire for dentures, but the issue was not resolved through the facility’s dental process. Staff stated Health Drive was available for residents without an outside dentist and that residents could be helped to obtain one, yet the social worker had not contacted Health Drive or the family member to clarify costs or services. Health Drive reported the resident had been enrolled for dental services on one occasion and then canceled the next day, after which the resident was placed in a do-not-treat status. The Administrator also could not identify whether the family member was the POA or conservator, and the resident had not been included in the upcoming dental schedule.
Missing Antibiotic Time Out and Incomplete Antibiotic Stewardship Tracking
Penalty
Summary
The facility failed to ensure an antibiotic time out was completed for Resident #94 after the resident was started on Erythromycin Ophthalmic ointment for an eye infection. Resident #94 had diagnoses including Parkinson's disease, atrial fibrillation, and dementia, and the quarterly MDS identified severely impaired cognition and dependence for personal hygiene. The physician's order directed the ointment to be instilled in both eyes at bedtime and continued until seen by ophthalmology. Review of the resident's clinical record and interviews with the ADNS and RN #4 on 3/13/26 found no documentation that an antibiotic time out was completed within 48 to 72 hours of starting the antibiotic, and staff stated this review should have been completed by the IP nurse with provider feedback to determine whether the antibiotic was working and whether it should continue or change. The facility also failed to provide documentation of antibiotic usage, patterns, and resistant trends for the antibiotic stewardship program. Review of the Antibiotic Stewardship Program policy stated that the IP nurse is to track antibiotic starts, monitor response to therapy, review laboratory results when available, and provide written feedback on antibiotic use data to administration, medical and nursing staff, and the QAA committee. However, review of the facility's antibiotic stewardship program, monthly infection surveillance reports, and quarterly infection control reports for the period reviewed did not identify the number of antibiotic usages for several months, and the ADNS and RN #4 stated the reports had not been completed. The ADNS said she had only recently begun overseeing the IP program and was not familiar with the facility's IP program during the earlier period, while RN #4 stated she had started tracking antibiotic usage but had not completed the reports.
MDS assessments were inaccurately coded for PASRR status and pressure injuries
Penalty
Summary
The facility failed to ensure the comprehensive MDS assessment was accurately coded for a resident with bipolar disorder and schizophrenia. The resident had a positive PASRR level II assessment, but the annual MDS identified the resident as cognitively intact, without behaviors, and did not indicate a positive level 2 PASRR. The MDS Coordinator stated he was responsible for completing the PASRR section, checked the medical record for the level 2 PASRR, and did not recall verifying the information with social work, although he acknowledged the annual MDS should have been coded positive for a level 2 PASRR. The facility also failed to accurately code the admission MDS for a resident with type 2 diabetes mellitus, anemia, and pneumonia who was readmitted with multiple pressure injuries. The weekly wound evaluation identified a suspected deep tissue injury to the right heel, stage 2 pressure injuries to the left heel, right elbow, right outer ankle, and coccyx, but the admission MDS stated the resident was at risk for pressure ulcers/injuries and did not have any pressure ulcers present. The MDS Coordinators reviewed the wound documentation and acknowledged the assessment should have reflected the presence of the pressure ulcers/injuries, while also stating they were responsible for completing the skin section and ensuring the assessment was accurate.
Failure to Complete and Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and complete neurological monitoring following an unwitnessed fall involving a resident with diagnoses including Parkinson's disease, cervicalgia, and bipolar disorder. The resident, who was cognitively intact and independently ambulatory, was found outside the facility after an apparent elopement attempt. Initial assessments documented that the resident denied head injury and pain, and neurological checks were performed prior to the resident's transfer to the hospital. Upon return from the hospital, documentation of required neurological monitoring was missing for several hours, and the monitoring schedule was not followed as per facility standards. Further review revealed that neurological assessments were not resumed or documented upon the resident's return, despite the expectation for hourly checks to continue. The nurse responsible stated that vital signs were taken and the resident refused neurological monitoring at one point, but this refusal was not documented. Additionally, the nurse did not recall completing or attempting the required neurological assessments at the scheduled times, and documentation inaccurately indicated the resident was still hospitalized during periods when the resident was present in the facility. The facility lacked a clear policy or procedure directing staff on when to conduct post-fall neurological monitoring, relying instead on electronic medical record prompts. The Director of Nursing confirmed that neurological monitoring should have resumed upon the resident's return and continued for 72 hours, but acknowledged that the facility did not have a written policy to guide staff. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed the failure to complete and document neurological assessments as required.
Failure to Honor Resident's Advanced Directive Choices
Penalty
Summary
The facility failed to ensure that the advanced directive choices for a resident with severe cognitive impairment were reviewed and honored. The resident was admitted with a hospital discharge directive indicating a do not resuscitate (DNR) status, and a physician's order confirmed this status along with do not intubate (DNI) and a registered nurse may pronounce (RNP) orders. However, the advanced directive form in the clinical record was incorrectly signed by the resident as a full code, without a witness or physician's signature, despite the resident's severe cognitive impairment. The facility did not contact or educate the resident's representative to confirm the resident's wishes regarding the advanced directive. Interviews revealed that the resident's representative was not contacted within the expected 24-hour period after admission to discuss the resident's code status, and no progress notes indicated attempts to reach the representative. The Director of Nursing Services (DNS) acknowledged that the resident's cognitive impairment required the representative's involvement, and the current code status form was invalid. The case manager, responsible for coordinating care conferences, confirmed that the resident's representative was not asked to sign any legal forms, despite being present at the facility daily. The facility's policy required that decisions regarding advanced directives be documented and honored, but this was not adhered to in this case.
Failure to Provide Prescribed Ambulation for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the mobility of a resident, identified as Resident #80, who was admitted with diagnoses including falls, hip replacement, and chronic pain. The care plan required ambulation of 150 feet with a rolling walker and minimal assistance. However, the nursing assistant flow sheets revealed numerous missed opportunities for ambulation, with many instances lacking documentation or rationale for the failure to ambulate. Despite physician orders and the resident's expressed desire to ambulate twice daily to regain strength and independence, the nursing staff did not consistently follow through with the prescribed ambulation. Interviews with the resident, Director of Rehabilitation, nursing assistant, Director of Nursing Services (DNS), and APRN highlighted a breakdown in communication and adherence to the care plan. The resident reported that ambulation did not occur as ordered, and the nursing assistant admitted to not offering ambulation due to the resident's therapy and recreation schedule. The DNS and Administrator expected compliance with physician orders, and the APRN indicated a need for notification if ambulation did not occur. However, no notifications were made, and the resident's ambulation was not documented or communicated effectively, leading to a deficiency in care.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two certified nurse aides, NA #3 and NA #4, as required by their Performance Evaluation policy. NA #4, who was hired in 1995, did not have a documented performance review for 2023, with the last review dated in 2022. Similarly, NA #3, hired in 2022, also lacked a documented performance review for 2023. This deficiency was identified through a review of personnel files and interviews with facility staff. The Director of Human Resources acknowledged that the facility was undergoing a process change for completing annual evaluations, which resulted in some evaluations being missed. The Director of Nursing, who was not in her current role during the time the evaluations were missed, stated that she has since been completing evaluations around the anniversary of hire dates. The facility's policy mandates annual reviews to assess position goals and provide feedback, but this was not adhered to for the two nurse aides in question.
Failure to Monitor Behavior for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure behavior monitoring was conducted for a resident on antipsychotic medications, specifically Seroquel, which was prescribed for dementia with insomnia. The resident, who had severely impaired cognition and required total assistance with daily activities, was admitted with a physician's order for Seroquel. Despite the pharmacy's recommendation to update the antipsychotic order with a specific behavior that could be quantitatively and objectively documented, the APRN noted that the resident representative did not want the medications changed. The APRN indicated that behavior monitoring should have been initiated upon admission, but it was not implemented. Interviews with the psychiatric APRN and the DNS revealed that behavior monitoring flow sheets were not in place as required by the facility's policy. The DNS acknowledged that the nurse supervisor was responsible for ensuring behavior monitoring was initiated on admission, but it was not done for this resident. The facility's policy mandates that residents on psychotropic medications must have targeted behavior monitoring and receive non-pharmacological interventions to facilitate reduction or discontinuation of the medications. However, this was not adhered to in the case of the resident on Seroquel.
Call Bell System Malfunction Causes Disturbance
Penalty
Summary
The facility failed to maintain a homelike environment due to a malfunctioning call bell system that affected two of the three units. Observations identified continuous call bell ringing on the North unit, and an LPN confirmed the malfunction began several days prior. An email from the Maintenance Director indicated that the issue was known and an adapter was installed, but it did not resolve the problem. The Maintenance Director attempted to contact the vendor, but the issue persisted over the weekend, causing disturbances to residents and staff. The Administrator acknowledged the malfunction and agreed to contact the vendor for an immediate resolution. The facility's policy on noise control emphasizes providing care in a calm and comfortable environment, which was not upheld in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 718 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Manchester | 0.8 mi | ★★★★★ | 16 | 0 |
| Westside Care Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Glastonbury Center For Health & Rehabilitation | 3.6 mi | ★★★★★ | 12 | 0 |
| Civita Care Center At Salmon Brook | 4.6 mi | ★★★★★ | 4 | 0 |
| Riverside Health & Rehabilitation Center | 4.8 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Manchester Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.