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Deficiency Records for Medway Country Manor Skilled Nursing and Rehabilitat
A list of the most recent deficiencies for Medway Country Manor Skilled Nursing and Rehabilitat. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Medway Country Manor Skilled Nursing and Rehabilitat. 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 that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-02 | 2024-08-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-02 | 2024-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-02 | 2024-08-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-01-09 | 2024-02-13 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-17 | 2023-09-30 | 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 | 2023-08-17 | 2023-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Have an externally vented heating system. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-17 | 2023-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-22 | 2023-09-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-22 | 2023-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-22 | 2023-09-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-22 | 2023-09-22 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-10 | 2023-09-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-10 | 2023-09-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-10 | 2023-09-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-08-10 | 2023-09-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-10 | 2023-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-15 | 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 | 2023-08-10 | 2023-09-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-10 | 2023-09-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-08-10 | 2023-09-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-09-15 | 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 | 2023-08-10 | 2023-09-15 | 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 | 2023-08-10 | 2023-09-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-10 | 2023-09-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-10 | 2023-09-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-10 | 2023-09-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-10 | 2023-09-15 | 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 | 2023-08-10 | 2023-09-15 | 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 | 2023-08-10 | 2023-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-10 | 2023-09-15 | N |
| 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 | 2023-08-10 | 2023-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-09-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-10 | 2023-09-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-10 | 2023-09-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-10 | 2023-09-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-20 | 2023-04-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-03 | 2023-02-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-03 | 2023-02-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-03 | 2023-02-22 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-06-15 | 2022-08-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-15 | 2022-08-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-15 | 2022-08-18 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-15 | 2022-08-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-15 | 2022-08-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-15 | 2022-08-18 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-15 | 2022-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-08-08 | 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 | 2022-06-15 | 2022-08-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-15 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-08-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-15 | 2022-08-08 | 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 | 2022-06-15 | 2022-08-08 | 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 | 2022-06-15 | 2022-08-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-15 | 2022-08-08 | 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 | 2022-06-15 | 2022-08-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-15 | 2022-08-08 | N |
| 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 | 2022-06-15 | 2022-08-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-15 | 2022-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-15 | 2022-08-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-15 | 2022-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-08-08 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-15 | 2022-08-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-15 | 2022-08-08 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-06-15 | 2022-08-08 | N |
| Ensure resident rooms meet each resident's needs. | Health | 2022-06-15 | 2022-08-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-22 | 2022-08-05 | 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 | 2022-06-22 | 2022-08-05 | 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 | 2022-06-22 | 2022-08-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-22 | 2022-08-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-10 | 2021-06-11 | 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 | 2021-03-10 | 2021-06-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-03-10 | 2021-04-30 | 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 | 2021-03-10 | 2021-04-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-10 | 2021-04-30 | 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 | 2021-03-10 | 2021-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-10 | 2021-04-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-03-10 | 2021-04-30 | 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 | 2021-03-10 | 2021-04-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-10 | 2021-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-10 | 2021-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-10 | 2021-04-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-03-10 | 2021-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-10 | 2021-04-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-10 | 2021-04-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-03-10 | 2021-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-10 | 2021-04-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-15 | 2021-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-15 | 2021-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-10 | 2021-04-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-03-15 | 2021-04-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-03-15 | 2021-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-15 | 2021-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-15 | 2021-04-05 | N |
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