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Facility profile · CCN 225412

Medway Country Manor Skilled Nursing & Rehabilitat

86 federal citations on record , including 4 at the Immediate Jeopardy level, and 3 federal enforcement actions totaling $191,151.

Special Focus Status 4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
86
Total citations
58
Last 3 years
6
Actual harm+
3
Federal penalties
$191,151
Total fines
1
Overall ★ rating

Most common violation categories here

Most common F-tags at this facility

Citation history

86 on record
SurveyF-TagViolationSeveritySource
Feb 5, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Feb 5, 2025F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
Jan 29, 2025F880Provide and implement an infection prevention and control program.LComplaint
Jan 29, 2025F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.LComplaint
Jan 29, 2025F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.LComplaint
Jan 29, 2025F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.LComplaint
Nov 25, 2024F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.FStandard
Nov 25, 2024F924Put firmly secured handrails on each side of hallways.DStandard
Nov 25, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EStandard
Nov 25, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Nov 25, 2024F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.EStandard
Nov 25, 2024F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.EStandard
Nov 25, 2024F761Ensure 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.DStandard
Nov 25, 2024F759Ensure medication error rates are not 5 percent or greater.DStandard
Nov 25, 2024F758Implement 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.DStandard
Nov 25, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Nov 25, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Nov 25, 2024F730Observe each nurse aide's job performance and give regular training.FStandard
Nov 25, 2024F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.FStandard
Nov 25, 2024F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.EStandard
Nov 25, 2024F699Provide care or services that was trauma informed and/or culturally competent.DStandard
Nov 25, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DStandard
Nov 25, 2024F697Provide safe, appropriate pain management for a resident who requires such services.DStandard
Nov 25, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Nov 25, 2024F658Ensure services provided by the nursing facility meet professional standards of quality.DStandard
Nov 25, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Jul 2, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Jul 2, 2024F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
Jul 2, 2024F552Ensure that residents are fully informed and understand their health status, care and treatments.DComplaint
Jan 9, 2024F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.DComplaint
Aug 22, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Aug 22, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Aug 22, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
Aug 22, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.GComplaint
Aug 10, 2023F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EStandard
Aug 10, 2023F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Aug 10, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EStandard
Aug 10, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.DStandard
Aug 10, 2023F761Ensure 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.DStandard
Aug 10, 2023F759Ensure medication error rates are not 5 percent or greater.EStandard
Aug 10, 2023F758Implement 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.DStandard
Aug 10, 2023F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.DStandard
Aug 10, 2023F699Provide care or services that was trauma informed and/or culturally competent.DStandard
Aug 10, 2023F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DStandard
Aug 10, 2023F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Aug 10, 2023F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.DStandard
Aug 10, 2023F693Ensure 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.DStandard
Aug 10, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Aug 10, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.EStandard
Aug 10, 2023F685Assist a resident in gaining access to vision and hearing services.DStandard
Aug 10, 2023F658Ensure services provided by the nursing facility meet professional standards of quality.DStandard
Aug 10, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Aug 10, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Aug 10, 2023F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard
Aug 10, 2023F637Assess the resident when there is a significant change in conditionDStandard
Aug 10, 2023F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DStandard
Aug 10, 2023F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DStandard
Aug 10, 2023F565Honor the resident's right to organize and participate in resident/family groups in the facility.EStandard
Mar 20, 2023F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
Jun 15, 2022F910Ensure resident rooms meet each resident's needs.DStandard
Jun 15, 2022F909Regularly 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.FStandard
Jun 15, 2022F888Ensure staff are vaccinated for COVID-19CStandard
Jun 15, 2022F886Perform COVID19 testing on residents and staff.FStandard
Jun 15, 2022F885Report COVID19 data to residents and families.FStandard
Jun 15, 2022F880Provide and implement an infection prevention and control program.DStandard
Jun 15, 2022F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FStandard
Jun 15, 2022F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Jun 15, 2022F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Jun 15, 2022F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Jun 15, 2022F803Ensure 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.FStandard
Jun 15, 2022F761Ensure 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.FStandard
Jun 15, 2022F760Ensure that residents are free from significant medication errors.DStandard
Jun 15, 2022F758Implement 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.EStandard
Jun 15, 2022F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Jun 15, 2022F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Jun 15, 2022F700Try 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.DStandard
Jun 15, 2022F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Jun 15, 2022F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.FStandard
Jun 15, 2022F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Jun 15, 2022F658Ensure services provided by the nursing facility meet professional standards of quality.DStandard
Jun 15, 2022F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Jun 15, 2022F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Jun 15, 2022F610Respond appropriately to all alleged violations.DStandard
Jun 15, 2022F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DStandard
Jun 15, 2022F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DStandard
Jun 15, 2022F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard

Federal enforcement history

Federal regulators have imposed 3 enforcement actions against this facility, including 3 civil money penalties totaling $191,151 .

DateTypeFinePayment denial
Jan 29, 2025Fine$134,285
Sep 5, 2023Fine$6,293
Aug 10, 2023Fine$50,573
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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