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.
Record summary
Federal record · Q1 202686
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| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Feb 5, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Feb 5, 2025 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Jan 29, 2025 | F880 | Provide and implement an infection prevention and control program. | L | Complaint |
| Jan 29, 2025 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | L | Complaint |
| Jan 29, 2025 | F773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | L | Complaint |
| Jan 29, 2025 | F726 | 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. | L | Complaint |
| Nov 25, 2024 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | F | Standard |
| Nov 25, 2024 | F924 | Put firmly secured handrails on each side of hallways. | D | Standard |
| Nov 25, 2024 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | Standard |
| Nov 25, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Nov 25, 2024 | F805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | E | Standard |
| Nov 25, 2024 | F802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | E | Standard |
| Nov 25, 2024 | F761 | 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. | D | Standard |
| Nov 25, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Nov 25, 2024 | F758 | 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. | D | Standard |
| Nov 25, 2024 | F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard |
| Nov 25, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Nov 25, 2024 | F730 | Observe each nurse aide's job performance and give regular training. | F | Standard |
| Nov 25, 2024 | F726 | 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. | F | Standard |
| Nov 25, 2024 | F712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | E | Standard |
| Nov 25, 2024 | F699 | Provide care or services that was trauma informed and/or culturally competent. | D | Standard |
| Nov 25, 2024 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Nov 25, 2024 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Nov 25, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Nov 25, 2024 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Nov 25, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Jul 2, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Jul 2, 2024 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Jul 2, 2024 | F552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Complaint |
| Jan 9, 2024 | F626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | D | Complaint |
| Aug 22, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint |
| Aug 22, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint |
| Aug 22, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Aug 22, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | G | Complaint |
| Aug 10, 2023 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | Standard |
| Aug 10, 2023 | F849 | 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. | D | Standard |
| Aug 10, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Standard |
| Aug 10, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard |
| Aug 10, 2023 | F761 | 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. | D | Standard |
| Aug 10, 2023 | F759 | Ensure medication error rates are not 5 percent or greater. | E | Standard |
| Aug 10, 2023 | F758 | 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. | D | Standard |
| Aug 10, 2023 | F726 | 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. | D | Standard |
| Aug 10, 2023 | F699 | Provide care or services that was trauma informed and/or culturally competent. | D | Standard |
| Aug 10, 2023 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Aug 10, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Aug 10, 2023 | F694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | Standard |
| Aug 10, 2023 | F693 | 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. | D | Standard |
| Aug 10, 2023 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Aug 10, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | Standard |
| Aug 10, 2023 | F685 | Assist a resident in gaining access to vision and hearing services. | D | Standard |
| Aug 10, 2023 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Aug 10, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Aug 10, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Aug 10, 2023 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Aug 10, 2023 | F637 | Assess the resident when there is a significant change in condition | D | Standard |
| Aug 10, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Standard |
| Aug 10, 2023 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Aug 10, 2023 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Standard |
| Mar 20, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Jun 15, 2022 | F910 | Ensure resident rooms meet each resident's needs. | D | Standard |
| Jun 15, 2022 | F909 | 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. | F | Standard |
| Jun 15, 2022 | F888 | Ensure staff are vaccinated for COVID-19 | C | Standard |
| Jun 15, 2022 | F886 | Perform COVID19 testing on residents and staff. | F | Standard |
| Jun 15, 2022 | F885 | Report COVID19 data to residents and families. | F | Standard |
| Jun 15, 2022 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Jun 15, 2022 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Standard |
| Jun 15, 2022 | F849 | 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. | D | Standard |
| Jun 15, 2022 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Jun 15, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Jun 15, 2022 | F803 | 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. | F | Standard |
| Jun 15, 2022 | F761 | 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. | F | Standard |
| Jun 15, 2022 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Jun 15, 2022 | F758 | 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. | E | Standard |
| Jun 15, 2022 | F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard |
| Jun 15, 2022 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Standard |
| Jun 15, 2022 | F700 | 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. | D | Standard |
| Jun 15, 2022 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Jun 15, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | F | Standard |
| Jun 15, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Jun 15, 2022 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Jun 15, 2022 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Jun 15, 2022 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Jun 15, 2022 | F610 | Respond appropriately to all alleged violations. | D | Standard |
| Jun 15, 2022 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard |
| Jun 15, 2022 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Standard |
| Jun 15, 2022 | F552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Standard |
Federal enforcement history
Federal regulators have imposed 3 enforcement actions against this facility, including 3 civil money penalties totaling $191,151 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Jan 29, 2025 | Fine | $134,285 | — |
| Sep 5, 2023 | Fine | $6,293 | — |
| Aug 10, 2023 | Fine | $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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