Manatawny Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Manatawny Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 4, 2023

  Based on clinical record, facility policy and procedure, hospital record reviews and staff interview, it was determined the facility failed to monitor and assess a pressure ulcer present upon readmission causing actual harm to Resident 1 when the wound deteriorated and became infected causing septic shock for one of three residents reviewed. (Resident 1) Findings Include: Review of facility policy and procedure titled Prevention of Pressure Ulcer/Injuries, revised July 2017, revealed conduct a comprehensive skin assessment upon admission, including skin integrity- any evidence of existing or developing pressure ulcers or injuries. Skin assessments should be done weekly by a licensed nurse. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. […]

• Actual harm, isolatedF686Apr 13, 2023

  Based on clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to implement interventions to prevent pressure ulcers for three of 10 residents reviewed (Residents 12, 16, and 99) causing actual harm of a Stage 3 and two unstageable Pressure ulcers for Resident 12. Findings Include: Review of facility policy and procedure titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, Revised March 2014, revealed the nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility. […]

• No harm, potential for more than minimal, widespreadF730Apr 15, 2021

  Based on a review of employee personnel records and staff interview, it was determined that the facility failed to complete performance reviews for five of five nurse aides reviewed (Employee E5, E6, E7, E8 and E9). Findings Include: A list of nurse aides provided by the facility failed to reveal that the following employees had an annual performance review completed by the facility: Employee E5 (Date of Hire-March 11. 2019), Employee E6 (Date of Hire - November 18, 2019), Employee E7 (Date of Hire- January 9, 2020), and Employee E8 (Date of Hire-February 17, 2020), and Employee E9 (Date of Hire-March 9, 2020) An interview with the Nursing Home Administrator (NHA) on April 13, 2021, at 1:00 p.m. […]

• No harm, potential for more than minimal, patternF583Mar 19, 2026

  Based on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart).Findings include:During an observation conducted on A Wing on March 18, 2026, at 8:33 a.m., a medication cart assigned to a licensed nurse (Employee E8) was observed unattended with the computer screen open, displaying residents' personally identifiable information (PII). Employee E8 was not present in the hallway or in the immediate vicinity of the medication cart, creating the potential for unauthorized access to resident information.During a second observation conducted on A Wing on March 19, 2026, at 8:45 a.m., a medication cart assigned to a licensed nurse (Employee E9) was again… […]

• No harm, potential for more than minimal, patternF761Mar 19, 2026

  Based on observations, and staff interviews it was determined that the facility failed to properly secure medications in two of two medication carts located in nursing unit A.Findings include:Review of the facility policy Administering Medication last revised April 2020 states During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medication are kept on top of the cart.During an observation on Nursing Unit A on March 16, 2026, at 9:50 a.m., a medication cart was observed unlocked in the hallway outside a resident room with no nursing staff present in the immediate vicinity.During an interview on March 16, 2026, at 9:52 a.m., a licensed nurse (Employee E8) stated that the medication cart should have been… […]