Manchester Commons of Presbyterian Seniorcare

In the surveyor’s words

From the most serious findings on record at Manchester Commons of Presbyterian Seniorcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Oct 20, 2022

  Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to discard an expired [MEDICATION(S)] (TB) solution for two of two medications rooms observed ([NAME] and Eagle Pass). Findings include: Review of facility policy entitled, Medication Storage In The Facility, dated [DATE], with a policy review date of [DATE], indicated that Certain medications or package types, such as multiple dose injectable vials once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of manufacturer's instructions on the box of TB solution indicated to Discard 30 days after opening. Observation of Eagle Pass Medication Room on [DATE], at 11:30 a.m. […]

• No harm, potential for more than minimal, patternF802Dec 9, 2021

  Based on observations and staff interviews, it was determined that the facility failed to provide sufficient staff with appropriate competencies to carry out the functions of the food and nutrition services on two of five units (Avonia and Blue [NAME]). Findings include: During an interview with the Director of Nutritional Services on 12/6/21, at 2:40 p.m. revealed that dietary staff were transporting meals from the main kitchen to the units to be served from the dining areas on each unit. As there were only three dietary aides that were available to serve the meals, two of the five units utilized nursing staff to plate the foods and distribute the meals to the residents on their unit. Observations on Avonia on 12/06/21, at 5:00 p.m. revealed nursing staff plating food without hairnets. […]

• No harm, potential for more than minimal, isolatedF641Jul 31, 2026

  Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for one of 19 residents reviewed (Resident R67).Findings include:Resident R67's clinical record revealed an admission date of 4/24/26, with diagnoses including protein calorie malnutrition, pressure ulcer right buttock stage three (wound with full thickness tissue loss), diabetes mellitus and high blood pressure.Resident R67's clinical record revealed assessment documentation provided by the contracted wound care specialist as follows:-6/02/26, Right Buttock is a Deep Tissue Pressure Injury (DTI)… […]

• No harm, potential for more than minimal, isolatedF553Jul 2, 2025

  Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for one of 18 residents reviewed (Resident R6). Findings include: Review of facility policy dated 2/2025, entitled Skilled Nursing - Comprehensive Care Plans indicated the resident will be notified of his/her right to request meetings, revisions to care plan, and to be informed in advance of changes to care plan. The policy further stated that the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. […]

• No harm, potential for more than minimal, isolatedF578Jul 2, 2025

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Resuscitation Authorization (a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 18 residents reviewed (Resident R18). Findings include: A facility policy entitled Resident Rights Advance Directives POLST Resuscitation Code Status dated 2/2025, revealed Resuscitation Code Status is the individual's preference regarding CPR [Cardio Pulmonary Resuscitation-CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest] and other… […]