Manchester Healthcare Center

In the surveyor’s words

From the most serious findings on record at Manchester Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF759Feb 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Sixty-four medication errors out of 82 total opportunities contributed to an overall medication error rate of 78 % affecting 17 out of 20 residents observed during medication administration (Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99). The medication errors were as follows: 1. Omitted or late administration of Amiloride HCI (medication to treat high blood pressure) 10 milligram ([mg] unit of measurement) for hypertension ([HTN] high blood pressure), of Finasteride (medication to treat overgrowth of prostate) 5.0 mg for benign prostatic hyperplasia ([BPH] a condition when the prostate [male organ] and surrounding… […]

• Immediate jeopardy, widespreadF880Jan 6, 2021

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the Coronavirus ((COVID 19), a severe respiratory illness caused by [MEDICAL CONDITION] that spreads from person to person) in accordance with the facility's infection control policies and the Mitigation Plan ((MP), a plan to reduce loss of life and impact of COVID 19 in the facility) for 8 of 8 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8) by failing to: 1. Screen all staff and visitors entering the facility for COVID 19 signs and symptoms, history of travel, and contact with positive COVID 19 persons upon entering the facility. Visitor 1 was not screened upon entering the facility on 12/28/2020. 2. […]

• Actual harm, isolatedF684Jun 18, 2025

  Based on interview and record review, the facility failed to provide emergency care (the provision of care for conditions that require rapid intervention to avoid death or permanent disability) to the resident, who had an altered mental status (a change in a resident's level of awareness, cognition, often indicating an underlying medical or neurological issue [any condition that affects the nervous system, including the brain, spinal cord, and nerves) and high blood pressure (BP- of 200/109 millimeters of mercury ([mmHg, a unit of measurement], reference range is120/80 or lower) to prevent intracerebral hemorrhage ([ICH] a type of stroke involving bleeding within the brain tissue) for one of four sampled residents (Resident 1). The facility failed to: 1. […]

• Actual harm, isolatedF578Apr 2, 2021

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's POLST was completed upon admission to be a Full Code (all treatment measures used to revive a person when their heart stops beating and/or they stops breathing). Physician 1 changed Resident 1's POLST by writing error, over the POLST, that indicated the resident's wishes not to be a Full Code. The facility failed to adhere to Resident 1's POLST and perform cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain), as per the facility's policy and procedure (P/P) titled, POLST (crossed reference to F678). […]

• Actual harm, isolatedF678Apr 2, 2021

  Based on interview and record review, the facility's nursing staff failed to ensure two of three sampled residents (Residents 1 and 2), was provided with cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain) immediately upon confirming the residents had no pulse (heart rate) for as per the facility's policy and procedures (P/P) Cardiopulmonary Resuscitation and the American Heart Association (AHA), by failing to: a) Provide immediate CPR upon finding Residents 1 unresponsive (unable to respond or wake-up) without vital signs (clinical measurement of pulse rate, temperature, respiration rate[breaths per minute], and blood pressure [pressure of circulating blood against the walls of blood vessels]) on [DATE] at 4… […]