Manchester Rehab and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF835May 1, 2023

  Based on observation, interview and record review, the facility failed to administer care in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident. The facility initiated the transfer of residents to other facilities, particularly within their corporation, without appropriate notice, reason or discharge planning (Residents #6, #7, #8, #100, #101, #104). Residents who had been transferred did not have their personal belongings and/or medically necessary equipment (Residents #100, #104 and #101). According to staff, residents had been heavily recruited by the Administration of a sister-facility to move, and had not initiated a move on their own. […]

• Immediate jeopardy, patternF689May 10, 2021

  Based on interview and record review, the facility failed to provide adequate supervision to prevent the elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) of three cognitively impaired residents (Resident #1, Resident #4 and Resident #7). Upon admission, Resident #1 was assessed as being at high risk for wandering and noted to have a history of wandering. While unsupervised, he/she eloped from the facility's secure unit, via an unlocked side door and patio gate, without staff knowledge, wandered away to a busy four lane intersection, and fell into a ditch incurring knee pain due to [MEDICATION(S)] trauma. […]

• Immediate jeopardy, isolatedF689May 23, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident received adequate supervision and interventions to ensure their safety. Resident #131 admitted on [DATE] from the hospital with altered mental status suspecting underlying dementia with psych issue, and in need of a secure unit. On 4/11/25, the resident left through an alarmed exit door on the secured memory care unit. The alarm sounded on the exit door, however, staff did not visually verify the location of residents on the unit. On 4/19/25, Resident #131 smashed a window with a toilet tank lid, cried and said he/she wanted to leave and threatened to jump out the window. He/She was hospitalized for two days and returned on 4/21/25 with a diagnosis of severe urinary tract infection (UTI). […]

• Immediate jeopardy, isolatedF600Apr 5, 2023

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when Certified Nurse Aide (CNA) E grabbed the resident's arm and threatened to break it which caused bruising to the resident's arm and caused him/her to be scared of the employee. The incident was witnessed by staff, who failed to report the abuse. CNA E finished working his/her shift and returned the next day, prior to the resident reporting the abuse and the facility beginning their investigation. The sample was five. The census was 41. The Administrator was notified on 4/5/23 at 1:22 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 1/25/23. […]

• Immediate jeopardy, isolatedF725May 10, 2021

  Based on interview and record review, the facility failed to maintain appropriate staffing levels, in order to provide adequate resident supervision and care. During the night shift of 4/28/21, the facility was staffed with two certified nurse aides (CNAs), one staffing agency nurse and one certified medication technician (CMT), to supervise and provide care to 53 residents. Resident #12 required 1:1 supervision for disruptive behaviors which included repeatedly entering other resident rooms, climbing into their beds and becoming combative with redirection. There were periods during which the secured unit (which housed residents with cognitive impairment and some with risk for elopement) was unsupervised. […]