Public Record
Medway Country Manor Skilled Nursing & Rehabilitat
From CMS
Facility profile
- Certified beds
- 123
- Avg. residents per day
- 111.6
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 118
- Inspections on file
- 12
- Last inspection
- 2025-02-05
*CMS
*CMS
*CMS
Citations
118 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0880Seriousimmediate jeopardy
Provide and implement an infection prevention and control program.
- 0726Seriousimmediate jeopardy
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.
- 0773Seriousimmediate jeopardy
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- 0835Seriousimmediate jeopardy
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0924Generalpotential for harm
Put firmly secured handrails on each side of hallways.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0712Generalpotential for harm
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
- 0726Generalpotential for harm
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.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0802Generalpotential for harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0626Generalpotential for harm
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0580Seriousactual harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0693Generalpotential for harm
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.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0726Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0849Generalpotential for harm
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.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0637Generalpotential for harm
Assess the resident when there is a significant change in condition
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0041Generalpotential for harm
Implement emergency and standby power systems.
- 0271Generalpotential for harm
Have exits that are accessible at all times.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0522Generalpotential for harm
Have an externally vented heating system.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0700Generalpotential for harm
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.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
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.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
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.
- 0803Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0849Generalpotential for harm
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.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0885Generalpotential for harm
Report COVID19 data to residents and families.
- 0886Generalpotential for harm
Perform COVID19 testing on residents and staff.
- 0888Generalno actual harm
Ensure staff are vaccinated for COVID-19
- 0909Generalpotential for harm
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.
- 0910Generalpotential for harm
Ensure resident rooms meet each resident's needs.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0020Generalpotential for harm
Establish policies and procedures including evacuation.
- 0026Generalpotential for harm
Establish roles under a Waiver declared by secretary.
- 0161Generalpotential for harm
Use approved construction type or materials.
- 0222Generalpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0352Generalpotential for harm
Properly install and monitor supervisory attachments on automatic sprinkler systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0531Generalpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection2 deficiencies
- View inspection reportInspection4 deficiencies
- View inspection reportInspection23 deficiencies
- View inspection reportInspection23 deficiencies
- View inspection reportInspection3 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection4 deficiencies
- View inspection reportInspection35 deficiencies
- View inspection reportInspection35 deficiencies
- View inspection reportInspection1 deficiency
Showing the 10 most recent inspections. 2 earlier inspections are also on record.
FAQ
Questions and answers
- What is Medway Country Manor Skilled Nursing & Rehabilitat?
- Medway Country Manor Skilled Nursing & Rehabilitat is a Medicare- and Medicaid-certified nursing home in Medway, MA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 225412.
- How many beds does Medway Country Manor Skilled Nursing & Rehabilitat have?
- Medway Country Manor Skilled Nursing & Rehabilitat is certified for 123 beds. It serves an average of 111.6 residents per day.
- How many citations does Medway Country Manor Skilled Nursing & Rehabilitat have?
- Medway Country Manor Skilled Nursing & Rehabilitat has 118 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Medway Country Manor Skilled Nursing & Rehabilitat last inspected?
- Medway Country Manor Skilled Nursing & Rehabilitat was last inspected on February 5, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/225412-medway-country-manor-skilled-nursing-rehabilitat