Inspection visit
Inspection
Citations
35 citations recorded*CMS
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.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
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.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F726 - Nursing Services
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.
F758 - Medication Errors
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F849 - Hospice services
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.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0041GeneralS&S Dpotential for harm
Implement emergency and standby power systems.
- 0271GeneralS&S Fpotential for harm
Have exits that are accessible at all times.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0522GeneralS&S Dpotential for harm
Have an externally vented heating system.
- 0541GeneralS&S Dpotential for harm
Install properly constructed and protected linen or trash chutes.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the August 10, 2023 survey of MEDWAY COUNTRY MANOR SKILLED NURSING & REHABILITAT?
This was a inspection survey of MEDWAY COUNTRY MANOR SKILLED NURSING & REHABILITAT on August 10, 2023. The surveyor cited 35 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MEDWAY COUNTRY MANOR SKILLED NURSING & REHABILITAT on August 10, 2023?
Yes, 35 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.