Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manchester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and existing stage 4 pressure ulcers had a care plan calling for turning, a low air-loss mattress, and heel offloading, but there was no physician order for offloading boots or for skin checks under the boots. Over several months, documentation did not show any directive to assess skin beneath the boots each shift, and a weekly skin check noted no new issues. Subsequently, an APRN and the ADON identified a new open area on the dorsal left foot, attributed by the ADON to rubbing from the boot strap, and a wound physician documented a full-thickness wound with 100% slough requiring ongoing treatment. Interviews with the APRN, the wound physician, and the ADON indicated the wound was not identified timely and that, had the boots been removed and the skin assessed every shift, the area could have been detected earlier and the wound’s progression potentially limited.
A resident with severe cognitive impairment, multiple chronic conditions, poor oral hygiene, and documented oral/dental problems was seen by a dental provider who found devastated dentition with cavities on every tooth, likely infection, and recommended full-mouth x‑rays, extractions, and frequent cleanings. The findings were not documented in the clinical record as progress notes, and the provider was not notified. Over the next several months, the resident repeatedly missed scheduled dental hygienist visits due to scheduling issues and hospitalizations, without evidence of nursing or provider notification or alternative follow-up. The social services director acknowledged seeing the dental note but did not inform nursing, the DON was unaware of the visit and missed appointments despite schedules addressed to her, and the APRN was not informed of the dental findings, contrary to the facility’s own notification-of-changes policy.
A resident with multiple diagnoses experienced an unwitnessed fall and was hospitalized. Upon return, required neurological monitoring was not completed or documented for several hours, and staff failed to follow the expected monitoring schedule. The facility did not have a clear policy guiding post-fall neurological checks, leading to missed assessments and inaccurate documentation.
A facility failed to honor a resident's advanced directive choices due to severe cognitive impairment. Despite a hospital directive for DNR status, the resident incorrectly signed as full code without a witness or physician's signature. The facility did not contact the resident's representative within 24 hours to confirm wishes, and no progress notes indicated attempts to reach them. The DNS acknowledged the need for representative involvement, and the case manager confirmed no legal forms were signed by the representative, despite daily visits.
A resident with a history of falls and hip replacement was not consistently ambulated as per physician orders, despite the care plan requiring ambulation twice daily with a walker. Nursing staff failed to document or provide rationale for missed ambulation opportunities, and the resident expressed concerns about not being walked regularly. Interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's mobility.
The facility failed to conduct annual performance reviews for two nurse aides, as required by their policy. The Director of HR admitted that a process change led to missed evaluations, and the DNS, who was not in her role at the time, has since been completing evaluations as expected.
A facility failed to conduct behavior monitoring for a resident on Seroquel, an antipsychotic medication prescribed for dementia with insomnia. Despite recommendations to update the medication order with specific behaviors for monitoring, the resident's representative did not want changes. The APRN and DNS acknowledged that behavior monitoring was not implemented as required by the facility's policy, which mandates targeted behavior monitoring and non-pharmacological interventions for residents on psychotropic medications.
A malfunctioning call bell system in two units caused continuous ringing, disturbing residents and staff. The issue began several days prior, and attempts to fix it with an adapter failed. The Maintenance Director tried to contact the vendor, but the problem persisted over the weekend. The Administrator acknowledged the malfunction, which violated the facility's noise control policy.
Failure to Monitor Offloading Boots and Prevent New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and monitoring for a dependent resident at high risk for skin breakdown. The resident had multiple diagnoses including dementia, Parkinson’s disease, CKD stage 3, hypothyroidism, protein-calorie malnutrition, and type 2 diabetes, and was dependent on staff for personal hygiene, bed mobility, and transfers. A quarterly MDS documented severely impaired cognition and three unhealed stage 4 pressure ulcers present on admission, and the care plan identified impaired skin integrity with interventions such as turning and repositioning every two hours, use of a low air-loss mattress, and offloading heels as tolerated. A Braden Scale assessment identified the resident as high risk for pressure injuries, and a wound care note documented that a prior left medial foot wound had resolved. Despite these identified risks and care plan interventions, the clinical record from mid-May through late September did not contain any physician order to utilize offloading boots or to check the skin under the boots every shift. A weekly skin check on 9/21/25 documented no new skin issues. On 9/23/25, an APRN was asked to evaluate a wound on the resident’s left foot and documented a left dorsal foot wound requiring daily cleansing and silver alginate dressing. Later that day, the ADON documented discovering an open area on the left dorsal foot, approximately 3 cm by 0.5 cm, and attributed it to the resident’s skin rubbing against the strap of the offloading booties. The ADON noted that the offloading boots were removed and replaced, and that new dressing orders were obtained, but there was no prior order directing use of the boots or skin checks under them. On 9/25/25, the wound care physician documented a new full-thickness wound on the left dorsal foot measuring 1.1 cm by 0.9 cm by 0 cm with 100% slough and moderate serosanguinous drainage, and recommended offloading heels per facility protocol. A later note on 3/19/26 showed the left dorsal foot wound persisted as a stage 4 pressure ulcer. Interviews with the APRN, the wound care physician, and the ADON indicated that the wound was not identified timely, that the resident should have had an order to offload both heels while in bed, and that offloading boots, once used, should have been removed every shift to assess the underlying skin. They stated that if the skin under the boots had been assessed every shift, the area could have been identified earlier and the progression to a full-thickness wound might have been prevented or less severe. The facility’s pressure injury policy referenced systematic prevention and management based on risk factors such as impaired mobility, comorbidities, cognitive impairment, and malnutrition, but there was no available policy specific to offloading boots.
Failure to Notify Provider and Follow Up on Significant Dental Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s provider and nursing staff of significant dental findings and to follow up on recommended dental care. A resident with dementia, Parkinson’s disease, stage 3 chronic kidney disease, hypothyroidism, protein-calorie malnutrition, type 2 diabetes mellitus, and three unhealed stage 4 pressure ulcers was care planned for oral/dental health problems, including poor oral hygiene and the need to monitor and report signs and symptoms of oral/dental issues. A dental visit on 9/25/25 documented that the resident had cavities on every tooth, devastated dentition likely infected or a great source of bacteria, and that the resident would be healthier without the remaining teeth. The dentist recommended an FMX to determine the best referral for further intervention and dental cleanings every three months due to poor oral health. However, from 9/25/25 through 3/25/26, the clinical record contained no progress notes about this dental visit, the need for x‑rays, the condition of the dentition, or any notification to the provider about these issues. Subsequent dental hygienist schedules showed that the resident was not treated on multiple dates over approximately six months, with reasons including not being on the hygienist’s list and the resident being at the hospital, and there was no evidence that these missed visits were communicated to nursing or the provider. The Director of Social Services, who managed outside providers, acknowledged seeing the 9/25/25 dental note but did not ensure nursing was aware of the findings or arrange additional follow-up, and confirmed the resident was repeatedly on the list but not seen. The DON stated she was unaware of the 9/25/25 dental visit and the missed hygienist visits, despite schedules being addressed to her, and indicated that the Director of Social Services should have notified nursing and a provider of the missed visits. The APRN reported she was unaware of the dental findings and would have evaluated and treated the resident if notified, and that alternative arrangements should have been made after missed appointments due to hospitalization. The facility’s Notification of Changes policy required informing and consulting with the provider and notifying the resident or representative when there is a significant change requiring alteration of treatment, but there was no policy available for outside consults and follow-up.
Failure to Complete and Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and complete neurological monitoring following an unwitnessed fall involving a resident with diagnoses including Parkinson's disease, cervicalgia, and bipolar disorder. The resident, who was cognitively intact and independently ambulatory, was found outside the facility after an apparent elopement attempt. Initial assessments documented that the resident denied head injury and pain, and neurological checks were performed prior to the resident's transfer to the hospital. Upon return from the hospital, documentation of required neurological monitoring was missing for several hours, and the monitoring schedule was not followed as per facility standards. Further review revealed that neurological assessments were not resumed or documented upon the resident's return, despite the expectation for hourly checks to continue. The nurse responsible stated that vital signs were taken and the resident refused neurological monitoring at one point, but this refusal was not documented. Additionally, the nurse did not recall completing or attempting the required neurological assessments at the scheduled times, and documentation inaccurately indicated the resident was still hospitalized during periods when the resident was present in the facility. The facility lacked a clear policy or procedure directing staff on when to conduct post-fall neurological monitoring, relying instead on electronic medical record prompts. The Director of Nursing confirmed that neurological monitoring should have resumed upon the resident's return and continued for 72 hours, but acknowledged that the facility did not have a written policy to guide staff. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed the failure to complete and document neurological assessments as required.
Failure to Honor Resident's Advanced Directive Choices
Penalty
Summary
The facility failed to ensure that the advanced directive choices for a resident with severe cognitive impairment were reviewed and honored. The resident was admitted with a hospital discharge directive indicating a do not resuscitate (DNR) status, and a physician's order confirmed this status along with do not intubate (DNI) and a registered nurse may pronounce (RNP) orders. However, the advanced directive form in the clinical record was incorrectly signed by the resident as a full code, without a witness or physician's signature, despite the resident's severe cognitive impairment. The facility did not contact or educate the resident's representative to confirm the resident's wishes regarding the advanced directive. Interviews revealed that the resident's representative was not contacted within the expected 24-hour period after admission to discuss the resident's code status, and no progress notes indicated attempts to reach the representative. The Director of Nursing Services (DNS) acknowledged that the resident's cognitive impairment required the representative's involvement, and the current code status form was invalid. The case manager, responsible for coordinating care conferences, confirmed that the resident's representative was not asked to sign any legal forms, despite being present at the facility daily. The facility's policy required that decisions regarding advanced directives be documented and honored, but this was not adhered to in this case.
Failure to Provide Prescribed Ambulation for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the mobility of a resident, identified as Resident #80, who was admitted with diagnoses including falls, hip replacement, and chronic pain. The care plan required ambulation of 150 feet with a rolling walker and minimal assistance. However, the nursing assistant flow sheets revealed numerous missed opportunities for ambulation, with many instances lacking documentation or rationale for the failure to ambulate. Despite physician orders and the resident's expressed desire to ambulate twice daily to regain strength and independence, the nursing staff did not consistently follow through with the prescribed ambulation. Interviews with the resident, Director of Rehabilitation, nursing assistant, Director of Nursing Services (DNS), and APRN highlighted a breakdown in communication and adherence to the care plan. The resident reported that ambulation did not occur as ordered, and the nursing assistant admitted to not offering ambulation due to the resident's therapy and recreation schedule. The DNS and Administrator expected compliance with physician orders, and the APRN indicated a need for notification if ambulation did not occur. However, no notifications were made, and the resident's ambulation was not documented or communicated effectively, leading to a deficiency in care.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two certified nurse aides, NA #3 and NA #4, as required by their Performance Evaluation policy. NA #4, who was hired in 1995, did not have a documented performance review for 2023, with the last review dated in 2022. Similarly, NA #3, hired in 2022, also lacked a documented performance review for 2023. This deficiency was identified through a review of personnel files and interviews with facility staff. The Director of Human Resources acknowledged that the facility was undergoing a process change for completing annual evaluations, which resulted in some evaluations being missed. The Director of Nursing, who was not in her current role during the time the evaluations were missed, stated that she has since been completing evaluations around the anniversary of hire dates. The facility's policy mandates annual reviews to assess position goals and provide feedback, but this was not adhered to for the two nurse aides in question.
Failure to Monitor Behavior for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure behavior monitoring was conducted for a resident on antipsychotic medications, specifically Seroquel, which was prescribed for dementia with insomnia. The resident, who had severely impaired cognition and required total assistance with daily activities, was admitted with a physician's order for Seroquel. Despite the pharmacy's recommendation to update the antipsychotic order with a specific behavior that could be quantitatively and objectively documented, the APRN noted that the resident representative did not want the medications changed. The APRN indicated that behavior monitoring should have been initiated upon admission, but it was not implemented. Interviews with the psychiatric APRN and the DNS revealed that behavior monitoring flow sheets were not in place as required by the facility's policy. The DNS acknowledged that the nurse supervisor was responsible for ensuring behavior monitoring was initiated on admission, but it was not done for this resident. The facility's policy mandates that residents on psychotropic medications must have targeted behavior monitoring and receive non-pharmacological interventions to facilitate reduction or discontinuation of the medications. However, this was not adhered to in the case of the resident on Seroquel.
Call Bell System Malfunction Causes Disturbance
Penalty
Summary
The facility failed to maintain a homelike environment due to a malfunctioning call bell system that affected two of the three units. Observations identified continuous call bell ringing on the North unit, and an LPN confirmed the malfunction began several days prior. An email from the Maintenance Director indicated that the issue was known and an adapter was installed, but it did not resolve the problem. The Maintenance Director attempted to contact the vendor, but the issue persisted over the weekend, causing disturbances to residents and staff. The Administrator acknowledged the malfunction and agreed to contact the vendor for an immediate resolution. The facility's policy on noise control emphasizes providing care in a calm and comfortable environment, which was not upheld in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Manchester | 0.8 mi | — | 0 | 0 |
| Westside Care Center | 0.8 mi | — | 2 | 0 |
| Glastonbury Center For Health & Rehabilitation | 3.6 mi | — | 12 | 0 |
| Civita Care Center At Salmon Brook | 4.6 mi | — | 3 | 0 |
| Riverside Health & Rehabilitation Center | 4.8 mi | — | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.