Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Courville At Manchester during CMS and state inspections, most recent first.
A resident was potentially left on a bedpan since the morning shift, resulting in a red bottom. A LPN reported this to the Nursing Supervisor, who failed to notify the Administrator or DON as required by the facility's abuse policy.
A resident was potentially left on a bedpan for an extended period, resulting in a red bottom. An LPN reported the situation to the Nursing Supervisor, but it was not escalated to the Administrator or DON, leading to a failure in addressing the potential neglect.
A resident did not receive prescribed prune juice or M.O.M. for constipation despite not having a bowel movement for three consecutive days on multiple occasions. The facility's bowel management policy, which requires intervention by the second and third day without a bowel movement, was not followed, leading to a deficiency.
A resident requiring aspiration precautions was left unsupervised during meals, despite clear instructions for one-on-one assistance. Observations showed the resident eating alone, contrary to their Nutritional Care Plan and physician's orders. An LPN was unaware of the need for supervision, even after a previous choking incident.
The facility did not conduct a required annual performance review for an LNA, as revealed by a review of employee records and confirmed by the Administrator. The facility's assessment indicated that in-service training should address weaknesses identified in performance reviews, but no evaluations were completed for 2023 and 2024.
A resident received PRN orders for Lorazepam and Haloperidol without a specified duration, exceeding the 14-day limit without documented justification from the physician. Despite recommendations to add a stop date, the provider declined, citing the resident's stable hospice-respite status. This led to multiple doses being administered beyond the allowed period, violating facility policy.
A facility failed to implement contact precautions for a resident with VRE. Despite a posted sign indicating the need for PPE, an LPN entered the resident's room without donning the required gown and gloves. The LPN was unaware of the contact precautions, indicating a lapse in communication and adherence to infection control policies.
The facility failed to provide the required 12 hours of annual in-service training for LNAs, with Staff M completing only 8 hours in 2024. Additionally, the facility did not conduct annual performance reviews for LNAs, preventing the identification and addressing of areas of weakness. This was confirmed by the Administrator.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in discharge coding and resident identification. A resident's MDS was incorrectly coded as a discharge with return not anticipated, while another's was marked as an unplanned discharge despite being planned. Additionally, a resident's name was misspelled, creating a separate record in the iQIES System.
The facility failed to ensure proper dishwasher sanitization, maintain a sanitary dining environment, and enforce the use of beard restraints during food service. Observations revealed missing PPM test results, uncleanable surfaces in the dining area, and a dietary aide handling food without a beard restraint.
A resident with a Stage II pressure ulcer and a deep tissue injury did not receive the ordered physical therapy evaluation for a modified chair cushion. Instead, the resident was observed using bed pillows, which were not pressure-relieving devices, and spent most of the time in a reclining chair, leading to soreness. The DON confirmed these findings.
The facility failed to ensure a safe environment by leaving hazardous cleaning chemicals in an unlocked cabinet accessible to residents, including two at risk for wandering. This was confirmed by staff and violated the facility's policy on storing poisonous materials.
Failure to Implement Abuse Policy for Resident
Penalty
Summary
The facility failed to implement its abuse policy for a resident who was reviewed for abuse. On December 6, 2024, a progress note indicated that the resident had requested to use the bathroom around 4:40 p.m. and appeared to have been left on a bedpan since the morning shift, as noted by a Licensed Nursing Assistant. The resident was found with a red bottom, suggesting prolonged exposure to the bedpan. A Licensed Practical Nurse reported this situation to the Nursing Supervisor for the 3-11 shift. However, the Nursing Supervisor did not notify the Administrator or the Director of Nursing about the potential neglect, as required by the facility's Resident Abuse Prevention and Investigation Policy. This policy mandates immediate notification of the Administrator or DON by the supervisor in cases of alleged abuse, mistreatment, or neglect.
Failure to Report Alleged Neglect of Resident
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was potentially left on a bedpan for an extended period. On 12/6/24, a progress note indicated that the resident requested to use the bathroom around 4:40 p.m., and it appeared that the bedpan had been underneath them since the morning shift. The resident's bottom was noted to be red. A Licensed Practical Nurse (LPN) reported this observation to the Nursing Supervisor on the 3-11 shift. However, the Nursing Supervisor did not report the incident to the Administrator or the Director of Nursing, resulting in a failure to address the potential neglect in a timely manner.
Failure to Follow Physician's Orders for Bowel Management
Penalty
Summary
The facility failed to adhere to physician's orders for a resident experiencing bowel/bladder incontinence. The physician's orders specified that the resident should be offered 120 ml of prune juice by mouth on the 7-3 shift if there was no bowel movement for three days, and 30 ml of Milk of Magnesia (M.O.M.) on the 3-11 shift if constipation persisted. However, a review of the resident's Bowel Continence Record for December 2024 and January 2025 revealed multiple instances where the resident did not have a bowel movement for three consecutive days, specifically on December 15-17, December 20-22, January 5-7, and January 9-11. Despite these occurrences, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed prune juice or M.O.M. during these periods. An interview with the Unit Manager confirmed these findings. Additionally, the facility's bowel management policy, effective since June 2005, requires that if there is no bowel movement by the second night, the ordered laxative or prune juice should be administered, and if there is no bowel movement by the third day, a rectal suppository or enema should be given with a doctor's orders. This policy was not followed, leading to the deficiency.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who required assistance due to aspiration precautions. The resident, identified as needing one-on-one assistance with feeding, was observed eating lunch alone on two separate occasions. A sign above the resident's bed clearly indicated the need for aspiration precautions and one-on-one assistance with feeding. Despite this, the resident was left unsupervised during meals. The resident's Nutritional Care Plan and a physician's order both specified that meals should be consumed in a supervised area, with encouragement for small bites and frequent sips of fluid. An interview with a Licensed Practical Nurse revealed a lack of awareness regarding the resident's need for supervised meals, despite a previous incident where the resident was found choking at lunch, leading to the implementation of aspiration precautions.
Failure to Conduct Annual Performance Reviews for LNA
Penalty
Summary
The facility failed to conduct a performance review for a Licensed Nurse Assistant (LNA) at least once every 12 months, as required. The facility's assessment from August 2024 indicated that staff training and education, including in-service training for nurse aides, must be sufficient to ensure their continuing competence, with a minimum of 12 hours per year. This training should address areas of weakness identified in performance reviews and facility assessments. However, a review of Staff M's employee records revealed that no performance evaluation was completed for the years 2023 and 2024, despite their employment starting in November 2022. An interview with the facility's Administrator confirmed the lack of annual performance reviews for LNAs.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN orders for psychotropic medications, specifically for a resident identified as #71. The resident had PRN orders for Lorazepam and Haloperidol, both of which were prescribed without a specified duration. These orders were initiated on December 26, 2024, and continued beyond the 14-day limit without documented justification or a specified duration from the prescribing physician. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless the physician provides a documented rationale for extending the duration, which was not done in this case. The resident's medical record and pharmacy consultation reports indicated that recommendations to add a stop date to these PRN orders were declined by the provider, who noted that the patient was hospice-respite and stable on the current regimen. Despite this, the facility's policy was not adhered to, as the required documentation and indication of duration for the PRN orders were absent. This oversight led to the administration of multiple doses of Lorazepam and Haloperidol beyond the 14-day period without proper documentation or justification, resulting in a deficiency finding during the survey.
Failure to Implement Contact Precautions for Resident with VRE
Penalty
Summary
The facility failed to implement its policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for a resident on contact precautions. Resident #31 had a urinalysis culture that identified Vancomycin-Resistant Enterococci (VRE) on January 11, 2025, and a sign was posted in their room indicating the need for contact precautions, including the use of personal protective equipment (PPE) such as gowns and gloves by staff and visitors. However, on January 15, 2025, a Licensed Practical Nurse (Staff F) entered Resident #31's room without donning the required PPE. Upon interview, Staff F revealed they were unaware that Resident #31 was on contact precautions, indicating a lapse in communication and adherence to the facility's infection control policies. The facility's policy, revised in September 2022, clearly states that staff and visitors must wear gloves and a disposable gown upon entering the room of a resident on contact precautions. This incident highlights a failure in the implementation of these policies, as evidenced by the observation of Staff F's actions and their subsequent admission of not being informed about the resident's precautionary status.
Deficiency in LNA In-Service Training and Performance Reviews
Penalty
Summary
The facility failed to ensure that the required in-service training for nurse aides was conducted and maintained, specifically the annual minimum of 12 hours. This deficiency was identified through a review of the facility's assessment and Staff M's personnel and in-service training records. Staff M, a Licensed Nursing Assistant (LNA) who started at the facility in 2022, had only completed approximately 8 hours of in-service training for the year 2024, which included training on dementia, abuse, and facility policies on infection control practices. This was below the required 12 hours per year, as stipulated in the facility's policy and state regulations. Additionally, the facility did not conduct performance reviews for LNAs every 12 months, which is necessary to identify and address areas of weakness in their performance. This lapse was confirmed during an interview with Staff C, the Administrator, who acknowledged the failure to perform these reviews. The absence of regular performance reviews meant that the facility could not adequately address the special needs of residents or the areas of weakness in nurse aides' performance, as required by the facility's policy and state regulations.
Inaccurate MDS Assessments and Resident Identification Errors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for four residents. Resident #18's MDS was incorrectly coded as a discharge with return not anticipated, despite documentation indicating an unplanned hospital transfer with an anticipated return. Similarly, Resident #72's MDS was coded as an unplanned discharge, while records showed a planned discharge to home. Resident #73's MDS inaccurately indicated a discharge to a hospital, although the resident was discharged to home. These discrepancies were confirmed through interviews with staff members. Additionally, Resident #68's MDS contained an incorrect spelling of the resident's name, leading to the creation of a separate record in the iQIES System. This error was identified in the final validation report, which issued a warning message to verify the new information. The incorrect entry was confirmed by staff, highlighting a failure in maintaining accurate resident identification information.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure the dishwasher in the main kitchen was reaching proper temperatures and chemical sanitization levels. Observations and record reviews revealed missing parts per million (PPM) test results for several days in December 2023, January 2024, and February 2024. Staff interviews confirmed that the PPM readings were not consistently recorded as required by the facility's policy. Additionally, the facility's policy outlined specific steps to ensure the dishwasher's chemical agent was at the correct mixing level, which were not followed, leading to potential sanitation issues with dishware used in the facility. In the first floor main dining room, the facility failed to maintain a sanitary environment for food service. Observations noted missing laminate on countertops, peeling wallpaper with food stains, and chipped wooden countertops, all of which created uncleanable surfaces. Furthermore, a dietary aide was observed handling uncovered plates of food without wearing a beard restraint, despite having a full beard over an inch long. Interviews with staff confirmed that beard restraints were required but not consistently used. These deficiencies indicate lapses in maintaining sanitary conditions and adherence to food safety protocols in the facility.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that a resident received the ordered treatments for pressure ulcers. Resident #41 had a Stage II pressure ulcer on the left buttock and a deep tissue injury on the right buttock, with orders for a physical therapy evaluation for a modified chair cushion. Despite these orders, the resident was observed sitting in a reclining chair with two bed pillows under the buttocks, which were not pressure-relieving devices. Interviews with the resident and staff confirmed that the resident had not used a chair cushion since admission and spent most of the time in the reclining chair, leading to soreness in the buttocks. The Director of Nursing confirmed these findings during the surveyor's visit.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free of accident hazards as possible regarding the storage of chemical cleaning solutions on the First Floor Unit. During an observation in the main dining serving area, an unlocked cabinet below the sink was found to contain several hazardous cleaning chemicals, including Clean Force Stainless Steel Cleaner and Polish, Comet Cleaner With Bleach, ECOLAB Foam Hand Sanitizer, and Surface Cleaner Sanitizer. This observation was confirmed by the Cook and the Administrator, who acknowledged that residents could access the dining room at any time. An interview with the Director of Nursing revealed that there were two residents identified at risk for wandering or elopement. The facility's policy on the storage of poisonous and toxic materials mandates that such materials be kept out of direct reach of residents and stored according to manufacturer recommendations. However, the observed storage practices did not comply with this policy. The Safety Data Sheets for the chemicals indicated various health risks, including eye irritation and potential harm from inhalation, underscoring the hazard posed by the unlocked cabinet in an accessible area.
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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) |
|---|---|---|---|---|
| Mount Carmel Rehabilitation And Nursing Center | 0.9 mi | — | 0 | 0 |
| Maple Leaf Health Care Center | 0.9 mi | — | 2 | 0 |
| Saint Teresa Rehabilitation & Nursing Center | 1.6 mi | — | 0 | 0 |
| Hanover Hill Health Care Center | 2 mi | — | 2 | 0 |
| St Joseph Residence | 2 mi | — | 10 | 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.