Courville at Manchester

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pen to administer insulin to another resident. (Resident identifier is #1.)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from significant medication errors which resulted in a resident requiring intervention and hospitalization for multiple nights for 1 of 3 medication errors reviewed. (Resident identifier is #1.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were labeled in accordance with currently accepted professional principles, medications were not removed from use after expiration, and failed to keep medications stored securely for 2 of 3 medication carts observed. (Resident identifiers are #3 and #6.)

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to remove expired food, label thawed items, properly store thawing meats, and maintain clean cooking equipment and microwaves for 1 of 1 kitchen and 2 of 3 kitchenettes observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for choices in a final sample of 17 residents. (Resident identifier is #6.)

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 17 residents (Resident identifier is #17).

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for 1 of 1 resident reviewed for dialysis and 1 of 5 residents reviewed for unnecessary medications in a final sample of 17 residents (Resident Identifiers are #2 and #8).

Inspectors wroteBased on record review and interview, the facility failed to adequately monitor for adverse consequences for anticoagulant medication for 2 residents in a final sample of 17 residents (Resident identifiers are #5 and #7).

Inspectors wroteBased on interview, record review, and policy review, it was determined that the facility failed to implement the facility's abuse policy for 1 out of 1 residents reviewed for abuse in a final sample of 19 residents. (Resident Identifier is #21). Review on 1/17/25 of Resident #21's medical record revealed a progress note, dated 12/6/24, stating that Resident asked to use the bathroom this evening around 4:40 p.m. Resident appeared to still have the bed pan underneath of [pronoun omitted] bottom from the morning shift as LNA's [Licensed Nursing Assistant] stated. Resident appeared to have a red bottom . Interview on 1/17/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that he/she had reported to Staff J (Nursing Supervisor (3-11 Shift)) on 12/6/24 that they found Resident #21 on a bedpan for an undetermined amount of time and that their bottom was red. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to report an allegation of neglect to the administrator for 1 of 1 resident reviewed for abuse in a final sample of 19 (Resident Identifier is #21). Review on 1/17/25 of Resident #21's medical record revealed a progress note, dated 12/6/24, stating that Resident asked to use the bathroom this evening around 4:40 p.m. Resident appeared to still have the bed pan underneath of [pronoun omitted] bottom from the morning shift as LNA's [Licensed Nursing Assistant] stated. Resident appeared to have a red bottom . Interview on 1/17/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that he/she had reported to Staff J (Nursing Supervisor (3-11 Shift)) on 12/6/24 that they found Resident #21 on a bedpan for an undetermined amount of time and that their bottom was red. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow physicians orders for 1 out of 1 residents reviewed for bowel/bladder incontinence in a final sample of 19 residents. (Resident identifier is #31).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide supervision at meals for 1 of 1 resident reviewed for ADL's (Activities of Daily Living) in a final survey sample of 19 residents. (Resident identifier is #60).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a performance review at least once every 12 months for 1 of 1 Licensed Nurse Assistant (LNA) reviewed.

Inspectors wroteBased on record review, it was determined that the facility failed to ensure that residents do not receive PRN (as needed) orders for psychotropic drugs that are limited to 14 days unless the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and indicate the duration for the PRN order for 1 of 4 residents reviewed for unnecessary medications (Resident Identifier is #71).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for 1 of 1 residents on TBP in a final sample of 19 residents. (Resident identifier is #31).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that required in-service training was conducted and maintained, including the required annual minimum 12 hours for nurse's aides and addressed areas of weakness as determined in nurse aides' performance reviews and the facility assessment for 1 of 1 Licensed Nursing Assistant (LNA) reviewed.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 of 19 residents in a final sample of 19 residents (Resident Identifiers are #18, #68, #72, and #73).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the dishwasher was reaching proper temperatures and chemical sanitization in the main kitchen, failed to ensure food was served in a sanitary environment on 1 of 3 units (First Floor Unit), and failed to ensure use of facial hair restraints when serving food from the kitchen to the main dining area on 1 of 3 units observed for meal service (First Floor Unit).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that residents received treatments that were ordered for 1 out of 2 residents reviewed for pressure ulcers in a final sample of 22 (Resident Identifier is #41).

Inspectors wroteBased on observation and interview, it was determined that 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 1 of 3 units observed (First Floor Unit).