A list of the most recent deficiencies for Courville at Manchester. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-05 | 2023-03-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-05 | 2023-03-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-06 | 2023-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-06 | 2023-02-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-01-06 | 2023-02-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-06 | 2023-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-06 | 2023-02-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-06 | 2023-02-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-06 | 2023-02-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-06 | 2023-02-09 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-06 | 2023-02-09 | N |
| 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. | Health | 2023-01-06 | 2023-02-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-21 | 2022-03-08 | N |
| 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. | Health | 2022-01-21 | 2022-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-03-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-19 | 2022-03-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-19 | 2022-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-19 | 2022-03-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-19 | 2022-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-19 | 2022-03-08 | N |
| Report COVID19 data to residents and families. | Health | 2021-11-08 | 2021-11-16 | N |
| 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. | Fire Safety | 2021-01-08 | 2021-02-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-01-08 | 2021-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-01-08 | 2021-02-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-08 | 2021-02-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-01-07 | 2021-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-07 | 2021-01-25 | N |
