Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Carmel Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident was prescribed Ativan, Cymbalta, and Lexapro for anxiety, restlessness, and depression, but the medical record had no documentation that the resident or representative was informed of the risks and benefits of these psychotropic medications. The DON confirmed that this information had not been provided.
COVID-19 vaccine consent was obtained for two residents, but no additional dose was administered after consent despite the facility policy for residents age 65 and older. The DON and IP confirmed that both residents had not received the vaccine after consenting, and immunization records showed their last COVID-19 doses were months earlier.
A resident was found to be self-administering medications without a clinical assessment to determine their capability, as required by facility policy. The resident had several medications in their room, some of which were not documented in their MAR, and was taking a blood pressure medication daily instead of every other day as prescribed. The facility failed to conduct the necessary assessment to ensure the resident's ability to manage their medications safely.
A grievance was filed by a resident's DPOA regarding missing jewelry, but the facility failed to report the misappropriation to the SSA or local police. Interviews with staff confirmed the oversight, which was contrary to the facility's policy requiring immediate reporting of such incidents.
The facility failed to follow physician orders for two residents regarding Midodrine administration, resulting in incorrect medication management. One resident's medication was withheld despite appropriate blood pressure levels, while another received the medication despite exceeding the blood pressure threshold. Additionally, a supplement was unavailable for a resident, and the attending physician was not notified, contrary to facility policy.
A medication cart on the third floor Westside was found unlocked and unattended, with four residents nearby. An MNA confirmed leaving the cart unlocked while stepping away. Facility policy requires medication carts to be locked when not in use or attended by authorized personnel.
The facility failed to ensure accurate MDS coding for three residents. One resident's MDS incorrectly indicated a hospital discharge instead of home, another's was wrongly coded as 'None of the above' instead of a discharge assessment, and a third resident's MDS inaccurately reported antipsychotic medication use despite its discontinuation months prior.
Failure to Inform Resident or Representative About Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident or the resident representative of the risks and benefits of psychotropic medications. Review of the resident’s physician orders showed Ativan 0.5 mg, 1/2 tablet twice daily and 1 tablet as needed for anxiety and restlessness, with the as-needed order limited to 14 days, along with Cymbalta 30 mg in the evening and 60 mg in the morning for depression, and Lexapro 10 mg daily for depression, all dated 7/18/2025. Review of the medical record found no documentation that the resident or the resident’s representative was informed of the risks and benefits of these psychotropic medications. During interview, the DON confirmed that the resident or the resident’s representatives had not been informed of the risks and benefits of the medications.
COVID-19 Vaccine Consent Not Followed for Two Residents
Penalty
Summary
The facility failed to implement its policy on COVID-19 immunizations for 2 of 5 residents reviewed for immunizations, identified as Resident #48 and Resident #79. The facility policy titled, "2025 Updated Covid-19 Vaccination for Nursing Home Residents and Healthcare Personnel," dated 3/1/25, stated that people ages 65 years and older are up to date when they have received 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. Resident #48, born in 1938, signed consent for the COVID vaccine on 7/4/25, and review of the immunization record showed the resident's last COVID immunization was on 10/1/24, with no additional dose given after consent. Resident #79, born in 1944, signed consent on 6/23/25, and review of the immunization record showed the resident's last COVID immunization was on 11/8/24, with no additional dose given after consent. The DON and the Infection Preventionist both confirmed that these two residents had not received a COVID-19 vaccine dose after consenting.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed for the ability to self-administer medications. During an observation, it was noted that a resident had several medications on a shelf in their room, including Biotics Calcium, Turmeric m1670, Vitamin C, and a liquid medication for blood pressure. The resident confirmed that they self-administered these medications, including taking the liquid medication daily, contrary to the physician's order of every other day. The resident's Medication Administration Record (MAR) did not include physician orders for Turmeric, Vitamin C, and Biotics Calcium, indicating a lack of oversight and documentation. Further investigation revealed that there was no assessment conducted to determine the resident's capability to self-administer medications, as required by the facility's policy. Interviews with the Director of Nursing and a Nurse Practitioner confirmed the absence of such an assessment and a lack of awareness regarding the resident's self-administration practices. The facility's policy mandates an interdisciplinary team assessment of a resident's cognitive, physical, and visual abilities before allowing self-administration, which was not adhered to in this case.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation to the State Survey Agency (SSA) for one resident. A grievance was filed by the Durable Power of Attorney (DPOA) for a resident regarding the missing gold and diamond wedding ring set. Despite the grievance being logged, the missing items were not reported to the SSA or the local police. Interviews with the facility's social worker and administrator confirmed these findings. The facility's policy on Abuse Prevention and Reporting mandates that all alleged violations, including misappropriation of resident property, be reported immediately to the state agency, which was not adhered to in this case.
Failure to Follow Physician Orders and Medication Shortage Notification
Penalty
Summary
The facility failed to adhere to physician orders for two residents regarding the administration of Midodrine, a medication used to manage blood pressure. For one resident, the medication was withheld despite systolic blood pressure readings being below the threshold specified in the physician's order. This was confirmed by the Director of Nursing during an interview. For another resident, the medication was administered despite systolic blood pressure readings exceeding the specified limit. The Licensed Practical Nurse involved admitted to not understanding the symbols used in the physician's order, leading to the incorrect administration of the medication on multiple occasions. Additionally, the facility did not follow its policy on medication shortages for a supplement prescribed to the second resident. The medication was unavailable on several days, and the attending physician was not notified of this shortage, as confirmed by the Nurse Practitioner. The facility's policy requires nursing staff to inform the physician of any shortages that impact a patient's immediate needs, but this protocol was not followed, resulting in the resident missing several doses of the prescribed supplement.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure the security of medications on one of the four medication carts observed. During an observation on the third floor Westside Medication Cart, it was found unlocked with no staff present, while four residents were seated nearby, eating breakfast. This occurred on 5/20/24 at 8:20 a.m. An interview with a Medication Nursing Assistant (MNA) confirmed that the cart was left unlocked while the staff member stepped away for a few minutes. The facility's policy on Medication Storage, dated 01/2021, states that medication carts should remain locked when not in use or attended by authorized personnel.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of three residents. For Resident #103, the MDS indicated a discharge to a short-term general hospital, while records showed the resident was discharged home. This discrepancy was confirmed by the Clinical Assessment Manager during an interview. Resident #83's MDS was incorrectly coded as 'None of the above' for the type of assessment, despite progress notes indicating a discharge to home. The Clinical Assessment Manager acknowledged the error, stating it should have been coded as a 'Discharge assessment - return not anticipated.' Additionally, Resident #89's MDS inaccurately reported the use of antipsychotic medication, although records showed no such medication was administered during the specified period. The Clinical Assessment Manager confirmed the MDS was incorrect, as the antipsychotic medication had been discontinued months earlier.
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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) |
|---|---|---|---|---|
| Maple Leaf Health Care Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Saint Teresa Rehabilitation & Nursing Center | 0.8 mi | ★★★★★ | 7 | 0 |
| Courville At Manchester | 0.9 mi | ★★★★★ | 12 | 1 |
| Hanover Hill Health Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| St Joseph Residence | 1.1 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 July 2026) and official state health department websites.