Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including medication administration, care planning, accident prevention, medication regimen review, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to assess clinical appropriateness for self-administration of medications, incomplete care plans for residents with safety risks, improper medication storage and administration practices, failure to timely review pharmacist recommendations, use of unnecessary antipsychotic medication without adequate indication, medication errors involving wrong resident administration, and failure to properly label and store medications according to professional standards.
Deficiencies (8)
Facility failed to determine if self-administration of medications was clinically appropriate for 1 of 4 residents reviewed.
Facility failed to develop and implement a comprehensive care plan for 1 of 3 residents reviewed for accidents.
Facility failed to follow professional standards for medication storage and administration for 1 of 3 medication carts observed.
Facility failed to maintain an environment free of accident hazards by not securing scissors when not in use for 1 of 3 residents reviewed for accidents.
Facility failed to ensure that the provider reviewed irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review timely for 3 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure that a resident receiving antipsychotic medication had an adequate indication for use for 1 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure residents remained free from significant medication errors for 1 of 3 residents reviewed for accidents and hazards.
Facility failed to label and store medications in accordance with professional standards for 2 of 3 medication carts observed.
Report Facts
Residents reviewed: 20
Residents reviewed for medication carts: 3
Residents reviewed for unnecessary medications: 5
Medication errors: 1
Medication regimen review dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse | Confirmed findings related to self-administration of medications for Resident #68 |
| Staff J | Licensed Nursing Assistant | Provided information about Resident #6's behavior and safety risks |
| Staff K | Registered Nurse | Confirmed leaving scissors unsecured on medication cart #4 |
| Staff E | Director of Nursing | Confirmed multiple findings including care plan deficiencies, medication regimen review issues, and medication errors |
| Staff B | Registered Nurse | Confirmed medication administration and storage issues related to Resident #69 |
| Staff C | Licensed Practical Nurse | Confirmed preparation of medications for Resident #69 and storage practices |
| Staff G | Nurse Practitioner/Psychiatric Provider | Provided information about Resident #1's psychiatric diagnosis and medication use |
| Staff L | Registered Nurse | Documented medication error involving Resident #9 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 10, 2024
Visit Reason
The inspection was conducted based on complaints and grievances regarding neglect, medication administration, accident hazards, record accuracy, and infection prevention at the nursing facility.
Complaint Details
The visit was complaint-related, triggered by grievances and allegations including neglect, medication errors, accident hazards, incomplete medical records, and infection control issues. The allegation of neglect was not reported to the State Survey Agency as required.
Findings
The facility failed to report an allegation of neglect, did not follow physician medication orders for a newly admitted resident, improperly applied seizure pads, had incomplete and inaccurate resident medical records, and failed to maintain infection prevention related to catheter care.
Deficiencies (5)
Failed to report an allegation of neglect to the State Survey Agency for 1 out of 3 grievances reviewed.
Failed to follow physician orders for medications for 1 of 2 newly admitted residents; medications were available but not administered.
Failed to ensure residents' environment was free from accident hazards; seizure pads were attached incorrectly for 1 of 3 residents reviewed.
Failed to ensure resident records were complete and accurate for 3 residents; missing documentation of blood sugar values and insulin administration.
Failed to maintain infection prevention related to catheter care; Foley catheter drainage bag and tubing were resting on the floor for 1 of 3 residents reviewed.
Report Facts
Residents reviewed for grievances: 3
Residents reviewed for medications: 20
Residents reviewed for accidents: 3
Residents reviewed for medical records: 20
Residents reviewed for catheters: 3
Medications not administered: 5
Insulin doses missing documentation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding failure to report allegation of neglect |
| Staff C | Unit Manager | Confirmed medication administration findings, seizure pad application, and record review findings |
| Staff B | Unit Manager | Confirmed catheter care findings |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to assess compliance with medication administration policies, medication labeling, storage, and security in the facility.
Findings
The facility failed to assess a resident's ability to self-administer medications, allowed unsupervised medication administration, failed to label opened medications with open dates, failed to remove expired supplements, and failed to secure medications and treatment carts properly.
Deficiencies (3)
Facility failed to assess a resident's ability to self-administer medications and allowed unsupervised medication administration.
Facility failed to ensure opened medications were labeled with open or expiration dates, failed to remove expired supplements, and failed to secure medications on one of three units observed.
Medication administration pass and treatment cart on Transitional Care Unit were left unlocked and unattended.
Report Facts
Residents reviewed for medication self-administration: 3
Residents in final sample: 23
Medications left in medication cup: 5
Apple Ensure clear therapeutic drinks: 13
Berry Ensure clear therapeutic drinks: 10
Time unattended medication cart: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unit Manager | Interviewed regarding facility policy on medication self-administration |
| Staff B | Registered Nurse | Left medications with Resident #41 unsupervised and confirmed medication administration |
| Staff C | Registered Nurse | Left medication cart unlocked and unattended on Transitional Care Unit |
| Staff D | Licensed Practical Nurse (LPN) | Confirmed expired supplements in medication room |
| Staff E | Licensed Practical Nurse (LPN) | Confirmed medications on carts lacked proper labeling |
| Staff F | Licensed Practical Nurse (LPN) | Confirmed treatment cart was unlocked and should be locked |
Viewing
Loading inspection reports...
