Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Census: 102
Deficiencies: 2
Feb 4, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration and infection prevention, including evaluation of the facility's water management program.
Findings
The facility failed to follow the seven rights of medication administration for 2 of 5 residents observed and did not develop or implement an adequate water management program to prevent growth of waterborne pathogens, affecting 102 residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow the seven rights of medication administration for 2 of 5 residents observed, including incorrect dosage and failure to check apical pulse as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a water management program to prevent growth of waterborne pathogens, including lack of detailed water system description, missing legionella testing, and no control or monitoring procedures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed for medication administration: 5
Residents affected by medication deficiency: 2
Census: 102
Legionella testing scheduled: 2
Legionella testing performed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Nursing Assistant | Administered incorrect dose of medication to Resident #6 |
| Staff F | Licensed Practical Nurse | Failed to check apical pulse for Resident #37 as ordered |
| Staff C | Director of Maintenance and Environmental Services | Unable to describe or identify areas of water system related to legionella risk |
| Staff B | Director of Nursing | Unable to explain water management program measures |
| Staff D | Infection Preventionist | Unable to explain water management program measures |
| Staff A | Administrator | Unable to explain water management program measures |
Inspection Report
Routine
Deficiencies: 2
Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning and medication administration standards at the nursing facility.
Findings
The facility failed to revise care plans for 2 of 2 residents reviewed and failed to follow professional medication administration standards for 1 medication administered out of 29 reviewed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to revise care plans for 2 residents, including lack of care plan interventions for monitoring adverse drug reactions and failure to update care plan after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional medication administration standards for 1 medication administered out of 29 medications, specifically not instructing a resident to rinse mouth after inhaling corticosteroid medicine. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medications administered: 29
Residents reviewed for care planning: 24
Residents with care plan deficiencies: 2
Medications with administration deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed findings related to care plan revisions and medication administration | |
| Licensed Practical Nurse | Confirmed findings related to care plan revisions | |
| Registered Nurse | Observed administering medication without instructing resident to rinse mouth |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 1, 2023
Visit Reason
The inspection was conducted to investigate complaints related to inadequate supervision and safety measures to prevent residents at risk of elopement from leaving the facility.
Findings
The facility failed to provide adequate supervision to prevent two residents from eloping or exhibiting exit-seeking behavior. Documentation showed inconsistent monitoring, including missing 15-minute checks prior to a resident eloping, and lack of timely interventions for residents identified at risk for elopement.
Complaint Details
The complaint investigation revealed that Resident #1 eloped from the facility on 5/13/23 without documented 15-minute checks in place. Resident #1 was found outside the facility and returned safely. Resident #2 had a history of exit-seeking behavior with no interventions implemented from 12/12/22 to 1/16/23.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent resident elopement and ensure safety measures for residents at risk of elopement. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Elopement Risk Score: 1
Elopement Risk Score: 4
15-minute checks missing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident #1's elopement and supervision |
Inspection Report
Annual Inspection
Deficiencies: 5
Feb 17, 2023
Visit Reason
The inspection was conducted as a final survey to assess compliance with regulatory requirements across multiple areas including medication self-administration, nurse staffing data retention, mental health services, vaccination policies, and COVID-19 vaccination education.
Findings
The facility was found deficient in several areas including failure to assess residents' ability to self-administer medications, failure to retain daily nurse staffing data for the required 18 months, failure to provide appropriate mental health services to residents with PTSD or mental disorders, failure to provide education and consent documentation for pneumococcal vaccinations, and failure to offer education and document COVID-19 vaccination status for eligible residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Potential for minimal harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to assess residents' ability to self-administer medications for 2 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to retain daily nurse staffing data for a minimum of 18 months. | Level of Harm - Potential for minimal harm |
| Facility failed to ensure residents diagnosed with mental disorders or PTSD received appropriate treatment and services for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide education on risks and benefits of Pneumococcal vaccination for 5 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to offer and provide education on COVID-19 vaccination for 4 of 5 residents reviewed and failed to properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for self-administration of medication: 21
Residents affected by medication self-administration deficiency: 2
Residents affected by nurse staffing data retention deficiency: 2
Residents reviewed for mental health services: 3
Residents affected by mental health services deficiency: 2
Residents reviewed for Pneumococcal immunizations: 5
Residents affected by Pneumococcal vaccination education deficiency: 5
Residents reviewed for COVID-19 immunizations: 5
Residents affected by COVID-19 vaccination education deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Confirmed residents #46 and #150 did not have orders for self-administration of medication |
| Staff F | Administrator | Confirmed missing daily nurse staffing postings for July and August 2022 |
| Staff G | Staffing Coordinator | Confirmed missing daily nurse staffing postings for July and August 2022 |
| Staff C | Social Services Director / Assistant Director of Nursing | Responsible for referrals for psychological services and confirmed lack of psychiatric services offered to Resident #50 and education for COVID-19 vaccination |
| Staff B | Minimum Data Set Nurse | Responsible for psychiatric service referrals and confirmed Resident #50 and #75 had not been offered psychiatric services |
| Staff D | Social Services | Confirmed no referral made for psychological services for Resident #75 |
| Staff A | Infection Preventionist | Confirmed no evidence of education provided regarding Pneumococcal vaccination for affected residents |
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