Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to investigate compliance with infection prevention and control protocols, specifically related to the use of Personal Protective Equipment (PPE) for residents on droplet precautions for COVID-19.
Complaint Details
The visit was complaint-related, focusing on infection control practices for residents with COVID-19. The report documents multiple observations and interviews confirming noncompliance with PPE protocols, including improper mask use and failure to doff PPE when exiting rooms.
Findings
The facility failed to follow CDC guidelines for appropriate PPE use to prevent infection spread for 4 of 8 residents on Transmission Based Precautions for COVID-19. Staff were observed not donning or doffing PPE correctly, including improper use of N95 vs KN95 masks and failure to remove masks when exiting COVID-19 positive rooms.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program consistent with CDC guidelines for PPE use for residents on droplet precautions for COVID-19.
Report Facts
Residents on Transmission Based Precautions for COVID-19: 8
Residents with PPE noncompliance: 4
Dates of COVID-19 positive diagnosis: Nov 6, 2024
Date of COVID-19 positive diagnosis: Nov 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Nurse Manager | Interviewed regarding Resident #84's droplet precautions and PPE use |
| Staff H | Licensed Nursing Assistant (LNA) | Observed and interviewed for failure to don protective eyewear or face shield entering Resident #84's room |
| Staff D | Infection Preventionist | Interviewed regarding PPE expectations and CDC guidelines |
| Staff A | Licensed Medication Nursing Assistant (LMNA) | Observed and interviewed for improper doffing of KN95 mask exiting Resident #2's room |
| Staff B | Director of Nursing | Interviewed confirming PPE protocol for Resident #2 |
| Staff C | Unit Manager (UM) | Interviewed regarding Residents #7 and #73 on droplet precautions |
| Staff F | Licensed Medication Nursing Assistant (LMNA) | Observed and interviewed for failure to doff KN95 mask exiting Resident #73's room |
| Staff I | Licensed Nursing Assistant (LNA) | Observed and interviewed for failure to doff KN95 mask exiting Resident #7's room |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to appropriately respond to alleged violations, including failure to assess and follow physician orders after a resident fall, failure to update care plans for pressure ulcers and nutrition, and failure to follow professional standards of care.
Complaint Details
The complaint investigation found substantiated issues including failure to assess Resident #22 after a fall, failure to update care plans for pressure ulcers and nutrition, and failure to follow physician orders for wound care.
Findings
The facility failed to take appropriate action after a resident fall resulting in fractures, failed to update care plans for pressure ulcers and weight loss, and did not follow physician orders for wound care. The facility also failed to assess the resident for injury before transferring them back to bed and did not provide education or corrective action to staff involved.
Deficiencies (3)
Failed to take appropriate action after investigation of abuse for Resident #22 following a fall resulting in pelvic fractures.
Failed to update resident care plans with new or revised interventions for pressure ulcers and nutrition for Residents #22 and #250.
Failed to follow professional standards for assessing injury after a fall and did not follow physician's orders for wound care for Resident #22.
Report Facts
Residents reviewed: 22
Weight loss: 15.4
Days for care plan development: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #22 fall and weight loss; confirmed lack of interventions. |
| Staff E | Licensed Nursing Assistant (LNA) | Provided written statement about Resident #22 fall response. |
| Staff F | Licensed Nursing Assistant (LNA) | Interviewed about Resident #22 fall response and lack of communication. |
| Staff C | Director of Nursing | Interviewed regarding fall assessment, wound care orders, and staff education. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Dec 21, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to respond appropriately to alleged violations, including failure to take appropriate action after an abuse investigation, failure to update care plans for pressure ulcers and nutrition, failure to follow professional standards for injury assessment after a fall, failure to provide activities to meet resident needs, failure to prevent pressure ulcers, and failure to ensure proper medication storage.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to appropriately respond to alleged violations including abuse investigation, care plan updates, injury assessment, activity provision, pressure ulcer prevention, and medication storage security.
Findings
The facility failed to appropriately investigate and respond to a resident fall resulting in fractures, failed to update care plans for pressure ulcers and weight loss, did not follow physician orders for wound care, failed to provide adequate activities for a resident, did not implement measures to prevent pressure ulcers, and allowed unauthorized access to medication storage rooms.
Deficiencies (6)
Failed to take appropriate action after investigation of abuse for Resident #22 following a fall resulting in pelvic fractures.
Failed to update care plans with new or revised interventions for pressure ulcers and nutrition for Residents #22 and #250.
Failed to follow professional standards for assessing injury after a fall and did not follow physician's orders for wound care for Resident #22.
Failed to provide facility-sponsored group and individualized activities to meet Resident #22's needs.
Failed to implement measures to prevent development of pressure ulcers for Resident #22, including lack of repositioning schedule and inadequate pressure ulcer care.
Failed to ensure all drugs are stored in locked compartments with only authorized personnel having access in one of two medication rooms.
Report Facts
Residents reviewed: 22
Residents reviewed for abuse: 2
Residents reviewed for pressure ulcers: 2
Residents reviewed for nutrition: 5
Weight loss: 15.4
Days for care plan development: 7
Dates with no documentation of toileting task completion: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #22's fall, pressure ulcer care, and weight loss interventions |
| Staff E | Licensed Nursing Assistant (LNA) | Provided written statement about Resident #22's fall and assisted with transferring resident back to bed |
| Staff F | Licensed Nursing Assistant (LNA) | Interviewed about response to Resident #22's fall and lack of communication about the incident |
| Staff C | Director of Nursing | Interviewed regarding fall assessment, wound care orders, medication storage access, and care plan updates |
| Staff I | Activities Director | Interviewed about lack of activities assessment and participation for Resident #22 |
| Staff H | Licensed Nursing Assistant (LNA) | Interviewed about Resident #22's daily routine and lack of repositioning schedule |
| Staff B | Staff Development Assistant | Observed with unsupervised access to medication storage room and confirmed lack of authorization to administer medications |
| Staff A | Licensed Practical Nurse (LPN) | Observed Staff B in medication storage room |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving injuries of unknown source, and to assess medication storage compliance.
Complaint Details
The complaint investigation found that the facility failed to report alleged abuse incidents involving Residents #2 and #3 within the required 2-hour timeframe. Resident #2 had a left ankle fracture diagnosed on 3/17/23 but the report was sent on 3/20/23. Resident #3 had a subcapital fracture of the left femoral neck on 4/7/23 but the report was sent on 4/10/23.
Findings
The facility failed to timely report alleged abuse incidents involving two residents, with reports submitted three days after the incidents occurred. Additionally, the facility failed to ensure medications were secured on one of three units observed, with medication carts found unlocked and unattended.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft to the State Survey Agency within 2 hours for 2 out of 3 incidents reviewed.
Failure to ensure medications were secured; medication carts were unlocked and unattended on the Rehabilitation Unit.
Report Facts
Days delay in reporting abuse incidents: 3
Medication dosage: 500
Units observed for medication security: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Director of Nursing | Confirmed the delayed reporting of abuse incidents for Residents #2 and #3. |
| Staff A | Licensed Practical Nurse (LPN) | Confirmed being in a resident's room while the Low Medication Cart was unlocked. |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed the High Medication Cart was unlocked and unattended. |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 9, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, including following physician's orders, resident care, staffing, food safety, COVID-19 reporting, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for resident weight monitoring, failure to maintain hearing aids for a resident, failure to post daily nurse staffing data timely, failure to properly clean an ice machine, failure to timely inform residents and families about COVID-19 cases and mitigation efforts, and failure to fully implement staff COVID-19 vaccination tracking and documentation policies.
Deficiencies (6)
Failed to follow physician's orders for weight monitoring for 1 of 3 residents reviewed for nutrition (Resident #54).
Failed to provide necessary care to ensure a resident's ability to hear was maintained with a communication device for 1 of 1 resident reviewed (Resident #36).
Failed to post daily nurse staffing data for 2 of 2 days observed and failed to post at the beginning of each shift on weekend days.
Failed to ensure the ice machine was properly cleaned in 1 of 4 kitchenettes observed.
Failed to inform residents, their representatives, and families of COVID-19 cases and mitigating actions by 5 p.m. the next calendar day following occurrence of infection.
Failed to implement policy on COVID-19 vaccination of facility staff regarding tracking, documentation, and ensuring all staff are fully vaccinated except those with exemptions or delays.
Report Facts
Residents reviewed for nutrition: 3
Residents reviewed for communication: 1
Days nurse staffing data not posted: 2
Staff total: 147
Staff completely vaccinated: 139
Staff with religious exemption: 5
Partially vaccinated staff: 3
Percentage of staff vaccination: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse | Documented weight as N/A for Resident #54 on 11/8/22. |
| Staff F | Unit Manager | Confirmed weight documentation issues for Resident #54 and hearing aid documentation for Resident #36. |
| Staff E | Registered Nurse | Documented hearing aid in for Resident #36 on 11/8/22. |
| Staff G | Medication Nursing Assistant | Documented hearing aid out for Resident #36 on 11/3/22. |
| Staff A | Staffing Coordinator | Responsible for daily nursing staff posting; confirmed failure to post on weekends. |
| Staff O | Cook | Observed black substance in ice machine on 11/6/22. |
| Staff P | Director of Facilities | Confirmed ice machine cleaning schedule and condition. |
| Staff I | Administrator | Confirmed COVID-19 notification process and documentation. |
| Staff K | Unit Manager | Notified only COVID-19 positive residents and representatives. |
| Staff J | Unit Manager | Notified only COVID-19 positive residents and representatives. |
| Staff B | Staff Development Coordinator/Infection Preventionist | Confirmed findings on staff COVID-19 vaccination tracking and documentation. |
| Staff L | Dietary Aide | Partially vaccinated staff missing 2nd dose of COVID-19 vaccine as of 11/9/22. |
| Staff M | Housekeeper | Partially vaccinated staff missing 2nd dose schedule. |
| Staff N | Licensed Nursing Assistant | Partially vaccinated staff missing 2nd dose schedule. |
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