Inspection Reports for
Jaffrey Rehabilitation and Nursing Center
20 PLANTATION DR, JAFFREY, NH, 03452
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, infection prevention, hospice services coordination, and medical record accuracy at Jaffrey Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set assessments for hospice residents, failure to follow professional standards for respiratory care, inadequate RN staffing coverage, medication errors exceeding 5%, improper storage of controlled medications, incomplete and inaccurate resident medical records, failure to coordinate hospice care schedules, inaccurate Payroll Based Journal staffing data submissions, and lack of a qualified infection preventionist with completed training.
Deficiencies (9)
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' hospice status for 2 of 3 residents reviewed.
Failed to follow professional standards for respiratory care for 1 resident due to oxygen administration without physician orders.
Failed to ensure a Registered Nurse was on duty for at least eight consecutive hours a day for 2 days in Fiscal Year Quarter 1 2025.
Medication error rate exceeded 5 percent with 2 errors out of 28 medication administrations observed.
Controlled medications were not maintained in separately locked, permanently affixed compartments; lock box code was written on the outside.
Resident medical records were inaccurate or incomplete for 3 residents, including missing documentation of falls, wound care, and treatments.
Failed to coordinate hospice care schedules; no calendar or schedule of planned hospice visits was available for 3 residents reviewed.
Failed to submit complete and accurate Payroll Based Journal staffing data for Fiscal Year Quarter 1 2025.
Failed to employ an Infection Preventionist who had completed specialized training in infection prevention and control.
Report Facts
Medication error rate: 7.14
RN coverage failure days: 2
Days failed to have RN hours for 8 consecutive hours: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | RN - MDS Coordinator | Confirmed MDS assessments did not correctly indicate hospice status for residents #12 and #38 |
| Staff H | Licensed Practical Nurse (LPN) | Confirmed resident #223 was receiving oxygen without physician orders and involved in medication administration error for resident #224 |
| Staff L | Licensed Practical Nurse (LPN) | Administered incorrect medication to resident #38 |
| Staff E | Director of Nursing | Confirmed double locking required for controlled substances and lack of documentation for resident falls |
| Staff K | Human Resources | Confirmed no RN coverage on 10/7/24 and 11/24/24 and 24-hour Licensed Nursing coverage |
| Staff B | Infection Preventionist | Had not completed required Nursing Home Infection Preventionist Training Course |
| Staff G | Licensed Social Worker (LSW) | Revealed hospice schedule should be in resident binder but was not provided to units |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, food safety, infection control, laboratory result notification, call system functionality, and other facility operations at Jaffrey Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to provide therapeutic dietary recommendations and monitor nutritional status, failure to promptly notify providers of critical lab results, improper food storage and failure to monitor food and dishwasher temperatures, inadequate use of PPE during linen handling, and failure to ensure an effective call bell system for residents.
Deficiencies (5)
Failed to offer therapeutic dietary recommendations and monitor nutritional status for residents.
Failed to promptly notify the ordering practitioner of critical laboratory results for insulin.
Failed to store and serve food in accordance with professional standards and failed to monitor dishwasher temperatures.
Failed to use Personal Protective Equipment (PPE) when handling, processing, and transporting linens.
Failed to ensure that the call bell system was equipped to allow residents to call for staff assistance effectively.
Report Facts
Residents reviewed for nutrition: 22
Residents affected by nutrition deficiency: 2
Resident #36 weight loss percentage: 5
Resident #61 weight gain over 6 days: 42.9
Vanilla Mighty Shakes without thawed or use by date: 41
Call bell system resident census: 73
Resident Council attendees reporting wait times: 10
Resident Council attendees: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Confirmed findings related to nutrition monitoring and lab notification |
| Staff N | Dietician | Signed dietary notes and recommendations for residents #36 and #61 |
| Staff J | Unit Manager | Confirmed weights and lab notification issues |
| Staff D | Laundry Aide | Observed not using PPE properly during linen handling |
| Staff C | Infection Preventionist | Confirmed PPE deficiencies and lack of education documentation |
| Staff G | Director of Maintenance, Housekeeping and Laundry | Provided information on PPE training and call bell system |
| Staff H | Licensed Nursing Assistant (LNA) | Reported call bell system limitations and resident complaints |
| Staff F | Administrator in Training | Confirmed PPE and call bell system findings |
Inspection Report
Routine
Census: 65
Deficiencies: 5
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident notification of Medicare non-coverage, pressure ulcer care, food safety, infection prevention, and COVID-19 vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to provide Medicare non-coverage notices to residents, inadequate pressure ulcer care documentation and monitoring, improper food temperature monitoring and documentation, lack of a qualified infection preventionist with specialized training, and failure to implement COVID-19 precautions for unvaccinated staff.
Deficiencies (5)
Failed to ensure residents and/or representatives were informed of Skilled Nursing Facility Notice of Medicare Non-Coverage or Advance Beneficiary Notice for 2 of 3 residents reviewed.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 3 of 4 residents reviewed, including lack of weekly wound measurements and documentation.
Failed to ensure proper food storage and preparation temperatures were maintained and documented for multiple months and refrigerators.
Failed to employ an Infection Preventionist who completed specialized training in infection prevention and control.
Failed to ensure a policy and implementation of additional COVID-19 precautions for unvaccinated staff; unvaccinated staff were not required to wear masks.
Report Facts
Residents affected: 2
Residents affected: 3
Months of food temperature logs missing: 4
Kitchen refrigerators with temperature log deficiencies: 3
Kitchenette refrigerators with temperature log deficiencies: 2
Facility census: 65
Unvaccinated staff: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Business Office Manager | Confirmed failure to provide Medicare non-coverage notices to residents #2 and #30 |
| Staff B | Director of Nursing | Confirmed pressure ulcer care deficiencies and part-time Infection Preventionist role |
| Staff I | Dietary Manager | Confirmed missing food temperature documentation and refrigerator temperature logs |
| Staff D | Cook | Confirmed failure to check internal food temperatures on 4/10/23 |
| Staff H | Assistant Director of Nursing | Unvaccinated for COVID-19, not wearing face mask, confirmed lack of additional precautions |
| Staff F | Licensed Nursing Assistant | Unvaccinated for COVID-19, not wearing face mask, unaware of additional precautions |
| Staff G | Licensed Nursing Assistant | Unvaccinated for COVID-19, not wearing face mask, unaware of additional precautions |
| Staff A | Administrator | Confirmed all staff stopped wearing masks on 4/7/23 and no additional COVID-19 precautions for unvaccinated staff |
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