Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Census: 24
Deficiencies: 3
Date: Feb 7, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards related to medication storage, food safety, and infection prevention and control programs at the facility.
Findings
The facility was found to have deficiencies including unlocked medication carts, failure to document PPM testing for the dishwasher, unsanitary kitchen conditions, and failure to implement a water management program for prevention of waterborne pathogens.
Deficiencies (3)
Failure to follow professional principles for the storage of medications; medication cart left unlocked and unattended.
Failure to label and store food properly, failure to measure PPM for dishwasher sanitization, and unsanitary kitchen environment.
Failure to implement a water management program to prevent waterborne pathogens, including not running hot water in unoccupied rooms and not taking weekly storage tank temperatures.
Report Facts
Facility census: 24
Unoccupied room durations: 7
Dishwasher PPM concentration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Clinical Corporate Nurse | Confirmed medication cart policy and findings |
| Staff J | Food Services Manager | Interviewed regarding dishwasher PPM testing and food safety |
| Staff H | Regional Dietary Manager | Confirmed findings related to food safety and dishwasher sanitization |
| Staff I | Cook | Confirmed kitchen sanitation findings |
| Staff K | Director of Maintenance | Interviewed regarding water management program and hot water usage in unoccupied rooms |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to evaluate the facility's implementation of COVID-19 vaccination policies and procedures for residents.
Findings
The facility failed to implement policies and procedures for providing COVID-19 vaccines for 2 of 5 residents reviewed, with no documentation that the residents received the vaccine after giving consent.
Deficiencies (1)
Failure to implement policies and procedures for providing COVID-19 vaccines to residents who consented.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Staff A (Director of Nursing) confirmed the findings regarding COVID-19 vaccine availability and administration. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 13, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards for medication administration and pharmaceutical services, including the management and documentation of controlled substances.
Findings
The facility failed to follow physician's orders for medication administration for several residents, including incorrect dosing of morphine and calcium supplements. Additionally, the facility did not maintain accurate records for controlled substances, lacking required nurse signatures and proper logging in narcotic count records.
Deficiencies (2)
Failed to follow physician's orders for medication administration for residents #11, #70, and #71, including incorrect morphine dosing and calcium supplement administration.
Failed to establish a system of records for receipt and disposition of controlled drugs in sufficient detail to enable accurate reconciliation, including missing nurse signatures and incomplete narcotic count records.
Report Facts
Residents with medication administration issues: 3
Narcotic books reviewed: 2
Medication administration observations: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Staff A involved in medication storage and narcotic count. | |
| Interim Director of Nursing Services | Staff B confirmed findings related to medication errors and narcotic record keeping. | |
| Registered Nurse (RN) | Staff D observed administering medications to residents #70 and #71. |
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