Inspection Reports for
Maple Leaf Healthcare Center
198 PEARL STREET, Manchester, NH, 03104
Back to Facility ProfileDeficiencies (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
Deficiencies: 4
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, activities of daily living, medication storage, infection control, and wound care at Maple Leaf Health Care Center.
Findings
The facility was found deficient in accurately documenting resident assessments, providing adequate assistance with activities of daily living, securing medication storage, and implementing infection prevention and control policies, including proper wound care procedures.
Deficiencies (4)
Failure to ensure the Minimum Data Set (MDS) assessment accurately reflected residents' status for tobacco use.
Failure to provide necessary care and assistance for activities of daily living, resulting in poor personal hygiene for residents.
Failure to ensure medications and biologicals were stored in locked compartments in medication rooms.
Failure to implement infection prevention and control policies for transmission-based precautions and wound care.
Report Facts
Residents reviewed: 22
Residents affected by tobacco use assessment deficiency: 2
Residents affected by ADL care deficiency: 2
Medication rooms observed: 2
Residents reviewed for infection control: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Confirmed inaccuracies in resident assessments for tobacco use |
| Staff B | Director of Nursing | Confirmed findings related to ADL care deficiencies and medication room security |
| Staff C | Licensed Nurses Assistant | Observed not wearing eye protection during transmission-based precautions |
| Staff E | Infection Preventionist | Confirmed facility policy on transmission-based precautions and PPE use |
| Staff F | Licensed Practical Nurse | Observed not following wound care infection control procedures |
Inspection Report
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage regulations in the facility.
Findings
The facility failed to properly label medications on one of four medication carts observed, specifically an open insulin pen without patient identification and a liquid suspension with an illegible label.
Deficiencies (1)
Failure to properly label medications on the third floor medication cart #5, including an open Levemir insulin flex pen without a patient identifier and a liquid suspension with a peeled off label making it illegible.
Report Facts
Medication carts observed: 4
Medication cart with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Interviewed and confirmed medication labeling deficiencies on the third floor medication cart #5 |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols, specifically adherence to hand hygiene and Transmission Based Precautions (TBP) as per CDC guidelines.
Findings
The facility failed to ensure proper hand hygiene and use of personal protective equipment for residents under contact precautions for MRSA and C-diff. Observations revealed staff and visitors not performing hand hygiene or wearing appropriate PPE when required, posing a minimal harm risk to residents.
Deficiencies (1)
Failure to ensure hand hygiene and Transmission Based Precautions were followed for 3 of 5 residents observed under contact precautions.
Report Facts
Residents observed for Transmission Based Precautions: 5
Residents with failed TBP adherence: 3
Dates of observations: Jan 25, 2023
Dates of observations: Jan 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Staff A observed failing to perform hand hygiene after doffing PPE and before medication prep | |
| Licensed Practical Nurse (LPN) | Staff D observed administering medications without gown and gloves and failing hand hygiene | |
| Housekeeper | Staff B observed cleaning resident room without gown and failing hand hygiene | |
| Director of Nursing | Staff C interviewed regarding hand hygiene policies for residents with contact precautions |
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