Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to investigate complaints related to abuse, neglect, and failure to follow professional standards in care at the facility.
Complaint Details
The complaint investigation focused on abuse and neglect allegations involving Resident #21, including failure to implement abuse policies and failure to report neglect. Additional concerns included inaccurate assessments, failure to follow physician orders, inadequate supervision, incomplete staff performance reviews and training, improper medication orders, and infection control failures.
Findings
The facility was found deficient in multiple areas including failure to implement abuse prevention policies, failure to report neglect allegations timely, inaccurate resident assessments, failure to follow physician orders, inadequate supervision during meals, incomplete nurse aide performance reviews and training, improper use of psychotropic medication PRN orders, and failure to implement infection control precautions.
Deficiencies (9)
Failed to implement the facility's abuse policy for 1 out of 1 residents reviewed for abuse.
Failed to timely report suspected abuse, neglect, or theft to proper authorities.
Failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected residents' status for 4 of 19 residents.
Failed to follow physicians orders for bowel/bladder incontinence for 1 resident.
Failed to provide supervision at meals for 1 resident requiring assistance.
Failed to complete a performance review at least once every 12 months for 1 Licensed Nurse Assistant.
Failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless otherwise documented.
Failed to implement policies and procedures for Transmission Based Precautions to prevent infection spread.
Failed to ensure required in-service training was conducted and maintained for nurse aides.
Report Facts
Residents reviewed: 19
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
LNA performance reviews missing: 1
In-service training hours: 8
PRN Lorazepam doses: 7
PRN Haloperidol doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Licensed Practical Nurse | Reported Resident #21 left on bedpan with red bottom |
| Staff J | Nursing Supervisor (3-11 Shift) | Failed to notify Administrator or Director of Nursing about Resident #21 incident |
| Staff L | Director of Social Services | Confirmed inaccuracies in resident discharge assessments |
| Staff K | MDS Coordinator | Confirmed MDS coding errors and incorrect resident name entry |
| Staff D | Unit Manager | Confirmed failure to follow physician orders for Resident #31 |
| Staff F | Licensed Practical Nurse | Unaware Resident #31 was on contact precautions and Resident #60 needed supervised meals |
| Staff C | Administrator | Confirmed missing performance reviews and in-service training deficiencies |
| Staff G | Staff Development | Confirmed insufficient in-service training hours for Staff M |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to pressure ulcer care, accident hazard prevention, food safety, and sanitation in the nursing home.
Findings
The facility was found deficient in providing ordered pressure ulcer treatments for one resident, maintaining a safe environment free from chemical hazards, ensuring proper dishwasher sanitization and food service sanitation, and enforcing facial hair restraints for food service staff. Deficiencies were noted in pressure ulcer care, chemical storage, dishwasher logs, food service area conditions, and staff hygiene practices.
Deficiencies (5)
Failed to ensure residents received ordered treatments for pressure ulcers, specifically a missing modified chair cushion for Resident #41.
Failed to ensure the residents' environment was free from accident hazards due to unlocked cabinet containing chemical cleaning solutions accessible to residents.
Failed to ensure dishwasher reached proper temperatures and chemical sanitization; missing parts per million (PPM) test results on multiple days.
Failed to ensure food was served in a sanitary environment; food service area had damaged countertops and walls exposing porous and uncleanable surfaces.
Failed to ensure use of facial hair restraints by kitchen staff during meal service; staff observed with uncovered full beard over an inch long.
Report Facts
Residents reviewed for pressure ulcers: 22
Residents affected by pressure ulcer deficiency: 1
Chemical cleaning products observed: 8
Days missing PPM test results: 16
Areas of missing laminate: 3
Length of wallpaper peeling: 12
Length of chipped wood countertop: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Interviewed regarding pressure ulcer care and use of pillows as pressure relieving device |
| Staff H | Director of Nursing | Confirmed findings related to pressure ulcer care and chemical hazard storage |
| Staff B | Cook | Observed chemical storage and dishwasher logs; confirmed food service area conditions |
| Staff E | Administrator | Confirmed chemical hazard storage and food service area deficiencies |
| Staff D | Food Services Director | Confirmed dishwasher log deficiencies and facial hair restraint policy enforcement |
| Staff C | Dietary Aide | Observed serving food with uncovered beard |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 11
Date: Jan 6, 2023
Visit Reason
The inspection was conducted as a final survey of the nursing facility to assess compliance with professional standards of quality, infection control, medication management, food safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to follow physician's medication orders, improper catheter care, medication labeling and storage issues, incomplete food temperature documentation, inadequate labeling of resident food items, insufficient attendance at Quality Assurance meetings, failure to adhere to infection control masking protocols, incomplete antibiotic stewardship program, lack of qualified infection preventionist training completion, failure to provide pneumococcal vaccination to a resident, and failure to timely notify residents and families of COVID-19 cases.
Deficiencies (11)
Failure to follow physicians' orders for medication administration for Resident #60.
Failure to follow professional standards for catheter/urinary tract infections for Resident #30.
Medications were not labeled with resident identifiers, open or use by dates, and expired medications were not separated from unexpired medications in medication rooms and carts.
Failure to ensure proper final internal cooking temperatures of food before serving during 15 meals in December 2022.
Failure to follow professional standards for labeling and storage of food items brought by family in 2 of 3 kitchenettes.
Failure to ensure minimum required Quality Assurance and Performance Improvement committee members attended meetings at least quarterly.
Failure to adhere to infection control practices for universal masking recommended by CDC during multiple observations.
Failure to implement an antibiotic stewardship program including tracking and monitoring antibiotic use.
Failure to employ a qualified infection preventionist who completed specialized training and passed competency examination.
Failure to offer pneumococcal vaccination to Resident #43 despite consent.
Failure to notify residents, representatives, and families timely of COVID-19 infections for 5 of 6 days in December 2022.
Report Facts
Residents reviewed: 17
Residents present: 67
Medication carts observed: 3
Medication rooms observed: 2
Meals with missing food temperature documentation: 15
Quarterly QAPI meetings reviewed: 4
Quarterly meetings missing medical director attendance: 3
Residents receiving antibiotics in October 2022: 10
Residents receiving antibiotics in November 2022: 2
Additional residents receiving antibiotics in October 2022: 11
Additional residents receiving antibiotics in November 2022: 10
COVID-19 positive test days reviewed: 6
COVID-19 notifications sent: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse | Confirmed medication administration outside physician's orders |
| Staff A | Licensed Practical Nurse | Confirmed catheter bag should not be on floor and medication cart observations |
| Staff B | Licensed Practical Nurse | Confirmed medication room observations |
| Staff C | Licensed Practical Nurse | Confirmed medication room observations and pneumococcal vaccine not given to Resident #43 |
| Staff D | Licensed Practical Nurse | Confirmed medication cart observations |
| Staff E | Registered Nurse | Confirmed medication cart observations |
| Staff J | Dietary Manager | Confirmed missing food temperature documentation and unlabeled food items |
| Staff K | Licensed Nursing Assistant | Confirmed catheter bag placement below bladder |
| Staff L | Administrator | Confirmed QAPI attendance issues and COVID-19 notification process |
| Staff M | Director of Nursing | Confirmed infection control masking issues, antibiotic stewardship deficiencies, and infection preventionist training status |
| Staff N | Infection Preventionist | Did not pass infection preventionist competency exam and did not retake |
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