Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
100% occupied
Based on a January 2024 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 10
Date: Jan 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, rights, medication management, staffing, infection control, and facility operations at The Elms Center nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were fully informed in their primary language, failure to honor advance directives, untimely comprehensive assessments after significant changes, lack of routine interdisciplinary care plan meetings, failure to post nurse staffing information daily, improper medication labeling and storage, inadequate food labeling and kitchen cleanliness, incomplete facility-wide staffing assessment, insufficient attendance at Quality Assurance meetings, and failure to implement and review the water management plan according to standards.
Deficiencies (10)
Failed to ensure a resident was fully informed of care and treatment in a language understood (Resident #44).
Failed to ensure resident's right to formulate advance directives (Resident #35).
Failed to conduct comprehensive Minimum Data Set (MDS) assessment within 14 days after significant change (Residents #47 and #24).
Failed to hold routine interdisciplinary care plan meetings for 2 of 16 residents (Residents #24 and #44).
Failed to post daily nurse staffing information at facility entrances.
Failed to label multidose medications with opened/expiration dates and remove expired medications.
Failed to ensure food was labeled and maintain a clean environment in the main kitchen.
Facility assessment did not include specific staffing needs for each shift (day, evening, night).
Failed to ensure required members attended Quality Assurance Performance Improvement meetings at least quarterly.
Failed to implement and review annually the facility's water management plan affecting 46 residents.
Report Facts
Residents reviewed: 16
Residents affected: 46
QAPI meetings reviewed: 4
QAPI meetings with missing Infection Preventionist: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Services | Utilized personal translator application to communicate with Resident #44. |
| Staff B | Licensed Nursing Assistant (LNA) | Reported Resident #44 understands most English and uses personal translator app. |
| Staff C | Director of Nursing | Confirmed no language interpreter services available; confirmed care plan meeting deficiencies; confirmed QAPI attendance issues; unfamiliar with water management plan. |
| Staff D | Regional MDS | Confirmed findings related to untimely MDS assessments. |
| Staff E | Administrator | Confirmed facility assessment lacked specific staffing needs per shift. |
| Staff F | Food Service Director | Confirmed unlabeled food containers and kitchen cleanliness issues. |
| Staff G | Unit Manager | Confirmed medication labeling deficiencies and lack of posted nurse staffing information. |
| Staff H | Nursing Scheduler | Admitted to not posting nurse staffing information daily since October 2024. |
| Staff I | Registered Nurse | Confirmed medication in use without open date labeling. |
| Staff J | Maintenance Director | Confirmed water management plan deficiencies and lack of documentation. |
| Staff K | Cook | Confirmed kitchen fan dust accumulation and use during meal preparation. |
| Staff L | Infection Preventionist | Started November 2024; had not reviewed water management plan. |
| Staff N | Advanced Practice Nurse | Reported no order given to change Resident #35's code status to DNR. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall related to the failure to assess a resident after implementing a new wheelchair device without a seatbelt.
Complaint Details
The complaint investigation found that Resident #26 fell due to the absence of a seatbelt on a new wheelchair and lack of assessment after the device change. The fall caused serious injuries including fractures confirmed by hospitalization records.
Findings
The facility failed to assess Resident #26 after providing a new wheelchair without a seatbelt, resulting in the resident slipping and falling with serious injury including multiple fractures. Documentation and assessment were lacking following the wheelchair change.
Deficiencies (1)
Failure to assess a resident after implementing a new wheelchair device without a seatbelt, resulting in a fall with serious injury.
Report Facts
Residents reviewed for accidents: 4
Total residents in sample: 20
Date wheelchair received: Nov 1, 2023
Date of fall: Nov 4, 2023
Date of care plan revision: Dec 19, 2023
Date of hospitalization discharge summary: Nov 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Therapy | Interviewed regarding lack of assessment after wheelchair change |
Inspection Report
Routine
Census: 52
Capacity: 52
Deficiencies: 8
Date: Jan 25, 2024
Visit Reason
Routine inspection to assess compliance with regulatory standards including care plan participation, medication administration, accident prevention, staffing adequacy, medication storage, feeding assistance, and infection control.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of care plan meetings, late medication administration for multiple residents, inadequate treatment documentation, failure to assess a resident after wheelchair change resulting in a fall with serious injury, insufficient nursing staff leading to delayed care, improper medication storage, failure to properly supervise feeding assistants, and failure to follow transmission-based precautions for infection control.
Deficiencies (8)
Failed to notify resident and/or resident's representative of care plan meetings for 1 resident.
Failed to follow physician orders for medication administration timing for 5 residents.
Failed to ensure treatments were signed off as completed for multiple residents.
Failed to assess resident after implementing new wheelchair without seatbelt, resulting in fall with serious injury.
Failed to provide sufficient nursing staff to meet resident needs, resulting in delayed care and medication administration.
Failed to store medication and therapeutic nutrition according to manufacturer instructions.
Failed to ensure resident with complicated feeding problems was assisted by feeding assistants appropriately and supervised.
Failed to follow transmission-based precautions for a resident with C-Diff infection.
Report Facts
Residents in sample: 20
Facility census: 52
Total licensed capacity: 52
Number of residents affected: 1
Number of residents affected: 5
Number of residents affected: 4
Number of LNAs scheduled: 4
Number of LNAs scheduled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Administrator | Confirmed no updated care plan for Resident #31 and lack of invitations to care plan meetings |
| Staff F | Admission Director/Social Worker | Revealed not sending invitations or setting up care plan meetings |
| Staff H | Director of Nursing | Confirmed late medication administration and treatment sign-offs |
| Staff A | Infection Preventionist | Confirmed incomplete treatment sign-offs and failure to follow contact precautions |
| Staff C | Licensed Practical Nurse | Confirmed medication storage issues and feeding assistant supervision issues |
| Staff K | Medication Nursing Assistant | Reported medications often given late |
| Staff G | Unit Manager | Confirmed normal staffing levels and census |
| Staff I | Director of Therapy | Confirmed lack of assessment after wheelchair change for Resident #26 |
| Staff D | Activity Aide | Observed feeding Resident #12 without proper supervision |
Inspection Report
Routine
Census: 50
Deficiencies: 4
Date: Jan 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASRR screening, bowel management, infection control practices, and COVID-19 reporting.
Findings
The facility failed to complete a required PASRR screening for one resident, failed to administer prescribed bowel medications to another resident, did not adhere to proper infection control masking protocols, and failed to notify residents and families timely about COVID-19 infections on multiple occasions.
Deficiencies (4)
Failed to obtain a Preadmission Screening and Resident Review (PASRR) for mental illness and/or intellectual disability for 1 of 1 resident reviewed.
Failed to provide care by not following a resident's bowel regimen, with no bowel medications administered despite orders.
Failed to adhere to infection control practices for universal masking, with multiple staff observed not wearing masks properly.
Failed to notify residents, representatives, and families of COVID-19 infections by 5:00 p.m. the next calendar day for 7 of 10 days reviewed.
Report Facts
Residents reviewed for PASRR: 22
Residents reviewed for bowel and bladder incontinence: 43
Facility census: 50
COVID-19 positive cases: 10
COVID-19 positive cases: 2
COVID-19 positive cases: 3
COVID-19 positive cases: 4
COVID-19 positive cases: 6
COVID-19 positive cases: 11
COVID-19 positive cases: 2
COVID-19 positive cases: 2
COVID-19 positive cases: 1
COVID-19 positive cases: 4
COVID-19 positive cases: 3
COVID-19 positive cases: 2
COVID-19 positive cases: 1
COVID-19 positive cases: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Confirmed failure to complete PASRR screening and responsible for COVID-19 notifications |
| Staff B | Director of Nurses | Confirmed no bowel medications administered and responsible for COVID-19 notifications |
| Staff C | Licensed Nursing Assistant | Observed not wearing surgical mask properly during infection control deficiency |
| Staff D | Unit Aid | Observed pulling mask down below chin in kitchen during infection control deficiency |
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