Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management and food safety in the facility.
Findings
The facility failed to ensure a gradual dose reduction (GDR) of psychotropic medication for one resident despite no clinical contraindications, and failed to maintain proper chemical sanitizer levels in the dishwasher, risking inadequate dish sanitization.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure that dishes were sanitized according to manufacturer's instructions due to lack of chlorine sanitizer in the dishwasher. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for unnecessary medications: 5
Residents in final sample: 24
Psychotropic medication dose: 2
Minimum dishwasher temperature: 120
Required chlorine concentration: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Staff A confirmed no GDR attempted for Resident #76 | |
| RN | Staff C reported Resident #76 was pleasant and quiet with no psychotic episodes | |
| Dietary Services Director | Staff B observed and tested dishwasher sanitizer levels |
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, medication administration, psychotropic medication use, infection prevention and control practices, and adherence to regulatory requirements.
Findings
The facility was found deficient in several areas including improper insulin administration technique, failure to limit PRN psychotropic medication orders to 14 days, and inadequate infection control practices related to the use of gowns when handling soiled laundry. These deficiencies were associated with minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow professional standards when administering insulin for 1 out of 31 medications observed (Resident #83). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure PRN psychotropic drugs were limited to 14 days for 2 residents (Residents #112 and #11). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow infection control guidelines by not wearing gowns when handling soiled linen and clothing in the laundry. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medications observed: 31
Residents in sample: 26
PRN Lorazepam doses given: 3
Duration of PRN orders: 14
Months Staff F worked in laundry: 7
Months Staff H worked in laundry: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administered insulin incorrectly to Resident #83 |
| Staff B | Director of Nursing | Confirmed lack of 14 day stop date or evaluation for PRN psychotropic medication orders and expectation for laundry staff gown use |
| Staff F | Laundry Aide | Reported no gowns available and never used gowns when handling soiled laundry |
| Staff G | Housekeeping Supervisor | Reported facility practice on PPE use in laundry and confirmed no gowns available |
| Staff H | Laundry Aide | Reported no gown use and lack of education on gown necessity when handling soiled laundry |
| Staff E | Infection Preventionist | Reported facility practice on gown use only for residents on transmission based precautions |
| Staff I | Corporate Director of Nurses | Confirmed facility follows CDC guidelines for infection control policy and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 2, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding medication administration and facility compliance with medication and food safety standards.
Findings
The facility failed to ensure admission medications were available and administered to a newly admitted resident, resulting in missed doses of several medications including potassium. Additionally, the facility failed to store thickened liquids according to manufacturer's instructions and did not label opened glucometer control solution bottles with expiration dates.
Complaint Details
The complaint investigation focused on medication administration errors involving a newly admitted resident who did not receive ordered medications on admission, including potassium. The resident's potassium lab was low, and the facility was aware of the missed medication but failed to notify the physician timely. Additional issues included improper storage of thickened liquids and unlabeled glucometer control solutions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure admission medications were available for a newly admitted resident, resulting in missed administration of clonazepam, donepezil, potassium (Klor-Con), and metformin. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that a newly admitted resident received potassium medication as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store thickened liquids according to manufacturer's instructions in multiple kitchenettes and dining areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label opened glucometer control solution bottles with expiration dates to ensure safe operating condition. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Potassium lab value: 2.8
Medication doses missed: 4
Storage time for thickened liquids: 7
Control solution discard timeframe: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse | Documented medications not administered and admitted to not administering medications on a busy night. |
| Staff B | Unit Manager | Confirmed awareness of missed potassium medication and additional dose given due to low lab value. |
| Staff D | Director of Nursing | Was not aware of missed medications until after the fact and expected notification from Staff F. |
| Staff E | Director of Food and Nutrition | Confirmed thickened liquids were not dated when opened. |
| Staff B | Licensed Practical Nurse / Nurse Manager | Confirmed glucometer control solution bottles were not labeled with opening dates. |
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