Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jaffrey Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to implement Legionella water management controls was identified after review of the facility's plan and policy and interview with the DOR of Maintenance. The facility had no documentation that required annual flushing of the hot water tank sediment or cleaning of shower heads, handheld wands, strainers, and pressure restrictors had been performed, despite these measures being listed in the Legionella Water Management Plan.
Missing informed consent for psychotropic medication. A resident was started on clonazepam for anxiety related to dementia, but the record did not show a signed consent from the resident or representative at initiation. The DON confirmed there was no documentation that the resident or representative was informed in advance of the risks and benefits, alternatives, and right to accept or decline treatment.
Failure to document an annual GDR for psychotropic meds. A resident receiving Seroquel and Remeron had no GDR documented in the past year, and psych notes showed no clinical contraindication for a dose reduction. The DON confirmed the lack of GDR documentation and no documented contraindication in the medical record.
A resident’s scheduled Ativan was not administered for several days because the medication was unavailable, and the progress notes did not document that the provider was notified. An RN confirmed the MAR and chart review findings.
Unlocked Medication Cart: The facility failed to keep the Chapel Unit med cart locked when not in use. During observation, the cart was left unlocked for about 3 minutes with no responsible staff nearby, and an MNA confirmed the finding. Facility policy states medication carts and other compartments containing meds and biologicals are to be locked when not in use.
Dietary Preference Not Followed for Resident Breakfast: A resident stated that bacon was wanted with breakfast, but the meal served did not include it. Record review showed ST had cleared the resident for bacon cut into bite-sized pieces and a diet slip indicated bacon was allowed, yet the dietary director was not aware of the diet change. The resident's care plan directed staff to serve the diet as ordered, and facility policy required nursing to notify FNS of diet changes and food preferences.
The facility failed to ensure its facility assessment identified specific staffing needs for each resident unit for a census of 72 residents. The assessment listed overall direct care staffing for day, evening, and night shifts, but it did not break down staffing needs by resident unit. An HR director confirmed that the assessment did not include unit-specific staffing.
The facility failed to store and serve food in accordance with professional standards for food safety and did not monitor high dishwasher temperatures to ensure proper sanitization. Observations revealed that Vanilla Mighty Shakes lacked thawed dates or use-by dates, and temperature logs for serving food and dishwashing were incomplete, contrary to facility policies.
The facility failed to use PPE when handling, processing, and transporting linens, leading to potential infection control issues. A Laundry Aide was observed transporting overflowing soiled linens in contact with their clothing and loading the washing machine without a gown. The facility's policy on handling soiled laundry was not followed, and there was no documentation of specific training for the Laundry Aide on the laundry process.
The facility's call bell system failed to effectively alert staff, resulting in residents waiting 30-45 minutes or longer for assistance. A cognitively intact resident reported accidents due to long wait times, and staff confirmed the system's limitations in alerting them when away from hallway monitors.
The facility failed to offer therapeutic dietary recommendations and monitor nutritional status for two residents. One resident experienced significant weight loss without timely intervention, while another had significant weight fluctuations without reweights or implementation of dietary recommendations.
The facility failed to promptly notify the ordering practitioner of a resident's critically low glucose level. Despite the lab result being called to the facility, there was no documentation that the provider had been informed, contrary to the facility's policy.
Failure to Implement Legionella Water Management Controls
Penalty
Summary
The facility failed to implement control measures from its Legionella Water Management Plan to prevent the growth and spread of Legionella and other water borne pathogens in a facility with a census of 72 residents. Review of the plan showed required control measures to flush the hot water tank sediment at least annually and to remove and clean shower heads, including handheld wands used for resident bathing, and clear strainers and pressure restrictors of sediment and potential biofilm at least annually. During interview, the Director of Maintenance confirmed there was no documentation that these control measures had been performed. Review of the facility's Legionella Water Management Program policy, revised in September 2022, also identified that the water management program includes control limits or parameters that are acceptable and monitored.
Missing Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to provide documentation that a resident or the resident representative was informed in advance of the risks and benefits, options, and alternatives before psychotropic medication was initiated for Resident #31. Review of the current physician’s orders showed Clonazepam 0.5 mg, ordered on 11/14/25 as 0.5 tablet by mouth daily for anxiety related to dementia and 1 tablet by mouth at bedtime. Review of the medical record showed no consent signed by the resident or resident representative at the initiation of the medication. The DON confirmed these findings during interview. The facility policy on psychotropic medication use states that prior to initiating, increasing, or switching psychotropic medications, staff and the physician are to review non-pharmacological alternatives, the indications and rationale, potential risks and benefits, and the resident’s or representative’s right to accept or decline treatment.
Failure to Document Annual GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications had a gradual dose reduction (GDR) for one of five residents reviewed for unnecessary medications. Resident #6 had medication orders for Seroquel 50 mg, ordered on 8/17/23, and Remeron 30 mg, ordered on 3/2/23. Review of the resident’s psychiatric notes dated 2/4/26, 2/18/26, 4/15/26, 5/13/26, and 5/18/26 revealed no clinical contraindication for a GDR. Review of the resident’s progress notes for the last year showed no documentation of a GDR. During interview on 5/21/26 at approximately 12:30 p.m., the DON confirmed that Resident #6 had not had a GDR in the last year and that there was no documentation of a clinical contraindication for a GDR in the medical record. The facility policy stated that after the first year, a GDR will be attempted at least annually unless clinically contraindicated, and that GDR attempts and the rationale for contraindications are to be documented in the medical record.
Failure to Administer Scheduled Ativan and Notify Provider
Penalty
Summary
The facility failed to follow a physician’s order for one resident reviewed for choices in the final sample of 18 residents. Review of the resident’s May 2026 MAR showed a scheduled Ativan order for daily bedtime, but the medication was not administered from 5/5/26 through 5/9/26. Review of the resident’s progress notes for those dates showed that the Ativan was unavailable, and there was no documentation that the provider was notified. During interview on 5/21/26, a Registered Nurse confirmed these findings.
Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were maintained in a locked cart in 1 of 2 medication carts observed, specifically the Chapel Unit medication cart. During observation on 5/19/26 at approximately 8:15 a.m., the Chapel Unit medication cart was left unlocked for approximately 3 minutes with no responsible staff nearby. Staff H, the Medication Nursing Assistant, confirmed the cart had been left unlocked. Review of the facility policy titled Medication Labeling and Storage, revised February 2023, stated that compartments containing medications and biologicals, including carts, are locked when not in use.
Dietary Preference Not Followed for Resident Breakfast
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences were taken into consideration for breakfast. Resident #12 stated that he/she did not get what he/she wanted for breakfast and wanted bacon with breakfast each day. On observation, the resident's breakfast consisted of fried eggs, oatmeal with syrup, and pancakes, and the resident stated that bacon was not served and that he/she was not allowed to have bacon. Record review showed that the speech therapist screened the resident during lunch and documented that the resident requested bacon be added back to the diet. The note stated the resident was educated on current diet texture implications and was agreeable to bacon cut into bite-sized pieces, and the diet order was clarified. Additional record review showed a diet order and diet slip dated 5/10/26 indicating a texture change to bite size and that bacon was allowed. Staff interviews revealed that the dietary director was not aware of the diet change, while the director of rehabilitation and an RN stated that the updated diet slip had been provided to nursing and delivered to the kitchen. The resident's care plan directed staff to provide and serve the diet as ordered, and the facility policy required nursing to notify food and nutrition services of diet orders and changes, including food preferences.
Facility Assessment Lacked Unit-Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility assessment included specific staffing needs for each resident unit for a census of 72 residents. Review of the facility assessment on 5/20/26 showed a staffing plan stating that direct care staff would include 3 licensed nurses and 7 nurse aides on day shift, 3 licensed nurses and 7 nurse aides on evening shift, and 2 licensed nurses and 4 nurse aides on night shift, with staffing intended to fluctuate based on acuity and staff competency. Further review found that the assessment did not identify staffing needs by resident unit. During an interview on 5/21/26 at approximately 10:23 a.m., Staff F, the Director of Human Resources, confirmed that the facility assessment did not break down staffing for each resident unit.
Failure to Adhere to Food Safety and Sanitization Standards
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for food safety, as well as to monitor high dishwasher temperatures to ensure proper sanitization. Observations revealed that Vanilla Mighty Shakes in various refrigerators lacked thawed dates or use-by dates, and staff were unaware of when the shakes were thawed. The manufacturer's instructions indicated that thawed product should be used within 14 days and kept refrigerated. Additionally, temperature logs for serving food from 4/1/24 to 4/22/24 showed numerous instances where internal food temperatures were not recorded for breakfast, lunch, and dinner, contrary to the facility's policy that required temperatures to be taken and recorded for all meals. The facility's policy also mandated that the cook ensure all food is at the proper temperature and that these temperatures be recorded on extended menus. Furthermore, the facility's dishwasher temperature logs from 4/1/24 to 4/22/24 revealed multiple days where no dishwasher temperatures were recorded, despite the facility's policy requiring that the temperature be checked prior to washing dishes and recorded on the dish machine temperature log for every meal. The lack of recorded temperatures for both food holding and dishwashing indicates a failure to adhere to established procedures designed to ensure food safety and proper sanitization, potentially increasing the risk of foodborne illness among residents.
Failure to Use PPE When Handling and Transporting Linens
Penalty
Summary
The facility failed to use Personal Protective Equipment (PPE) when handling, processing, and transporting linens, leading to potential infection control issues. Observations revealed that a Laundry Aide, Staff D, was seen exiting the South shower room with an overflowing cart of soiled linens that were in contact with their clothing. Staff D then transported the soiled linens down a hallway with residents and other staff present. Additionally, Staff D was observed loading the washing machine with soiled linens while wearing gloves but no gown. Interviews with the Infection Preventionist and Staff D confirmed these observations, and Staff D admitted to not being aware of the need to wear a gown when handling soiled linens. Furthermore, Staff D stated that they folded clean laundry in the same clothes worn while transporting soiled laundry and delivered clean laundry without a protective cover. The facility's policy on handling soiled laundry, which requires the use of gloves and gowns and mandates that contaminated linen be bagged or contained at the point of collection, was not followed. The Infection Preventionist was unable to provide documentation of education related to the laundry process for Staff D, and the Director of Maintenance, Housekeeping, and Laundry revealed that Staff D had only received PPE training when hired eight years ago. A review of Staff D's PPE Competency Validation showed training on donning and doffing PPE for standard and transmission-based precautions but no specific training for handling, processing, and transporting linens.
Ineffective Call Bell System Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call bell system was equipped to allow residents to call for staff assistance effectively. Resident #59, who was cognitively intact and required extensive staff assistance for toilet use and transfers, reported waiting 45 minutes or longer for staff to respond to the call button, resulting in accidents. Interviews with staff revealed that the call bell system did not continuously sound, and staff could only see call alerts on monitors located in the hallways, which were not always in view when attending to other residents. This led to long wait times for residents needing assistance. During a Resident Council meeting, 10 out of 21 residents reported waiting 30 minutes or longer for call bells to be answered, with complaints about staff not hearing the call system. Staff interviews confirmed that the call bell system was mechanically functioning but was not effective in alerting staff when they were not near the monitors. The facility's policy emphasized timely response to call systems, but the current setup did not support this, leading to significant delays in resident care.
Failure to Implement Dietary Recommendations and Monitor Nutritional Status
Penalty
Summary
The facility failed to offer therapeutic dietary recommendations to maintain body weight and failed to monitor parameters of nutritional status for two residents. Resident #36 experienced significant weight loss over a short period, with weights recorded as 126.4 pounds, 126.8 pounds, 117.6 pounds, and 116.6 pounds. Despite a dietician's recommendation on 3/21/24 to trial 4-ounce nutrition shakes daily and add ice cream for supplemental calories, no orders were placed until 4/19/24. Additionally, a reweight requested on 4/19/24 was not performed within the required 24-hour period, as confirmed by the Director of Nursing (Staff A). The facility's policy on weight management was not followed, leading to a failure in addressing the resident's nutritional needs promptly and effectively. Resident #61's care plan included monitoring weight per facility protocol and recommending juice and protein supplements for wound healing and malnutrition. However, the resident's weights showed significant fluctuations, with recorded weights of 267.6 pounds, 310.5 pounds, 156.1 pounds, and 255 pounds. Despite dietician recommendations on 4/9/24 for juice and protein supplements, these were not started, and reweights were not obtained as required. Staff J confirmed the inaccuracies in weight measurements and the lack of reweights, while Staff A confirmed that dietary recommendations were not implemented. The facility's failure to adhere to its weight management policy and promptly address dietary recommendations resulted in inadequate nutritional care for the residents.
Failure to Notify Practitioner of Critical Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of critical laboratory results for a resident reviewed for insulin. The resident's lab result collected on 4/23/24 at 8:06 a.m. revealed a critically low glucose level of 26 mg/dL. However, there was no documentation in the resident's medical record indicating that the provider had been notified of this critical result. Interviews with the Director of Nursing and the Unit Manager confirmed the lack of documentation and revealed that the critical lab result was called to the facility on the same day at 5:03 p.m. The facility's policy requires urgent communication with the attending physician based on the seriousness of any abnormality, but this protocol was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jaffrey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pheasant Wood Center | 8 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Baldwinville | 13.7 mi | ★★★★★ | 10 | 0 |
| Alpine Healthcare Center | 15.9 mi | ★★★★★ | 4 | 0 |
| Wachusett Manor | 16.2 mi | ★★★★★ | 8 | 0 |
| Gardner Rehabilitation And Nursing Center | 16.5 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.