Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lafayette Center during CMS and state inspections, most recent first.
The facility failed to follow CDC laundry guidance when clean linen was stored in cardboard boxes on the dirty side of the laundry room, including on the floor near the doorway, behind the washer, and next to the rinse sink. The facility also did not update its water management plan after a water infection control risk assessment identified 2 water bubblers and different ice machine cleaning frequency, and the plan did not include hot water boiler/heater temperature monitoring or the required temperature controls for Legionella surveillance.
Failure to Monitor Antibiotic Use: The facility did not implement its antibiotic stewardship monitoring system for 5 residents reviewed for UTI treatment. Although the policy required nursing to monitor antibiotic starts and complete an antibiotic time out within 48-72 hours using updated McGeer criteria, C&S results were not available to review during the time out for the affected residents, and the IP confirmed this during interview.
Failure to complete AIMS monitoring for a resident receiving an antipsychotic medication. The resident had quetiapine for dementia with psychosis, and the care plan included AIMS testing per protocol, but the AIMS assessment and related scoring fields were left incomplete on admission screenings. An LPN confirmed no AIMS testing was completed at admission or quarterly as required by policy.
Failure to Assist Resident With Meals: A resident with care plans calling for setup to partial assist, cuing, and assistance with eating as needed was observed struggling to eat at multiple meals. The resident had difficulty handling hamburger, scrambled egg, ground chicken, and broccoli, with food spilling onto the tray and lap, while staff stated they only set up the tray and did not otherwise assist; the RD confirmed the resident required some meal assistance.
Failure to Follow Fall and Elopement Safety Interventions: A resident who required two-person assist for all transfers fell during a toilet transfer when only one aide was assisting, despite the care plan and MDS indicating substantial/maximal assistance for toilet transfer. Two residents at risk for elopement also were observed without their ordered wander guards, and an LPN confirmed one resident had an active order for the device but was not wearing it.
A resident was hospitalized multiple times, and the facility provided a Bed Hold Notice that did not include the duration of the bed hold or reserve bed payment information required by policy. The Administrator confirmed the notice given at each transfer lacked those details.
A resident developed pressure ulcers that were not promptly reported to a provider, resulting in delayed treatment orders and incomplete documentation of wound size and care. Nursing staff did not consistently follow physician orders or facility policy for wound assessment and treatment, leading to worsening of the wounds and lack of regular monitoring.
Staff did not follow infection control protocols during wound care for two residents, including failing to use clean field barriers and required PPE under Enhanced Barrier Precautions. Additionally, the facility lacked a water management plan specific to its actual water system, as required by policy.
The facility did not keep residents informed about the status or resolution of ongoing concerns raised in Resident Council Meetings regarding LNAs discussing residents and being loud, nor did it document responses or actions taken in meeting minutes, as required by facility policy.
Two residents with pressure ulcers did not have their care plans updated or developed to address new or existing wounds. In both cases, staff confirmed that new wounds were not reflected in the care plans, and necessary interventions were not documented or implemented as required.
A resident with bipolar disorder and Tardive Dyskinesia received multiple medications, including Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion, significantly later than scheduled on numerous occasions. The resident, who was cognitively intact, reported frequent late medication administration, which was confirmed by audit reports and staff interview. This practice did not comply with facility policy requiring medications to be given within 60 minutes of the scheduled time.
A resident with a history of hearing impairment and a documented need for hearing aids requested an audiology consult due to worsening hearing, but the facility did not arrange the appointment as requested. The resident continued to experience communication difficulties, and staff confirmed the request was not fulfilled, contrary to facility policy.
A resident missed a scheduled knee x-ray and physician visit because staff failed to arrange necessary transportation, despite appointment paperwork being present at the nurses station and communication between staff about the appointment. The resident was not provided the required assistance, resulting in the missed medical appointment.
A resident with dementia and a low BIMS score was repeatedly subjected to inappropriate sexual behavior by other residents. Despite having care plans in place, the facility failed to implement effective interventions to prevent these incidents, resulting in a deficiency in resident safety and protection from abuse.
The facility failed to report alleged abuse incidents to the SSA within the required timeframe. In one case, an LNA observed inappropriate touching between two residents, which was reported internally but not to the SSA until the next day. In another case, a resident reported being attacked, but the incident was not reported to the SSA for several days. A third incident involving inappropriate touching was not reported to the SSA at all.
The facility failed to update care plans for two residents involved in abuse incidents. One resident exhibited increased sexual and wandering behaviors, while another allegedly caused a fall. Despite these incidents, their care plans lacked new interventions addressing these behaviors.
A resident with a history of trauma was re-traumatized when another resident entered their room without consent and allegedly assaulted them, resulting in physical injuries. Despite the resident's known traumatic past and expressed fears, the facility failed to document care plan interventions to prevent such incidents.
A facility failed to accurately document an abuse incident involving two residents. A LNA witnessed inappropriate contact and reported it to an LPN, who documented the event. However, the note was struck out and moved to a non-medical record system by the DON, leaving no evidence of the incident in the official medical record.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels due to the facility's failure to implement necessary interventions for pressure redistribution. Despite being identified as at risk, the resident's care plan lacked specific measures for offloading and repositioning. Staff interviews revealed a lack of awareness regarding the implementation of these interventions, and the DTIs were confirmed to be facility-acquired by the DON.
The facility failed to secure chemical cleaning solutions, leaving them accessible to wandering residents in the Birch and Spruce Units. Observations confirmed by staff interviews revealed that chemicals were not stored according to facility policy, posing potential health risks. The DON acknowledged the presence of 13 wandering residents, emphasizing the need for proper chemical storage.
The facility failed to properly store and label medications in the Birch Unit Medication Room and Pine Unit Medication Cart. The Birch Unit's medication refrigerator was found at an incorrect temperature, and the temperature log was incomplete. In the Pine Unit, insulin pens and vials were not labeled with open or expiration dates, and one vial was beyond its expiration period. These deficiencies were confirmed by LPNs during observations.
A dietary aide failed to perform proper hand hygiene during dishwashing procedures. The aide was observed handling both dirty and clean dishes without washing hands in between, contrary to the facility's policy. This was confirmed during an interview with the aide.
The facility did not follow CDC guidelines for PPE use for two residents. One resident receiving IV medication and with a wound did not have proper gown use by a nurse. Another resident on contact precautions for viral herpes had staff unaware of the precautions' reasons, leading to improper PPE use. Facility policies and CDC guidelines were not adhered to.
The facility failed to develop and update care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident with PTSD lacked a care plan for trauma-related interventions, while another on Coumadin for Atrial Fibrillation had no care plan for anticoagulation therapy. Additionally, a resident with new heel injuries did not have an updated care plan, despite facility policy requiring revisions upon status changes.
Laundry Storage and Water Management Deficiencies
Penalty
Summary
The facility failed to follow CDC guidelines for laundry services. On observation in the laundry room, clean linen was stored in cardboard boxes on the floor on the dirty side of the laundry room, including boxes just inside the doorway, behind the washing machine, and next to the rinse sink. Staff H, the Infection Preventionist, confirmed that clean linen was being stored in cardboard boxes on the dirty side of the laundry room. The facility also failed to update its water management program after a recent water infection control risk assessment. The 3/9/26 water management plan identified one dead leg/capped pipe in the DON's office and stated the 2 ice machines would be cleaned bi-annually, but it did not include the 2 water bubblers as a potential risk area with control measures and did not identify that the hot water boiler/heaters needed to be maintained at or above 140 degrees Fahrenheit. The facility's 6/4/26 water infection control risk assessment identified the 2 water bubblers, stated there were no dead legs in the facility, and indicated the 2 ice machines would be cleaned by vendor quarterly. The facility policy for Legionella surveillance stated hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit. The Administrator confirmed the water management plan was not updated after the risk assessment and that water temperatures were not taken at the hot water boiler/heaters.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its system for monitoring antibiotic use for 5 of 7 residents reviewed for antibiotic stewardship, identified as residents #6, #7, #35, #45, and #60. The facility policy titled Antibiotic Stewardship Program, revised in 6/2025, stated that the facility uses updated McGeer criteria to define infections and that nursing will monitor the initiation of antibiotics and conduct an antibiotic time out within 48-72 hours of antibiotic therapy to monitor response, review laboratory results, and consult with the practitioner about whether the antibiotic should continue or be adjusted. Review of the antibiotic use line listing for April 2026 through June 2026 showed that these residents were prescribed antibiotics for a diagnosis of UTI, but a Culture and Sensitivity was not available to review during the antibiotic time out. Resident #7 was prescribed an antibiotic on 4/14/26, resident #6 on 5/10/26, resident #35 on 5/24/26, resident #45 on 6/2/26, and resident #60 on 6/5/26. During interview on 6/24/26, the Infection Preventionist confirmed that a Culture and Sensitivity was not available to review during the antibiotic time out for these residents.
Failure to Complete AIMS Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to implement a care plan for psychotropic medications for one resident reviewed for unnecessary medications. Resident #3 had a care plan dated 2/20/26 that identified risk for complications related to psychotropic medication use and included an intervention for AIMS testing per protocol. The resident had a physician’s order for Quetiapine Fumarate for dementia with psychosis since admission. Record review showed that the admission Screening Assessment dated 2/20/26 documented the resident was not assessed for AIMS due to impaired cognition, and the AIMS Assessment section and related movement and scoring fields were not completed. A later admission Screening Assessment dated 5/27/26 also left the AIMS Assessment and related sections incomplete. The facility’s policy required residents receiving an antipsychotic medication to have an AIMS test on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN, or as per facility policy. Staff L confirmed that the resident had been taking an antipsychotic medication since admission and that no AIMS testing was completed at admission or quarterly as required.
Failure to Assist Resident With Meals
Penalty
Summary
The facility failed to provide assistance with eating during meals for Resident #47, despite care plan interventions indicating the resident needed setup to partial assistance for eating, cuing for safety and sequencing, and assistance with eating as needed. The ADL care plan, initiated on 5/1/26, and the nutrition care plan, initiated on 5/4/26, both documented that the resident required support with eating and monitoring for changes in ability to feed self and nutritional status. During observations on 6/22/26 and 6/23/26, Resident #47 was seen struggling to eat independently at multiple meals. At lunch on 6/22/26, the resident tried for several minutes to pick up a piece of hamburger, but the ground meat fell out of the bun. At breakfast on 6/23/26, the resident used fingers to eat scrambled egg, with egg on the lap and tray. At lunch on 6/23/26, the resident attempted to scoop ground chicken and broccoli with a spoon, with several empty spoonfuls placed in the mouth and food falling onto the tray; the resident ate about 25% of the ground chicken, half of a cut dinner roll, none of the broccoli, none of the macaroni, and all of the dessert. Staff E, an LPN, and Staff F, a CNA, stated that staff did not offer assistance at meals other than setting up the tray, and Staff G, the dietitian, confirmed the resident did require some assistance with meals.
Failure to Follow Fall and Elopement Safety Interventions
Penalty
Summary
The facility failed to implement interventions to reduce hazards and risks for residents at risk for elopement and for a resident at risk for falls. Resident #49 had a care plan requiring two-person assist with a walker and gait belt for all transfers, including toilet transfers, and the MDS coded the resident as needing substantial/maximal assistance for toilet transfer. Despite this, the resident reported falling in the bathroom shortly after admission when one aide was helping and the resident’s knee gave out. Staff M later stated they were the only person assisting the resident with the toilet transfer when the resident slipped, and Staff N also stated they assisted the resident to the bathroom and toilet by themselves earlier that day. Staff L confirmed the resident was supposed to be a two-person assist for all transfers, including to the toilet. Resident #10 had an active physician’s order for a wander guard on the right wrist due to poor safety awareness, and the wandering assessment documented a daily history of wandering and elopement risk. However, the resident was observed eating breakfast on two separate occasions with no wander guard on either wrist, and Staff K confirmed the resident had an active order for the device but did not have one on. Resident #56’s wandering assessment and care plan identified elopement risk and specified a wander guard on the left ankle, but the device was observed sitting on the resident’s nightstand during multiple observations, and the resident was not wearing it. Staff B stated the resident wears a wander guard on the left ankle but is known to remove it.
Missing Bed Hold Notice Information
Penalty
Summary
The facility failed to provide Resident #26 or the resident's representative with a bed hold notice that included the duration of the bed hold and reserve bed payment information when the resident was hospitalized. Facility policy titled Bed Hold Notice, revised 6/2025, required that at the time of a transfer to the hospital or therapeutic leave, the resident and/or resident representative be given written information specifying the duration of the State bed-hold policy, if any, and the reserve bed payment policy in the state plan, if any. Review of Resident #26's record showed hospital transfers on 2/10/26, 3/21/26, and 6/22/26, and that copies of the facility's Bed Hold Notice policy dated June 2025 were provided at those times. During interview, the Administrator confirmed the Bed Hold Notice provided to Resident #26 did not include the duration of the bed hold or reserve bed payment information for those hospital transfers.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer prevention and treatment for one resident. Upon admission, the resident had no pressure ulcers, but subsequently developed open areas on the right and left buttocks. The right buttock wound was first noted as a small open area, but there was no documentation that the provider was notified or that a physician's order was obtained for treatment for six days. During this period, the wound worsened and was later assessed as an unstageable pressure ulcer. Treatment orders were not obtained until several days after the wound was identified, and the treatment was not documented as completed until two days after the order was written. For the left buttock, a stage 2 pressure ulcer was identified, but there was no treatment ordered or documented for a period of three weeks. Additionally, there was a lack of weekly documentation of the size and measurements of both the right and left buttock pressure ulcers for extended periods after their identification. Interviews with nursing staff confirmed that wounds were not measured or documented as required, and that treatment orders were delayed or not followed according to physician instructions. During wound care observations, staff did not follow physician's orders for wound treatments and failed to take measurements of wounds at the time of dressing changes. Facility policies required wound treatment to be provided in accordance with physician orders, prompt notification of providers for new wounds, and regular documentation of wound characteristics and measurements. These policies were not followed, resulting in incomplete and delayed care for the resident's pressure ulcers.
Failure to Implement Infection Control and Water Management Policies
Penalty
Summary
Surveyors observed that staff failed to follow established infection prevention and control policies during wound care for two residents. Specifically, the infection preventionist and an advanced practice registered nurse gathered wound care supplies on an uncleaned clipboard without using a clean field barrier, and entered rooms marked for Enhanced Barrier Precautions (EBP) without donning isolation gowns. During wound care, contaminated items such as scissors were placed on the clipboard and then returned to the treatment cart without proper cleaning. These actions were confirmed by staff interviews and were not in accordance with the facility's policies, which require the use of gowns and gloves for high-contact care activities like wound care, and the establishment of a clean field for dressing changes. Additionally, the facility failed to develop and implement a water management program tailored to its actual water system. The provided water management plan described a four-story building, while the facility is only one story, and did not accurately reflect the flow of the water system. The administrator confirmed the absence of a water management plan specific to the facility, despite policy requirements for such a program as part of the infection prevention and control program.
Failure to Communicate and Document Resident Council Grievance Responses
Penalty
Summary
The facility failed to keep residents informed about the progress and resolution of concerns raised during Resident Council Meetings, and did not maintain documentation demonstrating the response and rationale to these grievances. Over a three-month period, meeting minutes consistently documented resident complaints regarding LNAs discussing other residents in front of them and being loud in hallways and at nurse's stations. Despite these ongoing concerns, residents reported that no follow-up or communication about actions taken was provided to them. Interviews with staff confirmed that while concerns from Resident Council Meetings were verbally relayed to department heads, there was no written follow-up or evidence of actions taken documented in subsequent meeting minutes. The facility's policy requires that concerns and recommendations from the Resident Council be acted upon and that decisions be communicated back to the Council, but this process was not followed as required.
Failure to Update and Develop Comprehensive Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop and update comprehensive care plans for two residents with pressure ulcers. For one resident, a provider note documented a new open area on the sacrum, but no new treatment orders were written, and the care plan for skin had not been updated since a previous date. Interviews with staff confirmed that the new wound was not addressed in the care plan and that treatments had not been completed as required. The medication administration record also did not reflect any new orders for the newly identified wound area. For another resident, progress notes indicated the development of multiple pressure ulcers, including an unstageable area, a stage 2 ulcer, and a deep tissue injury. Observation confirmed the presence of these wounds, but the care plan, which was initiated earlier, had not been updated to include interventions for the new pressure areas. Staff interviews confirmed the absence of care plan interventions for the pressure ulcers that developed subsequently.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality in medication administration for one resident. Multiple instances were identified where medications were administered outside of the prescribed time frames. Specifically, medications such as Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion were given significantly later than their scheduled times, with delays ranging from over an hour to several hours past the ordered administration times. These findings were confirmed through review of the Medication Administration Audit Report and interviews with both the resident and an Advanced Practice Registered Nurse. The resident involved had a diagnosis of bipolar disorder and Tardive Dyskinesia, and was prescribed several medications to be administered at specific times, including early morning and evening doses. The resident was cognitively intact, as evidenced by a Basic Interview for Mental Status (BIMS) score of 15 out of 15, and reported that medications were often given late, a statement corroborated by the audit report covering the previous 30 days. The late administration of medications included both time-critical and non-time-critical drugs, with some doses being administered several hours after the scheduled time. Facility policy required that medications be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. The observed practice did not align with this policy, as numerous medications were administered well outside the acceptable window. The failure to adhere to scheduled medication times was confirmed by staff interview and documentation review, establishing a deficiency in meeting professional standards and following physician orders for medication administration.
Failure to Assist Resident in Accessing Hearing Services
Penalty
Summary
A resident who had been diagnosed with abnormal auditory perceptions in the left ear and was identified as a good candidate for bilateral hearing aids requested to be seen by an audiologist due to worsening hearing. Despite the resident's expressed concerns and a documented need for hearing services, the facility failed to make an appointment with the audiologist as requested. The resident's Durable Power of Attorney confirmed ongoing communication difficulties, and staff acknowledged that the request for a hearing consult was not acted upon. Facility policy required that outside clinical services be provided as ordered and available, but this was not followed in this instance.
Failure to Arrange Transportation for Scheduled X-ray Appointment
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident in arranging transportation for a scheduled x-ray appointment. The resident, who had been admitted in December 2024, was supposed to have a knee x-ray at an orthopaedic clinic. The resident reported being upset after being informed by the staff member responsible for transportation arrangements that they were unaware of the appointment and had not set up transportation. Another staff member confirmed seeing paperwork regarding the appointment at the nurses station and communicated this to the transportation coordinator. Further interviews confirmed that the resident had been given paperwork with the appointment details during a previous clinic visit, but the necessary transportation was not arranged, resulting in the resident missing the scheduled x-ray and physician visit. The report is based on interviews with the resident and staff, as well as a review of the resident's medical record and communication with the orthopaedic clinic, all of which confirmed the missed appointment due to the lack of transportation arrangements.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, involving multiple incidents with other residents. Resident #5, who has unspecified dementia and a Brief Interview for Mental Status (BIMS) score of 3, was involved in several inappropriate interactions. On 5/5/24, a staff member observed Resident #2 with their hand down Resident #5's pants. Staff A, the Activities Director, was aware of multiple incidents of Resident #2 being sexually inappropriate with cognitively impaired residents. Additionally, on 7/27/24, Staff H, an LNA, witnessed Resident #2 rubbing Resident #5's genital area. Further incidents involved Resident #1, who was seen touching Resident #5 inappropriately on 8/13/24 and again on another occasion by Staff L. Resident #2, with a BIMS score of 12, had a care plan addressing potential physical behaviors and sexually inappropriate behavior, but interventions were not effectively preventing these incidents. Resident #1, with a BIMS score of 3 and similar diagnoses to Resident #5, had a care plan for potential verbal/physical behaviors, but it lacked specific interventions to prevent inappropriate sexual behavior. The facility's failure to implement effective interventions and protect Resident #5 from repeated abuse incidents constitutes a deficiency in ensuring resident safety and freedom from abuse.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse to the State Survey Agency (SSA) within the required timeframe for three out of four reviewed cases. In the first case, a Licensed Nursing Assistant (LNA) observed a resident with their hands on another resident's genital area. The incident was reported to a nurse, who left a note for the Assistant Director of Nursing. However, the incident was not reported to the SSA until the following day, exceeding the two-hour reporting requirement for abuse allegations. In the second case, a resident reported being attacked by another resident, resulting in a fall. The incident was witnessed by a Registered Nurse who heard a commotion and found the resident on the floor. Despite the incident occurring on one day, it was not reported to the SSA until several days later. In the third case, an LNA witnessed inappropriate touching between two residents and reported it to a Licensed Practical Nurse. This incident was not reported to the SSA at all, further demonstrating the facility's failure to adhere to reporting protocols.
Failure to Revise Care Plans Following Abuse Incidents
Penalty
Summary
The facility failed to revise care plans for two residents involved in incidents of abuse. Resident #1 was observed by a Licensed Nursing Assistant with their hand on the genital area of another resident. A progress note indicated increased sexual behaviors and wandering, but the care plan, last revised on 7/15/24, did not include new interventions for these behaviors. The care plan only included an evaluation for a Psych/Behavioral Health consultation. Resident #3 was involved in an incident where they allegedly hit another resident, causing them to fall. Despite this incident, Resident #3's care plan, initiated on 8/23/23, did not include any new interventions for aggressive behaviors. The existing care plan focused on verbal behaviors and included interventions such as discouraging head shaving and providing a consistent caregiver, but it did not address the recent physical aggression.
Failure to Protect Trauma Survivor from Re-traumatization
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma was free from re-traumatization. An incident occurred where a resident was found on the floor with a hematoma on the head, a skin tear on the elbow, and complaints of rib pain after another resident entered their room without consent and allegedly hit them. The affected resident had previously disclosed a traumatic past to the social services staff and had expressed fear of the other resident, even wearing a whistle for protection. Despite this, there were no care plan interventions documented in the medical record to address the resident's history of trauma.
Failure to Accurately Document Abuse Incident in Medical Record
Penalty
Summary
The facility failed to maintain an accurately documented medical record for a resident involved in an alleged abuse incident. On 8/13/24, a Licensed Nursing Assistant (Staff K) witnessed an inappropriate interaction between two residents, where one resident was seen touching another resident's inner thigh. Staff K immediately separated the residents and reported the incident to a Licensed Practical Nurse (Staff M). Staff M documented the incident in a nurse's note on the same day. However, this note was later struck out by someone other than Staff M, as directed by the Director of Nursing (Staff F), who claimed it was placed in the wrong section of the medical record. The incident was instead recorded in the Risk Management System, which is not part of the official medical record. A review of the medical record confirmed the absence of documentation regarding the incident.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide appropriate care and services to prevent an avoidable pressure ulcer for a resident identified as being at risk. The facility's policy on Pressure Injury Prevention and Management required the development of a care plan with measurable goals and evidence-based interventions for residents at risk of pressure injuries. Despite this, the care plan for the resident, who was assessed with a Braden Scale score indicating risk for pressure ulcers, lacked specific interventions for offloading and repositioning. The resident's care plan included goals to prevent skin breakdown and interventions such as weekly skin checks and daily observation during ADL care, but it did not address the need for pressure redistribution. The deficiency was further highlighted by the development of deep tissue injuries (DTIs) on the resident's left and right heels, which were noted in physician documentation. The task for offloading the resident's heels was only initiated after the left heel DTI was identified. Interviews with staff revealed a lack of awareness and implementation of the necessary interventions, with discrepancies in the understanding of when the resident's heels were supposed to be floated. The Director of Nursing confirmed that the DTIs on the resident's heels were acquired within the facility, indicating a failure to adhere to the facility's pressure injury prevention policy.
Chemical Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that the residents' environment was free from accident hazards, specifically regarding the storage of chemical cleaning solutions. Observations were made on multiple occasions in the Birch Unit Tub Room, where a bottle of Rapid Multi Disinfectant Spray was found hanging on the wall within reach of wandering residents. Similarly, in the Spruce Unit Tub Room, a container of Super Sani-Cloth Germicidal wipes was observed on top of a portable cart, also within reach of wandering residents. These observations were confirmed by interviews with staff members, including a Licensed Practical Nurse and a Licensed Nursing Assistant. The facility's policy mandates that any area used for storing chemicals should be locked at all times, which was not adhered to in these instances. The Director of Nursing confirmed the presence of 13 wandering residents in the facility, highlighting the potential risk posed by the unsecured chemicals. The Safety Data Sheets for the chemicals indicated potential health effects, such as eye irritation and respiratory tract irritation, underscoring the importance of proper storage to prevent resident exposure.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed in the Birch Unit Medication Room and the Pine Unit Medication Cart. In the Birch Unit, the temperature log for the medication refrigerator was incomplete, with missing entries on multiple dates. During an observation, the refrigerator was found to be at 50 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees Fahrenheit for storing medications such as Sanofi High-Dose Influenza Vaccinations, Insulin Flex Touch Pens, and Purified Protein Derivative (PPD). This was confirmed by a Licensed Practical Nurse (LPN) present during the observation. In the Pine Unit, an open Lispro Insulin Pen and Lantus Insulin Pen were found without an open or expiration date, and an open vial of Lispro Insulin was beyond its 28-day expiration period. The facility's policy requires medications to be labeled with a 'date opened' sticker and to adhere to manufacturer-recommended expiration dates. The LPN confirmed these findings during the observation. The facility's failure to adhere to proper storage and labeling protocols for medications was evident in these observations.
Failure in Hand Hygiene During Dishwashing
Penalty
Summary
The facility failed to ensure proper hand hygiene by dietary staff during dishwashing procedures, as observed on 5/14/24. Staff K, a Dietary Aide, was seen stacking plate warmers, bowls, and plates onto racks and rinsing food debris off the dishes with ungloved hands before sanitizing them through a high-temperature dish machine. After wiping their hands with a paper towel, Staff K did not perform hand hygiene before handling clean and sanitized dishes and utensils. This action was confirmed during an interview with Staff K at the time of observation. The facility's policy on cleaning dishes and using the dish machine, which was reviewed on the same day, specifies that the person loading dirty dishes should not handle clean dishes unless they change into a clean apron and wash their hands thoroughly before transitioning from handling dirty to clean dishes.
Failure to Follow PPE Protocols for Infection Control
Penalty
Summary
The facility failed to adhere to CDC guidelines for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for two residents. Resident #25, who was receiving intravenous medication and had a wound, was observed with an EBP sign on the door and PPE available outside the room. However, a registered nurse, Staff J, did not wear a gown while administering IV medications to the resident, which was confirmed during an interview. For Resident #212, who was on contact precautions due to a diagnosis of viral herpes, there was a lack of awareness among staff regarding the reason for these precautions. Staff B, an LPN, entered the resident's room without donning PPE while administering medications, despite a contact precaution sign being present. Interviews with Staff B, Staff G, and the Director of Nursing revealed a lack of understanding of the precautions required for Resident #212. The facility's policy on isolation precautions and CDC guidelines emphasize the need for gown and gloves during high-contact care activities, which was not followed in these instances.
Care Plan Deficiencies for Residents with PTSD, Anticoagulation Therapy, and Skin Breakdown
Penalty
Summary
The facility failed to develop, implement, and revise care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #2, diagnosed with Post Traumatic Stress Disorder (PTSD) upon admission, did not have a care plan that included focus areas or interventions related to PTSD. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed a lack of awareness regarding the resident's trauma, indicating a gap in communication and care planning. Resident #58, who was prescribed Coumadin for Atrial Fibrillation, did not have a care plan addressing anticoagulation therapy and monitoring for side effects. The facility also lacked a policy related to anticoagulation therapy, as confirmed by the Administrator. Additionally, Resident #48, who developed a new left heel Deep Tissue Injury and a blister on the right heel, had a care plan that was not updated to reflect these changes, despite the facility's policy requiring care plan revisions upon status changes. The Director of Nursing confirmed that the care plan had not been updated to include the actual skin breakdown identified.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 35 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Franconia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morrison Nursing Home | 12.1 mi | ★★★★★ | 7 | 0 |
| Grafton County Nursing Home | 16.2 mi | ★★★★★ | 8 | 0 |
| Glencliff Home For The Elderly | 17 mi | ★★★★★ | 7 | 0 |
| St. Johnsbury Health & Rehab | 19.5 mi | ★★★★★ | 11 | 0 |
| Country Village Center, Genesis Healthcare | 20.5 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.