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Lafayette Center

93 Main Street, Franconia, NH 03580 · For profit - Limited Liability company · 72 certified beds · (603) 823-5502 Medicare & Medicaid certified

Call the home — (603) 823-5502 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Special Focus candidate (CMS is watching this home)Abuse/neglect citation on record (F0600) — cited Aug 2024Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$50,164 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $50,164 in federal fines (most recent 2025-05-27)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 18% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
155 Main St · (603) 823-7078 · Call to confirm hours
Pharmacy
262 Cottage St · (603) 444-0094 · Call to confirm hours
Grocery
347 Main St · (603) 823-2064 · Call to confirm hours
Park
Franconia, NH, 278 Main St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased36.1%22.7%15.4%worse
Long-stay residents who lose too much weight8.5%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder2.9%1.1%0.9%worse
Long-stay residents with a urinary tract infection0.4%2.1%2.0%better
Long-stay residents with depressive symptoms77.5%13.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury6.2%4.4%3.3%worse
Long-stay residents whose ability to walk worsened28.1%17.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.6%19.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.4%98.0%95.3%typical
Long-stay residents with pressure ulcers8.0%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control24.2%25.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.4%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine81.5%83.0%79.4%typical
Short-stay residents rehospitalized after admission19.0%22.2%22.6%better
Short-stay residents with an outpatient ER visit25.2%13.4%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.261.641.67better
Long-stay outpatient ER visits per 1,000 resident days2.121.871.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

51.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.6%U.S. median 51.5%
Got home and stayed home
8.3%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 57.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 65% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.6%CMS range 43.1–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.3%CMS range 5.7–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge28.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay5.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 4.8–14.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.69
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.71
RN hoursweekends
54.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 72 beds and averages 61.4 residents a day — about 85% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 3.71 on weekdays — 13% thinner on weekends. RN hours go from 0.68 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-05-27)
6
at the previous standard inspection (2024-05-15)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-05-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to provide care consistent with professional standards of practice to promote healing for 1 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. The lack of treatment orders over a six day period resulted in a small open area that worsened into an Unstageable pressure area. (Resident identifiers is #158). Findings include: Review on 5/23/25 of Resident #158's admission Minimum Data Set with an Assessment Reference Date of 3/3/25 revealed that Resident #158 admitted to the facility on 2/2025 and under Section M - Skin Conditions was coded in item M0210 Unhealed Pressure Ulcers/Injuries as No (indicating that the Resident had no pressure ulcers during the 7 look-back period of 2/25/25 through 3/3/25). Right Buttock Review on 5/23/25 of Resident #158's Weekly Skin Review, dated 3/11/25, revealed that the Resident's skin was intact. This was completed by Staff H (Unit Manager). Review on 5/23/25 of Resident #158's Nursing Note, dated 3/18/25, revealed, Small open area…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-27 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 2 of 2 residents observed for wound care and failed to develop a water management program to minimize the risk of Legionella that had the potential to effect the facility census of 56 residents who resided at the facility. (Resident Identifiers are #32 and #158). Findings include: Resident #32 Observation on 5/23/25 at approximately 12:00 p.m. with Staff G (Infection Preventionist/ Wound Care Nurse) and Staff D (Advanced Practice Registered Nurse) performing wound care for Resident #32 revealed the following: Staff G gathered their supplies outside of the room and placed them on a clip board without cleaning the clipboard or placing a clean field barrier. There was a sign indicating the resident needed EBP (Enhanced Barrier Precautions) hanging on the outside of Resident #32's door. Staff G entered Resident #32's room. Staff G did not don an isolation gown. Staff G removed Resident #32's dirty coccyx wound dressing. Resident #158 Observation on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-27 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale of the resident group grievance for the attendees of the Resident Council Meeting for 3 of 3 months of meeting minutes reviewed. Findings include: Interview on 5/22/25 at approximately 10:00 a.m. during Resident Council Meeting revealed that the complaints about LNA's (Licensed Nursing Assistance) discussing other residents and being loud is an on going issue. All 9 residents at this meeting stated they do not feel this concern was addressed and that no one had followed up to inform them of what if any actions had been taken since the initiation of the concerns. Review on 5/22/25 of the facility's Resident Council Meeting minutes revealed the following documented concerns under Nursing: February 11, 2025 minutes: LNA's talking about residents in front of other residents; March 25, 2025 minutes: LNA's talking about residents in front of other residents. Has gotten better; April…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to develop and update comprehensive care plans for 2 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. (Resident identifiers are #32 and #158). Findings include: Resident #32 Review on 5/22/25 of Resident #32's medical record revealed a provider note dated 5/19/25 written by Staff D (Advanced Practice Registered Nurse) that stated; Previously closed sacral ulcer now has one open area, mid-line, continue with medihoney and silicone border dressings to open area. Review on 5/22/25 of Resident #32's MAR (Medication Administration Record) revealed a physician's order with a start date of 4/21/25 to Cleanse sites on inner left and right buttock. Apply Medi honey and cover with silicone dressing. Change 3x [three times a] week in the morning every Mon, Wed, Fri [Monday, Wednesday, and Friday]. Interview on 5/23/25 at approximately 8:30 a.m. with Staff H (Unit Manager) confirmed that there were no new orders addressing the 5/19/25 wound note that identified the new…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 of 3 residents reviewed for choices in a final sample of 16 residents (Resident Identifier is #21). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME] A., and [NAME].…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-27 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services for 1 of 1 resident reviewed for communication in a final sample of 16 residents (Resident Identifier is #42). Findings include: Interview on 5/22/25 at 10:40 a.m. with Resident #42 revealed that he/she had requested to be seen by the audiologist. Resident #42 stated that he/she felt that his/her hearing was getting worse, and he/she was concerned. Review on 5/23/25 of Resident #42's medical record revealed that Resident #42 was admitted to the facility in 2023 and diagnosed with abnormal auditory perceptions in the left ear in 9/2024. Review on 5/23/25 of Resident #42's ambulatory clinic notes for a hearing evaluation dated 5/23/24 revealed that Resident #42 was a good candidate for bilateral hearing aides. Interview on 5/23/25 at approximately 1:00 p.m. with Resident #42's Durable Power of Attorney (DPOA) revealed that Resident #42 had difficulty communicating with family both in person and on the telephone. Interview on 5/23/25 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-27 · tag F0778 — isolated
    Help the resident make transportation arrangements to and from radiology services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined the facility failed to provide the necessary assistance in making transportation arrangements for a scheduled x-ray which resulted in a missed appointments for 1 of 1 resident reviewed for transportation assistance in a final sample of 16 residents. (Resident Identifier is #13.) Findings include: Review on 5/21/25 of Resident #13's medical record revealed that he/she was admitted to the facility on 12/2024. Interview on 5/21/25 at 10:42 a.m. with Resident #13 revealed that he/she was upset because they were supposed to have an x-ray of their knee at the orthopaedic clinic, but was told by Staff F (Medical Records/Central Supply coordinator), who sets up the transportation, that they did not know anything about an appointment and transportation had not been set up. Interview on 5/22/25 at 2:28 p.m. with Staff L (Certified Occupational Therapy Assistant) confirmed that they had seen paperwork at the nurses station for Resident #13 regarding an appointment for an x-ray of the knee on 5/21/25 and that they had reached out to Staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined that the facility failed to ensure that a resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident Identifier #5). Findings include: Review on 8/7/24 of Resident #5's medical record revealed the following diagnosises: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Further review of the medical record that Resident #5 has a Brief Interview for Mental Status (BIMS) of 3. Review on 8/7/24 of a facility reported incident, dated 5/9/24, revealed that on 5/5/24, Resident #2 was observed by a staff member with his/her hand down the pants of Resident #5. Interview on 8/7/24 with Staff A (Activities Director) revealed on 5/5/24, Staff A observed Resident #2 with his/her hand down the pants of Resident #5. Further interview revealed that Staff A was aware of multiple incidents of Resident #2 being sexually inappropriate with residents who have cognitive issues. Interview on 8/7/24 at approximately 11:50 a.m. with Staff H (Licensed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported immediately to the State Survey Agency (SSA) for 3 of 4 allegations of abuse reviewed (Resident Identifiers are #1, #2 and #3). Findings include: Review on 8/7/24 of the facility policy titled, Abuse, Neglect and Exploitation, revised on 01/2024, revealed: .VII Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Resident #2 Review on 8/7/24 of a facility reported incident, reported to the State Agency on 7/28/24 at 6:02 a.m., revealed that Resident #2 was observed by Staff H…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to revise care plans for 2 of 3 residents reviewed for abuse (Resident Identifiers are #1 and #3). Findings include: Resident #1 Review on 8/7/24 of a facility reported incident revealed that Resident #1 was observed by Staff B (Licensed Nursing Assistant) with his/her hand placed on the genital area of Resident #6 on 7/28/24 at 4:40 p.m. Review on 8/7/24 of Resident #1's medical record revealed a provider progress note, dated 7/30/24, that stated Resident #1 had been seen for increased sexual behaviors towards others and also indicated staff reported increased wandering behaviors with difficulty to redirect. Review on 8/7/24 of Resident #1's care plan revealed a care plan for the potential to demonstrate verbal/physical behaviors towards others related to ineffective coping skills, created on 7/1/24 and revised on 7/15/24. Resident #1's behavior care plan revealed the following interventions: Evaluate need/provide for Psych/Behavioral Health consultation, created on 7/15/24. Further…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-16 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined that the facility failed to ensure that residents who are trauma survivors were free from re-traumatization for 1 of 1 residents reviewed for trauma (Resident Identifier #4). Findings include: Review on 8/7/24 of a facility reported incident revealed Resident #4 yelled out for help. Staff observed Resident #3 exiting Resident #4's room. Resident #4 was found lying on the floor with a hematoma to the top right side of his/her head, a skin tear to the right elbow and complaints of rib pain. Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that Resident #4 had told Staff G that he/she had a past history of trauma. Staff G further revealed that Resident #4's daughter had revealed to Staff G that Resident #4 had a past history of trauma. Interview on 8/7/24 at approximately 1:15 p.m. with Resident #4 revealed that he/she remembered Resident #3 coming to his/her room and hitting him/her. Resident #4 stated that he/she had a traumatic past and was upset with Resident #3 trying to get…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-08-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined that the facility failed to ensure an accurately documented medical record for 1 of 4 allegations of abuse (Resident Identifier is #1). Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (Licensed Nursing Assistant) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted] [genital area]. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 9:00 a.m. with Staff M revealed that he/she was the nurse on duty when the above incident occurred. Staff M also revealed that he/she wrote a nurse's note, on 8/13/24, giving an accurate account of the above incident. Staff M further revealed that their nurse's note detailing the incident had been struck out, not by Staff M. Staff M was told by Staff F (Director of Nursing) that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interviews, it was determined that the facility failed to provide appropriate care and services to aide in the prevention of an avoidable pressure ulcer for 1 of 1 residents reviewed for pressure ulcers in a final survey sample of 19 residents (Resident Identifier is #48). Findings include: Review on 5/15/24 of the facility policy Pressure Injury Prevention and Management, dated 07/2021 and Reviewed and Revised 10/2022 and 10/2023 revealed: .4. Interventions for Prevention and to Promote Healing .a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .i. Redistribute pressure (such as repositioning, protecting and/ or offloading heels, etc.) Review on 5/13/24 of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 2 of 3 units observed (Birch Unit & Spruce Unit). Findings include: Observations on 5/13/24 at 1:15 p.m; 5/14/24 at 8:30 a.m and 9:30 a.m; and 5/15/24 at 7:40 a.m. of the Birch Unit Tub Room revealed that the door was open with a bottle of Rapid Multi Disinfectant Spray chemical cleaning solution hanging on the wall within reach of wandering residents. Interview on 5/15/24 at 7:40 a.m. with Staff F (Licensed Practical Nurse) confirmed the above finding. Observation on 5/15/24 at 7:30 a.m. of the Spruce Unit Tub Room revealed that the door was open with a container of Super Sani-Cloth Germicidal wipes on top of a portable cart within reach of wandering residents. Interview on 5/15/24 at 7:30 a.m. with Staff I (Licensed Nursing Assistant) confirmed the above finding. Interview on 5/15/24 with Staff D (Director of Nursing) further confirmed the findings and revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored under proper temperature controls in 1 of 1 medication room observed and failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 2 medication carts observed. Findings include: Birch Unit Medication Room: Review on 5/13/24 at approximately 9:30 a.m. of the Birch Unit Temperature Log for Medication/Vaccine Refrigerators, revealed missing temperatures on the following dates: 3/23/24, 3/24/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/24/24, 4/25/24, 4/29/24, 4/30/24, 5/1/24, 5/2/24, 5/3/24, 5/4/24, and 5/5/24. Observation on 5/13/24 at approximately 9:30 a.m. with Staff F (Licensed Practical Nurse) of the Birch Unit Medication Room revealed the refrigerator temperature was 50 degrees Fahrenheit (F), and contained 3 boxes of Sanofi High-Dose Influenza Vaccinations, 9 unopened Insulin Flex Touch Pens (2 Novolog,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-15 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, it was determined that the facility failed to ensure that dietary staff washed their hands before handling clean and sanitized utensils during dishwashing procedures. Findings include: Standard: Review on 5/14/24 of the FDA 2017 Food Code, retrieved from: (https://www.fda.gov/media/110822/download), revealed .2-3 PERSONAL CLEANLINESS .2-301.11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: .(E) After handling soiled EQUIPMENT or UTENSILS; . Observation on 5/14/24 at approximately 8:45 a.m. in the kitchen dishwashing area revealed that Staff K (Dietary Aide) was stacking plate warmers, bowls and plates onto racks, then rinsing the food debris off the plates and bowls with ungloved hands…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 2 of 7 residents reviewed for infection control (Resident Identifiers are #25 and #212). Findings Include: Resident #25 Review on 5/14/24 of Resident #25's medical record revealed they received medication Intravenously (IV) and had a wound. Observation on 5/14/24 at approximately 8:30 a.m. of Resident #25 revealed an EBP sign on the door and PPE available outside of the resident's room. Further observation of Staff J (Registered Nurse) revealed while administering IV medications, they did not don a gown. Interview on 5/14/24 at approximately 8:30 a.m. with Staff J confirmed the above finding. Resident # 212 Observation on 5/13/24 at approximately 1:49 p.m. of Resident #212's room revealed a contact precautions sign on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-20 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 5 of 21 residents reviewed for care plans (Resident Identifiers are #24, #27, #31, #47 and #49). Findings include: Resident #49 Interview on 3/15/23 at 11:48 a.m. with Resident #49 revealed that Resident #49 does have pain and takes pain medication as needed. Review on 3/17/23 of Resident #49 March Medication Administration Record revealed that Resident #49 received Acetaminophen 650 milligrams (mg) for pain on 3/2/23, 3/13/23, 3/14/23 and 3/17/23. Further review revealed that Acetaminophen with Codeine 300-30mg was administered on 3/3/23, 3/4/23, 3/5/23, 3/9/23 and 3/16/23. The resident's pain levels were documented between a 3 and 8 (out of 10 pain scale). Review on 3/20/23 of Resident #49's admission Minimum Data Set (MDS) with an assessment reference date of 3/5/23 revealed that the resident admitted to the facility on [DATE]. Further review under Section J…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-20 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, it was determined that the facility failed to follow professional standards for labeling and storage of food items brought to residents by visitors to the facility for 2 of 2 kitchenettes reviewed. Findings include: Birch Kitchenette: Observation on 3/15/23 at 10:25 a.m. of the refrigerator revealed the following: One (1) container of strawberries with no resident name or received date; One (1) container of chocolate dip with a best by date of 10/3/22 with no resident name or received date; One (1) bottle of prune juice with no resident name or received date; Interview on 3/15/23 at 10:30 a.m. with Staff G (Unit Manager) confirmed the above. Country/Spruce Kitchenette: Observation on 3/15/23 at 10:45 a.m. of the refrigerator revealed the following: One (1) jar of maraschino cherries with no resident name or received by date; One (1) bottle of fat free balsamic vinaigrette with no resident name; One (1) bottle of Thousand Island dressing with no resident name; One (1) plastic bag filled with raisin bread with a use by date of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, it was determined that the facility failed to fully assess a resident's complaint of left leg pain after falling for 1 of 2 residents reviewed for falls (Resident identifier is #51) and failed to obtain physician's orders for wound care for 1 of 1 resident reviewed for skin conditions (Resident Identifier is #44) in a final sample of 21 residents. Findings include: Resident #51 Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20: When a Fall Occurs Step one: assessment. When a patient falls, don't assume that no injury has occurred - this can be a devastating mistake. Before moving the patient .Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. From Merck Manual Consumer Version, Hip Fractures by [NAME], MD, University of San Francisco - Fresno last modified [DATE].…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure that pain management was provided to a resident who requested pain medication based on physician's orders for 1 of 2 residents reviewed for pain management in a final sample size of 21 residents (Resident Identifier #49). Findings include: Interview on 3/15/23 at 11:48 a.m. with Resident #49 revealed that he/she had not received his/her Tylenol with Codeine for a few days when they had asked for it earlier in the week. Resident #49 stated that the facility had run out of his/her medication. Resident #49 stated he/she used Tylenol with Codeine on an as needed basis. Review on 3/17/23 of Resident #49's Tylenol with Codeine Narcotic Sheet revealed that on 3/11/23 at 8:00 p.m. the narcotic count for the medication was at 0. Further review revealed on 3/15/23 at 7:45 a.m. 60 tablets were added to the narcotic count. Observation and interview on 3/17/23 at 3:30 p.m. with Staff O (Licensed Practical Nurse (LPN)) of the facility's emergency medication kit revealed that it did not contain Tylenol with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, except if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days he/she would document their rational and indicate the duration for the PRN order, for 2 of 5 residents reviewed for psychotropic medication side effects in a final sample of 21 residents (Resident Identifiers are #27 and #47). Findings include: Resident #47 Review on 3/17/23 of Resident #47's active physician's order revealed an order for Olanzapine [antipsychotic] 5 milligram [mg], give 1 tablet every 6 hours as needed for agitation with a start date of 9/29/22, no duration or end date. Interview on 3/17/23 at approximately 2:40 p.m. with Staff L (Licensed Practical Nurse) confirmed the above findings. Review on 3/20/23 of Resident #47's provider notes and psychiatry consult notes revealed no documentation of duration or end date of the PRN Olanzapine 5 mg order and no documentation of rationale for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review it was determined that the facility failed to label, date, and store food in accordance to professional standards, maintain a sanitary environment, and ensure that the ice machine was properly cleaned for food service safety in 2 out of 2 kitchenettes (Birch and Country/Spruce) observed. Findings include: Birch Kitchenette: Observation on 3/15/23 at 10:20 a.m. revealed that the floor was sticky, had crumbs, and built up dirt in the corners by the base of the cabinets. Observation on 3/15/23 at 10:21 a.m. revealed a counter top ice machine with what appeared to be white water stains down the front and dripping water from a white plastic straw into a collection tray filled with murky, stagnant water to the top of the collection tray. Observation further revealed a pink stained substance collecting around the base of the white straw on the ice dispenser. Observation on 3/15/23 at 10:22 a.m. revealed a purple sticky substance on the bottom shelf of a kitchen cabinet containing condiments. Observation on 3/15/23 at 10:25 a.m. of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined the facility failed to notify resident representatives and families of those residing in the facility by 5:00 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection for 4 out of 9 days reviewed from 2/7/23 to 2/25/23 when there were newly identified positive COVID-19 antigen tests. Findings include: Review on 3/16/23 of the facility's COVID-19 line list revealed that the facility had positive COVID-19 antigen test results on the following dates: 2/7/23 (1 resident); 2/8/23 (1 staff); 2/9/23 (1 resident); 2/11/23 (1 resident, 2 staff); 2/12/23 (2 residents); 2/15/23 (2 residents); 2/18/23 (1 resident, 2 staff); 2/20/23 (10 residents, 1 staff); 2/23/23 (1 staff). Interview on 3/16/23 at approximately 11:00 a.m. with Staff B (Director of Nursing) revealed that Staff C (Administrator) was the staff responsible for notifying residents, representatives, and families of confirmed or suspected COVID-19 cases in the facility. Staff B stated that email was the primary mechanism used to inform…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that the residents' call system was functioning as designed or to provide residents with an alternate method to call for staff assistance for 1 resident in a facility census of 59 residents (Resident Identifier is #25). Findings include: Interview on [DATE] at 11:00 a.m. with Resident #25 revealed that the call system in the resident's bathroom was not working since [DATE]. Resident #25 stated he/she told staff but it hasn't been fixed yet. Observation on [DATE] at 11:10 a.m. revealed Resident #25's call system was not sounding at the nurse's station nor was the light blinking above the resident's door to alert staff. Interview on [DATE] with Staff G (Unit Manager) revealed that Staff G was not aware Resident #25's bathroom call system was not working. Interview on [DATE] at 9:31 a.m. with Resident #25 revealed that the call system was still not working. Interview on [DATE] at 9:32 a.m. with Staff H (Licensed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-05-15 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to develop, implement, and revise a care plan for 3 residents in a final survey sample of 19 residents (Resident Identifiers are #2, #48, and #58). Findings Include: Resident #2 Review on 5/13/24 of Resident #2's medical record revealed a diagnosis of Post Traumatic Stress Disorder (PTSD), upon admission on [DATE]. Review on 5/14/24 of Resident #2's care plan revealed no focus area or interventions related to PTSD. Interview on 5/14/24 at approximately 2:00 p.m. with Staff L (Licensed Practical Nurse) revealed they did not know the basis of Resident #2's trauma. Interview on 5/15/24 at approximately 9:55 a.m. with Staff D (Director of Nursing) confirmed the above finding. Staff D also did not know the basis of Resident #2's trauma. Resident #58 Review on 5/15/24 of Resident #58's medical record revealed an order for Coumadin for Atrial Fibrillation, since admission on [DATE]. Review on 5/15/24 of Resident #58's care plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-20 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform residents, both orally and in writing, of their rights and responsibilities of all the rules and regulations prior to, or upon admission, for 2 of 2 newly admitted residents reviewed (Resident Identifiers are #49 and #158). Findings include: Resident #49 Review on 3/15/23 of Resident #49's Minimum Data Set (MDS) with an assessment reference date of 3/5/23 revealed that Resident #49 admitted to the facility on [DATE]. Further review revealed that Resident #49's Brief Interview for Mental Status (BIMS) score was 15, meaning cognitively intact. Interview on 3/15/23 at 2:27 p.m. with Resident #49 revealed that he/she did not get any paperwork from the facility including resident rights or any paperwork regarding the facility's rules and regulations. Resident #158 Review on 3/15/23 of Resident #158's medical record revealed that Resident #158 admitted to the facility on [DATE]. Interview on 3/15/23 at 2:30 p.m. with Resident #158…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-20 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined that the facility failed to provide written notice of a transfer or discharge for 2 of 2 residents reviewed for hospitalization in a final survey sample of 21 residents (Resident Identifiers are #17 and #31). Findings include: Resident #17 Review on 3/20/23 of Resident #17's progress notes dated 3/12/23 revealed that Resident #17 was sent to the hospital and returned to the facility on 3/17/23 status post Cerebrovascular Accident. Interview on 3/20/23 at approximately 11:50 a.m. with Staff C (Administrator) revealed that the facility did not notify Resident #17, or their representative, of the written notice of transfer upon Resident #17's transfer to the hospital, and that the facility does not issue notices of transfer or discharge to residents when they are sent to the hospital. Resident #31 Review on 3/20/23 of Resident #31's progress notes dated 2/22/23 revealed that Resident #31 was sent to the hospital and returned to the facility on 2/25/23 status post Gastric Abscess. Interview on 3/20/23 at approximately 11:50 a.m.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-20 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that the facility failed to notify the resident, or the resident's representative, of the bed hold policy upon transfer to the hospital for 2 residents in a final survey sample of 21 residents (Resident Identifiers are #17 and #31). Findings include: Resident #17 Review on 3/20/23 of Resident #17's progress notes dated 3/12/23 revealed that Resident #17 was sent to the hospital on 3/12/23 and returned to the facility on 3/17/23 status post Cerebrovascular Accident. Interview on 3/20/23 at approximately 11:50 a.m. with Staff C (Administrator) revealed that the facility did not notify Resident #17, or their representative, of the facility's bed hold policy after Resident #17's transferred to the hospital, and that the facility does not notify residents, or resident representatives, of the facility's bed hold policy when residents are transferred to the hospital. Resident #31 Review on 3/20/23 of Resident #31's progress notes, dated 2/22/23, revealed that Resident #31 was sent to the hospital on 2/22/23 and returned to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$50,164 in federal fines across 1 penalty.

  • $50,164 — penalty dated 2025-05-27

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
AN MAGNOLIA OPCO, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST11%since 01/21/2022
EICHLER, ABRAHAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER40%since 01/21/2022
EISEN, MENASHEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST14%since 01/21/2022
KLEIN, YEHUDISIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 01/21/2022
PERLSTEIN, BARRYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 01/21/2022
PERIGROVE 1014 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/21/2022
DJALAYER, KASRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2021
MCCRACKEN, KATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2025
BERRY DUNN MCNEIL & PARKER LLCOrganizationADP OF THE SNFsince 07/01/2021
MAGNOLIA CARE CENTERS, LLCOrganizationADP OF THE SNFsince 07/01/2021

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.3M
Net patient revenuemost recent cost report
+0.3%
Operating marginrevenue minus expenses
$1.5M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 12%Other / private 22%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$367per resident / day
operating cost
$11,146per month
≈ monthly operating cost
$368per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Hampshire Medicaid page.

Typical monthly cost in New Hampshire
$12,243/mo
Nursing home (semi-private)
$13,444/mo
Nursing home (private)
$8,025/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 305077. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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