Brandon Woods of Dartmouth

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in two of three medication carts observed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment in two of three nourishment kitchenettes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician or clinician in a timely manner when one Resident (#5) had a change in their compliance with their treatment of wearing an ordered neck collar at all times to treat a new cervical fracture, out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and implement an individualized care plan for one Resident (#5), who had documented non-compliance with an ordered cervical neck collar to treat a fracture of the 7th cervical vertebrae, out of a total of 21 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an ordered fluid intake restriction of 1500 milliliters (ml) a day was documented, monitored, and followed, for one Resident (#1) to maintain proper hydration and health, out of a total sample of 21 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had a diagnosis of Dysphagia (difficulty swallowing), and required an altered textured diet, the Facility failed to ensure that he/she remained as free from hazards as is possible, when on 03/04/26, Resident #1 was served his/her lunch time meal tray with a food item that was inconsistent with his/her diet orders, he/she consumed it, started to choke and required staff intervention to help expel the food. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of dysphagia (difficulty swallowing) and required an altered (ground) texture diet, the Facility failed to ensure meals prepared and served to him/her met his/her individual needs and physicians order for diet, when on 03/04/26 dietary staff preparing his/her lunch time meal tray did not put the correct texture of food on his/her tray, he/she tried to consume it and experienced a choking episode. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on the assistance of staff for transfers, the Facility failed to ensure his/her environment was free from potential hazards as is possible when on 09/22/25 sometime around 10:00 P., as Resident #1 was being transferred into bed with the assistance of two staff members, his/her left lower extremity scraped up against an exposed piece of metal on the bed frame joint and he/she sustained a 10-centimeter (cm) laceration to his/her left lower extremity that required 10 sutures to close.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on the assistance of staff for transfers, the Facility failed to ensure staff provided care consistent with professional standards of practice, when on 09/22/25 at 9:55 P.M., Resident #1 was transferred into bed with the assistance of two staff members, without the use of a gait belt (safety device used to assist individuals with mobility challenges during transfers) per facility policy, his/her knees buckled during the transfer, and staff had to grab Resident #1 by the waist band of his/her pants to try to prevent him/her from falling.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in condition on 8/08/25, the Facility failed to ensure the Provider was notified.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure staff implemented appropriate use of personal protective equipment (PPE) for residents placed on Isolation Precautions and ensure staff implemented appropriate use of source control PPE while on the units in the facility during a COVID-19, Influenza (FLU) and Respiratory Syncytial Virus (RSV) outbreak to help prevent the further spread of illness on three of three units observed.

Inspectors wroteBased on record review and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and failed to complete antibiotic usage audit tools (line listings), which are used to track, report and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents. Specifically, the facility failed to discard food that was past the manufacturer's expiration and use by dates in one of three kitchenettes reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its staff maintained accurate documentation for one Resident (#25), out of a total of 20 residents. Specifically, the facility failed to ensure February 2025, Medication Administration Records (MAR) accurately reflected blood sugar values and dosage of insulin administered according to physician's orders.

Inspectors wroteBased on interview and record review, the facility failed to provide the Pneumococcal immunization as requested/consented in a timely manner for one Resident (#56), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for seven Residents (#16, #38, #43, #48, #49, #52, and #84).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) whose Plan of Care related to Activities of Daily Living (ADLs) indicated interventions included that he/she required continual supervision (staff member to be with him/her during entire task) with meals, the facility failed to ensure staff consistently implemented and followed interventions, when on 12/21/24, staff assistance was not provided as required, Resident #1 was served his/her lunch tray, left alone in his/her room while eating his/her meal, he/she choked on food and required the Heimlich Maneuver. Findings Include: Review of the Facility's Policy tilted, Care Planning-Comprehensive, dated as revised May 2017, indicated the following: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had a diagnosis of Dysphagia (difficulty swallowing), required an altered textured diet and continual supervision (staff member to stay with resident during entire task) during meals, the Facility failed to ensure that he/she was provided with the necessary level of staff supervision during meals in an effort to maintain his/her safety to prevent an incident of choking. On 12/21/24, Resident #1 was served his/her lunch time meal tray in his/her room, however the staff member did not stay to provide supervision while he/she ate. Resident #1 was also served food items that were inconsistent with his/her diet orders. Resident #1 choked on the food and required the Heimlich Maneuver. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of dysphagia (difficulty swallowing) and required an altered texture diet, the Facility failed to ensure meals prepared and served to him/her met his/her individual needs and physicians orders for diet. On 12/21/24 dietary staff preparing his/her lunch time meal tray did not put the correct texture of food on his/her tray, Resident #1 was observed choking on his/her food and required the Heimlich Maneuver to dislodge the food. Findings Include: Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a mechanical lift with the assistance of two staff members for transfers, the Facility failed to ensure his/her environment was free of accident hazards, as is possible, when on 10/02/24, as nursing staff attempted to transfer Resident #1 from a chair into his/her bed with the use of a mechanical lift, after positioning him/her in the mechanical lift sling required for use with a mechanical lift, as they started to lift him/her, one of the straps (looped end of sling pad that staff manually connect to the lift) became detached from the mechanical lift causing Resident #1 to slide out of the lift sling, he/she landed on the floor on his/her left side and immediately complained of left hip and knee pain. Finding Include: [...]

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), whose Plans of Care indicated that they required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in their Plans of Care while meeting his/her care needs. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2, who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. [...]

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who required the physical assistance of two staff members with transfers and/or bed mobility, the Facility failed to ensure they were provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. 1) On 08/05/24, Certified Nurse Aide (CNA) #2 provided care to Resident #2 who was in bed, without getting assistance from another staff member, CNA #2 left Resident #2 lying on his/her right side in bed, walked to the bathroom, heard a loud bang and found Resident #2 lying on the floor beside his/her bed on his/her left side. Resident #2 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left hip which required surgical intervention to repair. [...]

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to ensure there was a Registered Nurse (RN) to serve as the Director of Nurses (DON) on a full-time basis.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right elbow, the Facility failed to ensure he/she was provided care and treatment that met professional standards for quality of care, when after a follow-up appointment, Resident #1's orthopedic Physician Assistant (PA) made recommendations on the consult form for Nursing to remove the splint and change his/her right elbow dressing daily, until healed. However, the recommendations were not followed up on or implemented by Nursing, the dressing changes were not completed and at his/her next orthopedic follow-up appointment is was discovered that Resident #1 had developed a pressure injury to his/her right elbow.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Infection Preventionist (IP) failed to attend three of the last three quarterly QAPI meetings.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff maintained an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure staff properly transported linens in two of two laundry room chutes to help prevent the spread of infection.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#44), of a total sample of 20 residents. Specifically, the facility failed to ensure an injury of unknown source was thoroughly investigated and reported to the Department of Public Health (DPH) within 24 hours as required.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#44), of a total sample of 20 residents. Specifically, the facility failed to ensure an injury of unknown source was reported to the Department of Public Health (DPH) within 24 hours as required.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#44), of a total sample of 20 residents. Specifically, the facility failed to ensure an injury of unknown source was thoroughly investigated as required.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure staff provided the necessary respiratory care and services in accordance with professional standards of practice for two Residents (#301 and #61), in a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #301, to ensure proper care and storage of the Resident's continuous positive airway pressure (CPAP) machine (uses mild air pressure to keep breathing airways open while you sleep); and 2. For Resident #61, to ensure the oxygen concentrator (a device that pulls air from the room and filters it into purified oxygen for breathing) was maintained in a clean and sanitary manner, to help decrease the risk of contamination and infection.

Inspectors wroteBased on observation, interview, and document and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to: a. ensure all medications were stored at proper temperatures to preserve their integrity in one of four medication refrigerators reviewed; and b. ensure staff labeled one packaging box and/or its multidose vial of Tuberculin (purified protein derivative, a combination of proteins that are used in the diagnosis of tuberculosis) stored inside the 1 North Unit medication refrigerator once opened.

Inspectors wroteBased on interview and record review, the facility failed to transmit timely, thorough completion of Minimum Data Set (MDS) assessments for the discharge of Resident #67 and the death of Resident #40.