Jaffrey Rehabilitation and Nursing Center

Inspectors wroteBased on interview and record review it was determined that the facility failed to implement control measures from their water management plan to prevent the growth and spread of Legionella and other water borne pathogens in a facility with a census of 72 residents. Findings Include: Review on 5/20/26 of facility's Legionella Water Management Plan revealed: Control Measures and Corrective Actions 4. Flush hot water tank sediment at least annually. 7. Remove and clean shower heads (including handheld wands) used for resident bathing. Clear strainers and pressure restrictors of sediment and potential biofilm, at least annually. Interview on 5/20/2026 at 9:28 a.m. with Staff B (Director of Maintenance) confirmed that there was no documentation the above control measures were performed. [...]

Inspectors wroteBased on Interview and record review, the facility failed to provide documentation that the resident or resident representative was informed in advance of treatment risks and benefits, options and alternatives prior to initiating psychotropic medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18. (Resident identifier is #31.)

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 or 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifier is #6 ).

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order for 1 of 2 residents reviewed for choices in a final sample of 18 residents (Resident identifier is #1).

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were maintained in a locked cart in 1 of 2 medication carts observed (Chapel Unit medication cart).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's dietary preferences were taken into consideration 1 of 2 residents reviewed for choices in a final sample of 18 residents. (Resident identifier is #12.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the facility assessment included specific staffing needs for each resident unit for a census of 72 residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight (8) consective hours a day, 7 days a week, for 2 days in Fiscal Year Quarter 1 2025.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent (%) for 2 of 28 medication administrations observed. (Resident Identifiers are #38 and #224).

Inspectors wroteBased on interview and record review it was determined that the facility failed to submit complete and accurate data for Payroll Based Journal (PBJ) for Fiscal Year Quarter 1 2025 (October 1, 2025 to December 31, 2025).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow professional standards for 1 of 1 residents reviewed for respiratory care in a final sample of 18 residents (Resident identifier is #223).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that controlled medications were maintained in separately locked, permanently affixed compartment for 1 of 1 medications rooms observed.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that resident medical records were accurate for 3 residents reviewed in a final sample of 18 residents (Resident Identifiers are #40, #123 and #274.) Findings Include: Resident #40 Review on 4/16/25 of Assessing Falls and Their Causes, Nursing Services Policy and Procedure Manual for Long Term Care, copyright 2001, provided by the facility revealed . Documentation When a resident falls the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatments administered. 4. Notification of the physician, family, as indicated. 6. [...]

Inspectors wroteResident #23 Review on 4/14/25 at approximately 2:00 p.m. of Resident #23 hospice binder revealed a hospice admission date of 7/7/24 and no schedule of visits or services to be provided. Interview on 4/15/25 at approximately 8:20 a.m. with Staff H (Licensed Practical Nurse (LPN)) revealed nursing is unaware of when or how often hospice visits are. Review on 4/15/25 at approximately 9:00 a.m. of Resident #23's hospice care plan revealed LNA [Licensed Nursing Assistant] visits per schedule. Interview on 4/16/25 at approximately 10:45 a.m. with Staff I (Licensed Nursing Assistant (LNA)) revealed there was no prediction of when visits will take place or how often. Interview on 4/16/25 at approximately 11:15 a.m. with Staff G (Social Services) revealed he/she had thought hospice was providing the units with a visits schedule. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to employ, at least on a part-time basis, an Infection Preventionist who had completed specialized training in infection prevention and control.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 2 of 3 resident reviewed for hospice in a final sample of 18 residents (Resident Identifiers are #12 and #38).

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety to prevent foodborne illness and failed to monitor the high dishwasher temperatures to ensure proper sanitization. Food Storage:

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to use Personal Protective Equipment (PPE) when handling, processing, and transporting linens to prevent the spread of infection.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the call bell system was equipped to allow residents to call for staff assistance for a census of 73 residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to offer therapeutic dietary recommendations to maintain body weight and failed to monitor parameters of nutritional status per facility protocol for 2 of 3 residents reviewed for nutrition in a final survey sample of 22 residents (Resident Identifiers #36 and #61).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to promptly notify the ordering practitioner of critical laboratory results for 1 of 1 resident reviewed for insulin in a final survey sample of 22 residents (Resident Identifier #13).