Penacook Place, Inc

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure staff consistently implemented and followed their abuse policy related to protection and reporting abuse allegations, when on 12/13/25 Certified Nurse Aide (CNA) #2 witnessed, but did not immediately report, that Resident #1 was allegedly verbally abused by a staff member, and waited until 12/16/25 (three days later) to report the incident, therefore placing Resident #1 and other residents on the unit at risk for potential abuse.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure staff consistently implemented and followed policies and procedures to immediately report an altercation of abuse to Administrative staff as required, so the Facility could report the incident to the State Survey Agency, within the required time frames. On 12/13/25 although a staff member witnessed Certified Nurse Aide (CNA) #1 engage in a suspected verbally abusive altercation with Resident #1, it was not reported to Administration until 12/16/25, and therefore not reported to their State Survey Agency, until three days later.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 03/18/25 he/she was administered the incorrect dose of long acting insulin. Resident #1 experienced an adverse reaction, including lethargy and malaise, for which he/she required treatment and increased monitoring by nursing until his/her blood sugar level stabilized.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow the plan of care for one Resident (#100) by not following a doctor's order to offload heels, out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to provide supervision with meals for one Resident (#37) out of a total sample of 24 residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that one Resident (#57), out of 24 total sampled residents, received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to obtain weekly wound measurements and failed to obtain recommendations for wound treatments from a follow-up physician appointment for Resident #57.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to ensure oxygen administration was in accordance with the medical plan of care for one Resident (#5) out of a total sample of 24 residents.

Inspectors wroteBased on record reviews, policy reviews and interviews, the facility failed to provide care and services consistent with professional standards for two Residents (#103 and #57) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) out of a total sample of 24 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident's #103 and #57 in case of an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).

Inspectors wroteBased on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 11/20/23, Certified Nurse Aide (CNA) #1 used a plastic bag to secure one of the wheels of Resident #1's wheelchair to restrict his/her movement and limit his/her ability to self propel the wheelchair on his/her own.

Inspectors wroteBased on observations, record reviews, policy reviews and interviews the facility failed to 1) provide a dignified dining experience for the residents on the Dementia Care Specialty Unity (DSCU) and 2a) failed to provide a dignified experience for 1 Resident (#188) by not providing a privacy bag for a foley catheter and 2b) For Resident #188 leaving him/her without a top sheet or blanket, leaving genitals exposed, out of a total sample of 35 residents.

Inspectors wrote3. Resident #239 was admitted in 03/2023 with diagnoses including localized edema. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #239 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's orders indicated that an order was initiated on 3/10/23 for ace wrap to left lower extremity daily prior to getting out of bed. Review of the behavior tracking documentation does not indicate that Resident #239 has any behaviors. During an observation on 3/15/23 at 7:54 A.M., Resident #239 was not wearing ACE wraps on his/her left lower extremity. During an observation on 3/17/23 at 11:26 A.M., Resident #239 was out of bed and not wearing ACE wraps on his/her left lower extremity. During an interview on 3/17/23 at 11:26 A.M., Resident #239 said that he/she has not had any ACE wraps on since admission. [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk foodborne illness and contamination.

Inspectors wroteBased on observation and interviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) to prevent the spread of infection on 2 out of 4 units.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 5 of 5 Certified Nursing Assistants reviewed, received 12 hours of mandatory in-service training in a year. During review of 5 of the facility's CNA education records on 3/17/23 at 1:30 P.M., there was no evidence that the CNA's received the 12 hours of required annual in-service education training. During an interview on 3/17/23 at 2:46 P.M., the Administrator said the facility did a poor job providing training last year and most of it had not been completed.

Inspectors wroteBased on record review and interview, the facility failed to obtain an informed consent for the use of psychotropic medication for 3 Residents (#12, #96 and #88) out of a total sample of 35 residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to report a potential incident of abuse for 1 Resident (discharged Resident #1) out of 35 sampled residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with meals for 2 Residents (#41 and #51) out of a total sample of 35 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure an air mattress was on the correct setting for 2 Residents (#51 and #24) who were at high risk of pressure ulcers, out of a total sample of 35 residents.

Inspectors wroteBased on record reviews, policy review and interviews, the facility failed to prevent a fall for 1 Resident (#68) out of a total sample of 35 residents.

Inspectors wroteBased on observations, record reviews, policy review and interviews, the facility 1) failed to address a significant weight loss for 1 Resident (#74) and 2) failed to implement nutritional interventions for 2 Residents (#96 and #51), out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow professional standards in changing tube feeding administration sets every 24 hours for 1 Resident (#188) out of a total sample of 35 residents. Review of facility policy titled, Enteral Tube Feeding-NG tube, G-tube, J-tube or other updated date April 2018 included: -Cover, label with initials and date, and refrigerate remaining formula. Use within 24 hours. -Change administration sets and administration supplies every 24 hours. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS) dated , 3/14/23, indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1). follow physicians' orders for oxygen use for one Resident (#188) and 2). failed to obtain a physician order for oxygen for one Resident (#24) out of a total of 35 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to develop a dementia care plan with measurable goals and interventions to address the care and treatment for a resident with dementia for 1 Resident (#88) out of a total sample of 35 residents. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set Assessment, dated 12/29/22, indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated: -A Health status note dated 3/9/23, indicated Resident #88 had exhibited increased behaviors, including yelling/screaming and using foul language. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide rehab services in a timely manner for 1 Resident (#114) out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document application of oxygen in the Treatment Administration Record (TAR) for 1 Resident (#188) out of a total sample of 35 residents. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required abdominal feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set assessment for 1 Resident (#137) out of a total sample of 35 residents.