Sardis Community Nh

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a newly identified skin breakdown to the sacrum for one (1) of three (3) residents reviewed (Resident #1).

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that a resident who developed skin breakdown to the sacrum received ordered treatment services to promote healing and prevent further skin breakdown for one (1) of three (3) residents reviewed for pressure ulcers. (Resident #1).

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident was free from abuse for one (1) of five (5) residents reviewed (Resident #1), when staff engaged in abusive conduct by pulling the resident from his seated position onto the floor, verbally berating him, and spraying him with an aerosol substance. This failure resulted in actual psychosocial harm, including fear, distress, and compromised dignity. Findings Include:Cross-Reference F610Review of the facility policy titled Incident Investigation & Reporting, revised 5/24, revealed, .1. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for one (1) of five (5) residents reviewed. (Resident #1) Findings Include:Cross-Reference F600Review of the facility policy titled Incident Investigation & Reporting, revised 5/24, revealed, .6 The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse. Record review revealed an allegation of abuse involving Resident #1 was reported on 9/17/25 after staff responded to the resident screaming for help and observed the resident on the floor following an altercation with Nurse Aide #1. [...]

Inspectors wroteBased on staff and resident interviews, record reviews and facility policy review, the facility failed to develop a comprehensive care plan for a resident taking an anticoagulant (Resident #32) and failed to implement an Activities of Daily Living (ADL) care plan (Resident #257) for two (2) of 26 resident's care plans reviewed. The scope for F656 was increased to E to indicate a pattern of noncompliance due to a prior citation during the last recertification survey 7/23/24.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to ensure that assistance with Activities of Daily (ADL) was provided to a resident that required assistance with bathing for one (1) of 26 sampled residents. Resident #257 Findings Include: Review of the facility's policy titled, Activities of Daily Living with a revision date of 11/24, revealed under Policy: Activities of Daily Living will be documented on a daily basis by the CNA (Certified Nursing Assistant) to reflect actual care rendered to the resident. The ADL shall become a permanent part of the residents' chart . 2. ADLS shall include, but are not limited to .bathing . On 6/29/25 at 4:58 PM, an observation of Resident #257 revealed a foul odor. An interview with Resident #257, revealed that he had not received a bath or shower since his admission two weeks ago. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide a homelike environment for one (1) of 55 residents residing in the facility. Resident #40.

Inspectors wroteBased on observation, staff interviews, record reviews, and facility policy review, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one (1) of 18 resident MDS assessments reviewed.

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to monitor the adverse effects of an anticoagulant medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #32.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to document wound treatments for a resident with a Stage 3 pressure ulcer for one (1) of three (3) residents with wounds reviewed.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to prevent the potential spread of infection by not ensuring staff performed proper hand hygiene during three (3) of nine (9) direct care observations. Specifically, staff failed to perform hand hygiene before and after medication administration and during wound care procedures, which poses a risk of cross-contamination and infection transmission.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medicare and Medicaid Services (CMS) for a resident who transferred to an acute care facility for one (1) of 16 MDS's reviewed. Resident # 38. Findings Include: Review of the facility policy titled MDS Process with a revision date of 12/20 revealed, The RAI (Resident Assessment Instrument) is the source document to be used for further MDS coding guidelines, time schedules and requirements. Record review of the Progress Notes revealed Resident #38's was transferred to a behavioral health center on 6/25/24 and returned to the facility on 7/9/24. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for nail and oral care (Resident #31) and failed to develop an individualized resident specific comprehensive care plan that identified potential fears, triggers, and/or behavioral expressions along with interventions for a resident with Post Traumatic Stress Disorder (PTSD) (Resident #37) for two (2) of 16 care plans reviewed. Findings Include: [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to provide Activities of Daily Living as evidenced by failure to provide daily oral care and nail care for one (1) of 16 residents reviewed. (Resident #31) Findings Included: Record review of the facility policy, Oral Hygiene with revision date of 10/17 revealed Purpose: To clean the mouth, teeth, gums .To remove bacteria and odor . Procedure .1. Offer oral hygiene before breakfast, and at bedtime . Record review of the facility policy, Nail Care with review date of 01/24 revealed Purpose: To promote cleanliness, safety and a neat appearance . Procedure .7. Remove any debris from under the nails with the orangewood stick . On 07/22/24 at 10:00 AM, an observation of Resident #31 revealed he was lying in bed, alert with his mouth open and a yellow substance covering all of his teeth. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to complete a Trauma Informed Care Assessment for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 1 resident reviewed for Trauma Informed Care. Resident #37 Findings Include: Review of the facility policy titled Social Documentation - Progress Notes with a revision date of 10/23 revealed under, Policy: Social Progress Notes should be entered into the resident's Medical Record during the observation period of each MDS (Minimum Data Set) and whenever unusual circumstances occur, or for changes in resident condition or status. An observation and interview with Resident #37 on 7/22/2024 at 12:35 PM, revealed she was sitting in a wheelchair in her room. Resident was verbal with few words and stated, I'm fine. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to notify the physician of the failure to obtain a medication for one (1) of 16 medications reviewed. Resident #18.

Inspectors wroteBased on observation, resident and family interview, staff interview, record review, and facility policy review the facility failed to ensure residents were free from restraints for one (1) of 59 residents reviewed. Resident #42 Findings Include: Record Review of the facility policy titled, Restraints and Safety Devices, with a revision date of 10/22, revealed, It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints . An observation on 6/6/23 at 9:15 AM, revealed Resident #42 was in the bed laying on a winged mattress with full siderails in the upright position on both sides of the bed. During an interview with Resident #42 on 6/6/23 at 9:16 AM, she shook her head no when asked if she knew why she was on the winged mattress and had full siderails up on either side of the bed. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to assure that services were being provided according to accepted standards of clinical practice as evidenced by Clopidogrel (Plavix) signed off as administered on the medication record for Resident #18 by staff on four (4) consecutive days when the medication had not been dispensed by a pharmacy for one (1) of 16 medications reviewed.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to meet the pharmaceutical needs of a resident when staff failed to obtain and provide the medication Clopidogrel for Resident #18 for one (1) of 16 medications reviewed.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to establish and maintain an infection prevention and control program designed to help prevent transmission of communicable diseases and infections as evidenced by failure to administer a second step Tuberculin (TB) skin test to employees prior to working in the facility for one (1) of 10 employees reviewed.