KEENE CENTER, GENESIS HEALTHCARE
For profit - Corporation
106 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
50/100
#53 of 73 in NH
Photo by Keene Center
Photo by Keene Center
Photo by Keene Center
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Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Keene Center, Genesis Healthcare, has received a Trust Grade of C, meaning it is average compared to other facilities, but not particularly strong. It ranks #53 out of 73 in New Hampshire, placing it in the bottom half of state facilities, and #6 out of 7 in Cheshire County, indicating limited local competition. The facility is showing signs of improvement, having decreased from three issues in 2024 to two in 2025. Staffing is a mixed bag; while the turnover rate of 47% is slightly better than the state average, the facility has been reported as short-staffed, leading to residents experiencing long wait times for assistance and meals. On a positive note, there have been no fines reported, which suggests compliance with regulations, although there have been concerning incidents, including delayed meal service and reports from residents about insufficient staff leading to unmet personal care needs.
- Trust Score
- C
- In New Hampshire
- #53/73
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Hampshire facilities.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for New Hampshire. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 28%
No red flags
3 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below New Hampshire average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 47%
Near New Hampshire avg (46%)
Higher turnover may affect care consistency
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
Apr 2025
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 2 of 6 residents reviewed...
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Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 2 of 6 residents reviewed for EBP. (Residents identifier are #71 and #135.)
Findings include:
Resident #71
Observation on 4/6/25 at approximately 10:30 a.m. in Resident #71's room revealed that Resident #71 had a catheter drainage bag hanging on his/her wheelchair.
Observation on 4/8/25 at approximately 9:10 a.m. in Resident #71's room revealed that Staff D (Licensed Nursing Assistant (LNA)) was adjusting Resident #71's bed linens without wearing a gown and gloves. After adjusting the linens, Staff D donned gloves and assisted Resident #71 to the bathroom. Further observation revealed a cart containing Personal Protective Equipment. Observation also revealed a sign beside Resident #71's door indicating the use of EBP (wear gown and gloves prior to activities such as dressing, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting).
Interview on 4/8/25 at approximately 9:10 a.m. with Staff D confirmed the above finding.
Review on 4/8/25 of Resident #71's care plan revealed that Resident #71 has an indwelling Foley catheter. Further review of the care plan revealed that were no care plan interventions for EBP.
Interview on 4/8/25 at approximately 1:25 p.m. with Staff B (Director of Nursing) confirmed the above finding.
Resident #135
Review on 4/8/25 of Resident #135's profile in the medical record revealed that Resident #135 was on EBP.
Observation on 4/8/25 at approximately 10:30 a.m. in Resident #135's room revealed that Staff F (LNA) was with Resident #135 wearing gloves and no gown.
Interview on 4/8/25 at approximately 10:30 a.m. with Staff F revealed that he/she was in the middle of Resident #135's morning care and getting Resident #135 up in the wheelchair.
Interview on 4/8/25 at approximately 10:30 a.m. with Staff G (Licensed Practical Nurse) confirmed that Resident was on EBP and that Staff F was providing morning care to Resident #135 with gloves and no gown.
Review on 4/8/25 of Resident #135's skin and wound evaluations, dated 4/7/25, revealed that Resident #135 had wounds on their left lateral calf and rear left thigh.
Review on 4/8/25 of Resident #135's progress notes, dated 4/8/25, revealed that EBP was initiated for Resident #135's chronic wounds and that Resident #135 has a wound older than 30 days to his/her left posterior thigh and left calf.
Interview on 4/8/25 at approximately 10:45 a.m. with Staff B revealed that Resident #135 was on EBP for his/her wounds.
Interview on 4/8/25 at approximately 10:45 a.m. with Staff H (Advanced Practical Registered Nurse) revealed that Resident #135 has a history of Methicillin-resistant Staphylococcus aureas (MRSA) on their wounds and should be on EBP.
Review on 4/8/25 of the facility's policy titled, Enhanced Barrier Precautions, revision date of 1216/24, revealed .Implementation of EBP .Patient Status .Has a wound or indwelling medical device .Use EBP Yes, if they do not meet criteria for Contact Precautions .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on interview, observation, and record review, it was determined that the facility failed to maintain an equipment per manufacturer's instruction for 1 of 1 room air conditioner observed. (Reside...
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Based on interview, observation, and record review, it was determined that the facility failed to maintain an equipment per manufacturer's instruction for 1 of 1 room air conditioner observed. (Resident identifier is #22.)
Findings include:
Observation on 4/6/25 at approximately 10:30 a.m. of Resident #22's room revealed an air conditioning unit that was vented outside through the window. Further observation revealed that Resident #22's room was significantly cooler than other resident rooms.
Observation on 4/8/25 at approximately 12:20 p.m. in Resident #22's room revealed an air conditioning unit filter that had gray discoloration and was covered with dust.
Interview on 4/8/2025 at approximately 12:20 p.m. of Resident #22 revealed he/she had been using the air conditioning unit within that last 2 weeks.
Interview on 4/8/25 at approximately 12:20 p.m. with Staff E (Maintenance Director) confirmed the above observation. Staff E stated that the air conditioning unit filter in Resident #22's room had not been cleaned.
Review on 4/8/25 of the Manufacturer's instructions for the air conditioner revealed .Air Filter .Air filters should be cleaned every two weeks .
Interview on 4/8/25 at approximately 1:00 p.m. with Staff E confirmed the above air conditioner manufacturer's instructions.
Apr 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #27
Review on 4/18/24 of Resident #27's Medication Administration Record (MAR) for April 2024 revealed a physician's or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #27
Review on 4/18/24 of Resident #27's Medication Administration Record (MAR) for April 2024 revealed a physician's order, with a start date of 4/12/24, for Novolog insulin per sliding scale before meals and at bedtime; if over 351 recheck the blood sugar in 2 hours; if the blood sugar was over 400 to notify the provider. Further review revealed the following:
4/13/24 at 4:30 p.m. the blood sugar was 379;
4/14/24 at 11:30 a.m. the blood sugar was 425 and at 4:30 p.m. was 399;
4/15/24 at 4:30 p.m. the blood sugar was 362 and at 9:00 p.m. was 466;
4/16/24 at 9:00 p.m. the blood sugar was 384;
4/17/24 at 11:30 a.m. the blood sugar was recorded as NA and at 4:30 p.m. the blood sugar was 577;
4/18/24 at 7:30 a.m. the blood sugar was 385, at 11:30 a.m. was 452, and at 9:30 p.m. was 399;
4/19/24 at 11:30 a.m. the blood sugar was 396.
Further review revealed that there was no documentation that the blood sugars were rechecked after 2 hours per the physician's order.
Review on 4/18/24 of Resident #27's progress notes for the above dates revealed;
1. No documentation that the provider was notified of the blood sugar above 400;
2. No documentation that a follow up blood sugar was done after 2 hours of blood sugar above 351;
3. No documentation that on 4/17/24 at 11:30 a.m. the physician was aware the blood sugar was not checked.
Interview on 4/19/24 at 1:03 p.m. with Staff B (Unit Manager) confirmed the above findings.
Review on 4/19/24 of Resident #27's Care Plan revealed .Focus .diagnosis of diabetes: Insulin Dependent . Interventions .Access and record blood glucose levels as ordered .Administer hypoglycemic medications as ordered .
Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 4 residents reviewed for nutrition and 1 of 5 residents reviewed for unnecessary medications in a final sample of 28 residents (Resident Identifiers #27 and #67).
Findings include:
Standards:
[NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009.
Page 336 - Physicians' Orders
The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary .
Resident #67
Review on 4/17/24 of Resident #67's Medication Administration Record (MAR) for April 2024 revealed a physician's order, with a start date of 4/3/24, Weigh every day shift every Wednesday for 4 weeks.
Further review of the MAR revealed the following:
4/3/24 - NN (No / See nurse's note)
4/10/24 - marked done; no weight recorded
4/17/24- NN (No / See nurse's note)
Review on 4/18/24 of Resident #67's nurses' notes revealed the following:
4/3/24 Weight not obtained with no further reason documented, written by Staff A (Licensed Practical Nurse (LPN));
4/17/24 Weight not obtained with no further reason documented, written by Staff A.
Review on 4/18/24 of Resident #67's Weights tab in the electronic record revealed a weight on 4/1/24 of 175.6 pounds. Further review revealed no other weights were documented under the weights tab.
Review on 4/19/24 of Resident #67's Nutritional assessment dated [DATE] revealed the Registered Dietitian's evaluation [Resident's name omitted] is consuming meals fairly well since admission however, not meeting increased needs with wound .Will monitor intake, weight, and wound healing for additional interventions if necessary .
Interview on 4/19/24 at 11:20 a.m. with Staff B (Unit Manager) confirmed the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to ensure the medication error rate was not greater than 5% (percent) for 2 of 36 medication opportunitie...
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Based on observation, interview, and record review, it was determined that the facility failed to ensure the medication error rate was not greater than 5% (percent) for 2 of 36 medication opportunities observed (Resident Identifier #11).
Findings include:
Review on 4/19/24 of Resident #11's Medication Administration Record (MAR) included a physician's order for:
Losartan potassium 25 milligrams (mg) 2 tabs [tablets] once daily and Sertraline 100 mg 2 tabs once daily.
Observation on 4/19/24 at 7:40 a.m. of Staff C (Licensed Practical Nurse (LPN)) during medication administration revealed that Staff C had prepared Resident #11's medication and was going to administer one tab of Losartan 25 mg and one tab of Sertraline 100 mg.
Interview on 4/19/24 at 7:45 a.m. with Staff C (LPN) confirmed the above findings.
Review on 4/19/24 of the facility's policy 6.0 General Dose Preparation and Medication Administration revised 1/1/22 revealed: .Facility staff should: .4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, . as set forth in facility's medication administration schedule .
There were 2 medication errors out of 36 medication administration opportunities resulting in a 5.56% error rate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Observation on 4/17/24 at 9:46 a.m. of the third floor North Medication Cart revealed an opened bottle of Latanoprost Ophthalmic Solution for Resident #56. There were instructions written on the outsi...
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Observation on 4/17/24 at 9:46 a.m. of the third floor North Medication Cart revealed an opened bottle of Latanoprost Ophthalmic Solution for Resident #56. There were instructions written on the outside container that read do not use after 42 days. There was no open or open expiration date written on the container. The pharmacy label indicated this medication had been filled on 12/30/23.
Interview on 4/17/24 at 9:46 a.m. with Staff D (LPN) confirmed the above finding.
Review on 4/17/24 of Resident #56's April 2024 Medication Administration Record revealed Latanoprost Ophthalmic solution 0.005% [percent] instill 1 drop in both eyes at bedtime for glaucoma. Further review revealed the medication had been signed off as administered daily through 4/18/24.
Review on 4/19/24 of the facility's policy Storage and Expiration Dating of Medications, Biologicals revised on 8/7/23, revealed .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shorted expiration date once opened .5.4 When an ophthalmic solution or suspension has a manufacturer's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container .
Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were secured in 2 of 3 medication carts observed and that medications were labeled in accordance with professional principles in 1 of 3 medication carts observed.
Findings include:
Observation on 4/19/24 at 7:40 a.m. of Staff C (Licensed Practical Nurse (LPN)), during medication administration revealed Staff C left the medication cart unlocked and no staff were within the line of sight of the medication cart. Further observation at 7:50 a.m. revealed that a second medication cart down the hall from the first medication cart was unlocked and no staff were within the line of sight of the medication cart.
Interview on 4/19/24 at 8:00 a.m. with Staff C confirmed that he/she was the nurse for both hallways on the unit and was administering medications to residents from both carts. Staff C confirmed the medication carts were unlocked and unattended.
Review on 4/19/24 of the facility's policy titled 6.0 General Dose Preparation and Medication Administration revised 1/1/22, revealed: .Procedure .3.10 Facility staff should not leave medications or chemicals unattended .7. Facility should ensure that medication carts are always locked when out of sight or unattended .
Interview on 4/19/24 at 10:10 a.m. with Staff E (Director of Nursing) confirmed medication carts should be locked when unattended.
Nov 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to make a Level II Pre-admission Screening and Resident Review (PASRR) referral for a resident with a newly evident men...
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Based on interview and record review, it was determined that the facility failed to make a Level II Pre-admission Screening and Resident Review (PASRR) referral for a resident with a newly evident mental disorder for 1 of 3 residents reviewed for PASRR in a final sample of 28 residents (Resident identifier is #8).
Findings include:
Review on 11/16/23 of Resident #8's medical record revealed an admission date of 4/8/18 without a recorded diagnosis of a severe mental illness.
Review on 11/16/23 of Resident #8's Level I PASRR form completed on 6/20/18 revealed:
Section 2: Screening for Mental Illness (MI), No was checked.
Section 6: Dementia Exclusion, Dementia - only for MI was not checked.
Section 8: Level Screening Summary, Not requiring PASRR involvement was checked.
Review on 11/16/23 of Resident #8's record revealed a diagnosis of Bipolar Disorder. Further review revealed that from 9/9/20 when Resident #8 was diagnosed with Bipolar Disorder to 11/16/23, the facility failed to make a PASRR referral to the appropriate state agency.
Interview on 11/16/23 at 1:50 p.m. with Staff F (Regional Nurse) confirmed the above finding.
Review on 11/16/23 of facility policy titled SS108 Pre-admission Screening for Mental Health Disorders and or Intellectual Disability Patients, last revised 1/15/21 revealed: 2. Social Services will review PASRR to determine appropriate care needs. 2.1 Refer to the appropriate state designated authority when a patient is identified as having an evident or possible MD, ID, or related condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and policy review, it was determined that the facility failed to ensure that food was prepared in accordance with professional standards for food service safety for 1 ...
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Based on observation, interview, and policy review, it was determined that the facility failed to ensure that food was prepared in accordance with professional standards for food service safety for 1 of 1 kitchens observed and the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 walk-in refrigerators observed.
Findings include:
Observation on 11/14/23 at 9:16 a.m. in the main kitchen with Staff E (Food Service Manager) revealed that the range hood over the stove had accumulated gray dust and grease debris on the grates located on the surface of the hood.
Interview on 11/14/23 at 8:40 a.m. with Staff E confirmed the above finding.
Review on 11/16/23 of the Food and Drug Administration (FDA) Food Code, retrieved from https://www.fda.gov/media/110822/download, revealed 4-601.11. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
Observation on 11/14/23 at approximately 9:30 a.m. of the walk-in refrigerator with Staff E revealed a box of celery containing numerous wilted discolored stalks of celery, without a use by/expiration date.
Interview on 11/14/23 at approximately 9:30 a.m. with Staff E confirmed the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, it was determined, that the facility failed to follow established smoking policies for 1 of 1 resident reviewed for smoking in a final sample of 28 ...
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Based on observation, record review, and interview, it was determined, that the facility failed to follow established smoking policies for 1 of 1 resident reviewed for smoking in a final sample of 28 residents (Resident identifier is #44).
Findings include:
Review on 11/16/23 of Resident #44's medical record revealed that the resident was a smoker. Further review revealed that the resident utilized oxygen on an as needed basis.
Review on 11/16/23 of Resident #44's Safe Smoking Evaluation dated 11/15/23 revealed that independent smoking was allowed.
Review on 11/16/23 of Resident #44's care plan revealed an intervention stating .Maintain (first name omitted) smoking materials at Main Reception Desk.
Interview on 11/16/23 at approximately 9:30 am with Staff C (Unit Manager) revealed that Resident #44's smoking material is kept at the Main Reception Desk. Staff C further stated that Resident #44 can smoke independently. Staff C also stated that Resident #44 would retrieve smoking materials at the Main Reception Desk and when finished smoking would return smoking materials to the receptionist.
Interview and observation on 11/16/23 at approximately 9:45 a.m. with Resident #44 revealed that the resident keeps his/her smoking materials in his/her jacket pocket. Observation revealed that Resident #44's jacket was hanging from a wheeled walker at the end of Resident #44's bed. Observation also revealed Resident #44's jacket pocket had a pack of cigarettes and a lighter. Resident#44 further stated that he/she used to leave his/her smoking materials with the receptionist but the company made staff cuts and there was rarely a receptionist there. Resident #44 also stated that he/she was supposed to leave the smoking materials with nursing staff but they told Resident #44 to just keep them.
Interview on 11/16/2023 at approximately 9:55 a.m. with Staff C confirmed the above findings.
Review on 11/16/23 of Policy titled OPS 137 Smoking revealed .
2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
Jun 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to ensure that alleged violations involving abuse, and/or neglect, including injuries of unknown source, were reported i...
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Based on interview and record review it was determined that the facility failed to ensure that alleged violations involving abuse, and/or neglect, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, to the State Survey Agency (SSA) for 1 incident reviewed for alleged abuse (Resident Identifier is #1).
Findings include:
Review on 6/12/23 of the initial report sent to the SSA on 6/7/23 revealed Resident #1 had an allergic reaction that required epinephrine. Further review of the report revealed that staff were aware of the incident on 6/4/23 at 6:00 p.m., 3 days before the report was sent.
Review on 6/12/23 of Resident #1's nursing notes revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 ate a strawberry that was on his/her dinner tray from the kitchen and experienced throat tightness, shortness of breath, and difficulty breathing. Epinephrine was administered as resident was noted grabbing his/her throat.
Interview on 6/12/23 at approximately 1:30 p.m. with Staff A (Director of Nursing) revealed that Staff D (Registered Nurse) confirmed that the incident was reported to the SSA on 6/7/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**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's order for da...
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**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's order for daily weight for 1 of 2 residents reviewed for nutrition (Resident #8), and wound dressing changes for 1 of 4 residents reviewed for skin (Resident #6).
Findings include:
The [NAME]-[NAME], 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary .
Resident #6
Review on 6/12/23 of Resident #6's Electronic Medical Record (EMR) revealed that Resident #6 was initially admitted to the facility on [DATE] and Resident #6 had an open lesion to their right lateral malleolus that was present on admission.
Review on 6/12/23 of Resident #6's May 2023 Electronic Medication Administration Record (EMAR) revealed that Resident #6 had an order for wound dressing changes every Monday and Thursday to cleanse wound with wound cleanser, pat dry, place liquid lidocaine on gauze and place onto wounds for adequate pain relief for 3-5 minutes, remove lidocaine gauze, place purocol to right lateral malleolus wound, moistened lightly with normal saline, cover with optifoam border, and case padding from toes to tibial tuberosity, followed by coban 50 percent stretch from base of toes to tibial tuberosity with a start date of 5/7/23 and discontinued date of 5/31/23. Further review of Resident #6's May 2023 EMAR revealed that the wound dressing change were scheduled for 5/25/23 and 5/29/23 with no documentation that the wound dressings were changed.
Review on 6/12/23 of Resident #6's wound evaluation note, dated 5/31/23, revealed that open lesion to right lateral malleolus was deteriorating, faint odor, moderate purulent drainage, fragile and macerated surrounding tissues. Further review of Resident #6's 5/31/23 wound evaluation note revealed that nurse practitioner assessed right lower extremity wound, dressing saturated with purulent drainage, and discontinue cast padding/coban wrap.
Review on 6/12/23 of Resident #6's wound evaluation note, dated 6/6/23, revealed a new open area to the right medial malleolus observed on 6/5/23. Wound was swollen, boggy, draining light serous fluid, wound area extending into medial shin graft with a few small scattered open areas, increase pain, increase warmth, and increase baseline discoloration in lower right extremity. Nurse practitioner assessed and swabbed wound for culture and new wound orders placed.
Interview on 6/15/23 at approximately 12:00 p.m. with Staff L (Advanced Practice Registered Nurse) confirmed above findings on Resident #6. Staff L stated that the last week of May 2023, Staff L and the wound nurse assessed Resident #6's wound to the right lateral malleolus and observed an old dressing, approximately 3-5 days old, and the wound had deteriorated. Staff L also stated that last week (6/6/23), he/she assessed Resident #6's wound to the right lateral malleolus and a new open area was noted to the right medial malleolus which he/she obtained a culture, prescribed new dressing orders and antibiotics.
Resident #8
Review on 6/12/23 of Resident #8's May 2023 Electronic Medication Administration Record (EMAR) revealed a physician's order to weigh daily in the morning and notify physician of weight gain of 4 pounds or greater with a start date of 5/26/23. Further review of Resident #8's May 2023 EMAR revealed no documented weight on 5/26/23 and NA [not applicable] documented on 5/27/23 to 5/30/23. First recorded weight was on 5/31/23 which as 485.3 pounds.
Review on 6/12/23 of Resident #8's progress notes revealed no documentation of weights or documentation of Resident #8's refusal to be weighed from 5/26/23 to 5/30/23.
Review on 6/12/23 of Resident #8's nurse practitioner note dated 5/30/23 revealed that Resident #8 reported to nurse practitioner that he/she has not had daily weights.
Interview on 6/12/23 at approximately 12:30 p.m. with Staff D (Registered Nurse) revealed that NA EMAR documentation meant that weight was not obtained.
Interview on 6/12/23 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings.
Interview on 6/15/23 at approximately 12:00 p.m. with Staff L revealed that he/she did not remember getting notification from nurse staff that weights were not done between 5/27/23 to 5/30/23. Staff L stated that Resident #8 reported to him/her that daily weights were not done
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to provide residents with food that accommodated resident allergies for 2 of 2 residents reviewed for dining (Resident I...
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Based on interview and record review it was determined that the facility failed to provide residents with food that accommodated resident allergies for 2 of 2 residents reviewed for dining (Resident Identifiers are #1 and #2).
Interview on 6/12/23 at approximately 11:20 a.m. with Staff N (Cook) revealed that they use the kitchen diet slip to serve meals and determine residents' diet orders and allergies.
Observation on 6/12/23 at approximately between 11:25 a.m. and 11:45 a.m. during a meal tray line service revealed that Staff N read the diet slip to the cook to prepare the meal tray for the resident. Staff N read the kitchen diet slip with the resident's diet order, meal choice, and allergies.
Interview on 6/12/23 at approximately 12:30 p.m. with Staff M (Cook) revealed that they use the kitchen diet slip for the meal tray line service to determine residents' diet orders, preferences, meal choices, diet texture, and allergies.
Resident #2
Interview on 6/12/23 at approximately 9:40 a.m. with Staff K (Registered Nurse (RN)) revealed that last week Resident #2 received a breakfast tray from the kitchen that had eggs with peppers. Staff K stated that Resident #2 has peppers listed as an allergy in their medical record.
Interview on 6/12/23 at 12:30 p.m. with Resident #2 revealed that he/she has an allergy to red and green peppers. Resident #2 stated that last week he/she had gotten red and green peppers in his/her meal from the kitchen. Resident #2 stated that he/she has also received red and green peppers in his/her eggs at breakfast and they needed to take Benadryl. Resident #2 stated they also have received red and green peppers at a lunch meal mixed with chicken and another occasion where they were mixed in vegetables.
Review on 6/12/23 of Resident #2's Clinical Care Profile revealed that Resident #2 has an allergy to peppers.
Review on 6/12/23 of Resident #2's kitchen diet slip revealed allergies to green/red peppers.
Review on 6/12/23 of Resident #2's Medication Administration Record revealed that on 6/7/23 Resident #2 received 25 milligrams of Benadryl.
Review on 6/12/23 of Resident #2's nurses note, dated 6/7/23, revealed that Resident #2 received food containing red and green peppers during lunch. Resident #2 was given Benadryl at 1:34 p.m. as Resident #2 reported that he/she was not feeling well.
Interview on 6/12/23 at 12:30 with Staff E (RN) confirmed the above findings.
Findings include:
Resident #1
Interview on 6/12/23 at approximately 8:15 a.m. with Resident #1 revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 was eating ambrosia and believed that there were raspberries in it. Resident #1 stated that he/she then experienced difficulty breathing and required an injection of epinephrine.
Review on 6/12/23 of Resident #1's kitchen diet slip revealed an allergy to strawberry.
Review on 6/12/23 of Resident #1's Clinical Care Profile revealed that Resident #1 has an allergy to strawberries with anaphylaxis as a reaction.
Review on 6/12/23 of Resident #1's care plan revealed a nutrition care plan for a therapeutic diet for diabetes management with an intervention of Allergy to strawberries and garlic causes anaphylaxis created on 5/26/23.
Review on 6/12/23 of Resident #1's medical diagnosis list revealed that Resident #1 has a diagnosis of legal blindness.
Review on 6/12/23 of Resident #1's nursing notes revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 ate a strawberry that was on his/her dinner tray from the kitchen and experienced throat tightness, shortness of breath, and difficulty breathing. Epinephrine was administered as resident was noted grabbing his/her throat.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined that the facility failed to ensure that there was a communication process between the facility and the hospice provider to ensure t...
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Based on observation, interview, and record review it was determined that the facility failed to ensure that there was a communication process between the facility and the hospice provider to ensure that the needs of the residents were addressed and met 24 hours per day for 1 of 1 residents reviewed for hospice (Resident Identifier #3).
Review on 6/12/23 of Resident #3's physician's orders revealed an order for a regular diet with dysphagia advanced texture, thick liquids-nectar consistency.
Review on 6/12/23 of facility's diet descriptions, updated date of 10/27/19, revealed Consistency Levels: Dysphagia Advanced (Level 3) .Intended for individuals with mild chewing or swallowing difficulty .Meat is ground and moistened. Ground meat is the size of a grain of rice .Chopped meats, vegetables and fruit are the size of pea .
Observation on 6/12/23 at approximately 12:10 p.m. of the second floor dining room revealed Resident #3 was served a lunch tray with chopped broccoli and ground meat.
Review on 6/12/23 at approximately 12:10 p.m. of Resident #3's meal ticket revealed a diet order for dysphagia advanced texture, thick liquids-nectar consistency.
Interview on 6/12/23 at approximately 12:15 p.m. with Staff C (Hospice Nurse) who assists Resident #3 with meals revealed that the meal tray that was delivered had the wrong diet order and that the hospice agency received a phone call from the facility on 6/11/23 at approximately 5:12 p.m. with a request to change Resident #3's diet order to a puree texture. Further interview with Staff C revealed that on 6/11/23 at 5:43 p.m. the hospice agency faxed a new order to change Resident #3's diet to puree texture.
Interview on 6/12/23 at approximately 12:15 p.m. with Staff D (Registered Nurse (RN)) revealed that Staff C asked Staff D about the new order Staff D checked the fax machine and confirmed that the order was there and had been received on 6/11/23 at 5:43 p.m. and that facility nurse staff did not enter the new order into the computer.
Interview on 6/12/23 at approximately 4:00 p.m. with Staff F (Licensed Practical Nurse) confirmed that he/she noted that Resident #3 had trouble with solid food and was on a dysphagia diet. Staff F confirmed that he/she contacted the hospice agency to request an order to downgrade Resident #3's diet to puree texture.
Interview on 6/12/23 at approximately 4:00 p.m. with Staff A (Director of Nursing) confirmed that the new diet order from the hospice agency had been received on 6/11/23 at 5:43 p.m. and that it had not been entered into the computer. Staff A further confirmed that Resident #3 received the wrong diet consistency on 6/12/23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review it was determined that the facility failed to store food and drinks in a manner that would prevent cross contaminations by having uncovered, undated,...
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Based on observation, interview, and record review it was determined that the facility failed to store food and drinks in a manner that would prevent cross contaminations by having uncovered, undated, and expired food and drinks observed in the main kitchen.
Finding include:
Observation on 6/12/23 at 8:20 a.m. of the main kitchen with Staff B (Food Service Director) revealed that in the dry storage room there was a package of 24 English muffins that had green fuzzy-like matter on them and with a use by date of 05/23/23.
Observation on 6/12/23 at 8:30 of the facility's main kitchen refrigerator with Staff B revealed 3 opened half gallons of 2 percent milk with use by dates of 5/30/23, 06/05/23, and 06/06/23. Further observation revealed 1 large box of cucumbers that were wet, soft, and had white fuzzy-like matter as well as black soft circular spots on the cucumbers. Observation also revealed 2 open uncovered/unwrapped packages of cheese that had hard edges, 1 container with watery-yellow substance on top of the mashed potatoes that was dated 6/9/23, 2 uncovered/unwrapped plates containing sliced tomatoes and lettuce with no prep date or use by date, 3 open bags of uncovered/unwrapped boiled sliced ham with no prep date or use by date, 1 large bowl of mixed salad dated 6/9/23 that was sitting in water and the lettuce was soft and brown, and 1 small container of scrambled eggs dated 6/10/23 with water at the bottom of the container.
Observation on 6/12/23 at 9:00 a.m. of the main kitchen's walk-in freezer with Staff B revealed 1 opened uncovered/unwrapped bag of collard greens with no prep date or use by date, 1 opened unsealed bag of 4 pounds kielbasa with no open date, 1 opened unsealed bag with three vegetable burgers with no open date, and an opened unsealed bag of 4 pounds pepperoni with no open date.
Observation on 6/12/23 at 9:10 a.m. with Staff B reveled that on the top of the milk cooler was a case of 23 bananas that were soft and dark, black-like.
Interview on 6/12/23 at 9:10 a.m. with Staff B confirmed above findings. Staff B stated that above mentioned items should have been thrown out and items that were open should have been covered or wrapped, and dated with an open date.
Observation on 6/12/23 at approximately 11:20 a.m. during the lunch service line revealed that food removed from the ovens and steamers were placed into steam table at 11:20 a.m. Further observation revealed that dietary staff did not obtain food temperatures of the sweet mash potatoes, broccoli, parslied potatoes, and glazed ham slices prior to meal service.
Review on 6/12/23 at 11:45 a.m. of the meal food temperature logs revealed missing data for 6/8/23 on all meal service and 6/12/23 breakfast and lunch meal service.
Interview on 6/12/23 at 12:00 noon with Staff B confirmed the above findings. Staff B stated that dietary staff should take the food temperature prior to serving food.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Interview on 6/12/23 at approximately 8:30 a.m. with Resident #13 revealed that on 6/11/23 lunch was not served until 2:00 p.m.
Interview on 6/12/23 at approximately 9:30 a.m. with Staff J who stated ...
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Interview on 6/12/23 at approximately 8:30 a.m. with Resident #13 revealed that on 6/11/23 lunch was not served until 2:00 p.m.
Interview on 6/12/23 at approximately 9:30 a.m. with Staff J who stated that meal tray delivery times were sporadic and that staff never know when the trays will be delivered to the units.
Observation on 6/12/23 of meal service to the third floor unit revealed that the residents in the dining room were served at 1:05 p.m. Based on observation, interview, and record review it was determined that the facility failed to employ sufficient dietary staff to safely and effectively carry out the functions of the food and nutrition service for 2 out of 2 units observed for dining and the main kitchen observed for meal tray line service (Resident Identifiers are #4, #7, #13, #16, #17, #18, and #19).
Findings include:
Review on 6/12/23 of the facility's meal deliver times revealed the following:
Breakfast - 2North 7:15 a.m., 2South 7:30 a.m., 3North 7:45 a.m., and 3South 8:00 a.m.
Lunch - 2North 11:30 a.m., 2South 11:45 a.m., 3North 12:00 p.m., and 3South 12:30 a.m.
Supper - 2North 5:15 p.m., 2 South 5:30 p.m., 3North 5:45 p.m., and 3South 6:00 p.m.
Scheduled Times may vary plus/minus 10 minutes.
Second Floor Unit
Interview on 6/12/23 at 9:00 a.m. with Resident #7 revealed that meals were served late. Resident #7 stated that this past week breakfast was served past 8:00 a.m., lunch was served past 1:00 p.m., this past weekend lunch was served at 2:00 p.m., and supper was served past 6:00 p.m. at one time it was 8:00 p.m. Resident #7 also stated that the nursing staff would tell them that the meal cart has not come up on the second floor unit.
Interview on 6/12/23 at 9:10 a.m. with Resident #4 revealed meals were served late. Resident #4 stated that this past week breakfast was served past 8:00 a.m, lunch was served past 1:30 p.m., and supper was served past 6:00 p.m. Resident #4 also stated that last night (6/11/23) supper was served at approximately 6:30 p.m.
Interview on 6/12/23 at 9:45 a.m. with Resident #16 and Resident #17 revealed that breakfast meals were served between 8:00 a.m and 8:20 a.m., lunch meals were served past 1:00 p.m., and supper meals were served between 6:00 p.m. and 8:00 p.m. Resident #16 stated that meal carts were delivered late.
Interview on 6/12/23 at 9:20 a.m. with Staff E (Registered Nurse (RN)) and Staff G (Licensed Nursing Assistant (LNA)) revealed that meals carts were delivered late to the second floor unit. Staff E stated that breakfast meal carts were brought up to the unit after 8:00 a.m., lunch meal carts were brought up to the unit after 1:00 p.m., and supper meal carts were brought up to the unit after 6:00 p.m. Staff G stated that last night (6/11/23) dinner was brought up at approximately 7:00 p.m. with no drinks to be served and Staff G had to ask dietary staff for it. Staff E and Staff G also stated that they were told by the dietary manager that meal carts were served late as the nursing staff could not get the resident meal trays back to the kitchen on time for the next service. Staff E and Staff G also stated that approximately last week Resident #18 and Resident #19 received meals with regular texture and not ground or chopped and both residents' diet was for ground texture.
Review on 6/12/13 of Resident #18's diet slip revealed Regular/Liberalized-Special Consistency ground meats with exception of cut up fish and ground beef like (meatloaf, Salisbury steak, meatball).
Review on 6/12/23 of Resident #19's diet slip revealed Regular/Liberalized-Dysphagia Advanced.
Review on 6/12/23 of facility's diet descriptions, updated date 10/27/19, revealed Consistency Levels: Dysphagia Advanced (Level 3) . Intended for individuals with mild chewing or swallowing difficulty . Meat is ground and moistened. Ground meat is the size of a grain of rice .Chopped meats, vegetables and fruit are the size of pea .
Interview on 6/12/23 at 9:35 a.m. with Staff J (RN) and Staff H (RN) revealed that breakfast meals were served after 8:00 a.m., lunch meals were served between 1:00 p.m. and 2:00 p.m., and supper meals were served between 6:30 p.m. and 8:00 p.m. as meal carts were delivered late to the second floor unit. Staff J stated that there was a weekend that he/she was notified, between 9:30 a.m. to 10:00 a.m., that meal carts were not delivered to the second floor unit.
Interview on 6/12/23 at 9:40 a.m. with Staff I (LNA) revealed that meal carts were delivered late to the second floor unit.
Observation on 6/12/23 of the lunch meal service to the second floor revealed that the first lunch cart was delivered to the floor at 12:10 p.m. and the second cart was delivered at 12:20 p.m.
Observation on 6/12/23 at approximately 12:25 p.m. at the second floor unit revealed that parallel to the elevator were 2 carts of empty breakfast trays. Observation also revealed that one of the meal carts had 4 empty breakfast trays that were taken out from the resident's rooms.
Interview on 6/12/23 at approximately 12:25 p.m. with Staff I confirmed above observations on the empty breakfast trays on the second floor unit.
Third Floor Unit
Observation on 6/12/23 at 12:30 p.m. at the third floor unit revealed that no meal carts were delivered in the unit.
Observation on 6/12/23 at 11:20 a.m. of the lunch service line in the main kitchen revealed that the tray service started at 11:30 a.m. for the second floor north wing meal cart and was completed at 12:00 noon.
May 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to remove from duty staff who were suspected of neglect and failed to provide staff re-education prior to returning to w...
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Based on interview and record review it was determined that the facility failed to remove from duty staff who were suspected of neglect and failed to provide staff re-education prior to returning to work to prevent abuse for 1 of 2 residents reviewed in a final sample of 24 residents (Resident Identifier is #21).
Findings include:
Interview on 5/22/23 with Resident #21 revealed that he/she was left on the commode for 1.5 hours.
Review on 5/22/23 of the witness statement from Staff M (Certified Medical Assistant) revealed that Resident #21 was placed on the commode with the assistance of Staff M and Staff N (Licensed Nursing Assistant) at approximately 1:30 p.m. on 3/5/23. Staff M stated that it was the end of their shift and Staff M asked second shift to assist Resident #21 off the commode.
Review on 5/24/23 of the facility's policy titled Abuse Prohibition revised 10/24/22 section 6.1 Anyone who witnesses and incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked 6.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation.
Interview on 5/24/23 with Staff K (Administrator) confirmed that the allegation was investigated and reported as substantiated on 3/10/23. Staff K further revealed that Staff M worked on 3/6/23 from 7:00 a.m. to 7:00 p.m. and provided documentation that Staff M was re-educated at 4:00 p.m. on 3/6/23, several hours into their shift.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 5/23/23 at approximately 10:00 a.m. with 14 residents at the Resident Council Meeting revealed the following concer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 5/23/23 at approximately 10:00 a.m. with 14 residents at the Resident Council Meeting revealed the following concerns:
Call bells were not answered for long periods of time especially on the evening shift; Baths and showers were not consistently provided weekly due to not enough staff; and there consistently being 2 LNAs on the floor to care for everyone.
Resident #13
Interview on 5/23/23 at approximately 10:00 a.m. with Resident #13 revealed they had not consistently been given a weekly bath or shower.
Review on 5/23/23 of Resident #13's shower schedule revealed they were scheduled to receive a shower on Mondays during the second shift.
Review on 5/23/23 of Resident #13's LNA documentation for baths and showers for the last 30 days revealed showers were marked as competed on 5/8/23 and 5/22/23. There was no documentation that Resident #13 received weekly showers/bath during the following weeks: 4/24/23, 5/1/23, and 5/15/23.
Resident #45
Review on 5/23/23 of Resident #45's shower/bath schedule revealed they were scheduled to receive a shower/bath on Tuesdays on day shift from date of admission [DATE]) until they moved rooms on 5/18/23. After room change on 5/18/23 weekly shower/bath was scheduled to be done on Thursdays on the evening shift.
Review on 5/23/23 of Resident #45's LNA documentation for baths and showers for the last 30 days revealed they received a bath on 4/25/23 and 5/9/23. Further review revealed that there was no documentation of bath/showers for the weeks of 5/2/23, 5/16/23, and 5/18/23.
Interview on 5/23/23 at approximately 2:00 p.m. with Staff G (LNA) revealed the second floor is staffed with 2 LNAs. Staff G stated that with 2 LNAs they are not able to get all the baths/showers done.
Interview on 5/24/23 at approximately 9:48 a.m. with Staff H (Anonymous) revealed that they were the only nurse on a unit with 39 residents, 13 of which are skilled. Staff H state they were working with 2 MNAs and 3 LNAs and did not think it was safe to continue to take more skilled admissions.
Interview on 5/24/23 at approximately 9:48 a.m. with Staff I (Anonymous) revealed that staffing is less than adequate and they have seen an increase in MASD [Moisture Associated Skin Damage] to the residents as a result of them not having time to do frequent and adequate incontinence care.
Interview on 5/24/23 at approximately 12:19 p.m. with Staff J (Director of Nursing) and Staff K (Administrator) revealed that staff have voiced concerns with the staffing levels and not being able to compete their work.
Interview on 5/22/23 at 11:00 a.m. with Staff O (Anonymous) revealed that staff are not always able to complete baths weekly due to staffing.
Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet the residents' needs for a census of 88 residents. (Resident Identifiers are #13 and #45).
Findings include:
Review on 5/23/23 of the Staffing and Personnel spreadsheet from the facility assessment revealed the following staffing levels for direct care staff:
Second floor
First shift - 2 RNs (Registered Nurse) or LPNs (Licensed Practical Nurse)/MNAs (Medication Nursing Assistant) and 4 LNAs (Licensed Nursing Assistant)
Second shift - 2 RNs or LPNs/MNAs and 4 LNAs
Third shift - 1 RN or LPN and 2 LNAs
Third floor
First shift - 2 RNs or LPNs/MNAs and 4 LNAs
Second shift - 2 RNs or LPNs/MNAs and 4 LNAs
Third shift - 1 RN or LPN and 2 LNAs
Review on 5/23/23 of the Daily Staffing Sheets for the month of May 2023 revealed the following:
5/22/23 - Third floor - First shift - 3 LNAs - Census - 49
5/19/23 - Third floor - Second shift - 3 LNA - Census - 48
5/18/23 - Second floor - Second shift - 2.5 LNAs - Census - 36
5/17/23 - Third floor - Second shift - 3.5 LNAs - Census - 48
5/16/23 - Third floor - First and Second shift - 3.5 LNAs - Census - 48
5/15/23 - Second floor - Second shift - 1.5 LNAs - Census - 36
5/15/23 - Third floor - First and Second shift - 3.5 LNAs - Census - 48
5/14/23 - Second floor - First shift - 2.25 LNAs - Third shift 1 LNA - Census - 37
5/14/23 - Third floor - First shift 1 MNA (no nurse) - Third shift 1 LNA - Census - 47
5/13/26 - Second floor - First shift - 2 LNAs - Census - 38
5/13/23 - Third floor - First shift - 3 LNAs - Census - 46
5/9/23 - Second floor - Second shift - 2.5 LNAs - Census - 37
5/9/23 - Third floor - Second shift - 3.5 LNAs - Census - 47
5/7/23 - Third floor - Second shift - 3 LNAs - Census - 47
5/6/23 - Third floor - Second shift - 2.5 LNAs - Census - 47
5/2/23 - Second floor - Second shift - 2 LNAs - Census - 37
Interview with Staff D on 5/23/23 at 1:25 p.m. confirmed that the above Daily Staffing Sheets were correct.
Interview on 05/23/23 at 08:25 a.m. with Staff C (Unit Manager) revealed that the third floor unit is staffed with 4 LNAs, 1 RN, and 1 LPN and/or MNA for both the day and evening shifts. If the unit census is above 48, they staff with 4.5 LNAs. Staff C confirmed that on 5/22/23 there were only 3 LNAs on the unit for the day shift with a census of 49 residents.
Feb 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview, record review and policy review, it was determined that the facility failed to investigate an allegation of abuse by a staff member for 1 out of 1 records reviewed for abuse (Resid...
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Based on interview, record review and policy review, it was determined that the facility failed to investigate an allegation of abuse by a staff member for 1 out of 1 records reviewed for abuse (Resident identifier is #1).
Findings include:
Interview on 2/21/23 at approximately 12:10 p.m. with Staff A (Unit Manager) revealed that Staff A recalled a meeting with the Hospice agency in December (unsure of exact date). Staff A revealed that shortly after the Hospice meeting, the prior Director of Nursing approached him/her with an accusation that an Licensed Nursing Assistant (LNA) was accused by hospice of pulling down his/her pants with their bottom in Resident #1's face. Staff A revealed that he/she interviewed Staff C (LNA) a few days later about the accusation and determined that it was unsubstantiated.
Interview on 2/21/23 at approximately 12:20 p.m. with Staff C revealed that he/she was approached by Staff A a few days after the allegation and stated that it was not factual. Staff C revealed that another LNA was present in the room and he/she did pull down his/her pants to approximately above his/her knees to show the other LNA his/her bruise. Staff C stated that he/she was facing Resident #1 when this occurred and there wasn't anything intentional done to the resident. Staff C also revealed that when he/she recalled the incident to Staff A that was last he/she heard anything about it. Staff C revealed that there was no education provided to him/her after the incident.
Interview on 2/21/23 at approximately 1:00 p.m. with Staff D (Administrator) revealed there was no documented evidence of the allegation being investigated or reported to the state agency.
Review on 2/21/23 of the facility policy titled, Abuse Prohibition, Revision Date 2/23/21 revealed:
.7. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following.
7.1 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made.
.7.3 Report allegations involving neglect, exploitation or mistreatment (including injuries or unknown source), suspected criminal activity, and misappropriation of resident property within twenty-four (24) hours if the event does not result in serious bodily injury.
7.4 Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries and other agencies as required.
.7.6 Initiate an investigation within 2 hours of an allegation of abuse that focuses on:
7.6.1 whether abuse or neglect occurred and to what extent;
7.6.2 clinical examination for signs of injuries, if indicated;
7.6.3 causative factors; and
7.6.4 Interventions to prevent further injury.
7.7 The investigation with be thoroughly documented.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to ensure that as needed (Pro re nata (PRN)) psychotropic drugs were limited to 14 days except if the attending physici...
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Based on record review and interview, it was determined that the facility failed to ensure that as needed (Pro re nata (PRN)) psychotropic drugs were limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days for 1 of 1 residents reviewed. (Resident identifier is #1.)
Findings include:
Review on 2/21/23 of Resident #1's February 2023 Medication Administration Record revealed the following orders:
1. Ativan (Lorazepam) oral tablet 0.5 milligrams (mg), Give 1 tablet by mouth every 4 hours as needed for moderate anxiety/agitation, start date 11/28/22.
2. Ativan (Lorazepam) oral tablet 0.5 mg, Give 2 tablets by mouth every 4 hours as needed for severe anxiety/agitation, start date 11/28/22.
Interview on 2/21/23 at approximately 11:30 a.m. with Staff B (Director of Nurses) confirmed that the above PRN medications did not have a documented stop date.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that within their Facility Assessment the facility failed to include the number of staff needed to ensure sufficient number of qualified staff a...
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Based on interview and record review, it was determined that within their Facility Assessment the facility failed to include the number of staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs and to ensure the residents attain or maintain their highest practicable level of physical, functional, mental and psychosocial well-being.
Findings include:
Review on 2/21/23 of the Facility Assessment revealed that the assessment did not include the number of staff needed to care for each resident's needs. Refer to F725: Sufficient Nursing Staff.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interview, and record review it was determined that the facility failed to provide sufficient nursing staff coverage in accordance with the recommendations of the Facility Assessment to meet ...
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Based on interview, and record review it was determined that the facility failed to provide sufficient nursing staff coverage in accordance with the recommendations of the Facility Assessment to meet each resident's needs (Resident Identifiers are #1, #2, #3, and #4).
Findings Include:
Interview on 2/21/23 at approximately 8:48 a.m. with Resident #2 revealed, The facility is very short staffed, that's all we ever hear. I have to lay in my own urine for hours because there is no one to help you here. This happens often but more frequently at meal times.
Interview on 2/21/23 at approximately 8:50 a.m. with Resident #3 revealed, The other night, I literally was laying with a urine soaked brief from dinner until the next morning because there is not enough staff.
Interview on 2/21/23 at approximately 8:55 a.m. with Staff E (Anonymous) revealed, The other night on 3-11 shift there were only 2 Licensed Nursing Assistants (LNAs) on the entire unit. 2 LNAs assisting 40 something residents to bed.
Interview on 2/21/23 at approximately 9:00 a.m. with Staff F (Anonymous) revealed, There are times we only have 1 LNA to each wing (2 per unit), we can't possibly give adequate care to 20 something residents each in 8 hours. We are doing the best we can but the residents are barely getting basics never mind showers. Showers are not done when we are short.
Interview on 2/21/23 at 09:15 a.m. with Staff G (Activities Aide) revealed that honestly, some days the LNAs are ready to cry, they are tired of working short, I see it in them.
Interview on 2/21/23 at 09:25 a.m. with Staff H (Unit Aide) revealed that we usually have 3-4 but sometimes have 2, it's hard with 2, sometimes we get baths done but its hard.
Interview on 2/21/23 at 09:30 a.m. with Resident #4 revealed that he/she feels staff are shorthanded, I ring my bell and wait for one hour, sometimes I get a bath and sometimes not.
Interview on 2/21/23 with Staff B (Director of Nursing) revealed that the facility's normal daily staffing pattern is to have 4 LNAs for each floor for the day and evening shifts with 2 nurses, one Unit Manager or one nurse, and one Medication Technician. The night shift has 1 nurse per unit with 2 LNAs. The on call nursing staff are to cover any callouts that drop below this number. Staff B was unable to state at which point in the census would staffing be adjusted for acuity.
Review on 2/21/23 of the Facility Assessment did not reveal the number of facility staff needed to ensure sufficient number of qualified staff to meet each resident's needs or the determination of staffing levels.
Review on 2/21/23 of the Facilities Actual Daily Staffing Sheets for the past 30 days revealed of that 30 days there were 22 days that the LNA staffing went below 3 LNAs with a census running from 31-38 on the second floor to 47-48 on the third floor during the day or evening shifts.
Interview on 2/21/23 at 1:30 p.m. with Staff B and Staff I (Staffing Coordinator) confirmed that there were days that the facility ran short.
Review on 2/21/23 at 1:45 p.m. of the facility's Fall Incident Log revealed that the facility has had 15 falls during the month of February. The days with both falls and low nursing staff were as follows:
1. 2/7/23 evening and day falls
2. 2/9/23 day and evening falls
3. 2/11/23 evening fall
4. 2/12/23 day and evening falls
5. 1/27/23 day and evening falls
Review on 2/22/23 of the Hospice Communication Log for Resident #1 revealed the following entries:
12/19/22 Pt. [patient] in bed in Johnny, has not had breakfast. Hospice LNA performed AM [morning] care .
12/28/22 Pt. awake in bed. Soaked to mattress, [NAME] on and lunch tray at bedside at 12:30.
1/11/23 Pt. in soaked urine bed, complete bed change, sore on right inner heel .
Review on 2/21/23 of Resident #2's LNA task Tub/shower Schedule revealed the weeks of 2/3/23 and 2/17/23 it was documented that a shower was Not Applicable. There was no other evidence that Resident #2 was offered a tub/shower those weeks.
Interview on 2/21/23 at approximately 1:30 p.m. with Staff B and Staff A confirmed the above findings.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most New Hampshire facilities.
Concerns
- • 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Keene Center, Genesis Healthcare's CMS Rating?
CMS assigns KEENE CENTER, GENESIS HEALTHCARE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New Hampshire, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Keene Center, Genesis Healthcare Staffed?
CMS rates KEENE CENTER, GENESIS HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 47%, compared to the New Hampshire average of 46%.
What Have Inspectors Found at Keene Center, Genesis Healthcare?
State health inspectors documented 21 deficiencies at KEENE CENTER, GENESIS HEALTHCARE during 2023 to 2025. These included: 21 with potential for harm.
Who Owns and Operates Keene Center, Genesis Healthcare?
KEENE CENTER, GENESIS HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 106 certified beds and approximately 84 residents (about 79% occupancy), it is a mid-sized facility located in KEENE, New Hampshire.
How Does Keene Center, Genesis Healthcare Compare to Other New Hampshire Nursing Homes?
Compared to the 100 nursing homes in New Hampshire, KEENE CENTER, GENESIS HEALTHCARE's overall rating (2 stars) is below the state average of 3.0, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Keene Center, Genesis Healthcare?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Keene Center, Genesis Healthcare Safe?
Based on CMS inspection data, KEENE CENTER, GENESIS HEALTHCARE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Hampshire. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Keene Center, Genesis Healthcare Stick Around?
KEENE CENTER, GENESIS HEALTHCARE has a staff turnover rate of 47%, which is about average for New Hampshire nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Keene Center, Genesis Healthcare Ever Fined?
KEENE CENTER, GENESIS HEALTHCARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Keene Center, Genesis Healthcare on Any Federal Watch List?
KEENE CENTER, GENESIS HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.