cms_NH: 78

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
78 DOVER CENTER FOR HEALTH & REHABILITATION 305018 307 PLAZA DRIVE DOVER NH 3820 2018-12-07 880 B 0 1 9HC411 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Transmission Based Contact Precautions were maintained with Personal Protective Equipment for two of two residents in a survey sample of 22 residents, failed to ensure a facility wide Infection Control surveillance and documentation was completed. (Resident identifiers are #41 and #292.) Findings include: Resident #292. Review on 12/6/18 of Resident #292's medical record showed that Resident #292 was admitted to the facility on [DATE] with the multiple [DIAGNOSES REDACTED]. Resident #292 was placed on Transmission Based Contact Precautions at the time of admission due to [MEDICAL CONDITION]. Observation 12/4/18 13:28 p.m. showed an individual (non staff member) in Resident #292's room without any gown or gloves (Personnel Protective Equipment) on for Transmission Based Contact Precautions going several times in & out of Resident #292's bathroom. Observation on 12/5/18 at approximately 12:30 P.M. showed two visitors in Resident #292's room with gowns & gloves on. Interview with these two individuals, identified by Resident #292 as son & daughter of Resident #292, revealed that these two individuals reported they know what to wear when visiting due to white index card attached to yellow over the door precaution supply of PPE. The son reported that at the hospital there was a sign posted on . (Resident #292) door indicating See nurse before entering and hospital staff would tell visitors what PPE was needed when visiting in (Resident #292's) room. Interview & observation on 12/6/18 at 1:30 p.m. with Staff A (Licensed Practical Nurse) confirmed that the PPE supplies contained in the yellow multi-pouched over the door hanger with a piece of white paper attached on the front of this yellow PPE supply container indicating STOP was checked off in boxes on this white paper indicating Gown, Gloves and wash hands. Staff A (LPN) confirmed that a gown & gloves would be worn by individuals when entering room to visit Resident #292 Observation on 12/5/18 at 1:30 p.m. with Staff A ( LPN) revealed that when Resident #292's room door is open the white sheet of paper indicating PPE is not visible and that visitors can enter Resident #292's room and visit without wearing PPE. Staff A ( LPN) agreed and reported no other signs or information is visible or posted to ensure individuals entering Resident #292's room wear gown and gloves to comply with Contact Precaution protocol. Observation and interview on 12/6/18 at approximately 3:25 p.m showed a female and male visitor in Resident #292's room with no gowns or gloves ( PPE) . Resident #292 introduced the female as his wife and the male visitor as a good friend. Wife reported that they don't have to use . (PPE) available on Resident #292's door because they told me at the hospital we only had to do that (pointing to the PPE) for 10 days and the 10 days are up. Resident #292 confirmed that the son & daughter visiting yesterday, 12/5/18, had the gowns and gloves on during the visit. Interview on 12/4/18 at approximately 11:30 a.m. with Staff I (Registered Nurse, Infection Control), revealed that walking rounds do not include the kitchen or the laundry. Staff I explained that she/he does walking rounds every Monday which consists of all the nursing areas. She/he does not go into the kitchen or the laundry as this is done by the maintenance staff for review of life safety and fire hazards, not infection control. Staff I presented a form, titled Facility Unit Rounds, this includes the areas that Staff I inspects every Monday for her/his walking rounds and do not include the kitchen, laundry or rehabilitation areas. Interview on 12/7/18 at approximately 2:30 p.m. with Staff [NAME] (Director of Nursing), revealed that walking rounds do not include the kitchen or the laundry. Staff [NAME] provided a form, titled Facility Unit Rounds, this includes the areas that are considered walking rounds that are currently reviewed by Staff I. This form consists of nursing unit specific areas only. At this time, the kitchen, laundry and rehabilitation areas are not being reviewed for potential infection control issues. Resident #41 Interview on 12/4/18 at approximately 9:30 a.m. with Staff G (Unit Manager) revealed that Resident #41 was on droplet precautions [MEDICAL CONDITIONS] in the nares, and that when entering the room a gown, gloves and a mask must be worn. Observation on 12/4/18 at approximately 11:15 a.m. revealed that Resident #41 was laying in their bed. Staff H (Housekeeper) was cleaning Resident #41's room, and was standing right next to Resident #41's bed using a mop to clean under the bed. Staff H was wearing a gown and gloves and was also wearing a mask, but the mask was only covering Staff H's mouth, it was not covering Staff H's nose. Interview on 12/4/18 at approximately 11:20 a.m. with Staff G (Unit Manager) confirmed that Staff H's mask should have been covering both their mouth and their nose. 2020-09-01