Grafton County Nursing Home

In the surveyor’s words

From the most serious findings on record at Grafton County Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to identify personal humidifiers in their Water Management Plan in which Legionella and other opportunistic waterborne pathogens could grow and spread. There were humidifiers on 3 of 4 units observed. (Granite, Profile and Maple Units). Findings include: Review on 3/31/26 of the facility's policy titled Legionella Water Management Program, revised on 3/7/25 revealed, . 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5.c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following. […]

• No harm, potential for more than minimal, patternF809Jan 31, 2025

  Based on observation, interview and record review, it was determined that the facility failed to offer the residents a nourishing snack at bedtime while having more than 14 hours between the evening meal and the breakfast meal for 4 of 4 units reviewed and without Resident Council consent. Findings include: Interview on 1/29/25 at approximately 2:15 p.m. at Resident Council (5 residents in attendance) revealed that HS (Hour of Sleep) snacks were not offered. The residents stated snacks were available when they asked for them. Review on 1/29/25 of the facility's scheduled meal service times revealed that the Supper meal time starts at 5:00 p.m. and the Breakfast meal time starts at 8:00 a.m. […]

• No harm, potential for more than minimal, patternF726Sep 30, 2021

  Based on interview and record review, the facility failed to ensure that licensed nurses have the skill sets necessary for medication administration for 3 of 3 nurses reviewed. Findings include: Resident #74 Review on 9/29/21 at approximately 1:00 p.m. of Resident #74's nurse's notes revealed an entry on 7/31/21 that stated Nurse A [Staff F] gave 20:00 [8:00 p.m.] medications ([MEDICATION(S)] and [MEDICATION(S)]) at 19:00 [7:00 p.m.] at the end of shift. Nurse A failed to hit save on EMAR [electronic medication administration record] before closing windows and logging out of Med [medication] Cart Laptop. Nurse B [Staff G] took cart shortly after and seeing the medications due on the EMAR, gave those medications. The result was that the resident received two doses in just under an hour. […]

• No harm, potential for more than minimal, patternF880Sep 30, 2021

  Based on observation, interview, and record review, it was determined that the facility failed to adhere to Center for Disease Control and Prevention (CDC) guidelines for screening staff for signs and symptoms of COVID-19 for 2 staff out of 20 staff reviewed. Findings include: Review on 9/29/21 at approximately 1:00 p.m. of staff screening forms, revealed that on 9/26/21 and 9/27/21 Staff C (dietary aide) had logged a temperature on screening form and failed to answer any questions regarding symptoms of COVID-19, exposure to COVID-19 or international travel. Further review of staff screening logs revealed that on 9/22/21 Staff D (Registered Nurse) answered yes to new respiratory symptoms. Interview on 9/29/21 at approximately 1:30 p.m. […]

• No harm, potential for more than minimal, isolatedF609Apr 2, 2026

  Based on interview and record review it was determined that the facility failed to report allegations of abuse to the state survey agency for 2 allegations of abuse reviewed residents. (Resident identifiers are #11, #29, #55, and #82). Findings include:Resident #11 Review on 3/31/26 of Resident #82's medical record revealed a nursing note dated 3/27/26 at 9:04 p.m. revealed Staff L (Licensed Practical Nurse) entered Resident #82's room and observed Resident #11 laying back in the recliner. Brief pulled off, pajama pulled up above pelvis. Resident #82 kneeling down in front of recliner attempting to have sex with Resident #11. […]