Penacook Place, Inc

In the surveyor’s words

From the most serious findings on record at Penacook Place, Inc, in the surveyor’s own words.

• Actual harm, patternF689Mar 25, 2022

  Based on observation, record review, and interview, the facility failed to implement effective or new interventions to prevent falls and complete thorough investigations following falls for 6 Residents (#27, #52, #50, #77, #2, #53) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Fall Prevention Policy, dated 01/2021, indicated the following: - Fall Review: The weekly sub-risk meeting meets once weekly to discuss most recent falls, and ensures current interventions in place are appropriate, and follow up measures have been taken. - Upon admission to the facility, nursing will complete a fall risk assessment in the electronic medical record. - Nurse in charge will determine the most appropriate fall interventions for the next 72 hours. […]

• Actual harm, isolatedF760Apr 29, 2025

  Based 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. Findings include: The Facility Policy, titled Insulin Administration, dated revised 09/2014, indicated nursing would verify the type of insulin, dosage requirements, strength, and method of administration before administration, to confirm it corresponds with the physician's orders. […]

• Actual harm, isolatedF604Jun 14, 2023

  Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired and was unable to make his/her needs known to staff, the Facility failed to ensure Resident #1's right to be free from physical restraints was honored and respected by staff, when he/she was discovered at 5:40 A.M. on 05/20/23 in a fetal position (legs tucked up into chest) with the bottom corners of his/her [NAME] tied together restricting his/her ability to straighten out or move his/her legs, at will. Findings include: Review of Facility's Incident Report, dated 05/20/23, indicated Resident #1 was lying down in bed, when the covers were pulled down, Resident #1's arms were through the [NAME]'s arm holes, and it was tied behind the neck appropriately. […]

• Actual harm, isolatedF656Mar 28, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of falls and required moderate to maximum assistance of two staff members with all transfers for safety, the Facility failed to ensure staff implemented and followed interventions identified in his/her Activities of Daily Living (ADL) plan of care related to transfers. On 2/25/23, during the day shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 from his/her bed to a shower chair without assistance from another staff member, Resident #1 had a near fall during the transfer, was caught by CNA #3, complained of pain after the incident, and was diagnosed two days later with a right rib fracture. […]

• Actual harm, isolatedF689Mar 28, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of falls and required moderate to maximum assistance of two staff members with all transfers for safety, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety in an effort to prevent incidents/accidents resulting in an injury. On 2/25/23, during the day shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 from the bed to a shower chair, without another staff member present to assist her, Resident #1 had a near fall, was caught by CNA #3 who grabbed him/her under the arms, Resident #1 complained of pain after the incident, and was diagnosed with a right sided rib fracture. […]