Inspection Reports for
Derry Rehabilitation and Nursing Center LLC
20 CHESTER ROAD, Derry, NH, 03038
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional principles for labeling and storing medications, specifically focusing on medication storage and expiration practices.
Findings
The facility failed to follow accepted professional principles for labeling and storing medications in one medication cart and one medication room, including lack of open dates and expiration dates on multiple medications and failure to discard medications according to manufacturer instructions.
Deficiencies (1)
Failure to label and store medications properly, including missing open dates and expiration dates on medication containers.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Staff A confirmed medication storage findings | |
| Registered Nurse | Staff B confirmed medication storage findings |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, bed hold notification policies, medication labeling, and infection prevention and control practices at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to assess resident appropriateness for self-administration of medications, failure to notify residents of bed hold policies upon hospital transfer, improper labeling of multi-dose medications, and failure to implement enhanced barrier precautions for infection control for residents colonized with multidrug-resistant organisms.
Deficiencies (4)
Failed to determine if self-administration of medications was appropriate for 1 of 1 resident reviewed.
Failed to notify residents or their representatives in writing about bed hold policy before hospital transfer for 2 of 2 residents reviewed.
Failed to ensure multi-dose medications were labeled appropriately in 1 medication cart observed.
Failed to follow CDC guidance for Enhanced Barrier Precautions for 2 of 2 residents reviewed for infection control.
Report Facts
Residents reviewed: 15
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed findings related to medication self-administration and medication labeling | |
| Business Office Manager | Confirmed no bed hold policy notification was provided at transfer | |
| Director of Nursing | Confirmed pressure ulcer and lack of precautions for Resident #10 | |
| Infection Preventionist | Confirmed failure to implement Enhanced Barrier Precautions | |
| Unit Manager | Confirmed Resident #4 was not on Enhanced Barrier Precautions despite colonization |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 4, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to implement residents' care plans for supervision during meals, food served at inappropriate temperatures, inadequate assistive eating devices, and food safety and sanitation issues in the facility.
Complaint Details
The visit was complaint-related focusing on supervision during meals, food temperature and palatability, assistive devices for eating, and food safety and sanitation practices. Substantiation status is not explicitly stated.
Findings
The facility failed to provide adequate supervision during meals for residents with care plan needs, served food at unappetizing low temperatures, did not provide necessary assistive eating devices, and failed to maintain proper food safety and sanitation standards including facial hair restraints for kitchen staff and proper food storage.
Deficiencies (5)
Failed to implement residents care plan regarding supervision with meals for 2 residents.
Failed to ensure adequate supervision to prevent choking accidents during meals for 1 resident.
Failed to provide food that is palatable and served at an appetizing temperature for 2 residents.
Failed to provide special eating equipment and utensils for 1 resident who needed them.
Failed to ensure dietary staff use facial hair restraints, maintain a clean kitchen environment, and store food properly to prevent foodborne illness.
Report Facts
Meals without supervision for Resident #1: 7
Meals without supervision for Resident #1: 35
Meals without supervision for Resident #2: 5
Meals without supervision for Resident #2: 24
Food temperatures at serving time: 76
Food temperatures at serving time: 81
Food temperatures at serving time: 85
Vanilla Mighty Shakes in kitchenette refrigerator: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Interviewed regarding expectation of supervision at meals |
| Staff C | Licensed Nursing Assistant (LNA) | Interviewed about Resident #1 eating alone after meal set up |
| Staff D | Dietary Manager | Interviewed about assistive devices for Resident #1 and kitchen cleaning schedule |
| Staff E | Cook | Interviewed and observed regarding food temperature, kitchen cleanliness, and facial hair restraint use |
| Staff F | Dietary Aide | Interviewed and observed regarding food temperature and uncovered food mixer |
| Staff I | Licensed Nursing Assistant | Confirmed food temperatures on test tray |
Inspection Report
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage requirements in accordance with professional principles and manufacturer instructions.
Findings
The facility failed to ensure that medications were properly labeled with open/expiration dates and stored correctly in locked compartments for 2 medication carts observed, including insulin pens without expiration dates and unidentifiable loose pills found in a medication cart drawer.
Deficiencies (2)
Medications were not labeled with open/expiration dates as required for insulin pens.
Medications were not stored in locked compartments as required; unidentifiable loose pills were found in a medication cart drawer.
Report Facts
Residents affected: 2
Unidentifiable loose pills: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Staff A confirmed medication labeling deficiencies | |
| Registered Nurse (RN) | Staff B confirmed presence of unidentifiable loose pills |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 5
Date: Mar 27, 2023
Visit Reason
The inspection was conducted due to a COVID-19 outbreak and complaint investigation regarding the facility's failure to effectively administer infection control policies, immunizations, and testing during the outbreak.
Complaint Details
The visit was complaint-related due to a COVID-19 outbreak and allegations that the facility failed to follow infection control policies, properly test symptomatic staff, and offer vaccinations. The complaint was substantiated with findings of immediate jeopardy to resident health and safety.
Findings
The facility failed to implement updated infection prevention and control policies consistent with national standards during a COVID-19 outbreak, including improper return-to-work guidelines for COVID-19 positive staff, inadequate PPE use, failure to offer and administer influenza, pneumococcal, and COVID-19 vaccinations to residents, and failure to test symptomatic staff for COVID-19.
Deficiencies (5)
Failed to administer the facility in a manner that enables it to use its resources effectively and efficiently during a COVID-19 outbreak.
Failed to provide and implement an infection prevention and control program consistent with national standards, including return to work guidelines and PPE use.
Failed to develop and implement policies and procedures for influenza and pneumococcal vaccinations, including offering and administering vaccines and providing education.
Failed to perform COVID-19 testing on symptomatic staff.
Failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and properly document vaccination status.
Report Facts
Census: 47
COVID-19 positive residents: 37
COVID-19 positive staff: 13
Residents administered medications by COVID-19 positive staff: 7
Staff positive test dates: 3
Residents reviewed for immunizations: 5
Residents affected by influenza/pneumococcal immunization deficiency: 1
Residents affected by COVID-19 vaccination deficiency: 2
Staff reviewed for COVID-19 testing deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding COVID-19 outbreak, policies, and staffing. |
| Staff B | Corporate Clinical Nurse | Interviewed regarding COVID-19 policies and testing. |
| Staff C | Registered Nurse | Tested positive for COVID-19 but worked during infectious period and administered medications to COVID-19 negative residents. |
| Staff I | Licensed Nursing Assistant (LNA) | Tested positive for COVID-19 and returned to work after 5 days. |
| Staff J | Licensed Nursing Assistant (LNA) | Tested positive for COVID-19 with symptom onset and worked during infectious period. |
| Staff K | Administration Staff | Tested positive for COVID-19 and returned to work after 5 days. |
| Staff F | Licensed Nursing Assistant (LNA) | Had medical waiver for N95 mask and cared for COVID-19 positive residents with surgical mask. |
| Staff G | Licensed Practical Nurse (LPN) | Observed not wearing required N95 mask and improperly handling PPE. |
| Staff M | Maintenance Director | Observed wearing loosely fitted N95 mask and could not recall fit-testing. |
| Staff O | Minimum Data Set Coordinator | Communicated with NH DHHS and confirmed receipt of COVID-19 consent forms. |
| Staff D | Infection Preventionist | Interviewed regarding COVID-19 vaccination ordering and documentation. |
| Staff P | Registered Nurse | Symptomatic staff not tested for COVID-19 despite screening positive. |
| Staff Q | Licensed Practical Nurse | Symptomatic staff not tested for COVID-19 despite screening positive and later tested positive. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 5
Date: Mar 27, 2023
Visit Reason
The inspection was conducted due to a COVID-19 outbreak and complaint investigation regarding the facility's failure to effectively administer infection control policies, immunizations, and testing during the outbreak.
Complaint Details
The investigation was complaint-driven due to concerns about the facility's management of a COVID-19 outbreak, including failure to follow infection control policies, improper PPE use, failure to test symptomatic staff, and failure to offer and administer vaccinations.
Findings
The facility failed to administer infection prevention and control consistent with national standards during a COVID-19 outbreak, including failure to follow return to work guidelines for COVID-19 positive staff, improper use of PPE, failure to offer and administer influenza, pneumococcal, and COVID-19 vaccinations, and failure to test symptomatic staff. Multiple staff worked while COVID-19 positive, and PPE use was inconsistent with policy.
Deficiencies (5)
Failed to administer the facility in a manner that enables it to use its resources effectively and efficiently during a COVID-19 outbreak.
Failed to provide and implement an infection prevention and control program consistent with national standards, including return to work guidelines and PPE use.
Failed to develop and implement policies and procedures for influenza and pneumococcal vaccinations, resulting in a resident not receiving vaccines after consent.
Failed to perform COVID-19 testing on symptomatic staff members who presented to work with symptoms.
Failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and properly document vaccination status.
Report Facts
Census: 47
COVID-19 positive residents: 37
COVID-19 positive staff: 13
Residents affected by deficiencies: Many
Residents affected by vaccination deficiencies: Few or Some
Staff tested positive dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding COVID-19 outbreak, policies, and staffing. |
| Staff B | Corporate Clinical Nurse | Interviewed regarding COVID-19 policies, testing, and outbreak management. |
| Staff C | Registered Nurse | Worked while COVID-19 positive, administered medications to COVID-19 negative residents. |
| Staff I | Licensed Nursing Assistant (LNA) | Tested positive and returned to work after 5 days. |
| Staff J | Licensed Nursing Assistant (LNA) | Tested positive with symptom onset, worked during positive period. |
| Staff K | Administration Staff | Tested positive and returned to work after 5 days. |
| Staff F | Licensed Nursing Assistant (LNA) | Had medical waiver for N95 mask, cared for COVID-19 positive residents with surgical mask. |
| Staff G | Licensed Practical Nurse (LPN) | Observed not wearing N95 mask in COVID-19 positive resident room, improperly handled PPE. |
| Staff M | Maintenance Director | Observed wearing loosely fitted N95 mask, unsure if fit-tested. |
| Staff O | Minimum Data Set Coordinator | Communicated with NH DHHS regarding COVID-19 operations. |
| Staff P | Registered Nurse | Worked while symptomatic with no COVID-19 testing documented. |
| Staff Q | Licensed Practical Nurse | Worked while symptomatic with no COVID-19 testing documented, later tested positive. |
| Staff D | Infection Preventionist | Confirmed lack of COVID-19 vaccination documentation and ordering delays. |
| Staff K | Medical Records / Administrative Staff | Confirmed lack of vaccination documentation for Resident #12. |
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