Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 21, 2025
Visit Reason
The inspection was conducted to investigate complaints related to medication self-administration, PASARR referrals, care plan implementation, medication administration, and medication labeling and storage at Harris Hill Center.
Findings
The facility was found deficient in multiple areas including failure to assess and document self-administration of medications, failure to refer a resident for required Level II PASARR, failure to implement care plans for weight gain and insulin management, improper insulin administration technique, and failure to properly label and remove expired medications from medication carts.
Complaint Details
The complaint investigation focused on medication self-administration, PASARR referral compliance, care plan implementation for weight and insulin management, medication administration technique, and medication labeling and storage practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to determine if self-administration of medications was appropriate for 1 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to refer resident with serious mental disorder for Level II PASARR as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement care plan for weight gain notification and insulin management for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure insulin was administered per manufacturer's instructions and facility policy for 1 of 4 residents observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were appropriately labeled and expired medications removed from use for 1 of 2 medication carts observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 18
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents observed: 4
Medication carts observed: 2
Weight increase: 3.2
Insulin dose: 4
Insulin priming dose: 1
Insulin pen hold time: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Medication Nursing Assistant | Confirmed Resident #25 did not have an order to self-administer Voltaren Cream |
| Staff C | Clinical Corporate Nurse | Confirmed Resident #25 did not have an assessment to self-administer medications |
| Staff G | Social Service Director | Revealed Resident #16 never had a Level II PASARR as required |
| Staff D | Medical Director | Confirmed no notification to provider for Resident #32 weight gain and Resident #58 low blood sugar |
| Staff A | Registered Nurse | Observed and confirmed improper insulin administration technique for Resident #77 |
| Staff B | Licensed Practical Nurse | Confirmed expired and unlabeled Albuterol Sulfate inhaler on medication cart |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 4, 2024
Visit Reason
The inspection was conducted due to a complaint or concern regarding the improper administration of insulin, specifically the use of one resident's insulin pen for another resident, risking bloodborne and bacterial pathogen transmission.
Findings
The facility failed to ensure that one of four residents reviewed for insulin was protected from exposure to bloodborne and bacterial pathogens when staff used another resident's previously used insulin pen. Interviews and record reviews confirmed the improper use of insulin pens, which is against facility policy and CDC guidelines. The facility conducted audits, staff training, and notified public health authorities following the incident.
Complaint Details
The complaint investigation found substantiated that staff used a previously used insulin pen from one resident to administer insulin to another resident, violating infection control policies and risking pathogen transmission.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and implement an infection prevention and control program related to insulin pen use. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for insulin: 4
Units of insulin administered: 10
Date of incident: May 28, 2024
Date of audit: May 30, 2024
Date of in-service training start: May 29, 2024
Date of Quality Assurance meeting: May 30, 2024
Date of public health notification: May 30, 2024
Date of public health follow-up: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Evening nurse who administered insulin using another resident's insulin pen |
| Staff A | Licensed Practical Nurse | Confirmed the use of another resident's insulin pen by Staff C |
| Staff B | Director of Nursing | Confirmed facility policy against borrowing medication and conducted audits and staff training |
Inspection Report
Routine
Deficiencies: 4
Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a nursing facility, including medication administration, accident hazard prevention, and food service practices.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for compression stockings, improper administration of medication via PICC line, inadequate supervision and control of smoking supplies, and failure to serve food in accordance with professional standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow physicians' orders to provide compression stockings for 1 resident with edema. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure professional standards were followed for administering medication in a PICC line for 1 observed medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an environment free of accident hazards related to smoking supplies for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food in accordance with professional standards by allowing food service staff to handle ready-to-eat food with bare hands. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for edema: 27
Residents reviewed for smoking: 27
PICC line medication administrations observed: 1
Dining rooms observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse | Confirmed findings related to compression stockings and medication administration |
| Staff G | Licensed Practical Nurse | Observed and confirmed improper PICC line medication administration |
| Staff E | Licensed Nursing Assistant | Interviewed regarding resident smoking supplies |
| Staff D | Licensed Practical Nurse | Interviewed regarding resident smoking supplies |
| Staff F | Licensed Nursing Assistant | Observed serving food with bare hands |
Inspection Report
Routine
Deficiencies: 13
Jan 23, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, medication management, staffing, and immunizations at Harris Hill Center, Genesis Healthcare.
Findings
The facility was found deficient in multiple areas including failure to document advance directives, maintain a safe environment, notify residents and ombudsman of transfers, develop and implement comprehensive care plans, follow physician orders for treatments, provide adequate supervision during meals, maintain sufficient staffing levels, ensure proper medication storage and labeling, and ensure appropriate use and monitoring of medications and immunizations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to document advanced directives for 1 of 33 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a clean and safe environment on 2 of 2 nursing units with multiple maintenance issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident and Ombudsman of hospital transfer for 1 of 1 residents reviewed. | Level of Harm - Potential for minimal harm |
| Failed to develop and implement a complete care plan for 2 of 2 residents reviewed for position and mobility and 2 of 5 residents reviewed for unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update care plan after resident sustained falls for 1 of 3 residents reviewed for accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's order for wound dressing change and medical treatments without physician's order for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care to maintain or improve range of motion for 2 residents with limited ROM. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure environment free from accident hazards and provide adequate supervision at meals for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient nursing staff to meet residents' needs on the third floor Dementia Unit for 16 of 30 days reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmacy irregularities identified on monthly drug regimen reviews were documented and acted upon for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure antipsychotic medication had adequate indication and monitoring for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications and biologicals were labeled and stored properly including expired medications and vaccines in medication rooms and carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident was offered pneumococcal vaccine. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advanced directives: 33
Residents reviewed for position and mobility care plans: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for accidents: 3
Residents reviewed for medical treatments: 3
Residents reviewed for Activities of Daily Living (ADL): 33
Nursing schedule days reviewed: 30
Residents on third floor Dementia Unit: 44
Staffing minimum LNAs on third floor Dementia Unit: 3
Residents requiring total assist for bathing on third floor Dementia Unit: 23
Residents requiring total assist for eating on third floor Dementia Unit: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse | Confirmed failure to follow wound dressing order for Resident #1 |
| Staff I | Interim Director of Nursing | Confirmed multiple findings including failure to notify transfer, care plan deficiencies, and medication review issues |
| Staff F | Social Service Specialist | Confirmed failure to notify resident and Ombudsman of transfer |
| Staff M | Third floor Nurse Manager | Confirmed care plan and medication monitoring deficiencies for Resident #50 |
| Staff O | Licensed Nursing Assistant | Reported Resident #50 refused C-grip splint application |
| Staff A | Licensed Practical Nurse | Confirmed expired and improperly stored medications |
| Staff K | Registered Nurse | Confirmed expired inhaler in medication cart |
| Staff L | Infection Preventionist | Confirmed failure to offer pneumococcal vaccine to Resident #59 |
| Staff P | Occupational Therapist | Confirmed care plan and restorative nursing program issues for Resident #4 and #50 |
| Staff Q | Speech Therapist | Confirmed need for supervision during meals for Resident #46 |
| Staff S | Licensed Practical Nurse | Confirmed Resident #41 requires total assist with meals |
| Staff U | Administrative Assistant | Provided staffing minimums for third floor Dementia Unit |
| Staff V | Licensed Nursing Assistant | Reported staffing shortages and meal assistance delays on third floor Dementia Unit |
| Staff W | Licensed Nursing Assistant | Confirmed need for supervision for Resident #46 during meals |
| Staff X | Human Resources | Denied concerns about staffing shortages |
| Staff Y | Scheduler | Denied concerns about staffing shortages |
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