Inspection Reports for
Hillsboro House Nursing Home
67 SCHOOL STREET, HILLSBORO, NH, 03244
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
79% occupied
Based on a September 2024 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with medication labeling, storage, and infection prevention and control policies during medication administration at Hillsboro House Nursing Home.
Findings
The facility failed to follow accepted professional principles for labeling and storing drugs and biologicals, including unlabeled medication cups and an undated vial of Tuberculin solution. Additionally, the facility failed to implement proper infection control practices during medication administration, as staff did not perform hand hygiene before or after resident contact.
Deficiencies (2)
Failure to label and properly store drugs and biologicals, including unlabeled medication cups and an undated vial of Tuberculin solution.
Failure to implement infection prevention and control policies during medication administration, including lack of hand hygiene by staff.
Report Facts
Residents affected: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Staff A involved in medication administration and interviews related to deficiencies |
Inspection Report
Routine
Census: 26
Deficiencies: 7
Date: Sep 5, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements including medication self-administration, bed rail use, medication storage, food service qualifications, kitchen sanitation, staffing, infection prevention, and water management.
Findings
The facility was found deficient in multiple areas including failure to assess and document clinical appropriateness for medication self-administration for residents, lack of bed rail assessment and informed consent, improper medication labeling and storage, unqualified food service director, inadequate dishwasher sanitation, insufficient facility assessment for infection preventionist role, and incomplete water management program.
Deficiencies (7)
Failed to determine clinical appropriateness of self-administration of medications for 2 of 4 residents reviewed.
Failed to ensure resident was assessed and informed consent obtained for use of full-length bed rails for 1 of 1 resident reviewed.
Failed to ensure medications were labeled and stored according to professional principles for 1 medication cart and 1 resident.
Failed to ensure food service director met minimum qualifications.
Failed to ensure dishes were sanitized according to manufacturer's instructions in the main kitchen.
Failed to determine amount of time required to fulfill role of designated Infection Preventionist in facility assessment.
Failed to develop and implement comprehensive infection control guideline for facility water management affecting 26 residents.
Report Facts
Residents reviewed: 13
Residents affected: 26
Medication pills observed: 5
Medication pills observed: 7
Medication pills observed: 3
Dishwasher temperature range: 160
Dishwasher temperature range: 176
Dishwasher wash temperature observed: 150
Dishwasher rinse temperature observed: 174
Infection Preventionist time dedicated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Confirmed lack of self-administration medication assessment and policy; confirmed lack of bed rail assessment and consent; stated IP role and time dedicated; confirmed medication storage policy |
| Staff B | Registered Nurse | Observed leaving medications for Resident #22; confirmed cognitive ability of Resident #22 to self-administer medications |
| Staff C | Administrator / Food Service Director | Confirmed part-time dietician and lack of food safety and management training |
| Staff E | Lead Cook | Interviewed regarding dishwasher temperature logs and knowledge of acceptable temperatures |
| Staff F | Dietary Aide | Observed dishwasher cycle temperatures |
| Staff G | Administrator Assistant | Revealed no logs for flushes or legionella test results |
Inspection Report
Census: 25
Deficiencies: 6
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, activities program qualifications, staffing, facility-wide assessments, staffing data submission, and vaccination policies at Hillsboro House Nursing Home.
Findings
The facility was found deficient in providing a private space for resident group meetings, ensuring the activities program was directed by a qualified professional, having a full-time Director of Nursing, conducting a comprehensive facility-wide assessment, submitting accurate direct care staffing data to CMS, and providing education on Pneumococcal vaccination to residents.
Deficiencies (6)
Failed to ensure residents were provided with a private space for a resident group to meet regularly.
Failed to ensure the activities program was directed by a qualified professional.
Failed to have a Director of Nursing serving on a full-time basis.
Failed to conduct and document a facility-wide assessment to determine necessary resources for competent resident care.
Failed to submit accurate direct care staffing information to CMS for Registered Nurse hours and other staff categories.
Failed to ensure a resident was offered or provided education on the risks and benefits of the Pneumococcal vaccination.
Report Facts
Facility census: 25
Days with no licensed nursing coverage: 10
Days reviewed for staffing data: 92
Days reviewed for staffing data: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Named in findings related to activities director qualifications, multiple roles held, and vaccination education deficiency |
| Staff B | Administrator | Interviewed regarding activities director qualifications, facility assessment, and staffing data submission |
| Staff C | Business Office Manager | Interviewed regarding Payroll Based Journal staffing data submission |
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