Inspection Reports for
Lebanon Center Genesis Healthcare
24 OLD ETNA ROAD, LEBANON, NH, 03766
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
73% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Oct 6, 2025
Visit Reason
The inspection was conducted due to a confirmed resident case of Legionella infection, to assess the facility's adherence to infection prevention and control policies and the Water Management Plan.
Complaint Details
The investigation was triggered by a confirmed case of Legionella pneumonia in Resident #1, who was hospitalized and subsequently died. The facility did not test or remediate the water system after the diagnosis, and a humidifier was used in the resident's room contrary to policy.
Findings
The facility failed to follow its infection control policies and Water Management Plan by not testing or remediating the water system after a confirmed Legionella case, allowing use of a humidifier in a resident's room, and failing to document control measures. These failures exposed the 80 residents to potential Legionella spread and growth.
Deficiencies (1)
Failure to adhere to infection prevention and control policies and Water Management Plan regarding Legionella prevention.
Report Facts
Resident census: 80
Water heater temperature: 160
Hot water storage tanks capacity: 120
Hot water storage tanks count: 2
Boilers count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Interviewed regarding infection control policies and Legionella testing |
| Staff C | Maintenance Supervisor | Interviewed regarding water management plan and Legionella testing |
| Staff E | Nurse Practitioner | Signed progress note regarding Resident #1's condition and hospital transfer |
| Staff A | Licensed Nursing Assistant | Interviewed about humidifier use in Resident #1's room |
| Staff D | Infection Preventionist | Interviewed about water sample collection from Resident #1's humidifier |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication self-administration, resident assessments, care planning, food service, infection control, and smoking policies.
Findings
The facility was found deficient in multiple areas including failure to assess and document residents' ability to self-administer medications, inaccurate Minimum Data Set (MDS) assessments, failure to hold routine interdisciplinary care plan meetings and develop comprehensive care plans, failure to accommodate resident dietary preferences and allergies, improper infection control practices related to laundry processing, and failure to implement the facility's smoking policy.
Deficiencies (6)
Failed to determine if self-administration of medications was clinically appropriate for 2 of 3 residents reviewed.
Failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 residents.
Failed to hold routine interdisciplinary care plan meetings for 2 residents and failed to develop and update comprehensive care plans for 1 resident.
Failed to follow menu preferences, allergies, and intolerances for 1 resident reviewed for food concerns and 1 resident reviewed for nutrition.
Failed to ensure proper storage of washed linens and proper processing of linens to reduce risk of accidental contamination.
Failed to implement the facility's smoking policy for 1 resident reviewed for smoking.
Report Facts
Residents reviewed: 18
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Vocational Nurse | Interviewed regarding medication self-administration for Resident #6 |
| Staff I | Licensed Practical Nurse | Interviewed regarding medication self-administration for Resident #8 |
| Staff L | Registered Nurse | Confirmed lack of self-administration assessment for Resident #8 and confirmed Resident #1 as independent smoker |
| Staff O | Director of Nursing | Confirmed MDS findings for Resident #1 |
| Staff B | MDS Coordinator | Confirmed MDS inaccuracies for Residents #4, #2, and #24 |
| Staff C | Wound Nurse | Confirmed wound assessment findings for Resident #2 |
| Staff F | Director of Social Services | Confirmed failure to hold routine care plan meetings |
| Staff G | Registered Nurse | Confirmed lack of care plan for Resident #47's CPAP use |
| Staff N | Speech Therapist | Confirmed dietary needs and preferences for Resident #17 |
| Staff M | Food Service Manager | Confirmed failure to provide appropriate finger foods and lactose-free milk for residents |
| Staff H | Infection Preventionist | Observed laundry practices |
| Staff P | Director of Housekeeping | Interviewed about laundry washing machine use and policies |
| Staff Q | Laundry Aide | Interviewed about laundry detergent and bleach use |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 7, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the management of residents' personal funds, including authorization to act as fiduciaries, provision of quarterly statements, and notification of residents about certain account balances.
Findings
The facility failed to obtain written authorization from residents to act as fiduciaries for their funds for 3 of 5 residents, did not provide quarterly statements to 2 of 5 residents or their representatives within 30 days after the quarter ended, and failed to notify 1 resident when their personal fund account balance exceeded the SSI resource limit.
Deficiencies (3)
Failed to obtain written authorization of a resident to act as a fiduciary of the resident's funds for 3 of 5 residents.
Failed to provide quarterly statements in writing to the resident or the resident's representative within 30 days after the end of the quarter for 2 of 5 residents.
Failed to notify a resident when the amount in the resident's personal fund account reached or exceeded $200 less than the SSI resource limit for 1 of 5 residents.
Report Facts
Resident count reviewed for personal funds: 5
Monthly balances for Resident #1: January $5784.29; February $5335.58; March $4958.66; April $4550.90; May $3604.10; June $4102.22
SSI resource limit: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Signed quarterly statements not by residents or their representatives; confirmed quarterly statements were not given to residents or representatives |
| Staff B | Regional Business Office Manager | Provided information on Medicaid SSI resource limit |
Inspection Report
Routine
Census: 88
Deficiencies: 13
Date: Jul 11, 2024
Visit Reason
Routine inspection to assess compliance with regulatory standards including care planning, medication administration, staffing, infection control, and other quality measures.
Findings
The facility was found deficient in multiple areas including failure to notify residents or representatives of care plan meetings, inaccurate resident assessments, medication errors, insufficient staffing, lack of qualified activities director, failure to post accurate nurse staffing information, improper psychotropic medication orders, inadequate snack offerings, incomplete Quality Assurance committee attendance, failure to follow infection control protocols, inadequate antibiotic stewardship, and lack of staff training on abuse and neglect.
Deficiencies (13)
Failed to notify resident and/or representative of quarterly care plan meetings for 1 of 19 residents reviewed.
Failed to ensure residents' Minimum Data Set (MDS) accurately reflected status for 4 of 19 residents.
Failed to ensure a resident received medication as ordered for 1 out of 26 medications observed (incorrect Heparin dose).
Failed to ensure the activities program was directed by a qualified professional for a facility census of 88 residents.
Failed to provide sufficient nursing staff as determined by facility assessment, with low weekend staffing.
Failed to update posted daily nurse staffing information to reflect actual hours worked.
Failed to ensure orders for psychotropic drugs were limited to 14 days for 1 of 1 residents reviewed.
Failed to ensure resident was free from significant medication error (incorrect Heparin dose).
Failed to offer residents a nourishing snack at bedtime with 15 hours between evening and breakfast meals.
Failed to ensure required Quality Assessment and Assurance committee members attended meetings at least quarterly.
Failed to follow CDC guidance for Enhanced Barrier Precautions for 1 resident with IV access.
Failed to use antibiotic use protocols to identify unnecessary or inappropriate antibiotic use for 2 of 4 months reviewed.
Failed to provide staff training on abuse, neglect, exploitation, and misappropriation of resident property for 1 of 5 staff reviewed.
Report Facts
Facility census: 88
Medications observed: 26
Residents reviewed for care plans: 19
Residents reviewed for psychotropic medication: 19
Staff training reviewed: 5
Hours Per Patient Day (HPPD) required: 1.63
Nurse aide HPPD on low staffing weekends: 1.43
Nurse aide HPPD on low staffing weekends: 1.57
Psychotropic medication doses after 14 days: 10
Antibiotic prescriptions without criteria met: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Social Services | Confirmed lack of documentation for quarterly care plan meetings |
| Staff A | MDS Coordinator | Confirmed inaccurate coding of Minimum Data Set assessments |
| Staff B | Licensed Practical Nurse | Administered incorrect dose of Heparin and confirmed error |
| Staff H | Activities Aide | Reported no Director of Activities at facility |
| Staff G | Administrator | Confirmed no Director of Activities and Quality Assurance committee attendance issues |
| Staff M | Scheduler/Human Resources | Confirmed low staffing and failure to update nurse staffing postings |
| Staff D | Director of Nurses | Confirmed psychotropic medication order violation and lack of staff training for Staff L |
| Staff C | Infection Preventionist | Confirmed failure to follow Enhanced Barrier Precautions and antibiotic stewardship issues |
| Staff L | Licensed Nursing Assistant | Lacked training on abuse, neglect, exploitation, and misappropriation of resident property |
| Staff F | Food Service Director | Confirmed inadequate bedtime snack offerings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding failure to inform a resident's representative about a treatment change and concerns about the sanitary environment of the nursing home.
Complaint Details
The complaint investigation found that the facility did not inform the resident's power of attorney about medication changes and failed to maintain a sanitary environment, as evidenced by soiled ceiling tiles. Residents affected were few and harm was minimal.
Findings
The facility failed to inform the resident's power of attorney about a medication discontinuation and restart for one resident, and the nursing home environment was found to be unsanitary with soiled ceiling tiles in the hallway.
Deficiencies (2)
Failed to inform the resident's representative of a treatment change for 1 of 1 resident reviewed for resident rights.
Failed to provide a sanitary environment; ceiling tiles outside rooms were soiled with a black spotted substance.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident care, including honoring resident choices for showers, adherence to psychotropic drug care plans, updating advance directives, medication storage and labeling, and food storage policies.
Complaint Details
The visit was complaint-related, focusing on issues such as failure to honor resident shower preferences, incomplete psychotropic drug care plans, failure to update advance directives, medication storage violations, and improper food labeling and storage. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in honoring resident shower preferences, failing to conduct required AIMS assessments for residents on psychotropic drugs, not updating advance directives in care plans, improper storage and labeling of medications including expired vaccines, and failure to label and store food items brought by visitors according to policy.
Deficiencies (5)
Failed to honor residents' choice for showers for 1 out of 5 residents reviewed for Activities of Daily Living.
Failed to follow the comprehensive care plan for 2 out of 2 residents reviewed for psychotropic drugs; no AIMS assessments were done as required.
Failed to update the comprehensive care plan within 7 days for 1 out of 1 resident reviewed for advance directives; care plan incorrectly documented full code status despite DNR order.
Failed to ensure expired vaccines were removed from use and all medication was secured; observed opened COVID-19 vaccine vials without open dates and unsecured aspirin in unlocked cabinet.
Failed to follow professional standards for labeling and storage of food items brought to residents by visitors in 2 kitchenettes; multiple food items unlabeled and undated.
Report Facts
Residents reviewed: 19
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication rooms reviewed: 2
Kitchenettes reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed shower scheduling and documentation for Resident #52 | |
| Licensed Practical Nurse | Confirmed no AIMS assessment done with Resident #26 | |
| Director of Nursing | Confirmed no AIMS assessments done with Residents #26 and #62 | |
| Registered Nurse | Confirmed Resident #26 was a DNR/POLST and care plan documentation discrepancy | |
| Dining Service Director | Confirmed unlabeled food items in kitchenettes |
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