Inspection Reports for
Mineral Springs
1251 WHITE MOUNTAIN HIGHWAY, North Conway, NH, 03860
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
55% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to follow a health care provider's order for a therapeutic diet for a resident with a swallowing issue.
Complaint Details
The complaint investigation found that Resident #43 was not provided the prescribed pureed diet for dysphagia, confirmed by observations, interviews with dietary and nursing staff, and review of the resident's care plan and speech therapy discharge summary.
Findings
The facility failed to provide pureed fruits and vegetables as ordered for Resident #43 with dysphagia, instead serving whole sliced fruits, which did not comply with the prescribed therapeutic diet. Interviews and observations confirmed the dietary noncompliance.
Deficiencies (1)
Failure to follow the health care provider's order for a therapeutic diet for a resident with dysphagia, serving whole fruits instead of pureed fruits and vegetables.
Report Facts
Residents reviewed for nutrition: 14
Residents with dietary order reviewed: 1
Date of dietary order: Apr 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Speech Language Pathologist | Confirmed discharge recommendations for pureed fruits and vegetables for Resident #43 |
| Staff B | Dietician | Confirmed that Resident #43's fruits and vegetables should have been pureed |
| Staff C | Dietary Manager | Confirmed that Resident #43's fruits and vegetables should have been pureed |
| Staff D | Medication Nursing Assistant | Confirmed that watermelon served was not pureed |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, medication administration, staffing, medical record accuracy, and other professional standards at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, failure to inform residents about Medicaid/Medicare coverage and pharmacy options, failure to follow physician orders for pain management, failure to maintain required RN staffing levels, improper labeling and storage of medications, and inaccurate documentation of medical records for a resident with PTSD.
Deficiencies (6)
Failed to ensure residents' right to formulate advance directives for 2 of 2 residents reviewed.
Failed to inform resident about Medicaid/Medicare coverage and potential liability for services not covered.
Failed to follow physician's orders for pain management for 1 of 2 residents reviewed.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours a day, 7 days a week, for 4 days in September 2024.
Failed to ensure medications were labeled and dated in accordance with professional principles for 2 medication carts observed.
Failed to ensure medical records were accurately documented for 1 resident reviewed for PTSD.
Report Facts
Residents reviewed: 15
Residents affected: 2
Residents affected: 1
Residents affected: 1
Days without RN coverage: 4
Medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Confirmed findings related to advance directives and medication labeling |
| Staff A | Nurse Manager | Confirmed findings related to advance directives and pain management |
| Staff B | Admissions Coordinator | Provided information about pharmacy options during admission |
| Staff D | Director of Nursing | Confirmed RN staffing deficiencies |
| Staff E | Registered Nurse | Confirmed medication labeling deficiencies |
| Staff F | Social Worker | Confirmed inaccurate PTSD documentation |
| Staff G | Advanced Practical Registered Nurse | Confirmed pain management documentation deficiencies |
Inspection Report
Routine
Census: 48
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with nursing staff requirements and resident care standards, focusing on staffing levels and their impact on resident well-being.
Findings
The facility failed to provide sufficient nursing staff as determined by their facility assessment, resulting in delays in care, late medication administration, and inadequate assistance with basic needs such as incontinent care and showers. Staffing shortages were documented across multiple shifts and dates, with interviews confirming the impact on resident care.
Deficiencies (1)
Failure to provide sufficient nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Census: 48
Staffing Deficiencies: 45
Residents Affected: Many residents affected as stated in the deficiency
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Assistant (LNA) | Interviewed regarding staffing shortages and impact on resident care |
| Staff L | Medication Nursing Assistant (MNA) | Interviewed regarding staffing shortages and impact on resident care |
| Resident #26 | Interviewed about delays in care and late medication administration | |
| Resident #45 | Interviewed about staffing shortages causing delayed assistance | |
| Resident #21 | Resident Council President | Interviewed about staffing problems on specific shifts |
| Staff R | Licensed Nursing Assistant (LNA) | Interviewed about difficulty providing showers with low staffing |
| Staff P | Licensed Nursing Assistant (LNA) | Interviewed about shift staffing and resident care prioritization |
| Staff Q | Licensed Nursing Assistant (LNA) | Interviewed about being the only LNA on shift and impact on resident care |
| Staff B | Scheduler | Confirmed staffing shortages documented in daily staffing sheets |
| Staff K | Advanced Practice Registered Nurse | Expressed concerns about staffing and residents not receiving consistent wound care |
Inspection Report
Routine
Census: 48
Deficiencies: 13
Date: Sep 12, 2024
Visit Reason
Routine inspection conducted to assess compliance with regulatory standards including resident care, medication administration, staffing, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, medication administration errors and delays, inadequate staffing levels, failure to provide showers, lack of weekend activities, unqualified activities director, incomplete pressure ulcer care documentation, improper medication storage and labeling, lack of a comprehensive QAPI plan, and inadequate infection prevention and control program including water management and infection preventionist training.
Deficiencies (13)
Failed to ensure resident's call bell was within reach for 1 of 1 residents reviewed.
Failed to provide a clean and homelike environment on 1 of 2 units observed.
Medication administrations documented as given outside of ordered timeframes for multiple residents.
Failed to provide showers for 1 of 3 residents reviewed for activities of daily living.
Failed to provide facility-sponsored activities on weekends and activities program directed by unqualified professional.
Failed to provide appropriate pressure ulcer care and weekly wound measurements for 1 resident.
Failed to provide sufficient nursing staff to meet resident needs for census of 48 residents.
Resident's drug regimen included untimely medication administration and inadequate monitoring for insulin for 1 of 3 residents reviewed.
Medication error rate was 5.56% with 2 errors out of 36 medication passes observed.
Failed to maintain locked storage of medications, failed to ensure accurate labeling, and discarded medications after expiration.
Failed to develop, implement, and maintain an effective comprehensive, data-driven QAPI plan.
Failed to follow infection control guidelines for water management and lacked system to monitor control measures to prevent Legionella.
Failed to designate an Infection Preventionist with specialized training in infection prevention and control.
Report Facts
Medication error rate: 5.56
Facility census: 48
Staffing levels: 45
Medication administration delays: 2.5
Medication administration delays: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Director of Activities | Unqualified activities director without required certifications or experience |
| Staff E | Director of Nursing | Confirmed findings related to wound care and insulin administration |
| Staff K | Advanced Practice Registered Nurse | Confirmed concerns with staffing and wound care, and lack of notification for insulin issues |
| Staff D | Infection Preventionist | Designated Infection Preventionist without specialized training |
| Staff N | Registered Nurse | Observed medication administration errors and improper medication disposal |
| Staff B | Scheduler | Confirmed staffing shortages and scheduling issues |
| Staff M | Registered Nurse | Confirmed expired medication storage issues |
| Staff L | Medication Nursing Assistant | Confirmed medication cart storage and labeling deficiencies |
| Staff I | Maintenance Director | Confirmed lack of water management monitoring for Legionella prevention |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate anticoagulant therapy to a resident, which led to a serious health risk.
Complaint Details
The complaint investigation found substantiated failure to provide anticoagulant therapy and required lab monitoring, leading to resident hospitalization for pulmonary embolisms.
Findings
The facility failed to ensure that a resident receiving anticoagulant therapy received necessary care for 5 days, resulting in the resident being sent to the hospital with bilateral pulmonary embolisms. The resident did not receive Coumadin as ordered, and required INR lab work was not completed.
Deficiencies (1)
Failure to provide anticoagulant therapy and perform required INR testing for Resident #1, resulting in immediate jeopardy to resident health or safety.
Report Facts
Days without anticoagulant therapy: 5
Date of inspection: May 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner | Documented resident's missed Coumadin doses and recommended emergency room evaluation. |
| Staff B | Unit Manager | Confirmed no INR testing was done as ordered. |
| Staff C | Administrator | Confirmed resident hospitalization due to missed anticoagulant therapy. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
The inspection was conducted due to complaints from residents regarding medication administration and staff responsiveness, specifically concerns that medications were not given timely or at all to certain residents.
Complaint Details
The complaint investigation was substantiated by interviews and record reviews showing that grievances about medication administration delays and staff conduct were not properly logged or resolved as required by facility policy.
Findings
The facility failed to follow its grievance policy for tracking, investigating, and resolving complaints for 2 of 4 residents reviewed. Multiple residents and staff confirmed grievances about medication delays and staff conduct, but no grievances were logged or investigated for the reported issues.
Deficiencies (1)
Failure to follow policy for tracking, investigating, and prompt resolution of grievances for 2 out of 4 residents reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in medication administration complaints by residents. |
| Staff B | Unit Manager | Received complaints from residents and verbally reported them to Director of Nursing. |
| Staff C | Director of Nursing | Reviewed patient concerns and was involved in grievance process but could not confirm grievance logging. |
| Staff D | Social Worker | Knew about grievances but had no record and was unsure of details. |
| Staff E | Activity Director | Received written grievance from Resident #2 and confirmed grievance submission. |
| Staff F | Interim Administrator | Confirmed no awareness of grievances including those from Resident Council Meeting. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 4
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to timely report suspected abuse, failure to thoroughly investigate alleged neglect, failure to follow physician orders, and insufficient nursing staff to meet residents' needs.
Complaint Details
The visit was complaint-related, triggered by grievances alleging abuse, neglect, and staffing inadequacies. The facility was found to have failed in timely reporting, investigation, and staffing adequacy. Substantiation status is not explicitly stated.
Findings
The facility failed to report allegations of abuse for 3 of 4 grievances, failed to investigate neglect allegations for 2 of 4 grievances, failed to follow physician orders for one resident, and failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed care and increased risk to residents.
Deficiencies (4)
Failed to timely report suspected abuse for 3 of 4 grievances reviewed.
Failed to ensure alleged violations of neglect were thoroughly investigated for 2 of 4 grievances reviewed.
Failed to follow physician orders for 1 of 2 residents reviewed, including failure to obtain urine specimen and incomplete antibiotic administration.
Failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed responses to call lights and inadequate care.
Report Facts
Grievances reviewed: 4
Residents census range: 68
Residents census range: 71
Minimum staffing Certified Nursing Assistants (CNA): 2
Minimum staffing Certified Nursing Assistants (CNA): 3
Nurse Aides Day Shift: 5
Nurse Aides Evening Shift: 4
Nurse Aides Night Shift: 3
Residents requiring two-person assist: 8
Residents requiring one-on-one assistance with meals: 5
Residents on night shift: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Named in findings related to failure to report abuse and failure to investigate neglect |
| Staff A | Nurse Practitioner | Named in findings related to failure to follow physician orders |
| Staff C | Licensed Nursing Assistant | Named in allegation of rudeness reported by Resident #4 |
| Staff D | Licensed Nursing Assistant | Interviewed regarding staffing inadequacies and resident care |
| Staff E | Anonymous Aide | Provided witness statement regarding staffing shortages |
| Staff F | Licensed Nursing Assistant | Interviewed regarding staffing shortages and resident care delays |
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