Inspection Reports for Mt. Carmel Rehabilitation and Nursing Center
NH, 03104
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to inform residents about the risks and benefits of psychotropic medications and failure to implement the facility's COVID-19 vaccination policy for eligible residents.
Findings
The facility failed to inform Resident #121 or their representative about the risks and benefits of prescribed psychotropic medications. Additionally, the facility failed to administer COVID-19 vaccines to Residents #48 and #79 after they consented, not following the facility's vaccination policy.
Complaint Details
The complaint investigation found substantiated issues regarding psychotropic medication information and COVID-19 vaccination administration failures for specific residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to inform Resident #121 or representative of the risks and benefits of psychotropic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement COVID-19 vaccination policy for Residents #48 and #79, resulting in no vaccine administration after consent. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for unnecessary medications: 22
Residents reviewed for immunizations: 5
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed failure to inform Resident #121 or representative about psychotropic medication risks and benefits; confirmed Residents #48 and #79 did not receive COVID-19 vaccine after consent. | |
| Infection Preventionist | Confirmed findings related to COVID-19 vaccination deficiencies. |
Inspection Report
Routine
Deficiencies: 5
May 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, abuse reporting, resident assessments, medication administration, medication storage, and overall facility quality standards.
Findings
The facility was found deficient in multiple areas including failure to ensure clinical appropriateness for resident self-administration of medications, failure to timely report an allegation of misappropriation, inaccurate resident assessments in Minimum Data Set (MDS) documentation, failure to follow physician medication orders, and failure to secure medication carts properly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Potential for minimal harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure that a resident was clinically appropriate to self-administer their medications. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely report an allegation of misappropriation to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure that residents' Minimum Data Set (MDS) accurately reflected the resident's status for 3 residents. | Level of Harm - Potential for minimal harm |
| Facility failed to follow physician orders for medication administration for 1 resident and for 1 medication observed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure medications were secured for 1 of 4 medication carts observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication self-administration: 3
Residents reviewed for allegations: 9
Residents reviewed for MDS accuracy: 22
Residents reviewed for medication administration: 23
Doses of Midodrine given with SBP greater than 110: 5
Dates medication not available: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Confirmed medications present in Resident #4's room |
| Staff F | Director of Nursing | Confirmed Resident #4 was not assessed for self-administration and confirmed medication administration findings |
| Staff K | Nurse Practitioner | Unaware of Resident #4 self-administering medication and not notified of medication shortage |
| Staff A | Social Worker | Revealed missing items were not reported to SSA or police |
| Staff D | Administrator | Confirmed failure to report misappropriation allegation |
| Staff G | Clinical Assessment Manager | Confirmed inaccuracies in MDS assessments for residents #83, #89, and #103 |
| Staff H | Licensed Practical Nurse | Administered medication against physician order and did not understand greater than symbol |
| Staff J | Medication Nursing Assistant (MNA) | Confirmed medication cart was unlocked while unattended |
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 25, 2023
Visit Reason
The inspection was conducted to investigate alleged violations of abuse, neglect, exploitation, or mistreatment for Resident #32 as part of a complaint investigation.
Findings
The facility failed to thoroughly investigate alleged abuse for Resident #32, failed to notify the provider of a change in condition, failed to assess and monitor identified areas of concern, and failed to properly dispose of expired medications in medication rooms and carts.
Complaint Details
The complaint investigation focused on Resident #32 regarding alleged abuse. The investigation found failure to investigate the injury, failure to notify the provider timely, and failure to monitor the resident's condition properly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure all alleged violations of abuse, neglect, exploitation or mistreatment were thoroughly investigated for Resident #32. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the provider of a change in Resident #32's condition and failed to assess and monitor identified areas of concern. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms and on 1 of 6 medication carts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 18
Residents reviewed for abuse with issues: 2
Medication rooms inspected: 3
Medication carts inspected: 6
Expired Pantoprazole Sodium tablets: 40
Expired Levothyroxine Sodium tablets: 75
Insulin Aspart units: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Nursing Assistant | Reported discolored area on Resident #32's wrist and hand |
| Staff F | Registered Nurse | Was made aware of discolored area on Resident #32's hand but did not write a note or call provider |
| Staff A | Nurse Manager | Unaware of Resident #32's injury and areas of concern |
| Staff G | Registered Nurse | Confirmed expired medications for Resident #67 |
| Staff H | Licensed Practical Nurse | Confirmed expired medications for Resident #67 |
| Staff I | Registered Nurse | Confirmed expired insulin for Resident #87 |
| Staff J | Assistant Director of Nursing | Confirmed expired insulin for Resident #87 |
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