Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
241% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 21, 2025
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards and resident care requirements.
Findings
The facility was found deficient in multiple areas including failure to provide scheduled showers to residents, unsafe and unclean living environments, involuntary seclusion of a resident, failure to follow care plans, improper medication labeling and storage, inadequate nutritional snacks for diabetic residents, unsafe food storage practices, and failure to implement proper infection prevention and control measures.
Deficiencies (8)
Failure to ensure residents scheduled for weekly showers received them for 3 of 8 residents reviewed.
Failure to provide a safe, clean, comfortable, and homelike environment including damaged flooring, soiled surfaces, and exposed drywall in resident rooms and kitchenettes.
Failure to keep a resident free from involuntary seclusion by blocking exit with furniture for 1 resident.
Failure to ensure residents receive care in accordance with plan of care for 1 resident regarding follow-up ENT appointment.
Failure to label medications with open expiration dates, monitor proper temperature controls, and restrict medication cart access to authorized personnel.
Failure to provide nourishing snacks consistent with diabetic residents' care plans.
Failure to store food in accordance with professional standards including unlabeled, undated items and spoiled produce in main kitchen and kitchenettes.
Failure to ensure proper processing of residents' clothing and failure to implement Enhanced Barrier Precautions for infection control.
Report Facts
Residents reviewed for ADL: 8
Residents in final sample: 35
Residents affected: 3
Medication carts observed: 6
Medication room refrigerators observed: 3
Missing temperature log days: 16
Missing temperature log days: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Licensed Nursing Assistant | Named in finding regarding failure to provide scheduled shower to Resident #176 |
| Staff L | Unit Manager | Confirmed no documentation of shower for Resident #176 |
| Staff M | Unit Manager | Confirmed no documentation of showers for Residents #36 and #107 |
| Staff G | Activity Aide | Observed blocking exit of Resident #131's room, contributing to involuntary seclusion |
| Staff J | Licensed Nursing Assistant | Observed blocking exit of Resident #131's room |
| Staff I | Licensed Nursing Aide | Observed blocking exit of Resident #131's room |
| Staff A | Physician | Confirmed Resident #131 had 1:1 supervision due to behaviors |
| Staff H | Administrator | Confirmed Resident #131 on 1:1 supervision and discussed involuntary seclusion policy |
| Staff D | Unit Manager | Interviewed regarding Resident #185's delayed ENT follow-up and Resident #183's EBP status |
| Staff E | Regional Registered Nurse | Observed accessing medication cart without authorization |
| Staff X | Licensed Practical Nurse | Confirmed unlabeled inhalers administered to Resident #123 |
| Staff W | Unit Manager | Confirmed missing medication refrigerator temperature logs |
| Staff Z | Licensed Practical Nurse | Confirmed missing medication refrigerator temperature logs |
| Staff U | Dietician | Discussed appropriate nourishing snacks for diabetic residents |
| Staff R | Food Services Director | Observed food storage deficiencies in main kitchen and kitchenettes |
| Staff O | Director of Housekeeping | Discussed use of residential washing machines for resident clothing |
| Staff P | Infection Preventionist | Observed laundry processing practices |
| Staff V | Laundry Aide | Described laundry washing machine settings and detergent use |
| Staff S | Regional Plant Operations | Uncertain about laundry water temperature requirements |
| Staff F | Hospice Licensed Nursing Assistant | Observed providing hygiene to Resident #183 without protective gown despite EBP |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding providing a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain a safe and clean environment in 3 of 5 units observed and 1 of 5 kitchenettes, with issues including lifting and loose floor tiles, exposed drywall, brown substances on bed rails and curtains, peeling furniture surfaces, and missing trim. These conditions were confirmed through observations and staff interviews.
Deficiencies (13)
Black tape adhered to floor threshold over uneven surface where the floor was lifting.
Oxygen concentrator had a layer of dust near the controls.
Wall between bathroom and resident's bed had exposed drywall and brown substance on bed rail.
Side table surface top peeling along 25 percent of the table.
Privacy curtain had brown substance in midsection facing away from resident's bed.
Wall between bathroom and resident's bed had multiple scraps, dings, and discoloration.
Long continuous crack resembling stairs on wall approximately six by twelve inches.
Floor at entrance was lifting.
Brown substance on outside mid-area of privacy curtain and smeared on bed rail; bedside table visually soiled with crumbs and dried brown/reddish substances.
Floor tiles on side of bed curled on edges and lifted.
Floor tile loose and could be moved completely out of place with light pressure.
Missing trim to bedside table.
Missing tiles in kitchenette resulting in uneven flooring; edges covered with black tape.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Staff D confirmed findings from Unit #6 | |
| Licensed Practical Nurse | Staff Y confirmed floor damage and tile movement | |
| Unit Manager | Staff W confirmed missing trim and loose/curled flooring | |
| Activities Aide | Staff Q confirmed missing tiles on kitchenette floor |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, infection control, medication management, food safety, and immunization policies at Southern New Hampshire Rehabilitation & Healthcare.
Findings
The facility was found deficient in multiple areas including failure to notify residents or representatives of bed hold policies upon hospital transfer, delayed comprehensive assessments after significant changes, inadequate assistance with activities of daily living, improper medication labeling, failure to provide dental care follow-up, failure to accommodate food allergies, improper food storage and handling, inadequate infection control related to water management, and failure to provide pneumococcal vaccination as per consent.
Deficiencies (9)
Failed to notify resident or representative of bed hold policy before hospital discharge for 2 residents.
Failed to conduct comprehensive Minimum Data Set assessment within 14 days after significant change for 2 residents.
Failed to provide care and assistance for activities of daily living including personal hygiene for 1 resident.
Failed to label and date opened multi-dose medications and store drugs properly on medication carts and rooms.
Failed to provide dental services and assist with dental appointments for 1 resident.
Failed to accommodate resident allergies and preferences in food service for 2 residents.
Failed to ensure dietary staff wore facial hair restraints and failed to label and store food properly in kitchens and kitchenettes.
Failed to follow infection control guidelines for water management including lack of documentation of water flushes and temperature monitoring.
Failed to provide pneumococcal immunization as consented for 1 resident.
Report Facts
Residents reviewed: 37
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Missing refrigerator temperature log dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Social Services Office Coordinator | Confirmed failure to notify bed hold policy for Resident #75 |
| Staff B | Administrator | Confirmed failure to notify bed hold policy for Resident #97 |
| Staff Z | MDS Coordinator | Confirmed delayed MDS assessments for Residents #165 and #11 |
| Staff L | Licensed Practical Nurse | Resident #62's nurse, unsure of last shower or shave |
| Staff R | Licensed Nursing Assistant | Confirmed no shower or shave for Resident #62 in past 7 days |
| Staff S | Licensed Nursing Assistant | Confirmed no shower or shave for Resident #62 in past 7 days |
| Staff AA | Assistant Director of Nursing | Confirmed lack of documented showers for Resident #62 |
| Staff F | Licensed Practical Nurse | Confirmed unlabeled insulin pen on medication cart |
| Staff A | Licensed Practical Nurse | Confirmed unlabeled Tuberculin vaccine in medication room |
| Staff X | Unit Manager | Confirmed dental care deficiencies for Resident #88 |
| Staff K | Medical Records | Confirmed no additional dental visits for Resident #88 |
| Staff X | Unit Manager | Confirmed Resident #4 allergy to chocolate and tomatoes |
| Staff E | Director of Culinary | Confirmed dietary staff not wearing beard restraints and food safety violations |
| Staff H | Cook | Observed not wearing beard restraint while preparing food |
| Staff I | Dietary Aide | Observed not wearing beard restraint while preparing food |
| Staff N | Unit Manager | Confirmed food storage and temperature log deficiencies |
| Staff CC | Unit Manager | Confirmed expired food in kitchenette |
| Staff J | Maintenance and Environmental Services Director | Confirmed lack of documentation for water flushes and temperature monitoring |
| Staff M | Infection Preventionist | Confirmed Resident #73 did not receive pneumococcal vaccine |
Inspection Report
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing appropriate foot care services to residents, specifically focusing on whether the facility assisted residents in making appointments to maintain good foot health.
Findings
The facility failed to provide services or assist a resident in making appointments to maintain good foot health for 1 of 3 residents reviewed for foot care. Resident #5 had overgrown toenails and had not received timely podiatry care despite documented medical necessity and requests.
Deficiencies (1)
Failed to provide services or assist a resident in making appointments to maintain good foot health for 1 of 3 residents reviewed for foot care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Observed Resident #5's toenails during inspection | |
| Director of Nursing | Confirmed findings regarding Resident #5's foot care |
Inspection Report
Routine
Census: 238
Deficiencies: 11
Date: Oct 6, 2023
Visit Reason
Routine inspection of Southern New Hampshire Rehabilitation & Healthcare to assess compliance with regulatory standards including resident care, medication management, staffing, food services, infection control, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to complete and transmit discharge assessments, follow physician's orders for medication administration, document complete discharge summaries, provide sufficient nursing staff, properly label and secure medications, serve food at safe temperatures and according to resident preferences, track COVID-19 positive residents on admission, and document COVID-19 and pneumococcal vaccinations appropriately.
Deficiencies (11)
Failure to ensure discharge assessments were completed and transmitted for residents #24 and #176.
Failure to follow physician's orders for medication administration for residents #3, #64, #83, #158, and #163.
Failure to document a complete discharge summary for resident #236.
Failure to provide sufficient nursing staff to meet residents' needs for a census of 238 residents.
Failure to label opened multi-dose medications and biologicals, secure medications, and remove expired medications from supply.
Failure to serve food and drink at a safe and appetizing temperature for 22 residents.
Failure to follow menu preferences, allergies, and intolerances for 5 residents.
Failure to follow policy for labeling and dating resident food items brought in by visitors for 3 of 5 kitchenettes observed.
Failure to include a data collection tool that tracked residents admitted while COVID-19 positive for 1 resident.
Failure to implement policies and procedures regarding offering and educating residents and staff on COVID-19 vaccination series for 2 residents and 1 staff member.
Failure to provide documentation of pneumococcal vaccination for 1 resident.
Report Facts
Residents affected: 2
Residents affected: 4
Medication administrations observed: 28
Residents affected: 1
Census: 238
Staffing levels: 2
Medication carts reviewed: 6
Medication rooms observed: 3
Residents affected: 22
Residents reviewed for meal/food concerns: 19
Residents affected: 5
Kitchenettes observed: 5
Residents reviewed for COVID-19 immunizations: 5
Staff reviewed for COVID-19 immunizations: 1
Residents reviewed for pneumococcal immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | MDS Coordinator | Confirmed failure to complete discharge assessments |
| Staff I | Unit Manager | Confirmed failure to notify physician of high SBP and awareness of food complaints |
| Staff J | Director of Nursing | Confirmed failure to follow physician's orders for multiple residents |
| Staff H | Licensed Practical Nurse | Observed medication administration and confirmed medication order |
| Staff T | Assistant Director of Nursing | Confirmed no discharge summary completed |
| Staff F | Administrator | Confirmed staffing levels |
| Staff P | Unit Manager | Reported staff callouts and low staffing on unit |
| Staff U | Director of Food Services | Confirmed food labeling and storage deficiencies |
| Staff C | Registered Nurse | Confirmed medication labeling and storage deficiencies |
| Staff E | Licensed Practical Nurse | Confirmed expired medication administration |
| Staff A | Licensed Practical Nurse | Confirmed medication labeling deficiencies |
| Staff D | Licensed Practical Nurse | Confirmed medication labeling deficiencies |
| Staff Q | Licensed Nursing Assistant | Reported frequent wrong food items served to residents |
| Staff R | Licensed Practical Nurse | Reported resident admitted COVID-19 positive and on precautions |
| Staff S | Infection Preventionist | Confirmed failure to track COVID-19 positive admissions and vaccination follow-up |
| Staff AA | Licensed Nursing Assistant | COVID-19 vaccination record reviewed |
| Staff N | Licensed Practical Nurse | Confirmed meal ticket and food preference deficiencies |
| Staff O | Dietitian | Confirmed meal ticket and food preference deficiencies |
| Staff I | Unit Manager | Aware of ongoing food complaints |
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