Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to investigate an alleged violation related to abuse and failure to implement appropriate interventions for a resident's transfer needs.
Complaint Details
The complaint investigation focused on alleged abuse related to a spiral fracture in Resident #1. The investigation found the facility did not interview relevant staff or identify the cause of the fracture. The complaint was substantiated by findings of inadequate investigation and failure to follow care plan interventions.
Findings
The facility failed to complete a thorough investigation of an alleged abuse incident involving a spiral fracture in one resident and failed to implement interventions consistent with the resident's assessed transfer needs, resulting in potential harm. Staff interviews and record reviews revealed inadequate investigation and communication regarding the resident's injury and transfer requirements.
Deficiencies (2)
Failed to complete a thorough investigation of an alleged abuse violation for one resident with a spiral fracture.
Failed to implement interventions addressing the resident's assessed limitations in transfer ability, including use of a mechanical lift.
Report Facts
Residents reviewed for alleged abuse: 6
Residents reviewed for transfer interventions: 6
Residents affected: 1
Date of injury note: Sep 22, 2025
Date of survey completion: Nov 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Nursing Assistant | Interviewed regarding care of Resident #1 and transfer incident. |
| Staff D | Director of Nursing | Interviewed and acknowledged failure to interview relevant staff regarding Resident #1's fracture. |
| Staff A | Physical Therapy Assistant | Provided physical therapy to Resident #1 and communicated transfer needs verbally to nursing staff. |
| Staff E | Physical Therapist | Co-signed physical therapy notes recommending mechanical lift for Resident #1. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer and discharge notifications, bed hold policies, and food safety standards at the nursing home.
Findings
The facility failed to provide timely written notice of transfer or discharge to residents or their representatives for 4 of 4 residents reviewed. The facility also failed to notify residents of the bed hold policy before transfers for the same residents. Additionally, the facility failed to ensure food was stored in accordance with professional food safety standards in the kitchen.
Deficiencies (3)
Failed to provide timely notification to residents and representatives before transfer or discharge, including appeal rights, for 4 residents.
Failed to notify residents or representatives in writing about how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave for 4 residents.
Failed to ensure food was stored in accordance with professional standards; observed open, undated frozen rib patties, moldy cheese, and tomatoes with black spots in the kitchen.
Report Facts
Residents reviewed for hospitalization: 17
Residents affected: 4
Kitchen observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Confirmed facility does not provide written notice of transfer and discharge |
| Staff D | Administrator | Confirmed findings related to transfer/discharge notices and bed hold policy |
| Staff E | Social Services | Confirmed no notice of transfer for Resident #48 due to hospital stay less than 24 hours |
| Staff F | Chef Manager | Confirmed food storage deficiencies in kitchen |
| Staff G | Assistant Chef Manager | Confirmed food storage deficiencies in kitchen |
| Staff H | Business Office | Revealed residents are not provided with bed-holds at each transfer |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure in timely notification to the State Long Term Care Ombudsman regarding resident transfers, inaccurate PASARR screenings for residents with mental disorders, incomplete care plans for PTSD diagnosis, inadequate pressure ulcer care, lack of accident hazard prevention related to bedrail assessments, and improper management of psychotropic medication orders.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to notification failures to the LTC Ombudsman, inaccurate PASARR screenings, incomplete PTSD care plans, inadequate pressure ulcer care, lack of bedrail assessments leading to injury, and improper psychotropic medication management.
Findings
The facility was found deficient in multiple areas including failure to notify the LTC Ombudsman of resident transfers, inaccurate PASARR screenings for mental disorders, lack of a comprehensive care plan for PTSD, failure to perform weekly pressure ulcer evaluations, incomplete bedrail assessments leading to resident injury, and failure to limit PRN psychotropic medication orders to 14 days as required.
Deficiencies (6)
Failure to ensure that the State Long Term Care Ombudsman received a copy of a written notice of transfer/discharge for 1 of 2 residents reviewed for hospitalizations.
Failure to ensure that residents with a mental disorder received an accurate Level I Pre-admission Screening and Resident Review (PASARR) for 2 of 4 residents reviewed.
Failure to ensure that a resident had a comprehensive person-centered care plan for a Post-Traumatic Stress Disorder (PTSD) diagnosis.
Failure to ensure that a resident's pressure ulcer was evaluated weekly.
Failure to ensure that a resident remained free of accident hazards in regards to assessments of bedrail use.
Failure to ensure that as needed psychotropic drugs were limited to 14 days for 1 resident.
Report Facts
Residents reviewed for PASARR: 4
Residents in final sample: 19
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Wound measurement: 3
Wound measurement: 5
Wound measurement: 4
Wound measurement: 5
BIMS score: 15
PRN Lorazepam start date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Interviewed regarding notification to LTC Ombudsman and PASARR screening |
| Staff D | Social Worker | Interviewed regarding PTSD care plan deficiency |
| Staff E | Licensed Practical Nurse | Interviewed regarding pressure ulcer care deficiency |
| Staff F | Licensed Practical Nurse | Interviewed regarding bedrail use and resident injury |
| Staff B | Director of Nursing | Interviewed regarding bedrail assessments and psychotropic medication management |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 22, 2022
Visit Reason
The inspection was conducted to investigate complaints related to alleged abuse or neglect, injuries of unknown origin, inaccurate resident assessments, failure to obtain required PASRR screenings, lack of registered nurse coverage, medication labeling and storage issues, and failure to report COVID-19 cases to residents and families.
Complaint Details
The complaint investigation focused on allegations of abuse or neglect, injuries of unknown origin, inaccurate resident assessments, failure to obtain PASRR screenings, lack of RN coverage, medication labeling and storage issues, and failure to report COVID-19 cases. The investigation substantiated failures in reporting, investigating, assessment accuracy, PASRR screening, staffing, medication management, and COVID-19 communication.
Findings
The facility failed to timely report and investigate an injury of unknown origin involving Resident #106, inaccurately coded Minimum Data Set (MDS) assessments for Residents #44 and #106, failed to obtain required PASRR screenings for Residents #3 and #16, lacked registered nurse coverage for 2 days, failed to properly label and remove expired or discontinued medications on medication carts, and failed to notify residents and families of COVID-19 positive cases in a timely manner.
Deficiencies (7)
Failed to timely report suspected abuse or neglect involving injuries of unknown origin to the State Survey Agency for Resident #106.
Failed to have evidence that alleged violations involving abuse or neglect, including injuries of unknown origin, were investigated for Resident #106.
Failed to ensure that the resident's Minimum Data Set (MDS) accurately reflected the resident's status for Residents #44 and #106.
Failed to obtain a Preadmission Screening and Resident Review (PASRR) for mental illness and/or intellectual disability for Residents #3 and #16.
Failed to have a Registered Nurse on duty for 8 consecutive hours 7 days a week for 2 of 28 days reviewed.
Failed to label 3 insulin pens with an open date, failed to remove 1 insulin pen after its discard date, and failed to remove inhaler medication after it had been discontinued on 2 of 2 medication carts observed.
Failed to inform residents, their representatives, and families of confirmed COVID-19 infections by 5 p.m. the next calendar day following occurrence.
Report Facts
Residents reviewed for accidents: 4
Residents reviewed for MDS accuracy: 22
Residents reviewed for PASRR: 2
Days without RN coverage: 2
Insulin pen discard timeframe: 28
Medication discard timeframe: 30
Date of last documented fall for Resident #106: May 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding lack of reporting injury of unknown origin and COVID-19 notifications |
| Staff B | MDS Coordinator | Confirmed inaccuracies in MDS coding for Residents #44 and #106 |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed about Resident #106's pain and lack of witnessed trauma |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed about Resident #106's pain and lack of witnessed trauma |
| Staff E | Social Worker | Confirmed lack of PASRR screening for Residents #3 and #16 |
| Staff F | Human Resource Manager/Scheduler | Confirmed lack of RN coverage on specific dates |
| Staff G | Licensed Practical Nurse (LPN) | Confirmed medication labeling and discard issues |
| Staff H | Licensed Practical Nurse (LPN) | Confirmed discontinued medication found in med cart |
| Staff I | Assistant Director of Nursing | Confirmed medication labeling and discard issues |
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