Citations in New Hampshire
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Hampshire.
Statistics for New Hampshire (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Hampshire
A resident admitted with a right groin wound did not receive physician-ordered wound care because no treatment orders were transcribed or implemented at admission. The wound went untreated for seven days, resulting in deterioration and subsequent hospitalization for surgical debridement.
A wound nurse did not consistently perform hand hygiene or use required PPE during a dressing change for a resident on Enhanced Barrier Precautions. The nurse failed to clean hands between glove changes, did not perform hand hygiene after removing gloves and gown, and did not don a gown when returning to complete wound care, contrary to facility policy and CDC guidelines.
Residents were unable to access their personal funds during evenings and weekends because staff did not have access to petty cash outside of regular business hours, despite facility policy stating such access should be available.
Multiple units and a kitchenette were found with unsafe and unclean conditions, including lifting and loose floor tiles, exposed drywall, soiled furniture, and dust accumulation on medical equipment. Staff confirmed these findings, and a resident was observed traversing uneven flooring in the kitchenette.
A resident sustained a spiral fracture of the left tibia, and the facility did not conduct a thorough investigation as required by its policy. The DON did not interview LNAs who had cared for the resident prior to the injury, and key staff were not asked to provide statements, resulting in the cause of the injury remaining unidentified.
A resident assessed as dependent for transfers and requiring a mechanical lift was repeatedly transferred by staff using unsafe manual techniques, despite clear recommendations from PT and an updated care plan. The resident expressed pain during these transfers and was later found to have a spiral fracture of the lower leg.
A resident was hospitalized and tested positive for Legionella, but the facility did not follow its own water management plan by failing to test or remediate the water system, nor did it document control measures as required. Staff confirmed that a humidifier, which was prohibited by policy, was used in the resident's room, and water samples from the device were not tested. These lapses in infection control procedures exposed all residents to potential Legionella risk.
Staff members engaged in emotionally abusive behavior by mocking and ridiculing three residents, recording these actions on video, and sharing the videos via social media with a third party. The incidents involved staff lying in a resident's bed, making derogatory comments, and laughing at residents' cognitive or communicative limitations. The abusive actions were not reported until months later, after the videos were shown to a nurse who then notified facility leadership.
The facility did not properly sanitize dishware as the high-temperature dish machine failed to reach the required final rinse temperature, and temperature logs were not maintained. Dishes washed at insufficient temperatures were subsequently used to serve meals, as confirmed by staff and record review.
A resident was prescribed Cipro for a UTI, but the facility did not complete an antibiotic time out or document stewardship practices as recommended by CDC guidelines. The infection did not meet criteria for antibiotic initiation, and the facility's policy lacked requirements for antibiotic time outs or stewardship documentation.
Failure to Obtain and Implement Admission Orders for Wound Care
Penalty
Summary
A deficiency occurred when a resident was admitted with a puncture wound to the right groin, but no physician's orders for wound treatment were obtained at the time of admission. The resident's clinical admission assessment documented the presence of the wound, and the hospital discharge summary included instructions for daily wound care. However, a review of the admission orders and the Treatment Administration Record (TAR) showed that no wound treatment orders were transcribed or carried out for the right groin wound. As a result, the resident went seven days without any wound treatment after admission. During a vascular surgery follow-up appointment, it was noted that the dressing had not been changed, and the wound had deteriorated, showing signs of dehiscence, maceration, slough, and seroma drainage. This led to the resident being hospitalized for surgical debridement. The Director of Nursing confirmed that the wound had not been treated during this period.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during a dressing change for a resident under Enhanced Barrier Precautions (EBP). The wound nurse performed hand hygiene and donned gloves and a gown before starting the dressing change. However, after removing the initial wound dressing, the nurse changed gloves without performing hand hygiene in between. Following wound cleansing, the nurse removed their gown and gloves, exited the room, and did not perform hand hygiene before retrieving additional supplies from the treatment cart. Upon returning to the resident's room, the nurse performed hand hygiene and donned gloves but did not put on a gown before applying treatment and a new dressing to the wound. These actions were confirmed by the nurse during an interview. Review of facility policies and CDC guidelines indicated that hand hygiene should be performed before donning gloves, immediately after glove removal, and that gowns and gloves are required for high-contact activities such as wound care under EBP.
Failure to Provide Resident Access to Personal Funds During Off-Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds during off business hours. Review of the facility's Resident Petty Cash Policy indicated that procedures were in place to allow residents access to their funds during evenings and weekends through designated staff such as charge nurses or supervisors. However, interview with the Business Office Manager revealed that, in practice, residents could only request cash during regular business hours, as staff did not have access to the facility's petty cash during evenings or weekends. This resulted in residents being unable to access their personal funds outside of standard business hours, despite the facility managing personal accounts for 25 residents.
Failure to Maintain Safe and Clean Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment across several units and a kitchenette. On Unit #6, rooms were found with black tape covering uneven and lifting floor thresholds, dust accumulation on an oxygen concentrator, exposed drywall, brown substances on bed rails and privacy curtains, peeling surfaces on bedside tables, and visibly soiled furniture. Additional observations included cracked walls, multiple scrapes and discoloration, and further instances of lifting flooring at room entrances. Staff interviews confirmed these findings. On Unit #5, rooms had floor tiles that were curled, lifted, and loose, with some tiles able to be moved with light pressure. There was also missing trim on a bedside table. Staff confirmed the presence of these hazards. In Unit #1 West, the kitchenette had missing tiles resulting in uneven flooring, with black tape covering the edges of remaining tiles. A resident was observed walking over this uneven surface. Staff interviews corroborated the observations of missing tiles and uneven flooring.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged violation involving a resident who sustained a spiral fracture of the left tibia. Nursing progress notes indicated that the resident was found with pain, swelling, and redness in the left lower extremity, which was later diagnosed as a minimally displaced spiral oblique fracture. The injury was considered of unknown source, as the cause could not be explained by the resident and was not observed by staff. Despite the seriousness of the injury, the facility did not follow its own policy requiring a comprehensive investigation of such incidents. Interviews revealed that the Director of Nursing did not interview any Licensed Nursing Assistants (LNAs) who had cared for the resident on the days leading up to the discovery of the injury. One LNA reported that the resident had expressed pain during a transfer and had been kept in bed due to leg pain, but was not interviewed or asked to provide a statement regarding the injury. The facility's policy mandates that all nursing department witnesses and suspects be interviewed and their statements recorded, but this was not done, and the cause of the fracture was not identified.
Failure to Implement Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate transfer interventions for a resident who was assessed as requiring a mechanical lift (hoyer) with two staff for transfers. Despite repeated recommendations and notifications from physical therapy staff, including documentation on multiple occasions that the resident was dependent for transfers and unable to bear weight through the lower extremities, nursing staff continued to use unsafe transfer techniques such as a one-person stand-pivot and bear hugging. These methods were explicitly identified as unsafe for both the resident and staff, and the need for a mechanical lift was communicated verbally and in writing to nursing staff and the unit manager. On one occasion, a licensed nursing assistant transferred the resident using a stand-pivot technique, during which the resident expressed pain. The following day, the resident was kept in bed due to complaints of pain and was observed holding their left leg. Subsequent nursing assessment revealed swelling, redness, and tenderness in the left lower extremity, and an x-ray confirmed a minimally displaced spiral fracture of the mid to distal tibia. The resident's care plan had been updated to require a two-person hoyer transfer, but this intervention was not followed, resulting in injury.
Failure to Implement Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Legionella prevention and response. After a resident, who had been admitted since November 2024, was transferred to the hospital with acute respiratory failure and subsequently tested positive for Legionella, the facility did not conduct required testing or remediation of its water system as outlined in its Water Management Plan. Staff interviews confirmed that neither the water system nor equipment where Legionella could proliferate were tested following the confirmed case, despite the facility's policy and CDC guidance requiring such actions after a healthcare-associated Legionnaires' disease diagnosis. Additionally, the facility did not document the results of control measures as required by its Water Management Plan. The maintenance supervisor acknowledged that water heater temperatures were checked but not logged, and there was no documentation to show which portable air conditioning units had been cleaned. The facility's water management plan also did not identify humidifiers as a risk for waterborne pathogens, and routine Legionella monitoring was not performed, contrary to the plan's requirements for outbreak investigation and control. Furthermore, a humidifier was found in the affected resident's room, which was against the facility's own procedures for Legionnaires' disease prevention. Staff were unaware of the prohibition on humidifiers until after the resident's hospitalization. Although a water sample from the humidifier was collected, it was not tested. These failures in following established policies and procedures exposed the facility's residents to the potential spread and growth of Legionella.
Staff Emotional Abuse and Exploitation of Residents via Social Media
Penalty
Summary
Staff members engaged in emotionally abusive and exploitative behavior toward three residents by recording videos in which they mocked and ridiculed the residents. In one instance, a licensed nurse aide was recorded lying in a resident's bed, talking about cuddling, and mocking the resident, while another staff member filmed and both giggled. In other cases, a staff member was recorded sitting on the edge of a resident's bed, mocking the resident's cognitive state, and in another, standing next to a resident's bed and mocking the resident's speech. These videos were shared via social media with a third party, specifically the daughter of a registered nurse at the facility. The incidents were not immediately reported; the videos were shown to the registered nurse months after they were created, who then reported them to the facility's administrator and director of nursing. The residents involved were later interviewed, but did not recall the incidents, and telepsychology assessments found no identified trauma. The staff members involved were identified through investigation and their actions were confirmed through interviews and record review.
Failure to Ensure Proper Dishware Sanitization Due to Inadequate Final Rinse Temperatures
Penalty
Summary
The facility failed to ensure proper sanitization of dishware in the kitchen, as required by regulatory standards and facility policy. Observations revealed that the high-temperature dish machine did not reach the minimum required final rinse temperature of 180 degrees Fahrenheit, instead achieving only 172 degrees Fahrenheit in the morning and 168 degrees Fahrenheit at midday. Additionally, the dish machine temperature logs had not been updated since 7/28/25, and there was no documentation of corrective action when out-of-range temperatures were observed. Despite the inadequate sanitization, dishes washed at the lower temperature were used to serve lunch. These findings were confirmed through staff interviews and review of facility records.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic use protocols that address unnecessary or inappropriate antibiotic use for one resident reviewed for antibiotic stewardship. Specifically, a physician's order was issued for Cipro to treat a urinary tract infection (UTI), but the resident's medical record did not include documentation of an antibiotic time out for this medication. Additionally, the Revised McGeer Criteria for Infection Surveillance Checklist, completed for the UTI, indicated that the infection did not meet the established criteria for initiating antibiotic therapy. An interview with the Director of Nursing confirmed that the facility's policy on Antibiotic Management did not include provisions for antibiotic stewardship or the use of antibiotic time outs. The facility did not document antibiotic time outs, despite following CDC guidelines for antibiotic use, which recommend implementing an antibiotic review process for all antibiotics prescribed. The facility's policy focused on individualized prescribing and lab work but lacked standardized stewardship practices as outlined by the CDC.
Some of the Latest Corrective Actions taken by Facilities in New Hampshire
- The facility conducted a Quality Assurance (QA) meeting, evaluated the affected residents with provider-ordered hepatitis and HIV testing, performed a facility-wide audit of insulin availability, provided education and competencies on medication protocols, insulin pen policies, and CDC injection safety, and initiated an insulin inventory sheet. (J - F0880 - NH)
- Staff received in-service training on proper insulin pen administration and the prohibition of using another resident's insulin. Audits were conducted to ensure no additional missing insulin, and staff competencies were reinforced prior to first shifts. A root cause analysis was performed, and the incident was reported to New Hampshire Public Health for follow-up. (J - F0880 - NH)
- The facility updated its insulin administration policy, provided in-service education to all nurses specifically on administering Humulin R U-500 insulin pens, conducted competency evaluations, initiated weekly audits of insulin administration, and planned to review these audits during quarterly Quality Assurance and Performance Improvement meetings. (J - F0760 - NH)
Improper Use of Insulin Pen for Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used one insulin pen to administer insulin to two residents on multiple days. Specifically, a Licensed Practical Nurse (LPN) used a Lantus insulin pen designated for one resident to administer insulin to another resident on two consecutive days. This pen was then returned to the medication cart and subsequently used again for the original resident without the knowledge of another LPN, who was unaware of the pen's prior use for a different resident. The facility's records confirmed that both residents had active physician's orders for Lantus insulin, which was administered according to the schedule. However, the use of a single insulin pen for multiple residents contravened the manufacturer's instructions, the facility's pharmacy policy, and the Centers for Disease Control and Prevention (CDC) guidelines, all of which emphasize that insulin pens are for single-patient use only to prevent the risk of bloodborne pathogen transmission.
Removal Plan
- QA meeting was conducted
- The provider evaluated Resident #1 and Resident #2 and ordered Hepatitis panel and HIV blood tests and a retest for the hepatitis panel and HIV blood test was ordered
- Facility-wide audit of all residents insulin availability was conducted
- Education and competencies of facility's medication availability protocol, facility's insulin pen policy, and CDC's injection safety were conducted
- Insulin inventory sheet was created and initiated
Insulin Pen Misuse Leads to Pathogen Exposure
Penalty
Summary
The facility failed to ensure that a resident was free from exposure to bloodborne and bacterial pathogen transmission when a registered nurse administered insulin from another resident's used insulin pen. The incident occurred when the nurse was unable to locate the resident's prescribed Humalog 75/25 insulin or any backup stock in the medication room for the scheduled dose. Consequently, the nurse used another resident's Humalog 75/25 insulin pen, which had already been opened and used, to draw up 10 units of insulin with a syringe and administer it to the resident. The facility's policy explicitly prohibits borrowing medication from another resident and sharing insulin pens due to the risk of infection transmission. The Humalog Mix 75/25 KwikPen insert and the CDC guidelines both emphasize that insulin pens should not be shared between individuals, as backflow of blood can occur, posing a risk of pathogen transmission. The facility's pharmacy policy also states that prefilled pen devices should never be accessed with a syringe and needle, and the same pen should not be used for more than one resident.
Removal Plan
- In-service staff regarding administration of insulin pens and not using another resident's insulin.
- Conduct audits for all residents to ensure no additional missing insulin.
- Start in-service training for insulin pen administration, medications not available, and abuse/misappropriation.
- Train all staff on competencies for medication not being available, abuse, insulin pens, following physician's orders, and insulin replacement prior to working their first shift.
- Conduct a root cause analysis and review audits as part of the Ad Hoc Quality Assurance and Performance Improvement meeting.
- Notify New Hampshire Public Health regarding the incident and follow up.
Insulin Overdose Due to Syringe Misuse
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a resident receiving an overdose of insulin. The error occurred when a registered nurse used a U-100 insulin syringe instead of a U-500 syringe to administer Humulin R U-500 insulin from the resident's insulin pen. This mistake led to the resident receiving five times the prescribed dose of insulin on two separate occasions. The manufacturer's instructions for Humulin R U-500 clearly state that the insulin should not be transferred from the pen into a syringe, as this can lead to severe overdoses and dangerously low blood sugar levels. As a result of the overdose, the resident experienced hypoglycemia, with blood glucose levels dropping to as low as 40 mg/dL. The resident became lethargic and was only arousable with repeated stimuli, necessitating the administration of insta glucose gel and subsequent transfer to the hospital for evaluation and treatment. The resident's medical records indicated several episodes of hypoglycemia overnight, confirming the severity of the medication error.
Removal Plan
- Updated the policy titled: Insulin
- Completed in-service education to all nurses on the administration of insulin with an insulin pen specific to Humulin R U-500
- Conducted competencies with all nurses on the administration of insulin with an insulin pen
- Monitoring insulin administration through weekly audits
- Reviewing these audits at quarterly Quality Assurance and Performance Improvement meetings
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