Saint Vincent Rehabilitation & Nursing Center
29 Providence Avenue, Berlin, NH 03570 · Non profit - Church related · 80 certified beds · (603) 752-1820 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.9% | 22.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.0% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.9% | 2.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.4% | 13.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.4% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.0% | 17.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.3% | 19.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 25.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.8% | 17.8% | 17.1% | better |
| Short-stay residents rehospitalized after admission | 8.6% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 34.6% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 1.64 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.57 | 1.87 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.6%CMS range 28.6–57.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.2–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 72.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 56.5 residents a day — about 71% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.13 hrs/resident/day on weekends vs 3.80 on weekdays — 18% thinner on weekends. RN hours go from 0.76 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · D2025-06-19 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, it was determined that the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 16 residents. (Resident identifier is #2.) Findings include: Review on 6/18/25 of Resident #2's physician orders revealed an order for Sertraline (antidepressant) 50 milligrams (mg) daily for Depression, dated 9/14/23, and an order for Seroquel (antipsychotic) 25 mg daily at bedtime for delusions, dated 9/14/23. Review on 6/18/25 of Resident #2's medical record revealed no attempts to perform a GDR or documentation of clinical necessity of either Sertraline or Seroquel. Interview on 6/19/25 at approximately 2:00 p.m. with Staff E (Corporate Nurse) confirmed there was no documentation of a GDR attempt or of a contraindication for a GDR to be attempted. Review on 6/19/25 of facility policy titled Utilization and Documentation of Psychotropic Medications revised 7/20/17 revealed .Residents who use psychotropic medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 3 residents reviewed for pressure ulcers (Resident Identifier is #29). Findings include: Review on 6/19/25 of Resident #29's progress note, dated 3/15/25, revealed that Resident has two wounds to bilateral heels. Right inner heel is black/blue and reddened area . No measurements or wound stage were indicated. Further review of Resident #29's medical record revealed nurse's notes with descriptions and measurements of Resident #29's wounds on the following dates: 3/17/25, 4/2/25 (two weeks from prior assessment), 5/16/25 (6 weeks from previous assessment and is from wound clinic note), 5/23/25, and 6/4/25 (2 weeks from prior assessment and wound clinic note). Review on 6/19/25 of wound clinic note, dated 6/4/25, revealed Resident #29 had Active problems Unstageable pressure ulcer R heel.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to obtain physician's orders for oxygen for 1 of 1 residents reviewed for respiratory care in a final sample of 16 residents (Resident identifier is #54). Findings include: Observation on 6/17/25 at approximately 7:15 p.m. of Resident #54 revealed that Resident #54 was lying in bed using oxygen via nasal canula. Observation on 6/18/25 at approximately 2:45 p.m. of Resident #54 revealed he/she was in bed with the head of bed elevated and oxygen on at 1 liter via nasal canula. Observation on 6/19/25 at approximately 11:45 a.m. Resident #54 revealed he/she was in a wheelchair in the dining room with a portable oxygen tank via nasal canula. Review on 6/19/25 of Resident #54's clinical notes dated 6/14/25 revealed the following: Resident returned from hospital in wheelchair .Resident was admitted for acute bronchitis, UTI [urinary tract infection], early pneumonia and reactive airway disease . Resident is on 1L [liter] on NC [nasal canula] .Resident is currently sleeping nasal canula in place…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for 1 of 1 residents reviewed for TBP in a final sample of 16 residents. (Resident identifier is #44.) Findings include: Observation on 6/18/25 between 8:46 a.m. and 8:52 a.m. of Resident #44's room revealed a sign on the door of the room stating Enteric Contact Isolation . Prior to entering the room*: Clean Hands, Gown, Gloves, Clean Hands With Soap + [and] Water on Exit. Further observation revealed Staff F (Laundry) standing inside of Resident #44's room at the doorway holding empty hangers. Staff F exited Resident #44's room without washing his/her hands with soap and water and proceeded to push the laundry rack down the hallway and enter the residents room. Interview on 6/18/25 at 8:50 a.m. with Staff F confirmed the above findings. Staff F was not aware that Resident #44 was on contact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-19 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 4 of 5 residents reviewed for immunizations (Resident Identifiers are #22, #29, #36, and #39). Findings include: Review on 6/19/25 of the current CDC immunization guidelines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed People ages 65 years and older .are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. Resident #22 Review on 6/19/25 of Resident #22's vaccination records revealed Resident #22, born in 1933, received the COVD-19 Bivalent Booster (Pfizer) on 10/17/24. There was no documentation of Resident #22 being offered or educated about the next dose recommendations. Resident #29 Review on 6/19/25 of Resident #29's vaccination records revealed Resident #29, born in 1932, received the COVID-19 Bivalent Booster (Pfizer) on 10/17/24. There was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-07 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 of 92 days reviewed between October 1, 2023 and December 30, 2023. Findings include: Review on 5/5/24 of the facility's Payroll Based Journal Staffing Data Report for Quarter 1 2024 (October 1-December 1, 2023) revealed that there were no RN hours for the following days: 10/7/23, 10/21/23, 12/16/23, and 12/17/23. Review on 5/7/24 of the facility's daily nursing time sheets for October and December 2023 revealed the following: On 10/7/23 there were only 6 RN hours worked; On 10/8/23, 10/21/23, 10/22/23 there were no RN hours documented as worked; On 12/16/23 and 12/17/23 there were no RN hours documented as worked; On 12/31/23 there were 2 RN hours worked. Interview on 5/6/24 at 3:15 p.m. and on 5/7/24 at 1:58 p.m. with Staff J (Human Resources) confirmed the above findings.
- Potential for harm · E2024-05-07 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 6 of 12 months reviewed for antibiotic use. Findings include: Review on 5/6/24 of the facility's line listing for antibiotic use from May 2023 through April 2024 revealed that the facility did not track antibiotic use within the facility from December 2023 through April 2024. Interview on 5/7/24 at 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview further revealed that the facility did not have monthly antibiotic monitoring, tracking, or review documented from December to present, including documentation that antibiotics met criteria for use. Staff A confirmed that the facility had residents with infections and who were on antibiotics from December 2023 through April 2024. Review on 5/7/24 of the facility's policy titled, Antibiotic Stewardship, revised 2/11/22, revealed: .The Infection Preventionist, in conjunction with the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-07 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities (Resident Identifiers are #45, #55, and #63). Findings include: Observation on 5/5/24 at approximately 2:00 p.m. of the Second Floor Unit revealed Resident #45 sitting in his/her wheelchair in the hall with eyes closed. Further observation of the second floor unit revealed that there were no activities in place on the unit. Review on 5/5/24 of the Second Floor Unit posted activity calendar for 5/5/24 revealed that the afternoon activity scheduled was a lemonade cart at 2:00 p.m. Observation on 5/6/24 at approximately 10:00 a.m. of the Second Floor Unit revealed Resident #45 with approximately five other residents sitting in their wheelchairs in the hall at the nurse's desk. Further observation revealed no activities occurring on the unit.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure residents were offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza Vaccination for 2 of 5 residents reviewed for vaccinations (Resident Identifiers are #29 and #59). Findings include: Resident #29 Review on 5/7/24 of Resident #29's medical record revealed that there was no record that the influenza vaccination had been offered for the 2023/2024 flu season. Interview on 5/7/24 at 3:10 p.m. with Staff G (Regional Clinical Director) confirmed the above finding. Review on 5/7/24 of the facility's policy titled, Immunizations: Influenza (Flu) Vaccination of Residents, Staff and Volunteers dated 2015, revealed: .II. Administration Procedure: A. Current and newly admitted residents, all staff, and volunteers will be offered the influenza vaccine from October of each year through the end of March the following year . Resident #59 Review on 5/7/24 of Resident #59's medical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-29 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs for 12 out of 32 days reviewed. Findings include: Interview on 10/27/23 at approximately 12:00 p.m. with Staff I (Anonymous) revealed: . normal staffing was one nurse to first floor no LNA [Licensed Nursing Assistant], second floor 1 nurse and 1 LNA and third floor 1 nurse and 1 to 1 and 1/2 LNAs on average. This means 3 nurses and 2 and 1/2 LNAs to care for 63 residents. This is not safe. Review on 11/29/23 of the facility Nursing Schedule from 10/28/23 through 11/28/23 revealed: 10/28/23 3:00 p.m. until 7:00 p.m. there were 2 nurses, 1 Medication Nursing Assistant (MNA) and 2 LNAs, from 7:00 p.m. until 11:00 p.m. there was no nurse in the facility and 1 MNA and from 11:00 p.m. to 7:00 a.m. there was no nurse, 2 MNAs and 1 LNA in the facility. Facility census was 63. 10/29/23 7:00 a.m. until 3:00 p.m. there was 1 nurse and 1 MNA and from 7:00 p.m. until 11:00 p.m. there was no nurse and 2 MNAs. Facility census was 63 residents. 11/5/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Ecited before2023-11-29 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review it was determined that the facility failed to ensure that medications were labeled and stored in accordance with the manufacturer's instructions for 2 of 4 medication carts observed (Resident identifiers are #1, #2, and #3). Findings include: Second Floor Observation on 11/29/23 at approximately 10:20 a.m. of the Second Floor [NAME] Wing medication cart with Staff B (Medication Nursing Assistant (MNA)) revealed the following: Resident #2's open Novolog insulin pen with a pharmacy sticker that read Discard 28 days after opening and a handwritten discard date of 10/11/23; Resident #2's other open Novolog insulin pen with no open or expiration date and a pharmacy sticker that read Discard 28 days after opening, and a pharmacy delivery date of 9/19/23; Resident #3's open Lantus insulin pen with a pharmacy sticker that read Discard 28 days after opening and a handwritten open expiration date of 11/24/23. Review of Resident #2's November 2023 Medication Administration Record (MAR) revealed they had received 4 units of Novolog insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for conducting COVID-19 testing for 1 of 1 unit observed. Findings include: Third Floor Memory Care Unit Observation on 11/29/23 at approximately 11:15 a.m. on the Third Floor revealed Staff G (Memory Care Coordinator) and Staff H (Licensed Nursing Assistant (LNA)) in the process of completing COVID-19 testing on residents. Further observation revealed that Staff G and Staff H were not wearing N95 masks during the process of collecting the sample for COVID-19 testing. Both Staff G and Staff H were wearing a surgical masks. Interview on 11/29/23 at approximately 11:25 a.m. with Staff G confirmed the above observation. Staff G stated they were not aware that an N95 mask would be needed when collecting COVID-19 samples. Interview on 11/29/23 at approximately 11:45 a.m. with Staff F (Director of Nursing) revealed that they would expect that an N95 is to be worn when collecting COVID-19 samples. Staff F stated they had an ample supply of N95…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to follow the Center for Disease Control and Prevention's (CDC) return to work guidelines for healthcare personnel (HCP) who were positive for COVID-19 and failed to implement a system for surveillance to monitor all staff who had worked and tested positive for COVID-19 for 8 of 10 healthcare personnel reviewed for COVID-19 infection. Findings Include: Review on 9/6/23 of the CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposure to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to report an allegation of abuse immediately, but no later than 24 hours, to the State Survey Agency (SSA) and the results of the investigation to the SSA within 5 working days of the incident for 1 of 3 residents reviewed for alleged abuse (Resident Identifier is #1). Findings include: Interview on 8/8/23 at approximately 9:30 a.m. with Staff C (Licensed Nursing Assistant) revealed that they witnessed Staff B (Licensed Practical Nurse) grab Resident #1's wrists and said Look into my eyes, this is not okay. Staff C stated that he/she could not recall the date when the incident happened. Staff C also stated that he/she reported to Staff A (Director of Nursing) immediately on the same day of the alleged abuse. Interview on 8/8/23 at approximately 1:00 p.m. with Staff A revealed that Staff C reported to him/her that Staff B grabbed Resident #1's face to have Resident #1 look in Staff B's direction. Staff A stated that the incident happened on the 7/16/23 day shift (7:00 a.m. to 3:00 p.m.). Interview with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to prevent further potential abuse by allowing a staff member to continue to work with residents after an allegation of abuse was reported to the designated representative for 1 of 3 residents reviewed for alleged abuse (Staff Identifier is Staff B and Resident Identifier is #1). Findings include: Interview on 8/8/23 at approximately 9:30 a.m. with Staff C (Licensed Nursing Assistant) revealed that Staff C witnessed Staff B (Licensed Practical Nurse) grab Resident #1's wrists and said Look into my eyes, this is not okay. Staff C could not recall the date of the incident. Staff C stated that he/she reported to Staff A (Director of Nursing) immediately on the same day of the incident. Interview on 8/8/23 at approximately 11:00 a.m. with Staff A revealed that Staff C reported to him/her that Staff B grabbed Resident #1's face to have Resident #1 look in Staff B's direction. Review on 8/8/23 of Staff A's email to the contracted staffing agency, dated 7/17/23, revealed .On 7/16 Same resident [Resident #1]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-13 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 10 of 90 days reviewed for Quarter 2 (January 1 - March 31, 2023). Findings include: Review on 6/11/23 of the facility's Payroll Based Journal Staffing Data Report for Quarter 2 (2023) revealed that there were no RN hours for the following days; 1/21/23, 1/22/23, 2/4/23, 2/5/23, 2/11/23, 2/12/23, 2/18/23, 2/19/23, 3/4/23 and 3/5/23. Review on 6/13/23 of the facility's daily staffing for January, February, and March 2023 revealed the following; On 1/21/23 and 1/22/23 there was no RN hours documented as worked; On 2/4/23 an RN worked for 5.5 consecutive hours; On 2/5/23 an RN worked for 7 consecutive hours; On 2/11/23, 2/12/23, 2/18/23 and 2/19/23 there were no RN hours documented as worked; and on 3/4/23 and 3/5/23 there were no RN hours documented as worked. The above 10 days fell on weekends. Interview on 6/13/23 at 1:40 p.m. with Staff C (Assistant Director of Nursing) confirmed the above findings.
- Potential for harm · E2023-06-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review it was determined that the facility failed to label, date, and store food in accordance to professional standards in the main kitchen and in 2 of 3 kitchenettes observed and failed to monitor the dishwasher temperature to ensure proper temperatures were achieved. Findings include: Review on 6/13/23 of the Food Code U.S. Public Health Service 2022 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2022 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility's policy and procedure it was determined that the facility failed to ensure expired medications were removed on 1 of 3 medication carts and 1 of 2 medication storage rooms observed (Resident Identifier is #53). Findings include: Second Floor Medication Room Observation on 6/12/23 at approximately 8:55 a.m. revealed the following: Emergency Kit with an expiration date of 5/31/23. Interview on 6/12/23 at approximately 8:56 a.m. with Staff B (Licensed Nurse Assistant) confirmed the above finding. Second Floor Medication Cart Observation on 6/12/23 at approximately 8:57 a.m. revealed Resident # 53's Latonprost 0.005 percent Opthalmic Solution 2.5 milliliters (ml) with an expiration date of 1/23. Interview on 6/12/23 at approximately 8:58 a.m. with Staff B confirmed Resident #53 was prescribed the above medications and confirmed the above finding. Review on 6/13/23 of Resident's #53s June Medication Administration Record (MAR) revealed that the resident had received the Latonprost from June 1-11, 2023. Review on 5/15/23 of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-13 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to maintain patient equipment (oxygen filter) for the use of oxygen for 2 of 2 residents reviewed for respiratory care in a final survey sample of 23 residents (Resident identifiers are #19 and #30). Findings include: Resident #19 Observation on 6/11/23 of Resident #19 at 11:44 a.m. revealed resident was sitting in a recliner with his/her nasal cannula in place. Further observation revealed resident's oxygen filters on both sides of the concentrator were covered in lint and dust. Interview on 6/11/23 with Resident #19 at 11:45 a.m. revealed that he/she used oxygen continuously. Observation on 6/12/23 of Resident #19 at 8:20 a.m. revealed resident was sitting in a recliner, eating breakfast with a nasal cannula in place. Further observation revealed resident's oxygen filters on both sides of the concentrator were covered in lint and dust. Interview on 6/12/23 with Staff H (Licensed Nursing Assistant (LNA)) at 8:15 a.m. confirmed Resident #19's oxygen filter was covered in lint and dust.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2025-06-19 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed, in writing, the items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 2 of 3 residents reviewed for Beneficiary Notices who remained in the facility (Resident identifiers are #44 and #45). Findings include: Resident #44 Review on 6/18/25 of the Beneficiary Notice - Resident discharged within the last 6 months form, completed by the facility, revealed Resident #44 was discharged from Medicare services and remained in the facility. Resident #44's last covered day was 5/15/25. Review on 6/18/25 of Resident #44's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) dated 5/13/25 revealed that beginning on 5/15/25, Resident #44 will no longer require Physical Therapy, Occupational Therapy, Skilled Nursing Care, and will no longer be covered by Medicare. Further review revealed the SNF ABN did not contain the services that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-05-07 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed timely of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) for 2 out of 3 residents reviewed for beneficiary notices (Resident Identifiers are #5 and #65). Findings include: Resident #5 Review on 5/6/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #5 was discharged from Medicare Services on 2/28/24 and remained in the facility. Review on 5/6/24 of Resident #5's SNF Beneficiary Notification Review form, completed by the facility, revealed that Resident #5's last covered day of Medicare Part A Skilled Services was 2/27/24 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review on 5/6/24 of Resident #5's SNF ABN revealed that it was signed by Resident #5 on 2/27/24. Review on 5/6/24 of Resident #5's NOMNC revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-05-07 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 2 of the 4 quarterly meetings reviewed. Findings include: Review on 5/7/24 of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets revealed the following required members were not in attendance: Quarter 2 - Medical Director and Infection Preventionist; and Quarter 3 - 1 other member of the facility's staff. Interview on 5/7/24 at approximately 2:30 p.m. with Staff A (Director of Nursing) confirmed the above findings.
- No harm found · Ccited before2023-11-29 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that the daily nurse staffing data was posted for 25 of the 30 days reviewed. Findings include: Review of the last 30 days of Daily In House Nursing Staff postings revealed that the facility had the following daily postings available, 11/19/23, 11/26/23, 11/27/23, 11/28/23, and 11/29/23. Interview on 11/29/23 at approximately 11:30 a.m. with Staff D (Administrator) confirmed the above findings and revealed that the there were no other daily postings done within the last 30 days.
- No harm found · Ccited before2023-06-13 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to update or post the daily nurse staffing data since 5/19/23. Findings include: Observation on 6/11/23 at 10:25 a.m. revealed that the daily nursing staffing data which was posted on the wall near the elevator and business office had a date of 5/19/23. Interview on 6/11/23 at 10:27 a.m. with Staff A (Director of Nursing) and Staff D (Licensed Practical Nurse) confirmed that the daily nurse staffing data posting was not updated or posted since 5/19/23. Review on 6/12/23 of the facility's policy titled Daily Posting of Nurse Staffing Information established 1/10/07, revealed, .It is the policy of this center to post on a daily basis for each shift the total number of hours worked by licensed [Registered Nurses, Licensed Practical Nurses, Licensed Medication Nursing Assistant, and Licensed Nursing Assistants] who are directly responsible for resident care . The Charge Nurse is responsible for updating the posting on his/her assigned shift. The [Director of Nursing] is ultimately responsible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CATHOLIC CHARITIES NEW HAMPSHIRE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.5 | -2.5 vs chain |
| Health inspection | 1 of 5 | 3.5 | -2.5 vs chain |
| Staffing | 4 of 5 | 4.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 5 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NH CATHOLIC CHARITIES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/01/1990 |
| BERNARD, ALAIN | Individual | W-2 MANAGING EMPLOYEE | — | since 10/01/2018 |
| LACROIX, JEFFREY | Individual | W-2 MANAGING EMPLOYEE | — | since 10/03/2017 |
| RICHARDSON, SARAH | Individual | W-2 MANAGING EMPLOYEE | — | since 10/18/2018 |
| ZIRKLE, KAREN | Individual | W-2 MANAGING EMPLOYEE | — | since 10/18/2018 |
| BARRETT, KEVIN | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| BLONSKI, THOMAS | Individual | CORPORATE DIRECTOR | — | since 07/01/2006 |
| COUGHLIN, ADAM | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| DEMERS, KATE | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| DESROSIERS, KEVIN | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| FORD, PATRICK | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| HILTON, RICHARD | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| HUARD, SUSAN | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| JALBERT, JASON | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| LIBASCI, PETER | Individual | CORPORATE DIRECTOR | — | since 04/01/2016 |
| MCLEAN, JEFFREY | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| MIRABLE, CATHERINE | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| MULLIKIN, ANU | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| OUELLETTE, RUSS | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| PATENAUDE, JOHN | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| POWERS, EDWARD | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| HILDENBRAND, DAVID | Individual | CORPORATE OFFICER | — | since 04/12/2017 |
CMS files one row per role, so the 23 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $482K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Hampshire Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 305066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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