Lebanon Center, Genesis HealthCare
24 Old Etna Road, Lebanon, NH 03766 · For profit - Limited Liability company · 110 certified beds · (603) 448-2234 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- it has citations for mishandling residents’ money or property (F0567, F0568, F0569)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $72,924 in federal fines (most recent 2025-08-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 2 to 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 | 31.5% | 22.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.2% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 14.3% | 13.7% | 6.5% | typical for the 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 | 3.9% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 30.6% | 17.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 19.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 25.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.4% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.2% | 83.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.5% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.7% | 13.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.78 | 1.64 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.93 | 1.87 | 1.80 | better |
‡ 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.
55.5% 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 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.5% 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 120 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 | 55.5%CMS range 46.0–66.7 | 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 | 10.7%CMS range 8.0–13.9 | 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 | 57.5% | 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 | 48.3% | 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 | 54.2% | 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 | 99.4% | 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 | 93.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 94.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 7.7% | 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 | 7.4%CMS range 4.2–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 110 beds and averages 77.9 residents a day — about 71% occupied, or roughly 32 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.86 hrs/resident/day on weekends vs 3.30 on weekdays — 13% thinner on weekends. RN hours go from 0.59 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.
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 fewer than at the previous inspection — improving. 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Lcited before2025-10-06 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 observations, interviews, and record reviews, the facility failed to adhere to its policies and procedures for infection control and Legionella prevention. The facility failed to follow the established water management plan by neglecting remediation or testing of the water system after a confirmed resident case of Legionella. Furthermore, the facility failed to document the results of control measures as required by the Water Management Plan. Additionally, the facility allowed the use of a humidifier in a resident's room, which creates a potential risk for the spread and growth of Legionella. Collectively, these failures in following policies, procedures, and the Water Management Plan expose the facility's census of 80 residents to the potential spread and growth of Legionella.Findings include:Review on 10/6/25 of Resident #1's medical record revealed that Resident #1 was admitted and resided at the facility since November 2024. Resident #1 was transferred to the hospital on 9/30/25 for acute…
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 · D2025-08-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 determine if self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 18 residents. (Resident identifiers are #6 and #8.) Findings include:Resident #6 Observation on 8/12/25 at approximately 10:08 a.m in Resident # 6's room revealed that there were 2 prescription lotions, Ammonium Lactate External Lotion 12% and Anti-Itch External Lotion 0.5-5%, located on the Resident's windowsill. Interview on 8/12/25 at approximately 10:08 a.m with Resident #6 revealed that Resident #6 would have the above mentioned lotion applied by nursing staff and that he/she would also apply the lotion as needed. Observation on 8/12/25 at approximately 10:18 a.m. of Resident #6's room revealed that the prescription lotions remained at the resident's bedside on a bedside table. Observation on 8/13/25 at approximately 1:50 p.m. with Staff A (Licensed Vocational Nurse) revealed that the 2 prescription lotions remained in the resident's room, at…
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 before2025-08-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 hold routine interdisciplinary care plan meetings for 2 of 18 residents and failed to develop and update comprehensive care plans for 1 of 18 reviewed in a final sample of 18 residents. (Resident identifiers are #13, #24 and #47.)Findings include:Resident #13Interview on 8/13/25 at approximately 8:41 a.m. with Resident #13 revealed that they have had meetings about his/her care, but not for several months. Resident #13 would like to attend his/her care planning meetings.Review on 8/13/25 of Resident #13's medical record revealed that the last documented care plan meeting was 9/4/24.Interview on 8/13/25 at approximately 2:08 p.m. with Staff F (Director of Social Services) confirmed the above findings. Resident #24Interview on 8/12/25 at approximately 2:05 p.m. with Resident #24's DPOA (Durable Power of Attorney) revealed that he/she was invited to a care plan meeting twice last year. The last meeting he/she recalled attending was in December of 2024. DPOA stated that he/she attended all meetings…
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 · D2025-08-14 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 follow menu preferences, allergies, and intolerances for 1 resident of 1 resident reviewed for food concerns and 1 resident of 1 resident reviewed for nutrition in a final sample of 18 residents. (Resident Identifiers are #17 and #73.)Findings include:Resident #17Observation on 8/12/25 at approximately 12:58 p.m. of Resident #17 in the dining room, during lunch, revealed Resident #17's meal ticket to read ADD FINGER FOODS TO MEALS. Further observation revealed no finger food items provided and Resident #17 was attempting to pick up the ground chicken and gravy with his/her fingers. Resident #17 attempted to drink their pudding from the dish.Observation on 8/13/25 at approximately 8:00 a.m. in the dining room, during breakfast, revealed Resident #17 attempting to eat a bowl of milk-soaked cereal with his /her fingers. Further observation revealed a scoop of scrambled eggs that were untouched on Resident #17's plate. There was no finger food items on Resident #17's plate.Review on 8/13/25…
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 before2025-08-14 · 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, interview, and record review, it was determined that the facility failed to ensure proper storage of washed linens and ensure proper processing of linens to reduce risk of accidental contamination for 1 of 1 laundry observed. Findings include: Observation on 8/14/25 between 10:09 a.m. and 10:45 a.m. in the laundry room with Staff H (Infection Preventionist) and Staff P (Director of Housekeeping) revealed a small residential washing machine was running on normal mode and cold water setting. Interview on 8/14/25 between 10:09 a.m. and 10:45 a.m. with Staff P revealed the residential washing machine had been used for almost a year for resident's clothes, kitchen rags, bed sheets, and other linens. They use a household detergent bought from a local store on all linens and added bleach for white linens. The washing machine was not hooked up to the hot water and ran loads with cold water. Staff P was unable to provide the facility's policy for using the residential washing machine, in regards to the manufacturer's' instructions, temperature, detergent or laundry…
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 · D2025-08-14 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
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 implement their smoking policy for 1 of 1 residents reviewed for smoking in a final sample of 18 residents. (Resident identifier is #1.)Findings include: Review on 8/14/25 of the facility's smoking policy with a review date of 2/24/25, revealed .Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc. [etcetera]) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .Interview on 8/12/25 at 10:44 a.m. with Resident #1 revealed that Resident #1 was an independent smoker and he/she kept his/her cigarettes and lighter in their room in a black bag. Interview on 8/13/25 at 2:36 p.m. with Staff L (Registered Nurse) confirmed that Resident #1 was an independent smoker and that Resident #1 kept his/her cigarettes and lighter in their room. Observation on 8/14/25 at 1:10 p.m. in Resident #1's room revealed that Resident #1's…
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 · D2025-07-07 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 obtain written authorization of a resident to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility for 3 of 5 residents reviewed. (Resident identifiers are #1, #2, and #3.)Findings include:Resident #1Review on 7/7/25 of Resident #1's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed that Resident #1's social security benefit was direct deposited into their resident fund on 1/3/25, 2/3/25, 3/3/25, 4/3/25, 5/2/25, and 6/3/25. The following amounts of money were transferred directly to the facility with description Care Cost Auto WDL: $3058.04 on 1/9/25; $40.00 on 1/21/25; $1399.00 on 2/3/25; $1399.00 on 3/3/25; $1399 on 4/3/25; $1399.00 on 5/2/25; and $949.00 on 6/3/25.Review on 7/7/25 of Resident #1's Resident Fund Management Service form, the facility's authorization and agreement to handle resident funds, dated 5/31/24, revealed that Resident #1 did not authorize the facility to…
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 · D2025-07-07 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 provide Quarterly statements in writing to the resident or the resident's representative within 30 days after the end of the quarter for 2 of 5 residents reviewed for personal funds. (Resident identifiers are #1 and #2.) Findings include:Resident #1Review on 7/7/25 of Resident #1's quarterly statement for the quarter ending 12/31/24 revealed the quarterly statement was signed by Staff A (Administrator) on 2/3/25, not Resident #1 or Resident #1's guardian. Review on 7/7/25 of Resident #1's quarterly statement for the quarter ending 3/31/25 revealed the quarterly statement was signed by Staff A on 4/14/25, not Resident #1 or Resident #1's guardian. Interview on 7/7/25 at approximately 1:45 p.m. with Resident #1's guardian revealed that they had not received quarterly statements for Resident #1's personal fund account. Resident #2Interview on 7/7/25 at 11:20 a.m. with Resident #2 revealed they had not received any quarterly statements for their personal funds and thought they might be sent to their…
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 · D2025-07-07 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 record review and interview, it was determined that the facility failed to notify a resident when the amount in the resident's personal fund account reaches or exceeds $200 less than the SSI (supplemental security income) recourse limit for 1 of 5 residents reviewed for personal funds. (Resident identifier is #1.)Findings include:Review on 7/7/25 of Resident #1's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed the following monthly balances: January $5784.29; February $5335.58; March $4958.66; April $4550.90; May $3604.10; June $4102.22. Interview on 7/7/25 at 1:00 p.m. with Staff B (Regional Business Office Manager) revealed that the [NAME] Medicaid SSI resource limit is $2500. Interview on 7/7/25 at 1:53 p.m. with Staff A (Administrator) revealed the facility did not notify Resident #1 that they had exceeded their SSI resource limit each month from January 2025 through June 2025. Review on 7/7/25 of the facility's policy titled Accounts Receivable Policies and Procedures,…
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 · E2024-07-11 · 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 record review and interview, it was determined that the facility failed to provide sufficient nursing staff as determined by their facility assessment. Findings Include: Review on 7/9/24 of the facilities Payroll Based Journal Staffing Data report Quarter 2, 2024 (January 1-March 31) revealed the facility had excessively low weekend staffing. Review on 7/11/24 of the facility assessment nursing staff and personnel total number needed revealed that the facility assessment determined the required Hours Per Patient Day (HPPD) for nurses aides was 1.63 HPPD. Review on 7/10/24 of the nursing staff punch reports for 6/9/24-7/10/24 revealed the following weekend dates had staffing that was below the staffing numbers determined by the facility assessment: Sunday 6/9/24- Nurse aides 1.57 HPPD; Saturday 6/22/24- Nurses aides 1.49 HPPD; Sunday 6/23/24- Nurse aides 1.45 HPPD; Saturday 6/29/24- Nurses aides 1.49 HPPD; Saturday 7/6/24- Nurses aides 1.47 HPPD; Sunday 7/7/24- Nurses aides 1.43 HPPD. Interview on 7/11/24 at approximately 1:15 p.m. with Staff M (Scheduler/Human Resources)…
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 · E2024-07-11 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, review of facility policy, and review of the facility menu, it was determined that the facility failed to offer the residents a nourishing snack at bedtime while having 15 hours between the evening meal and the breakfast meal. Findings include: Interview on 7/9/24 at approximately 2:00 p.m. with the facility's Resident Council (13 residents) revealed that the majority of the residents that attended did not receive bedtime snacks. The Resident Council President stated he/she met with Staff F (Food Service Director) back in January to request more substantial snacks such as tuna, egg salad or chicken salad be available in the kitchettes. Review on 7/10/24 of the facility dining times revealed the following meal schedule: Breakfast 7:30 a.m.; Lunch 11:30 a.m.; Dinner 4:30 p.m. Review on 7/11/24 of the facility's Week At A Glance Menu of week 2 revealed the following evening snack: Sunday: Cranberry Juice and Oatmeal Creme Cookie; Monday: Apple Juice and Chocolate Creme Cookie Tuesday: Cranberry Juice and [NAME] Crackers; Wednesday: Apple Juice and…
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 19 citations
- Potential for harm · D2024-07-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 ensure that a resident received medication as ordered for 1 out of 26 medications observed (Resident Identifier #32). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/9/24 at approximately 1:00 p.m. with Staff B (Licensed Practical Nurse) of the Intravenous (IV) medication of Heparin administration, revealed Staff B administered 50 units of Heparin. Review on 7/9/24 of Resident #32's Medication Administration Record (MAR) revealed the following physician's order: Heparin Sodium (Porcine)…
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 · D2024-07-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 orders for psychotropic drugs are limited to 14 days for 1 of 1 residents reviewed for psychotropic/opiod side effects (SE) in a final sample of 19 residents reviewed (Resident Identifier #83). Findings include: Review on 7/10/24 of Resident #83's Medication Administration Record (MAR) revealed the following physician's order: Ativan Oral Tablet 0.5 milligrams (mg) (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for Anxiety/Nausea, Start Date 6/16/24 with no stop date indicated. Further review revealed of Resident #83's MAR revealed that Resident #83 received 10 doses of the as needed Ativan after 14 days of the order being initiated. Interview on 7/11/24 at approximately 10:45 a.m. with Staff D (Director of Nurses) confirmed the above findings. Review on 7/11/24 of the facility policy titled, 3.8 Psychotropic Medication Use, Revision Date 10/24/22 revealed: .8. PRN (as needed) psychotropic medications should be ordered for no more than 14 days
- Potential for harm · D2024-07-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 ensure that a resident was free from a significant medication error for 1 out of 26 medications observed. (Resident identifier is # 32.) Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/9/24 at approximately 1:00 p.m. with Staff B (Licensed Practical Nurse) of the IV (Intravenous) medication of heparin administration, revealed Staff B administered 50 units of Heparin. Review on 7/9/24 of Resident #32's MAR (Medication Administration Record) revealed the following physician's order: Heparin…
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 before2024-07-11 · 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, interview, record review, and policy review, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance for Enhanced Based Precautions (EBP) for 1 of 1 residents with an Intravenous (IV) access in a final sample of 19 residents (Resident Identifier #32). Findings include: Observation on 7/9/24 at approximately 10:00 a.m. of Resident #32's room door revealed signage stating EBP required. Observation on 7/9/24 at approximately 12:55 a.m. of Staff B (Licensed Practical Nurse) accessing Resident #32's IV site revealed Staff B did not put on a gown while accessing Resident #32's IV site. Interview on 7/9/24 at approximately 12:55 p.m. with Staff B confirmed the above findings. Interview on 7/10/24 at approximately 8:00 a.m. with Staff C (Infection Preventionist) revealed that the facility would expect a gown to be worn when accessing a IV. Review on 7/10/24 of the facility policy titled, IC308 Enhanced Barrier Precautions, Revision Date 1/8/24 , revealed: .purpose, to reduce the risk of transmission 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 · D2024-07-11 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, review of the facility's policy for antibiotic stewardship, review of the facility's antibiotic stewardship program, and review of the facility's antibiotic line listings from March 2024 - June 2024, the facility failed to use antibiotic use protocols that identify unnecessary or inappropriate antibiotic use for 2 out of 4 months reviewed, which could affect all residents prescribed antibiotics. Findings include: Review on 7/10/24 of the Antibiotic Line Listings revealed the following antibiotic was prescribed that did not meet the facilities criteria for determining antibiotic use: April 2024- 1 resident was prescribed antibiotics for a Urinary Tract Infection (UTI); and June 2024- 6 residents were prescribed antibiotics for UTI's. Interview on 7/11/24 at approximately 07:30 a.m. with Staff C (Infection Preventionist) confirmed that the above antibiotics were prescribed to residents without the facility's criteria for antibiotic use being met. Review on 7/11/24 of the facility policy titled, IC402 Antibiotic Stewardship, with a revision date of 7/1/24, 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 · D2024-07-11 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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 training and education was provided to staff on abuse, neglect, exploitation, and misappropriation of resident property for 1 of 5 staff reviewed (Staff Identifier is Staff L (Licensed Nursing Assistant)). Finding include: Review on 7/11/24 of Staff L's education file revealed no documentation of training or education for abuse, neglect, exploitation and misappropriation of resident property. Interview on 7/11/24 at 2:30 p.m. with Staff D (Director of Nursing) confirmed that Staff L did not have training or education for abuse, neglect exploitation and misappropriation of resident property prior to Staff L's start date on 4/23/2024. Review on 7/11/23 of facility policy titled, Abuse Prohibition, revised on 10/24/22, revealed .4. Training and reporting obligations will be provided to all employees - through orientation, Code of Conduct training, and a minimum of annually - and will include .
- Potential for harm · D2023-11-21 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 inform the resident's representative of a treatment change for 1 of 1 resident reviewed for resident rights (Resident identifier is #1). Findings include: Review on 11/21/23 of Resident #1's medical record revealed that Resident #1's diagnosis list included but was not limited to; dementia, depression, anxiety, mood disturbance, and psychotic disturbance. Further review of Resident #1's medical record revealed that Resident #1's power of attorney for healthcare was activated by the physician on 4/21/23. Review on 11/21/23 of Resident #1's physician orders revealed an order for Olanzapine that was discontinued on 7/19/23 and restarted on 8/19/23. Interview on 11/21/23 at approximately 11:00 a.m. with Resident #1's power of attorney for healthcare revealed that they were not informed that the above medication was discontinued and they were not aware that it was until they asked staff about an increase in depression in Resident #1.
- Potential for harm · D2023-11-21 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview it was determined that the facility failed to provide a sanitary environment for its residents, staff, and public. Observation on 11/21/23 at 09:20 a.m. of the hallway ceiling tiles outside of rooms 101, 110, 108, and 126 (the left 100 hallway) revealed that the ceiling tiles surrounding the metal vents were soiled with a black spotted substance that had been smeared in places. Interview on 11/21/23 at 10:00 a.m. with Staff B (Infection Preventionist) revealed that the tiles had the above substance on them for a few months and he/she was unaware of the cause of the soiling of the tiles. Interview on 11/21/23 at 10:30 a.m. with Staff C (Maintenance Director) confirmed the above findings.
- Potential for harm · D2023-04-19 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 honor residents' choice for showers for 1 out of 5 residents reviewed for Activities of Daily Living in a final sample of 19 residents (Resident identifier is #52). Findings include: Interview on 4/17/23 at 11:19 a.m. with Resident #52 revealed that he/she had not had a shower in a couple of weeks and that he/she had requested one be given today. Review on 4/18/23 of Resident #52's Significant Change Minimum Data Set (MDS) with an assessment reference date of 4/6/23 revealed that Resident #52 required physical assistance for bathing. Further review revealed that Resident #52 had a Brief Interview of Mental Status (BIMS) of 15, meaning cognitively intact. Review on 4/18/23 of Resident #52's tub/shower schedule under tasks in the electronic medical record revealed no showers documented from 3/31/23 through 4/17/23. Review on 4/19/23 of the second floor shower schedule paper form revealed that Resident #52 was scheduled for Tuesdays on the 7-3 shift. Interview on 4/19/23 at 12:17 p.m. with Staff B (MDS…
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 · D2023-04-19 · 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
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 ensure that expired vaccines were removed from use for 1 of 2 medication rooms reviewed and that all medication was secured. Findings include: Observation on [DATE] at approximately 9:20 a.m. of the first floor medication storage room vaccination refrigerator with Staff A (Registered Nurse) revealed: -1 opened vial of Pfizer COVID-19 Vaccine, Bivalent, with a manufacturer's expiration date of [DATE] and no open date. -1 opened vial of Pfizer COVID-19 Vaccine, Bivalent, with a manufacturer's expiration date of [DATE] and no open date. Interview on [DATE] at approximately 9:20 a.m. with Staff A confirmed the above finding. Staff A stated that the Pfizer COVID-19 Bivalent Vaccine vial should have been labeled with an open date and time and that the vial should have been discarded after 12 hours. Review on [DATE] of the facility's policy Storage and Expiration Dating of Medications, Biologicals with revision date 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 · D2023-04-19 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 follow professional standards for labeling and storage of food items brought to residents by visitors to the facility for 2 out of 2 kitchenettes reviewed. Findings include: First floor dining room kitchenette: Observation on 4/17/23 at approximately 9:30 a.m. of the first floor refrigerator in the dining room kitchenette revealed the following: One (1) glass bottle of chocolate milk half empty with no resident name or received by date; One (1) plastic covered container with several unknown food items inside with no resident name or received by date; One (1) plastic bag with (1) container of yogurt with no resident name or received by date; One (1) bottle of iced tea half empty with no resident name or received by date; Two (2) containers of yogurt with no resident names or received by date. Observation on 4/17/23 at approximately 9:45 a.m. of the first floor dining room kitchenette cabinet revealed the following: Two (2) boxes of Girl Scout cookies with no resident names or received by…
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 before2025-08-14 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 residents in a final sample of 18 residents. (Resident identifiers are #1, #2, #4, and #24).Findings include:Resident #1 Interview on 8/12/25 at 10:44 a.m. with Resident #1 revealed that he/she was an independent smoker since he/she was admitted to the facility in June 2025. Review on 8/13/25 of Resident #1's smoking care plan, initiated on 6/26/25, revealed that Resident #1 was an independent smoker. Interview on 8/13/25 at 2:36 p.m with Staff L (Registered Nurse) confirmed that Resident #1 was an independent smoker since Resident #1's admission. Review on 8/13/25 of Resident #1's admission MDS with an Assessment Reference Date (ARD) of 6/30/25 revealed that under section J1300 (Current Tobacco use) Resident #1 was coded as no. Interview on 8/14/25 at 8:26 a.m. with Staff O (Director of Nursing) confirmed the above MDS findings for…
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 · C2024-07-11 · tag F0680 — widespreadEnsure the activities program is directed by a qualified professional.
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 the activities program was directed by a qualified professional for a facility census of 88 residents. Findings include: Interview on 7/10/24 at 12:47 p.m. with Staff H (Activities Aide) revealed that there was no Director of the Activities program at the facility. Interview on 7/10/24 at 2:36 p.m. with Staff G (Administrator) confirmed thier was currently no Director of Activities program and that the past director left the position in February 2024. Review on 7/10/24 of the facility's job description for Director of Recreation Services, revised 4/25/17, revealed: The Director of Recreation Services is responsible for the development, implementation, and supervision of the full scope of recreation services in the nursing center . Review on 7/10/24 of the facility's policy titled, Recreation Program Components, revised 4/1/18, revealed .1. The Recreation Director will ensure that the recreation programs may include the following .
- No harm found · C2024-07-11 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, it was determined that the facility failed to update the posted daily nurse staffing information of the actual hours worked at the beginning of each shift on a daily basis. Findings include: Review on 7/11/24 of the facility daily nursing staff postings from 6/9/24 through 7/10/24 revealed they did not match the daily nursing schedules provided. Interview on 7/11/24 at approximately 1:30 p.m. with Staff M (Scheduler/Human Resources) verified the above information. Staff M stated that they did not update and change the postings to reflect the actual staffing. Review on 7/11/24 of facility policy titled Posting Staffing, revised 8/7/23, revealed .In accordance with federal and state regulations, Centers will post the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff who are directly responsible for patient care for each shift and on a daily basis .3. The posting should be: .3.4 Adjusted either upward or downward if staffing changes .
- No harm found · C2024-07-11 · tag F0868 — widespreadHave 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 3 of the 4 quarterly meetings reviewed in 2023/24. Findings include: Review on 7/11/24 of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets from 2023/24 revealed the following required members were not in attendance: Quarter 1 - Medical Director; Quarter 2 - Medical Director; and Quarter 4 - Infection Preventionist. Interview on 7/11/24 1:52 p.m. with Staff G (Administrator) confirmed the above findings. Review on 7/11/24 of the facility's policy titled, Quality Assurance/Assessment and Performance Improvement Plan, revised 3/16/24, revealed: . The Quality Assessment and Assurance (QAA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the infection control and prevention officer .
- No harm found · B2024-07-11 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 notify the resident and/or representative of quarterly care plan meetings for 1 of 19 residents reviewed for care plans (Resident Identifier #52). Findings include: Resident #52 Interview on 7/9/24 at approximately 12:00 p.m. with Resident #52's activated alternate Durable Power of Attorney (DPOA) revealed he/she had been invited to two care plan meetings since Resident #52 was admitted in April of 2023. Review on 7/10/24 of Resident #52's medical record revealed two quarterly care plan attendance sheets dated 4/26/23 and 2/27/24. Both attendance sheets had identified that the DPOA and the alternate DPOA were in attendance. Interview on 7/10/24 at approximately 2:20 p.m. with Staff K (Social Services) confirmed the above findings. Staff K was unable to provide documentation of other quarterly care plan meetings.
- No harm found · Bcited before2024-07-11 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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, observation, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the resident's status for 4 of 19 residents (Resident Identifiers #11, #24, #53, and #76). Findings include: Resident #11 Review on 7/10/24 of Resident #11's Quarterly MDS dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Review on 7/11/24 of Resident #11's Bed Rail Evaluation, dated 1/6/20, revealed that Resident #11 requested to use two half upper rails on the bed to enable mobility and assist with transfers and was not a restraint. Interview on 7/11/24 at approximately 11:00 a.m. with Staff A (MDS Coordinator) confirmed the above findings. Resident #76 Review on 7/9/24 of Resident #76's MDS, dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used…
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 · B2023-04-19 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 follow the comprehensive care plan for 2 out of 2 residents reviewed for psychotropic drugs in a final sample of 19 residents (Resident identifiers are #26 and #62). Findings include: Resident #26 Review on 4/18/23 of Resident #26's medical diagnosis list revealed that Resident #26 had a diagnosis of post-traumatic stress disorder, depression, anxiety, and hallucinations upon admission dated 3/24/23. Review on 4/18/23 of Resident #26's current physician's orders revealed that Resident #26 had an order for Quetiapine Fumerate (antipsychotic) Tablet 25 milligram (mg), give 1 tablet by mouth at bedtime for anxiety, with a start date of 3/30/23. Review on 4/18/23 of Resident #26's current care plan initiated 3/31/23 revealed the following focus, goal, and interventions: .Focus: .[name omitted] is at risk for complications related to the use of psychotropic drugs .Goal: .[name omitted] will have the smallest .Interventions: .AIMS [Abnormal Involuntary Movement Scale] testing per protocol . Review on…
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 before2023-04-19 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 record review and interview, it was determined that the facility failed to update the comprehensive care plan for 1 out of 1 residents reviewed for advance directives (Resident identifier is #26). Findings include: Review on [DATE] of Resident #26's medical record revealed an initial admission date of [DATE]. Review on [DATE] of Resident #26s care plan, created on [DATE], revealed that Resident #26 was a full code. Review on [DATE] of Resident #26's current physician's order dated [DATE] revealed an order for Do Not Resuscitate (DNR) on the Physician's Orders for Life Sustaining Treatment (POLST). Review on [DATE] of Resident #26's Minimum Data Set (MDS) with an assessment reference date of [DATE] revealed Resident #26 had a Basic Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #26's National POLST Form: Portable Medical Order. signed by the physician and Resident #26 on [DATE], revealed No CPR [Cardiopulmonary Resuscitation]: Do Not Attempt Resuscitation was checked.…
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
$72,924 in federal fines across 1 penalty.
- $72,924 — penalty dated 2025-08-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GENESIS HEALTHCARE — 184 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 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
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 |
|---|---|---|---|---|
| GENESIS NH HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2011 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS OPERATIONS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/31/2011 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 12/01/2012 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| VANCE, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/12/2023 |
CMS files one row per role, so the 17 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners 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 $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2023. 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, FY2023). 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 305050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.