Nashua Post Acute Care
55 Harris Road, Nashua, NH 03062 · For profit - Limited Liability company · 290 certified beds · (603) 888-1573 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0603), cited Nov 2025
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure 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 | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 | 26.7% | 22.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.9% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 64.9% | 13.7% | 6.5% | worse 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 | 6.1% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.9% | 17.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 19.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.9% | 25.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.6% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 83.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.1% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.4% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.10 | 1.64 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.87 | 1.87 | 1.80 | typical |
‡ 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.
51.6% 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 362 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.2% 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 180 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 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 32% 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 | 51.6%CMS range 46.0–57.5 | 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 | 10.4%CMS range 8.2–13.1 | 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 | 52.2% | 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 | 45.0% | 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 | 44.4% | 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 | 60.3% | 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 | 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 | 1.6% | 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 | 0.8% | 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 | 9.2%CMS range 6.5–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 290 beds and averages 228.2 residents a day — about 79% occupied, or roughly 62 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.54 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 2.63 hrs/resident/day on weekends vs 3.18 on weekdays — 17% thinner on weekends. RN hours go from 0.78 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% 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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · E2025-11-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 and interview, it was determined that the facility failed to provide a safe and clean environment for 3 of 5 units observed and 1 of 5 kitchenettes observed.Findings include:Unit #6 Observation on 11/18/25 at approximately 9:11 a.m. in room [ROOM NUMBER] revealed there was black tape adhered to floor threshold over uneven surface where the floor was lifting. Observation on 11/18/25 at approximately 9:18 a.m. in room [ROOM NUMBER] revealed the oxygen concentrator had a layer of dust on the concentrator near the controls. Observation on 11/18/25 at approximately 9:23 a.m. in room [ROOM NUMBER] revealed the wall between the bathroom and the resident's bed had a two by four foot area with exposed drywall. Further observation revealed a brown substance on the bed rail. The side table surface top was peeling along 25 percent of the table. Observation on 11/18/25 at approximately 9:50 a.m. in room [ROOM NUMBER] revealed the privacy curtain had a brown substance in the midsection of the curtain…
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 before2025-11-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety for main kitchen and 3 of 5 kitchenettes observed. Findings Include:Review of the facilities Food Receiving and Storage Policy , undated, on 11/18/25 revealed . Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.Foods and Snacks Kept on Nursing Units.2. All foods belonging to residents are labeled with the resident's name, the item and the use by date. 3. Refrigerators must have a working thermometers and are monitored for temperature according to specific guidelines.Main KitchenObservation on 11/18/25 at approximately 8:25 a.m. with Staff R (Food Services Director), of the Deli 2 refrigerator revealed the following items without and open…
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 before2025-11-21 · 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
Based on observation, interview, and record review, it was determined that the facility failed to ensure proper processing of resident's clothing and failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for EBP.Findings include:Observation on 11/20/25 between at approximately 11:00 a.m. in the laundry room with Staff P (Infection Preventionist) and Staff O (Director of Housekeeping) revealed two residential washing machines were running on the normal mode and the warm water setting. Interview on 11/20/25 at approximately 11:00 a.m. with Staff O revealed the residential washing machines had been used for over a year for cleaning the resident's personal clothes. They use a household detergent on all personal clothes. Interview on 11/20/25 at approximately 2:30 pm with Staff V (laundry aide) revealed that the residential washers were used on the Normal Mode using the warm water setting and that the only detergent that was used was a household detergent. Staff V did not know the water temperature used when the warm water…
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 · D2025-11-21 · 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 ensure residents who chose and were scheduled to have a weekly showers received showers for 3 of 8 residents reviewed for activities of daily living (ADL) in a final sample of 35 residents (Resident Identifiers are #36, #107 and #176).Findings include:Resident #176Interview on 11/18/25 at 11:55 a.m. with Resident #176 revealed that he/she gets a shower once a month and they would like one weekly. Review on 11/21/25 of Resident #176's Care Plan, dated 8/6/25, revealed that the he/she required one staff assistance with bathing. Review on 11/21/25 of the Unit 1 Licensed Nursing Assistants (LNA) Assignment Sheet revealed that Resident #176 was scheduled for showers weekly on the 3-11 p.m. shift every Thursday.Review on 11/21/25 of LNA Task Documentation for Resident #176's during the past 30 days revealed that under Shower Thursday 3-11 there was no documentation that a shower had been completed. Interview on 11/21/25 at 10:35 a.m. with Staff K (LNA) revealed that he/she had worked 11/20/25 (Thursday) 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.
- Potential for harm · D2025-11-21 · tag F0603 — failed to not confine residents against their will — isolatedProtect each resident from separation (from other residents, his/her room, or confinement to his/her room).
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, it was determined that the facility failed to keep a resident free from involuntary seclusion for 1 of 1 resident reviewed for restraints in a final sample of 35 residents (Resident identifier is #131).Findings include:Observation on 11/18/25 at 8:30 a.m. through approximately 9:30 a.m., 12:00 p.m. through approximately 2:00 p.m. revealed Resident #131 sitting in his/her room at the bedside table coloring. Staff G (Activity Aide) was sitting in a chair with a bedside table outside of Resident #131's room blocking Resident #131's exit. Interview on 11/18/25 at approximately 9:00 a.m. with Staff G revealed that he/she was sitting outside of Resident #131's door for the day because Resident #131 required 1:1 (constant) supervision. Further interview revealed that Resident #131 Had been on 1:1's for about a week due to wandering. Interview on 11/18/25 at approximately 9:10 a.m. with Resident #131 revealed that he/she was unable to answer simple questions requiring a yes and no response. Observation on 11/19/25 at approximately 8:30…
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 · D2025-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 residents receive care in accordance with plan of care for 1 of 8 residents reviewed for choices in a final sample of 35 residents. (Resident identifier is #185.)Findings include:Interview on 11/18/25 at approximately 9:30 a.m. with Resident #185 revealed that he/she has been waiting to go to a follow up visit with the ENT (Ear, Nose, and Throat Specialist) for months. Further interview revealed that Resident #185 had been having an ongoing sore throat since September and had been asking nursing to make an appointment.Review on 11/21/25 of Resident #185's ENT office visit note, dated 7/1/25 revealed: . the following physician's order: nystatin (Mycostatin) 100,000 unit/ml suspension, Swish and swallow 5 ml (500,000 Units) four times daily for 10 days, Start Date 7/1/25, End Date 7/11/25, Indications: Chronic sore throat. Further review of the office visit note revealed, Follow up in about 8 weeks (around approximately 8/26/25).Review on 11/19/25 of Resident #185's medical record revealed that…
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 before2025-11-21 · 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 record review, it was determined that the facility failed to label medications with open expiration dates, monitor proper temperature controls, and permit only authorized personnel to have access to the keys for 2 of 6 medication carts observed and 2 of 3 medication room refrigerators observed. Findings Include:Observation on 11/18/25 at approximately 10:45 a.m. on Unit #6 revealed Staff E (Regional Registered Nurse) going through medications inside medication cart #5302 with no other facility staff present. Staff E appeared to be removing medications. Interview on 11/18/25 at approximately 10:45 a.m. with Staff E revealed that he/she was not assigned to the cart. Further interview revealed that Staff E works at another facility and was in the facility assisting during the survey. Interview on 11/18/25 at approximately 11:40 a.m. with Staff H (Administrator) confirmed that Staff E was not an employee of the facility. Staff E was employed by the corporation. Review on 11/18/25 of the facility policy titled, Medication Labeling and Storage, Dated…
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 · D2025-11-21 · tag F0809 — failed to serve meals on a reasonable schedule — isolatedEnsure 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, and record review, it was determined that the facility failed to ensure that a nourishing snacks was provided to residents consistent with the resident's plan of care for 1 of 1 residents reviewed for food and 1 of 6 residents reviewed for nutrition in a final sample of 35 residents. (Resident identifiers are #53 and #181).Findings include:Resident #53Interview on 11/18/25 at 11:23 a.m. with Resident #53 revealed that he/she was not offered snacks and the only snacks available when Resident #53 requests snacks were crackers and cookies.Review on 11/20/25 of Resident #53's care plan revealed that Resident #53 had potential for nutritional problems due to diabetes. Further review revealed an intervention initiated on 7/1/25 to offer a nourishing HS (Hour of Sleep) snack daily. Resident #181Interview on 11/18/25 at 9:54 a.m. with Resident #181 revealed that snacks offered in the evening were saltines or graham crackers and juice. He/she stated that he/she was a diabetic and he/she was not offered a snack with protein. Interview further revealed that staff had told…
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 before2024-10-10 · 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
Unit 5 Kitchenette: Review on 10/8/2024 of September 2024 refrigerator temperature logs for Unit 5 Kitchenette revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29.Based on observation, interview, and review, it was determined that the facility failed to ensure that dietary staff used facial hair restraints when cooking and serving food from the steam table for 1 of 1 kitchens observed for meal service, and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchens and 5 of 7 kitchenettes observed. Findings include: Review on 10/10/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 2 Management and Personnel .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard…
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 before2024-10-10 · 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
Based on observation, record review, and interview, it was determined that the facility failed to follow established infection control guidelines for facility water management that had the potential to effect the facility census of 220 residents who resided at the facility. Findings include: Observation on 10/8/24 at approximately 8:30 a.m. of Unit 4 revealed the unit was not in use. Review on 10/9/24 of the facility's Legionella Surveillance with a revised date of 6/2023, revealed .5. Primary prevention strategies: .d. Temperature controls: . ii. Hot water shall be stored above 140 degrees Fahrenheit . Review on 10/9/24 of the facility's undated Water Management Plan Overview for: Premier Rehab and Healthcare revealed on page 12 .Control Measures: Hot Water Systems .Water Heater Control Measure: Check flow and return temperatures at hot water heater .Frequency: Monthly .Monitoring: Supply Temperature should be checked at the outlet of the Hot Water Heater and should not be lower than 140 degrees [Fahrenheit] . Further review revealed on page 21 .Risk factors: Little used Outlets…
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 · D2024-10-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 a resident who was unable to carry out activities of daily living (ADL) received services to maintain good personal hygiene for 1 of 3 residents reviewed for ADL in a final sample of 37 residents (Resident Identifier #62). Findings include: Observation on 10/8/24 at 9:39 a.m. of Resident #62 revealed he/she was in their room dressed and sitting in a chair. Resident #62 had disheveled hair and long dark stubble on their face and chin. During an interview on 10/8/24 at 9:39 a.m. with Resident #62, the resident asked Can you help me shave and shower? Observation on 10/9/24 at 11:00 a.m. of Resident #62 revealed there was long, dark stubble on their face and chin. This was again observed on 10/10/24 at 9:25 a.m. Review on 10/10/24 of Resident #62's Quarterly Minimum Data Set revealed under Section GG - Functional Abilities and Goals, the resident had been coded as Dependent for showers/bathing and for personal hygiene (which included shaving). Review on 10/10/24 of Resident #62's care…
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 before2024-10-10 · 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 5 East Medication Cart Observation on [DATE] at approximately 8:14 a.m. of the 5 East Medication Cart with Staff F (Licensed Practical Nurse) revealed one opened Lispro Insulin Quik Pen with no name, open date or expiration date. Interview on [DATE] at approximately 8:14 a.m. with Staff F confirmed the above findings. Review on [DATE] of policy titled, Insulin Pen, date reviewed 2/2024, revealed: .2. Insulin pens must be clearly labeled with the resident name, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used . Based on observation, interview, and record review, it was determined that the facility failed to label and date opened multi-dose medications on 1 of 6 medications carts observed and 1 of 5 medication rooms observed. Findings include: 100's Medication Room Observation on [DATE] at approximately 8:30 a.m. of the medication refrigerator revealed influenza vaccine (1 box of prefilled syringes) and of Tuberculin Protein Derivitative (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 · D2024-10-10 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 provide dental services and assist the resident with making dental appointments when referred to an oral surgeon for 1 of 1 residents reviewed for dental services in a final sample of 37 residents (Resident Identifier #88). Findings include: Interview on 10/8/24 at 1:19 p.m. with Resident #88 revealed that their teeth were all broken. Resident #88 stated that they had been asking to see a dentist, but was told by the facility that they can't get him/her in to see a dentist. Observation on 10/8/24 at 1:19 p.m. of Resident #88's teeth revealed nearly all were broken and black. Review on 10/10/24 of Resident #88's care plan, initiated on 5/26/23 with a target date of 11/17/24, revealed that the resident had dental health problems with multiple decaying teeth and roots. Interventions included to coordinate arrangements for dental care and transportation as needed. Review on 10/10/24 of Resident #88's Dental Visit notes revealed the following; On 4/26/21, patient states all teeth are broken…
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 before2024-10-10 · 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 2 of 8 residents reviewed for meal/food concerns in a final sample of 37 residents (Resident Identifiers are #4 and #49). Findings include: Resident #4 Interview on 10/8/24 at approximately 8:15 a.m. with Resident #4 revealed they frequently received meal trays with items they have allergies to, such as chocolate and tomatoes. Resident #4 stated that they get sick to their stomach if they eat chocolate or tomatoes. Observation on 10/10/24 at approximately 11:45 a.m. of Resident #4's lunch tray revealed vanilla cake with chocolate frosting. Review of their meal ticket revealed an allergy to chocolate and tomatoes. Review on 10/10/24 of Resident #4's record revealed an allergy to chocolate and tomatoes. Interview on 10/10/24 at approximately 11:55 a.m. with Staff X (Unit Manager) stated Resident #4 had an allergy to chocolate and tomatoes and confirmed Resident #4 had received vanilla cake with chocolate frosting for lunch. Resident…
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 before2024-10-10 · 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
Based on record review and interview, it was determined that the facility failed to provide pneumococcal immunization for 1 of 5 residents reviewed for pneumoccocal vaccination in a final sample of 37 residents (Resident Identifier #73). Findings include: Review on 10/9/24 of Resident #73 immunizations revealed: Pneumococcal - historical type unknown: Pneumoccocal given 3/1/2017. Review on 10/9/24 of Resident #73 medical record revealed a consent for pneumococcal vaccine signed by the resident on 4/5/23. Further review revealed the pneumoccocal vaccine was not given to Resident #73. Interview on 10/10/24 at approximately 11:45 p.m. with Staff M (Infection Preventionist) confirmed Resident #73 had not received the consented second pneumoccocal vaccine. Review on 10/10/24 of the facility policy titled Pneumococcal Vaccine (Series), revised 5/2023, revealed: .Policy Explanation and Compliance Guidelines: .6. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23) offered .in accordance with current CDC (Center for Disease Control and Prevention) guidelines and recommendations .TABLE…
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 · D2024-07-25 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 provide services or assist a resident in making appointments to maintain good foot health for 1 of 3 residents reviewed for foot care (Resident Identifier #5). Findings include: Interview on 7/26/24 at approximately 12:30 p.m. with Resident #5 revealed they had been requesting to see a podiatrist for overgrown toenails. Review on 7/26/24 of Resident #5's medical record revealed a podiatry visit note dated 9/14/23 that stated .Routine podiatry care is medically necessary due to patient's atherosclerosis of the extremities and DM II [Diabetes Mellitus Type 2] due to the associated increased risk of bone infection, and digital or limb loss . Further review of Resident #5's medical record revealed no other podiatry visit notes. Review on 7/26/24 of Resident #5's Dialysis Communication Book revealed an entry dated 7/3/24 from the Dialysis Center to the Facility that stated .Please make sure [name omitted] has [pronoun omitted] toenails trimmed ASAP [as soon as possible], they are too long…
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 · E2023-10-06 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 interview, observation, and record review, it was determined that the facility failed to ensure that physician's orders were followed for 4 residents in a final sample size of 41 residents and 1 out of 28 medication administrations observed. (Resident Identifiers are #3, #64, #83, #158, and #163) 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 . Resident #163 Review on 10/3/23 of Resident #163's September 2023 and October 2023 Medication Administration Records (MAR) revealed the following physician's order: Hydralazine HCL [Hydrochloric Acid] Tablet 25 mg [milligrams] Give 1 tablet by mouth four…
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 · E2023-10-06 · 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
Observation on 10/2/23 at approximately 6:00 p.m. revealed a strong odor of urine on the nursing units. Interview on 10/3/23 at approximately 8:45 a.m. with Resident #115 revealed that he/she had concerns with staffing at the facility. Sometimes I have to wait for a half hour for my call light to be answered and then another hour or so for them to find someone help me. Interview on 10/3/23 at approximately 9:00 a.m. with Resident #187 revealed that receiving help from staff can be anywhere from 30 minutes to 2 hours. It is horrible, I wet myself sometimes and will be in pain for that long because there is no one to answer my call bell. Interview on 10/3/23 at approximately 10:00 a.m. with Resident #186 revealed, Over this past weekend there were a bunch of no shows which meant we waited for anything we needed. All of these people (staff members) are not on the floor helping out, this is only because you are here. Interview on 10/6/23 at approximately 9:15 a.m. with Staff L (Anonymous) and Staff M (Anonymous) revealed, Staffing is horrible and the residents suffer from it. At times…
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 before2023-10-06 · 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, review of manufacturer's instructions, and review of the facility's policy and procedure it was determined that the facility failed to label opened multi-dose medications and biologicals, failed to ensure that medications were secured, and failed to ensure that expired medications were removed from supply and not given on 5 of 6 medications carts reviewed and in 1 of 3 medication rooms observed (Resident identifiers are #130, #140, #174, #234, #89, #146, and #20). Findings include: Building 2 East Side Medication Cart Observation on 10/2/23 at approximately 6:10 p.m. of the Building 2 East Side Medication Cart revealed an opened Ozempic Pen with no resident name and no date of opening. Interview on 10/2/23 at approximately 6:10 p.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above finding. Review on 10/4/23 of the manufacturer's instructions for Ozempic, dated 2023 revealed: .Store your pen in use for 56 days at room temperature .The Ozempic pen you are using should be disposed of (thrown away) after 56 days, even if it still has…
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 · E2023-10-06 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined that the facility failed to provide meals served at an appetizing temperature for 22 residents in a final survey sample of 41 (Resident Identifiers are #3, #21, #41, #46, #56, #63, #82, #86, #107, #114, #118, #125, #136, #138, #181, #186, #204, #221, #224, #231, #387, #397). Findings include: Review on 10/4/23 of the Food and Drug Administration (FDA) food code 2022, January 18, 2023 version revealed: .(D) TIME/TEMPERATURE CONTROLS FOR SAFETY FOOD that is cooked to a temperature . and received hot shall be at a temperature of 57 degrees [ degrees ] C [Celsius] (135 degrees F [Fahrenheit]) or above. Review on 10/4/23 of the facility's meal time schedule revealed that Unit 2 dining room lunch service time was scheduled for 12:50 p.m. Observation on 10/4/23 between 11:00 a.m. to 1:20 p.m. in the kitchen with Staff U (Director of Food Services) revealed the following: -during line service the plates and pellets were cold to touch. -meal line service completed and test tray was placed on Unit 2 dining room cart at 1:20 p.m. Interview…
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 before2023-10-06 · tag F0806 — failed to honor food preferences — patternEnsure 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
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 follow menu preferences, allergies, and intolerances for 5 residents (Resident identifiers are #27, #56, #79, #138, and #210) of 19 residents reviewed for meal/food concerns (Resident Identifiers are #21, #41, #48, #53, #82, #83, #86, #107, #125, #136, #181, #186, #231, #397). Findings include: Building 3 (300 Unit) Resident #79 Review on 10/3/23 of Resident #79's lunch meal ticket revealed that Resident #79 was to have extra gravy and an egg salad sandwich along with his/her meal. Observation on 10/3/23 at 11:39 a.m. of Resident #79 eating his/her lunch revealed a plate of spaghetti with red ground meat sauce on it. Not all of the spaghetti has sauce on it. There was no egg salad sandwich on his/her tray. Interview on 10/3/23 at 11:39 a.m. with Resident #79 revealed that he/she had recently had 6 teeth removed and needed the extra gravy on foods to make it easier to chew and confirmed he/she did not get an egg…
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 · D2023-10-06 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 document a complete discharge summary for 1 out of 3 residents reviewed for closed records (Resident Identifier is #236). Findings include: Review on 10/6/23 of Resident #236's medical record revealed that Resident #236 was admitted to the facility on [DATE] from the hospital. Review on 10/6/23 at 9:39 a.m. of Resident #236's social service note dated 7/13/23 revealed Emotional support extended to [name omitted] this am [morning] related to pain, discomfort and desire to return home. [Name omitted] was discharged at the end of June with good progress in therapy, when [pronoun omitted] returned to ortho [orthopaedics] for follow up the screws had loosened per [name omitted], [name omitted] had to have them corrected. [Name omitted] is in significant pain. Emotional support and encouragement extended. This writer reached out to APRN [Advanced Practice Registered Nurse] to follow up to extend support and assist with the discharge…
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 · D2023-10-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to follow their policy for labeling and dating resident food items brought in by visitors for 3 of 5 kitchenettes observed. Findings include: Review on 10/2/23 at approximately 6:50 p.m. of Unit 5 kitchenette revealed the following: 1 bottle of French's Yellow mustard in the refrigerator with an expiration date of 2/2023 1 bottle of Gatorlyte in the refrigerator with no resident name or date present 1 pint of [NAME]-Dazs chocolate chocolate chip ice cream in the freezer with no resident name or date present 1 pint of Ben and Jerry's ice cream in the freezer with no resident name or date present 1 open box of Life Cereal in the cabinet with no resident name or open date present Interview on 10/2/23 with Staff U (Director of Food Services) confirmed the above findings. Observation on 10/2/23 at approximately 7:00 p.m. of Unit 6 kitchenette revealed 2 Stouffers frozen meals (1 beef stroganoff and 1 classic meatloaf) in the freezer 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 · Dcited before2023-10-06 · 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 include a data collection tool that tracked residents when admitted to the facility while COVID-19 positive for 1 of 1 resident reviewed for transmission-based precautions (Resident Identifier is #396). Findings include: Observation on 10/2/23 at 6:00 p.m. of the facility's COVID-19 Notification and Daily Update dated 10/2/23 and posted in the main lobby revealed that there were no active COVID-19 cases in the facility (both resident and staff). Interview on 10/2/23 at approximately 7:00 p.m. with Staff R (Licensed Practical Nurse) revealed that Resident #396 was admitted to the facility COVID-19 positive and was currently on transmission-based precautions. Observation on 10/4/23 at 8:46 a.m. of Resident #396's room revealed signage on the door for droplet transmission-based precautions. Review on 10/6/23 of Resident #396's Discharge Summary dated 9/29/23 revealed that Resident #396 tested positive for COVID-19 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.
- Potential for harm · Dcited before2023-10-06 · 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
Based on interview and record review it was determined that the facility failed to provide documentation of pneumococcal vaccination for 1 out of 5 residents reviewed for pneumococcal immunizations (Resident Identifier is #143). Findings Include: Review on 10/6/23 of Resident #143's Immunization Tab in the electronic record revealed under pneumococcal was coded Resident Refused. Review on 10/6/23 of Resident #143's Immunization Consent form dated 10/20/22 revealed under pneumococcal vaccination was checked I have already received pneumococcal vaccination . with no date of when. Review on 10/6/23 of Resident #143 medical record revealed no follow-up to what type of pneumococcal vaccination had been administered prior to admission or if Resident #143 needed a follow-up vaccination. Interview on 10/6/23 at 9:52 a.m. with Staff V (Licensed Practical Nurse) confirmed the above findings. Review on 10/6/23 of the facility's policy titled Pneumococcal Vaccine (Series) revised 2/2023 revealed: . 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report 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 · D2023-10-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to implement policies and procedures regarding offering and educating residents and staff the COVID-19 vaccination series for 2 of 5 residents reviewed for COVID-19 immunizations and 1 of 1 staff reviewed for COVID-19 immunizations (Resident Identifiers are #143 and #208. Staff identifier is Staff AA). Findings include: Resident #143 Review on 10/6/23 of Resident #143's COVID-19 immunization tab in the electronic record revealed that Resident #143 last COVID-19 vaccination was 4/20/22. Review on 10/6/23 of Resident #143's medical record revealed that Resident #143 admitted to the facility on [DATE]. Further review revealed that there was no documentation that a COVID-19 booster shot had been offered. Interview on 10/6/23 at approximately 11:15 a.m. with Staff S (Infection Preventionist) confirmed the above findings. Staff S stated that he/she did not follow up on Resident #143. Resident #208 Review on 10/6/23 of Resident #208'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.
- No harm found · B2024-10-10 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 the resident or resident representative of the bed hold policy before discharge to the hospital for 2 of 2 residents reviewed for hospitalizations in a final sample of 37 residents (Resident Identifiers are #75 and #97). Findings include: Resident #75 Review on 10/9/24 of Resident #75's nursing notes revealed a note dated 4/27/24 stating the resident was sent to hospital and admitted . Interview on 10/10/24 at approximately 11:15 a.m. with Staff T (Social Services Office Coordinator) confirmed Resident #75 was hospitalized on [DATE]. Staff T revealed that the facility provides residents their bed hold policy on admission but not upon transfer. Staff T stated the facility will readmit all residents after hospitalization. Resident #97 Review on 10/10/24 of Resident #97's progress notes revealed that the resident was sent to the hospital on 8/11/24 and on 9/9/24. Review on 10/10/24 of Resident #97'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.
- No harm found · B2024-10-10 · tag F0637 — patternAssess the resident when there is a significant change in condition
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 conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change was determined for 2 of 4 residents reviewed for hospice in a final sample of 37 residents (Resident identifiers are #165 and #11). Findings include: Resident #165 Review on 10/8/24 of Resident #165's medical record revealed he/she was admitted to Hospice on 7/5/24. Further review revealed the Significant Change MDS was completed on 8/2/24, 28 days after the determination of the significant change. Resident #11 Review on 10/9/24 of Resident #11's medical record revealed he/she was admitted to hospice on 9/13/24. Further review revealed the Significant Change MDS was completed on 10/4/24, 21 days after the determination of the significant change. Interview on 10/10/24 at approximately 12:00 p.m. with Staff Z (MDS Coordinator) confirmed the above findings.
- No harm found · B2023-10-06 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 discharge assessments were completed and transmitted to 2 of 2 residents reviewed for resident assessment Minimum Data Set (MDS) records over 120 days old (Resident Identifiers are #24 and #176). Findings include: Resident #24 Review on 10/4/23 of Resident #24's progress notes revealed that Resident #24 discharged home on 6/9/23 and was no longer in the facility. Review on 10/4/23 of Resident #24's electronic MDS revealed that there was no discharge assessment for the 6/9/23 discharge. Resident #176 Review on 10/4/23 of Resident #176's progress notes revealed that Resident #176 discharged to a hospital on 6/9/23 and was no longer in the facility. Review on 10/4/23 of Resident #176's electronic MDS revealed that there was no discharge assessment for the 6/9/23 discharge. Interview on 10/4/23 at 2:59 p.m. with Staff K (MDS Coordinator) confirmed the above findings.
“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 MARQUIS HEALTH SERVICES — 87 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 | 3.0 | -2.0 vs chain |
| Health inspection | 1 of 5 | 2.6 | -1.6 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 4.3 | -2.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; 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 | Since |
|---|---|---|---|
| PREMIER HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| NFR 2020 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| QUINTO NEXGEN LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| RSBRMK HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| SK NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| SKILLED VENTURE LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/05/2025 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| UAK 2020 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| UKR NEXGEN LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| YK NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| YR NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/05/2025 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST | since 06/05/2025 |
| GREENHALGH, KATRINA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/05/2025 |
| VEIGA, CARLY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 06/05/2025 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/15/2025 |
| NUTRACO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/16/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| POSEN, MINDEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/05/2025 |
| SHAH, ANURADHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/05/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/15/2025 |
| KAHANOW, AVIVA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/15/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/15/2025 |
| ROKEACH, FRAIDE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/15/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/15/2025 |
| PREMIER REAL PROPERTY LLC | Organization | ADP OF THE SNF | since 06/05/2025 |
CMS files one row per role, so the 46 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
16 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.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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.
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 305005. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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.