Mineral Springs
1251 White Mountain Highway, North Conway, NH 03860 · For profit - Limited Liability company · 87 certified beds · (603) 356-7294 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,148 in federal fines (most recent 2024-05-30)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 22% of its spending goes to commonly-owned related companies
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 2026-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 | 29.9% | 22.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.9% | 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 | 0.5% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 19.1% | 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 | 4.0% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.3% | 17.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.2% | 19.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.9% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.6% | 25.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.8% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 90.0% | 83.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.2% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.9% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.20 | 1.64 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.02 | 1.87 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.8% 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 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.0% 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 50 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 48.8%CMS range 39.0–58.1 | 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 | 11.2%CMS range 8.2–15.7 | 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 | 40.0% | 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 | 44.0% | 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 | 22.0% | 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 | 89.5% | 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 | 81.1% | 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 | 100.0% | 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 | 1.5% | 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 | 7.1%CMS range 3.8–13.5 | 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 87 beds and averages 72.5 residents a day — about 83% occupied, or roughly 14 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.70 hrs/resident/day on weekends vs 4.20 on weekdays — 12% thinner on weekends. RN hours go from 1.06 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · J2024-05-30 · 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 record review and interview, it was determined that the facility failed to ensure that a resident receiving anticoagulant (blood thinner) therapy received the necessary care and services for anticoagulation treatment for 5 days for 1 of 3 residents reviewed for anticoagulation therapy (Resident Identifier #1). Findings include: Record review on 5/30/24 of Resident #1's electronic medical record revealed a nurses note, dated 5/1/24 at 6:47 p.m. that stated Resident #1 was noted to have lips slightly cyanotic with vital signs as follows: Blood pressure of 124/87, heart rate of 163, respirations of 40, O2 [oxygen] saturation of 83% on 3 liters of oxygen and a temperature of 97.7 degrees Fahrenheit. Further review of the medical record revealed a note by Staff A (Nurse Practitioner) dated 5/1/24 and entered at 12:56 p.m., stating: The patient had not received [pronoun omitted] Coumadin since April 25 and was due for repeat INR [International Normalization Ratio] lab work however this appears to have not been done so the Coumadin was not re-dosed. The Nurse Practitioner's note…
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 · D2025-08-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 the health care provider's order for a therapeutic diet for a swallowing issue for 1 of 2 residents reviewed for nutrition in a final sample of 14 residents (Resident identifier is #43). Findings include:Review on 8/5/25 of Resident #43's physician's order revealed a dietary order dated 4/10/25 for Regular/Liberalized dysphagia (difficulty swallowing) advanced texture, pureed fruit and vegetables. Review on 8/5/25 of Resident #43's Care Plan revealed that Resident #43 was at nutritional risk for dysphagia with a goal of exhibiting no overt dysphagia with texture modification with a target date of 9/11/25. Further review revealed there was an intervention to provide a dysphagia diet as ordered. Observation on 8/5/25 at 12:15 p.m. of Resident #43 revealed that he/she was in their bed with their lunch tray set up in front of them with Resident #43's meal ticket which read Pureed Fruits and Vegetables. Further observation revealed there was a bowl of sliced whole pears on the tray.…
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 · D2025-02-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 the residents' right to formulate advance directives for 2 out of 2 residents reviewed for Advance Directives in a final sample of 15 residents. (Resident Identifier's are #102 and #152.) Findings include: Resident #102 Review on 2/19/25 of Resident #102's medical record revealed a physician's order, dated 2/15/25, for Full Code (meaning the patient wishes to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). Further review of Resident #102's medical record revealed a Portable Do Not Resuscitate (DNR) form, dated 7/11/22, that indicated Resident #102 was a DNR (meaning the patient wishes not to have cardiopulmonary resuscitation attempted on them if their heart or breathing stops). Review on 2/20/25 of Resident #102's care plan for advanced directives revealed Resident #102's code status was DNR. Interview on 2/20/25 at approximately 12:20 p.m. with Staff C (Registered Nurse) confirmed the above findings. Resident #152 Review on 2/19/25 of 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 · D2025-02-21 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to inform each resident before, or at the time of admission, of services available in the facility and of charges for those services for 1 resident in a final sample of 15 residents. (Resident identifier is #43.) Findings include: Interview on 2/19/25 at approximately 12:00 p.m. with Resident #43's DPOA (Durable Power of Attorney) revealed that his/her spouse was admitted to the facility in December 2024. He/she stated that they gave the facility their prescription card but was told that they needed to use the facility's pharmacy. Interview revealed they have been billed monthly for co-pays from the facility's pharmacy. They would not have co-pays at their pharmacy and the facility did not tell them they would be charged. Interview on 2/21/25 at approximately 8:30 a.m. with Staff B (Admissions Coordinator) revealed that during the admission process, the option of using an outside pharmacy was not discussed with Resident #43 or their DPOA. Staff B also revealed that Resident #43's DPOA gave him/her an…
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 before2025-02-21 · 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 interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 2 residents review for pain management in a final sample of 15 residents (Resident identifier is #44.) Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 2/20/25 of Resident #44's Medication Administration Record (MAR) revealed a physician order for Acetaminophen Tablet 325 mg [milligrams] Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice nurse . Review on 2/20/25 of Resident #44's MAR for January and February 2025 revealed that Resident #44…
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 · D2025-02-21 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 4 days in the month of September 2024. Findings include: Review on 2/19/25 of the Facility's Payroll Based Journal Staffing Data Report for Quarter 4 2024 (July 1-September 30, 2024) revealed that there were no RN hours submitted for the following days: 9/1/24, 9/15/24, 9/28/25, and 9/29/24. Interview on 2/20/25 at 1:00 p.m. with Staff D (Director of Nursing) confirmed the above findings and revealed that the facility could not provide documentation to show that there was an RN on duty during the above dates.
- Potential for harm · Dcited before2025-02-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and manufacturer's instruction review, it was determined that the facility failed to ensure that medications were labeled and dated in accordance with currently acceptable professional principles for 2 out of 2 medication carts observed. (Resident identifiers are #152 and #36.) Findings include: Observation on 2/19/25 at 9:07 a.m. of the [NAME] Front medication cart revealed a small clear plastic medication cup in the top drawer containing 3 pills (medications). The cup was unlabeled and undated. Interview on 2/19/25 at 9:10 a.m. with Staff C (Registered Nurse) confirmed the above findings and revealed that the medications belonged to Resident #36. Observation on 2/19/25 at 9:45 a.m. of the [NAME] Woods medication cart revealed one Symbicort inhaler, not in a box or bag, with no resident identifier or open date or open expiration date. Further observation revealed an Advair Diskus inhaler in a box for Resident #152 without an open date or open expiration date. The pharmacy…
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 · D2025-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, it was determined that the facility failed to ensure that medical records were accurately documented for 1 out of 1 resident reviewed for Post Traumatic Stress Disorder. (Resident Identifier is #202.) Findings include: Review on 2/20/25 of Resident #202's medical record revealed a diagnosis list, dated 2/13/25, that showed Resident #202 had a diagnosis of Post Traumatic Stress Disorder. Further review of Resident #202's medical record revealed a Social Services Assessment and Documentation, signed on 2/17/25 by Staff F (Social Worker). Section C of the assessment titled Mental Health and Wellness .4. Trauma History: Does the patient/resident report or does the medical record reflect any history of trauma and/or Post-Traumatic Stress Disorder (PTSD)? The box is shaded in for the answer 2 NO Interview on 2/20/25 at 1:49 P.M. with Staff F revealed that he/she did not ask Resident #202 about the trauma and did not completed the assessment accurately. Review on 2/20/25 of the facility's policy titled: Trauma Informed Care 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 · Fcited before2024-09-12 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 48 residents. Interview on 9/10/24 at approximately 1:40 p.m. with Resident #26 revealed that he/she was frequently told that staff were too busy and it caused delays in the care that he/she needed, and medications administered were frequently late. Interview on 9/10/24 at approximately 1:00 p.m. with Resident #45 revealed that the facility was short staffed, and it caused longer responses to call lights and getting the assistance he/she needed. Resident #45 stated: I waited on the toilet for 45 minutes the other day. Interview on 9/11/24 at approximately 8:00 a.m. with Staff H (Licensed Nursing Assistant (LNA)) and Staff L (Medication Nursing Assistant (MNA)) revealed that at times, it is just an MNA 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 · F2024-09-12 · 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
Based on interview and record review, it was determined that the facility failed to follow established infection control guidelines for facility water management by not having a system to monitor control measures to minimize the risk of Legionella and other opportunistic pathogens that has the potential to effect the facility census of 48 residents who resided at the facility. Findings include: Interview on 9/11/24 at approximately 10:30 a.m. with Staff D (Infection Preventionist) revealed they did not know if the facility had a system to monitor control measures in place to prevent the introduction and spread of Legionella. Review on 9/12/24 of the facility's policy, Legionella Water Management, dated 2017, revealed: .These domestic unmixed water tanks have a high-volume use and high temperature that make it completely inhospitable for the Legionella bacteria to grow. These tanks are also purged at the base to remove any settled impurities monthly by the maintenance staff using the TELS Maintenance System. All basement boiler and water flow systems are monitored for flow, pressure,…
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 before2024-09-12 · 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 and record review, it was determined that the facility failed to follow physician orders or provide medications timely for 5 residents in a final sample of 19 residents (Resident Identifiers are #1, #17, #26, #34, #47). 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 . [NAME], [NAME]; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022. Page 597 - Safe Medication Preparation: Right Time With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed…
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 16 citations
- Potential for harm · E2024-09-12 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
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 the activities program was directed by a qualified professional for a facility census of 78 residents. Findings include: Interview on 9/11/24 at 9:56 a.m. with Staff C (Director of Activities) revealed that he/she was promoted to Director of Activities in September 2024. He/she had been working as an activities aid at the facility since June 2024. Interview further revealed that Staff C had no prior certifications in activities, degrees in recreation, or any prior experience working in an activity program. Interview on 9/11/24 at 10:00 a.m. with Staff A (Administrator) confirmed the above findings and that Staff C was not qualified. Review on 9/11/24 of the facility's job description for Director of Recreation Services, revised 4/25/17, revealed: . Education/Vocational Requirements: 1. Certification in accordance with regulatory agencies governing the center, by the National Certification Council of Activity Professionals (ADC) or the National Council of Therapeutic Recreation Certification…
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 · E2024-09-12 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined the facility failed to designate an Infection Preventionist that completed specialized training in infection prevention and control. Findings include: Record review on 9/11/24 revealed that the facility could not provide evidence of specialized training in infection control for Staff D (Infection Preventionist). Interview on 9/11/24 at 10:30 a.m. with Staff D revealed that Staff D was hired on 5/23/24 and was currently designated as the Infection Preventionist. Interview on 9/11/24 at 12:00 p.m. with Staff E (Director of Nursing) confirmed the above findings. Review on 9/11/24 of the facility's job description for Infection Preventionist, revised 8/3/20, revealed: .Specific Education/Vocational Requirements .2. Must complete specialized training in infection prevention within 90 days of hire . Review on 9/12/24 of the facility's policy, Infection Prevention and Control Program (IPCP), revised 7/1/24, revealed: .The Infection Preventionist develops, implements, monitors and maintains the IPCP and fulfills the basic requirements…
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 · D2024-09-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 ensure resident's needs were accommodated by keeping their call bell within reach for 1 of 1 reviewed for environment in a final sample of 16 residents (Resident Identifier #12). Findings include: Observation on 9/10/24 at approximately 11:44 a.m. revealed Resident #12's call bell hanging over their roommates light fixture over their roommates bed. Interview on 9/10/24 at approximately 11:44 a.m. with Resident #12 revealed that he/she would yell for help if needed because he/she is unable to reach the call bell. Observation on 9/11/24 at approximately 10:29 a.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over their roommates bed in the same spot as the day prior. Resident #12 was sitting in their wheel chair on a hoyer pad by their window. Resident #12 was unable to reach the call bell on the opposite side of his/her bed. Observation on 9/11/24 at approximately 3:18 p.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over 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 · D2024-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, 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 clean and homelike environment on 1 of 2 units observed. Observation on 9/11/24 from approximately 7:00 a.m. until 7:20 a.m. of the [NAME] Unit revealed three large areas of smeared brown substance adhered to the carpet. One area (approximately 4 feet (ft.)) long and 1 ft. wide) was on the floor in the hallway and the two other areas (approximately 2 ft. long and 1 ft. wide) were on the floor in front of the nursing station. Further observation revealed two residents walking on the areas. Interview on 9/11/24 at approximately 7:15 a.m. with Staff H (Licensed Nursing Assistant) revealed that the areas on the floor were from a resident having loose stools on 9/10/24 in the evening.
- Potential for harm · D2024-09-12 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 showers for 1 out of 3 residents reviewed for Activities of Daily Living (ADL's) in a final sample of 19 residents (Resident Identifier #42). Findings include: Review on 9/13/24 of the facilities policy titled, Resident Showers, not dated, revealed: Policy Explanation and Compliance Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident #42 Review on 9/11/24 of Resident #42's medical record, Care Plan Meeting Note, dated 7/5/24 revealed Resident #42's family was concerned about Resident #42 not getting his/her shower weekly. Review on 9/12/24 of Resident #42's bathing documentation for July, August and September 2024 revealed that Resident #42 did not receive any showers. There was no documentation of refusal of showers. Interview on 9/12/24 at approximately 1:35 p.m. with Staff J (Clinical Nursing Officer) confirmed that there was no documentation that Resident #42 received a shower in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, it was determined that the facility failed to ensure that facility-sponsored groups and individualized activities were provided to support residents based on the resident's preferences, interests, and all needs for each resident for the weekend days in September 2024. Findings include: Interview on 9/10/24 at approximately 2:15 p.m. with the facility's Resident Council (8 residents) revealed that all the residents that attended complained that there were no weekend activities the past 2 weekends and that nothing was on the September activities calendar for the weekends. 1 resident stated that he/she watched television all day and 7 residents stated that there was nothing for them to do. Review on 9/11/24 of the September 2024 activity calendars revealed that there were no activities documented on Saturdays and Sundays (9/1/24, 9/7/24, 9/8/24, 9/14/24, 9/15/24, 9/21/24, 9/22/24, 9/28/24, and 9/29/24). Interview on 9/11/24 at 9:55 a.m. with Resident #37 and Resident #43 revealed that they would attend activities on the weekends. Interview 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 · D2024-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer and treatment orders for pressure ulcers for 1 out of 1 residents reviewed for pressure ulcers (Resident Identifier #1). Findings include: Review on 9/11/24 of Resident #1's physician progress note dated 7/9/24 revealed the following note: Left leg had been placed in a cast. [Pronoun omitted] started to develop pain around [pronoun omitted] Achilles tendon. [Pronoun omitted] was seen for follow-up and found to have a pressure ulcer. Review on 9/12/24 of Resident #1's skin and wound evaluations revealed that on the following dates, wound measurements were taken: 7/13/24, 8/1/24, 8/8/24, 8/10/24, and 8/25/24. Interview on 9/12/24 at approximately 12:00 p.m. with Staff E (Director of Nursing) confirmed the above findings and that measurements were not taken weekly. Review on 9/12/24 of the facility policy…
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 · D2024-09-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure that resident's diabetes regimen included timely medication administration and adequate monitoring for 1 of 3 residents reviewed for insulin in a final sample of 19 residents (Resident Identifier #30). Findings Include: Resident #30 Interview on 9/10/24 at approximately 10:45 a.m. with Resident #30 revealed he/she was a diabetic and concerned about his/her blood sugars being inconsistent and he/she questioned whether he/she was receiving the correct insulins. Review on 9/10/24 of Resident #30 medical record revealed physician orders for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/milliliter (ML), Inject 10 units subcutaneously two times a day for Diabetes Mellitus with breakfast and lunch, scheduled at 8 a.m. and 12 p.m. Review on 9/10/24 of Resident #30 Medication Administration Record (MAR) revealed on 8/7/24 for the 8:00 a.m. Fiasp Insulin dose, it was administered at 10:32 a.m. (2.5 hours late). Review on 9/10/24 of Resident #30 MAR revealed on 8/19/24 for the 12:00 p.m.…
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 · D2024-09-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medication error rate was less than 5 percent (%) for medication administration for 2 of 36 medications observed (5.56 % error rate) (Resident Identifier #34). Findings include: Review on 9/12/24 of Resident #34's September 2024 Medication Administration Record (MAR) revealed the following physician's orders: 1. Olanzapine 2.5 milligram (mg) by mouth in the morning for Borderline personality 2. Metoprolol Succinate Extended Relief (ER) 24 hour 100 mg, give 1 tablet by mouth one time a day for hypertension. Observation on 9/12/24 at approximately 7:30 a.m. of Staff N (Registered Nurse) administering medications to Resident #34 revealed Staff N was going to administer an Olanzapine 5 mg (prescribed 2.5 mg) and was not going to administer Metoprolol Succinate ER 24 hour 100 mg. Interview on 9/12/24 at approximately 7:30 a.m. with Staff N confirmed the above findings. Review on 9/12/24 of the facility policy titled, Medication Administration, dated 2024 revealed: .10. Ensure 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 before2024-09-12 · 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 the facility failed to maintain locked storage of medications, failed to ensure resident medications had accurate labeling of medications in 1 of 2 med carts, and medications were discarded after expiration in 1 of 1 medication rooms observed ([NAME] Medication Room and Brettonwoods Medication Cart). Findings include: [NAME] Medication Room Observation on [DATE] at approximately 9:15 a.m. of [NAME] Medication room medication refrigerator revealed one open vial of Tuberculin PPD-Aplisol without an open date or open expiration date and one open vial of Tuberculin PPD-Aplisol with an open date of [DATE] (expired on 9/6). Review on [DATE] of Tuberculin PPD-Aplisol manufacturer instructions revealed: .Vials in use more than 30 days should be discarded due to possible oxidation and which may affect potency . Interview on [DATE] at approximately 9:15 a.m. with Staff M (Registered Nurse) confirmed above findings. Brettonwoods Medication Cart…
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 · D2024-02-01 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to follow its policy for tracking, investigating, and prompt resolution for 2 out of 4 residents reviewed for grievances (Resident Identifiers are #1 and #2). Findings include: Review on 2/1/24 of the facility's policy Grievance/Concern with an effective date of 6/1/96 and revised on 1/8/24 revealed, .Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient . Social Services personnel will serve as patient advocates in the grievance/concern process. The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process . receiving and tracking grievances through to their conclusion . Process . 1.4 The right to obtain a written decision regarding their grievance . 3. Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern . 4. Upon receipt of the Grievance/Concern Form, The Administrator or designed will document the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs. Findings include: Review on 11/7/23 of a witness statement to an allegation of abuse on 9/29/23 written by Staff E (Anonymous) revealed the following: On Friday morning, 9/29/23 around 7 a.m. [pronoun omitted] was informed that [pronoun omitted] was the only aide on [NAME] Wing Interview on 11/7/23 at approximately 11:20 a.m. with Staff E revealed that the resident care suffers. We all have a job to do and I help the LNAs [Licensed Nursing Assistants] as much as I can but it is not enough. When there is one LNA on the floor that leaves them with about 30 residents to care for. Staff E also revealed that there is no assistance on the floor from ancillary staff when call-outs happen. We do the bare minimum and the best that we can. Interview on 11/7/23 at approximately 2:45 p.m. with Staff D (LNA) revealed that the facility staffs the units with two LNAs each. It is…
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 · D2023-11-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to report allegations of abuse to the State Survey Agency (SSA) for 3 out of 4 grievances reviewed for alleged abuse (Resident Identifiers are #2, #3, and #4). Findings include: Review on 11/7/23 of the Facility Grievance Log from September 2023 to November 2023 revealed the following allegations: 9/21/23 - Resident #2 reported staff rudeness. 10/10/23 - Resident #3's wife reported that the resident called her and reported that a brief was thrown at Resident #3 and he/she was told to change it themself. 11/6/23 - Resident #4 reported rudeness by Staff C (Licensed Nursing Assistant) Interview on 11/7/23 at approximately 11:20 a.m. with Staff B (Director of Nursing) revealed that he/she is the person responsible for reporting allegations. Staff B confirmed that the above allegations were not reported to the SSA. Staff B had no knowledge of the allegation on 11/6/23 from Resident #4 with Staff C. Review on 11/8/23 of the facility policy titled, OPS 300 Abuse Prohibition, Revision Date 10/24/22 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 · D2023-11-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 2 out of 4 grievances reviewed (Resident Identifiers are #2 and #3). Findings include: Review on 11/7/23 of the Facility Grievance Log from September 2023 to November 2023 revealed the following allegations: 9/21/23 - Resident #2 reported staff rudeness. 10/10/23 - Resident #3's wife reported that the resident called her and reported that a brief was thrown at Resident #3 and he/she was told to change it themself. Interview on 11/7/23 at approximately 2:20 p.m. with Staff B (Director of Nursing) confirmed that the above allegations were not investigated. Review on 11/8/23 of the facility policy titled, OPS 300 Abuse Prohibition, Revision Date 10/24/22 revealed: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1…
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 · Dcited before2023-11-08 · 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 interview and record review it was determined that the facility failed to follow physician orders for 1 of 2 residents reviewed for physician orders (Resident Identifier is #1). 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 . Review on 11/7/23 of Resident #1's October 2023 Medication Administration Record (MAR) revealed the following: Please obtain UA [urinalysis]/culture if indicated. For increased frequency and increased incontinence. one time for UTI [Urinary Tract Infection] symptoms for 1 day, Start Date 10/27/23. Further review revealed that the urine was checked off in the MAR as being…
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 · C2024-09-12 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
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 develop, implement and maintain an effective comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) plan. Findings include: Interview on 9/12/23 at 2:20 p.m. with Staff A (Administrator) revealed that the facility was unable to provide documentation of a written QAPI plan.
“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
$32,148 in federal fines across 2 penalties.
- $16,801 — penalty dated 2024-05-30
- $15,347 — penalty dated 2023-09-13
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 603 HEALTHCARE — 7 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 | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 2 of 5 | 3.6 | -1.6 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 6 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BLACK MOUNTAIN PEAK HEALTHCARE, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/25/2024 |
| PR NH HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 02/19/2024 |
| RR NH HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 02/19/2024 |
| 603 HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/28/2024 |
| HERNANDEZ, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2024 |
| MARTIN, CHRIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/04/2024 |
| STEVENSON, SEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/29/2024 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 22% 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 305084. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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 →
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