Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Derry Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
Medication labeling and storage were not maintained according to accepted professional principles in the med room and on the East med cart. An open PPD vial was kept beyond the documented open period, and several resident medications, including eye drops and inhalers, had no open date or beyond-use date recorded. An LPN and an RN confirmed the findings, and the facility policy required open dates and expiration/beyond-use dates to be recorded and checked before administration.
A survey of a medication cart in an LTC facility revealed multiple instances of improperly labeled multi-dose medications, including insulin pens and vials without open or discard dates. Some medications also lacked resident identifiers, violating the facility's labeling policy and manufacturer's instructions. An LPN confirmed these findings.
A facility failed to assess a resident's ability to self-administer medication. An albuterol inhaler was found in the resident's room, and the resident reported using it as needed. However, there was no physician's order or self-administration assessment in the medical record. An LPN confirmed these findings, which were contrary to the facility's policy requiring an interdisciplinary team assessment for self-administration safety.
The facility failed to notify residents of the bed hold policy before hospital transfers, as required by their policy. Two residents were transferred without receiving this notification, confirmed by a review of medical records and an interview with the Business Office Manager. The facility's policy mandates written notification at the time of transfer or within 24 hours in emergencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a history of ESBL colonization and another with a pressure ulcer. Observations revealed the absence of EBP signs and PPE, and interviews confirmed non-compliance with CDC guidelines and facility policy, which require gown and glove use during high-contact care activities.
The facility failed to implement care plans for two residents requiring meal supervision. One resident with mobility and weakness issues was observed eating alone in bed, contrary to their care plan. Documentation showed they ate independently multiple times without supervision. Another resident with mobility, vision, and cognitive deficits was also observed eating alone, despite their care plan requiring supervision. The DON expected staff to visually supervise residents during meals, which was not done.
A resident with dysphagia and a self-care performance deficit was observed eating alone in bed, contrary to their care plan which required staff supervision after meal setup. Despite a previous choking incident, documentation showed multiple instances of the resident eating without supervision, highlighting a failure to provide adequate supervision during meals.
The facility failed to maintain appropriate food temperatures, resulting in cold meals being served to residents. Despite initial compliance with temperature guidelines, food temperatures dropped significantly by the time of service. Residents had previously complained about cold food, and staff interviews revealed a lack of necessary equipment to maintain food temperature.
A resident was observed eating breakfast without the necessary assistive devices, such as a nosey cup and built-up silverware, which were specified on their meal ticket. The Dietary Manager confirmed these items should have been provided, as per the facility's policy on adaptive devices for residents who need them.
The facility failed to ensure dietary staff used facial hair restraints, maintain a clean kitchen environment, and properly store food. A cook was observed preparing and serving food without a beard restraint, and the kitchen had accumulated food debris and sticky floors. Additionally, Vanilla Mighty Shakes in the kitchenette lacked thawed or use-by dates, contrary to storage guidelines.
Failure to Document Post-Fall Assessments and Vital Signs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not documenting required post-fall assessments for two residents. For Resident #1, a registered nurse (Staff C) reported that after a fall on 1/21/26, the resident was found on the floor leaning against the wall, complaining of head pain and groin pain. Staff C stated the resident had a lump on the back of the head and groin sensitivity, and that the resident was transferred from the floor to a chair with a licensed nursing assistant and then to bed with assistance from Staff B. Once in bed, the resident had increased right leg pain. Staff C acknowledged performing an assessment after the fall but did not document any of these findings in the medical record. Record review for Resident #1 showed a progress note by Staff B at 1:50 p.m. stating the resident was found on the floor complaining of severe pain in the right parietal scalp and right leg/hip/pelvis, unable to extend the leg due to pain, and that the provider was notified and the resident sent to the ER. An IDT note the following day stated the resident had a small abrasion on the right side of the head, a full body assessment was done with no other injuries noted, the resident would not extend the leg straight, and pain prevented assessment of the right lower extremity for shortening or rotation; x‑rays were ordered but not completed due to pain, and the resident was sent to the ER. Despite these narrative notes, there was no documentation of vital signs, no neurological checks, and no documentation by Staff C of the assessment performed while the resident was on the floor, even though the resident remained at the facility for approximately two hours before hospital transfer. The DON confirmed the absence of documented vital signs and neuro checks and stated the resident should not have been moved while complaining of pain. For Resident #2, the medical record contained a progress note dated 1/19/26 indicating the resident was found on the floor next to the bed, stated they did not want to wait for help, had no skin issues, and was moved from the floor to a wheelchair. An IDT note dated 1/20/26 documented that the resident had a fall in the room while trying to transfer from bed to chair, that no injuries were noted on a full body assessment by the unit manager, and that the resident was assisted back to bed. There were no additional progress notes or documentation of the resident’s assessment after the fall, and Staff B confirmed there was no documentation of the full body assessment referenced in the IDT note. Review of facility policies on assessing falls and accident/incident reporting showed that post-fall documentation was required to include assessment data, vital signs, obvious injuries, and the condition of the resident, which was not completed for these two residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to follow currently accepted professional principles for labeling and storing medications in the medication room and East medication cart. In the medication room, an open bottle of Tuberculin Purified Protein Derivative (Mantoux) was observed with an open date of 10/22/25 and a discard-after-30-days instruction, and Staff A, an LPN, confirmed the finding. The manufacturer’s instructions reviewed for Tubersol stated that a vial entered and in use for 30 days should be discarded. In the East medication cart, an open bottle of Brimodine eye drops for Resident #21 had no open date or open expiration date, and Symbicort inhalers for Resident #1 and Resident #34, as well as an open Breyna inhaler for Resident #34, also had no open date or open expiration date. Staff B, an RN, confirmed these findings. The facility policy titled Administering Medications stated that the expiration/beyond use date on the medication label is checked prior to administering and that when opening a multi-dose container, the open date is recorded on the container.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that multi-dose medications were labeled appropriately, as observed during a survey of the East Medication Cart. The survey revealed multiple instances where insulin pens and vials, as well as other medications, were not labeled with open or discard dates. Specifically, medications for several residents, including Humalog, Lispro, Lantus, Lyumjev, Tresbia, Basaglar, Admelog, and Apidra insulin pens, were found without proper labeling. Additionally, some medications lacked resident identifiers, such as an open bottle of Systane gel eye drops and Prednisolone eye drops. The facility's policy on labeling medication containers, revised in April 2019, requires that individual resident medications include necessary information such as the resident's name, expiration date, and directions for use. However, the survey findings indicated non-compliance with this policy, as confirmed by an interview with Staff A, a Licensed Practical Nurse. The manufacturer's instructions for the medications observed also specify discard dates after opening, which were not adhered to in the facility's practice.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to determine if self-administration of medications was appropriate for a resident. During an observation, an albuterol inhaler was found on the resident's bedside table, and the resident confirmed using it as needed. However, a review of the resident's medical record showed no physician's order for the inhaler and no completed self-administration assessment. A Licensed Practical Nurse confirmed these findings. The facility's policy requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and clinically appropriate.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transferring them to a hospital, as required by their own policy. This deficiency was identified during a review of medical records and interviews, which revealed that two residents were transferred to the hospital without being informed of the bed hold policy. Resident #8 was discharged to the hospital on April 15, 2024, and Resident #47 was discharged on August 20, 2024, and again on September 21, 2024, without receiving the necessary notification. Additionally, Resident #51 was transferred to the hospital on July 29, 2024, without being informed of the bed hold policy. An interview with the Business Office Manager confirmed that the facility did not provide the bed hold policy at the time of transfer, although it was included in the admission packet. The facility's policy, revised in March 2022, mandates that residents be given written information about bed hold policies at the time of transfer or within 24 hours in emergency situations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to the CDC guidance for Enhanced Barrier Precautions (EBP) for two residents, leading to a deficiency in infection prevention and control. Resident #4, who had a history of colonization with Extended Spectrum Beta-Lactamase (ESBL) in their urine, did not have an EBP sign or Personal Protective Equipment (PPE) outside their room. Despite having a care plan that included maintaining EBP due to the colonization, the Unit Manager confirmed that Resident #4 was not on EBP. This oversight was identified during an observation and confirmed through interviews with staff. Similarly, Resident #10, who had an open wound on the right heel upon admission, was not placed on any precautions. The Director of Nursing confirmed the presence of a pressure ulcer, yet no EBP sign or PPE was observed inside or outside the resident's room. Interviews with the resident and the Infection Preventionist confirmed that staff only wore gloves during wound care, without the use of protective gowns, which is contrary to the facility's policy and CDC guidelines. The facility's policy, revised in August 2023, mandates the use of gown and gloves for high-contact care activities, which was not followed in these cases.
Failure to Implement Meal Supervision Care Plans
Penalty
Summary
The facility failed to implement the care plans for two residents who required supervision during meals. Resident #1, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. Despite the care plan specifying the need for staff supervision after meal setup and encouraging the resident to get out of bed for meals, documentation over the last 30 days showed that the resident ate independently seven times and received only setup or cleanup assistance 35 times. Interviews with the resident and a Licensed Nursing Assistant confirmed that the resident always eats alone in their room after meal setup. Similarly, Resident #2, who has a self-care performance deficit related to declined mobility, poor vision, and declined cognition, was also observed eating breakfast alone in their room. The care plan for this resident also required staff supervision after meal setup. However, documentation from the last 30 days indicated that the resident ate independently five times and received setup or cleanup assistance 24 times. An interview with the Director of Nursing revealed that the expectation for supervision at meals was for staff to maintain a visual on the residents, which was not adhered to in these cases.
Inadequate Supervision During Meals for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision to prevent choking accidents during meals for a resident with a diagnosis of dysphagia. The resident, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. The care plan for the resident indicated that staff supervision was required after meal setup, and the resident was encouraged to get out of bed for meals as tolerated. However, interviews with the resident and a Licensed Nursing Assistant (LNA) revealed that the resident always eats alone in his room after meal setup. A review of the resident's medical record and nursing notes indicated a previous choking incident on a dinner meal, where the resident began to choke and required assistance to be sat up and expel the food. Despite this incident, documentation over the last 30 days showed that the resident had meals without supervision multiple times, with seven instances of eating independently and 35 instances of only setup or cleanup assistance. This lack of supervision during meals is a direct violation of the resident's care plan and poses a significant risk given the resident's medical condition.
Deficiency in Food Temperature Control
Penalty
Summary
The facility failed to provide food that is palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. The U.S. Food and Drug Administration Food Code requires that time/temperature control for safety food be maintained at specific temperatures, but the facility did not adhere to these guidelines. During a food service observation, it was noted that while the holding temperatures of scrambled eggs, toast, and cream of wheat were initially within acceptable ranges, the temperatures significantly dropped by the time the food was served to residents. A test tray showed that scrambled eggs, toast, and cream of wheat were served at unappetizing low temperatures, which were confirmed by staff interviews. Residents had previously raised concerns about cold food during Food Council and Resident Council meetings, but these grievances were not addressed. Interviews with staff revealed that the facility lacked equipment such as a plate warmer or heated food cart, which contributed to the issue of cold food being served, especially for breakfast in resident rooms. Observations also showed that meal carts were left open during service, further contributing to the temperature drop. Residents expressed dissatisfaction with the temperature of their meals, confirming the deficiency in food service quality.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide a resident with the necessary assistive devices for eating, as observed during a survey. On the morning of June 4, 2024, a resident was seen eating breakfast alone in bed without the required assistive devices, specifically a nosey cup and built-up silverware, which were indicated on the resident's meal ticket. An interview with the Dietary Manager confirmed that these items should have been included on the resident's breakfast tray. A review of the facility's policy on assistance with meals, revised in March 2022, stated that adaptive devices should be provided for residents who need or request them, including items like silverware with enlarged handles and specialized cups.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure that dietary staff used facial hair restraints while cooking and serving food, as observed in the kitchen. Staff E, a cook, was seen preparing and serving food without a beard restraint, despite having a beard over an inch long. Interviews with Staff E and the Dietary Director confirmed that the facility did not provide beard restraints, and Staff E admitted to never wearing one. This lack of compliance with the facility's policy on employee hygiene and sanitary practices was evident during meal service observations. Additionally, the facility did not maintain a clean kitchen environment. Observations revealed food particles and debris accumulated under counters and the steam table, with sticky floors and dried liquid stains present. Staff E confirmed that the floors were supposed to be swept after each meal and mopped at night, but often remained dirty the following morning. A review of the cleaning schedule showed no documentation of nightly mopping, and the Dietary Director confirmed these findings. The facility also failed to store food according to professional standards. In the kitchenette, ten Vanilla Mighty Shakes were found without thawed or use-by dates, and Staff F was unaware of when they were thawed. This oversight contradicts the manufacturer's instructions, which require thawed products to be used within 14 days and kept refrigerated. The lack of proper date marking and storage practices poses a risk of foodborne illness, as confirmed by the facility's policy review.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Derry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Valley Nursing And Rehab Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Warde Health Center | 6.3 mi | ★★★★★ | 2 | 0 |
| Holy Cross Health Center | 7.6 mi | ★★★★★ | 4 | 0 |
| Villa Crest Nursing And Retirement Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Hanover Hill Health Care Center | 9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.