Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Harris Hill Center, Genesis Healthcare during CMS and state inspections, most recent first.
A resident was observed self-administering multiple meds without staff present even though the resident’s assessment said assistance was needed and self-administration was not approved. The MAR showed several scheduled meds documented as given that morning, and the active orders had no order for self-administration. An LPN confirmed the meds were provided for the resident to take independently despite the lack of approval.
Failure to Send Transfer or Discharge Notices to the LTC Ombudsman: The facility did not document that notices of transfer or discharge were sent to the LTC Ombudsman for three residents. One resident was transferred to the hospital, one resident was discharged home, and another resident had a hospitalization with no completed transfer/discharge notice in the record. The Administrator confirmed the missing documentation, and facility policy required discharge documentation to include a Notice of Transfer or Discharge.
A facility failed to follow ordered wound care for two residents and administered gabapentin incorrectly to another resident. One resident’s lower leg dressings and another resident’s heel dressing were documented as completed, but observations showed the dressings were older than ordered and had not been changed as scheduled; staff confirmed the care was not done when required. During medication pass, an LPN gave gabapentin based on the bingo card instructions instead of the provider’s order, and the APN confirmed the ordered dose was different.
Missed Admission Medications: A resident reported not receiving all ordered meds upon admission. The MAR showed multiple evening meds documented as not given, including antidepressant, insulin, antidiabetic, cardiac, anticonvulsant, and antibiotic meds. Nurse notes later stated several meds were not available from the pharmacy, with no documentation of provider notification, and the med inventory showed some of the missed meds were actually on hand.
Unauthorized Access to Medication Rooms: The facility failed to restrict access to 2 medication rooms to authorized personnel only. The Maintenance Director kept keys to the 2nd- and 3rd-floor med rooms because oxygen tanks were stored there and entered both rooms to work on HVAC systems. During observation, the Maintenance Director used those keys to access rooms containing oxygen tanks, medication cards, OTC meds, IV meds, and unlocked med refrigerators, with no nurse or medication aide present.
Failure to offer COVID-19 vaccine to staff: The facility did not document that an LPN was offered the COVID-19 vaccine or given information on how to obtain it. The LPN had prior COVID-19 vaccinations documented, but no record of any later vaccination or of being offered the vaccine since working at the facility. The IP confirmed the omission and stated the facility did not offer the vaccine or information to agency staff, despite policy including contracted personnel.
Failure to maintain respiratory and cooling equipment per manufacturer instructions. A resident with sleep apnea had a CPAP machine that showed a motor-life warning and had not been used for months, while the resident reported the air filter needed changing and no replacement was available. Staff did not replace CPAP filters, and the Maintenance Director confirmed the machine needed replacement but had no documentation of contacting the vendor. A portable air conditioner in a med room also had heavily dust-covered filters, despite manufacturer guidance to clean the filter every 2 weeks.
A resident was found self-applying Voltaren cream kept at their bedside without a documented assessment or provider order authorizing self-administration, despite facility policy requiring evaluation and authorization for such practices. Staff confirmed the absence of the required assessment and order, even though the resident demonstrated no cognitive impairment.
A resident with multiple mental health diagnoses was admitted and identified through a Level I PASARR screening as needing a Level II evaluation for long-term care placement. However, the facility did not complete the required referral for the Level II PASARR, as confirmed by record review and staff interview.
The facility did not follow care plan interventions for two residents: one with congestive heart failure who experienced a significant weight gain without required physician notification, and another with insulin-dependent diabetes who had a hypoglycemic episode but did not have the physician notified as ordered. In both cases, the medical director confirmed that the necessary notifications were not made.
A resident with diabetes mellitus type II did not receive insulin according to manufacturer and facility protocols when a nurse primed the Novolog Flex Pen with only 1 unit instead of 2 and held the pen in place for just 3 seconds after injection, rather than the required duration. This resulted in a deficiency related to medication administration standards.
An LPN was observed with an Albuterol Sulfate inhaler on a medication cart that lacked a resident identifier, was not in the pharmacy-dispensed container, and was expired. Facility policy requires medications to be stored in their original containers and expired medications to be removed immediately.
A resident was exposed to potential bloodborne pathogens when a nurse used another resident's used insulin pen to administer insulin. The nurse could not find the prescribed insulin or backup stock and resorted to using a pen that had already been used by another resident, contrary to facility policy and CDC guidelines.
Unapproved Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident who self-administered medications was assessed as clinically appropriate for self-administration. During observation, the resident was seen in the room with a medicine cup and pills, self-administering the medications without staff present. However, the resident’s self-administration assessment, dated earlier in the year, stated that the resident required assistance to administer oral medications and was not approved for self-administration. Record review also showed that the resident had multiple medications documented as administered that morning, including Ascorbic Acid, Blood-Builder-Supplement, Calcium Citrate, Cholecalciferol, Choline-Inositol, Vitamin A, Vitamin B Complex, and Lactobacillus. The resident’s active physician orders contained no order to self-administer medications. An LPN who cared for the resident that day confirmed that the medications were given to the resident to self-administer and acknowledged that there was no order for self-administration. The facility policy stated that residents who request to self-administer medications must be evaluated for safe and clinically appropriate capability, and if approved, a physician or APP order is required.
Failure to Send Transfer or Discharge Notices to the LTC Ombudsman
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the LTC Ombudsman for three residents reviewed. Resident #77 was transferred to the hospital on 3/7/26, and the record contained no documentation that the LTC Ombudsman was sent a copy of the notice of transfer. Resident #79 was discharged home on 2/11/26, and there was no documentation that the LTC Ombudsman was sent a copy of the notice of discharge. Staff A, the Administrator, confirmed both findings and was unable to provide documentation showing the notices were sent. Resident #1 had a hospitalization on 1/30/26, but the record contained no completed notice of transfer/discharge and no evidence that the notice was sent to the LTC Ombudsman for that hospitalization. Staff A confirmed this finding during interview. Review of facility policy COR412 Discharge Record Processing, revised 1/15/26, showed that discharge documentation must include a Notice of Transfer or Discharge.
Failure to Perform Ordered Wound Care and Incorrect Medication Administration
Penalty
Summary
The facility failed to follow professional standards for wound care for two residents. One resident had an order for lower leg wound care that included cleansing, applying collagen and Xeroform to open or weeping areas, covering with ABDs and conform gauze, and applying Ace bandages on Monday and Friday evenings. The treatment record showed the care as completed on 4/10/26 and 4/13/26, but observation on 4/13/26 found Ace wraps on both legs dated 4/8/26, and on 4/15/26 the dressings removed from both legs were also dated 4/8/26. The resident stated that dressings were not done on all scheduled days and some were skipped. Staff B and Staff C confirmed the dressings had not been changed when ordered. A second resident had an order for left heel pressure injury care to cleanse the wound, apply skin prep, Pluogel, a bordered heel dressing, and use Heelzup offloading in bed every Monday, Wednesday, and Friday. The treatment record showed the care as completed on 4/13/26, but observation on 4/15/26 found the left heel dressing removed was dated 4/11/26. Staff B and Staff C confirmed the dressing had not been changed when ordered, and Staff D stated the dressing was documented as completed on 4/13/26 even though the treatment was not done. The facility policy required wound care treatments to be implemented as ordered.
Missed Admission Medications
Penalty
Summary
The facility failed to administer drugs and biologicals to Resident #82, who was admitted on 4/10/26, during the new admission period. The resident stated in interview that not all medications were received upon admission. Review of the April 2026 MAR showed that on 4/10/26 the 8 p.m. and 9 p.m. doses of Bupropion XL 300 mg, Celexa 20 mg, Insulin Lispro 100 unit/ml, Metformin 1000 mg, Metoprolol Tartrate 25 mg, Topiramate 25 mg, and Vancomycin 125 mg were documented as not given with NN. Progress notes confirmed the admission date, but there were no nurse notes for 4/10/26 documenting the missed medications. Nurse notes dated 4/11/26 stated that Metformin, Insulin Glargine 100 unit/ml, Metoprolol Tartrate, Vancomycin, Topiramate, Celexa, and Bupropion were not available from the pharmacy, and there was no documentation of provider notification. Staff E confirmed the findings, and the facility’s medication inventory later showed that Celexa, Metformin, Metoprolol Tartrate, and Vancomycin were available in the medication room.
Unauthorized Access to Medication Rooms
Penalty
Summary
The facility failed to permit only authorized personnel to have access to medication room keys for 2 of 2 medication rooms observed. During interview, the Maintenance Director stated that he/she had keys to the second-floor and third-floor medication rooms because oxygen tanks were stored there, and also stated that he/she accessed the medication rooms to perform maintenance on the HVAC systems located inside those rooms. During observation, the Maintenance Director used the keys he/she kept to enter the third-floor medication room and then the second-floor medication room. The third-floor medication room contained oxygen tanks, medication bingo cards on the counter, over-the-counter medications on the shelves, and an unlocked medication refrigerator with medications inside. The second-floor medication room contained oxygen tanks, intravenous medications on the counter, over-the-counter medications on the shelves, and an unlocked medication refrigerator with medications inside. No nurses or medication nursing assistants were present while the Maintenance Director accessed either medication room. Facility policy titled, Storage of Medication, stated that medication supplies shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access.
Failure to Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that a staff member was offered the COVID-19 vaccine or given information on how to obtain the COVID-19 vaccine for 1 of 1 staff reviewed for COVID-19 vaccination. Review of the Licensed Practical Nurse's vaccination record showed COVID-19 vaccines were received on 12/30/20, 1/20/21, and 12/31/21, but there was no documentation of any COVID-19 vaccination after 12/31/21 and no documentation that the staff member was offered the vaccine or provided information on obtaining it. During interview, the Infection Preventionist confirmed the staff member's vaccination record and stated that the COVID-19 vaccine had not been offered and information on obtaining the vaccine had not been provided. The Infection Preventionist also stated that the facility did not offer the COVID-19 vaccine or provide information on obtaining it to agency staff. The staff member interviewed stated that he/she had not been offered the COVID-19 vaccine or provided information on obtaining it since working at the facility. The facility policy stated that staff includes individuals working regularly in the facility and those under contract or arrangement, and that employees are encouraged to obtain COVID-19 vaccination from their personal health provider, health department, or community health partners.
Failure to Maintain CPAP Equipment and Portable Air Conditioner Filters
Penalty
Summary
The facility failed to maintain equipment according to manufacturer instructions for a resident who used CPAP therapy for sleep apnea. Resident #28 had a non-invasive mechanical ventilator/CPAP machine in the room, and the resident reported not using the machine for 2 to 3 months because a warning indicator showed it required service from the contracted rental company. On observation, the CPAP machine initially did not display a warning, but after buttons were pressed it displayed a message that the motor life had been exceeded and to call the provider. Staff G confirmed the finding and was unaware of any issue with the machine. The resident also stated the CPAP air filter needed to be changed, but there was no new filter available, and the resident could not recall when it was last replaced. Record review showed the CPAP treatment order was active, with instructions to clean the filter, reservoir, mask, and tubing weekly and clean the mask daily, but there was no order to replace the air filter every six months as stated in the manufacturer instructions. Staff G stated nursing staff did not replace the CPAP air filter, and Staff J, the Maintenance Director, stated the facility did not replace the air filter of any CPAP machine. Staff J also confirmed the resident's CPAP machine needed to be replaced and could not provide documentation of communication to the respiratory healthcare company about the machine's "motor life exceeded" message before survey. In a separate finding, a portable air conditioner in the second floor medication room had an upper filter with dust accumulation and a lower filter heavily covered with dust on both sides, and Staff J confirmed the observation. The manufacturer instructions stated the air filter should be cleaned every 2 weeks for optimal performance.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was observed to have a container of Voltaren cream at their bedside and reported self-applying the cream as needed for pain. The resident stated that nursing staff refilled the container as needed. Review of the resident's medical record showed a physician's order for Diclofenac Sodium External Gel (Voltaren) to be applied topically twice daily, but there was no documented assessment to determine if self-administration was clinically appropriate. Additionally, staff confirmed that the resident did not have an order to self-administer the medication. Further review of the resident's records revealed a recent BIMS score of 15/15, indicating little to no cognitive impairment. The facility's policy requires an evaluation of a resident's capability to self-administer medications, a provider order, and ongoing assessments. Despite these requirements, there was no evidence that the necessary assessment or authorization for self-administration had been completed for this resident.
Failure to Refer Resident for Required Level II PASARR Evaluation
Penalty
Summary
A deficiency was identified when a resident with a known history of schizoaffective disorder, bipolar type, anxiety disorder, and panic disorder was admitted to the facility. Upon admission, a Level I PASARR screening was completed, which indicated the need for a Level II PASARR evaluation due to the resident's mental health diagnoses and associated symptoms. The Level I screening specifically noted suspected diagnoses, behavioral concerns, and the requirement for a Level II face-to-face assessment for long-term care placement. Despite these findings, the facility failed to refer the resident for the required Level II PASARR evaluation. This was confirmed through record review and an interview with the Social Service Director, who acknowledged that the Level II PASARR had not been completed as indicated by the Level I screening. Facility policy also required referral to the appropriate state authority when a resident is identified as having an evident or possible mental disorder, but this process was not followed in this case.
Failure to Implement Care Plan Interventions for Change of Condition and Insulin Management
Penalty
Summary
The facility failed to implement the care plan interventions for two residents as required. For one resident with congestive heart failure, the care plan specified daily weights and physician notification if the resident gained more than two pounds in a day. On review, the resident's weight increased by 3.2 pounds in one day, but there was no documentation that the physician was notified, and the medical director confirmed that no notification occurred. For another resident with insulin-dependent diabetes, the care plan required blood glucose monitoring and physician notification if blood glucose was less than 70 or greater than 250. The resident experienced a low blood glucose episode, received glucose, and had a repeat low reading, but there was no documentation of physician notification as required by both the care plan and physician orders. The medical director confirmed that no notification was made in this instance.
Insulin Administration Not Performed per Manufacturer and Facility Policy
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer insulin according to both the manufacturer's instructions and the facility's policy for a resident with diabetes mellitus type II. The physician's order specified the use of a Novolog Flex Pen to inject 4 units of insulin subcutaneously before meals. During observation, the nurse primed the insulin pen with only 1 unit instead of the required 2 units as per the manufacturer's guidelines and the facility's policy. Additionally, after administering the insulin, the nurse held the pen in place for only 3 seconds, whereas the manufacturer's instructions require the pen to be held in place for at least 6 seconds, and the facility's policy specifies a slow count to 10 before withdrawing the needle. The nurse confirmed during an interview that the pen was primed with only 1 unit and held in place for 3 seconds after injection. Review of the manufacturer's instructions and facility policy both indicated that a 2-unit airshot should be performed before each injection and that the needle should remain in the skin for a longer duration to ensure the full dose is delivered. These deviations from established protocols led to the identified deficiency in medication administration for the resident.
Expired and Unlabeled Medication Found on Medication Cart
Penalty
Summary
During an observation of a medication cart on the second floor, an Albuterol Sulfate inhaler was found without a resident identifier and not stored in the pharmacy-dispensed container. The inhaler also had a manufacturer's expiration date of 2/23, indicating it was expired. These findings were confirmed by an LPN present at the time. Review of the facility's medication storage policy showed that medications for oral inhalation are to be stored in their dispensed containers according to manufacturer guidelines, and that outdated medications are to be immediately removed from stock.
Insulin Pen Misuse Leads to Pathogen Exposure
Penalty
Summary
The facility failed to ensure that a resident was free from exposure to bloodborne and bacterial pathogen transmission when a registered nurse administered insulin from another resident's used insulin pen. The incident occurred when the nurse was unable to locate the resident's prescribed Humalog 75/25 insulin or any backup stock in the medication room for the scheduled dose. Consequently, the nurse used another resident's Humalog 75/25 insulin pen, which had already been opened and used, to draw up 10 units of insulin with a syringe and administer it to the resident. The facility's policy explicitly prohibits borrowing medication from another resident and sharing insulin pens due to the risk of infection transmission. The Humalog Mix 75/25 KwikPen insert and the CDC guidelines both emphasize that insulin pens should not be shared between individuals, as backflow of blood can occur, posing a risk of pathogen transmission. The facility's pharmacy policy also states that prefilled pen devices should never be accessed with a syringe and needle, and the same pen should not be used for more than one resident.
Removal Plan
- In-service staff regarding administration of insulin pens and not using another resident's insulin.
- Conduct audits for all residents to ensure no additional missing insulin.
- Start in-service training for insulin pen administration, medications not available, and abuse/misappropriation.
- Train all staff on competencies for medication not being available, abuse, insulin pens, following physician's orders, and insulin replacement prior to working their first shift.
- Conduct a root cause analysis and review audits as part of the Ad Hoc Quality Assurance and Performance Improvement meeting.
- Notify New Hampshire Public Health regarding the incident and follow up.
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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 Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Presidential Oaks | 1.2 mi | ★★★★★ | 9 | 0 |
| Pleasant View Center | 1.5 mi | — | 9 | 0 |
| Havenwood-heritage Heights | 2.1 mi | ★★★★★ | 6 | 0 |
| Epsom Healthcare Center | 9.1 mi | ★★★★★ | 11 | 0 |
| Hackett Hill Healthcare Center | 10.8 mi | ★★★★★ | 5 | 0 |
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