Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Hillsborough County Nursing Home during CMS and state inspections, most recent first.
Infection control was deficient because a resident with an indwelling urinary catheter was not placed on EBP as required by facility policy, and PPE supplies and precaution signage were not present. The resident’s care plan included EBP, but staff were unaware of the status and used only gloves during care. The facility also had an incomplete water management plan that did not identify specific areas where Legionella could grow and spread, and documentation was lacking for required replacement of shower wands and kitchen hoses.
A resident receiving Humalog Kwikpen insulin was given a 2-unit dose by an RN without priming the pen first. The RN confirmed the pen had not been primed per manufacturer instructions, even though the resident’s CBG of 168 required 2 units per the sliding-scale order.
Medication storage and labeling were deficient when a med room refrigerator was found out of range with unopened meds such as insulin and Retacrit stored inside, and a resident’s open inhalers on a med cart lacked open dates or open expiration dates. Staff confirmed the refrigerator temperature was above the required range and the inhalers were not labeled as required by the manufacturer and facility policy.
A LPN was observed crushing an extended release Magnesium Lactate tablet and handling oral medications with bare hands, despite clear pharmacy warnings and facility policy prohibiting these actions. There was no practitioner order to crush the medication, and the DON confirmed the absence of such an order.
Staff failed to follow required hand hygiene protocols after providing care and cleaning for a resident on contact precautions for recurrent C-diff infection. Instead of washing hands with soap and water after glove and gown removal, staff used alcohol-based hand rub, contrary to facility policy and CDC guidelines.
A resident was observed self-administering medications from a napkin without staff supervision. An LPN confirmed this was a regular practice, but the resident's medical record lacked a physician order or assessment for self-administration. Facility policy prohibits leaving medications at the bedside, which was not followed.
The facility failed to ensure weekly documentation of pressure ulcer assessments for a resident with a coccyx ulcer. The medical record showed missing documentation for one week, with measurements indicating both improvement and deterioration on other dates. This was confirmed by the wound nurse.
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets as outlined in the facility assessment. A review revealed that an RN's last competency documentation was completed in 2021, and the Staff Development Coordinator confirmed that competencies are only reassessed upon hire or if issues arise.
The facility failed to maintain a clean environment for dishwashing and did not ensure proper food storage temperatures in six kitchenettes. Observations revealed dusty fans blowing towards clean dishes and a food mixer with built-up debris. Additionally, multiple instances of missing refrigerator temperature recordings were noted, contrary to facility policy.
Infection Control Program Deficiencies: EBP and Water Management
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with an indwelling urinary catheter and did not maintain a water management plan with all necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. Review of the revised Water Management Plan showed it did not identify specific areas in the facility where Legionella could grow and spread. The plan’s mitigation section stated that shower wands and kitchen hoses were to be replaced every 6 months, but the checklist showed the shower wands were last replaced on 9/22/25 and there was no documentation that the kitchen hoses had been replaced. The Administrator confirmed the plan did not include the areas where waterborne pathogens could grow and spread, and Maintenance was unable to provide documentation for the kitchen hoses. For Resident #77, review of the facility policy showed EBP were indicated for residents with wounds and/or indwelling medical devices, and the resident’s foley catheter care plan included an EBP intervention. Observation of the resident in the room showed a urinary catheter bag hanging from the wheelchair, but there were no PPE supplies or signage indicating precautions. Staff who provided morning care stated they were not aware the resident was on EBP and had only worn gloves, not a gown. A Registered Nurse confirmed the resident should be on EBP because of the urinary catheter and stated that residents on EBP should have a caution triangle sign outside the room, PPE supplies, and EBP signage on the bathroom door.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to properly prepare insulin according to the manufacturer’s instructions for one resident receiving insulin. During observation of medication administration, a registered nurse turned the Humalog Kwikpen dial to two units and administered the dose to the resident without priming the pen first. When interviewed at the time of the observation, the nurse confirmed that the insulin pen had not been primed according to manufacturer instructions before the dose was given. The resident’s MAR showed an order for Humalog Kwikpen insulin to be given before meals and at bedtime using a sliding scale, and the resident had a capillary blood glucose of 168, which required 2 units of Lispro insulin per the order. Manufacturer instructions reviewed by surveyors stated that the pen must be primed before each injection by selecting 2 units and pushing the dose knob until insulin appears at the needle tip.
Medication Storage Temperature and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored in accordance with accepted principles when the Unit B2 medication room refrigerator was found at 50 F during observation with the RN. Unopened resident medications stored in the refrigerator included Epoetin Alfa-epbx (Retacrit), Lispro insulin (Humalog), and Lantus insulin. The RN confirmed the findings, and the manufacturer instructions reviewed for each medication required refrigeration between 36 F and 46 F. The unit log also showed the refrigerator temperature was recorded above 46 F on multiple dates in April and May 2026, including 15 days documented at 48 F. Medications were also not labeled with open dates or open expiration dates on the Unit B2 front medication cart for Resident #78. Two open boxes of Fluticasone Furoate/Vilanterol inhalation powder were observed with opened foil trays, but neither the boxes, foil trays, nor inhalers had open dates or open expiration dates. The pharmacy dispensing dates showed one inhaler had been open for 9 weeks and 5 days and the other for 6 weeks and 5 days, while the manufacturer instructions stated the inhaler should be discarded 6 weeks after opening the moisture-protective foil tray. Staff confirmed the medications were not labeled as required, and the resident’s May 2026 MAR showed the medication was administered daily.
Failure to Follow Medication Administration Standards and Handling Procedures
Penalty
Summary
A Licensed Practical Nurse (Staff A) was observed administering medication to a resident and failed to follow professional standards and facility policy. Specifically, Staff A crushed a Magnesium Lactate Extended Release (ER) 84 mg tablet, despite clear manufacturer instructions and a pharmacy warning label stating that the medication should not be crushed. Additionally, Staff A handled oral solid medications with bare hands, placing fingers into the medication cup to remove pills, which is contrary to both professional standards and the facility's own policy. Further review of the resident's physician orders confirmed there was no order permitting the crushing of medications for this resident. Interviews with both Staff A and the Director of Nursing (Staff B) corroborated that no such order existed. The facility's policy on oral medication administration explicitly states that oral solid medications should not be touched with bare hands and that certain medications should not be crushed unless there is a specific practitioner order, which was not present in this case.
Failure to Follow Hand Hygiene Protocols for C-diff Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies for a resident on contact precautions due to a recurrent Clostridium difficile (C-diff) infection. Observations revealed that staff members, including a housekeeper and a licensed nursing assistant, did not perform handwashing with soap and water after removing gloves and gowns upon exiting the resident's room. Instead, they used alcohol-based hand rub (ABHR), which is not effective against C-diff spores, as per both facility policy and CDC guidelines. The facility's policy and CDC guidelines specifically require handwashing with soap and water after contact with C-diff to prevent transmission. The resident in question had a documented history of recurrent C-diff infections, with positive tests and ongoing treatment, and was under contact precautions at the time of the observations. Staff interviews confirmed the observed practices and acknowledged the facility's policy requiring handwashing. The failure to follow proper hand hygiene protocols after providing care or cleaning in the resident's room constituted a breach of infection control procedures.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for the ability to self-administer medication. Specifically, Resident #116 was observed in bed self-administering medications from a napkin containing approximately 5 pills without any staff present. An interview with an LPN confirmed that this was a regular practice with the resident. A review of the resident's medical record revealed no physician order or assessment for self-administration of medications. The facility's policy stated that medications should not be left at the bedside, which was not adhered to in this case.
Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer. This deficiency was identified for one resident who had a pressure ulcer on the coccyx. The medical record review revealed that while there were wound measurements documented on two occasions, there was a missing assessment for one week. Specifically, the wound measurements were recorded as 0.73 cm x 0.99 cm (improving) on one date, and 1.29 cm x 0.4 cm (deteriorating) on another date, with no documented assessment in between. This was confirmed by an interview with the wound nurse.
Failure to Maintain Up-to-Date Competency Testing for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets as outlined in the facility assessment. Specifically, the facility assessment indicated that all nurses, Medication Nursing Assistants (MNAs), and Licensed Nursing Assistants (LNAs) should complete an annual Knowledge and Competency Testing form. However, a review of Staff A's (RN) records revealed that their last Knowledge and Competency Documentation was completed in 2021. An interview with the Staff Development Coordinator confirmed that competencies are only completed upon hire and are not reassessed unless there are identified medication errors or questionable medication pass techniques, which are observed by unit managers or staff development. This lapse in regular competency testing was identified during a review and interview process, highlighting a deficiency in maintaining up-to-date competencies for nursing staff.
Failure to Maintain Cleanliness and Proper Food Storage Temperatures
Penalty
Summary
The facility failed to maintain a clean environment for proper washing and sanitizing of dishes and utensils in the main kitchen and did not ensure food was kept at the proper temperature in six kitchenettes. Observations in the main kitchen revealed two wall fans with accumulated gray dust and grease debris blowing air towards clean dishes, and a food mixer with built-up food debris and grease that had not been used since the previous day. These findings were confirmed by the Food Services Director during the inspection. The facility's policy on cleaning and sanitization of surfaces was reviewed, which mandates that non-food contact surfaces must be cleaned and rinsed, and food contact surfaces must be cleaned, rinsed, and sanitized. In addition, a review of the refrigerator temperature logs for six kitchenettes showed multiple instances of missing temperature recordings for March and April 2024. The facility's policy requires that refrigerator and freezer temperatures be checked twice daily by an assigned team member. The Food Services Director confirmed the missing temperature recordings during the interview. These deficiencies indicate a failure to adhere to the facility's policies on maintaining cleanliness and proper food storage temperatures, potentially compromising food safety and hygiene standards.
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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 Goffstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Goffstown Nursing And Rehab Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Bedford Nursing & Rehabilitation Center | 3.3 mi | ★★★★★ | 7 | 1 |
| Hackett Hill Healthcare Center | 3.4 mi | ★★★★★ | 5 | 0 |
| Courville At Manchester | 3.6 mi | ★★★★★ | 12 | 1 |
| Bedford Hills Center | 4.2 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.