Citations in New Hampshire
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Hampshire.
Statistics for New Hampshire (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Hampshire
The facility did not properly sanitize dishware as the high-temperature dish machine failed to reach the required final rinse temperature, and temperature logs were not maintained. Dishes washed at insufficient temperatures were subsequently used to serve meals, as confirmed by staff and record review.
A resident was prescribed Cipro for a UTI, but the facility did not complete an antibiotic time out or document stewardship practices as recommended by CDC guidelines. The infection did not meet criteria for antibiotic initiation, and the facility's policy lacked requirements for antibiotic time outs or stewardship documentation.
A resident with dysphagia was not provided with the prescribed pureed fruits and vegetables, instead receiving whole sliced pears and cut watermelon on multiple occasions. Staff confirmed these items were not pureed, despite clear physician orders, care plan interventions, and facility policy requiring pureed foods for this resident.
Residents were not served their meals at the same time as others seated at their table, resulting in some eating while others waited without food or drink. Multiple observations showed residents expressing hunger and frustration, and staff confirmed there was no process to ensure coordinated meal service. The Food Service Director acknowledged ongoing issues with meal service timing.
A resident admitted to hospice did not have a hospice certification or plan of care in their records, and required hospice visits were not documented. Facility staff, including an LNA and RN, were unaware of hospice visit schedules or the care being provided, and the staff member responsible for coordination confirmed that no schedule or plan of care was received from the hospice provider.
Two residents with documented mental health conditions, including PTSD, major depression, and anxiety, had inaccurate Level I PASARR screenings that failed to reflect their diagnoses. The errors were confirmed by the Social Service Director, and one resident was later identified as needing a Level II evaluation.
Staff failed to follow facility policies on Enhanced Barrier Precautions (EBP) and cleaning of a glucometer. Two residents requiring EBP due to wounds, a PICC line, and a Foley catheter received high-contact care from staff who wore gloves but not gowns, contrary to policy. Additionally, a glucometer was observed with dried residue, indicating it was not disinfected after use as required.
Two residents did not receive meals in accordance with their stated preferences: one did not receive the requested chocolate milk needed for a dialysis diet, and another repeatedly received scrambled eggs despite expressing a dislike and was not offered an alternative. Facility policy requiring alternatives for refused meals was not followed.
The facility did not include specific staffing requirements for each unit and shift in its facility assessment, instead providing only overall staff numbers and general notes about adjustments based on census and acuity. The assessment failed to reflect the building's two units or detail staffing for day, evening, and night shifts, as confirmed by the Administrator.
Staff failed to ensure proper sanitization of dishes when dietary aides used a low-temperature chemical sanitizing dishwasher without verifying chlorine levels, resulting in no detectable chlorine during multiple tests. Facility procedures and manufacturer instructions requiring specific sanitizer concentrations and temperature were not followed.
Failure to Ensure Proper Dishware Sanitization Due to Inadequate Final Rinse Temperatures
Penalty
Summary
The facility failed to ensure proper sanitization of dishware in the kitchen, as required by regulatory standards and facility policy. Observations revealed that the high-temperature dish machine did not reach the minimum required final rinse temperature of 180 degrees Fahrenheit, instead achieving only 172 degrees Fahrenheit in the morning and 168 degrees Fahrenheit at midday. Additionally, the dish machine temperature logs had not been updated since 7/28/25, and there was no documentation of corrective action when out-of-range temperatures were observed. Despite the inadequate sanitization, dishes washed at the lower temperature were used to serve lunch. These findings were confirmed through staff interviews and review of facility records.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic use protocols that address unnecessary or inappropriate antibiotic use for one resident reviewed for antibiotic stewardship. Specifically, a physician's order was issued for Cipro to treat a urinary tract infection (UTI), but the resident's medical record did not include documentation of an antibiotic time out for this medication. Additionally, the Revised McGeer Criteria for Infection Surveillance Checklist, completed for the UTI, indicated that the infection did not meet the established criteria for initiating antibiotic therapy. An interview with the Director of Nursing confirmed that the facility's policy on Antibiotic Management did not include provisions for antibiotic stewardship or the use of antibiotic time outs. The facility did not document antibiotic time outs, despite following CDC guidelines for antibiotic use, which recommend implementing an antibiotic review process for all antibiotics prescribed. The facility's policy focused on individualized prescribing and lab work but lacked standardized stewardship practices as outlined by the CDC.
Failure to Provide Prescribed Pureed Diet for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia had a physician's order for a regular/liberalized dysphagia advanced texture diet, specifically requiring pureed fruits and vegetables. The resident's care plan identified them as being at nutritional risk due to dysphagia, with interventions in place to provide a dysphagia diet as ordered. Despite these orders and care plan interventions, observations on two separate occasions revealed that the resident was served whole sliced pears and cut pieces of watermelon, rather than pureed fruits as required. Staff interviews confirmed that these items were not pureed and did not meet the dietary requirements specified for the resident. Further review of the resident's speech therapy discharge summary confirmed the ongoing need for pureed fruits and vegetables due to swallowing issues. The facility's own Diet and Nutrition Care Manual and policy on therapeutic diet orders also specified that foods for residents on a dysphagia puree diet must be provided in pureed form. Both dietary and nursing staff were responsible for ensuring therapeutic diets were provided as prescribed, but failed to do so in this instance, resulting in the resident not receiving the appropriate diet texture as ordered.
Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring that all residents seated at the same table in the main dining room were served their meals together. Multiple observations across several meals revealed that some residents were eating while others at the same table were left waiting without food or drink. For example, one resident was nearly finished with breakfast while another at the same table had not received any food or drink. Similar patterns were observed during lunch, where some residents waited for extended periods while others at their table had already been served and finished eating. In one instance, a resident waiting for their meal took food from another resident who had already been served, and another resident repeatedly attempted to leave the dining room while waiting for their meal. Staff interviews confirmed there was no process in place to ensure simultaneous meal service for all residents at the same table. The Food Service Director acknowledged that the facility was aware of ongoing issues with meal service timing in the main dining room. Residents were observed expressing hunger and frustration, with some verbally stating they were hungry or asking for their meals while waiting. These repeated delays and lack of coordinated meal service directly impacted the residents' dining experience and dignity.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate hospice care for a resident who had been admitted to hospice services. Record review showed that the resident was admitted to hospice, but there was no hospice certification or plan of care available in the hospice binder. The resident's care plan listed several hospice interventions, including visits from hospice nursing, a licensed nursing assistant, a social worker, and a volunteer. However, the resident sign-in sheet only documented an admission visit and a spiritual care visit, with no evidence of other required visits. Interviews with facility staff, including a licensed nursing assistant and a registered nurse, revealed that they were unaware of when hospice staff were scheduled to visit or what care was being provided. The staff member responsible for coordinating hospice care confirmed that the hospice provider had not supplied a schedule or plan of care for the resident.
Inaccurate PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Level I Pre-admission Screening and Resident Review (PASARR) for two residents with documented mental health diagnoses. For one resident, the medical record listed diagnoses of Post Traumatic Stress Disorder, Anxiety, Major Depression, and a personal history of suicidal behavior, but the PASARR Level I screening indicated no mental illness. For the second resident, the medical record included diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, Anxiety Disorder, and Borderline Personality Disorder, yet the initial PASARR did not indicate any mental illness diagnoses. A subsequent PASARR for this resident later identified the need for a Level II face-to-face evaluation. These inaccuracies were confirmed by the Social Service Director during interviews.
Failure to Implement Enhanced Barrier Precautions and Device Disinfection
Penalty
Summary
The facility failed to implement its own policies regarding Enhanced Barrier Precautions (EBP) and the cleaning and disinfection of a point-of-care device. During observation, a glucometer was found on top of a medication cart with a dried pink/red smear on its back, and a Licensed Practical Nurse confirmed that the glucometer should be cleaned after each use with EPA-approved disinfectant wipes, as per facility policy. Review of the policy confirmed the requirement to clean and disinfect the blood glucose meter after each use, but the observed condition of the glucometer indicated this was not done. Additionally, the facility did not follow its EBP policy for two residents who required these precautions due to chronic wounds, a PICC line, and an indwelling Foley catheter. In one case, a Registered Nurse provided perineal care to a resident with wounds and a PICC line while wearing only gloves and not a gown, despite an active physician's order and care plan for EBP. In another case, a Licensed Nursing Assistant provided personal hygiene to a resident with an indwelling Foley catheter while wearing gloves but not a gown, and initially stated the resident was not on EBP, which was later contradicted by another staff member and the resident's medical record. The Infection Preventionist confirmed that the facility policy required both gown and gloves for high-contact care activities for residents on EBP.
Failure to Accommodate Resident Meal Preferences and Provide Alternatives
Penalty
Summary
The facility failed to provide meals that accommodated the individual preferences of two residents. One resident, who is on dialysis and requires extra protein, repeatedly did not receive the requested chocolate milk with meals as indicated on their meal ticket. Observations over multiple meals confirmed that chocolate milk was not provided, nor was any substitution offered. The Food Service Director later confirmed that chocolate milk was unavailable due to financial and vendor issues, and acknowledged that an alternative should have been offered. Another resident consistently received scrambled eggs for breakfast despite expressing a dislike for them to the Food Service Director. Observations showed that the resident refused to eat the eggs and was not offered an alternative meal. The resident's food preference assessment did not list scrambled eggs as a dislike, but the Food Service Director confirmed being informed of the resident's preference. Facility policy requires that alternative food be offered if a resident refuses a meal or desires something else, but this was not followed in these cases.
Facility Assessment Lacks Specific Staffing by Unit and Shift
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit and for each shift, such as day, evening, and night. Record review showed that the facility assessment did not specify staffing levels by unit or shift, despite the building having two units. The assessment only listed total numbers of staff needed and included general notes about staffing adjustments based on census and acuity, but did not provide detailed breakdowns for each unit or shift. An interview with the Administrator confirmed these findings.
Failure to Sanitize Dishes per Manufacturer's Instructions in Kitchen
Penalty
Summary
The facility failed to ensure that dishes were sanitized according to the manufacturer's instructions in the kitchen. During an observation, two dietary aides were seen using a low-temperature chemical sanitizing dishwasher. When the Dietary Services Director tested the chemical sanitizer (chlorine) with a test strip, the strip did not change color, indicating a lack of chlorine. The Director stated that the sanitizer needed to be replaced as it was low, and confirmed that the dietary aides had not checked the chemical sanitizer before washing dishes. After a new sanitizer bottle was attached and the dishwasher was put back into use, a retest still showed no chlorine present, and the aides had not retested the chlorine before resuming dishwashing. A review of the facility's procedures indicated that staff were required to ensure detergent and sanitizer dispensers were properly loaded and to check and record chemical concentrations, following manufacturer recommendations. The manufacturer's instructions for the dishwasher specified a minimum temperature of 120 degrees Fahrenheit and a required 50 parts per million (ppm) of available chlorine rinse. These requirements were not met during the observed dishwashing process.
Some of the Latest Corrective Actions taken by Facilities in New Hampshire
- The facility conducted a Quality Assurance (QA) meeting, evaluated the affected residents with provider-ordered hepatitis and HIV testing, performed a facility-wide audit of insulin availability, provided education and competencies on medication protocols, insulin pen policies, and CDC injection safety, and initiated an insulin inventory sheet. (J - F0880 - NH)
- Staff received in-service training on proper insulin pen administration and the prohibition of using another resident's insulin. Audits were conducted to ensure no additional missing insulin, and staff competencies were reinforced prior to first shifts. A root cause analysis was performed, and the incident was reported to New Hampshire Public Health for follow-up. (J - F0880 - NH)
- The facility updated its insulin administration policy, provided in-service education to all nurses specifically on administering Humulin R U-500 insulin pens, conducted competency evaluations, initiated weekly audits of insulin administration, and planned to review these audits during quarterly Quality Assurance and Performance Improvement meetings. (J - F0760 - NH)
Improper Use of Insulin Pen for Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used one insulin pen to administer insulin to two residents on multiple days. Specifically, a Licensed Practical Nurse (LPN) used a Lantus insulin pen designated for one resident to administer insulin to another resident on two consecutive days. This pen was then returned to the medication cart and subsequently used again for the original resident without the knowledge of another LPN, who was unaware of the pen's prior use for a different resident. The facility's records confirmed that both residents had active physician's orders for Lantus insulin, which was administered according to the schedule. However, the use of a single insulin pen for multiple residents contravened the manufacturer's instructions, the facility's pharmacy policy, and the Centers for Disease Control and Prevention (CDC) guidelines, all of which emphasize that insulin pens are for single-patient use only to prevent the risk of bloodborne pathogen transmission.
Removal Plan
- QA meeting was conducted
- The provider evaluated Resident #1 and Resident #2 and ordered Hepatitis panel and HIV blood tests and a retest for the hepatitis panel and HIV blood test was ordered
- Facility-wide audit of all residents insulin availability was conducted
- Education and competencies of facility's medication availability protocol, facility's insulin pen policy, and CDC's injection safety were conducted
- Insulin inventory sheet was created and initiated
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.
Insulin Overdose Due to Syringe Misuse
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a resident receiving an overdose of insulin. The error occurred when a registered nurse used a U-100 insulin syringe instead of a U-500 syringe to administer Humulin R U-500 insulin from the resident's insulin pen. This mistake led to the resident receiving five times the prescribed dose of insulin on two separate occasions. The manufacturer's instructions for Humulin R U-500 clearly state that the insulin should not be transferred from the pen into a syringe, as this can lead to severe overdoses and dangerously low blood sugar levels. As a result of the overdose, the resident experienced hypoglycemia, with blood glucose levels dropping to as low as 40 mg/dL. The resident became lethargic and was only arousable with repeated stimuli, necessitating the administration of insta glucose gel and subsequent transfer to the hospital for evaluation and treatment. The resident's medical records indicated several episodes of hypoglycemia overnight, confirming the severity of the medication error.
Removal Plan
- Updated the policy titled: Insulin
- Completed in-service education to all nurses on the administration of insulin with an insulin pen specific to Humulin R U-500
- Conducted competencies with all nurses on the administration of insulin with an insulin pen
- Monitoring insulin administration through weekly audits
- Reviewing these audits at quarterly Quality Assurance and Performance Improvement meetings
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