Hillsboro House Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, New Hampshire.
- Location
- Po Box 400 67 School Street, Hillsboro, New Hampshire 03244
- CMS Provider Number
- 305092
- Inspections on file
- 17
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Hillsboro House Nursing Home during CMS and state inspections, most recent first.
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility did not implement a comprehensive infection control guideline for water management, affecting 26 residents. The program lacked essential details such as water flow descriptions and plumbing schematics. Interviews revealed that staff were unable to provide information on water management or legionella testing, and no logs for flushes or test results were available.
The facility failed to assess two residents for the clinical appropriateness of self-administering medications. One resident was observed with pills left on their tray table to take at their own pace, while another had a cup of pills left by a nurse for self-administration. Neither resident had a documented assessment or physician's order for self-administration, and the facility lacked a policy for such procedures.
The facility did not ensure that the food service director met the necessary qualifications. The administrator, acting as the food service director, admitted to not having completed a required course in food safety and management, while the dietician was only part-time.
The facility did not sanitize dishes according to the manufacturer's instructions, as observed in the main kitchen. Temperature logs from August to September 2024 showed only one recorded temperature per day, without specifying if it was for the wash or rinse cycle. The Lead Cook was unaware of the correct temperature ranges. An observation revealed a wash temperature of 150°F and a rinse temperature of 174°F, while the manufacturer's instructions required a minimum of 150°F for wash and 180°F for rinse.
A facility failed to assess a resident and obtain informed consent for the use of full-length bed rails. The resident was observed with bed rails raised on both sides of the bed, but their medical record lacked the necessary assessment and consent documentation. The facility's policy requiring periodic reviews of bed rail use was not followed, as confirmed by the DON.
The facility failed to properly label and store medications. An open vial of Lantus insulin was found without a resident identifier and past its discard date. Additionally, a resident had eye drops stored at their bedside, against facility policy requiring medications to be stored in a locked drawer. The DON confirmed the policy.
The facility did not determine the necessary time for the Infection Preventionist (IP) role in its assessment. The Director of Nursing, who serves as the IP, reported spending only one hour per week on the Infection Prevention and Control Program (IPCP), indicating a deficiency in resource planning.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Inadequate Water Management Program
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control guideline for water management, affecting the census of 26 residents. The Facility Water Management Program, revised in January 2024, included strategies such as annual testing for legionella and weekly flushing of vacant rooms. However, it lacked a description of water flow, a schematic, or a map of plumbing, and did not identify areas of concern. During interviews, the Infection Preventionist was unable to answer questions regarding water management or legionella testing, and the Administrator Assistant revealed that there were no logs for flushes or legionella test results available.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medications for two residents. For Resident #19, an observation revealed that five pills were left on a tray table for the resident to take at their own pace, as per their request. However, a review of the resident's medical record showed no assessment or physician's order for self-administration of medications. Similarly, for Resident #22, a nurse left a cup of seven pills for the resident to take independently, believing the resident was cognitively capable. Yet, there was no physician's order or self-administration assessment documented in the resident's medical record. Interviews with staff confirmed these findings, and the Director of Nursing acknowledged that neither resident had been assessed for self-administration of medications. Additionally, the facility was unable to provide a policy regarding self-administration of medications, indicating a lack of procedural adherence and oversight in ensuring residents' ability to safely self-administer their medications.
Food Service Director Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the food service director met the minimum qualifications required for the position. During an interview, the administrator, identified as Staff C, revealed that the dietician was only part-time and that Staff C had been serving as the food service director for several years. However, Staff C admitted to not having completed a course of study in food safety and management, which is a necessary qualification for the role.
Dishwasher Sanitization Deficiency
Penalty
Summary
The facility failed to ensure that dishes were sanitized according to the manufacturer's instructions for food service safety in the main kitchen. During a review of the facility's dishwasher temperature logs from August to September 2024, it was found that only one temperature per day was documented, ranging between 160 to 176 degrees Fahrenheit. The logs did not specify the acceptable temperature range or whether the temperature was recorded during the wash or rinse cycle. An interview with the Lead Cook revealed that the recorded temperatures were for the wash cycle only, and the cook was unaware of the acceptable temperatures for both the wash and rinse cycles. An observation of a dishwasher cycle with a Dietary Aide showed a wash temperature of 150 degrees Fahrenheit and a rinse temperature of 174 degrees Fahrenheit. A review of the manufacturer's instruction label for the dishwasher indicated that the minimum temperature ranges should be 150 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and informed consent was obtained for the use of full-length bed rails. This deficiency was identified for one resident who was observed on multiple occasions throughout the day with full-length bed rails raised on both sides of the bed. A review of the resident's medical record revealed the absence of a bed rail assessment and informed consent documentation. Additionally, the facility's policy on bed rail consent, which mandates periodic and annual reviews and re-evaluations of bed rail use, was not adhered to. The Director of Nursing confirmed these findings during an interview.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to currently accepted professional principles. During an observation of the medication cart, an open vial of Lantus insulin was found without a resident identifier and with an expired discard date. The manufacturer's instructions for Lantus specify that opened vials should be stored at room temperature for up to 28 days, which was not adhered to in this case. Additionally, a resident was observed with Refresh eye drops stored at their bedside, contrary to the facility's policy that medications should be stored in a locked drawer in the patient's room. The Director of Nursing confirmed the facility's policy during an interview.
Inadequate Time Allocation for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included a determination of the amount of time required for the designated Infection Preventionist (IP) to fulfill their role. During a review of the facility's assessment, which was last updated in June 2024, it was found that there was no specified time allocation for the IP's responsibilities. An interview with the Director of Nursing, who is also the designated IP, revealed that only one hour per week is dedicated to the facility's Infection Prevention and Control Program (IPCP). This lack of a comprehensive time assessment for the IP role constitutes a deficiency in the facility's planning and resource allocation.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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