Citations in New Hampshire
Statistics, citations and compliance trends for long-term care facilities in New Hampshire.
Statistics for New Hampshire (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in New Hampshire
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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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