Based on interview and record review, it was determined that the facility failed to ensure that residents received adequate supervision, during and after a fire alarm, which resulted in a resident eloping and a delay in locating the resident in which the resident was held at the hospital for observation and treatment for hypothermia for 1 of 3 resident reviewed for elopement in a final sample of 39 residents (Resident Identifier #99). Findings include: Interview on 3/19/24 at approximately 11:00 a.m. with Staff D (Administrator) revealed that on 3/13/24, the fire alarm sounded at 12:50 a.m. due to smoke coming from a resident room. The fire alarm sounded and the locking mechanism of the locked doors disengaged which led to all exit doors being unlocked. …
F689 citations in New Hampshire
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Hampshire cites F689 less often than its own record predicts
0.13 times the national share — cited less often here than elsewhere.
Of every deficiency written in New Hampshire in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Hampshire surveyors wrote
F689 findings written in New Hampshire, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, it was determined that the facility failed to ensure that staff use equipment properly during transfers, resulting in a fall with a fracture for 1 of 1 residents reviewed for accidents (Resident Identifier #1). Finding include: Review on 4/16/24 of Resident #1's nurse's note dated 3/25/24 revealed that Staff A (Registered Nurse) heard a loud noise in Resident #1's room. Upon entering, Resident #1 was on the floor. The Licensed Nursing Assistants (LNAs) informed Staff A that Resident #1 slid off the Hoyer pad while being lifted. Resident #1 was complaining of back pain. Resident #1 was sent to the hospital for further evaluation. …
Based on interview and record review, the facility failed to ensure that the residents' environment remained as free as possible from accident hazards for 1 of 2 residents reviewed for falls in a final sample of 23 residents (Resident identifier is #94).Findings include:Interview on 6/30/26 at approximately 9:00 a.m. with Resident #94's Durable Power of Attorney for Health Care revealed that they were concerned with the number of falls that Resident #94 has had.Review on 6/29/26 of Resident #94's Progress notes for June 2026 revealed the following falls were documented:6/23/26 seen falling out of wheelchair while trying to reach and touch the ground;6/26/26 seen lying on the ground, head against bedside table, unable to give description;6/27/26 found on floor with bedside table on them,… …
The short window
Recent years
| Year | Share of New Hampshire citations | vs expected |
|---|---|---|
| 2023 | 3.28% | 0.66× |
| 2024 | 3.60% | 0.67× |
| 2025 | 0.72% | 0.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Hampshire surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction