Based on interview and record review, it was determined that the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for reporting alleged violations of abuse and neglect. Findings include: Review on 2/26/25 of Resident #5's medical record revealed the following nursing note written by Staff E (Registered Nurse), dated 2/23/25 at 4:17 p.m.: During morning medication round I inadvertently administered the incorrect medication to the patient. While verifying the medication administration record (MAR) I recognized that the following medications were given. …
F867 citations in New Hampshire
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Hampshire cites F867 more often than its own record predicts
1.09 times the share F867 takes of citations nationally.
Of every deficiency written in New Hampshire in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Hampshire surveyors wrote
F867 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, the facility failed to implement a plan of action to correct for an identified system failure for 1 of 2 medication errors reviewed. Findings include: Review on 9/29/21 at 11:47 a.m. of facility reported incident from July 31, 2021 for Resident #37 revealed a medication error occurred by a nurse who administered medications to the wrong resident. Review on 9/30/21 at 10:00 a.m. of facility reported incident from July 31, 2021 for Resident #74 revealed a medication error occurred because a nurse did not document the administration of medication. Interview on 9/30/21 at 10:00 a.m. with Staff B (Director of Nursing) confirmed the above findings. Interview on 9/30/21 at 1:00 p.m. …
What else New Hampshire surveyors cite →
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