COOS COUNTY NURSING HOME

364 CATES HILL RD PO BOX 416, BERLIN, NH 03570 (603) 752-2343
Government - County 100 Beds Independent Data: November 2025
Trust Grade
45/100
#47 of 73 in NH
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Last Inspection: December 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Coos County Nursing Home has a Trust Grade of D, indicating below-average care with some concerning issues. It ranks #47 out of 73 facilities in New Hampshire, placing it in the bottom half, and #3 out of 5 in Coos County, meaning there are only two local options that perform better. The facility is worsening, with issues increasing from 2 in 2023 to 7 in 2024. Staffing is average with a 3/5 star rating, but the turnover rate is alarming at 98%, significantly higher than the state average of 50%. There have been no fines reported, which is a positive aspect, and RN coverage is also average, suggesting some level of oversight. However, there are serious concerns revealed in inspector findings. One resident was found unable to move due to locked wheels on their chair, which violates safety protocols. Additionally, staff failed to report an alleged abuse incident involving another resident, indicating potential neglect in safeguarding residents. Lastly, the facility did not properly assess a resident for serious mental health issues, which could affect their care. Overall, while there are some strengths, the significant weaknesses may raise red flags for families considering this nursing home for their loved ones.

Trust Score
D
45/100
In New Hampshire
#47/73
Bottom 36%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
2 → 7 violations
Staff Stability
⚠ Watch
98% turnover. Very high, 50 points above average. Constant new faces learning your loved one's needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most New Hampshire facilities.
Skilled Nurses
✓ Good
Each resident gets 58 minutes of Registered Nurse (RN) attention daily — more than average for New Hampshire. RNs are trained to catch health problems early.
Violations
⚠ Watch
13 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 2 issues
2024: 7 issues

The Good

  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below New Hampshire average (3.0)

Below average - review inspection findings carefully

Staff Turnover: 98%

52pts above New Hampshire avg (47%)

Frequent staff changes - ask about care continuity

Staff turnover is very high (98%)

50 points above New Hampshire average of 48%

The Ugly 13 deficiencies on record

Dec 2024 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, it was determined that the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in ...

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Based on observation, record review, and interview, it was determined that the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 18 residents (Resident identifier is #72). Findings include: Observation on 12/16/24 at approximately 12:00 p.m. revealed Resident #72 in the unit dining room, sitting in his/her broda chair with the back wheels locked, and his/her feet on the ground. Resident #72 was attempting to push back away from the table and attempted to tip table over. Interview on 12/16/24 at approximately 12:00 p.m. with Staff J (Licensed Nursing Assistant) confirmed the back wheels of Resident #72's broda chair were locked and the resident was unable to move the broda chair back. Observation on 12/18/24 at approximately 8:00 a.m. revealed Resident #72 in the unit dining room, sitting in his/her broda chair with the back wheels locked, and his/her feet touching the ground. Interview on 12/18/24 at approximately 9:10 a.m. with Staff J revealed Staff J locked the back wheels of Resident #72's broda chair primarily at dining table so Resident #72 will stay at the table to eat. Review on 12/18/24 of Resident #72's physician orders, assessments and care plan revealed no orders, assessment or care plan in place for restraint the resident's wheel chair during dining. Review on 12/18/24 of facility policy title RESTRAINTS-PHYSICAL , dated 11/3/2006, revealed .IMPLEMENTATION 1. Restraints will only be used after alternatives have been tried unsuccessfully, .A physician order is required with associated diagnosis. A Pre-Restraining Assessment Form will be completed to determine if a restraint is needed because Medical symptom(s) warrant restraint use .2 .A restraint is any method or device which restricts freedom of movement .3. Physical restraints shall not be used to limit resident mobility or for the convenience of the staff .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, it was determined that the staff failed to report an alleged violation of abuse immediately to the Administrator and the facility failed to report to the State Su...

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Based on interview and record review, it was determined that the staff failed to report an alleged violation of abuse immediately to the Administrator and the facility failed to report to the State Survey Agency (SSA) for 1 of 1 resident reviewed for abuse in a final sample of 18 residents (Resident identifier is #57). Findings include: Review on 12/16/24 of Resident #57's provider progress notes, written by Staff B (Advanced Practice Registered Nurse), revealed the following: 12/10/24, .Resident states [pronoun omitted] R [right] shoulder is in increased pain. [pronoun omitted] says one of the LNA's [Licensed Nursing Assistant] pulled [pronoun omitted] and [pronoun omitted] has [pronoun omitted] right shoulder and upper arm hurts now . Interview on 12/17/24 at approximately 2:15 p.m. with Staff B revealed that Staff B did not report the allegation to the administrator. Review on 12/18/24 of the facility policy titled, Instructions For Reporting Alleged Resident Abuse, revision date 11/24, revealed .2. Notify NHA (Nursing Home Administrator) and DON (Director of Nursing) (or their designees) of all mistreatment, abuse, neglect and misappropriation of resident property incidents via home/cell phone as soon as possible . Review on 12/18/24 of the facility policy titled, Abuse Policy and Procedures, revision date 11/24, revealed .Reporting Resident Abuse or Neglect, Observation or suspicion of alleged resident abuse, neglect or misappropriation of resident property must be reported and investigated IMMEDIATELY .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder and intellectual disability for a Level I Pre...

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Based on record review and interview, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder and intellectual disability for a Level I Pre-admission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARR in a final sample of 18 residents (Resident identifier is #1). Findings include: Review on 12/16/24 of Resident #1's most recent Level I PASARR screening completed on 7/23/13 for new admission, revealed no indication of mental illness or intellectual disability. Review on 12/16/24 of Resident #1's medical diagnosis list revealed a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 8/22/24 and Personal History of Traumatic Brain Injury (TBI) dated 8/3/17. Review on 12/16/24 of Resident #1's mental health provider note, dated 8/19/24, revealed Resident #1 had an episode of recent aggression with an aide when attempt was made to redirect from the elevator focus on military and past trauma related to this .h/o [history of] TBI .confused about immediate situation and conflates this with past events leading to aggression as response . Review on 12/16/24 of Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/3/24, revealed in Section I (Active Diagnosis) lists Traumatic Brain Dysfunction as primary reason for admission, it also revealed TBI and PTSD selected. Review on 12/16/24 of Resident #1's care plan revealed PTSD and TBI had interventions in place for cognition and behaviors At times I talk about past events as though they are current (or delusions as I believe happened in my past, but are not true/accurate) e.g. I have cockroaches in my room and the Communist (but did not) .I display verbal behaviors (yelling and cursing) I reject care @ x's [at times] . Interview on 12/17/24 at approximately 2:15 p.m. with Staff L (Social Services Director) confirmed above findings and further revealed they have no process for referring for Level I PASARR screening with newly identified mental/intellectual disabilities.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 resident out of 3 residents reviewed for pressure ulcers in a final sample of 18 residents (Resident identifier is #36). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 12/17/24 at approximately 1:45 p.m. of Staff C (Licensed Practical Nurse) changing Resident #36's dressing to his/her coccyx revealed a separate dressing that was applied to his/her left gluteal fold, dated 12/16. Staff C removed the dressing and there was a pinpoint area noted to Resident #36's gluteal fold with a thick layer of cream applied under the dressing. Interview on 12/17/24 at approximately 1:45 p.m. with Staff C revealed that Staff C was unaware of any other dressing orders for Resident #36. Review on 12/17/24 of Resident #36's December 2024's TAR (Treatment Administration Record) and physician's orders revealed that there were no physicians order for the dressing applied to Resident #36's left gluteal fold. Interview on 12/17/24 at approximately 2:30 p.m. with Staff D (Assistant Director of Nurses/Wound Nurse) revealed that Staff D would not expect a dressing to be applied without a physician's order.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on interview and record review, it was determined that the facility failed to ensure a resident does not develop pressure ulcers unless the individual's clinical condition demonstrates that they...

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Based on interview and record review, it was determined that the facility failed to ensure a resident does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 2 residents reviewed for pressure ulcers in a final sample of 18 residents (Resident identifier is #69). Findings include: Review on 12/17/24 of Resident #69's medical record revealed the following progress notes: 11/8/24 at 11:15 a.m.: Weekly skin check done. Pt [patient] currently has a bruise on the outer left heel.; 11/8/24 at 3:12 p.m.: .very lethargic today .Laid down in [pronoun omitted] bed and has been sleeping since noon; 11/10/24 at 7:32 a.m.: Resident has been in bed since yesterday .noticed a golf [sic] size blister on [pronoun omitted] left heel that is weeping .Pillows were placed under [pronoun omitted] legs in order to float [pronoun omitted] heels. supervisor [name omitted]was notified .; 11/10/24 at 9:46 a.m.: Golf ball size blister noted to be draining serous fluid. Will notify MD [Medical Doctor].; 11/10/24 at 11:47 a.m.: New order to flush left heel blister with normal saline, pat dry, apply vaseline and cover with foam border dressing, keep moist and change dressing as needed until healed; Review on 12/17/24 of Resident #69's Skin integrity care plan that was initiated on 11/7/23 revealed the following: Focus was updated on 11/27/24 to include Stage 3 pressure injury to left heel; Interventions updated on 11/21/24 to include Keep heels elevated at all times with heels off cushion when in bed, and Multiboot to left foot when out of bed to off-load heel. Interview on 12/17/24 at approximately 1:30 p.m. with Staff D (Assistant Director of Nursing/Wound Nurse) confirmed that their were no orders for treatment of Resident #69's left heel until 11/10/24 when the blister was discovered. Staff D confirmed that there were no new care plan interventions added to Resident #69's care plan until 11/21/24. Staff D stated that they were not aware of the finding of the bruise on 11/8/24 to Resident #69's left heel until after the development of the blister on 11/10/24. Review on 12/17/24 of Resident #69's Licensed Nursing Assistant task documentation revealed the following: Multiboot to left foot when out of bed to offload heel and Keep heels elevated at all times with heels off cushion when in bed were both initiated on 11/20/24, 12 days after the identification of the bruised area to left heel. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F (Director of Nursing) confirmed the above findings.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with an order for a CPAP (continuous positive airway pressure) machine recieved trea...

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Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with an order for a CPAP (continuous positive airway pressure) machine recieved treatment consistant with the providers orders for 1 of 2 residents reviewed for Respiratory Care in a final sample of 18 residents (Resident identifier is #18). Findings include: Interview on 12/17/24 at approximately 10:15 a.m. with Resident #18 revealed that they have not been able to use their CPAP at night due to the mask not sealing. Resident #18 stated that staff were aware and that this has been going on for at least a week. Review on 12/17/24 of Resident #18's medical record revealed an order for CPAP on at bedtime and remove in the morning related to obstructive sleep apnea, start date of 11/21/23. Further review of Resident #18's medical record revealed the following order administration notes: 12/8/24 at 9:02 a.m. did not wear CPAP last night; 12/8/24 at 11:52 p.m. CPAP mask has a tear; 12/10/24 at 12:25 a.m. CPAP is broken; 12/10/24 at 7:35 a.m. CPAP is broken; 12/14/24 at 12:33 a.m. CPAP is broken; 12/14/24 at 6:01 a.m. CPAP is broken; 12/15/24 at 4:41 a.m. CPAP mask has a tear at the top; 12/15/24 at 7:05 a.m. CPAP mask has a tear; 12/16/24 at 1:00 a.m. CPAP mask has a tear at the top; 12/16/24 at 6:06 a.m. CPAP is broken; 12/17/24 at 12:01 a.m. CPAP mask has a tear at the top; 12/17/24 at 6:23 a.m. CPAP has a tear. Interview on 12/17/24 at approximately 12:00 p.m. with Staff E (Registered Nurse) confirmed that Resident #18's CPAP was not functioning properly due to a tear in the mask and that no one had notified the provider of the CPAP not being used as ordered.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined the facility failed to ensure that medical records were accurate for 2 residents reviewed in a final sample of 18 residents (Resident identifier...

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Based on record review and interview, it was determined the facility failed to ensure that medical records were accurate for 2 residents reviewed in a final sample of 18 residents (Resident identifiers are #17 and #81). Findings include: Resident #17 Interview on 12/16/24 at approximately 2:00 p.m. with Resident #17 revealed that he/she has been using a hoyer lift for transfers for a few weeks. Interview on 12/18/24 at approximately 8:30 a.m. with Staff I (Licensed Nursing Assistant (LNA)) revealed that LNA's use the Resident Profiles that are hanging in the residents closets for resident transfer statuses. Review on 12/18/24 of Resident #17's Resident Profile in Resident #17's closet in his/her room revealed .Transfers 2 assist mechanical stand lift, Instructions: [pronoun omitted] sling PRN (as needed) . Interview on 12/18/24 at approximately 9:10 a.m. with Staff H (Director of Rehabilititation) confirmed that Resident #17 was no longer safe using a stand lift and had transitioned to a hoyer lift a few weeks ago. Interview on 12/18/24 at approximately 9:15 a.m. with Staff A (Administrator) revealed that he/she expects the Resident Profiles to be updated when any changes are made with a residents care needs. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F (Director of Nursing) confirmed that Resident Profiles are part of the residents medical record. Resident #81 Review on 12/18/24 of Resident #81's progress notes revealed an entry on 11/11/24, at 6:30 a.m., that stated This nurse was notified by resident's visiting POA [Power of Attorney] that [pronoun omitted] was not breathing. [name omitted] RN [Registered Nurse] notified to pronounce. Further review of Resident #81's progress notes revealed no documentation regarding pronouncement of death. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F confirmed the above findings. Review on 12/18/24 of the facility policy titled Death of a Resident revised 7/15, revealed .5. The licensed nurse will make the following entries on the residents' chart: a. Time of death b. Pronouncement of death by physician or Registered Nurse .
Dec 2023 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 resident reviewed for restraints in a fi...

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Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 resident reviewed for restraints in a final sample of 22 residents (Resident Identifier is #69). Findings include: Observation on 12/7/23 at approximately 11:10 a.m. of Resident #69 revealed that they were in a reclining wheelchair with a fastened seatbelt. Resident #69 has a diagnosis of cerebral palsy and is unable to release the seat belt or to move the reclining wheelchair from a reclined position to an upright position. Review on 12/7/23 of Resident #69's medical record revealed that there was no assessment of the seat belt and no physician's order for the seat belt. Further review of the medical record revealed that there was no care plan for the usage of the seat belt and that Section P of the quarterly MDS (Minimum Data Set) dated 11/14/23 titled Restraints and Alarms was coded 0 for not used. Observation on 12/8/23 at approximately 1:06 p.m. of Resident #69 revealed they were seated in the reclining wheelchair with the fastened seat belt in place. Interview on 12/8/23 at approximately 1:10 p.m. with Staff F (Director of Nursing) confirmed that there was no care plan for Resident #69's seat belt and no physician's order. Interview on 12/8/23 at approximately 1:15 p.m. with Staff G (Licensed Nursing Assistant (LNA)) who revealed that the seat belt is removed when Resident #69 goes to bed. Interview on 12/8/23 at approximately 1:20 p.m. with Staff H (LNA) who confirmed that Resident #69 has the seat belt removed only at bedtime. Interview on 12/8/23 at approximately 1:25 p.m. with Staff C (LNA) confirmed that Resident #69 has the seat belt removed only at bedtime. Interview on 12/8/23 at approximately 1:30 p.m. with Staff I (Minimum Data Set Nurse) who confirmed that Section P is not coded for the use of a restraint. Review on 12/8/23 of the facility policy titled, Restraints-Physical Nursing Handbook/Safety, Security, Enabling 11/3/2006 revealed 1. A physician order is required with associated diagnosis, a Pre-Restraining Assessment form will be completed to determine if a restraint is needed .5. c. Restrained residents must be repositioned at least every two (2) hours on all shifts and recorded in the LNA Restraint Record .7. The need for restraints will be reevaluated on the Physical Restraint Elimination Review Form at least quarterly .8. The resident's Assessments (i.e. MDS, RAP Summary) and Care Plan will be evidence that the restraint has been re-evaluated.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews it was determined that the facility failed to follow physician's orders for 1 resident in...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews it was determined that the facility failed to follow physician's orders for 1 resident in a final sample of 22 residents (Resident Identifier is #8). Findings include: Professional references: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Review on 12/8/23 of Resident #8's November 2023 Medication Administration Record (MAR) revealed the following orders: Acetaminophen tablet 500 mg [milligrams], give 2 tablets by mouth two times a day for pain related to other specified arthritis, multiple sites. See corresponding order. Wait 4 hours between scheduled and PRN [as needed] dose *** NTE [not to exceed] 3 gm [grams] every 24 hrs [hours] with a start date of 6/2/23. The scheduled dose is for 9:00 a.m. and 8:00 p.m. Acetaminophen tablet 500 mg, give 2 tablets by mouth as needed for pain. Pain 2 tabs [tablet] po [by mouth] 1 every 24 hours. NTE 3 gm in 24 period. Wait 4 hours between scheduled and PRN dose. With an order date of 6/2/2023. Acetaminophen was administered PRN on the following dates: on 11/20/23 at 4:15 a.m. for a pain level of 6, effective and on 11/20/23 at 1:52 p.m. for a pain level of 8, effective. The scheduled dose of Acetaminophen tablet was also administered on 11/20/23 totaling 4 grams, therefore, exceeding 3 grams. Interview on 12/8/23 with Staff F (Director of Nursing) at approximately 12:30 p.m. confirmed the above findings. Review on 12/8/23 of Resident #8's December 2023 MAR revealed the following orders: Acetaminophen tablet 500 mg. Give 2 tablets by mouth as needed for pain. Pain 2 tabs po x 1 every 24 hours. NTE 3 grams in 24 period. Wait 4 hours between scheduled and PRN dose. With an order date of 6/2/23. Further review of Resident #8's December 2023 MAR revealed the following order for tramadol HCL [hydrochloride] oral tablet 50 mg. Give 0.5 tablet by mouth every 24 hours as needed for pain. May give 4 hours after previous dose 0.5 tablet = 25mg with a start of 11/21/2023 and a discontinue date of 12/8/2023. Further review of the December 2023 MAR for PRN Acetaminophen tablet 500 mg and Tramadol 0.5 mg did not have written parameters or pain scale on when to administer them. Interview on 12/8/23 with Staff F at approximately 12:30 p.m. confirmed the above findings.
Nov 2022 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on interview, record review, and policy review, it was determined that the facility failed to ensure that as needed (PRN) psychotropic medication did not extend beyond 14 days without a document...

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Based on interview, record review, and policy review, it was determined that the facility failed to ensure that as needed (PRN) psychotropic medication did not extend beyond 14 days without a documented physician rationale for 1 out of 5 residents reviewed for unnecessary medications in a final sample size of 19 residents. (Resident identifier is #40.) Findings include: Review on 11/3/22 of the pharmacy review dated 6/30/22 revealed: Recommendation: Resident is on PRN Lorazepam with no stop date on MAR [Medication Administration Record] entry--- Per facility policy, all PRN psychotropic medications need to have a stop date on the MAR. Review on 11/3/22 of the pharmacy review dated 8/19/22 revealed: THIS IS A DUPLICATION OF A PREVIOUS MRR [Medication Regimen Review]. PLEASE ADDRESS THE ISSUE. Resident is on PRN Lorazepam with no stop date on MAR entry---Per facility policy, all PRN psychotropic medications need to have a stop date on the MAR. Review on 11/3/22 of Resident #40's July and August 2022 MAR revealed the following: Lorazepam Tablet 0.5 milligrams (mg) Give 1 tablet by mouth as needed for for anxiety **[pronoun omitted] MAY NOT DRIVE for 6 HOURS if [pronoun omitted] takes it at hs [hour of sleep]. **[pronoun omitted] SHOULD NOT BE DRINKING WHILE TAKING THIS MEDICATION**), start date 6/2/22, D/C [discontinue] date 8/4/22. Further review of Resident #40's July 2022 MAR revealed that Resident #40 received 30 PRN doses in July 2022. Further review of Resident #40's August 2022 MAR's revealed that Resident #40 received 1 PRN dose in August 2022. Interview on 11/3/22 at approximately 12:10 p.m. with Staff D (Director of Nursing) revealed that pharmacy recommendations are expected to be addressed by the facility upon receiving them and that PRN psychotropic medications should have a 14 day stop date. Review on 11/3/22 of the facility policy titled, Medication Monitoring, Medication Regimen Review, and Reporting, dated 9/18 revealed: .8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and policy review it was determined that the facility failed to label 2 insulin pens with an open date, an open expiration date, and failed to store medication in its ...

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Based on observation, interview, and policy review it was determined that the facility failed to label 2 insulin pens with an open date, an open expiration date, and failed to store medication in its original container on 1 of 2 med carts observed. Findings include: Observation on 11/1/22 at approximately 10:15 a.m. of 3 East Medication Cart revealed the following insulin pens opened and not labeled with an open date or open expiration date. Resident #5 Lantus Solostar insulin pen Resident #13 Basaglar insulin pen Further review of the 3 East Medication Cart revealed 2 white pills in a medication cup without any identifying markers. Interview on 11/1/22 at approximately 10:15 a.m. with Staff C (Licensed Practical Nurse) confirmed that the above 2 insulin pens were opened and not labeled with an open date or open expiration date and that Staff A (Charge Nurse) put the 2 pills in a medication cup in the cart and was going to administer them to a resident. Review on 11/2/22 of the manufacturer's instructions for Lantus Solostar insulin pen, revision date December 2020 revealed: .How should I store Lantus? . The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin in it . Review on 11/2/22 of the manufacturer's instruction for Basaglar insulin pen, dated July 2021 revealed: .Storage .In-use Pen .Throw away the Pen you are using after 28 days, even if it still has insulin in it . Review on 11/2/22 of the facility policy titled, Medication Storage, Storage of Medication, dated 9/18 revealed: .12. Note the date on the label for insulin vials and pens when first used. Review on 11/2/22 of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider, Medications and Medication Labels, dated 5/16 revealed: .10. Floor stock medications kept in the original manufacturer's container must have the expiration date and lot numbers clearly evident. The manufacturer's or pharmacy's label shall include the following: a. Medication name b. Medication strength c. quantity d. Accessory information e. Lot number f. Expiration date
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined that the facility failed to ensure that resident's records were complete and accurate for 1 of 2 residents reviewed for urinary catheter in a fi...

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Based on record review and interview, it was determined that the facility failed to ensure that resident's records were complete and accurate for 1 of 2 residents reviewed for urinary catheter in a final sample of 19 residents (Resident identifier is #42). Findings include: Review on 11/3/22 at approximately 8:50 a.m. of Resident #42's physician's orders for October 2022 revealed an order for Renacidin Solution use 30 milliliters (ml) via irrigation every day and night shift for occlusion prevention. Irrigate and clamp for 30 minutes dwell time, then release to drain gravity, with a start date of 2/8/21. Review on 11/3/22 at approximately 9:00 a.m. of Resident #42's Medication Administration Record (MAR) for October 2022 revealed that there was no documentation that the irrigation had been done on October 3rd, 4th, 9th, 10th, 13th, 24th, and 26th. Interview on 11/3/22 at approximately 9:15 a.m. with Staff A (Charge Nurse) revealed that Resident #42 was in the quarantine unit during October and that staff did perform the irrigation but did not document it on the MAR.
MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

Deficiency Text Not Available

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Deficiency Text Not Available
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most New Hampshire facilities.
Concerns
  • • 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • Grade D (45/100). Below average facility with significant concerns.
  • • 98% turnover. Very high, 50 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Coos County's CMS Rating?

CMS assigns COOS COUNTY NURSING HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New Hampshire, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Coos County Staffed?

CMS rates COOS COUNTY NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 98%, which is 52 percentage points above the New Hampshire average of 47%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Coos County?

State health inspectors documented 13 deficiencies at COOS COUNTY NURSING HOME during 2022 to 2024. These included: 12 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Coos County?

COOS COUNTY NURSING HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 76 residents (about 76% occupancy), it is a mid-sized facility located in BERLIN, New Hampshire.

How Does Coos County Compare to Other New Hampshire Nursing Homes?

Compared to the 100 nursing homes in New Hampshire, COOS COUNTY NURSING HOME's overall rating (2 stars) is below the state average of 3.0, staff turnover (98%) is significantly higher than the state average of 47%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Coos County?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Coos County Safe?

Based on CMS inspection data, COOS COUNTY NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Hampshire. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Coos County Stick Around?

Staff turnover at COOS COUNTY NURSING HOME is high. At 98%, the facility is 52 percentage points above the New Hampshire average of 47%. Registered Nurse turnover is particularly concerning at 100%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Coos County Ever Fined?

COOS COUNTY NURSING HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Coos County on Any Federal Watch List?

COOS COUNTY NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

COOS COUNTY NURSING HOME

364 CATES HILL RD PO BOX 416, BERLIN, NH 03570 | (603) 752-2343

D
Trust Grade (45/100)
2.0
CMS Rating
13
Deficiencies

Strengths

  • 4-star quality

Concerns

  • 2-star rating

Ask about: Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025