SULLIVAN COUNTY HEALTH CARE

5 NURSING HOME DRIVE, UNITY, NH 03743 (603) 542-9511
Government - County 156 Beds Independent Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
36/100
#59 of 73 in NH
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Last Inspection: October 2024

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

Overview

Sullivan County Health Care in Unity, New Hampshire, has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. Ranking #59 out of 73 in the state places it in the bottom half, and #2 out of 3 in Sullivan County suggests there is only one local option that is better. Although the facility is improving, having reduced its issues from 4 in 2024 to just 1 in 2025, it still faces serious challenges, including $16,153 in fines, which is higher than 77% of other New Hampshire facilities. Staffing is a relative strength with a 4/5 rating and a turnover rate of 56%, which is average for the state; however, RN coverage is concerning as it falls below 89% of similar facilities. Specific incidents of concern include a critical error where a staff member used one resident's insulin pen to administer medication to another, risking serious health complications, and a resident was found on the floor after a fall, indicating potential issues with supervision and care.

Trust Score
F
36/100
In New Hampshire
#59/73
Bottom 20%
Safety Record
High Risk
Review needed
Inspections
Getting Better
4 → 1 violations
Staff Stability
⚠ Watch
56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
⚠ Watch
$16,153 in fines. Higher than 84% of New Hampshire facilities, suggesting repeated compliance issues.
Skilled Nurses
✓ Good
Each resident gets 44 minutes of Registered Nurse (RN) attention daily — more than average for New Hampshire. RNs are trained to catch health problems early.
Violations
⚠ Watch
15 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 1 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

2-Star Overall Rating

Below New Hampshire average (3.0)

Below average - review inspection findings carefully

Staff Turnover: 56%

Near New Hampshire avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $16,153

Below median ($33,413)

Minor penalties assessed

Staff turnover is elevated (56%)

8 points above New Hampshire average of 48%

The Ugly 15 deficiencies on record

1 life-threatening
Jun 2025 1 deficiency 1 IJ
CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected 1 resident

Based on interview and record review, it was determined that the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pe...

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Based on interview and record review, it was determined that the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pen to administer insulin to another resident (Resident identifiers are #1 and #2.) Findings include: Interview on 6/6/25 at approximately 10:03 a.m. with Staff A (Licensed Practical Nurse (LPN)) revealed that on 6/3/25 he/she administered insulin to Resident #2 using Resident #1's used insulin pen. Interview on 6/6/25 at approximately 10:09 a.m. with Staff C (LPN) revealed that on 6/3/25 he/she received shift report from Staff A that Resident #2 ran out of insulin and Staff A used Resident #1's insulin pen to administer insulin to Resident #2. Staff C stated that he/she reported to the night supervisor and both resident's providers about the above mentioned incident on 6/3/25. Resident #1's insulin pen was discarded on 6/3/25. Review on 6/6/25 of Resident #1's June 2025's Electronic Medication Administration Record (EMAR) revealed an active physician's order for Basaglar Kwikpen (insulin glargine) and was signed as given on 6/3/25. Review on 6/6/25 of Resident #2's June 2025 EMAR revealed an active physician's order for Semeglee (insulin glargine) one time a day and was signed as given on 6/3/25. Interview on 6/6/25 at approximately 10:30 a.m. with Staff B (Director of Nursing) revealed that he/she was made aware of the above mentioned incident on 6/4/25. An Adhoc Quality Assurance meeting was held by Staff B, Assistant Director of Nursing, and Administrator about the incident and developed a corrective action plan on 6/4/25. Staff B stated that corrective actions taken included staff interviews on safe insulin administration and facility policy for unavailable medication and found no deviation to facility policy, education was provided to Staff A on safe insulin administration and facility policy on unavailable medications on 6/4/25 and 6/5/25, Staff B assigned online education to Staff A on understanding blood-borne pathogen and avoiding common medication errors before returning to work, and Staff A will have random insulin administration observations during the next 2 weeks. Further interview with Staff B also revealed that both resident's providers were notified on 6/3/25 and blood-borne pathogen testing was ordered on 6/5/25 for Resident #1 and Resident #2. Review on 6/6/25 of the Basaglar (insulin glargine) manufacturer's instruction dated 2015, revealed: .Instructions for use .Do not share your BASAGLAR KwikPen with other people, even if the needle has been changed. You may give other people a serious infection or get a serious infection from them . Review on 6/6/25 of the facility's policy titled, Medication Administration-General Guidelines, effective date of May 2018, revealed .Medications supplied for one resident are never to be administered to another resident . Review on 6/6/25 of the Centers for Disease Control and Prevention (CDC) website titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, retrieved 6/6/25, from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=medications%20in%20pockets.-,Insulin%20administration,Training%20and%20oversight revealed: .Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices permit self-injection, but healthcare providers may also use them to administer insulin. Each pen is designed to be safe for just one patient to use multiple times with a new, fresh needle for each injection. Pens must never be used for more than one patient because blood may be present in the pen after use . Review on 6/6/25 of the facility's documentation of corrective action revealed the following: Staff A was educated on safe insulin administration on 6/4/25; all staff were interviewed to ensure staff had knowledge of safe insuling administration; blood-borne pathogen testing was performed on 6/5/25 for Resident #1 and Resident #2, and an ad hoc Quality Assurance meeting was held on 6/4/24 to initiate a Quality Assurance Performance Imporvement plan that included monitoring.
Oct 2024 2 deficiencies
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 interview and record review it was determined that the facility failed to follow professional standards after a fall wi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to follow professional standards after a fall with identified hip pain for 1 of 1 resident reviewed for falls (Resident Identifier #120) Findings include: Review on 10/14/2024 of Resident #120's nursing note written by Staff F (Licensed Practical Nurse), dated 8/24/24 revealed: Resident was found on the floor lying on her left side close to [pronoun omitted] bed. Assessment done. AROM [active range of motion] on BUE [bilateral upper extremities], PROM [passive range of motion] on BLE [bilateral lower extremities], resident c/o [complained of] pain. Tender to touch on resident's left hip. Resident holds [pronoun omitted] side. Assisted resident back to bed with 2-3 person .Received order to send resident to ER [emergency room] for further evaluation. Interview on 10/16/2024 at approximately 11:00 a.m. with Staff F revealed that Resident #120 was found on the floor. Staff F assessed Resident #120 for injury. Staff F revealed that Resident #120 was complaining of pain and pointing to his/her left hip. Staff F further revealed that Resident #120 was transferred back to bed with assist of three staff. The provider was notified after the resident was transferred to bed and an order was obtained to send the resident to the emergency room for evaluation. Review on 10/16/2024 of Resident #120's hospital Discharge summary, dated [DATE], revealed: . [pronoun omitted] left pubic fracture . Review on 10/16/2024 of facility policy titled, Falls, dated 8/5/20, revealed: .(2) The charge nurse present performs a complete physical assessment to determine injury. She/he will use sound nursing judgement to determine necessary actions, first aid, transfer etc. Should the resident show evidence of a fracture or pain, keep him/her immobilized .Do not move the injured limb . Review on 10/16/2024 of the Journal of Nursing, Post Fall Care Nursing Algorithm, accessed on 1/21/20 revealed: The general scheme of the algorithm is as follows: the post-fall algorithm begins with a decision diamond that requires the nurse to . the next step is to determine whether serious injury has occurred; in this case, serious injury is defined as an injury involving the neck or spine, or any other major trauma. The attending nurse should not move the patient, but should call for assistance from another nurse and immediately notify a physician .The musculoskeletal system should be assessed for any deformities, pain, swelling, weakness, strength, and range of motion .
MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

Based on record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 residents reviewed for MDS in a final sample of 25 resident...

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Based on record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 3 residents reviewed for MDS in a final sample of 25 residents (Resident identifiers are #8, #29, and #118). Findings include: Resident #29 Review on 10/16/24 of Resident #29's current orders revealed an order dated 3/19/24 for dialysis three days a week. Review on 10/16/24 of Resident #29's Quarterly MDS with an Assessment Reference Date (ARD) of 9/21/24, Section O, Special Treatments, Procedures, and Programs, dialysis was coded as no. Interview on 10/16/24 at approximately 10:35 a.m. with Staff A (MDS Coordinator) confirmed that the resident was on dialysis, and that the MDS was coded incorrectly. Resident #118 Review on 10/14/2024 of Resident #118's Quarterly MDS assessment, dated 8/20/2024, Section N revealed that antipsychotic medications were received on a routine basis. Resident #118 was not receiving antipsychotic medications during the assessment reference period. Review on 10/16/2024 of Resident #118's August 2024 Medication Administration Record (MAR), revealed that Resident #118 was not receiving antipsychotic medications. Interview on 10/16/2024 at approximately 1:02 p.m. with Staff A confirmed the above findings. Resident #8 Review on 10/16/24 of Resident #8's hospice records revealed Resident #8 was admitted to hospice on 8/26/24. Review on 10/16/24 of Resident #8's Significant Change MDS Assessment with an ARD of 9/5/24, revealed that under Section OO0110, Special Treatments, Procedures, and Programs, Hospice care while a resident was not indicated. Interview on 10/16/24 at approximately 11:45 a.m. with Staff A confirmed that Resident #8 was receiving Hospice services, and the assessment was coded incorrectly.
Jan 2024 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrato...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrator, or designee, within 2 hours after the allegation, to prevent further abuse for 1 of 3 residents reviewed for abuse (Resident Identifier is #2). Findings include: Review on 1/4/24 of Resident #2's nursing note, dated 12/25/23 at 11:47 a.m., revealed Resident #2 stated the following: A few days ago he came and paused at the door and he was scratching himself when he came in. He was covered, but scratching at his balls. I asked him if he was here for my roommate, he did not talk but was moaning. He continued to scratch his balls and moved towards me and stood in front of me. I gestured for him to leave and told him you need to scratch somewhere else. He left the room and as he was leaving he stated I'll be back. I reported this occurrence when it happened, I actually told a number of people about this. I did not know if he was a visitor or who he was. When I saw him and recognized him the next day (12/24/2023), I rang my call bell to identify him to staff. I talked to a [NAME] young girl. She told me that they knew who he was and that he had done this before. Today, ([DATE]th, 2023) I'm sitting here on my computer and I saw him stop at the door. He came in with his fly down and got in front of my TV looking at me. This time he had his hands in the hole of his pants playing with himself and masturbating. I saw his penis this time. I told him to get out several times and reported this to [Licensed Nursing Assistant name removed]. I'm worried that he's a roaming predator, and thank god I know what is going on because other people may not be able to tell him to leave like I did. Interview on 1/4/24 at 11:15 a.m. with Staff K (Charge Nurse) and Staff L (Social Services) revealed that Resident #2 was alert and oriented and recalled the above event. Interview also revealed that the visitor was the spouse of another resident, Resident #1, and that there was another event where the visitor was allegedly touching Resident #1's roommate, that resulted in Resident #1 being moved to a single room near the nurses' station. Interview on 1/4/24 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B investigated the above incident and the investigation had revealed that the visitor had entered Resident #2's room on 12/23/23. Staff B confirmed that he/she was not aware of the incident on 12/23/23 and the investigation did not begin until the 12/25/23 incident.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrato...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff reported allegations of abuse to the administrator, or designee, within 2 hours after the allegation for 1 of 3 residents reviewed for abuse (Resident Identifier is #2) Findings include: Review on 1/4/24 of Resident #2's nursing note, dated 12/25/23 at 11:47 a.m., revealed the following Resident #2 stated the following: A few days ago he came and paused at the door and he was scratching himself when he came in. He was covered, but scratching at his balls. I asked him if he was here for my roomate, he did not talk but was moaning. He continuted to scratch his halls and moved toward me and stood in front of me. I gestured for him to leave and told him you need to scratch somewhere else. He left the room and as he was leaving he stated I'll be back. I reported this occurrence when it happened, I actually told a [NAME] of people about this. I did not know if he was a vistor or who he was. When I saw him and recognized him the next day (12/24/2023), I rang my call bell to identify him to staff. I talked to a [NAME] young girl. She told me that they knew who he was and that he had done this before. Today, ([DATE]th, 2023) I'm sitting here on my computer and I saw him stop at the door. He came in with his fly down and got in front of my TV looking at me. This time he had his hands in the hole of his pants playing with himself and masturbating. I saw his penis this time. I told [NAME] to get out several times and reported this to [Licensed Nursing Assistant name removed]. I'm worried that he's a romaing predator, and thank god I know what is going on because other people may not be able to tell him to leave like I did. Interview on 1/4/24 at 11:15 a.m. with Staff K (Charge Nurse) and Staff L (Social Services) revealed that Resident #2 was alert and oriented and recalled the above event. Interview also revealed that the visitor was the spouse of another resident, Resident #1, and that there was another event where the visitor was allegedly touching Resident #1's roommate, that resulted in Resident #1 being moved to a single room near the nurses station. Interview on 1/4/24 at appoimatley 1:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B investigated the above incident and the invesitgation had revealed that the visitor had entered Resident #2's room on 12/23/23. Staff B confirmed that he/she was not aware of the incident on 12/23/23 and the invesitgation did not begin until the 12/25/23 incident.
Oct 2023 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review it was determined that the facility failed to ensure that the residents' envi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible on 1 of 4 units (Stern 3 Unit). Findings include: Observations on 10/17/23 at 11:50 a.m. and 2:10 p.m. on the Stern 3 Unit revealed the bath room (where residents shower/bathe) door was open and unlocked in the resident hallway with one bottle of [NAME] facility cleaning solution on an open shelf and a container of bleach wipes on a Personal Protective Equipment (PPE) station left unsecured. Interview on 10/17/23 at 2:20 p.m. with Staff B (Registered Nurse) revealed that 11 residents on Stern 3 Unit have been identified to wander. Interview on 10/18/23 at 9:30 a.m. with Staff A (Licensed Practical Nurse) confirmed the above finding. Observation on 10/18/23 at 10:35 a.m. revealed the treatment room door was open on the Stern 3 Unit in the resident hallway with a sign that stated, Door Must Be Locked At All Times, with the following items: 3 pairs of scissors in an unlocked treatment cart, 2 oxygen tanks, and 8 bottles of alcohol-based hand sanitizer on an open shelf. Interview on 10/18/23 at 10:45 a.m. with Staff B confirmed the above finding. Review of the facility's policy titled, Incident/Accidents, dated 10/24/22 revealed: POLICY: To provide a safe and healthful living environment for all residents and staff of the facility. Review of the facility's policy titled, Tub Bath, dated 1/22/98 revealed: 6. Clean the tub .& return supplies to their proper place. Review of Safety Data Sheets revealed: Midlab-[NAME] Facility Peroxide Disinfectant - Hazard Statements - Causes eye irritation - Serious eye damage/eye irritation -Category 2B. Storage Conditions .Keep locked up . Clorox Healthcare Bleach Germicidal Wipes - Eye Contact - Liquid may cause irritation .Ingestion - Ingestion of liquid may cause slight irritation to mucous membranes and gastrointestinal tract. Purell Hand Sanitizer - Hazard Statements - H319 Causes serious eye irritation .
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

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

Deficiency F0761 (Tag F0761)

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 ensure that expired medication...

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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 ensure that expired medications and biologicals were removed from supply and were not given for 1 of 2 medication rooms and 1 of 4 medication carts observed. Findings include: Medication Cart: Observation on 10/17/23 at 10:20 a.m. of the [NAME] Unit, South Medication Cart with Staff G (Registered Nurse) revealed the following expired medications. 1 open bottle of Aspirin enteric coated 325 milligrams (mg), with a manufacturer's expiration date of 9/23; 1 glucagon kit 1mg with a manufacturer's expiration date of 9/23. Observation on 10/17/23 at 10:30 a.m. of the [NAME] Unit, Medication Room with Staff G (Registered Nurse) revealed the following expired medications: Medication room: 2 unopened bottles of aspirin enteric coated 325 mg, with a manufacturer's expiration date of 9/23; 1 bottle MI-Acid relief (Simethicone) with a manufacturer's expiration date of 09/23; 1 open vial of tuberculin purified protein derivative aplisol with an open date of 8/22/23, review on of manufacturer's instructions that read discard after 30 days of opening. Interview on 10/17/23 at approximately 10:40 a.m. with Staff G (Registered Nurse) confirmed the above findings. Review on 10/17/23 of the facility's policy titled Medication Storage In The Facility dated May 2018, revealed under expiration dating . B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. C. Certain medications(Manufacturer for Tuberculin) .once opened require an expiration date shorter than manufacturer's expiration date to ensure medication purity and potency.
CONCERN (E)

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

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected multiple residents

Resident #113 Review on 10/19/23 of Resident #113's physician visit notes revealed the following encounters: On 3/9/23, an admission visit was completed via telemedicine encounter; On 9/12/23, a 60 da...

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Resident #113 Review on 10/19/23 of Resident #113's physician visit notes revealed the following encounters: On 3/9/23, an admission visit was completed via telemedicine encounter; On 9/12/23, a 60 day visit was via telemedicine encounter Further review on 10/19/23 of Resident #113's medical record revealed that Staff J (Advanced Practice Registered Nurse) did visits on 2/22/23, 8/21/23, 9/1/23, 9/6/23, 10/2/23, 10/11/23, and 10/12/23. Further review of Resident #113's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at approximately 10:00 a.m. with Staff C confirmed the above findings. Resident #117 Review on 10/19/23 of Resident #117's physician visit notes revealed the following encounters: On 8/3/23, an admission visit was completed via telemedicine encounter; On 9/19/23, a 30 day visit was completed via telemedicine encounter; Further review of Resident #117's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at approximately 10:00 a.m. with Staff C confirmed the above findings. Resident #73 Review on 10/19/23 of Resident #73's physician visit notes revealed the following encounters: On 4/13/23, a 60 day recertification telemedicine encounter; On 6/15/23, a 60 day recertification telemedicine encounter; On 8/8/23, a 60 day recertification telemediciine encounter; On 10/13/23, a 60 day recertification telemediciine encounter. Further review of Resident #73's physician notes revealed that there were no in-person face-to-face visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at 9:11 a.m. with Staff H (Medical Records Clerk) confirmed the above findings. Interview on 10/19/23 at 10:20 a.m. with Staff I (Administrator) further confirmed Staff E had not met with residents face-to-face, and that Staff J met with residents on an incidental basis. Resident #40 Review on 10/18/23 of Resident #40's physician visit notes revealed the following; On 4/27/23 a 30 day recertification by telemedicine; On 6/23/23 a 30 day recertification by telemedicine; On 7/28/23 a 30 day recertification by telemedicine; On 9/12/23 a 30 day recertification by telemedicine. Further review of Resident #40's physician notes revealed that there were no in-person visits conducted during the above timeframe by the physician or a practitioner who was not employed by the facility. Interview on 10/19/23 at 9:25 a.m. with Staff F (UM) confirmed the above findings. Staff F revealed that Staff E (Medical Director) had only come to the facility a handful of times. Based on interview and record review, it was determined that the facility failed to ensure that the residents were seen face-to-face by a physician, at least once every 30 days, for the first 90 days after admission, and at least every 60 days thereafter for 7 out of 7 residents reviewed for physician visits in a final sample of 25 residents (Resident Identifiers are #1, #40, #62, #73, #113 and #117). Findings include: Resident #1 Review on 10/18/23 of Resident #1's physician visit notes revealed the following encounters: On 1/10/23, a 60 day recertification telemedicine encounter; On 3/23/23, a 60 day recertification telemedicine encounter; On 5/18/23, a 60 day recertification telemedicine encounter; On 7/28/23, a 60 day recertification telemedicine encounter On 9/26/23, a 60 day recertification telemedicine encounter. Resident #62 Review on 10/19/23 of Resident #62's physician visit notes revealed the following encounters: On 7/21/23, an admission telemedicine encounter; On 9/12/23, an admission telemedicine encounter; On 10/10/23, an admission telemedicine encounter. Interview on 10/19/23 at approximately 9:30 a.m. with Staff C (Unit Manager (UM) confirmed the above information.
Oct 2022 7 deficiencies
CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 out of 1 residents reviewed for self-...

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Based on observation, record review, and interview, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 out of 1 residents reviewed for self-administration of medication in a final sample of 24 residents. (Resident Identifiers is #318.) Findings Include: Resident #318 Observation on 10/3/22 of Resident #318's room at approximately 10:49 a.m. revealed two bottles of liquigel eye gel on the bedside table. Interview on 10/3/22 with Resident #318 at approximately 10:50 a.m. revealed that he/she uses the eye drops throughout the day when his/her eyes get dry. Review on 10/4/22 of Resident #318's medical record revealed no assessment for self-administration of medication and no order for self-administration of medications. Interview on 10/5/22 at approximately 1:49 p.m. with Staff B (Director of Nursing) confirmed that Resident #318 did not have any self-administration orders and there was no self-administration assessment done for Resident #318.
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 observation, interview, and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported to the State Survey Agency within 24 hours for 2...

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Based on observation, interview, and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported to the State Survey Agency within 24 hours for 2 of 6 residents reviewed for abuse in a final sample of 24 residents. (Resident identifiers are #23 and #75.) Findings include: Resident #23 Review on 10/4/22 of Resident #23's medical record revealed the following nursing notes: Nursing note, dated 9/8/22: LNA (Licensed Nursing Assistant) came to get this nurse to look at residents left side of stomach, [pronoun omitted] has a purplish bruise about the size of a baseball. Resident has pain when touching [pronoun omitted] anywhere. Will inform NP (Nurse Practioner) and family later in morning. Nursing note, dated 9/15/22: Resident experiencing pain with any care or movement, minimal relief from pain interventions, abdomen firm and pain to touch, two areas of bruising increased in size from previous days, bruise on LLQ (Left Lower Quadrant) 5cm (centimeter) x 5cm, bruise on left flank area 13cm x 5cm, . Interview on 10/4/22 at approximately 3:00 p.m. with Staff B (Director of Nursing) and Staff D (Social Worker) revealed there was no investigation into Resident #23's bruised areas, as Staff B and Staff D felt that it was related to Resident #23 being combative with care. Staff B and Staff D confirmed that these were not reported to the state agency. Resident #75 Review on 10/5/22 of Resident #75's medical record revealed the following notes under the social work section: Social Service Note dated, 10/3/22 revealed: Intermittent note Writer and another staff member met with [pronoun omitted] after [pronoun omitted] made statements regarding a male LNA. Interview on 10/5/22 at approximately 8:30 a.m. with Staff B and Staff D revealed that Resident #75 made a sexual allegation against 2 male LNAs. Further interview revealed that the allegation was not reported to the state agency within 24 hours from the allegation being made. Review on 10/5/22 of the investigation timeline into the accusation revealed the following: The Staff E (Night Supervisor) emailed the accusation to Staff D on 10/1/22. Interview on 10/5/22 at approximately 9:00 a.m. with Staff D revealed that Staff D did not read the email until 10/3/22 when he/she arrived to work. Interview on 10/5/22 at approximately 11:30 a.m. with Staff E confirmed that he/she sent email to the Staff D as notification of the allegation of abuse. Review on 10/4/22 of the facility policy titled, Abuse Reporting & Investigation, Dated 3/6/17 revealed: For the purpose of Definition and Investigation: . i. Injuries of unknown source should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time . III. Identification . B. All staff are to immediately report any suspected abuse to their Supervisor or Charge Nurse, This will include, but not limited to, bruising, skin tears, . IV. Investigation A. All incidents of suspected abuse must be reported to your immediate Supervisor who then notifies the DON (Director of Nurses) and the Administrator. An incident resulting in physical abuse, sexual abuse, neglect, misappropriation of property/funds and any other serious abuse issue shall be immediately reported to the Administrator and Director of Nursing. The Administrator will then determine whether or not local law enforcement authorities shall be notified. The Supervisor or Charge Nurse will complete an Alleged Resident Abuse Incident Report on any incident which is not consistent with the routine operation of the facility, . V. Reporting A. An initial notification of the incident involving suspected abuse will be faxed to the Ombudsman as directed by the Administrator or designee.
CONCERN (D)

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

Investigate Abuse (Tag F0610)

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 suspected violations of allegations involving abuse were thoroughly investigated to ensure ...

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Based on observation, interview, and record review it was determined that the facility failed to ensure that suspected violations of allegations involving abuse were thoroughly investigated to ensure that the residents were free from abuse and neglect for 2 of 6 residents reviewed for alleged abuse and neglect in a final sample of 24 residents. (Resident identifiers are #115 and #23.) Findings include: Resident #115 Observation on 10/3/22 at approximately 10:00 a.m. of Resident #115's bilateral forearms revealed bruises to both arms. Interview on 10/3/22 at approximately 10:00 a.m. with Resident #115 revealed that he/she could not elaborate on what had happened to his/her forearms. Observation on 10/4/22 at approximately 3:30 p.m. with Staff C (Unit Manager) confirmed the bruising to bilateral forearms. Interview on 10/4/22 at approximately 3:30 p.m. with Staff C revealed that Staff C was unaware of the bruising noted to Resident #115's bilateral forearms. Further interview revealed that the facility had not done an investigation into the cause of the bruising to Resident #115's bilateral forearms. Resident #23 Review on 10/4/22 of Resident #23's medical record revealed the following nursing notes: Nursing note, dated 9/8/22: LNA (Licensed Nursing Assistant) came to get this nurse to look at residents left side of stomach, [pronoun omitted] has a purplish bruise about the size of a baseball. Resident has pain when touching [pronoun omitted] anywhere. Will inform NP (Nurse Practioner) and family later in morning. Nursing note, dated 9/15/22: Resident experiencing pain with any care or movement, minimal relief from pain interventions, abdomen firm and pain to touch, two areas of bruising increased in size from previous days, bruise on LLQ (Left Lower Quadrant) 5cm (centimeter) x 5cm, bruise on left flank area 13cm x 5cm, . Interview on 10/4/22 at approximately 3:00 p.m. with Staff B (Director of Nursing) and Staff D (Social Worker) revealed there was no investigation into Resident #23's bruised areas, as Staff B and Staff D felt that it was related to Resident #23 being combative with care. Review on 10/4/22 of the facility policy titled, Abuse Reporting & Investigation, Dated 3/6/17 revealed: . For the purpose of Definition and Investigation: . i. Injuries of unknown source should be classified as an injury of unknown source when both of the following conditions are met: * The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and * The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. . III. Identification . B. All staff are to immediately report any suspected abuse to their Supervisor or Charge Nurse, This will include, but not limited to, bruising, skin tears, . . IV. Investigation A. All incidents of suspected abuse must be reported to your immediate Supervisor who then notifies the DON (Director of Nurses) and the Administrator. An incident resulting in physical abuse, sexual abuse, neglect, misappropriation of property/funds and any other serious abuse issue shall be immediately reported to the Administrator and Director of Nursing. The Administrator will then determine whether or not local law enforcement authorities shall be notified. The Supervisor or Charge Nurse will complete an Alleged Resident Abuse Incident Report on any incident which is not consistent with the routine operation of the facility, . V. Reporting A. An initial notification of the incident involving suspected abuse will be faxed to the Ombudsman as directed by the Administrator or designee.
CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 10/3/22 at approximately 12:30 p.m. with Staff A (Agency Nurse) revealed that he/she started working at the facilit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 10/3/22 at approximately 12:30 p.m. with Staff A (Agency Nurse) revealed that he/she started working at the facility on 10/3/22 and there had been no training, education, or competencies done with Staff A by the facility prior to his/her start of employment. Based on interview and record review, it was determined that the facility failed to ensure that licensed nurses contracted through nursing agencies had demonstrated competencies and skills necessary to care for residents' needs as identified in the facility assessment for 1 out of 1 agency staff reviewed for nursing competencies. (Staff identifier is Staff A) Findings include: Review on 10/4/22 of the facilities' facility assessment, updated date of 1/2022, revealed .Staff training/education and competencies 3.5 The following outlines the staff education and competencies required by SCHC [[NAME] County Healthcare] Upon hire and annual review: Resident's rights and facility responsibilities. Abuse, neglect, and exploitation, including identification and reporting requirements. Fire Safety/ Emergency Preparedness/ Material Safety Data Sheets. Infection Control/ Blood Bourne Pathogens. HIPAA [Health Insurance Portability and Accountability Act] Overview. False Claims Act and Whistleblower Protection. Compliance Policy. Additional Trainings and Competencies SCHC [[NAME] County Healthcare] Code of Ethics. Caring for Persons with Alzheimer's and Dementia. Therapeutic Activities . Review on 10/4/22 of Staff A's (agency nurse) training and competency records revealed that had no documentation of demonstrated competencies as mentioned in the facility assessment. Interview on 10/4/22 at approximately 11:00 a.m. with Staff B (Director of Nursing) revealed that the facility does not conduct training/education and competency checks for agency nurses before they work independently in the facility.
CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #75 Observation on [DATE] at approximately 10:10 a.m. on Resident #75's night stand revealed Biotene Mouth Spray. Obser...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #75 Observation on [DATE] at approximately 10:10 a.m. on Resident #75's night stand revealed Biotene Mouth Spray. Observation on [DATE] at approximately 1:15 p.m. on Resident #75's night stand revealed Biotene Mouth Spray. Interview on [DATE] at approximately 1:15 p.m. with Staff C (Unit Manager) revealed that Resident #75 could not physically use the mouth spray. Further interview revealed that the mouth spray should not be locked in the medication cart. Based on interview and observation, it was determined that the facility failed to ensure that insulin pens that have expired were disposed of after the expiration date for 1 out of 2 medication carts observed. (Resident identifiers are #25, and #69) Findings include: Resident #25 Observation on [DATE] at 09:10 a.m. of the [NAME] I medication cart 1 revealed the following: One Lispro Injection KwikPen insulin pen open with a label that stated discard after 28 days date [DATE] for Resident #25. Resident #69 One Lispro Injection KwikPen insulin pen open with a label that states discard after 28 days date [DATE] for Resident #69. Interview on [DATE] with Staff I (Medication Nursing Assistant) confirmed the above expiration date. Staff I also stated that the insulin pens should for Resident #25 and #6 had been used since expired and shuld have been discarded. Interview on [DATE] with Staff J (Registered Nurse) confirmed that the insulin pens were expired and should not be in the cart and discarded. Review on [DATE] of the [NAME] Lilly and Company's Lispro Insulin injection KwikPen revealed that .In use Pens .Throw away the Insulin Lispro injection pen you are using after 28 days, even if it has insulin left in it .
CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

Based on interview and record review, it was determined that the facility failed to ensure that the minimum required committee members attended meetings at least quarterly for 3 of 4 quarterly meeting...

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Based on interview and record review, it was determined that the facility failed to ensure that the minimum required committee members attended meetings at least quarterly for 3 of 4 quarterly meetings reviewed. Findings include: Review on 10/5/22 of the last 4 quarterly Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets revealed the following: January 2022 - The Medical Director or designee was not in attendance. April 2022 and August 2022 - no QAPI meeting attendance sheets were available to review to assure the minimum required committee members were in attendance at either meeting. Interview on 10/6/22 at approximately 2:00 p.m. with Staff H (Administrator) confirmed that the medical director or designee was not in attendance per the attendance sheet for the January 2022 QAPI meeting. Staff H stated that they could not locate a sign-in sheet for the April 2022 and the August 2022 QAPI meetings to verify who was in attendance.
CONCERN (D)

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

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to implement policies and procedures in regard ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to implement policies and procedures in regard to the facility's contingency plan for staff who are not fully vaccinated for COVID-19 for 1 out of 3 contracted staff reviewed. (Staff identifier is Staff G.) Findings include: Review on 9/4/22 of the facility's policy titled, Employee COVID-19 Vaccination Policy, revised on 2/23/22, revealed .SCHC {[NAME] County Health Care] requires, as a condition of employment, that all [NAME] County Employees who provide services to or are located at the [NAME] County Health Care be fully vaccinated with an FDA [Food and Drug Administration] approved (either under Emergency Use Authorization or final approval) COVID-19 vaccine .This requirement includes, but is not limited to: .Health Care contracted providers and consultants .SCHC must also explore possible reasonable accommodations for those employees who have a documented medical condition or a sincerely held religious belief that keeps them from getting the vaccine .Request for exemption for receiving the COVID-19 vaccine must be made through the Human Resources Department. Medical reasons must include a note from a qualified medical practitioner .Request for exemption must be made on an annual basis . Review on 10/4/22 at approximately 10:30 a.m. of Staff G's (contracted Medical Provider) revealed that Staff G had received only one of the two recommended COVID-19 vaccinations on 11/12/21. Interview on 10/4/22 at approximately 11:a.m. with Staff B (Director of Nursing) confirmed that Staff G is not fully vaccinated for COVID-19. Staff B stated that Staff G does not have a medical or religious exemption request on file and has not provided proof of COVID-19 testing while employed by the facility. Staff B stated that Staff G was new to the facility and had only been in the facility to see residents on 9/12/22, 9/14/22, 9/19/22, 9/21/22, 9/26/22, and 9/28/22.
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

  • "What changes have you made since the serious inspection findings?"
  • "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
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), Payment denial on record. Review inspection reports carefully.
  • • 15 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $16,153 in fines. Above average for New Hampshire. Some compliance problems on record.
  • • Grade F (36/100). Below average facility with significant concerns.
Bottom line: Trust Score of 36/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Sullivan County Health Care's CMS Rating?

CMS assigns SULLIVAN COUNTY HEALTH CARE 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 Sullivan County Health Care Staffed?

CMS rates SULLIVAN COUNTY HEALTH CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the New Hampshire average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Sullivan County Health Care?

State health inspectors documented 15 deficiencies at SULLIVAN COUNTY HEALTH CARE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 13 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Sullivan County Health Care?

SULLIVAN COUNTY HEALTH CARE 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 156 certified beds and approximately 122 residents (about 78% occupancy), it is a mid-sized facility located in UNITY, New Hampshire.

How Does Sullivan County Health Care Compare to Other New Hampshire Nursing Homes?

Compared to the 100 nursing homes in New Hampshire, SULLIVAN COUNTY HEALTH CARE's overall rating (2 stars) is below the state average of 3.0, staff turnover (56%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Sullivan County Health Care?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Sullivan County Health Care Safe?

Based on CMS inspection data, SULLIVAN COUNTY HEALTH CARE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Hampshire. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Sullivan County Health Care Stick Around?

Staff turnover at SULLIVAN COUNTY HEALTH CARE is high. At 56%, the facility is 10 percentage points above the New Hampshire average of 46%. 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 Sullivan County Health Care Ever Fined?

SULLIVAN COUNTY HEALTH CARE has been fined $16,153 across 1 penalty action. This is below the New Hampshire average of $33,240. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Sullivan County Health Care on Any Federal Watch List?

SULLIVAN COUNTY HEALTH CARE 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.

SULLIVAN COUNTY HEALTH CARE

5 NURSING HOME DRIVE, UNITY, NH 03743 | (603) 542-9511

F
Trust Grade (36/100)
2.0
CMS Rating
15
Deficiencies

Strengths

  • 4-star staffing

Concerns

  • 1 Immediate Jeopardy citation
  • 2-star rating

Ask about: Inspection Response, Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025