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Hanover nursing home under investigation after state report found it failed to prevent abuse

Hanover Terrace in Hanover, N.H., on Aug. 6, 2015.
Geoff Hansen
Valley News
Hanover Terrace is pictured here in August 2015. According to a DHHS report, the New Hampshire medical examiner conducted an autopsy on a resident who died at the facility in early January 2023 and found that person, who was identified only as resident No. 2, “had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death.”

This story was originally produced by the Valley News. NHPR is republishing it in partnership with the Granite State News Collaborative.

Hanover Terrace Health and Rehabilitation Center has been faulted for failing to prevent or properly address abuse that contributed to the painful death of a resident in January.

State inspectors found that the facility on Lyme Road put residents in “immediate jeopardy” because it “failed to recognize, report, investigate, prevent and correct allegations of abuse and neglect,” according to a report from the New Hampshire Department of Health and Human Services.

Now, the state is conducting a criminal investigation.

“Our office is aware of the DHHS report, and the New Hampshire Department of Justice is now conducting an ongoing investigation,” Michael Garrity, a spokesman for the department, said in a Tuesday email. He declined to provide any details about the status of the investigation.

The 44-page report was dated Feb. 9 and stemmed from an inspection that occurred between Jan. 5 and 25. Investigators faulted the facility’s administration for the deficiencies including:

  • Failing to ensure that residents weren’t abused or neglected;
  • Failing to develop and implement the facility’s abuse policy;
  • Failing to thoroughly investigate allegations of abuse and neglect;
  • Failing to ensure that the environment remained free of hazards;
  • And failing to provide sufficient staffing for the evening and night shift.

“Based on interview and record review, the facility failed to be administered in a manner permitting all residents to maintain or attain their highest practicable well being,” the report said.
As a result of the report’s findings, the Centers for Medicare & Medicaid Services fined Hanover Terrace nearly $176,000, according to a March 3 letter CMS sent to the facility. Had the facility failed to act to address the deficiencies cited in the report by late February, CMS would have begun denying payment to the facility, according to a Feb. 7 letter from CMS.

The report does not identify the resident who died. Bernard Moore, of White River Junction, was power of attorney for his 97-year-old aunt Mary Irene Moore, who died at Hanover Terrace on Jan. 4.

In an interview, Moore said someone from Hanover Terrace told him that his aunt had been bruised and he knew that the New Hampshire medical examiner had conducted an autopsy, but he had not seen the DHHS report or the autopsy. Under New Hampshire law, medical examiner’s reports are private documents that can only be requested by the family of the deceased.

“They said she got bruised but they didn’t know how,” he said in a Tuesday phone interview.

According to the DHHS report, the New Hampshire medical examiner conducted an autopsy on a resident who died at the facility in early January and found that person — who was identified only as "Resident #2" — “had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death.”

A licensed nursing assistant told investigators on Jan. 6 that an employee, identified as Staff F, had been “rough” with Resident #2 during a transfer, had placed hoyer lift pad incorrectly and pulled it out from under the resident so that the resident hit a railing.

That incident occurred some two-and-a-half months before the employee spoke with investigators, but the licensed nursing assistant told investigators that they had reported it to a nurse on duty.

On Dec. 27, a licensed nursing assistant reported that the resident had decreased arm strength and had bruising on their arms, according to nurse’s notes reviewed by investigators in early January.

By Jan. 1, the resident had 10 out of 10 levels of pain as evidenced by “facial grimacing, contraction of upper extremities, and increase respirations with holding of breath” and the bruising had worsened.

On Jan. 2 at 7:12 a.m., the resident received Tylenol with “no effect,” a nurse’s note said.

Later that morning, in consultation with the patient’s power of attorney, the doctor on-call ordered oxycodone for the resident, who was resting in bed but expressed 10 out of 10 pain when staff tried to reposition their right arm.

At that point, the notes included in the DHHS report indicate the resident was at the end of life and “bruising has spread (due) to poor circulation”.

On Jan. 5, Staff F was “suspended pending investigation” following a report of alleged abuse.

The DHHS report also includes allegations of abuse against other residents at the facility. In four out of six such cases, including the resident who died, the report found the facility “failed to develop and implement the facility’s abuse policy.”

In one case a resident had a bruise on their right eye, which a staff member reported may have been caused by the resident bumping their head on the crossbar of the hoyer lift. In another case, Staff F was alleged by a coworker to have hit a resident with an open hand on the resident’s abdomen.

A different resident alleged that a licensed nursing assistant “slapped his buttocks, smacked them with plastic bags, and laughed about it.” That resident said he told the licensed nursing assistant, “I wish to die if I am going to be beat,” and he alleged that the licensed nursing assistant responded, “I wish you would die too.” In a subsequent interview with the facility’s social worker, however, the resident voiced “no complaints”.

Another resident sought help with their ostomy bag at 1 a.m. on Dec. 28, but a licensed nursing assistant told the resident they were the only person there and that they would come back. The resident fell asleep waiting for assistance and woke up again at 7 a.m. with feces on their bed and their abdomen from the leaking ostomy bag. The licensed nursing assistant working the day shift helped clean the resident.

The report found fault with the facility’s reporting of these allegations of abuse and neglect.

The report also found that the facility failed to provide sufficient staff for the evening and night shift for 11 days out of the four weeks of nursing schedules the state investigators reviewed. On several nights in late December, the facility had one licensed practical nurse covering the whole facility, which had between 60 and 64 residents at the time.

In response to the survey, the facility has implemented a plan of correction, including interviewing, checking the skin of and the records of current residents to look for evidence of abuse, according to its response to the DHHS inspection. Instances of potential abuse or neglect have been investigated and reported by the director of nursing.

In addition, employees have received training in how to implement the facility’s abuse policy. The facility also has held staff meetings and a resident council meeting on the topic of abuse prevention.

As part of Hanover Terrace’s morning clinical meeting, there is now a review of any reports that might trigger the abuse policy. Residents now receive weekly skin checks for bruises and the facility maintains a log of reports that may be related to abuse or neglect. The administrator, Martha Ilsley who took leadership of the facility on Feb. 27, is responsible for conducting a weekly audit of accident and incident reports.

The facility, which is licensed for 100 beds, has a census of 57 in response to staffing challenges, she said.

Ilsley’s leadership of the facility marks a return for her. She previously held its reins before departing to lead the Lebanon Center Genesis facility last May. Under her previous tenure as Hanover Terrace’s administrator, which began in 2016, the nursing home was removed from a CMS list of “special focus” facilities, a list of facilities with a history of serious quality issues. In 2019, Bear Mountain Healthcare, based in Thomaston, Conn., purchased the facility from NSL Holdings, a limited liability company with ties to Great Neck, N.Y., and Massachusetts that had owned the property since May 2016.

Hanover Terrace had gone three years without being cited for a deficiency, according to its website. But it now has only one star on the CMS website. The ratings system is based on health inspections, staffing and quality metrics.

“It’s sad and we all feel badly,” Ilsley said in a Tuesday phone interview of the deficiencies included in the DHHS report. “We want to do everything we can do to be sure that something like this never happens again.”

These articles are being shared by partners in The Granite State News Collaborative. For more information

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