Mary Hitchcock Memorial Hospital
An acute care hospital in Lebanon, New Hampshire 03756
1 Medical Center Drive, Lebanon, New Hampshire 03756. (603) 650-5000.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 1 deficiency cited in the last three years
- 396 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Apr 14, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Apr 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 14, 2026: complaint inspection1 deficiency
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Patient Rights: Care In Safe Setting
The inspectors’ words, 984 words
“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 43002 Based on observation, interview, and record review, the hospital failed to ensure that patients received care in a safe enviornment by not following their policy for transitioning patients off secured units for 3 of 5 patients reviewed for elopement and 3 of 4 observations of staff transitioning unknown patients off secured units. (Patient identifiers are #1, #2 and #3). Findings include: Interview on 4/13/26 at 8:55 a.m. with Staff F (Risk Manager) revealed that on 4/7/26 at around 3:15 p.m. Staff A (Registered Nurse (RN)) was transitioning Patients #1, #2, and #3 off the secured Lincoln Unit (Adolescent Specialty Unit) due to a behavioral event happening on the unit. Staff F revealed after exiting the secured doors, Patients #1 and #2 ran towards an unlocked exterior door into an enclosed gated recreation area, climbed up the chain-link fence and onto the facility roof. Staff monitored Resident #1 and #2 until local police and fire could safely remove them from the roof. Patient #3 was placed in a physical hold by Staff A before they could exit the building. Interview on 4/13/26 at 12:00 p.m. with Staff A confirmed the above and that he/she transitioned the three patients off the unit with no other staff members. Interview on 4/13/26 at 12:40 p.m. with Staff B (RN Team Lead) revealed that on 4/7/26 he/she was on their way to the Lincoln Unit when they saw Staff A transitioning Patients #1, #2 and #3 off the unit. Staff B stated their policy was to have a minimum of two staff when transitioning patients to and from a secured unit, one staff in both the front and back of the line. Review on 4/13/26 of Patient #1’s Nursing Progress Note dated 4/7/26 evening shift revealed, “... Self-Injurious Behavior: Yes... Pt [patient] reports finding knife on roof of building and using it to cut arm. Superficial cuts noted to outer and inner forearm. Pt denies continued thoughts of SIB [Self-Injurious Behavior] at this time... Narrative: Pt eloped with peer at start of shift. Pt and peer reached roof of hospital and was observed from hospital windows, running across the rooftop. Law enforcement officers on premise to aid in the return of the patient into the building. Pt escorted by two law enforcement officers back into the building... Pt noted to have superficial cuts to outer and inner L [left] forearm...” Review on 4/13/26 of Patient #2’s Nursing Progress Note dated 4/7/26 Evening shift revealed, “... Self-Injurious Behavior: Yes, superficial scratches, no open areas or treatment required... At start of shift, inciting peers to elope and not let staff on or off unit, formed human chain, singing inappropriate sexualized rhymes, when a peer was being separated, pt [patient] and other staff tried joining in, pt and peers being taken off unit to room 75 [a classroom off the unit] where patient planned with 2 other peers to elope. Patient ended up on roof with another peer. It took police/fire to retrieve patient...” Review on 4/13/26 of Patient #3’s medical record revealed on 4/7/26 that Patient #3 attempted to elope but was stopped by staff before exiting the building. Interview on 4/14/26 at 9:55 a.m. with Staff C (Staff Development) confirmed when transitioning patients there should be two staff and a walkie-talkie should be used to communicate before and after transitioning. Interview on 4/14/26 at 10:06 a.m. with Staff A revealed their practice was to transition up to three patients by themselves to the classroom area depending on the patient’s behaviors. Staff A revealed that they would use the walkie-talkie to notify staff before transitioning a patient off the unit. Staff A confirmed they did not use the walkie-talkie on 4/7/26 when transitioning the above 3 patients off the unit. Observation on 4/14/26 at approximately 8:05 a.m. revealed an unknown staff member, with no other staff members, transitioning an unknown patient off the secured Washington Unit (Children’s Specialty Unit) to a classroom down the hall. Observation and interview on 4/14/26 at 10:50 a.m. with Staff D (Compliance Officer) of the unsecured hallway outside of Lincoln Unit revealed an unknown staff, with no other staff members, and an unknown patient transition off the Lincoln Unit and walk down the hallway and turn the corner. Further observation of this unsecured hallway revealed another unknown staff member, with no other staff members, with an unknown patient transitioning towards the Lincoln Unit and enter a classroom. Staff D confirmed they witnessed the above and revealed the first staff was a social worker and the second was a provider. Staff D stated providers, including social workers, transition patients alone. Interview with Staff E (Counselor Educator) revealed that there was education after the elopement (starting 4/10/26) regarding transitioning patients off of secured units. Review on 4/13/26 of the hospital’s policy titled “Patient Safety Checks” approved on 3/26/26 revealed, “... I. Purpose of Policy To ensure the safety of every patient admitted... Transitioning... 1. When transitioning patients from one location to another: a. Staff leaving one location with patients shall take a head count of the group and report the number of patients they are leaving with to staff on unit via walkie [talkie]. b. Staff on the unit shall confirm via walkie that they have accounted for the remaining number of patients. c. When traveling off unit with patients, staff must always be present at the front and end of the line...” Interview on 4/14/26 at 12:00 p.m. with Staff D confirmed the policy did not define the number of staff to patients when transitioning, if one staff could transition one patient, or state that clinicians/providers did not need two staff to transition patients off secured units. Staff D was unable to provide any additional policy for transitioning.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 14, 2026 | Complaint inspection | 1 deficiency cited |
| Feb 22, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 1 better and 1 worse of 8; safety of care, 4 better and 0 worse of 8; readmission, 1 better and 2 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (1,796 surveys completed, Oct 1, 2024 to Sep 30, 2025): 73% rated it 9 or 10 out of 10, and 79% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, worse than the national benchmark; surgical site infections after abdominal hysterectomy, worse than the national benchmark; MRSA bloodstream infections, better than the national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.3%, heart failure 10.4%, pneumonia 13.9%, COPD 7%, stroke 12.5%, heart bypass surgery 2.1%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.8%, heart failure 21.1%, pneumonia 18.7%, COPD 20%, heart bypass surgery 12.2%, hip or knee replacement 5.1%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, worse than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, worse than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 264 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 57% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1.02 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 96% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 32 owners or officers are people: Duane M Compton (corporate director, 0%); Roberta L Hines (corporate director, 0%); Kimberly Mender (corporate director, 0%); Kimberly Mender (managing employee (on the payroll), 0%); Jason T Garbarino (corporate director); Jonathan B Thyng (corporate director, 0%); Laurel J Richie (corporate director); David Paul (corporate director, 0%); Daniel P Jantzen (corporate officer, 0%); Jennifer Moyer (corporate director, 0%); Joanne Conroy (corporate officer, 0%); Joanne Conroy (managing employee (on the payroll)); Geraldine D. Bednash (corporate director, 0%); Celestina Dooley-Jones (corporate director, 0%); Tegan Deogburn (corporate director, 0%); Tegan Deogburn (managing employee (on the payroll)); Keith J Loud (corporate director); Patricia Drew (corporate director); Patricia Drew (runs it (operational or managerial control)); Wendy Fielding (corporate officer); Emily Phyllis Zeitler (corporate director); Mark Speers (corporate director, 0%); Laura M Chiang (corporate director); John Muhlen (corporate director); John Muhlen (managing employee (on the payroll)); Sherri C Oberg (corporate director, 0%); Barbara Moore (managing employee (under contract), 0%); Barbara Moore (corporate director, 0%); Nancy M Dunbar (corporate director, 0%); Marcus P Coe (corporate director, 0%); Gary V Desir (corporate director, 0%); Mary Elyse Allan (corporate director, 0%).
- CMS’s Provider of Services file records 3 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 5 hospitals CMS lists in Grafton County, 5 have an overall star rating from CMS: 2 rated 4 of 5, 2 rated 3 of 5, 1 rated 1 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Cottage Hospital | 4 |
| Littleton Regional Healthcare | 1 |
| Alice Peck Day Memorial Hospital | 4 |
| Speare Memorial Hospital | 3 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.