Goffstown Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Goffstown, New Hampshire.
- Location
- 29 Center Street, Goffstown, New Hampshire 03045
- CMS Provider Number
- 305096
- Inspections on file
- 20
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Goffstown Nursing And Rehab Center during CMS and state inspections, most recent first.
Residents were unable to access their personal funds during evenings and weekends because staff did not have access to petty cash outside of regular business hours, despite facility policy stating such access should be available.
The facility did not submit complete and accurate direct care staffing information to CMS for Fiscal Quarter 3, 2024. A review of the Payroll Based Journal Staffing Data Report showed the data was missing, which was confirmed by the Business Office Manager.
The facility did not have an RN on duty for 8 consecutive hours on three separate days, as required. This was confirmed by the scheduler and the DON, who was on call but not physically present during these times.
The facility did not follow antibiotic use protocols, failing to monitor, track, and review antibiotic use for 9 out of 12 months. From November 2023 to May 2024 and September 2024 to present, there was no documentation of antibiotic tracking. The Infection Prevention staff confirmed the lack of monitoring, and the facility's policy on Antibiotic Stewardship was not adhered to, resulting in the deficiency.
The facility failed to maintain a hoyer lift according to the manufacturer's instructions, as revealed by interviews with staff and a review of the lift's manual. The Maintenance Director admitted to not performing routine inspections or maintenance, and LNAs reported difficulties in maneuvering the lift. The manual specified regular inspections and maintenance, which were not conducted, leading to the deficiency.
A resident fell during a mechanical lift transfer, bumping their head, but the incident was not reported to the SSA as required. The facility's Administrator was unaware of the event until it was highlighted during an interview, and no investigation documentation was available.
A resident fell from a hoyer lift during a transfer, resulting in a slight head bump. The incident was reported to the DON, but the facility failed to investigate or document the event, contrary to its policy requiring thorough investigation and documentation of accidents.
A resident fell and hit their head during a transfer with a hoyer lift, but the facility failed to perform the required neurological assessments. Despite obtaining an order for 72-hour neuro checks, there was no documentation of these assessments being conducted, as confirmed by the facility's administrator. This oversight violated the facility's policy for monitoring residents with head injuries.
A facility failed to identify trauma triggers for a resident with PTSD, potentially leading to re-traumatization. Despite a care plan addressing behaviors like crying and withdrawal, no specific triggers were identified in the resident's records, including the Generations Psychiatry Progress Note and Social Services assessment. Behavior monitoring showed the resident exhibited behaviors such as grouchy, swearing, and shrieking when moved. The facility's administrator confirmed the lack of identified PTSD triggers.
A facility failed to document a Gradual Dose Reduction (GDR) or its clinical contraindication for a resident on Seroquel. Despite a recommendation for GDR by a Pharmacy Consultant, the provider declined without documenting clinical appropriateness. The last GDR attempt was in 2021, and no recent documentation supported the continued dosage. The DON confirmed the lack of documentation.
A facility failed to follow CDC guidance for PPE under Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. There was no signage or PPE provided, and an LNA provided care without PPE, unaware of the EBP status. The resident had orders for a urinary catheter, EBP, and Ciprofloxacin for a UTI. Interviews confirmed the resident was not on EBP.
The facility failed to provide two residents with the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for services not covered by Medicare. Both residents were discharged from Medicare services but remained in the facility without receiving the required SNF ABN Form CMS-10055 notice. The Director of Social Services confirmed the oversight during an interview.
Failure to Provide Resident Access to Personal Funds During Off-Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds during off business hours. Review of the facility's Resident Petty Cash Policy indicated that procedures were in place to allow residents access to their funds during evenings and weekends through designated staff such as charge nurses or supervisors. However, interview with the Business Office Manager revealed that, in practice, residents could only request cash during regular business hours, as staff did not have access to the facility's petty cash during evenings or weekends. This resulted in residents being unable to access their personal funds outside of standard business hours, despite the facility managing personal accounts for 25 residents.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for Fiscal Quarter 3, covering the period from April 1, 2024, to June 30, 2024. A review conducted on October 20, 2024, of the facility's Payroll Based Journal Staffing Data Report for this quarter revealed that the data was not submitted. This finding was confirmed during an interview on October 22, 2024, with the Business Office Manager, Staff F.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for 3 out of 30 days reviewed between September 15, 2024, and October 20, 2024. Specifically, on September 15, September 28, and October 13, 2024, there were no RN hours documented as worked. This was confirmed through interviews with the facility's scheduler and the Director of Nursing (DON). The DON stated that he/she was on call every other weekend when there was no RN working but was not physically present in the building for the required 8 consecutive hours.
Failure to Monitor and Track Antibiotic Use
Penalty
Summary
The facility failed to adhere to antibiotic use protocols by not implementing a system to monitor, track, and review antibiotic use for 9 out of 12 months reviewed. Specifically, from November 2023 through May 2024 and again from September 2024 to the present, there was no documentation of antibiotic tracking. An interview with the Infection Prevention staff confirmed the absence of monitoring and tracking, including documentation that antibiotics met criteria for use. The facility's policy on Infection Control - Antibiotic Stewardship, revised in February 2022, outlines the need for an Antibiotic Stewardship Program (ASP) team to be accountable for reviewing infections, monitoring antibiotic usage patterns, and reporting on antibiotic prescriptions and residents treated each month. However, these procedures were not followed, leading to the deficiency.
Failure to Maintain Hoyer Lift as per Manufacturer's Instructions
Penalty
Summary
The facility failed to maintain resident care equipment according to the manufacturer's instructions for the hoyer lift. During an interview, the Maintenance Director, Staff J, admitted that the legs on the hoyer lift were difficult to open and that no routine inspections or maintenance had been performed on the lift since their employment began four months ago. Staff J also confirmed the absence of any documentation indicating that the hoyer lift had been maintained, inspected, or repaired at any time, despite the lift being over a year old and requiring routine inspection and maintenance. Further interviews with two Licensed Nursing Assistants (LNAs), Staff K and Staff L, revealed that the hoyer lift was difficult to maneuver and wobbly when in use with a resident. A review of the hoyer lift manual indicated that after the first year of use, specific components of the lift should be inspected every three to six months for wear and tightness, with replacements made if necessary. Additionally, the manual specified that for institutional use, the lift and all components should be inspected or adjusted monthly. The facility's failure to adhere to these maintenance guidelines led to the deficiency.
Failure to Report Resident Fall Incident
Penalty
Summary
The facility failed to report an alleged violation of neglect to the State Survey Agency (SSA) concerning a resident who experienced a fall during a mechanical lift transfer. The incident occurred when the resident was being transferred from a wheelchair to a bed using a hoyer lift, resulting in the resident being lowered to the floor after bumping their head against a window sill. Despite the incident being documented in the resident's medical record, the facility's Administrator was unaware of the event until it was brought to their attention during an interview. The facility's policy requires the Administrator and/or Director of Nursing to ensure state reporting occurs within required time frames, but no documentation of an investigation or report to the SSA was provided.
Failure to Investigate Resident Fall from Hoyer Lift
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of neglect involving a resident who fell from a hoyer lift. The incident occurred approximately six weeks prior to the surveyor's interview with the resident, who reported falling during a mechanical lift transfer. The resident's medical record included a provider note indicating that the resident had an accidental fall during a transfer, resulting in a slight bump to the head. However, the facility's administrator was unaware of the incident and could not provide documentation of an investigation. Further interviews revealed that a Licensed Nursing Assistant and another staff member were involved in the transfer when the resident began flailing, causing the lift to tip. The staff reported the incident to the Director of Nursing, who was present at the time, but no written statement was requested from the staff involved. The facility's policy requires that all accidents and incidents be reviewed and investigated by the Administrator, DON, or designee, including conducting witness interviews and documenting the root cause. The lack of documentation and investigation indicates a failure to adhere to these policies.
Failure to Perform Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to perform neurological assessments after a resident fell and hit their head. This deficiency was identified for one out of three residents reviewed for falls in a sample of 15 residents. The incident involved a resident who fell while being transferred with a hoyer lift, resulting in a head injury. Although the provider was notified and an order was obtained to conduct neurological checks for 72 hours, there was no electronic documentation indicating that these assessments were performed. An interview with the facility's administrator confirmed the absence of documentation for the required neurological assessments following the fall. The facility's policy mandates that residents with head injuries be observed for neurological abnormalities, but this was not adhered to in this case.
Failure to Identify PTSD Triggers for a Resident
Penalty
Summary
The facility failed to identify trauma triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), which could potentially lead to re-traumatization. The resident's diagnosis of PTSD was confirmed through a record review, and the Minimum Data Set Assessment indicated PTSD as a current diagnosis. Despite having a care plan for behaviors such as crying, withdrawal, and lack of appetite associated with PTSD, no specific triggers were identified. Additionally, the Generations Psychiatry Progress Note and Social Services assessment did not list any PTSD triggers. Behavior monitoring records showed the resident exhibited behaviors like grouchy, swearing, and shrieking when moved. An interview with the facility's administrator confirmed the absence of identified PTSD triggers for the resident.
Failure to Document Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident taking psychotropic medication received a Gradual Dose Reduction (GDR) or documented if the GDR was clinically contraindicated. The resident was prescribed Seroquel 50 mg, to be taken three times a day. A Pharmacy Consultant Report recommended a GDR for the Seroquel, but the provider declined the recommendation without providing documentation of continued clinical appropriateness. The Generations Geriatric Psychiatry Progress Note indicated that the last GDR attempt was in May 2021, and suggested considering a medication decrease in the future, but did not document the clinical appropriateness of continuing the current dosage. The Director of Nursing confirmed the absence of documentation for a GDR attempt or its clinical contraindication.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to CDC guidance for wearing Personal Protective Equipment (PPE) under Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. During an observation, it was noted that there was no signage indicating the resident was on EBP, nor was PPE provided for care. A Licensed Nursing Assistant (LNA) was observed performing care without PPE. The LNA later confirmed they were unaware of the EBP status. A review of the resident's active orders showed an order for a urinary catheter and EBP, as well as an order for Ciprofloxacin for a Urinary Tract Infection (UTI). Interviews with the Director of Nursing and Infection Prevention staff confirmed the resident was not on EBP.
Failure to Provide SNF ABN Notices to Residents
Penalty
Summary
The facility failed to inform two residents and/or their representatives about the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for services not covered by Medicare. Resident #135 was discharged from Medicare services on June 28, 2024, but remained in the facility without receiving the SNF ABN Form CMS-10055 notice prior to the discharge from Medicare Part A services. Similarly, Resident #136 was discharged from Medicare services on May 3, 2024, and also remained in the facility without receiving the required notice. An interview with the Director of Social Services confirmed that the SNF ABN Form CMS-10055 was not completed for these residents. This oversight was identified during a review conducted on October 20, 2024, which highlighted the facility's failure to ensure proper notification regarding potential liability for services not covered by Medicare.
Latest citations in New Hampshire
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency as required by its abuse policy. In one case, an LNA was seen holding a resident off the ground with the resident’s back against the LNA’s chest while moving the resident. In another case, a resident was found with unexplained facial scratches and blood, which was reported internally but not to the state. In a third incident, an RN observed an LNA yelling at a resident to get into bed and then picking the resident up from the floor and forcefully placing the resident onto the bed. In each situation, leadership, including the Administrator and DON, were informed, but the allegations were not reported to the state within the required timeframes.
Two residents were involved in separate alleged abuse incidents by the same LNA that were not investigated as required by facility policy. In one case, an LNA reported witnessing another LNA hold a resident with the resident’s back against the LNA’s chest and the resident’s feet off the ground while being moved. In the other case, an RN reported seeing a resident screaming beside the bed while an LNA yelled at the resident to get into bed, then picked the resident up off the floor and forcefully placed the resident onto the bed. The administrator and DON acknowledged being informed of these allegations but did not initiate investigations or remove the alleged perpetrator from duty, contrary to the facility’s abuse, neglect, and exploitation policy that mandates immediate, thorough investigation and documentation of all alleged violations.
A resident was manually restrained and moved by an LNA, who held the resident from behind with the resident’s back against the LNA’s chest and feet off the ground after the resident reportedly became combative and struck the LNA. Another LNA witnessed the incident and later reported it. Review of the medical record showed no documentation of behaviors or use of a manual restraint around the time of the incident, no related entries on the Treatment Administration Report, and no care plan interventions for manual behavior management. The DON confirmed these findings and that the facility lacked a policy governing the use of manual physical restraints.
The facility failed to follow its abuse, neglect, and exploitation policy by not promptly investigating or reporting multiple abuse-related incidents to the SSA. In one case, an LNA was observed holding a resident off the ground while moving the resident; in another, an RN reported that an LNA yelled at a resident and then picked the resident up from the floor and forcefully placed the resident in bed. A separate resident was found with facial scratches and blood of unknown origin, and this was reported internally but not to the SSA. Additionally, the LNA involved lacked a documented criminal background check, and several staff members had not received the required annual abuse-prevention education, despite policy requirements for pre-employment screening and ongoing staff training.
A resident developed new LUE swelling and was evaluated by a PA, who noted edema with minimal erythema, warmth, and tenderness, and arranged an emergent hospital transfer to rule out DVT. The hospital identified a closed radial head (elbow) fracture, and an RN received a verbal report from the ED about the fracture before the resident returned. Despite this information and a written policy requiring investigation and timely reporting of injuries of unknown source to state and local authorities, including submission of findings within five working days, the DON acknowledged that no report was made to the State Survey Agency for this fracture.
A resident developed new LUE swelling and was evaluated by a PA, who noted edema with slight tenderness and concern for possible DVT, leading to an emergent hospital transfer. Hospital records showed a closed radial head (elbow) fracture, but the DON reported that no investigation was conducted into the cause of this injury. This failure occurred despite a facility policy requiring that injuries of unknown source be entered into the risk management system and investigated within 24 hours to determine whether abuse or neglect occurred and to identify causative factors.
A resident with severe hypoalbuminemia developed new LUE swelling and was emergently transferred to the hospital for evaluation of possible DVT, where an elbow fracture with radial head fracture was diagnosed. Review of the medical record showed that no Notice of Transfer/Discharge or bed-hold notification was completed or filed for this unplanned, acute hospital transfer, despite facility policy requiring verbal and written notification to the resident and representative and placement of the completed transfer form in the chart. The DON confirmed that the required transfer notice was not provided.
A resident with LUE swelling was evaluated by a PA, who documented concern for possible DVT and arranged an emergent hospital transfer; the hospital later diagnosed a closed radial head (elbow) fracture and provided instructions for follow-up, arm elevation, and ice application. However, nursing staff did not document when the resident left for the hospital or when they returned, and there was no record of a post-return nursing assessment or review and implementation of hospital recommendations, contrary to the facility’s nursing documentation policy.
A resident admitted with a right groin wound did not receive physician-ordered wound care because no treatment orders were transcribed or implemented at admission. The wound went untreated for seven days, resulting in deterioration and subsequent hospitalization for surgical debridement.
Failure to Document Post-Fall Assessments and Vital Signs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not documenting required post-fall assessments for two residents. For Resident #1, a registered nurse (Staff C) reported that after a fall on 1/21/26, the resident was found on the floor leaning against the wall, complaining of head pain and groin pain. Staff C stated the resident had a lump on the back of the head and groin sensitivity, and that the resident was transferred from the floor to a chair with a licensed nursing assistant and then to bed with assistance from Staff B. Once in bed, the resident had increased right leg pain. Staff C acknowledged performing an assessment after the fall but did not document any of these findings in the medical record. Record review for Resident #1 showed a progress note by Staff B at 1:50 p.m. stating the resident was found on the floor complaining of severe pain in the right parietal scalp and right leg/hip/pelvis, unable to extend the leg due to pain, and that the provider was notified and the resident sent to the ER. An IDT note the following day stated the resident had a small abrasion on the right side of the head, a full body assessment was done with no other injuries noted, the resident would not extend the leg straight, and pain prevented assessment of the right lower extremity for shortening or rotation; x‑rays were ordered but not completed due to pain, and the resident was sent to the ER. Despite these narrative notes, there was no documentation of vital signs, no neurological checks, and no documentation by Staff C of the assessment performed while the resident was on the floor, even though the resident remained at the facility for approximately two hours before hospital transfer. The DON confirmed the absence of documented vital signs and neuro checks and stated the resident should not have been moved while complaining of pain. For Resident #2, the medical record contained a progress note dated 1/19/26 indicating the resident was found on the floor next to the bed, stated they did not want to wait for help, had no skin issues, and was moved from the floor to a wheelchair. An IDT note dated 1/20/26 documented that the resident had a fall in the room while trying to transfer from bed to chair, that no injuries were noted on a full body assessment by the unit manager, and that the resident was assisted back to bed. There were no additional progress notes or documentation of the resident’s assessment after the fall, and Staff B confirmed there was no documentation of the full body assessment referenced in the IDT note. Review of facility policies on assessing falls and accident/incident reporting showed that post-fall documentation was required to include assessment data, vital signs, obvious injuries, and the condition of the resident, which was not completed for these two residents.
Failure to Timely Report Multiple Alleged Abuse Incidents to State Agency
Penalty
Summary
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency (SSA) as required by its abuse, neglect, and exploitation policy. For one resident, a licensed nursing assistant (Staff D) reported witnessing another licensed nursing assistant (Staff C) holding the resident with the resident’s back against Staff C’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident occurred on or around January 1, 2026, but was not reported by Staff D until January 14, 2026. The Administrator (Staff A) confirmed awareness of this allegation as of January 14, 2026, and acknowledged that it was not reported to the SSA. For another resident, the Unit Manager (Staff I), who was on call, was notified on the night of November 19, 2025, that the resident was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. Staff I reported this to both the Administrator (Staff A) and the Director of Nursing (Staff B), and Staff A confirmed awareness of the incident on that date but did not report it to the SSA. In a separate incident involving a third resident, an email from an RN (Staff G) to the DON (Staff B) described observing the resident standing beside the bed screaming while an LNA (Staff C) yelled at the resident to get into bed; when the resident did not comply, Staff G observed Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed being informed of this incident on January 1, 2026, and Staff A confirmed that this allegation also was not reported to the SSA. These failures occurred despite a written facility policy requiring all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Investigate Alleged Abuse Incidents Involving Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that alleged violations of abuse were thoroughly investigated for two residents. For the first resident, a licensed nursing assistant (LNA), identified as Staff D, reported that he/she witnessed another LNA, identified as Staff C, holding the resident with the resident’s back against Staff C’s chest and arms around the resident, with the resident’s feet off the ground while being moved to another area. Staff D stated this incident occurred on or around January 1, 2026, and was reported on January 14, 2026. The Administrator, identified as Staff A, confirmed awareness of this incident as of January 14, 2026, and confirmed that the incident was not investigated. For the second resident, an email from a registered nurse (RN), identified as Staff G, to the Director of Nursing (DON), identified as Staff B, described an incident in which the RN opened the door to a resident’s room and observed the resident standing beside the bed screaming while LNA Staff C was yelling at the resident to get into bed. When the resident did not comply, the RN reported observing Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed receiving this email and stated that they did not remove Staff C from working and did not investigate the incident when notified. Review of the facility’s Abuse, Neglect and Exploitation policy showed that it requires an immediate investigation of any suspicion or report of abuse, including identifying responsible staff, preserving evidence, interviewing all involved persons, determining if abuse occurred, and providing complete documentation, which was not carried out in these cases.
Improper Use of Manual Physical Restraint Without Assessment or Care Plan
Penalty
Summary
The facility failed to ensure the appropriate use and documentation of a physical restraint for one resident when a staff member used a manual hold to control and move the resident without any corresponding assessment or care plan interventions. On or around January 1, 2026, a licensed nursing assistant (Staff C) reported that the resident had been combative and had struck Staff C in the nose and genitals, after which Staff C approached the resident from behind, put their arms around the resident’s shoulders, and moved the resident approximately four to five feet, with another licensed nursing assistant (Staff D) observing the resident’s back against Staff C’s chest, Staff C’s arms around the resident, and the resident’s feet off the ground while being moved. Staff C stated they believed the resident was a danger to self and others and that no one else wanted to intervene. Record review showed no progress notes around that date documenting behaviors or the use of a manual method to restrain the resident, no documented behaviors on the Treatment Administration Report from late December 2025 through mid-January 2026, and no care plan interventions addressing the use of a manual method for behavior management. The Director of Nursing confirmed these findings and also confirmed there was no facility policy for the use of physical restraint by manual method.
Failure to Report, Investigate, Screen, and Train Regarding Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy for reporting and investigating allegations of abuse, as well as failure to ensure required staff screening and abuse training. For one resident, a licensed nursing assistant (LNA) reported witnessing another LNA holding the resident with the resident’s back against the staff member’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident reportedly occurred on or around January 1, 2026, but was not reported by the witness until January 14, 2026. The administrator confirmed awareness of the allegation as of that date and acknowledged that the allegation was neither investigated nor reported to the State Survey Agency (SSA), contrary to the facility’s written abuse policy requiring immediate investigation and timely reporting. A second allegation involved another resident, where an RN emailed the DON describing an event in which the RN opened a resident’s room door and observed the resident standing beside the bed screaming while an LNA yelled at the resident to get into bed. When the resident did not comply, the RN reported that the LNA picked the resident up off the floor and forcefully placed the resident onto the bed. The DON confirmed being notified of this incident on the date it occurred and acknowledged that the incident was not investigated and not reported to the SSA, despite the facility’s policy requiring immediate investigation and reporting of alleged abuse within specified timeframes. A third incident involved a resident who was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. The unit manager, who was on call, reported this to both the administrator and the DON. The administrator confirmed that this incident, involving injuries of unknown origin, was not reported to the SSA. In addition, review of the human resources file for the LNA implicated in the above allegations showed no criminal background check, despite the facility’s policy requiring background, reference, and credential checks for potential employees and documentation that screening occurred. Review of staff education files for multiple staff members showed that required annual abuse education had not been provided since 2021 or 2023, contrary to the facility’s policy that existing staff receive annual training on abuse prohibition, recognition, and reporting.
Failure to Report Injury of Unknown Source to State Survey Agency
Penalty
Summary
The facility failed to report an injury of unknown source to the State Survey Agency as required by its abuse prohibition policy. A resident was evaluated on-site by a physician assistant for new left upper extremity (LUE) swelling, with findings of edema, minimal erythema/warmth, slight tenderness, and concern for possible LUE deep vein thrombosis (DVT). The provider documented that the swelling was most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident’s report of sleeping on the left side, and ordered an emergent transfer to the hospital for a Doppler study to rule out DVT. Hospital documentation for that visit identified a closed fracture of the radial head (elbow fracture). A registered nurse reported receiving a phone call and verbal report from the hospital emergency room, prior to the resident’s return, that the resident had a fracture. The DON confirmed that the facility did not submit a report to the State Survey Agency for this elbow fracture, which constituted an injury of unknown origin. Review of the facility’s Abuse Prohibition policy showed that injuries of unknown source are to be investigated and reported to appropriate state and local authorities, including reporting allegations involving neglect, exploitation, or mistreatment (including injuries of unknown source) within specified time frames, and reporting findings of completed investigations within five working days, which did not occur in this case.
Failure to Investigate Injury of Unknown Source After Elbow Fracture
Penalty
Summary
The facility failed to investigate an injury of unknown source for a resident who was evaluated for left upper extremity (LUE) swelling. On 12/8/25, a progress note by a physician assistant documented that nursing had requested an evaluation for new LUE edema. The assessment indicated swelling most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident’s report of sleeping on the left side, with some non-pitting swelling, minimal erythema/warmth, and slight tenderness. Although cellulitis was doubted, there was concern for a possible LUE DVT, and the resident was transferred emergently to the hospital for a Doppler study to rule out DVT. Hospital documentation from the same date showed the resident was diagnosed with a closed fracture of the radial head (elbow fracture). During an interview, the DON stated that the facility did not conduct an investigation regarding this elbow fracture. This inaction occurred despite the facility’s Abuse Prohibition policy, which requires that injuries of unknown source be investigated to determine if abuse or neglect is suspected, that allegations be entered into the facility’s risk management portal, and that an investigation be initiated within 24 hours focusing on whether abuse or neglect occurred, causative factors, and interventions to prevent further injury, with thorough documentation of the investigation and interviews in the risk management system.
Failure to Provide Required Hospital Transfer and Bed-Hold Notice
Penalty
Summary
The facility failed to provide required notice of transfer and bed-hold to a resident or the resident’s representative when the resident was sent to the hospital. Record review showed that the resident was evaluated on 12/8/25 by a physician assistant for new left upper extremity (LUE) swelling, with findings most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident sleeping on the left side. Due to concern for possible LUE deep vein thrombosis (DVT), the provider ordered an emergent transfer to the hospital for a Doppler study to rule out DVT. Hospital documentation indicated that the resident was seen for a closed fracture of the radial head and elbow fracture. Review of the resident’s medical record revealed that no Notice of Transfer/Discharge was completed for this hospital transfer. The Director of Nursing confirmed that the notice was not provided. The facility’s own “Discharge and Transfer” policy, revised 6/11/25, states that for unplanned, acute transfers, the patient and representative will be notified verbally prior to transfer, followed by written notification using the Notice of Hospital Transfer or state-specific form, and that a copy of this form will be placed in the medical record; this documentation was absent for the resident’s transfer.
Incomplete Documentation of Hospital Transfer and Return
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for one resident related to an episode of left upper extremity (LUE) swelling and subsequent hospital transfer. On 12/8/25 at 11:26 a.m., a progress note by a physician assistant documented that nursing had requested an evaluation for LUE swelling. The assessment indicated new LUE edema, thought most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident sleeping on the left side, but also noted minimal erythema, warmth, slight tenderness, and concern for possible LUE DVT, leading to a decision to transfer the resident emergently to the hospital for a Doppler study. Hospital documentation dated 12/8/25 at 11:02 a.m. showed the resident was seen for a closed fracture of the radial head (elbow fracture) with instructions for orthopedic and family medicine follow-up in two days, arm elevation, and use of ice packs. Despite this episode of care, the resident’s medical record lacked nursing documentation of when the resident was transferred to the hospital and when they returned. Upon the resident’s return, there was no documentation that the resident was assessed or that the hospital’s recommendations were reviewed or implemented. The only hospital paperwork in the record was the Patient Visit Information summarizing the diagnosis and basic follow-up instructions, with no additional hospital documents present. The DON confirmed there was no nursing documentation regarding the emergency room visit or return on 12/8/25. These omissions were inconsistent with the facility’s Nursing Documentation policy, which requires timely entries specifying patient status, nursing assessments, interventions, and all relevant patient information to be documented or entered in the clinical record following established guidelines.
Failure to Obtain and Implement Admission Orders for Wound Care
Penalty
Summary
A deficiency occurred when a resident was admitted with a puncture wound to the right groin, but no physician's orders for wound treatment were obtained at the time of admission. The resident's clinical admission assessment documented the presence of the wound, and the hospital discharge summary included instructions for daily wound care. However, a review of the admission orders and the Treatment Administration Record (TAR) showed that no wound treatment orders were transcribed or carried out for the right groin wound. As a result, the resident went seven days without any wound treatment after admission. During a vascular surgery follow-up appointment, it was noted that the dressing had not been changed, and the wound had deteriorated, showing signs of dehiscence, maceration, slough, and seroma drainage. This led to the resident being hospitalized for surgical debridement. The Director of Nursing confirmed that the wound had not been treated during this period.
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