Hackett Hill Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, New Hampshire.
- Location
- 191 Hackett Hill Road, Manchester, New Hampshire 03102
- CMS Provider Number
- 305038
- Inspections on file
- 17
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hackett Hill Healthcare Center during CMS and state inspections, most recent first.
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.
A wound nurse did not consistently perform hand hygiene or use required PPE during a dressing change for a resident on Enhanced Barrier Precautions. The nurse failed to clean hands between glove changes, did not perform hand hygiene after removing gloves and gown, and did not don a gown when returning to complete wound care, contrary to facility policy and CDC guidelines.
Two residents were prescribed psychotropic medications for anxiety without documented consent regarding the risks and benefits of these medications, as required by facility policy. This was confirmed by the Clinical Lead and through review of medical records.
Three residents experienced deficiencies in care when staff failed to follow professional standards: a LPN administered insulin based on an outdated CBG result, a resident received IV antibiotics without a specified infusion rate or proper labeling, and another resident had a dressing applied without a physician's order or date.
Staff failed to disinfect a glucometer between use on two residents during blood glucose testing and did not use required PPE, including a gown and face shield, when accessing a resident's PICC line. These actions were not in accordance with facility infection control policies and Enhanced Barrier Precautions.
A resident's CPAP machine components, including the head strap and tubing, were found to be discolored and in disrepair, with staff confirming that these parts had not been replaced since the resident's admission. This occurred despite orders and manufacturer instructions requiring regular replacement of deteriorated equipment.
Two residents who remained in the facility after Medicare coverage ended were not given written notice detailing the specific items, services, and associated charges for which they could be held financially responsible. Instead, the facility provided only a general 'Medicaid Rate' without itemizing costs, and this practice was confirmed by the Clinical Care Coordinator.
A hospice agency and facility failed to provide coordinated services for a resident, resulting in discrepancies between the care plan and actual services. The lack of communication and coordination led to missed hospice visits and unavailability of nursing assistants and volunteers.
The facility failed to maintain a medication error rate below 5%, with errors involving improper insulin administration for a resident and incorrect administration route for another resident's medication, resulting in a 10.34% error rate.
The facility failed to label open injectable medications according to manufacturer's instructions and did not monitor refrigeration temperatures daily for medication storage. Open Lantus Insulin Pen and Tuberculin Purified Derivative were found without open or expiration dates, and several days of temperature logs were missing.
A resident with Bilateral Hearing Loss did not receive necessary treatment after an audiology visit revealed excessive ear wax, making it difficult to determine the degree of hearing loss. Despite recommendations for a medical consult, no further treatment was provided.
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.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during a dressing change for a resident under Enhanced Barrier Precautions (EBP). The wound nurse performed hand hygiene and donned gloves and a gown before starting the dressing change. However, after removing the initial wound dressing, the nurse changed gloves without performing hand hygiene in between. Following wound cleansing, the nurse removed their gown and gloves, exited the room, and did not perform hand hygiene before retrieving additional supplies from the treatment cart. Upon returning to the resident's room, the nurse performed hand hygiene and donned gloves but did not put on a gown before applying treatment and a new dressing to the wound. These actions were confirmed by the nurse during an interview. Review of facility policies and CDC guidelines indicated that hand hygiene should be performed before donning gloves, immediately after glove removal, and that gowns and gloves are required for high-contact activities such as wound care under EBP.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform two residents or their representatives about the risks and benefits associated with the use of psychotropic medications. For one resident, a physician's order for Ativan (Lorazepam) was initiated for anxiety, but there was no documentation of consent for the medication's use. Similarly, another resident was prescribed Buspirone HCL for anxiety, and again, no documentation of consent was found in the medical record. These findings were confirmed by the Clinical Lead during an interview. Review of the facility's policy indicated that consent should be obtained when a medication is ordered for behavioral symptoms, but this was not followed in these cases.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to follow professional standards of care for three residents. For one resident, a LPN administered insulin based on a capillary blood glucose (CBG) result that was obtained by a nurse on the previous shift and recorded on a piece of paper, rather than performing the CBG immediately prior to insulin administration as required by the physician's sliding scale order. The nurse practitioner confirmed that CBGs should be performed closer to the time of administration or meals when using a sliding scale for insulin. For another resident, a review of physician orders for intravenous Ertapenem revealed that the order did not specify an infusion rate. Observation showed an IV bag in the resident's room with only a handwritten label and no pharmacy label or infusion rate indicated. Additionally, a third resident was found to have a dressing applied to the lower left thigh without a corresponding physician's order, and the dressing was undated. The nurse who applied the dressing confirmed that it was done without an order, and the treatment administration record did not show an active order for this intervention.
Failure to Follow Infection Control Policies for Glucometer Disinfection and PPE Use
Penalty
Summary
Staff failed to follow infection prevention and control policies in two separate instances. In the first instance, a Medication Nursing Assistant was observed moving between two residents' rooms to perform capillary blood glucose (CBG) testing without disinfecting the glucometer between uses. The staff member carried the glucometer and supplies in a cup but did not have cleaning or disinfecting wipes, and confirmed during interview that the device was not disinfected between residents, contrary to facility policy and manufacturer instructions which require cleaning with an EPA-approved disinfectant before and after each use. In the second instance, a Registered Nurse accessed a resident's Peripherally Inserted Central Catheter (PICC) line without wearing a face shield or protective gown, as required by the facility's infection control standards and Enhanced Barrier Precautions (EBP) policy. The nurse confirmed not using the required personal protective equipment (PPE), and the facility's Infection Preventionist also confirmed that PPE should have been worn during this procedure. The resident involved had a PICC line, which is considered an indwelling medical device, and the policy specifies the use of gown, gloves, and face protection for such care activities.
Failure to Maintain and Replace CPAP Equipment per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain patient care equipment according to the manufacturer's instructions for a resident receiving respiratory care. The resident reported that parts of their Continuous Positive Airway Pressure (CPAP) machine, specifically the headpiece, needed replacement and that no assistance had been provided. Observation confirmed that the head strap was discolored and in disrepair, and the tubing was yellowed. Staff interviews verified that the face mask, tubing, and headgear had not been changed since the resident's admission in July 2024. Review of the treatment order indicated that CPAP supplies were to be changed or cleaned per manufacturer’s instructions, and the manufacturer’s guidelines specified that visibly deteriorated components should be replaced. Despite this, the equipment had not been replaced as required.
Failure to Provide Written Notice of Charges After Medicare Coverage Ends
Penalty
Summary
The facility failed to provide written notice to residents and/or their representatives regarding the specific items and services offered, the charges for those services, and the amount of those charges when Medicare coverage ended and the residents remained in the facility. For two residents who were discharged from Medicare services but continued to reside in the facility, the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) did not include a detailed list of services and associated costs. Instead, the facility listed only the 'Medicaid Rate' as the per day/item or service charge, without specifying the actual services or their individual costs. Record reviews confirmed that both residents' SNF ABNs lacked the necessary information about potential financial liability for non-covered services. An interview with the Clinical Care Coordinator verified that it was standard practice to write 'Medicaid Rate' rather than providing an estimated cost breakdown for items and services. This omission resulted in residents and their representatives not being properly informed, in writing, about the facility's charges and their potential financial responsibility after Medicare coverage ended.
Failure to Provide Coordinated Hospice Services
Penalty
Summary
The hospice agency and the facility failed to provide collaborative services for a resident receiving hospice care. The resident's care plan indicated that hospice nursing was to be provided 2-3 times a week and as needed, along with other services such as social work and volunteer visits. However, the hospice plan of care showed a different frequency of visits, and the medical record only documented sporadic nursing visits with no notes from other hospice services. Interviews with staff revealed a lack of communication and coordination between the hospice agency and the facility, resulting in discrepancies between the care plans and the actual services provided. The facility's policy requires that hospice services meet professional standards and that a coordinated plan of care be established and agreed upon. However, the hospice liaison admitted there was no communication regarding visit schedules, and the hospice agency did not have nursing assistants or volunteers available for the resident. This lack of coordination and communication led to the failure to provide the necessary hospice services as outlined in the resident's care plan and the hospice plan of care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was not 5 percent or greater for two residents observed for medication administration. For Resident #24, a Licensed Practical Nurse (LPN) prepared and administered 16 units of Novolin N Insulin without following proper procedures. The LPN did not roll the insulin pen to ensure the correct dosage, did not prime the pen, and did not wait the required 5 seconds before removing the pen from the resident's abdomen. The resident's Medication Administration Record (MAR) confirmed the physician's order for 16 units of Novolin N Insulin and 81 mg of Aspirin for cardiac health. The manufacturer's instructions and the facility's procedure for insulin administration were not followed, as confirmed by the LPN during an interview. For Resident #41, another LPN administered Miralax Oral Powder through the resident's Jejunostomy tube, contrary to the physician's order to give it by mouth. The MAR confirmed the order for Miralax to be given orally for bowel management. The LPN confirmed the error during an interview. These errors contributed to a medication error rate of 10.34%, with 3 errors out of 29 medication administration opportunities.
Failure to Label and Monitor Medications Properly
Penalty
Summary
The facility failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions. During an observation of the Webster Street Medication Cart, an open Lantus Insulin Pen was found without an open or open expiration date. This finding was confirmed by a Registered Nurse. The manufacturer's instructions for the Lantus Insulin Pen specify that it should be discarded 28 days after opening. Additionally, an open vial of Tuberculin Purified Derivative was found in the Derryfield Medication Room without an open or open expiration date, which was also confirmed by a Registered Nurse. The manufacturer's instructions for this medication state that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency. The facility's policy requires that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer, which was not adhered to in these instances. Furthermore, the facility failed to monitor refrigeration temperatures daily for medication storage. A review of the medication refrigerator logs for March 2024 revealed missing temperature recordings on several dates. This was confirmed by a Registered Nurse. The facility's policy mandates that the temperature of medication storage areas be monitored at least once a day, which was not consistently followed. These deficiencies indicate lapses in the facility's adherence to its own policies and the manufacturer's instructions for medication storage and labeling.
Failure to Provide Treatment for Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident received treatment for hearing loss. The resident, who was very hard of hearing and had a medical diagnosis of Bilateral Hearing Loss, reported having wax in their ears. An audiology visit revealed that the degree of hearing loss could not be determined due to excessive wax in both ear canals. Although some wax was removed, the resident could not tolerate further cleaning, and a medical consult was needed for wax removal orders. Despite these findings, the resident had not received any treatment after the audiology consult.
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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