GOFFSTOWN NURSING AND REHAB CENTER
For profit - Individual
41 Beds
Independent
Data: November 2025
Trust Grade
20/100
#62 of 73 in NH
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Goffstown Nursing and Rehab Center has received a Trust Grade of F, indicating significant concerns about its care quality. Ranking #62 out of 73 facilities in New Hampshire places it in the bottom half, and #18 out of 21 in Hillsborough County means that only a few local options are better. While the facility is improving, having reduced issues from 20 in 2023 to 11 in 2024, it still faces serious concerns, such as not having a Registered Nurse on duty for eight hours a day on multiple occasions, which raises alarms about resident care. Although staffing turnover is at a commendable 0%, the facility has less RN coverage than 94% of facilities in the state, which is worrying, especially since they have had issues with tracking antibiotic use properly. On a positive note, they have not incurred any fines, but families should weigh these strengths against the significant weaknesses in care and oversight.
- Trust Score
- F
- In New Hampshire
- #62/73
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Hampshire facilities.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for New Hampshire. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Bottom 16%
No red flags
20 → 11 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 20 issues
2024: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below New Hampshire average (3.0)
Significant quality concerns identified by CMS
The Ugly 41 deficiencies on record
Oct 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to report alleged violations of neglect to the State Survey Agency (SSA) for 1 of 3 residents reviewed for falls in a f...
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Based on interview and record review, it was determined that the facility failed to report alleged violations of neglect to the State Survey Agency (SSA) for 1 of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26).
Findings include:
Interview on 10/20/24 at approximately 10:48 a.m. with Resident #26 revealed that Resident #26 had fell from the hoyer lift about six weeks ago.
Review on 10/22/24 of Resident #26's medical record revealed an Incident Note, entered 8/21/24, dated 8/20/24, that stated: .resident was being transferred from [pronoun omitted] wheelchair to [pronoun omitted] bed using a hoyer lift .More staff were called in for assistance and resident was lowered to the floor after moving the bed away and releasing the hoyer lift pad .
Review on 10/22/24 of Resident #26's medical record revealed a provider note, dated 8/23/24, that stated .nursing reported that 2 days ago, [pronoun omitted] had an accidental fall during a mechanical lift transfer and got between [pronoun omitted] bed and [pronoun omitted] window sill slightly bumping [pronoun omitted] head .
Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed that Staff A was not aware of the above incident until 10/22/24 and was unable to provide any documentation of an investigation to determine if it should have been reported to the SSA.
Review on 10/22/24 of facility policy titled, Accidents/Incidents Policy, dated 8/24/2024, revealed: .3. Reporting: D. The Administrator and/or DON (Director of Nursing) will verify that state reporting occurs within required time frames and via appropriate method of reporting .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 1 of 3 residents reviewed for falls in a ...
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Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 1 of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26).
Findings include:
Interview on 10/20/24 at approximately 10:48 a.m. with Resident #26 revealed that Resident #26 had fell from the hoyer lift about six weeks ago.
Review on 10/22/24 of Resident #26's medical record revealed a provider note, dated 8/23/24, that stated .nursing reported that 2 days ago, [pronoun omitted] had an accidental fall during a mechanical lift transfer and got between [pronoun omitted] bed and [pronoun omitted] window sill slightly bumping [pronoun omitted] head .
Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed Staff A was not aware of the incident and Staff A was unable to provide documentation of an investigation of the incident.
Interview on 10/22/24 at approximately 12:12 p.m. with Staff I (Licensed Nursing Assistant) revealed that he/she and another staff member were using the hoyer lift to transfer Resident #26 from Resident #26's wheelchair to their bed. The resident was flailing their arms and legs causing the hoyer lift to tip, and staff lowered Resident #26 to the floor. Staff I stated that the incident was reported to the Director of Nursing (DON), who was in the facility working on the unit at that time, but was not asked to provide a written statement of the incident.
Review on 10/22/24 of facility policy titled Accidents/Incidents Policy dated 8/24/2024, revealed .4. Follow-up/Investigation: B. The Administrator, DON, or designee will review all accident/incidents to determine if: i) Accidents/Incidents or allegations have been appropriately and timely reported; ii) Required documentation has been completed; iii) Accident/Incident has been investigated . D. When conducting an investigation, the Administrator, DON, or designee will: i) Make every effort to ascertain the cause of the accident/incident; ii) Initiate a timeline chronology . iv) Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident; v) Document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident . vii) Complete the investigation within five working days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to perform neurological assessments after a resident fell and hit their head for 1 out of 3 residents reviewed for fall...
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Based on interview and record review, it was determined that the facility failed to perform neurological assessments after a resident fell and hit their head for 1 out of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26).
Findings include:
Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20:
When a Fall Occurs
Step three: monitoring and reassessment. After the patient returns to bed, perform frequent neurologic and vital sign checks.
Interview on 10/20/24 at approximately 10:50 a.m. with Resident #26 revealed that Resident #26 had a fall when being transferred with the hoyer lift, resulting in Resident #26 hitting their head.
Review on 10/22/24 of Resident #26's medical record revealed an Incident note, dated 8/20/24, entered 8/21/24, that stated .Provider got notified and order was obtained to do neuro [neurological] checks for 72 hours . Further review revealed no electronic documentation indicating neurological assessments had been performed.
Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed Staff A was unable to provide any documentation indicating neurological assessments had been performed following the fall on 8/20/24.
Review on 10/22/24 of the facility's policy, Accidents/Incidents Policy, dated 8/27/24, revealed: .Evaluation/Assessment, Medical Assistance, Documentation: .v) The physician/APP (Advanced Practice Provider) will be notified of any fall resulting in head injury, suspected head injury .These residents will be observed for neurological abnormalities by performing neuro checks according to the Neurological Evaluation policy and procedure after the accident/incident occurs .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to identify trauma triggers to eliminate or mit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to identify trauma triggers to eliminate or mitigate triggers that may cause re-traumatization of the resident in 1 of 1 residents reviewed for Post Traumatic Stress Disorder (PTSD) in a final sample of 15 residents (Resident Identifier #10).
Findings include:
Record review on 10/22/24 of Resident #10's diagnosis list revealed a diagnosis of PTSD.
Record review on 10/22/24 of Resident #10's last Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/8/24 revealed PTSD was a current diagnosis.
Record review on 10/22/24 of Resident #10's care plans revealed a care plan for behaviors of crying, withdrawal, and lack of appetite associated with PTSD without identified triggers listed.
Record review on 10/22/24 of Resident #10's Generations Psychiatry Progress Note dated 10/9/24, revealed no identified triggers for PTSD.
Record review on 10/22/24 of Resident #10's behavior monitoring for [DATE] revealed Resident #10 had behaviors of grouchy, swearing and shrieking when moved.
Record review on 10/22/24 of Resident #10's Social Services assessment dated [DATE] revealed no identified triggers for Resident #10's PTSD.
Interview on 10/22/24 at approximately 10:45 a.m. with Staff A (Administrator) confirmed the facility had not been identified PTSD triggers for Resident #10.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to ensure that resident's who take psychotropic medications received a Gradual Dose Reduction (GDR) or document if GDR ...
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Based on record review and interview, it was determined that the facility failed to ensure that resident's who take psychotropic medications received a Gradual Dose Reduction (GDR) or document if GDR was clinically contraindicated for 1 of 5 resident's reviewed for unnecessary medications in a final sample of 15 residents (Resident Identifier #13).
Findings include:
Review on 10/21/24 of Resident #13's physician orders revealed an order for Seroquel 50 milligrams (mg), 1 tablet by mouth 3 times a day.
Review on 10/21/24 of Resident #13's Pharmacy Consultant Report, dated 8/8/2024, revealed a recommendation to attempt a gradual dose reduction for Resident #13's Seroquel medication. The report further revealed the provider checked decline and wrote please see visit note from 9/5/24. The report was signed 9/24/24. There was no documentation of continued clinical appropriateness for the Seroquel.
Review on 10/22/24 of Resident #13's Generations Geriatric Psychiatry Progress Note in Facility, dated 9/5/24, revealed the last GDR attempt was May 2021, and further revealed .Goals for Next Visit: consider med decrease . Follow up interval: 2-3 months . There was no documentation of continued clinical appropriateness for the Seroquel.
Interview on 10/22/24 at approximately 11:30 a.m. with Staff B (Director of Nursing) confirmed there was no documentation for an attempt or documentation of GDR being clinically contraindicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for E...
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Based on observation, record review, and interview, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 of 1 residents reviewed for an indwelling catheter in a sample of 15 residents (Resident Identifier #32).
Findings include:
Observation on 10/20/24 of Resident #32's room revealed an indwelling catheter bag hanging from the bed. There was no sign posted indicating Resident #32 was on EBP, and there was no PPE provided for care. Further observation revealed an Licensed Nursing Assistant (LNA) performing care without PPE.
Interview on 10/22/24 at 8:34 a.m. with Staff M (LNA) confirmed he/she provided care to Resident #32 on 10/20/24 without using PPE. Staff M stated they were not aware Resident #32 was on EBP.
Review on 10/22/24 of Resident #32's active orders revealed an order for a urinary catheter, entered on 10/15/24 and an order for EBP, entered on 10/20/24. Further review revealed an order for Ciprofloxacin (Cipro) Oral Table 250 milligrams (mg) by mouth every 12 hours for Urinary Tract Infection (UTI), dated 10/22/24.
Interview on 10/22/24 at 8:30 a.m. with Staff B (Director of Nursing) and Staff C (Infection Prevention) confirmed that Resident #32 was not on EBP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 3 of 30 days revie...
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Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 3 of 30 days reviewed between September 15, 2024 - October 20, 2024.
Findings include:
Review on 10/21/24 of the facility's daily nursing time sheets for September 15, 2024 - October 19, 2024, revealed the following:
On 9/15/24 there were no RN hours documented as worked;
On 9/28/24 there were no RN hours documented as worked;
On 10/13/24 there were no RN hours documented as worked.
Interview on 10/21/24 at 9:00 a.m. with Staff E (Scheduler) confirmed that there was no RN on duty on 9/15/24, 9/28/24, and 10/13/24.
Interview on 10/21/24 at 10:00 a.m. with Staff B (Director of Nursing) revealed that he/she was on call every other weekend when there was not an RN working but was not physically in the building for 8 consecutive hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing ant...
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Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 9 of 12 months reviewed for antibiotic use.
Findings include:
Review on 10/21/24 of the facility's line listing for antibiotic use from November 2023 through October 2024 revealed that the facility did not have documentation of a system to track antibiotic use within the facility from November 2023 through May 2024 and September 2024 to present.
Interview on 10/21/24 at 12:00 p.m. with Staff C (Infection Prevention) confirmed the above findings. Interview further revealed that the facility did not have antibiotic monitoring and tracking from September 13, 2024, to present, including documentation that antibiotics met criteria for use. Staff A (Administrator) confirmed that the facility had residents with infections and who were on antibiotics from September 2024 to date.
Review on 10/21/24 of the facility's policy titled, Infection Control - Antibiotic Stewardship, revised 2/11/22, revealed: .2. Accountability: a. An ASP Team will establish to be accountable for stewardship activities . i. Review infections and monitor antibiotic usage patterns on a regular basis. ii. Obtain and review antibiograms for institutional trends of resistance. iii. Monitor Antibiotics resistance patterns . iv. Report on number of antibiotics prescribed (e.g., days of therapy) and the number of residents treat each month. iv. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infections .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on interview and record review, it was determined that the facility failed to maintain resident care equipment according to manufacturer's instructions for the hoyer lift.
Findings include:
Int...
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Based on interview and record review, it was determined that the facility failed to maintain resident care equipment according to manufacturer's instructions for the hoyer lift.
Findings include:
Interview on 10/22/24 at approximately 9:57 a.m. with Staff J (Maintenance Director) revealed that the legs on the hoyer lift were difficult to open. Staff J stated that they had not performed routine inspections on the hoyer lift to determine any wear since he/she became employed at the facility approximately four months ago. Staff J revealed they had never performed routine maintenance on the hoyer lift, and did not have any documentation that the hoyer lift had been maintained, inspected or repaired at any time. Staff J confirmed that the hoyer lift was more than a year old and routine inspection and maintenance was required.
Interview on 10/22/24 at approximately 10:29 a.m. with Staff K (Licensed Nursing Assistant(LNA)) revealed the hoyer lift is difficult to maneuver when a resident is in the lift.
Interview on 10/22/24 at approximately 10:37 a.m. with Staff L (LNA) revealed the hoyer lift was hard to move and wobbly at times.
Review on 10/22/24 of the hoyer lift manual, page 12 revealed: .Performing Maintenance, After the first year of use, the hooks of swivel bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, replacements must be made .Casters and axle bolts require inspections every six months to check tightness and wear. After the first twelve months of operation, inspect the swivel bar and the eye of the boom (to which it attaches) for wear. If the metal is worn, the parts MUST be replaced. Make this inspection every six months thereafter. Regular maintenance of patient lifts and accessories is necessary to assure proper operation .
Review on 10/22/24 of the Maintenance Safety Inspection Checklist in the hoyer lift manual, page 32, revealed: .for institution use of the hoyer lift, the lift and all components should be inspected or adjusted monthly .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on interview and record review, it was determined that the facility failed to submit to the Centers for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information ...
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Based on interview and record review, it was determined that the facility failed to submit to the Centers for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information based on payroll data for Fiscal Quarter 3 (April 1, 2024 - June 30, 2024).
Review on 10/20/24 of the facility's Payroll Based Journal Staffing Data Report for Quarter 3 2024 (April 1, 2024 - June 30, 2024) revealed that the facility failed to submit data for the quarter.
Interview on 10/22/24 at 1:00 p.m. with Staff F (Business Office Manager) confirmed the above findings.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility (SNF) Advance B...
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Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 2 out of 3 residents reviewed for beneficiary notices (Resident Identifiers are #135 and #136).
Findings include:
Resident #135
Review on 10/20/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #135 was discharged from Medicare Services on 6/28/24 and remained in the facility.
Review on 10/20/24 of Resident #135's SNF Beneficiary Protection Notification Review form revealed that Resident #135 was not provided a SNF ABN Form CMS-10055 notice prior to discharge from Medicare Part A services.
Resident #136
Review on 10/20/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #136 was discharged from Medicare Services on 5/3/24 and remained in the facility.
Review on 10/20/24 of Resident #136's SNF Beneficiary Protection Notification Review form revealed that Resident #136 was not provided a SNF ABN Form CMS-10055 notice prior to discharge from Medicare Part A services.
Interview on 10/20/24 at 2:15 p.m. with Staff D (Director of Social Services) confirmed the above findings. Staff D stated that they had not completed the SNF ABN Form CMS-10055 for Resident #135 and Resident #136.
Oct 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to update a residents care plan with new or revised interventions after a fall for 1 of 1 residents reviewed for accide...
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Based on interview and record review, it was determined that the facility failed to update a residents care plan with new or revised interventions after a fall for 1 of 1 residents reviewed for accidents in a final sample of 13 residents (Resident identifier is #1).
Findings include:
Observation on 10/24/23 at approximately 9:30 a.m. of Resident #1's room door revealed the door was closed.
Review on 10/24/23 of Resident #1's nursing notes revealed that he/she had tested positive for COVID 19 on 10/20/23. Resident was placed on precautions on 10/20/23 with the residents room door being closed. Resident #1 had a fall on 10/22/23.
Observation on 10/25/23 at approximately 8:00 a.m. of Resident #1's room door revealed the door was closed.
Review on 10/25/23 of Resident #1's falls care plan revealed that there were no new interventions or revised interventions after the fall or with being placed on precautions.
Interview on 10/25/23 at approximately 10:00 a.m. with Staff D (Licensed Nursing Assistant) confirmed that Resident #1 had been on precautions with the door closed since 10/20/23. Staff D also revealed that Resident #1 does ambulate with a walker in room.
Observation 10/26/23 at approximately 9:30 a.m. of Resident #1's room door revealed the door was closed.
Interview on 10/26/23 at approximately 12:00 p.m. with Staff A (Director of Nursing) confirmed the above findings.
Review on 10/26/23 of the facility policy titled, Falls-Clinical Protocol, Revised June 2023 revealed:
.
Monitoring and Follow-Up
.
4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders for 5 residents in a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders for 5 residents in a final sample of 13 residents (Resident identifiers are #25, #5, #6, #28, and #27).
Findings include:
Physician's Orders
Standards:
[NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009.
Page 336- Physicians' Orders
The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary .
Review on 10/24/23 of Resident #25's medical record revealed the following physician's order:
2,000 ml [milliliters] fluid restriction every shift, start date 8/11/23.
Further review of Resident #25's medical record revealed the following:
9/3/23 Resident #25's intake was 2,610 ml.
9/22/23 Resident #25's intake was 2,040 ml.
9/23/23 Resident #25's intake was 2,750 ml.
10/1/23 Resident #25's intake was 2,340 ml.
10/2/23 Resident #25's intake was 2,260 ml.
10/6/23 Resident #25's intake was 2,520 ml.
10/7/23 Resident #25's intake was 2,640 ml.
10/16/23 Resident #25's intake was 2,940 ml.
Further review of Resident #25's medical record revealed that there was no documentation of the physician being notified.
Resident #5
Review on 10/24/23 of Resident #5's medical record revealed the following physician's order:
2,000 ml. FR (Fluid Restriction) every shift, start date 8/12/23.
Further review of Resident #5's medical record revealed the following:
10/1/23 Resident #5's intake was 2,170 ml's.
10/16/23 Resident #5's intake was 2,400 ml's.
10/17/23 Resident #5's intake was 2,280 ml's.
Further review of Resident #5's medical record revealed that there was no documentation of the physician being notified.
Interview on 10/25/23 at approximately 9:45 a.m. with Staff E (Unit Manager) revealed that the physician should have been notified of the above dates of Resident #25 going above the fluid restriction. Further interview with Staff E revealed that there was no documentation of the physician being notified.
Resident #6:
Review on 10/24/23 of Resident #6's medical record revealed the following physician's order:
Metoprolol Tartrate 25mg [milligrams] Oral Tablet 25 mg, Give 1 tab by mouth 2 times a day related to Hypertension secondary to other renal disorders, Hold for SBP [systolic blood pressure] <100 or HR [heart rate] <60, start date 9/7/23. Further review of Resident #6's medical record revealed that there were no documented SBP's or HR's for medication administration.
Interview on 10/26/23 at approximately 10:00 a.m. with Staff B (Infection Preventionist) confirmed the above findings.
Resident #27
Record review on 10/25/23 revealed the following orders:
Hydralazine 25mg, give 1 tablet by mouth two times a day related to hyperstension. Hold SBP (systolic blood pressure) less than 160. Order dated 8/9/23. Other order reads Hydralazine 50mg give one tablet by mouth with meals related to hypertension. Order dated 8/9/23.
Resident received Hydralazine 25mg with SBP below 160, 15 times in the month of October documented in the Medication Administration Record (MAR).
Interview on 10/26/23 at approximately 10:30 a.m. with Staff B confirmed that Resident #27 received Hydralazine 25mg with SBP less than 160 on 15 medication times that were scheduled.
Interview on 10/26/23 at approximately 11:15a.m. Staff H (Nurse Practitioner) confirmed that the Hydralazine 25mg should have been held with SBP less than 160 and that the order was written that way so if Resident #27's blood pressure was greater than SBP of 160, Resident #27 would get Hydralazine 25mg with scheduled dose of Hydralazine 50mg.
Resident #28
Review on 10/26/23 of Resident #28's bowel record from 9/26/23 through 10/26/23 revealed the following:
9/26/23 through 9/29/23; no bowel movement (4 days)
10/16/23 through 10/19/23; no bowel movement (4 days)
10/21/23 through 10/25/23; no bowel movement (5 days)
Review on 10/26/23 of Resident #28's September 2023 and October 2023 MAR revealed the following physician's orders for as needed bowel medications:
Dulcolax Suppository 10 milligrams (mg) (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for constipation for no bowel movement for 3 days, start date 8/13/23.
Enema Rectal Enema (Sodium Phosphates) Insert 10 mg rectally as needed for constipation, if no bowel movement after fleet enema, call MD [physician], start date 8/13/23.
Give 30 ml's prune juice for no bowel movement for 3 days as needed for constipation for no bowel movement for 3 days, start date 8/13/23.
Milk of Magnesia Suspension 1200 mg/15 ml (Magnesium Hydroxide) Give 30 ml by mouth as for constipation for no bowel movement for 3 days, start date 8/13/23.
Further record review revealed that during the above time periods no as needed bowel medications were administered to Resident #28.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had documentation of weekly assessments that contained me...
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Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 1 resident reviewed for pressure ulcers in a final sample of 13 residents (Resident identifier is #19).
Findings include:
Review on 10/24/23 of Resident #19's nursing notes revealed the following:
9/16/23 Res [resident] skin check performed. Res skin is not intact. [pronoun omitted] is intact everywhere, except on R [right] ear, there are 2 small areas on outer ear. one is 7 mm [millimeter] in diameter and one is 2 mm in diameter. Res says they have been there a very long time and [pronoun omitted] scratches them off occasionally. Buttocks are intact but does have red areas. Also continues to have red/brown areas on L [left]shoulder and L hip from insisting on lying on L side most of the day and night.
9/23/23 .Skin Issue #001: New. Issue type: Redness. Location: Buttocks-generalized .
Observation on 10/25/23 at approximately 9:30 a.m. with Staff O (Licensed Nursing Assistant) revealed:
1. Behind left ear, 3 centimeter (cm) x .25 cm., pink in color (non blanchable) area where oxygen (02) tubing was.
2. Left shoulder on bony prominence a 2 cm. x 2 cm. reddened area, non blanchable.
3. Left hip on bony prominence a 3 cm. x 3 cm. reddened area, non blanchable.
Interview on 10/25/23 at approximately 9:30 a.m. with Staff O (Licensed Nursing Assistant) revealed that Resident #19 will only lay on his/her left side and that these areas are not new.
Review on 10/25/23 of Resident #19's Weekly Skin Evaluations from 8/1/2023 through 10/24/23 revealed 1 weekly skin assessment, dated 9/23/23 that revealed:
New issue of redness to buttocks, No interventions were initiated on the assessment.
Review on 10/26/23 of Resident #19's Braden Scale Assessments dated, 8/6/23 and 9/26/23 revealed a score of 15 on both. A score of 15 indicates Mild Risk (15-18).
Interview on 10/26/23 at approximately 9:46 a.m. with Staff A (Director of Nursing) revealed that there was no weekly monitoring on the areas that are noted in the above.
Interview on 10/26/23 at approximately 11:45 a.m. with Staff H (Nurse Practitioner) revealed that he/she was not aware of any current skin concerns with Resident #19. Staff H stated that he/she has only been notified of Resident #19's left hip in the past but nothing recently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure that licensed nursing staff had demonstrated competencies and skills necessary to care for residents' needs f...
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Based on interview and record review, it was determined that the facility failed to ensure that licensed nursing staff had demonstrated competencies and skills necessary to care for residents' needs for 7 out of 7 licensed staff reviewed for competencies (Staff identifiers are Staff B, Staff J, Staff K, Staff L, Staff P, Staff M, Staff N).
Findings include:
Annual Competencies
Review of annual competencies for licensed staff revealed:
Staff P (Licensed Practical Nurse) was hired 5/29/2019 and had no annual competencies.
Competencies at hire:
Review of the competencies upon hire for licensed staff revealed:
Staff B (Infection Preventionist) was hired 5/02/2023 and no competencies were completed.
Staff J (Licensed Nursing Assistant) was hired 6/29/23 and no competencies were completed.
Staff K (Licensed Nursing Assistant) was hired 7/31/23 and no competencies were completed.
Staff L (Medication Assistant) as hired 7/24/23 and no competencies were completed.
Contracted Agency Staff:
A review of the competencies prior to working at the facility revealed:
Staff M (Registered Nurse) had no competencies completed.
Staff N (Licensed Practical Nurse) had no competencies completed.
Review on 10/25/23 of the Facility Assessment section titled Competency revealed skills needed as direct care giver: Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of interventions, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. Cultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural,and linguistic needs of residents.
Person-centered care- This should include but not limited to person-centered care planning, education of resident and family/resident treatment preferences, end of life care, and advance care planning. Activities of daily living-bathing (e.g., tub, shower), bed-making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teethe or dentures,) providing resident privacy, range of motion, (upper or lower extremity) transfers, using gait belt, using mechanic lifts. Infection control-hand hygiene, isolation, standard universal precautions including use of personal protective equipment, MRSA/VRE/CDI precautions, environmental cleaning.Medication administration- injectable, oral, subcutaneous, topical.
Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, redial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone.Resident assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment.Caring for persons with Alzheimer's or other dementia.
Interview on 10/25/23 at 2:00 p.m. with Staff B (Infection Preventionist) revealed that the Licensed Staff should have competencies completed upon hire and annually. He/she also confirmed the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 5 of 90 days review...
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Based on interview and record review it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 5 of 90 days reviewed between April 1, 2023 and June 30, 2023.
Findings include:
Review on 10/25/23 of the facility's Payroll Based Journal Staffing Data Report for Quarter 3 (April 1, 2023-June 30, 2023) revealed that there were no RN hours for the following days: 5/27/23, 6/03/23, 6/04/23, 6/10/23, 6/25/23.
Interview on 10/25/23 at 10:00 a.m. with Staff B (Infection Preventionist/Staffing Coordinator) confirmed the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to provide a stop date for a as needed (PRN) psychotropic medication for 1 of 5 residents reviewed for unnecessary medi...
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Based on record review and interview, it was determined that the facility failed to provide a stop date for a as needed (PRN) psychotropic medication for 1 of 5 residents reviewed for unnecessary medications in a final sample of 13 residents (Resident identifier is #26).
Findings include:
Record review on 10/25/23 revealed that Resident #26 had an order for Ativan 0.5 milligram (mg): Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation, start date 9/25/23.
Interview on 10/25/23 at approximately 1:30 p.m. with Staff A (Director of Nursing) confirmed the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to follow manufacturer's recommendations on 1 of 2 medication carts observed (Resident identifier is #10)...
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Based on observation, interview, and record review, it was determined that the facility failed to follow manufacturer's recommendations on 1 of 2 medication carts observed (Resident identifier is #10).
Findings include:
Observation on 10/24/23 at 8:30 am of the South Wing Medication Cart with Staff F (Medication Nursing Assistant) revealed an open multidose vial of Humalog insulin Lispro with an open date of 9/23/23 and a discard date of 10/21/23 for Resident #10.
Interview on 10/24/23 at 8:30 a.m. with Staff F confirmed the above findings.
Review on 10/24/23 of the Manufacturer's Recommendations for the use of Humalog Lispro Insulin: .Preparing your Humalog dose .Do not use Humalog past the expiration date printed on the label or 28 days after you first use it.
Review on 10/25/23 of the facility's policy titled Storage of Medications revised April 2007 Policy Interpretation and Implementation .4. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to provide residents with the necessary assistive devices for dining for 4 residents observed for assisti...
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Based on observation, interview, and record review, it was determined that the facility failed to provide residents with the necessary assistive devices for dining for 4 residents observed for assistive devices out of a sample of 6 residents reviewed (Resident identifiers are #6, #88, #24, and #1).
Findings Include:
Review on 10/24/23 of a list of residents that use adaptive equipment, provided by the facility, revealed that 6 residents require adaptive equipment with meals.
Resident #88:
Observation on 10/25/23 at approximately 7:45 a.m. of Resident #88's breakfast tray revealed that Resident #88 received plastic utensils, a paper plate and a 1 handle coffee mug.
Review on 10/25/23 of Resident #88's dietary meal ticket, under adaptive, revealed the following items that should be on Resident #88's meal tray: a divided red plate, built up foam for all utensils and a two handle cup.
Resident #1:
Observation on 10/25/23 at approximately 8:00 a.m. of Resident #1's breakfast tray revealed that he/she had a paper plate.
Review on 10/25/23 of Resident #1's dietary meal ticket, under adaptive, revealed the following item should have been on Resident #1's meal tray: a white divided plate.
Resident #20:
Observation on 10/25/23 at approximately 8:05 a.m. of Resident #20's breakfast tray revealed that he/she had a paper plate.
Review on 10/25/23 of Resident #20's dietary meal ticket, under adaptive, revealed the following item should have been on Resident #20's meal tray: a red lip plate, no dividers.
Resident #24:
Observation on 10/25/23 at approximately 8:06 a.m. of Resident #24's breakfast tray revealed that he/she had a paper plate.
Review on 10/25/23 of Resident #24's dietary meal ticket, under adaptive, revealed the following item should have been on Resident #24's meal tray: a red, divided plate.
Interview on 10/25/23 at approximately 8:15 a.m. with Staff D (Licensed Nursing Assistant) revealed that the facility had switched to paper/plastic products for meals since the facility's COVID-19 outbreak began and adaptive equipment was not being given to the residents.
Interview on 10/25/23 at 8:20 a.m. with Staff G (Dietary Manager) confirmed the above findings.
Review on 10/26/23 of the facility COVID-19 outbreak tracking list revealed the outbreak began on 10/19/23.
Review of policy titled, Adaptive Equipment with Meals, no date.
Standard: Resident will be given adaptive equipment as needed/ ordered for all meals and snacks.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse properly in a contained dumpster with a lid or cover.
Findings Include:
Observation on 1...
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Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse properly in a contained dumpster with a lid or cover.
Findings Include:
Observation on 10/25/23 at 9:15 a.m. of the dumpster located in the back of the facility revealed multiple clear bags with waste noted on the ground in front of the dumpster. The dumpster was not covered.
Observations on 10/26/23 at 9:00 a.m. of the dumpster located in the back of the facility revealed multiple clear bags with waste noted on the ground in front of the dumpster. The dumpster was not covered.
Interview on 10/26/23 at 9:00 a.m. with Staff C (Administrator) confirmed the above findings.
Review on 10/26/23 at 10:00 a.m. of the facility policy titled Solid Waste Disposal Policy .Garbage containers are covered at all times .All Employees Place trash and garbage directly into designated receptacles. Keep lids to all outside trash receptacles closed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on interview it was determined that the facility failed to report to the State Department of Public Health an outbreak of COVID-19 Infection that included 16 out of 29 residents.
Findings Inclu...
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Based on interview it was determined that the facility failed to report to the State Department of Public Health an outbreak of COVID-19 Infection that included 16 out of 29 residents.
Findings Include:
Interview on 10/25/23 at 1:00 p.m. with Staff B (Infection Preventionist) revealed that Staff B had not reported the current COVID-19 outbreak that began on 10/19/23 to the State Department Of Public Health.
Interview on 10/26/23 at 10:00 a.m. with Staff C (Administrator) confirmed the above findings.
Review on 10/26/23 of the facility's Infection Control Policy and Procedure Manual Titled: Surveillance Dated 5/2014 .Outbreak of Communicable Diseases .The Administrator will be responsible for: 1. Telephoning a report to the health department .3. Submitting periodic progress reports to the health department as requested .6. Forwarding Communicable Disease Report Cards to the health department as required.
Review on 10/27/23 of the New Hampshire Communicable Disease Report Form 2011. NH RSA 141-C and He-P300 mandate reporting of the listed communicable diseases by all physicians, labs and health care providers Fax
COVID -19 reports to
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to have an antibiotic stewardship program that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to have an antibiotic stewardship program that included a system to monitor antibiotic use.
Findings Include:
Review on 10/24/23 of the facility's line listing for antibiotic use from January 2023 through October 2023 revealed that the facility did not track antibiotic use within the facility from February 2023 through April 2023.
Interview on 10/25/23 at 1:30 p.m. with Staff B (Infection Preventionist) confirmed the above findings.
Review on 10/25/23 at 2:00 p.m. of the facility's policy titled [NAME]-Air Nursing and Rehab Antibiotic Stewardship Program 2. Policy: [NAME]-Air Nursing and Rehab Center will implement an antibiotic stewardship program based on the Center for Disease Control's: Core Elements of Antibiotic Stewardship for Nursing Homes, and will be evaluated annually or more frequently if needed for effectiveness during review of the Infection Control Program 4.4 The infection Preventionist (IP) will track antibiotic starts, perform antibiotic Time Outs, monitor adherence to evidence-based published criteria during the evaluation and management of treated infections, and review antibiotic resistant patterns in the facility to understand which infections are caused by resistant organisms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that the facility failed to revise the pneumococcal policy, and ensure/implement a facility system for the monitoring and recording of pneumococc...
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Based on record review and interview it was determined that the facility failed to revise the pneumococcal policy, and ensure/implement a facility system for the monitoring and recording of pneumococcal immunizations for 4 out of 5 residents reviewed for immunizations (Resident identifiers are #19, #12, #24, #27).
Findings Include:
Resident #19
Review on 10/24/23 of Resident #19's medical record revealed that he/she was admitted to the facility 10/2019. Further review of Resident #19's medical record revealed that there was no documented evidence of pneumococcal vaccination being offered or received.
Resident #12
Review on 10/24/23 of Resident #12's medical record revealed that he/she was admitted to the facility 6/2022. Further review of Resident #12's medical record revealed that there was no documented evidence of pneumococcal vaccination being offered or received.
Resident #24
Review on 10/24/23 of Resident #24's medical record revealed that he/she was admitted to the facility 12/2022. Further review of Resident #24's medical record revealed that there was no documented evidence of pneumococcal vaccination being offered or received.
Resident #27
Review on 10/24/23 of Resident #27's medical record revealed that he/she was admitted to the facility 11/2021. Further review of Resident #27's medical record revealed that there was no documented evidence of pneumococcal vaccination being offered or received.
Interview on 10/24/23 at 12:15 p.m. with Staff B (Infection Preventionist) confirmed the above findings.
Review on 10/25/23 of the facility's Policy titled: Pneumococcal Vaccine Revised December 2017 Policy Statement: All residents will be offered the Pneumovax (pneumococcal Vaccine) to aid in preventing pneumococcal infections. (e.g. Pneumonia) 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine), and when indicated, will be offered the vaccination with in thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccinations status will be conducted within 5 working days of the resident's admission if not conducted prior to admission 5. Residents/representatives have the right to refuse vaccinations. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination.
Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV [Pneumococcal Polysaccharide Vaccine] 23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete .
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, it was determined that the facility failed to post the Nursing Staffing Data on a daily basis.
Findings Include:
Observation on 10/24/23 at 9:00 a.m. of the facilit...
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Based on observation and interview, it was determined that the facility failed to post the Nursing Staffing Data on a daily basis.
Findings Include:
Observation on 10/24/23 at 9:00 a.m. of the facility common areas revealed no daily Nursing Staff Data Posting.
Observation on 10/25/23 at 10:00 a.m. of the facility common areas revealed no daily Nursing Staff Data Posting.
Interview on 10/25/23 at 10:15 a.m. with Staff C (Administrator) confirmed that the facility was not posting staffing data daily.
Review on 10/26/23 of the facility's policy titled: Posting Direct Care Daily Staffing Numbers: Policy Statement Our facility will post, on a daily basis for each shift, the number of nursing personal responsible for providing direct care to residents.
Jun 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse were thoroughly investigated for 1 out of 1 resident reviewed for allege...
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Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse were thoroughly investigated for 1 out of 1 resident reviewed for alleged abuse (Resident Identifier is #1).
Findings include:
Interview on 6/6/23 at 8:55 a.m. with Resident #1 revealed that one staff member didn't treat him/her with respect and played with his/her inside. He/She stated it was Staff B (LNA) and told him/her to stop. Staff B did not stop. Resident #1 stated that it happened at night and happened one time only. He/She stated that the facility staff was told about the incident during the Resident Council meeting in May.
Interview on 6/6/23 at 10:28 a.m. with Staff A (Administrator) revealed that he/she, along with Staff F (Licensed Practical Nurse/Staff Development Coordinator) and Staff G (Social Services), interviewed Resident #1 on 5/26/23 regarding the above allegation. Staff A stated that he/she met with Staff B and placed him/her on suspension. Staff A stated that the facility was still waiting for a statement from Staff B and another LNA who had worked that shift. He/She also stated that other residents and staff were interviewed for the investigation but this was not documented.
Interview on 6/6/23 at 1:00 p.m. with Staff A revealed that there was no documentation of any interviews done with other staff or other residents regarding Staff B.
Review on 6/6/23 of facility policy titled Abuse Investigations dated April 2010 stated All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .3. The individual conducting the investigation will, at a minimum: .g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; .i. Interview other residents to whom the accused employee provides care of services; .5. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to update and implement policies and procedures...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to update and implement policies and procedures to ensure that screening of contracted agency staff was conducted prior to working for 3 out of 3 contracted agency staff reviewed (Staff Identifiers are Staff B, D, and E).
Findings include:
Review on [DATE] of the facility's monthly schedules revealed the following;
Staff B (Licensed Nursing Assistant (LNA)) worked 22 shifts in February 2023; 9 shifts in [DATE]; 32 shifts in [DATE]; and 24 shifts in [DATE].
Staff D (Licensed Practical Nurse (LPN)) worked 9 shifts in [DATE] and 4 shifts in [DATE].
Staff E (LNA) worked 20 shifts in February 2023; 8 shifts in [DATE]; 15 shifts in [DATE]; 17 shifts in [DATE], and 3 shifts in [DATE].
Interview on [DATE] at 10:28 with Staff A (Administrator) revealed that the facility relies on the contracted agency to do background checks. Staff A confirmed that the facility did not have a process to track that background checks or abuse training on contracted agency staff was completed.
Review on [DATE] of the facility's policy titled Agency Staffing revised [DATE] revealed, .3. As needed the agency will provide licenses or other information required for staffing audits. It is the agencies responsibility to ensure their staff is up to date on licensees, CPR [Cardiopulmonary Resuscitation], medical information, etc. 4. All agency personnel are oriented to the facility.
Review on [DATE] of the facility's policy titled Abuse Prevention Program revised [DATE], revealed, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents . 2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Protocols for conducting employment background checks; b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc.; . f. Timely and thorough investigations of all reports and allegations of abuse .
Review on [DATE] of the facility's policy titled Preventing Resident Abuse revised [DATE], revealed, .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners . l. Conducting background investigations to avoid hiring persons . who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry .
Interview on [DATE] at 11:48 a.m. with Staff A confirmed that the above policies were the most recent policies and was unsure when the policies had last been reviewed by the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on [DATE] at 10:28 a.m. with Staff A (Administrator) revealed that there is no formal orientation for agency staff. St...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on [DATE] at 10:28 a.m. with Staff A (Administrator) revealed that there is no formal orientation for agency staff. Staff A revealed that the facility relies on the agency to do the necessary training for the agency staff and that the facility does not keep documentation of any trainings for agency staff. Staff A revealed that Staff B's background check information was obtained on [DATE] and [DATE].
Review on [DATE] of the Abuse/Neglect binder revealed that the most recent training was done on [DATE] for the facility staff.
Interview on [DATE] at 1:20 p.m. with Staff F (Licensed Practical Nurse/Staff Development Coordinator) confirmed the above finding.
Based in interview and record review it was determined that the facility failed to ensure that the contracted agency verified licensure for Licensed Nursing Assistants (LNAs) and failed to verify that staff met required competencies and training requirements to work as LNAs for 1 of 3 agency staff reviewed (Staff Identifier is Staff B).
Findings include:
Interview on [DATE] at 10:15 a.m. with Staff C (Corporate Assistant) revealed that Staff B (LNA) started working at the facility in February 2023.
Review on [DATE] of the facility's monthly schedules revealed the following;
Staff B worked 22 shifts in February 2023; 9 shifts in [DATE]; 32 shifts in [DATE]; and 24 shifts in [DATE].
Review on [DATE] of Staff B's New Hampshire Online Licensing for license type LNA revealed that Staff B's licensed had expired in 2021.
Review on [DATE] of Staff B's background checks revealed that they Bureau of Elderly and Adult Services check had been completed on [DATE] and the Department of Safety Criminal Conviction Record check had been completed on [DATE]. The facility did not have evidence that these had been completed prior to when Staff B started to work at the facility in February.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to ensure that training and education was provid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to ensure that training and education was provided to staff on abuse, neglect and misappropriation of resident property for 5 of 6 staff reviewed (Staff Identifiers are Staff B, D, E, H, and J).
Finding include:
Interview on [DATE] at 10:28 a.m. with Staff A (Administrator) revealed that the facility did not do any training with agency staff and relied on the agency to do training. Staff A revealed that the facility did not obtain or validate that any training had been completed for any agency staff, including Staff B (Licensed Nursing Assistant (LNA)), Staff D (Licensed Practical Nurse LPN)), or Staff E (LNA).
Interview on [DATE] at 11:15 a.m. with Staff H (Medication Nursing Assistant (MNA)) revealed that he/she could not recall when he/she had last been trained for abuse and neglect, and thought maybe a year ago. Staff H stated he/she had worked at the facility for 11 years.
Interview on [DATE] at 1:00 p.m. with Staff J (LNA) revealed that he/she last had abuse training maybe over a year ago. Staff J stated he/she had worked at the facility for 6 years.
Interview on [DATE] with Staff A revealed that the last facility abuse training documented was from [DATE] for the facility.
Review on [DATE] of the facility's policy titled Agency Staffing revised [DATE] revealed, .3. As needed the agency will provide licenses or other information required for staffing audits. It is the agencies responsibility to ensure their staff is up to date on licensees, CPR [Cardiopulmonary Resuscitation], medical information, etc . 4. All agency personnel are oriented to the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to ensure that required in-service training was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to ensure that required in-service training was conducted and maintained, including the required annual minimum 12 hours for nurse's aides for 4 of 5 nurse's aides reviewed (Staff Identifiers are Staff B, E, H, and J).
Finding include:
Interview on [DATE] at 10:28 a.m. with Staff A (Administrator) revealed that the facility did not do any training with agency staff and relied on the agency to do training. Staff A revealed that the facility did not obtain or validate that any training had been completed for any agency staff, including Staff B (Licensed Nursing Assistant (LNA)) or Staff E (LNA).
Interview on [DATE] with Staff A revealed that the last facility abuse training documented was from [DATE]. Staff A revealed that the facility did not have any training for the above staff since 2021.
Review on [DATE] of the facility's policy titled Agency Staffing revised [DATE] revealed, .3. As needed the agency will provide licenses or other information required for staffing audits. It is the agencies responsibility to ensure their staff is up to date on licensees, CPR [Cardiopulmonary Resuscitation], medical information, etc . 4. All agency personnel are oriented to the facility.
Review on [DATE] of the facility's policy titled Abuse Prevention Program revised [DATE], revealed, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents .3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Protocols for conducting employment background checks; b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc; . f. Timely and thorough investigations of all reports and allegations of abuse .
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0837
(Tag F0837)
Minor procedural issue · This affected most or all residents
Based on record review and interview it was determined the facility failed to establish and implement policies regarding the management and operation of the facility.
Findings include:
During the comp...
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Based on record review and interview it was determined the facility failed to establish and implement policies regarding the management and operation of the facility.
Findings include:
During the complaint investigation on 6/6/23 the following policies were received from the facility:
Abuse Investigations - revised April 2010
Agency Staffing - revised April 2007
Abuse Prevention Program - revised August 2006
Preventing Resident Abuse - revised December 2006
Interview on 6/6/23 at 11:48 a.m. with Staff A (Administrator) confirmed that the above policies were the most recent policies. Staff A was unsure when the policies had last been reviewed by the facility or if they had been reviewed and approved after the facility changed ownership in July 2022.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0840
(Tag F0840)
Minor procedural issue · This affected most or all residents
Based on interview and record review it was determined that the facility failed to ensure that there was a contract for 1 of 1 contracted staffing agencies reviewed which provided nursing services to ...
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Based on interview and record review it was determined that the facility failed to ensure that there was a contract for 1 of 1 contracted staffing agencies reviewed which provided nursing services to the facility.
Findings included:
Review on 6/6/23 of the daily staffing schedule for the month of May revealed that Staff B (Licensed Nursing Assistant (LNA)) from Agency A worked at the facility on the following dates: 5/2/23, 5/5/23, 5/6/23, 5/11/23, 5/12/23, 5/13/23, 5/14/23, 5/15/23, 5/19/23, 5/20/23, 5/21/23 and 5/23/23.
Interview on 6/6/23 at approximately 1:15 p.m. with Staff A (Administrator) revealed that the facility did not have a contract with the staffing agency (Agency A). Staff A confirmed that he/she could not provide any contracts for any of the staffing agencies the facility used, including for Staff B, D (Licensed Practical Nurse LPN)) and E (LNA).
Interview on 6/6/23 at 2:30 p.m. with Staff C (Corporate Assistant) confirmed that Staff B worked on the above dates.
Oct 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Resident #8
Review of Resident #8's electronic medical record revealed a nurses note dated 9/1/22 at 7:01 a.m. Licensed Nurse Assistant (LNA) reported large bruising to the left thigh. Bruising area i...
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Resident #8
Review of Resident #8's electronic medical record revealed a nurses note dated 9/1/22 at 7:01 a.m. Licensed Nurse Assistant (LNA) reported large bruising to the left thigh. Bruising area is approximately 15 centimeter (cm) x 8 cm. Bruising is mixed purple and yellow. Resident states no pain to bruised area. No other issues noted will continue to monitor. Further review of Resident #8 medical record revealed a diagnosis of atrial fibrillation. Review also revealed Resident #8 was receiving Warfarin Sodium 2 milligram (mg) one tablet by mouth daily.
Interview on 10/18/22 at 1:03 p.m. with Staff C (Assistant Director of Nursing), regarding the bruise. Staff C stated that no one knew how it got there. The resident complained about it in therapy. It started as a bruise which got bigger over time. He/she stated that Resident #8 discontinued therapy until it got better.
Staff C could not produce a copy of the facility investigation regarding Resident #8's bruise.
Review on 10/18/22 of facility policy titled Resident Abuse/Neglect Policy revised 10/27/16 revealed .Reporting-2 When an alleged violation, suspected case of mistreatment, neglect or misappropriation of property is reported to the Administrator or his/her designee will notify the following agencies of the incident: a. Health Facilities Administration .
Based on interview and record review, it was determined that the facility failed to ensure the alleged violation involving abuse or mistreatment, including injuries of unknown sources, were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility for 2 of 4 residents reviewed for abuse in a final sample of 12 residents (Resident identifiers are #8 and #30).
Findings include:
Resident #30
Review on 10/17/22 at approximately 2:00 p.m. of Resident #30's nurses notes revealed an entry dated 10/6/22 that stated Resident #31 reported to the Activities Director that they were hit by another resident during an activity.
Interview on 10/18/22 at approximately 10:42 a.m. with Staff D (Social Services) revealed that the note above was in the wrong chart. Staff D stated that it was Resident #30 that had reported this. Staff D stated that they were informed on 10/7/22. Staff D stated that they did not report to the Administrator or to the Director of Nursing as no one witnessed the event.
Interview on 10/18/22 at approximately 11:30 a.m. with Staff F (Administrator) stated they were not aware of Resident #30's allegation made on 10/6/22 until today.
Interview on 10/18/22 at approximately 11:45 a.m. with Staff G (Activities Director) revealed that on 10/6/22 around 11:00 a.m. during a religious service, Resident #30 informed Staff G that the resident sitting next to them had hit them in the arm. Staff G stated that he/she separated the two residents and reported it immediately to the nurse on duty. Staff G stated that the resident who was accused of doing the hitting is known to have dementia with behavioral episodes like this.
Interview on 10/18/22 at approximately 11:55 a.m. with Resident #30 revealed they could not recall what happened on 10/6/22.
Review on 10/18/22 of the facility policy titled Resident Abuse/Neglect Policy revised on 10/27/16, revealed, . 1. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Charge Nurse, DNS [Director of Nursing Services], and/or Administrator immediately and an incident accident report is to be completed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8
Review of Resident #8's electronic medical record revealed a nurses note dated 9/1/22 at 7:01 a.m. Licensed Nurse As...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8
Review of Resident #8's electronic medical record revealed a nurses note dated 9/1/22 at 7:01 a.m. Licensed Nurse Assistant (LNA) reported large bruising to the left thigh. Bruising area is approximately 15 cm x 8 cm. Bruising is mixed purple and yellow. Resident #8 states no pain to bruised area. No other issues noted will continue to monitor. Further review revealed the Resident #8 with a diagnosis of atrial fibrillation. Review also revealed Resident was receiving Warfarin Sodium 2 mg one tablet by mouth daily
Interview on 10/18/22 at 1:03 p.m. with Staff C (Assistant Director of Nursing) regarding the bruise. Staff C stated that no one knew how it got there. Resident #8 complained about it in therapy. It started as a bruise which got bigger over time. Staff C stated that the resident discontinued therapy until it got better.
Staff C could not produce a copy of the investigation or evidence that the facility reported the allegation to the State Survey Agency before the survey concluded.
Review on 10/18/22 of facility policy titled Resident Abuse/Neglect Policy revised 10/27/16 revealed .Identification .2-a The [NAME]-Air Management will investigate incidents, accidents and injuries of unknown origin for patterns of abuse or neglect .
Based on interview and record review, it was determined that the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 out of 4 residents for abuse in a final sample of 12 residents (Resident identifiers are #8 and #30).
Findings include:
Resident #30
Interview on 10/18/22 at approximately 10:42 a.m. with Staff D (Social Services) revealed that they were informed on 10/7/22 of an incident reported by Resident #30. Staff D stated that they did not further investigate as no one witnessed the alleged event. Staff D confirmed that there are working video cameras in the area where the alleged abuse occurred but they had not reviewed the footage.
Interview on 10/18/22 at approximately 11:45 a.m. with Staff G (Activities Director) revealed that on 10/6/22 around 11:00 a.m, during a religious service, Resident #30 informed Staff G that the resident sitting next to them had hit them in the arm. Staff G stated that they separated the two residents and reported it immediately to the nurse on duty. Staff G stated that the resident who was accused of doing the hitting is known to have dementia with behavioral episodes like this.
Review on 10/18/22 of the facility policy titled Resident Abuse/Neglect Policy revised on 10/27/16, revealed .3. The Supervisor is to follow the following steps: A. Immediate investigation into the alleged incident. 1. Interview staff members implicated. Get written statements. 2. Interview visitors or other staff members. Should document incident in written narrative. 3. Interview with resident or resident witness. Supervisor to document written statement from resident(s). 4. Review circumstances surrounding the incident. 5. Call the Director of Nursing and/or the Administrator as soon as possible .C. Preliminary investigation is to be sent to the Director of Nurses and Administrator .4. The Administrator or his/her designee will appoint a staff member(s) to investigate the allegation of abuse, neglect or misappropriation of property in more depth. That individual(s) will complete a detailed investigation as soon as possible but no later than four days .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for preparing medications for 2 unavailable residents on 1 out of 1 medication carts observed and failed to follow the manufacturer's instructions for an inhaled medication for 1 out of 1 inhaled medications observed. (South Medication Cart)
Findings include:
Observation on 10/17/22 at approximately 8:35 a.m. of medications being administered to Resident #5. Staff B (Medication Nursing Assistant) assisted the resident with using the Flovent HFA (Hydroflouroalkane) inhaler. Staff B did not offer Resident #5 to rinse his/her mouth with water after the inhalation of the medication.
Interview on 10/17/22 at approximately 8:35 a.m. with Staff B revealed that he/she does not routinely offer water to rinse residents' mouths after inhalers are administered.
Review on 10/18/22 of the manufacturers' instructions for Flovent inhaler, Revised 8/2021 revealed:
.
2.1 Administration Information
Flovent HFA should be administered by the orally inhaled route only. After inhalation, rinse mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis.
Review of [NAME] A. [NAME] and [NAME], Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 769 revealed the following: Nurses administer only medications that they prepare, and prepared medications are never left unattended.
Observation on 10/17/22 at approximately 9:10 a.m. of the South Medication Cart, in the second drawer, revealed 2 plastic cups with medications in each of them. 1 cup had Resident #14's name written on the cup and the other had Resident #6's name written on the cup.
Interview on 10/17/22 at approximately 9:10 a.m. with Staff B revealed that he/she had prepared the medications prior but the residents were in the dining room and unavailable to take the medications.
Review on 10/18/22 of Resident #14's October 2022 MAR (Medication Administration Record) revealed the following list of medications that were in a cup in the medication cart:
1 - Aspirin 81 milligram (mg) tablet
1 - Multivitamin tablet
1 - Vitamin B-12 500 microgram (mcg) tablet
1 - Docusate Sodium 100 mg capsule
2 - Acetaminophen 325 mg tablets
Review on 10/18/22 of Resident #6's October 2022 MAR revealed the following list of medications that were in a cup in the medication cart:
1 Metoprolol Tartrate 25 mg tablet
1 Triamterene HCTZ (Hydrochlorothiazide) 37.5-25 mg capsule
2 Primidone 50 mg tablets
2 Preservision Areds Soft gels
1 Cranberry 425 mg capsule
1 Calcium 600-Vitamin D3 400 tablet
Interview on 10/17/22 at approximately 9:10 a.m. with Staff B confirmed that the above medications were in a plastic cup in the medication cart.
Review on 10/8/22 of the facility policy titled, Preparation and General Guidelines, Medication Administration-General Guidelines, Revised December 2019 revealed:
.
B. Administration
.
4. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not prepoured either in advance of the med (medication) pass or for more than one resident at a time
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure that a resident had adequate supervision and interventions to prevent falls for 1 of 1 resident reviewed for ...
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Based on interview and record review, it was determined that the facility failed to ensure that a resident had adequate supervision and interventions to prevent falls for 1 of 1 resident reviewed for accident hazards in a final sample of 12 residents. (Resident identifier is #29)
Findings include:
Review on 10/17/22 at 9:05 of Resident's #29 electronic medical record revealed that Resident #29 was admitted from home on 8/10/22 after a fall with a left hip fracture. Further record review revealed that Resident #29 had four falls at the facility on 8/30/22, 9/7/22, 9/19/22, and 9/28/22.
Review of Resident #29's medical record on 10/18/22 revealed a nurses note on 8/30/22 which stated the resident fell. Nurses note stated Resident found on edge of bed. Advanced Practice Registered Nurse (APRN) and son was notified. Alarm removed from clothing.
Review of Resident #29's medical record on 10/18/22 revealed a nurses note on 9/7/22 that the resident was found on floor. Nurses note stated Alarm sounded. No injury.
Review of Resident #29's fall on 10/18/22 revealed a nurses note on 9/19/22 that the resident had a witnessed fall at 1600 [4:00 p.m.] today. No injury noted.
Review of Resident #29's fall on 10/18/22 revealed a nurses note on 9/28/22 that the resident was found sitting on floor at 1455 [2:45 p.m.]. No injury noted.
Interview with Staff C on 10/18/22 confirmed the above findings and that he/she could only produce two incident reports for the four falls. Staff C was unable to provide documentation of comprehensive evaluations to prevent falls for above mentioned falls.
Review on 10/18/22 of the facility policy titled Falls and Fall Risk, Managing dated 12/14 revealed .4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined that the facility failed to ensure that expired medications were removed from inventory in one of one medication rooms and one of two medication ca...
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Based on observation and interview it was determined that the facility failed to ensure that expired medications were removed from inventory in one of one medication rooms and one of two medication carts observed.
Findings include:
Observation on 10/17/22 at approximately 9:00 a.m. of the facility medication room revealed the following expired medications:
3 bottles of saline nasal spray, expiration date 5/22
Observation on 10/17/22 at approximately 9:05 a.m. of the South Medication Cart revealed the following expired medication:
1 vial of Resident #22's Levemir insulin, labeled with an expiration date of 10/12/22
Interview on 10/17/22 at approximately 9:10 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings.
Review on 10/17/22 of the manufacturers' instructions for Levemir insulin (Revision date of 7/22) revealed:
After the vials have been opened:
.
Throw away all opened Levemir vials after 42 days, even if they still have insulin left in them.
.
Review on 10/18/22 of the facility policy titled, Medication Storage in the Facility, Storage of Medications, Effective Date, May 2018 revealed:
.
H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, and disposed of according to procedures for medication disposal, .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing ant...
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Based on record review and interview, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 1 out of 6 months reviewed antibiotic use.
Findings include:
Review on 10/18/22 of the facility's Antibiotic Line Listings revealed that three were no entries in September 2022.
Review on 10/18/22 of the pharmacy report titled, Antibiotic Usage Report, dated September 2022 revealed that 7 residents were prescribed antibiotics in September 2022.
Interview on 10/18/22 at approximately 2:30 p.m. with Staff C (Assistant Director of Nursing) revealed that the antibiotics prescribed during the time above were not evaluated for meeting criteria and Staff C confirmed that there was no antibiotic monitoring, tracking, or reviewing done in September 2022.
Review on 10/18/22 of the facility policy titled, [pronoun omitted] and Rehab Antibiotic Stewardship Program, Adopted Date 11/28/17 revealed:
.
4.4 The Infection Preventionist (IP) will track antibiotic starts, perform antibiotic Time Outs, monitor adherence to evidence-based published criteria during the evaluation and management of treated infections, and review antibiotic-resistant patterns in the facility to understand which infections are caused by resistant organisms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure surveillance testing for COVID-19 was performed for staff who were not up to date with COVID-19 vaccination b...
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Based on interview and record review, it was determined that the facility failed to ensure surveillance testing for COVID-19 was performed for staff who were not up to date with COVID-19 vaccination based on level of community transmission for 3 of 5 staff reviewed for COVID-19 vaccination.
Findings include:
Review on 10/17/22 of the facility COVID-19 Staff Vaccination Status for Providers revealed the following staff members were unvaccinated:
Staff J (Maintenance) hire date 2/23/22, Staff I (Licensed Practical Nurse) hire date 3/18/22 and Staff K (Activity Aide) 1/3/22.
Review on 10/18/22 of the Rapid COVID-19 antigen (Ag) Card Tracking log for 6/1/22 through 10/12/22 revealed the following COVID-19 were performed on the above staff:
Staff I - 6/1/22, 7/5/22, 8/10/22, and 10/5/22
Staff J - 6/1/22, 7/13/22, 8/17/22, 9/21/22, and 10/5/22
Staff K - 7/27/22
Review on 10/18/22 of the CDC (Center for Disease Control) County Positivity Rates for Hillsborough County, New Hampshire from 6/1/22 through 10/12/22 revealed the following:
6/1/22 - 6/23/22 high transmission rate
6/24/22 - 6/26/22 substantial transmission rate
6/27/22 - 7/7/22 high transmission rate
7/8/22 - 7/10/22 substantial transmission rate
7/11/22 - 8/12/22 high transmission rate
8/13/22 - 8/18/22 substantial transmission rate
8/19/22 - 9/6/22 high transmission rate
9/7/22 - substantial transmission rate
9/8/22 - 9/16/22 high transmission rate
9/17/22 - 9/18/22 substantial transmission rate
9/19/22 - 10/12/22 high transmission rate
Interview on 10/18/22 at approximately 1:30 p.m. with Staff C (Assistant Director of Nursing) confirmed that the facility has no other documented evidence of the the above 3 unvaccinated staff members being tested for COVID-19 from 6/1/22 through 10/12/22.
Review on 9/28/22 of the Centers for Medicare & Medicaid Services (CMS) memo QSO-20-38-NH titled, Interim Final Rule (IFR), CMS-340-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, revision date of 3/10/22 revealed:
.Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community .
When the level of COVID-19 community transmission is HIGH then testing of staff who are not up to date with COVID-19 vaccination should be conducted at a minimum of twice a week.
Review of the facility policy titled, Mandatory Vaccination Policy, undated revealed:
.
COVID-19 Testing
If an employee covered by this policy is not fully vaccinated (e.g., if they are granted an exception from the mandatory vaccination requirement because the vaccine is contraindicated for them), the employee will be required to comply with the policy for testing. Employees who report to the workplace at least once every seven days:
(A) must be tested for COVID-19 at least once every seven days: .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to do a Quarterly Minimal Data Set (MDS) assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to do a Quarterly Minimal Data Set (MDS) assessment three months after the previous MDS assessment was completed for 6 out of 6 residents reviewed for resident assessment in a final sample of 18 residents (Resident Identifiers are #1, #2 #3, #4, #5, and #6).
Findings Include:
Resident #1:
Review on 10/18/22 of Resident #1's Medical Record revealed that Resident #1's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #1 revealed that Record Submitted Late: The submission date is more than 14 days after Z0500B on this new assessment.
Resident #2:
Review on 10/18/22 of Resident #2's Medical Record revealed that Resident #2's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #2 revealed that The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #3:
Review on 10/18/22 of Resident #3's Medical Record revealed that Resident #3's last Quarterly MDS Assessment was submitted on 6/15/22. Further review revealed that the next quarterly review needed to be completed by 9/14/22 with a submission date of 10/12/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #3 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #4:
Review on 10/18/22 of Resident #4's Medical Record revealed that Resident #4's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #4 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #5:
Review on 10/18/22 of Resident #5's Medical Record revealed that Resident #5's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #5 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #6:
Review on 10/18/22 of Resident #6's Medical Record revealed that Resident #6's last Quarterly MDS Assessment was submitted on 6/15/22. Further review revealed that the next quarterly review needed to be completed by 9/14/22 with a submission date of 10/12/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #6 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Interview on 10/18/22 at 10:30 a.m. with Staff C (Citation Text for Tag 0638, Regulation FF11
[NAME], [NAME] M.
Based on record review and interview, it was determined that the facility failed to do a Quarterly Minimal Data Set (MDS) assessment three months after the previous MDS assessment was completed for 6 out of 6 residents reviewed for resident assessment in a final sample of 18 residents (Resident Identifiers are #1, #2 #3, #4, #5, and #6).
Findings Include:
Resident #1:
Review on 10/18/22 of Resident #1's Medical Record revealed that Resident #1's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #1 revealed that Record Submitted Late: The submission date is more than 14 days after Z0500B on this new assessment.
Resident #2:
Review on 10/18/22 of Resident #2's Medical Record revealed that Resident #2's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #2 revealed that The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #3:
Review on 10/18/22 of Resident #3's Medical Record revealed that Resident #3's last Quarterly MDS Assessment was submitted on 6/15/22. Further review revealed that the next quarterly review needed to be completed by 9/14/22 with a submission date of 10/12/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #3 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #4:
Review on 10/18/22 of Resident #4's Medical Record revealed that Resident #4's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #4 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #5:
Review on 10/18/22 of Resident #5's Medical Record revealed that Resident #5's last Quarterly MDS Assessment was submitted on 6/8/22. Further review revealed that the next quarterly review needed to be completed by 9/7/22 with a submission date of 10/5/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #5 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Resident #6:
Review on 10/18/22 of Resident #6's Medical Record revealed that Resident #6's last Quarterly MDS Assessment was submitted on 6/15/22. Further review revealed that the next quarterly review needed to be completed by 9/14/22 with a submission date of 10/12/22. Review of the Centers for Medicaid and Medicare Services (CMS) MDS Validation Report for Resident #6 revealed that Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
Interview on 10/18/22 at 10:30 a.m. with Staff C (Assistant Director of Nursing), revealed that all six assessments were not completed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New Hampshire facilities.
Concerns
- • Multiple safety concerns identified: Special Focus Facility. Review inspection reports carefully.
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Goffstown Nursing And Rehab Center's CMS Rating?
CMS assigns GOFFSTOWN NURSING AND REHAB CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New Hampshire, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Goffstown Nursing And Rehab Center Staffed?
CMS rates GOFFSTOWN NURSING AND REHAB CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.
What Have Inspectors Found at Goffstown Nursing And Rehab Center?
State health inspectors documented 41 deficiencies at GOFFSTOWN NURSING AND REHAB CENTER during 2022 to 2024. These included: 36 with potential for harm and 5 minor or isolated issues.
Who Owns and Operates Goffstown Nursing And Rehab Center?
GOFFSTOWN NURSING AND REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 41 certified beds and approximately 33 residents (about 80% occupancy), it is a smaller facility located in GOFFSTOWN, New Hampshire.
How Does Goffstown Nursing And Rehab Center Compare to Other New Hampshire Nursing Homes?
Compared to the 100 nursing homes in New Hampshire, GOFFSTOWN NURSING AND REHAB CENTER's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Goffstown Nursing And Rehab Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Goffstown Nursing And Rehab Center Safe?
Based on CMS inspection data, GOFFSTOWN NURSING AND REHAB CENTER has documented safety concerns. The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New Hampshire. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Goffstown Nursing And Rehab Center Stick Around?
GOFFSTOWN NURSING AND REHAB CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Goffstown Nursing And Rehab Center Ever Fined?
GOFFSTOWN NURSING AND REHAB CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Goffstown Nursing And Rehab Center on Any Federal Watch List?
GOFFSTOWN NURSING AND REHAB CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.