Hackett Hill Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, New Hampshire.
- Location
- 191 Hackett Hill Road, Manchester, New Hampshire 03102
- CMS Provider Number
- 305038
- Inspections on file
- 17
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hackett Hill Healthcare Center during CMS and state inspections, most recent first.
A resident admitted with a right groin wound did not receive physician-ordered wound care because no treatment orders were transcribed or implemented at admission. The wound went untreated for seven days, resulting in deterioration and subsequent hospitalization for surgical debridement.
A wound nurse did not consistently perform hand hygiene or use required PPE during a dressing change for a resident on Enhanced Barrier Precautions. The nurse failed to clean hands between glove changes, did not perform hand hygiene after removing gloves and gown, and did not don a gown when returning to complete wound care, contrary to facility policy and CDC guidelines.
Two residents were prescribed psychotropic medications for anxiety without documented consent regarding the risks and benefits of these medications, as required by facility policy. This was confirmed by the Clinical Lead and through review of medical records.
Three residents experienced deficiencies in care when staff failed to follow professional standards: a LPN administered insulin based on an outdated CBG result, a resident received IV antibiotics without a specified infusion rate or proper labeling, and another resident had a dressing applied without a physician's order or date.
Staff failed to disinfect a glucometer between use on two residents during blood glucose testing and did not use required PPE, including a gown and face shield, when accessing a resident's PICC line. These actions were not in accordance with facility infection control policies and Enhanced Barrier Precautions.
A resident's CPAP machine components, including the head strap and tubing, were found to be discolored and in disrepair, with staff confirming that these parts had not been replaced since the resident's admission. This occurred despite orders and manufacturer instructions requiring regular replacement of deteriorated equipment.
Two residents who remained in the facility after Medicare coverage ended were not given written notice detailing the specific items, services, and associated charges for which they could be held financially responsible. Instead, the facility provided only a general 'Medicaid Rate' without itemizing costs, and this practice was confirmed by the Clinical Care Coordinator.
A hospice agency and facility failed to provide coordinated services for a resident, resulting in discrepancies between the care plan and actual services. The lack of communication and coordination led to missed hospice visits and unavailability of nursing assistants and volunteers.
The facility failed to maintain a medication error rate below 5%, with errors involving improper insulin administration for a resident and incorrect administration route for another resident's medication, resulting in a 10.34% error rate.
The facility failed to label open injectable medications according to manufacturer's instructions and did not monitor refrigeration temperatures daily for medication storage. Open Lantus Insulin Pen and Tuberculin Purified Derivative were found without open or expiration dates, and several days of temperature logs were missing.
A resident with Bilateral Hearing Loss did not receive necessary treatment after an audiology visit revealed excessive ear wax, making it difficult to determine the degree of hearing loss. Despite recommendations for a medical consult, no further treatment was provided.
Failure to Obtain and Implement Admission Orders for Wound Care
Penalty
Summary
A deficiency occurred when a resident was admitted with a puncture wound to the right groin, but no physician's orders for wound treatment were obtained at the time of admission. The resident's clinical admission assessment documented the presence of the wound, and the hospital discharge summary included instructions for daily wound care. However, a review of the admission orders and the Treatment Administration Record (TAR) showed that no wound treatment orders were transcribed or carried out for the right groin wound. As a result, the resident went seven days without any wound treatment after admission. During a vascular surgery follow-up appointment, it was noted that the dressing had not been changed, and the wound had deteriorated, showing signs of dehiscence, maceration, slough, and seroma drainage. This led to the resident being hospitalized for surgical debridement. The Director of Nursing confirmed that the wound had not been treated during this period.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during a dressing change for a resident under Enhanced Barrier Precautions (EBP). The wound nurse performed hand hygiene and donned gloves and a gown before starting the dressing change. However, after removing the initial wound dressing, the nurse changed gloves without performing hand hygiene in between. Following wound cleansing, the nurse removed their gown and gloves, exited the room, and did not perform hand hygiene before retrieving additional supplies from the treatment cart. Upon returning to the resident's room, the nurse performed hand hygiene and donned gloves but did not put on a gown before applying treatment and a new dressing to the wound. These actions were confirmed by the nurse during an interview. Review of facility policies and CDC guidelines indicated that hand hygiene should be performed before donning gloves, immediately after glove removal, and that gowns and gloves are required for high-contact activities such as wound care under EBP.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform two residents or their representatives about the risks and benefits associated with the use of psychotropic medications. For one resident, a physician's order for Ativan (Lorazepam) was initiated for anxiety, but there was no documentation of consent for the medication's use. Similarly, another resident was prescribed Buspirone HCL for anxiety, and again, no documentation of consent was found in the medical record. These findings were confirmed by the Clinical Lead during an interview. Review of the facility's policy indicated that consent should be obtained when a medication is ordered for behavioral symptoms, but this was not followed in these cases.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to follow professional standards of care for three residents. For one resident, a LPN administered insulin based on a capillary blood glucose (CBG) result that was obtained by a nurse on the previous shift and recorded on a piece of paper, rather than performing the CBG immediately prior to insulin administration as required by the physician's sliding scale order. The nurse practitioner confirmed that CBGs should be performed closer to the time of administration or meals when using a sliding scale for insulin. For another resident, a review of physician orders for intravenous Ertapenem revealed that the order did not specify an infusion rate. Observation showed an IV bag in the resident's room with only a handwritten label and no pharmacy label or infusion rate indicated. Additionally, a third resident was found to have a dressing applied to the lower left thigh without a corresponding physician's order, and the dressing was undated. The nurse who applied the dressing confirmed that it was done without an order, and the treatment administration record did not show an active order for this intervention.
Failure to Follow Infection Control Policies for Glucometer Disinfection and PPE Use
Penalty
Summary
Staff failed to follow infection prevention and control policies in two separate instances. In the first instance, a Medication Nursing Assistant was observed moving between two residents' rooms to perform capillary blood glucose (CBG) testing without disinfecting the glucometer between uses. The staff member carried the glucometer and supplies in a cup but did not have cleaning or disinfecting wipes, and confirmed during interview that the device was not disinfected between residents, contrary to facility policy and manufacturer instructions which require cleaning with an EPA-approved disinfectant before and after each use. In the second instance, a Registered Nurse accessed a resident's Peripherally Inserted Central Catheter (PICC) line without wearing a face shield or protective gown, as required by the facility's infection control standards and Enhanced Barrier Precautions (EBP) policy. The nurse confirmed not using the required personal protective equipment (PPE), and the facility's Infection Preventionist also confirmed that PPE should have been worn during this procedure. The resident involved had a PICC line, which is considered an indwelling medical device, and the policy specifies the use of gown, gloves, and face protection for such care activities.
Failure to Maintain and Replace CPAP Equipment per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain patient care equipment according to the manufacturer's instructions for a resident receiving respiratory care. The resident reported that parts of their Continuous Positive Airway Pressure (CPAP) machine, specifically the headpiece, needed replacement and that no assistance had been provided. Observation confirmed that the head strap was discolored and in disrepair, and the tubing was yellowed. Staff interviews verified that the face mask, tubing, and headgear had not been changed since the resident's admission in July 2024. Review of the treatment order indicated that CPAP supplies were to be changed or cleaned per manufacturer’s instructions, and the manufacturer’s guidelines specified that visibly deteriorated components should be replaced. Despite this, the equipment had not been replaced as required.
Failure to Provide Written Notice of Charges After Medicare Coverage Ends
Penalty
Summary
The facility failed to provide written notice to residents and/or their representatives regarding the specific items and services offered, the charges for those services, and the amount of those charges when Medicare coverage ended and the residents remained in the facility. For two residents who were discharged from Medicare services but continued to reside in the facility, the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) did not include a detailed list of services and associated costs. Instead, the facility listed only the 'Medicaid Rate' as the per day/item or service charge, without specifying the actual services or their individual costs. Record reviews confirmed that both residents' SNF ABNs lacked the necessary information about potential financial liability for non-covered services. An interview with the Clinical Care Coordinator verified that it was standard practice to write 'Medicaid Rate' rather than providing an estimated cost breakdown for items and services. This omission resulted in residents and their representatives not being properly informed, in writing, about the facility's charges and their potential financial responsibility after Medicare coverage ended.
Failure to Provide Coordinated Hospice Services
Penalty
Summary
The hospice agency and the facility failed to provide collaborative services for a resident receiving hospice care. The resident's care plan indicated that hospice nursing was to be provided 2-3 times a week and as needed, along with other services such as social work and volunteer visits. However, the hospice plan of care showed a different frequency of visits, and the medical record only documented sporadic nursing visits with no notes from other hospice services. Interviews with staff revealed a lack of communication and coordination between the hospice agency and the facility, resulting in discrepancies between the care plans and the actual services provided. The facility's policy requires that hospice services meet professional standards and that a coordinated plan of care be established and agreed upon. However, the hospice liaison admitted there was no communication regarding visit schedules, and the hospice agency did not have nursing assistants or volunteers available for the resident. This lack of coordination and communication led to the failure to provide the necessary hospice services as outlined in the resident's care plan and the hospice plan of care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was not 5 percent or greater for two residents observed for medication administration. For Resident #24, a Licensed Practical Nurse (LPN) prepared and administered 16 units of Novolin N Insulin without following proper procedures. The LPN did not roll the insulin pen to ensure the correct dosage, did not prime the pen, and did not wait the required 5 seconds before removing the pen from the resident's abdomen. The resident's Medication Administration Record (MAR) confirmed the physician's order for 16 units of Novolin N Insulin and 81 mg of Aspirin for cardiac health. The manufacturer's instructions and the facility's procedure for insulin administration were not followed, as confirmed by the LPN during an interview. For Resident #41, another LPN administered Miralax Oral Powder through the resident's Jejunostomy tube, contrary to the physician's order to give it by mouth. The MAR confirmed the order for Miralax to be given orally for bowel management. The LPN confirmed the error during an interview. These errors contributed to a medication error rate of 10.34%, with 3 errors out of 29 medication administration opportunities.
Failure to Label and Monitor Medications Properly
Penalty
Summary
The facility failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions. During an observation of the Webster Street Medication Cart, an open Lantus Insulin Pen was found without an open or open expiration date. This finding was confirmed by a Registered Nurse. The manufacturer's instructions for the Lantus Insulin Pen specify that it should be discarded 28 days after opening. Additionally, an open vial of Tuberculin Purified Derivative was found in the Derryfield Medication Room without an open or open expiration date, which was also confirmed by a Registered Nurse. The manufacturer's instructions for this medication state that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency. The facility's policy requires that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer, which was not adhered to in these instances. Furthermore, the facility failed to monitor refrigeration temperatures daily for medication storage. A review of the medication refrigerator logs for March 2024 revealed missing temperature recordings on several dates. This was confirmed by a Registered Nurse. The facility's policy mandates that the temperature of medication storage areas be monitored at least once a day, which was not consistently followed. These deficiencies indicate lapses in the facility's adherence to its own policies and the manufacturer's instructions for medication storage and labeling.
Failure to Provide Treatment for Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident received treatment for hearing loss. The resident, who was very hard of hearing and had a medical diagnosis of Bilateral Hearing Loss, reported having wax in their ears. An audiology visit revealed that the degree of hearing loss could not be determined due to excessive wax in both ear canals. Although some wax was removed, the resident could not tolerate further cleaning, and a medical consult was needed for wax removal orders. Despite these findings, the resident had not received any treatment after the audiology consult.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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