Inspection Reports for
Goffstown Nursing and Rehab Center
29 CENTER STREET, Goffstown, NH, 03045
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
241% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 10
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, financial access, discharge procedures, equipment safety, and other facility operations at Goffstown Nursing and Rehab Center.
Findings
The facility was found deficient in multiple areas including failure to inform residents about psychotropic medication risks, limited resident access to personal funds during off hours, improper medication disposal, failure to maintain residents' range of motion, untimely pharmacist review of medication irregularities, medication administration errors exceeding 5%, expired and unlabeled medications on carts, and failure to maintain a resident's humidifier per manufacturer instructions.
Deficiencies (10)
Failed to inform resident or representative of risks and benefits of psychotropic medication use.
Failed to ensure residents had access to personal funds during off business hours.
Failed to ensure PRN orders for antipsychotic drugs are limited to 14 days without physician evaluation.
Failed to ensure documented discharge summary, medication reconciliation, or post-discharge plan for discharged resident.
Failed to dispose of medication in proper receptacle during medication administration observation.
Failed to provide services to maintain/prevent decrease in range of motion/mobility for resident.
Failed to ensure pharmacist irregularities were reviewed timely during monthly medication regimen review.
Medication error rate exceeded 5% during observed medication administrations.
Failed to remove expired medication and label medications with shortened shelf life on medication carts.
Failed to maintain resident humidifier per manufacturer's instructions and facility policy.
Report Facts
Residents reviewed for unnecessary medications: 12
Residents affected by psychotropic medication information deficiency: 1
Residents affected by personal funds access deficiency: 25
Residents affected by PRN antipsychotic order deficiency: 1
Residents affected by discharge summary deficiency: 1
Medications observed during disposal observation: 27
Residents observed for mobility and positioning: 1
Residents reviewed for pharmacist medication irregularities: 5
Medication administrations observed: 27
Medication errors observed: 3
Medication error rate: 11.11
Medication carts observed: 2
Resident humidifier water level: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Director of Nursing | Confirmed findings related to psychotropic medication information, PRN orders, discharge summary, medication disposal, range of motion care, and humidifier maintenance |
| Staff E | Business Office Manager | Confirmed residents must request cash during business hours due to lack of access during off hours |
| Staff A | Licensed Practical Nurse | Observed medication disposal errors and medication administration errors |
| Staff G | Rehabilitation Director | Confirmed occupational therapy intervention for wrist splint application |
| Staff B | Administrator | Confirmed pharmacist medication irregularity review findings |
| Staff H | Licensed Practical Nurse | Confirmed humidifier observation and maintenance issues |
| Staff D | Director of Social Services | Confirmed lack of discharge documentation |
Inspection Report
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to manage their personal financial affairs, specifically regarding access to personal funds during off business hours.
Findings
The facility failed to ensure residents had access to their personal funds during evenings and weekends as staff did not have access to the facility's petty cash during off hours, limiting residents' ability to obtain cash outside regular business hours.
Deficiencies (1)
Failure to ensure residents had access to their personal funds during off business hours.
Report Facts
Residents with personal accounts managed by facility: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding access to residents' personal funds during off hours |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Oct 22, 2024
Visit Reason
The inspection was conducted to investigate multiple complaints including failure to provide Medicaid/Medicare beneficiary notices, failure to report and investigate alleged neglect related to resident falls, failure to perform neurological assessments after falls, failure to identify trauma triggers for PTSD, failure to ensure RN coverage, failure to implement gradual dose reductions for psychotropic medications, failure to submit accurate staffing data, failure to follow infection control protocols, failure to monitor antibiotic use, and failure to maintain resident care equipment.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed in multiple regulatory requirements including notification of Medicare beneficiary rights, reporting and investigating neglect, neurological assessments after falls, trauma-informed care, staffing requirements, medication management, infection control, antibiotic stewardship, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide required beneficiary notices to residents, failure to timely report and investigate neglect allegations, failure to perform neurological assessments after a fall, failure to identify PTSD trauma triggers, failure to ensure RN coverage for 8 consecutive hours on certain days, failure to document gradual dose reductions for psychotropic medications, failure to submit complete staffing data to CMS, failure to follow CDC PPE guidance for residents on enhanced barrier precautions, failure to monitor antibiotic use appropriately, and failure to maintain the hoyer lift equipment according to manufacturer instructions.
Deficiencies (11)
Failed to ensure residents were informed of Skilled Nursing Facility Advance Beneficiary Notice prior to discharge from Medicare Part A services for 2 of 3 residents reviewed.
Failed to timely report alleged violations of neglect to the State Survey Agency for 1 of 3 residents reviewed for falls.
Failed to thoroughly investigate alleged violations of neglect for 1 of 3 residents reviewed for falls.
Failed to perform neurological assessments after a resident fell and hit their head for 1 of 3 residents reviewed for falls.
Failed to identify trauma triggers to eliminate or mitigate re-traumatization for 1 of 1 residents reviewed for PTSD.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours a day, 7 days a week, for 3 of 30 days reviewed.
Failed to ensure residents taking psychotropic medications received a Gradual Dose Reduction or documentation if clinically contraindicated for 1 of 5 residents reviewed.
Failed to submit complete and accurate direct care staffing information to CMS for Fiscal Quarter 3 (April 1, 2024 - June 30, 2024).
Failed to follow CDC guidance for wearing Personal Protective Equipment for Enhanced Barrier Precautions for 1 of 1 residents reviewed with an indwelling catheter.
Failed to implement a program that monitors antibiotic use, including tracking and reviewing antibiotic use for 9 of 12 months reviewed.
Failed to maintain resident care equipment according to manufacturer's instructions for the hoyer lift.
Report Facts
Residents reviewed for beneficiary notices: 3
Residents reviewed for falls: 15
Days without RN coverage: 3
Residents reviewed for unnecessary medications: 5
Fiscal quarter missing staffing data: 3
Months without antibiotic monitoring: 9
Facility sample size for infection control: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Director of Social Services | Confirmed failure to complete SNF ABN forms for residents #135 and #136 |
| Staff A | Administrator | Unaware of fall incident and unable to provide investigation documentation; confirmed failure to identify PTSD triggers; confirmed lack of neurological assessment documentation |
| Staff I | Licensed Nursing Assistant | Reported details of fall incident involving Resident #26 |
| Staff E | Scheduler | Confirmed no RN on duty on specified dates |
| Staff B | Director of Nursing | Confirmed no RN coverage for 8 consecutive hours on certain days; confirmed no documentation of gradual dose reduction for psychotropic medication |
| Staff F | Business Office Manager | Confirmed failure to submit staffing data to CMS |
| Staff M | Licensed Nursing Assistant | Confirmed providing care without PPE for Resident #32 |
| Staff C | Infection Prevention | Confirmed Resident #32 was not on Enhanced Barrier Precautions; confirmed lack of antibiotic monitoring |
| Staff J | Maintenance Director | Confirmed lack of routine maintenance and inspection of hoyer lift |
| Staff K | Licensed Nursing Assistant | Reported hoyer lift difficult to maneuver |
| Staff L | Licensed Nursing Assistant | Reported hoyer lift was hard to move and wobbly |
Inspection Report
Routine
Deficiencies: 13
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including care planning, physician orders, pressure ulcer care, staff competencies, nurse staffing, medication management, infection control, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to update care plans after resident falls, failure to follow physician orders for multiple residents, inadequate pressure ulcer documentation, lack of staff competency assessments, insufficient RN coverage, failure to post daily nurse staffing data, improper medication management, failure to provide adaptive eating equipment, improper garbage disposal, failure to report a COVID-19 outbreak, lack of antibiotic stewardship monitoring, and failure to properly document pneumococcal vaccinations.
Deficiencies (13)
Failed to update a resident's care plan with new or revised interventions after a fall.
Failed to follow physician orders for 5 residents including fluid restrictions and medication administration.
Failed to ensure weekly assessments with measurements and descriptions for a resident's pressure ulcer.
Failed to ensure licensed nursing staff demonstrated necessary competencies for resident care.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours a day, 7 days a week, for 5 of 90 days reviewed.
Failed to post nursing staffing data daily in the facility common areas.
Failed to provide a stop date for a PRN psychotropic medication for one resident.
Failed to follow manufacturer's recommendations for medication storage and use of an open multidose vial of insulin past discard date.
Failed to provide residents with necessary adaptive eating equipment as ordered.
Failed to properly dispose of garbage and refuse in a covered dumpster.
Failed to report a COVID-19 outbreak involving 16 of 29 residents to the State Department of Public Health.
Failed to implement an antibiotic stewardship program that monitors antibiotic use.
Failed to revise pneumococcal vaccination policy and ensure monitoring and recording of vaccinations for 4 residents.
Report Facts
Residents reviewed: 13
Residents affected: 1
Residents affected: 5
Residents affected: 1
Licensed staff reviewed: 7
Days without RN coverage: 5
Medication administration errors: 15
Residents requiring adaptive equipment: 6
Residents affected: 4
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Confirmed findings related to care plan update and psychotropic medication stop date |
| Staff B | Infection Preventionist | Confirmed findings related to physician orders, RN staffing, antibiotic stewardship, and vaccination documentation |
| Staff C | Administrator | Confirmed findings related to nurse staffing posting and COVID-19 outbreak reporting |
| Staff D | Licensed Nursing Assistant | Confirmed findings related to care plan update and adaptive equipment use |
| Staff F | Medication Nursing Assistant | Confirmed medication storage deficiency |
| Staff G | Dietary Manager | Confirmed findings related to adaptive eating equipment |
| Staff H | Nurse Practitioner | Confirmed medication administration errors |
| Staff E | Unit Manager | Confirmed failure to notify physician of fluid restriction violations |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation to assess allegations of abuse, neglect, and compliance with staffing and training requirements at Goffstown Nursing and Rehab Center.
Complaint Details
The complaint investigation was triggered by an allegation that Staff B (LNA) did not treat Resident #1 with respect and engaged in inappropriate behavior. The facility's investigation was incomplete, lacking documentation of interviews with other staff and residents. Staff B was suspended pending investigation.
Findings
The facility failed to update and implement adequate policies and procedures for screening contracted agency staff, failed to thoroughly investigate alleged abuse, did not verify licensure and training of agency staff, lacked contracts with staffing agencies, and failed to provide required in-service training and education to staff on abuse prevention and dementia care.
Deficiencies (7)
Failed to update and implement policies and procedures to ensure screening of contracted agency staff prior to working.
Failed to ensure all alleged violations of abuse were thoroughly investigated for one resident.
Failed to verify licensure and training requirements for contracted agency Licensed Nursing Assistants.
Failed to establish and implement policies regarding management and operation of the facility.
Failed to ensure a contract existed with the staffing agency providing nursing services.
Failed to provide staff education on dementia care and abuse, neglect, and exploitation reporting.
Failed to ensure required in-service training was conducted and maintained for nurse aides.
Report Facts
Shifts worked by Staff B: 22
Shifts worked by Staff B: 9
Shifts worked by Staff B: 32
Shifts worked by Staff B: 24
Dates Staff B worked in May 2023: 12
Number of staff reviewed for training: 6
Number of nurse aides reviewed for in-service training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Confirmed facility policies, investigation process, and training deficiencies |
| Staff B | Licensed Nursing Assistant (LNA) | Involved in abuse allegation, worked multiple shifts, had expired license, lacked verified training |
| Staff C | Corporate Assistant | Confirmed staffing dates for Staff B |
| Staff D | Licensed Practical Nurse (LPN) | Contracted agency staff reviewed for screening and training |
| Staff E | Licensed Nursing Assistant (LNA) | Contracted agency staff reviewed for screening and training |
| Staff F | Licensed Practical Nurse/Staff Development Coordinator | Confirmed training and orientation deficiencies |
| Staff G | Social Services | Participated in abuse investigation interview |
| Staff H | Medication Nursing Assistant (MNA) | Interviewed regarding training on abuse and neglect |
| Staff J | Licensed Nursing Assistant (LNA) | Interviewed regarding training on abuse and neglect |
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