Alpine Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Keene, New Hampshire.
- Location
- 298 Main Street, Keene, New Hampshire 03431
- CMS Provider Number
- 305062
- Inspections on file
- 19
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Alpine Healthcare Center during CMS and state inspections, most recent first.
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency as required by its abuse policy. In one case, an LNA was seen holding a resident off the ground with the resident’s back against the LNA’s chest while moving the resident. In another case, a resident was found with unexplained facial scratches and blood, which was reported internally but not to the state. In a third incident, an RN observed an LNA yelling at a resident to get into bed and then picking the resident up from the floor and forcefully placing the resident onto the bed. In each situation, leadership, including the Administrator and DON, were informed, but the allegations were not reported to the state within the required timeframes.
Two residents were involved in separate alleged abuse incidents by the same LNA that were not investigated as required by facility policy. In one case, an LNA reported witnessing another LNA hold a resident with the resident’s back against the LNA’s chest and the resident’s feet off the ground while being moved. In the other case, an RN reported seeing a resident screaming beside the bed while an LNA yelled at the resident to get into bed, then picked the resident up off the floor and forcefully placed the resident onto the bed. The administrator and DON acknowledged being informed of these allegations but did not initiate investigations or remove the alleged perpetrator from duty, contrary to the facility’s abuse, neglect, and exploitation policy that mandates immediate, thorough investigation and documentation of all alleged violations.
A resident was manually restrained and moved by an LNA, who held the resident from behind with the resident’s back against the LNA’s chest and feet off the ground after the resident reportedly became combative and struck the LNA. Another LNA witnessed the incident and later reported it. Review of the medical record showed no documentation of behaviors or use of a manual restraint around the time of the incident, no related entries on the Treatment Administration Report, and no care plan interventions for manual behavior management. The DON confirmed these findings and that the facility lacked a policy governing the use of manual physical restraints.
The facility failed to follow its abuse, neglect, and exploitation policy by not promptly investigating or reporting multiple abuse-related incidents to the SSA. In one case, an LNA was observed holding a resident off the ground while moving the resident; in another, an RN reported that an LNA yelled at a resident and then picked the resident up from the floor and forcefully placed the resident in bed. A separate resident was found with facial scratches and blood of unknown origin, and this was reported internally but not to the SSA. Additionally, the LNA involved lacked a documented criminal background check, and several staff members had not received the required annual abuse-prevention education, despite policy requirements for pre-employment screening and ongoing staff training.
Surveyors identified multiple environmental deficiencies in the memory care unit, including chipped and missing paint on doorways, missing laminate on a closet, exposed and crumbling sheetrock, lifted floor tiles, a hole in hallway tile, and rough, exposed wood on handrails. Staff interviews confirmed these issues, and only one work order had been placed for the lifted tiles, with no work orders for the other deficiencies.
A resident with multiple wounds did not consistently receive wound care as ordered by the physician, with several missed treatments and no documentation of care completion or refusals. The DON confirmed that the medical record and TAR lacked required documentation for both completed and refused wound care.
A resident with a history of trauma and PTSD experienced distress after witnessing a confrontation, but their care plan did not include known trauma triggers such as loud noises and confrontation, despite staff awareness and facility policy requiring such documentation.
Surveyors found that expired and discontinued medications, including controlled substances and insulin pens, were not removed from use on two medication carts. Two residents' medications were involved, with staff confirming the presence of expired Morphine, Lorazepam, and insulin pens that were either unlabeled or past their in-use expiration dates.
Dishware was not properly sanitized because the chemical sanitizer solution in the three-compartment sink was not tested before use and was found to be below the required concentration. Documentation of testing was also missing, and staff confirmed the solution was not checked prior to washing dishware, contrary to facility procedures and manufacturer instructions.
A resident's care plan did not include the most recent hospice plan of care or a description of services provided by the hospice agency. The hospice binder lacked required documentation, and staff interviews revealed confusion about the resident's hospice status and missing details in the care plan.
Two residents and/or their representatives were not given timely SNF Advance Beneficiary Notices (ABN) regarding the end of Medicare Part A coverage. In one case, the ABN was not provided at all, and in another, notification was given only one day in advance instead of the required two days, as confirmed by staff and record review.
The facility did not follow its antibiotic stewardship program for May, June, and July 2024, failing to track or trend antibiotic use and appropriateness. Despite having protocols to optimize infection treatment and reduce adverse events, there was no data on antibiotic appropriateness or infection rates. This was confirmed by the Clinical Consultant and DON. Reports showed multiple antibiotics prescribed without systematic review.
The facility failed to secure lighters and cigarettes for two residents who required supervision with smoking. One resident kept smoking materials in their room, while another kept them in their jacket pocket, both contrary to their care plans. Staff interviews confirmed the residents were supposed to return these items to nursing staff, indicating a lapse in policy implementation.
The facility failed to maintain proper temperature documentation for medication storage and did not dispose of expired medications. In the Unit 2 Medication Room, temperature logs were incomplete, and recorded temperatures were outside the acceptable range. Additionally, an expired Lispro U-100 Insulin Kwikpen was found in the Unit 1 Treatment Cart, exceeding the manufacturer's 28-day usage guideline once opened.
The facility did not follow CDC guidelines for Enhanced Barrier Precautions for two residents with indwelling medical devices. One resident with an indwelling catheter had no PPE available, and another with a gastrostomy tube was attended to by an RN who only used gloves, despite orders requiring gowns, gloves, and masks. The facility's policy and CDC guidelines require gown and glove use during high-contact care activities to prevent MDRO spread.
Failure to Timely Report Multiple Alleged Abuse Incidents to State Agency
Penalty
Summary
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency (SSA) as required by its abuse, neglect, and exploitation policy. For one resident, a licensed nursing assistant (Staff D) reported witnessing another licensed nursing assistant (Staff C) holding the resident with the resident’s back against Staff C’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident occurred on or around January 1, 2026, but was not reported by Staff D until January 14, 2026. The Administrator (Staff A) confirmed awareness of this allegation as of January 14, 2026, and acknowledged that it was not reported to the SSA. For another resident, the Unit Manager (Staff I), who was on call, was notified on the night of November 19, 2025, that the resident was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. Staff I reported this to both the Administrator (Staff A) and the Director of Nursing (Staff B), and Staff A confirmed awareness of the incident on that date but did not report it to the SSA. In a separate incident involving a third resident, an email from an RN (Staff G) to the DON (Staff B) described observing the resident standing beside the bed screaming while an LNA (Staff C) yelled at the resident to get into bed; when the resident did not comply, Staff G observed Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed being informed of this incident on January 1, 2026, and Staff A confirmed that this allegation also was not reported to the SSA. These failures occurred despite a written facility policy requiring all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Investigate Alleged Abuse Incidents Involving Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that alleged violations of abuse were thoroughly investigated for two residents. For the first resident, a licensed nursing assistant (LNA), identified as Staff D, reported that he/she witnessed another LNA, identified as Staff C, holding the resident with the resident’s back against Staff C’s chest and arms around the resident, with the resident’s feet off the ground while being moved to another area. Staff D stated this incident occurred on or around January 1, 2026, and was reported on January 14, 2026. The Administrator, identified as Staff A, confirmed awareness of this incident as of January 14, 2026, and confirmed that the incident was not investigated. For the second resident, an email from a registered nurse (RN), identified as Staff G, to the Director of Nursing (DON), identified as Staff B, described an incident in which the RN opened the door to a resident’s room and observed the resident standing beside the bed screaming while LNA Staff C was yelling at the resident to get into bed. When the resident did not comply, the RN reported observing Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed receiving this email and stated that they did not remove Staff C from working and did not investigate the incident when notified. Review of the facility’s Abuse, Neglect and Exploitation policy showed that it requires an immediate investigation of any suspicion or report of abuse, including identifying responsible staff, preserving evidence, interviewing all involved persons, determining if abuse occurred, and providing complete documentation, which was not carried out in these cases.
Improper Use of Manual Physical Restraint Without Assessment or Care Plan
Penalty
Summary
The facility failed to ensure the appropriate use and documentation of a physical restraint for one resident when a staff member used a manual hold to control and move the resident without any corresponding assessment or care plan interventions. On or around January 1, 2026, a licensed nursing assistant (Staff C) reported that the resident had been combative and had struck Staff C in the nose and genitals, after which Staff C approached the resident from behind, put their arms around the resident’s shoulders, and moved the resident approximately four to five feet, with another licensed nursing assistant (Staff D) observing the resident’s back against Staff C’s chest, Staff C’s arms around the resident, and the resident’s feet off the ground while being moved. Staff C stated they believed the resident was a danger to self and others and that no one else wanted to intervene. Record review showed no progress notes around that date documenting behaviors or the use of a manual method to restrain the resident, no documented behaviors on the Treatment Administration Report from late December 2025 through mid-January 2026, and no care plan interventions addressing the use of a manual method for behavior management. The Director of Nursing confirmed these findings and also confirmed there was no facility policy for the use of physical restraint by manual method.
Failure to Report, Investigate, Screen, and Train Regarding Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy for reporting and investigating allegations of abuse, as well as failure to ensure required staff screening and abuse training. For one resident, a licensed nursing assistant (LNA) reported witnessing another LNA holding the resident with the resident’s back against the staff member’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident reportedly occurred on or around January 1, 2026, but was not reported by the witness until January 14, 2026. The administrator confirmed awareness of the allegation as of that date and acknowledged that the allegation was neither investigated nor reported to the State Survey Agency (SSA), contrary to the facility’s written abuse policy requiring immediate investigation and timely reporting. A second allegation involved another resident, where an RN emailed the DON describing an event in which the RN opened a resident’s room door and observed the resident standing beside the bed screaming while an LNA yelled at the resident to get into bed. When the resident did not comply, the RN reported that the LNA picked the resident up off the floor and forcefully placed the resident onto the bed. The DON confirmed being notified of this incident on the date it occurred and acknowledged that the incident was not investigated and not reported to the SSA, despite the facility’s policy requiring immediate investigation and reporting of alleged abuse within specified timeframes. A third incident involved a resident who was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. The unit manager, who was on call, reported this to both the administrator and the DON. The administrator confirmed that this incident, involving injuries of unknown origin, was not reported to the SSA. In addition, review of the human resources file for the LNA implicated in the above allegations showed no criminal background check, despite the facility’s policy requiring background, reference, and credential checks for potential employees and documentation that screening occurred. Review of staff education files for multiple staff members showed that required annual abuse education had not been provided since 2021 or 2023, contrary to the facility’s policy that existing staff receive annual training on abuse prohibition, recognition, and reporting.
Failure to Maintain Safe and Homelike Environment in Memory Care Unit
Penalty
Summary
Surveyors observed multiple deficiencies in the memory care unit related to the physical environment. Several resident room doorways were found to be chipped, scraped, and missing paint. In one room, the closet was missing a laminate piece in the lower corner, and a section of the lower wall had exposed sheetrock that was crumbling onto the floor due to the absence of a baseboard. Additionally, the floor in another room had 3-4 tiles lifting up in front of the bed, and a hole was noted in the hallway tile outside a resident room. The handrails along the main hallway were also observed to have faded paint and exposed wood, resulting in a rough surface. Interviews with staff confirmed these observations. A Licensed Medication Nursing Assistant acknowledged the conditions of the benches in the hallway and the issues in one of the rooms. The maintenance staff reported that a work order had been placed for the lifted tiles in one room since the previous month, but there were no work orders for the other observed deficiencies in the memory care unit. No information was provided regarding the medical history or condition of the residents in the affected rooms at the time of the deficiency.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care for a resident with multiple wounds, as evidenced by missing documentation of wound care completion on several dates. The resident reported not always receiving daily wound care, and review of the Treatment Administration Record (TAR) for May and June showed multiple instances where wound care was not documented as completed for both left and right wounds, including specific treatments such as cleansing, application of santyl, collagen, medi-honey, and dressing changes. There was also no documentation indicating that the resident refused care on these dates. During an interview, the Director of Nursing confirmed the findings and acknowledged that the resident occasionally refused care, but the medical record and TAR did not reflect refusals or provide explanations for missed treatments. The lack of documentation and failure to follow physician's orders for wound care constituted a deficiency in meeting professional standards of quality for the resident's pressure ulcers.
Failure to Identify and Document Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to ensure that trauma triggers were properly identified and documented for a resident with a known history of trauma and PTSD. Interviews and record reviews revealed that the resident experienced distress after witnessing an altercation between other residents, specifically being upset by hearing threatening language. The resident's social history and social services assessments both indicated a history of trauma and the presence of trauma triggers, but did not specify what those triggers were, despite the resident exhibiting symptoms such as anxiety, fear, irritability, mood changes, and sleep disturbances. Further investigation showed that staff were aware of the resident's trauma triggers, including loud noises and confrontation, but these were not included in the resident's care plan. The care plan referenced the resident's history of trauma and noted an incident where PTSD was triggered by a verbal argument, but failed to identify loud noises as a specific trigger. The facility's own policy requires that trauma triggers be identified and included in care plans to prevent re-traumatization, but this was not followed in this case.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from use on two of four medication carts inspected. For one resident, expired Morphine Sulfate IR and Lorazepam tablets were found on the medication cart, despite both medications having been discontinued in the previous year. Staff confirmed the presence of these expired and discontinued medications during the inspection, and a review of physician orders verified that these drugs were no longer prescribed for the resident. Additionally, another resident's insulin and treatment cart contained an open Lispro insulin pen with no documented open or expiration date, and an open Lantus Solostar insulin pen that had exceeded the manufacturer's recommended in-use period of 28 days. Staff confirmed these findings, and a review of manufacturer instructions supported that both insulin pens should have been discarded after 28 days of use. These observations indicate that the facility did not ensure proper labeling and timely removal of expired or discontinued medications from active medication storage areas.
Failure to Ensure Proper Dishware Sanitization Due to Inadequate Chemical Testing
Penalty
Summary
The facility failed to ensure proper sanitization of dishware in the kitchen, as observed when a cook tested the chemical sanitizer solution in the three-compartment sink and found it to be at 150 ppm, which is below the required 200-400 ppm for effective sanitization. There was no documentation on the Three-Compartment Sink Logs indicating that the sanitizer solution was tested prior to use that morning. The cook confirmed that the solution was not tested before washing dishware, and the log for that day was incomplete. Facility procedures and manufacturer instructions both require that the sanitizer be tested and within the specified range before use, but these steps were not followed.
Failure to Include Hospice Plan of Care and Service Details in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's written plan of care included both the most recent hospice plan of care and a description of the services provided by the hospice agency. Review of the resident's hospice binder revealed the absence of hospice certification, a hospice plan of care, and schedules of services furnished by the hospice agency. The resident's nursing home care plan for hospice did not contain a schedule or description of hospice services. During interviews, a registered nurse was unaware that the resident was still receiving hospice services and confirmed that the care plan lacked details about services provided by the hospice agency. The social services staff member, who coordinates services between the hospice agency and the facility, confirmed that the resident was currently receiving hospice services.
Failure to Provide Timely SNF Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) to residents and/or their representatives for two of three residents reviewed. For one resident, the last covered day of Medicare Part A skilled services was identified, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted; however, the SNF ABN was not signed by the resident, and staff confirmed that the notice was not provided. For another resident, the spouse was notified of the SNF ABN by telephone only one day prior to the last covered day of Medicare Part A services, rather than the required two days in advance, as confirmed by staff interview. Review of the facility's policy on Advanced Beneficiary Notices indicated that notices should be provided at least two days before the end of a Medicare covered Part A stay to allow residents or their representatives sufficient time to make decisions regarding services and financial responsibility. The failure to provide timely and properly documented ABNs for these residents constituted noncompliance with both facility policy and regulatory requirements.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to adhere to its established antibiotic stewardship program and system of monitoring antibiotic use for the months of May, June, and July 2024. The facility's policy, revised on May 23, 2023, outlines the purpose of the program to optimize infection treatment while reducing adverse events associated with antibiotic use. It includes protocols for using CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tools to define infections, and the Loeb Minimum Criteria to determine the necessity of antibiotic treatment. The policy also mandates monitoring the response to antibiotics and reviewing antibiotic orders for appropriateness upon admission or from consulting providers. However, a review of the facility's Line List/Antibiotic Stewardship binder revealed a lack of tracking or trending of antibiotics for the specified months, with no data on antibiotic appropriateness, facility or healthcare-acquired information, or infection rates. This deficiency was confirmed during an interview with the Clinical Consultant and the Director of Nursing. Additionally, a report from Pharmscript indicated that one resident was on antibiotic treatment for a urinary tract infection starting July 11, 2024, and previous reports showed 15 antibiotics prescribed in June and 9 in May, highlighting the absence of a systematic review process during these months.
Failure to Secure Smoking Materials for Residents
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not securing lighters and cigarettes for two residents who were identified as requiring supervision with smoking. Resident #7 was observed with a pack of cigarettes and a lighter on their overbed table, despite their care plan indicating that smoking materials should be returned to the nurses' desk after use. Interviews with the resident and staff confirmed that the resident kept smoking materials with them at all times, contrary to the facility's policy and the resident's care plan. Similarly, Resident #68 was found to keep cigarettes and a lighter in their jacket pocket, and they reported going to the smoking area alone. The resident's care plan required them to return smoking materials to the nursing staff after use, but this was not being followed. Staff interviews confirmed that the resident was supposed to return these items to the nursing staff, indicating a failure in implementing the facility's smoking safety policy.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to maintain proper documentation and temperature control for medication storage, as observed in the Unit 2 Medication Room. Specifically, the temperature logs for the medication refrigerator were incomplete, with missing entries on several dates in June and July 2024. Additionally, recorded temperatures on certain dates were outside the acceptable range of 36 to 46 degrees Fahrenheit, as specified by both the facility's policy and the manufacturer's instructions for Aplisol, a Tuberculin Purified Protein Derivative. This discrepancy was confirmed through interviews with facility staff, including a Med Tech and a Clinical Consultant. Furthermore, the facility did not dispose of expired medications as required. During an observation of the Unit 1 Treatment Cart, an open Lispro U-100 Insulin Kwikpen was found with an expiration date that had passed. The insulin, which was opened on 6/16/24, had an open expiration date of 7/14/24, exceeding the manufacturer's guideline of a 28-day usage period once opened. This finding was confirmed by a Registered Nurse during the inspection.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to CDC guidance for Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident #16, who had an indwelling catheter, was observed without any Personal Protective Equipment (PPE) available in or near their room. Staff H, a Licensed Nursing Assistant, confirmed that Resident #16 was not on EBP, and a review of the resident's care plan showed no EBP interventions for the indwelling catheter. Additionally, Resident #18, who had a gastrostomy tube, was observed being attended to by Staff C, a Registered Nurse, who donned only gloves while accessing the gastrostomy tube to administer medications. The physician's orders for Resident #18 included EBP, which required the use of gowns, gloves, and masks during high-contact care activities involving device care. The facility's policy and CDC guidelines both emphasize the necessity of using gown and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms (MDROs), especially for residents with indwelling medical devices.
Latest citations in New Hampshire
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency as required by its abuse policy. In one case, an LNA was seen holding a resident off the ground with the resident’s back against the LNA’s chest while moving the resident. In another case, a resident was found with unexplained facial scratches and blood, which was reported internally but not to the state. In a third incident, an RN observed an LNA yelling at a resident to get into bed and then picking the resident up from the floor and forcefully placing the resident onto the bed. In each situation, leadership, including the Administrator and DON, were informed, but the allegations were not reported to the state within the required timeframes.
Two residents were involved in separate alleged abuse incidents by the same LNA that were not investigated as required by facility policy. In one case, an LNA reported witnessing another LNA hold a resident with the resident’s back against the LNA’s chest and the resident’s feet off the ground while being moved. In the other case, an RN reported seeing a resident screaming beside the bed while an LNA yelled at the resident to get into bed, then picked the resident up off the floor and forcefully placed the resident onto the bed. The administrator and DON acknowledged being informed of these allegations but did not initiate investigations or remove the alleged perpetrator from duty, contrary to the facility’s abuse, neglect, and exploitation policy that mandates immediate, thorough investigation and documentation of all alleged violations.
A resident was manually restrained and moved by an LNA, who held the resident from behind with the resident’s back against the LNA’s chest and feet off the ground after the resident reportedly became combative and struck the LNA. Another LNA witnessed the incident and later reported it. Review of the medical record showed no documentation of behaviors or use of a manual restraint around the time of the incident, no related entries on the Treatment Administration Report, and no care plan interventions for manual behavior management. The DON confirmed these findings and that the facility lacked a policy governing the use of manual physical restraints.
The facility failed to follow its abuse, neglect, and exploitation policy by not promptly investigating or reporting multiple abuse-related incidents to the SSA. In one case, an LNA was observed holding a resident off the ground while moving the resident; in another, an RN reported that an LNA yelled at a resident and then picked the resident up from the floor and forcefully placed the resident in bed. A separate resident was found with facial scratches and blood of unknown origin, and this was reported internally but not to the SSA. Additionally, the LNA involved lacked a documented criminal background check, and several staff members had not received the required annual abuse-prevention education, despite policy requirements for pre-employment screening and ongoing staff training.
A resident developed new LUE swelling and was evaluated by a PA, who noted edema with minimal erythema, warmth, and tenderness, and arranged an emergent hospital transfer to rule out DVT. The hospital identified a closed radial head (elbow) fracture, and an RN received a verbal report from the ED about the fracture before the resident returned. Despite this information and a written policy requiring investigation and timely reporting of injuries of unknown source to state and local authorities, including submission of findings within five working days, the DON acknowledged that no report was made to the State Survey Agency for this fracture.
A resident developed new LUE swelling and was evaluated by a PA, who noted edema with slight tenderness and concern for possible DVT, leading to an emergent hospital transfer. Hospital records showed a closed radial head (elbow) fracture, but the DON reported that no investigation was conducted into the cause of this injury. This failure occurred despite a facility policy requiring that injuries of unknown source be entered into the risk management system and investigated within 24 hours to determine whether abuse or neglect occurred and to identify causative factors.
A resident with severe hypoalbuminemia developed new LUE swelling and was emergently transferred to the hospital for evaluation of possible DVT, where an elbow fracture with radial head fracture was diagnosed. Review of the medical record showed that no Notice of Transfer/Discharge or bed-hold notification was completed or filed for this unplanned, acute hospital transfer, despite facility policy requiring verbal and written notification to the resident and representative and placement of the completed transfer form in the chart. The DON confirmed that the required transfer notice was not provided.
A resident with LUE swelling was evaluated by a PA, who documented concern for possible DVT and arranged an emergent hospital transfer; the hospital later diagnosed a closed radial head (elbow) fracture and provided instructions for follow-up, arm elevation, and ice application. However, nursing staff did not document when the resident left for the hospital or when they returned, and there was no record of a post-return nursing assessment or review and implementation of hospital recommendations, contrary to the facility’s nursing documentation policy.
A resident admitted with a right groin wound did not receive physician-ordered wound care because no treatment orders were transcribed or implemented at admission. The wound went untreated for seven days, resulting in deterioration and subsequent hospitalization for surgical debridement.
Failure to Document Post-Fall Assessments and Vital Signs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not documenting required post-fall assessments for two residents. For Resident #1, a registered nurse (Staff C) reported that after a fall on 1/21/26, the resident was found on the floor leaning against the wall, complaining of head pain and groin pain. Staff C stated the resident had a lump on the back of the head and groin sensitivity, and that the resident was transferred from the floor to a chair with a licensed nursing assistant and then to bed with assistance from Staff B. Once in bed, the resident had increased right leg pain. Staff C acknowledged performing an assessment after the fall but did not document any of these findings in the medical record. Record review for Resident #1 showed a progress note by Staff B at 1:50 p.m. stating the resident was found on the floor complaining of severe pain in the right parietal scalp and right leg/hip/pelvis, unable to extend the leg due to pain, and that the provider was notified and the resident sent to the ER. An IDT note the following day stated the resident had a small abrasion on the right side of the head, a full body assessment was done with no other injuries noted, the resident would not extend the leg straight, and pain prevented assessment of the right lower extremity for shortening or rotation; x‑rays were ordered but not completed due to pain, and the resident was sent to the ER. Despite these narrative notes, there was no documentation of vital signs, no neurological checks, and no documentation by Staff C of the assessment performed while the resident was on the floor, even though the resident remained at the facility for approximately two hours before hospital transfer. The DON confirmed the absence of documented vital signs and neuro checks and stated the resident should not have been moved while complaining of pain. For Resident #2, the medical record contained a progress note dated 1/19/26 indicating the resident was found on the floor next to the bed, stated they did not want to wait for help, had no skin issues, and was moved from the floor to a wheelchair. An IDT note dated 1/20/26 documented that the resident had a fall in the room while trying to transfer from bed to chair, that no injuries were noted on a full body assessment by the unit manager, and that the resident was assisted back to bed. There were no additional progress notes or documentation of the resident’s assessment after the fall, and Staff B confirmed there was no documentation of the full body assessment referenced in the IDT note. Review of facility policies on assessing falls and accident/incident reporting showed that post-fall documentation was required to include assessment data, vital signs, obvious injuries, and the condition of the resident, which was not completed for these two residents.
Failure to Timely Report Multiple Alleged Abuse Incidents to State Agency
Penalty
Summary
The facility failed to immediately report multiple alleged abuse incidents to the State Survey Agency (SSA) as required by its abuse, neglect, and exploitation policy. For one resident, a licensed nursing assistant (Staff D) reported witnessing another licensed nursing assistant (Staff C) holding the resident with the resident’s back against Staff C’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident occurred on or around January 1, 2026, but was not reported by Staff D until January 14, 2026. The Administrator (Staff A) confirmed awareness of this allegation as of January 14, 2026, and acknowledged that it was not reported to the SSA. For another resident, the Unit Manager (Staff I), who was on call, was notified on the night of November 19, 2025, that the resident was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. Staff I reported this to both the Administrator (Staff A) and the Director of Nursing (Staff B), and Staff A confirmed awareness of the incident on that date but did not report it to the SSA. In a separate incident involving a third resident, an email from an RN (Staff G) to the DON (Staff B) described observing the resident standing beside the bed screaming while an LNA (Staff C) yelled at the resident to get into bed; when the resident did not comply, Staff G observed Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed being informed of this incident on January 1, 2026, and Staff A confirmed that this allegation also was not reported to the SSA. These failures occurred despite a written facility policy requiring all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Investigate Alleged Abuse Incidents Involving Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that alleged violations of abuse were thoroughly investigated for two residents. For the first resident, a licensed nursing assistant (LNA), identified as Staff D, reported that he/she witnessed another LNA, identified as Staff C, holding the resident with the resident’s back against Staff C’s chest and arms around the resident, with the resident’s feet off the ground while being moved to another area. Staff D stated this incident occurred on or around January 1, 2026, and was reported on January 14, 2026. The Administrator, identified as Staff A, confirmed awareness of this incident as of January 14, 2026, and confirmed that the incident was not investigated. For the second resident, an email from a registered nurse (RN), identified as Staff G, to the Director of Nursing (DON), identified as Staff B, described an incident in which the RN opened the door to a resident’s room and observed the resident standing beside the bed screaming while LNA Staff C was yelling at the resident to get into bed. When the resident did not comply, the RN reported observing Staff C pick the resident up off the floor and forcefully place the resident onto the bed. Staff B confirmed receiving this email and stated that they did not remove Staff C from working and did not investigate the incident when notified. Review of the facility’s Abuse, Neglect and Exploitation policy showed that it requires an immediate investigation of any suspicion or report of abuse, including identifying responsible staff, preserving evidence, interviewing all involved persons, determining if abuse occurred, and providing complete documentation, which was not carried out in these cases.
Improper Use of Manual Physical Restraint Without Assessment or Care Plan
Penalty
Summary
The facility failed to ensure the appropriate use and documentation of a physical restraint for one resident when a staff member used a manual hold to control and move the resident without any corresponding assessment or care plan interventions. On or around January 1, 2026, a licensed nursing assistant (Staff C) reported that the resident had been combative and had struck Staff C in the nose and genitals, after which Staff C approached the resident from behind, put their arms around the resident’s shoulders, and moved the resident approximately four to five feet, with another licensed nursing assistant (Staff D) observing the resident’s back against Staff C’s chest, Staff C’s arms around the resident, and the resident’s feet off the ground while being moved. Staff C stated they believed the resident was a danger to self and others and that no one else wanted to intervene. Record review showed no progress notes around that date documenting behaviors or the use of a manual method to restrain the resident, no documented behaviors on the Treatment Administration Report from late December 2025 through mid-January 2026, and no care plan interventions addressing the use of a manual method for behavior management. The Director of Nursing confirmed these findings and also confirmed there was no facility policy for the use of physical restraint by manual method.
Failure to Report, Investigate, Screen, and Train Regarding Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy for reporting and investigating allegations of abuse, as well as failure to ensure required staff screening and abuse training. For one resident, a licensed nursing assistant (LNA) reported witnessing another LNA holding the resident with the resident’s back against the staff member’s chest, arms around the resident, and the resident’s feet off the ground while being moved to another area. This incident reportedly occurred on or around January 1, 2026, but was not reported by the witness until January 14, 2026. The administrator confirmed awareness of the allegation as of that date and acknowledged that the allegation was neither investigated nor reported to the State Survey Agency (SSA), contrary to the facility’s written abuse policy requiring immediate investigation and timely reporting. A second allegation involved another resident, where an RN emailed the DON describing an event in which the RN opened a resident’s room door and observed the resident standing beside the bed screaming while an LNA yelled at the resident to get into bed. When the resident did not comply, the RN reported that the LNA picked the resident up off the floor and forcefully placed the resident onto the bed. The DON confirmed being notified of this incident on the date it occurred and acknowledged that the incident was not investigated and not reported to the SSA, despite the facility’s policy requiring immediate investigation and reporting of alleged abuse within specified timeframes. A third incident involved a resident who was found with scratches and blood on the face, with staff unable to explain how the injuries occurred. The unit manager, who was on call, reported this to both the administrator and the DON. The administrator confirmed that this incident, involving injuries of unknown origin, was not reported to the SSA. In addition, review of the human resources file for the LNA implicated in the above allegations showed no criminal background check, despite the facility’s policy requiring background, reference, and credential checks for potential employees and documentation that screening occurred. Review of staff education files for multiple staff members showed that required annual abuse education had not been provided since 2021 or 2023, contrary to the facility’s policy that existing staff receive annual training on abuse prohibition, recognition, and reporting.
Failure to Report Injury of Unknown Source to State Survey Agency
Penalty
Summary
The facility failed to report an injury of unknown source to the State Survey Agency as required by its abuse prohibition policy. A resident was evaluated on-site by a physician assistant for new left upper extremity (LUE) swelling, with findings of edema, minimal erythema/warmth, slight tenderness, and concern for possible LUE deep vein thrombosis (DVT). The provider documented that the swelling was most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident’s report of sleeping on the left side, and ordered an emergent transfer to the hospital for a Doppler study to rule out DVT. Hospital documentation for that visit identified a closed fracture of the radial head (elbow fracture). A registered nurse reported receiving a phone call and verbal report from the hospital emergency room, prior to the resident’s return, that the resident had a fracture. The DON confirmed that the facility did not submit a report to the State Survey Agency for this elbow fracture, which constituted an injury of unknown origin. Review of the facility’s Abuse Prohibition policy showed that injuries of unknown source are to be investigated and reported to appropriate state and local authorities, including reporting allegations involving neglect, exploitation, or mistreatment (including injuries of unknown source) within specified time frames, and reporting findings of completed investigations within five working days, which did not occur in this case.
Failure to Investigate Injury of Unknown Source After Elbow Fracture
Penalty
Summary
The facility failed to investigate an injury of unknown source for a resident who was evaluated for left upper extremity (LUE) swelling. On 12/8/25, a progress note by a physician assistant documented that nursing had requested an evaluation for new LUE edema. The assessment indicated swelling most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident’s report of sleeping on the left side, with some non-pitting swelling, minimal erythema/warmth, and slight tenderness. Although cellulitis was doubted, there was concern for a possible LUE DVT, and the resident was transferred emergently to the hospital for a Doppler study to rule out DVT. Hospital documentation from the same date showed the resident was diagnosed with a closed fracture of the radial head (elbow fracture). During an interview, the DON stated that the facility did not conduct an investigation regarding this elbow fracture. This inaction occurred despite the facility’s Abuse Prohibition policy, which requires that injuries of unknown source be investigated to determine if abuse or neglect is suspected, that allegations be entered into the facility’s risk management portal, and that an investigation be initiated within 24 hours focusing on whether abuse or neglect occurred, causative factors, and interventions to prevent further injury, with thorough documentation of the investigation and interviews in the risk management system.
Failure to Provide Required Hospital Transfer and Bed-Hold Notice
Penalty
Summary
The facility failed to provide required notice of transfer and bed-hold to a resident or the resident’s representative when the resident was sent to the hospital. Record review showed that the resident was evaluated on 12/8/25 by a physician assistant for new left upper extremity (LUE) swelling, with findings most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident sleeping on the left side. Due to concern for possible LUE deep vein thrombosis (DVT), the provider ordered an emergent transfer to the hospital for a Doppler study to rule out DVT. Hospital documentation indicated that the resident was seen for a closed fracture of the radial head and elbow fracture. Review of the resident’s medical record revealed that no Notice of Transfer/Discharge was completed for this hospital transfer. The Director of Nursing confirmed that the notice was not provided. The facility’s own “Discharge and Transfer” policy, revised 6/11/25, states that for unplanned, acute transfers, the patient and representative will be notified verbally prior to transfer, followed by written notification using the Notice of Hospital Transfer or state-specific form, and that a copy of this form will be placed in the medical record; this documentation was absent for the resident’s transfer.
Incomplete Documentation of Hospital Transfer and Return
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for one resident related to an episode of left upper extremity (LUE) swelling and subsequent hospital transfer. On 12/8/25 at 11:26 a.m., a progress note by a physician assistant documented that nursing had requested an evaluation for LUE swelling. The assessment indicated new LUE edema, thought most consistent with dependent edema in the setting of severe hypoalbuminemia and the resident sleeping on the left side, but also noted minimal erythema, warmth, slight tenderness, and concern for possible LUE DVT, leading to a decision to transfer the resident emergently to the hospital for a Doppler study. Hospital documentation dated 12/8/25 at 11:02 a.m. showed the resident was seen for a closed fracture of the radial head (elbow fracture) with instructions for orthopedic and family medicine follow-up in two days, arm elevation, and use of ice packs. Despite this episode of care, the resident’s medical record lacked nursing documentation of when the resident was transferred to the hospital and when they returned. Upon the resident’s return, there was no documentation that the resident was assessed or that the hospital’s recommendations were reviewed or implemented. The only hospital paperwork in the record was the Patient Visit Information summarizing the diagnosis and basic follow-up instructions, with no additional hospital documents present. The DON confirmed there was no nursing documentation regarding the emergency room visit or return on 12/8/25. These omissions were inconsistent with the facility’s Nursing Documentation policy, which requires timely entries specifying patient status, nursing assessments, interventions, and all relevant patient information to be documented or entered in the clinical record following established guidelines.
Failure to Obtain and Implement Admission Orders for Wound Care
Penalty
Summary
A deficiency occurred when a resident was admitted with a puncture wound to the right groin, but no physician's orders for wound treatment were obtained at the time of admission. The resident's clinical admission assessment documented the presence of the wound, and the hospital discharge summary included instructions for daily wound care. However, a review of the admission orders and the Treatment Administration Record (TAR) showed that no wound treatment orders were transcribed or carried out for the right groin wound. As a result, the resident went seven days without any wound treatment after admission. During a vascular surgery follow-up appointment, it was noted that the dressing had not been changed, and the wound had deteriorated, showing signs of dehiscence, maceration, slough, and seroma drainage. This led to the resident being hospitalized for surgical debridement. The Director of Nursing confirmed that the wound had not been treated during this period.
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