Courville At Manchester
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, New Hampshire.
- Location
- 44 West Webster Street, Manchester, New Hampshire 03104
- CMS Provider Number
- 305057
- Inspections on file
- 16
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Courville At Manchester during CMS and state inspections, most recent first.
A resident was potentially left on a bedpan since the morning shift, resulting in a red bottom. A LPN reported this to the Nursing Supervisor, who failed to notify the Administrator or DON as required by the facility's abuse policy.
A resident was potentially left on a bedpan for an extended period, resulting in a red bottom. An LPN reported the situation to the Nursing Supervisor, but it was not escalated to the Administrator or DON, leading to a failure in addressing the potential neglect.
A resident did not receive prescribed prune juice or M.O.M. for constipation despite not having a bowel movement for three consecutive days on multiple occasions. The facility's bowel management policy, which requires intervention by the second and third day without a bowel movement, was not followed, leading to a deficiency.
A resident requiring aspiration precautions was left unsupervised during meals, despite clear instructions for one-on-one assistance. Observations showed the resident eating alone, contrary to their Nutritional Care Plan and physician's orders. An LPN was unaware of the need for supervision, even after a previous choking incident.
The facility did not conduct a required annual performance review for an LNA, as revealed by a review of employee records and confirmed by the Administrator. The facility's assessment indicated that in-service training should address weaknesses identified in performance reviews, but no evaluations were completed for 2023 and 2024.
A resident received PRN orders for Lorazepam and Haloperidol without a specified duration, exceeding the 14-day limit without documented justification from the physician. Despite recommendations to add a stop date, the provider declined, citing the resident's stable hospice-respite status. This led to multiple doses being administered beyond the allowed period, violating facility policy.
A facility failed to implement contact precautions for a resident with VRE. Despite a posted sign indicating the need for PPE, an LPN entered the resident's room without donning the required gown and gloves. The LPN was unaware of the contact precautions, indicating a lapse in communication and adherence to infection control policies.
The facility failed to provide the required 12 hours of annual in-service training for LNAs, with Staff M completing only 8 hours in 2024. Additionally, the facility did not conduct annual performance reviews for LNAs, preventing the identification and addressing of areas of weakness. This was confirmed by the Administrator.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in discharge coding and resident identification. A resident's MDS was incorrectly coded as a discharge with return not anticipated, while another's was marked as an unplanned discharge despite being planned. Additionally, a resident's name was misspelled, creating a separate record in the iQIES System.
The facility failed to ensure proper dishwasher sanitization, maintain a sanitary dining environment, and enforce the use of beard restraints during food service. Observations revealed missing PPM test results, uncleanable surfaces in the dining area, and a dietary aide handling food without a beard restraint.
A resident with a Stage II pressure ulcer and a deep tissue injury did not receive the ordered physical therapy evaluation for a modified chair cushion. Instead, the resident was observed using bed pillows, which were not pressure-relieving devices, and spent most of the time in a reclining chair, leading to soreness. The DON confirmed these findings.
The facility failed to ensure a safe environment by leaving hazardous cleaning chemicals in an unlocked cabinet accessible to residents, including two at risk for wandering. This was confirmed by staff and violated the facility's policy on storing poisonous materials.
Failure to Implement Abuse Policy for Resident
Penalty
Summary
The facility failed to implement its abuse policy for a resident who was reviewed for abuse. On December 6, 2024, a progress note indicated that the resident had requested to use the bathroom around 4:40 p.m. and appeared to have been left on a bedpan since the morning shift, as noted by a Licensed Nursing Assistant. The resident was found with a red bottom, suggesting prolonged exposure to the bedpan. A Licensed Practical Nurse reported this situation to the Nursing Supervisor for the 3-11 shift. However, the Nursing Supervisor did not notify the Administrator or the Director of Nursing about the potential neglect, as required by the facility's Resident Abuse Prevention and Investigation Policy. This policy mandates immediate notification of the Administrator or DON by the supervisor in cases of alleged abuse, mistreatment, or neglect.
Failure to Report Alleged Neglect of Resident
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was potentially left on a bedpan for an extended period. On 12/6/24, a progress note indicated that the resident requested to use the bathroom around 4:40 p.m., and it appeared that the bedpan had been underneath them since the morning shift. The resident's bottom was noted to be red. A Licensed Practical Nurse (LPN) reported this observation to the Nursing Supervisor on the 3-11 shift. However, the Nursing Supervisor did not report the incident to the Administrator or the Director of Nursing, resulting in a failure to address the potential neglect in a timely manner.
Failure to Follow Physician's Orders for Bowel Management
Penalty
Summary
The facility failed to adhere to physician's orders for a resident experiencing bowel/bladder incontinence. The physician's orders specified that the resident should be offered 120 ml of prune juice by mouth on the 7-3 shift if there was no bowel movement for three days, and 30 ml of Milk of Magnesia (M.O.M.) on the 3-11 shift if constipation persisted. However, a review of the resident's Bowel Continence Record for December 2024 and January 2025 revealed multiple instances where the resident did not have a bowel movement for three consecutive days, specifically on December 15-17, December 20-22, January 5-7, and January 9-11. Despite these occurrences, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed prune juice or M.O.M. during these periods. An interview with the Unit Manager confirmed these findings. Additionally, the facility's bowel management policy, effective since June 2005, requires that if there is no bowel movement by the second night, the ordered laxative or prune juice should be administered, and if there is no bowel movement by the third day, a rectal suppository or enema should be given with a doctor's orders. This policy was not followed, leading to the deficiency.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who required assistance due to aspiration precautions. The resident, identified as needing one-on-one assistance with feeding, was observed eating lunch alone on two separate occasions. A sign above the resident's bed clearly indicated the need for aspiration precautions and one-on-one assistance with feeding. Despite this, the resident was left unsupervised during meals. The resident's Nutritional Care Plan and a physician's order both specified that meals should be consumed in a supervised area, with encouragement for small bites and frequent sips of fluid. An interview with a Licensed Practical Nurse revealed a lack of awareness regarding the resident's need for supervised meals, despite a previous incident where the resident was found choking at lunch, leading to the implementation of aspiration precautions.
Failure to Conduct Annual Performance Reviews for LNA
Penalty
Summary
The facility failed to conduct a performance review for a Licensed Nurse Assistant (LNA) at least once every 12 months, as required. The facility's assessment from August 2024 indicated that staff training and education, including in-service training for nurse aides, must be sufficient to ensure their continuing competence, with a minimum of 12 hours per year. This training should address areas of weakness identified in performance reviews and facility assessments. However, a review of Staff M's employee records revealed that no performance evaluation was completed for the years 2023 and 2024, despite their employment starting in November 2022. An interview with the facility's Administrator confirmed the lack of annual performance reviews for LNAs.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN orders for psychotropic medications, specifically for a resident identified as #71. The resident had PRN orders for Lorazepam and Haloperidol, both of which were prescribed without a specified duration. These orders were initiated on December 26, 2024, and continued beyond the 14-day limit without documented justification or a specified duration from the prescribing physician. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless the physician provides a documented rationale for extending the duration, which was not done in this case. The resident's medical record and pharmacy consultation reports indicated that recommendations to add a stop date to these PRN orders were declined by the provider, who noted that the patient was hospice-respite and stable on the current regimen. Despite this, the facility's policy was not adhered to, as the required documentation and indication of duration for the PRN orders were absent. This oversight led to the administration of multiple doses of Lorazepam and Haloperidol beyond the 14-day period without proper documentation or justification, resulting in a deficiency finding during the survey.
Failure to Implement Contact Precautions for Resident with VRE
Penalty
Summary
The facility failed to implement its policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for a resident on contact precautions. Resident #31 had a urinalysis culture that identified Vancomycin-Resistant Enterococci (VRE) on January 11, 2025, and a sign was posted in their room indicating the need for contact precautions, including the use of personal protective equipment (PPE) such as gowns and gloves by staff and visitors. However, on January 15, 2025, a Licensed Practical Nurse (Staff F) entered Resident #31's room without donning the required PPE. Upon interview, Staff F revealed they were unaware that Resident #31 was on contact precautions, indicating a lapse in communication and adherence to the facility's infection control policies. The facility's policy, revised in September 2022, clearly states that staff and visitors must wear gloves and a disposable gown upon entering the room of a resident on contact precautions. This incident highlights a failure in the implementation of these policies, as evidenced by the observation of Staff F's actions and their subsequent admission of not being informed about the resident's precautionary status.
Deficiency in LNA In-Service Training and Performance Reviews
Penalty
Summary
The facility failed to ensure that the required in-service training for nurse aides was conducted and maintained, specifically the annual minimum of 12 hours. This deficiency was identified through a review of the facility's assessment and Staff M's personnel and in-service training records. Staff M, a Licensed Nursing Assistant (LNA) who started at the facility in 2022, had only completed approximately 8 hours of in-service training for the year 2024, which included training on dementia, abuse, and facility policies on infection control practices. This was below the required 12 hours per year, as stipulated in the facility's policy and state regulations. Additionally, the facility did not conduct performance reviews for LNAs every 12 months, which is necessary to identify and address areas of weakness in their performance. This lapse was confirmed during an interview with Staff C, the Administrator, who acknowledged the failure to perform these reviews. The absence of regular performance reviews meant that the facility could not adequately address the special needs of residents or the areas of weakness in nurse aides' performance, as required by the facility's policy and state regulations.
Inaccurate MDS Assessments and Resident Identification Errors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for four residents. Resident #18's MDS was incorrectly coded as a discharge with return not anticipated, despite documentation indicating an unplanned hospital transfer with an anticipated return. Similarly, Resident #72's MDS was coded as an unplanned discharge, while records showed a planned discharge to home. Resident #73's MDS inaccurately indicated a discharge to a hospital, although the resident was discharged to home. These discrepancies were confirmed through interviews with staff members. Additionally, Resident #68's MDS contained an incorrect spelling of the resident's name, leading to the creation of a separate record in the iQIES System. This error was identified in the final validation report, which issued a warning message to verify the new information. The incorrect entry was confirmed by staff, highlighting a failure in maintaining accurate resident identification information.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure the dishwasher in the main kitchen was reaching proper temperatures and chemical sanitization levels. Observations and record reviews revealed missing parts per million (PPM) test results for several days in December 2023, January 2024, and February 2024. Staff interviews confirmed that the PPM readings were not consistently recorded as required by the facility's policy. Additionally, the facility's policy outlined specific steps to ensure the dishwasher's chemical agent was at the correct mixing level, which were not followed, leading to potential sanitation issues with dishware used in the facility. In the first floor main dining room, the facility failed to maintain a sanitary environment for food service. Observations noted missing laminate on countertops, peeling wallpaper with food stains, and chipped wooden countertops, all of which created uncleanable surfaces. Furthermore, a dietary aide was observed handling uncovered plates of food without wearing a beard restraint, despite having a full beard over an inch long. Interviews with staff confirmed that beard restraints were required but not consistently used. These deficiencies indicate lapses in maintaining sanitary conditions and adherence to food safety protocols in the facility.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that a resident received the ordered treatments for pressure ulcers. Resident #41 had a Stage II pressure ulcer on the left buttock and a deep tissue injury on the right buttock, with orders for a physical therapy evaluation for a modified chair cushion. Despite these orders, the resident was observed sitting in a reclining chair with two bed pillows under the buttocks, which were not pressure-relieving devices. Interviews with the resident and staff confirmed that the resident had not used a chair cushion since admission and spent most of the time in the reclining chair, leading to soreness in the buttocks. The Director of Nursing confirmed these findings during the surveyor's visit.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free of accident hazards as possible regarding the storage of chemical cleaning solutions on the First Floor Unit. During an observation in the main dining serving area, an unlocked cabinet below the sink was found to contain several hazardous cleaning chemicals, including Clean Force Stainless Steel Cleaner and Polish, Comet Cleaner With Bleach, ECOLAB Foam Hand Sanitizer, and Surface Cleaner Sanitizer. This observation was confirmed by the Cook and the Administrator, who acknowledged that residents could access the dining room at any time. An interview with the Director of Nursing revealed that there were two residents identified at risk for wandering or elopement. The facility's policy on the storage of poisonous and toxic materials mandates that such materials be kept out of direct reach of residents and stored according to manufacturer recommendations. However, the observed storage practices did not comply with this policy. The Safety Data Sheets for the chemicals indicated various health risks, including eye irritation and potential harm from inhalation, underscoring the hazard posed by the unlocked cabinet in an accessible area.
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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