Derry Center For Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Derry, New Hampshire.
- Location
- 20 Chester Road, Derry, New Hampshire 03038
- CMS Provider Number
- 305095
- Inspections on file
- 22
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Derry Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
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.
A survey of a medication cart in an LTC facility revealed multiple instances of improperly labeled multi-dose medications, including insulin pens and vials without open or discard dates. Some medications also lacked resident identifiers, violating the facility's labeling policy and manufacturer's instructions. An LPN confirmed these findings.
A facility failed to assess a resident's ability to self-administer medication. An albuterol inhaler was found in the resident's room, and the resident reported using it as needed. However, there was no physician's order or self-administration assessment in the medical record. An LPN confirmed these findings, which were contrary to the facility's policy requiring an interdisciplinary team assessment for self-administration safety.
The facility failed to notify residents of the bed hold policy before hospital transfers, as required by their policy. Two residents were transferred without receiving this notification, confirmed by a review of medical records and an interview with the Business Office Manager. The facility's policy mandates written notification at the time of transfer or within 24 hours in emergencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a history of ESBL colonization and another with a pressure ulcer. Observations revealed the absence of EBP signs and PPE, and interviews confirmed non-compliance with CDC guidelines and facility policy, which require gown and glove use during high-contact care activities.
The facility failed to implement care plans for two residents requiring meal supervision. One resident with mobility and weakness issues was observed eating alone in bed, contrary to their care plan. Documentation showed they ate independently multiple times without supervision. Another resident with mobility, vision, and cognitive deficits was also observed eating alone, despite their care plan requiring supervision. The DON expected staff to visually supervise residents during meals, which was not done.
A resident with dysphagia and a self-care performance deficit was observed eating alone in bed, contrary to their care plan which required staff supervision after meal setup. Despite a previous choking incident, documentation showed multiple instances of the resident eating without supervision, highlighting a failure to provide adequate supervision during meals.
The facility failed to maintain appropriate food temperatures, resulting in cold meals being served to residents. Despite initial compliance with temperature guidelines, food temperatures dropped significantly by the time of service. Residents had previously complained about cold food, and staff interviews revealed a lack of necessary equipment to maintain food temperature.
A resident was observed eating breakfast without the necessary assistive devices, such as a nosey cup and built-up silverware, which were specified on their meal ticket. The Dietary Manager confirmed these items should have been provided, as per the facility's policy on adaptive devices for residents who need them.
The facility failed to ensure dietary staff used facial hair restraints, maintain a clean kitchen environment, and properly store food. A cook was observed preparing and serving food without a beard restraint, and the kitchen had accumulated food debris and sticky floors. Additionally, Vanilla Mighty Shakes in the kitchenette lacked thawed or use-by dates, contrary to storage guidelines.
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.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that multi-dose medications were labeled appropriately, as observed during a survey of the East Medication Cart. The survey revealed multiple instances where insulin pens and vials, as well as other medications, were not labeled with open or discard dates. Specifically, medications for several residents, including Humalog, Lispro, Lantus, Lyumjev, Tresbia, Basaglar, Admelog, and Apidra insulin pens, were found without proper labeling. Additionally, some medications lacked resident identifiers, such as an open bottle of Systane gel eye drops and Prednisolone eye drops. The facility's policy on labeling medication containers, revised in April 2019, requires that individual resident medications include necessary information such as the resident's name, expiration date, and directions for use. However, the survey findings indicated non-compliance with this policy, as confirmed by an interview with Staff A, a Licensed Practical Nurse. The manufacturer's instructions for the medications observed also specify discard dates after opening, which were not adhered to in the facility's practice.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to determine if self-administration of medications was appropriate for a resident. During an observation, an albuterol inhaler was found on the resident's bedside table, and the resident confirmed using it as needed. However, a review of the resident's medical record showed no physician's order for the inhaler and no completed self-administration assessment. A Licensed Practical Nurse confirmed these findings. The facility's policy requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and clinically appropriate.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transferring them to a hospital, as required by their own policy. This deficiency was identified during a review of medical records and interviews, which revealed that two residents were transferred to the hospital without being informed of the bed hold policy. Resident #8 was discharged to the hospital on April 15, 2024, and Resident #47 was discharged on August 20, 2024, and again on September 21, 2024, without receiving the necessary notification. Additionally, Resident #51 was transferred to the hospital on July 29, 2024, without being informed of the bed hold policy. An interview with the Business Office Manager confirmed that the facility did not provide the bed hold policy at the time of transfer, although it was included in the admission packet. The facility's policy, revised in March 2022, mandates that residents be given written information about bed hold policies at the time of transfer or within 24 hours in emergency situations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to the CDC guidance for Enhanced Barrier Precautions (EBP) for two residents, leading to a deficiency in infection prevention and control. Resident #4, who had a history of colonization with Extended Spectrum Beta-Lactamase (ESBL) in their urine, did not have an EBP sign or Personal Protective Equipment (PPE) outside their room. Despite having a care plan that included maintaining EBP due to the colonization, the Unit Manager confirmed that Resident #4 was not on EBP. This oversight was identified during an observation and confirmed through interviews with staff. Similarly, Resident #10, who had an open wound on the right heel upon admission, was not placed on any precautions. The Director of Nursing confirmed the presence of a pressure ulcer, yet no EBP sign or PPE was observed inside or outside the resident's room. Interviews with the resident and the Infection Preventionist confirmed that staff only wore gloves during wound care, without the use of protective gowns, which is contrary to the facility's policy and CDC guidelines. The facility's policy, revised in August 2023, mandates the use of gown and gloves for high-contact care activities, which was not followed in these cases.
Failure to Implement Meal Supervision Care Plans
Penalty
Summary
The facility failed to implement the care plans for two residents who required supervision during meals. Resident #1, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. Despite the care plan specifying the need for staff supervision after meal setup and encouraging the resident to get out of bed for meals, documentation over the last 30 days showed that the resident ate independently seven times and received only setup or cleanup assistance 35 times. Interviews with the resident and a Licensed Nursing Assistant confirmed that the resident always eats alone in their room after meal setup. Similarly, Resident #2, who has a self-care performance deficit related to declined mobility, poor vision, and declined cognition, was also observed eating breakfast alone in their room. The care plan for this resident also required staff supervision after meal setup. However, documentation from the last 30 days indicated that the resident ate independently five times and received setup or cleanup assistance 24 times. An interview with the Director of Nursing revealed that the expectation for supervision at meals was for staff to maintain a visual on the residents, which was not adhered to in these cases.
Inadequate Supervision During Meals for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision to prevent choking accidents during meals for a resident with a diagnosis of dysphagia. The resident, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. The care plan for the resident indicated that staff supervision was required after meal setup, and the resident was encouraged to get out of bed for meals as tolerated. However, interviews with the resident and a Licensed Nursing Assistant (LNA) revealed that the resident always eats alone in his room after meal setup. A review of the resident's medical record and nursing notes indicated a previous choking incident on a dinner meal, where the resident began to choke and required assistance to be sat up and expel the food. Despite this incident, documentation over the last 30 days showed that the resident had meals without supervision multiple times, with seven instances of eating independently and 35 instances of only setup or cleanup assistance. This lack of supervision during meals is a direct violation of the resident's care plan and poses a significant risk given the resident's medical condition.
Deficiency in Food Temperature Control
Penalty
Summary
The facility failed to provide food that is palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. The U.S. Food and Drug Administration Food Code requires that time/temperature control for safety food be maintained at specific temperatures, but the facility did not adhere to these guidelines. During a food service observation, it was noted that while the holding temperatures of scrambled eggs, toast, and cream of wheat were initially within acceptable ranges, the temperatures significantly dropped by the time the food was served to residents. A test tray showed that scrambled eggs, toast, and cream of wheat were served at unappetizing low temperatures, which were confirmed by staff interviews. Residents had previously raised concerns about cold food during Food Council and Resident Council meetings, but these grievances were not addressed. Interviews with staff revealed that the facility lacked equipment such as a plate warmer or heated food cart, which contributed to the issue of cold food being served, especially for breakfast in resident rooms. Observations also showed that meal carts were left open during service, further contributing to the temperature drop. Residents expressed dissatisfaction with the temperature of their meals, confirming the deficiency in food service quality.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide a resident with the necessary assistive devices for eating, as observed during a survey. On the morning of June 4, 2024, a resident was seen eating breakfast alone in bed without the required assistive devices, specifically a nosey cup and built-up silverware, which were indicated on the resident's meal ticket. An interview with the Dietary Manager confirmed that these items should have been included on the resident's breakfast tray. A review of the facility's policy on assistance with meals, revised in March 2022, stated that adaptive devices should be provided for residents who need or request them, including items like silverware with enlarged handles and specialized cups.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure that dietary staff used facial hair restraints while cooking and serving food, as observed in the kitchen. Staff E, a cook, was seen preparing and serving food without a beard restraint, despite having a beard over an inch long. Interviews with Staff E and the Dietary Director confirmed that the facility did not provide beard restraints, and Staff E admitted to never wearing one. This lack of compliance with the facility's policy on employee hygiene and sanitary practices was evident during meal service observations. Additionally, the facility did not maintain a clean kitchen environment. Observations revealed food particles and debris accumulated under counters and the steam table, with sticky floors and dried liquid stains present. Staff E confirmed that the floors were supposed to be swept after each meal and mopped at night, but often remained dirty the following morning. A review of the cleaning schedule showed no documentation of nightly mopping, and the Dietary Director confirmed these findings. The facility also failed to store food according to professional standards. In the kitchenette, ten Vanilla Mighty Shakes were found without thawed or use-by dates, and Staff F was unaware of when they were thawed. This oversight contradicts the manufacturer's instructions, which require thawed products to be used within 14 days and kept refrigerated. The lack of proper date marking and storage practices poses a risk of foodborne illness, as confirmed by the facility's policy review.
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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