Elm Wood Center At Claremont
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, New Hampshire.
- Location
- 290 Hanover Street, Claremont, New Hampshire 03743
- CMS Provider Number
- 305041
- Inspections on file
- 15
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Elm Wood Center At Claremont during CMS and state inspections, most recent first.
Staff members engaged in emotionally abusive behavior by mocking and ridiculing three residents, recording these actions on video, and sharing the videos via social media with a third party. The incidents involved staff lying in a resident's bed, making derogatory comments, and laughing at residents' cognitive or communicative limitations. The abusive actions were not reported until months later, after the videos were shown to a nurse who then notified facility leadership.
Residents were not served their meals at the same time as others seated at their table, resulting in some eating while others waited without food or drink. Multiple observations showed residents expressing hunger and frustration, and staff confirmed there was no process to ensure coordinated meal service. The Food Service Director acknowledged ongoing issues with meal service timing.
Two residents with documented mental health conditions, including PTSD, major depression, and anxiety, had inaccurate Level I PASARR screenings that failed to reflect their diagnoses. The errors were confirmed by the Social Service Director, and one resident was later identified as needing a Level II evaluation.
Two residents did not receive meals in accordance with their stated preferences: one did not receive the requested chocolate milk needed for a dialysis diet, and another repeatedly received scrambled eggs despite expressing a dislike and was not offered an alternative. Facility policy requiring alternatives for refused meals was not followed.
A resident admitted to hospice did not have a hospice certification or plan of care in their records, and required hospice visits were not documented. Facility staff, including an LNA and RN, were unaware of hospice visit schedules or the care being provided, and the staff member responsible for coordination confirmed that no schedule or plan of care was received from the hospice provider.
Staff failed to follow facility policies on Enhanced Barrier Precautions (EBP) and cleaning of a glucometer. Two residents requiring EBP due to wounds, a PICC line, and a Foley catheter received high-contact care from staff who wore gloves but not gowns, contrary to policy. Additionally, a glucometer was observed with dried residue, indicating it was not disinfected after use as required.
The facility did not include specific staffing requirements for each unit and shift in its facility assessment, instead providing only overall staff numbers and general notes about adjustments based on census and acuity. The assessment failed to reflect the building's two units or detail staffing for day, evening, and night shifts, as confirmed by the Administrator.
The facility failed to provide necessary audiology services to residents, resulting in missed appointments. Despite requests being sent, the facility did not complete the necessary paperwork, leading to the cancellation of clinics. This highlights a deficiency in managing resident care and coordination with external service providers.
The facility experienced insufficient staffing levels on weekends during January, February, and March 2024, as confirmed by PBJ Staffing Data and staff interviews. Staffing levels for licensed nurses and nurse aides were consistently below the facility's assessment requirements, leading to forced additional shifts for staff due to call-outs.
The facility failed to follow physician's orders for three residents regarding the administration of Metoprolol Tartrate. A resident received the medication despite having a systolic blood pressure (SBP) below the prescribed threshold, while another resident was given the medication without documented blood pressure readings. These actions were confirmed by the Unit Manager and an LPN, indicating a lapse in medication management protocols.
A resident admitted with a high pain level did not receive prescribed Oxycodone until the next morning due to a lack of a written prescription and difficulty reaching an on-call provider. The facility's policy for emergency authorization of Schedule II substances was not effectively followed, resulting in the resident experiencing prolonged pain.
The facility failed to maintain accurate records of controlled substances, as required by policy, due to missing dual nurse signatures on narcotic shift count sheets. Interviews with LPNs confirmed the oversight, and the DON acknowledged the need for proper documentation.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN prepared the wrong dose of Folic Acid and the incorrect probiotic for a resident, contrary to the physician's orders. The errors were confirmed through observation and interview, indicating a lapse in following the facility's medication administration policy.
The facility failed to provide timely Medicare non-coverage notices to two residents. One resident did not receive the SNF ABN when Medicare Part A services ended, and another was discharged without receiving the NOMNC. Staff confirmed these oversights.
Staff Emotional Abuse and Exploitation of Residents via Social Media
Penalty
Summary
Staff members engaged in emotionally abusive and exploitative behavior toward three residents by recording videos in which they mocked and ridiculed the residents. In one instance, a licensed nurse aide was recorded lying in a resident's bed, talking about cuddling, and mocking the resident, while another staff member filmed and both giggled. In other cases, a staff member was recorded sitting on the edge of a resident's bed, mocking the resident's cognitive state, and in another, standing next to a resident's bed and mocking the resident's speech. These videos were shared via social media with a third party, specifically the daughter of a registered nurse at the facility. The incidents were not immediately reported; the videos were shown to the registered nurse months after they were created, who then reported them to the facility's administrator and director of nursing. The residents involved were later interviewed, but did not recall the incidents, and telepsychology assessments found no identified trauma. The staff members involved were identified through investigation and their actions were confirmed through interviews and record review.
Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring that all residents seated at the same table in the main dining room were served their meals together. Multiple observations across several meals revealed that some residents were eating while others at the same table were left waiting without food or drink. For example, one resident was nearly finished with breakfast while another at the same table had not received any food or drink. Similar patterns were observed during lunch, where some residents waited for extended periods while others at their table had already been served and finished eating. In one instance, a resident waiting for their meal took food from another resident who had already been served, and another resident repeatedly attempted to leave the dining room while waiting for their meal. Staff interviews confirmed there was no process in place to ensure simultaneous meal service for all residents at the same table. The Food Service Director acknowledged that the facility was aware of ongoing issues with meal service timing in the main dining room. Residents were observed expressing hunger and frustration, with some verbally stating they were hungry or asking for their meals while waiting. These repeated delays and lack of coordinated meal service directly impacted the residents' dining experience and dignity.
Inaccurate PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Level I Pre-admission Screening and Resident Review (PASARR) for two residents with documented mental health diagnoses. For one resident, the medical record listed diagnoses of Post Traumatic Stress Disorder, Anxiety, Major Depression, and a personal history of suicidal behavior, but the PASARR Level I screening indicated no mental illness. For the second resident, the medical record included diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, Anxiety Disorder, and Borderline Personality Disorder, yet the initial PASARR did not indicate any mental illness diagnoses. A subsequent PASARR for this resident later identified the need for a Level II face-to-face evaluation. These inaccuracies were confirmed by the Social Service Director during interviews.
Failure to Accommodate Resident Meal Preferences and Provide Alternatives
Penalty
Summary
The facility failed to provide meals that accommodated the individual preferences of two residents. One resident, who is on dialysis and requires extra protein, repeatedly did not receive the requested chocolate milk with meals as indicated on their meal ticket. Observations over multiple meals confirmed that chocolate milk was not provided, nor was any substitution offered. The Food Service Director later confirmed that chocolate milk was unavailable due to financial and vendor issues, and acknowledged that an alternative should have been offered. Another resident consistently received scrambled eggs for breakfast despite expressing a dislike for them to the Food Service Director. Observations showed that the resident refused to eat the eggs and was not offered an alternative meal. The resident's food preference assessment did not list scrambled eggs as a dislike, but the Food Service Director confirmed being informed of the resident's preference. Facility policy requires that alternative food be offered if a resident refuses a meal or desires something else, but this was not followed in these cases.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate hospice care for a resident who had been admitted to hospice services. Record review showed that the resident was admitted to hospice, but there was no hospice certification or plan of care available in the hospice binder. The resident's care plan listed several hospice interventions, including visits from hospice nursing, a licensed nursing assistant, a social worker, and a volunteer. However, the resident sign-in sheet only documented an admission visit and a spiritual care visit, with no evidence of other required visits. Interviews with facility staff, including a licensed nursing assistant and a registered nurse, revealed that they were unaware of when hospice staff were scheduled to visit or what care was being provided. The staff member responsible for coordinating hospice care confirmed that the hospice provider had not supplied a schedule or plan of care for the resident.
Failure to Implement Enhanced Barrier Precautions and Device Disinfection
Penalty
Summary
The facility failed to implement its own policies regarding Enhanced Barrier Precautions (EBP) and the cleaning and disinfection of a point-of-care device. During observation, a glucometer was found on top of a medication cart with a dried pink/red smear on its back, and a Licensed Practical Nurse confirmed that the glucometer should be cleaned after each use with EPA-approved disinfectant wipes, as per facility policy. Review of the policy confirmed the requirement to clean and disinfect the blood glucose meter after each use, but the observed condition of the glucometer indicated this was not done. Additionally, the facility did not follow its EBP policy for two residents who required these precautions due to chronic wounds, a PICC line, and an indwelling Foley catheter. In one case, a Registered Nurse provided perineal care to a resident with wounds and a PICC line while wearing only gloves and not a gown, despite an active physician's order and care plan for EBP. In another case, a Licensed Nursing Assistant provided personal hygiene to a resident with an indwelling Foley catheter while wearing gloves but not a gown, and initially stated the resident was not on EBP, which was later contradicted by another staff member and the resident's medical record. The Infection Preventionist confirmed that the facility policy required both gown and gloves for high-contact care activities for residents on EBP.
Facility Assessment Lacks Specific Staffing by Unit and Shift
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit and for each shift, such as day, evening, and night. Record review showed that the facility assessment did not specify staffing levels by unit or shift, despite the building having two units. The assessment only listed total numbers of staff needed and included general notes about staffing adjustments based on census and acuity, but did not provide detailed breakdowns for each unit or shift. An interview with the Administrator confirmed these findings.
Deficiency in Audiology Services for Residents
Penalty
Summary
The deficiency involves a failure to provide necessary audiology services to residents at the facility. The report highlights that a resident, along with others, was not seen by an audiologist despite having been scheduled for appointments. The facility had not ensured that the resident received the required audiology services, which was a concern given the resident's condition. The facility had not responded to the audiology company's requests for necessary paperwork, leading to the cancellation of scheduled clinics. The report indicates that the facility had not adequately communicated with the audiology company, resulting in missed appointments for the residents. Despite the requests being sent, the facility did not complete the necessary paperwork, leading to the cancellation of the clinics. This lack of communication and follow-up resulted in the residents not receiving the required audiology services, highlighting a deficiency in the facility's management of resident care and coordination with external service providers.
Insufficient Weekend Staffing in Winter Months
Penalty
Summary
The facility failed to provide sufficient staffing levels to meet the needs of residents on weekends during the months of January, February, and March 2024. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2 2024 indicated excessively low weekend staffing. Interviews with staff, including a Unit Manager and a Staff Scheduler, confirmed that short staffing was a significant issue during these months, particularly on weekends. The facility's assessment outlined specific staffing levels for licensed nurses and nurse aides, but the Daily Staffing Sheets revealed that actual staffing levels were consistently below these requirements on multiple weekend shifts. The deficiency was further corroborated by interviews with staff members, including an LNA and an LPN, who reported being forced to work additional shifts due to call-outs, especially during the winter months. The Director of Nursing confirmed that a staffing action plan was developed in response to these concerns. Despite some reported improvements in staffing levels in recent months, the documented staffing shortages during the specified period indicate a failure to meet the required staffing levels to adequately care for the residents.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, resulting in the administration of Metoprolol Tartrate despite contraindicated blood pressure readings. Resident #25 had a physician's order to hold the medication if the systolic blood pressure (SBP) was less than 100. However, the medication was administered on multiple occasions when the SBP was below this threshold, as confirmed by both the Unit Manager and the Licensed Practical Nurse involved. Similarly, Resident #22 received Metoprolol despite blood pressure readings below the specified limit of 100/60, with documented instances of administration when the blood pressure was 84/55 and 93/56. Resident #64's records revealed a failure to document blood pressure readings prior to administering Metoprolol on several occasions, contravening the physician's order to hold the medication for SBP less than 100. The Unit Manager confirmed these findings, indicating a systemic issue in following physician's orders and documenting necessary vital signs before medication administration. These deficiencies highlight a lapse in the facility's adherence to professional standards of quality in medication management.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who was admitted with a pain level of 7 out of 10. Upon admission, the resident was in pain and did not receive their prescribed pain medication, Oxycodone, until the following morning. The delay in administering the medication was due to the absence of a written prescription for the Schedule II narcotic from the hospital and difficulty in reaching an on-call provider to authorize the prescription. This process took approximately 3-4 hours, during which the resident remained in pain. The facility's Unit Manager acknowledged awareness of the resident's pain upon admission and noted that the nurse should have notified the pharmacy once the prescription was obtained. This would have allowed access to the Emergency Medication Kit to provide the resident with the necessary medication. The facility's policy on new orders for Schedule II controlled substances indicates that verbal authorization should be provided in emergency situations, which was not effectively executed in this case.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records in order. This deficiency was identified in two out of three narcotic books reviewed. The facility's policy on Controlled Substance Management requires that two licensed nurses perform a shift count and maintain an ongoing inventory of all Schedule II-IV controlled substances at shift changes or when narcotic keys are transferred between nursing staff. However, during the review of Medication Cart #1 and Medication Cart #2, it was found that on several occasions, only one nurse had signed the narcotic shift count sheets, indicating a failure to comply with the policy. Interviews with nursing staff confirmed these findings. Staff A, a Licensed Practical Nurse, admitted to forgetting to sign the controlled inventory count sheet for Medication Cart #1. Similarly, Staff K, another Licensed Practical Nurse, confirmed the lack of dual signatures for Medication Cart #2. The Director of Nursing acknowledged that the Controlled Substance Inventory Count Sheets should be signed and dated by the nursing staff at the time of the actual counts, and all required information should be documented on the form. This oversight in documentation and adherence to policy led to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during medication administration. This deficiency was identified during an observation of medication administration for a resident, where a Licensed Practical Nurse (LPN) prepared and intended to administer the incorrect dose of Folic Acid and the wrong probiotic. The resident's Medication Administration Record (MAR) indicated a physician's order for 1 mg of Folic Acid and a Lactobacillus probiotic, but the LPN prepared 400 mcg of Folic Acid and Saccharomyces Boulardii instead. The LPN confirmed the error during an interview, acknowledging the preparation of the wrong medications. The facility's policy on medication administration requires staff to verify the correct medication and dose before administration. However, this protocol was not followed, leading to two medication errors out of 25 opportunities. The errors were documented through observation, interview, and record review, highlighting a failure to adhere to established medication administration procedures.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notification to residents or their representatives regarding the termination of Medicare Part A Skilled Services, resulting in a deficiency. For Resident #33, the facility did not issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN), Form CMS-10055, when the resident's Medicare Part A services were discontinued on February 28, 2024, despite the resident remaining in the facility. This oversight was confirmed by Staff J, the Business Officer, who acknowledged that the SNF ABN was not completed for Resident #33. Similarly, for Resident #217, the facility did not provide the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, before the resident's last covered day of Medicare services on February 12, 2024. Resident #217 was discharged home without receiving the required notice, as confirmed by Staff J. The NOMNC is mandated to be delivered at least two calendar days before the end of Medicare-covered services, which was not adhered to in this case.
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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