Exeter Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Exeter, New Hampshire.
- Location
- 8 Hampton Road, Exeter, New Hampshire 03833
- CMS Provider Number
- 305064
- Inspections on file
- 17
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Exeter Center during CMS and state inspections, most recent first.
An LPN was observed storing an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) in the medication refrigerator without documenting the open date or expiration date, contrary to manufacturer instructions and facility policy requiring such labeling for product integrity.
Surveyors found that food items in the kitchen were not stored according to professional standards, with several items lacking proper labeling, dating, or covering, and some foods being kept beyond recommended timeframes. The facility's own policies and the FDA Food Code require proper storage, labeling, and timely use or disposal of food, but these procedures were not followed, as confirmed by dietary staff.
Two residents with documented Stage 2 pressure ulcers present on admission were incorrectly coded on their MDS assessments, with one not marked as having a pressure ulcer and the other not identified as having the ulcer on admission. These errors were confirmed by facility staff.
The facility failed to follow bowel management protocols for two residents, leading to one requiring hospitalization. A resident with hepatic failure and cirrhosis did not receive prescribed Lactulose, resulting in unresponsiveness and hospitalization. Another resident with cirrhosis did not meet bowel movement goals, and staff failed to notify the provider. Staff interviews revealed communication lapses in tracking bowel movements.
The facility failed to maintain adequate staffing levels, as outlined in their Facility Assessment, during April and May 2024. Interviews with staff and residents revealed that the shortage of LNAs led to long wait times for assistance, particularly during mealtimes and when residents required lifts. Residents reported waits of up to 45 minutes and instances of soiling themselves due to delayed responses. Staff expressed that the administration considered only the census, not the acuity of residents, when scheduling, leading to overworked LNAs and insufficient care.
The facility failed to ensure that staff were wearing proper hair restraints in the main kitchen. A cook was observed serving scrambled eggs without a facial hair restraint, despite having facial hair. The cook confirmed this practice, which is against the facility's policy and FDA food code requirements.
The facility failed to follow physician orders and document a resident's injury after a fall. An observation revealed a gauze border dressing on the resident's right elbow without a date, and there was no documentation or order for the dressing. Interviews confirmed the lack of documentation, violating the facility's policy on skin integrity and wound management.
The facility failed to ensure accurate medical records for a resident's wound care, with discrepancies in treatment documentation and wound location evaluations confirmed by staff.
Failure to Label Open Multi-Dose Injectable Medication
Penalty
Summary
During an observation in the Chase Unit medication room, an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) was found in the medication refrigerator without an open date or an open expiration date. This was confirmed by an LPN present at the time. Review of the manufacturer's instructions indicated that a vial in use for 30 days should be discarded, and the facility's own policy required multi-dose vials to be labeled with the date opened to ensure product integrity. The lack of labeling on the vial was not in accordance with both manufacturer instructions and facility policy.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen. Items found included a small dish of salad covered in plastic wrap without a preparation or use by date, a container of tuna fish labeled with a preparation date, a container of chicken salad with a preparation date, and a bowl of cooked potatoes that was uncovered and undated. Additionally, thawed chicken breasts, cucumbers that were leaking fluid and had black spots, and thawed sliced deli meats with dates indicating they had been pulled from the freezer well beyond recommended timeframes were found in the walk-in refrigerator. These findings were confirmed by the dietary cook during the survey. A review of the facility's food storage policies revealed requirements for all foods to be wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination. The policies also specified storage timeframes for ready-to-eat and raw foods. The FDA Food Code was also referenced, which outlines standards for date marking, storage, and discarding of foods to prevent contamination. The facility failed to follow these professional standards and its own policies, resulting in the cited deficiency.
Incorrect MDS Coding for Pressure Ulcers on Admission
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to pressure ulcers. For one resident, documentation showed a pressure area was present on admission, and the 5-day MDS assessment indicated one Stage 2 pressure ulcer. However, the section indicating whether the Stage 2 ulcer was present on admission was incorrectly coded as zero. The resident's care plan also confirmed the presence of a pressure area on the coccyx upon admission, and the MDS nurse acknowledged the coding error during an interview. For another resident, both the hospital discharge summary and the facility's admission note documented a Stage 2 pressure injury on the right heel at the time of admission. Despite this, the 5-day MDS assessment did not code the resident as having a pressure ulcer or being at risk, and the section for unhealed pressure ulcers was marked as zero. The MDS Coordinator confirmed in an interview that this was an incorrect coding, as the resident did have a Stage 2 pressure ulcer present on admission.
Failure in Bowel Management Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for bowel management. For one resident, the Medication Administration Record (MAR) indicated that the prescribed Lactulose was not administered as needed when the resident did not have the required three bowel movements daily. This oversight led to the resident becoming unresponsive and requiring hospitalization due to concerns of encephalopathy, as the resident had a history of hepatic failure and alcoholic cirrhosis. Another resident also did not receive the necessary bowel management as per the physician's orders. The MAR showed that the resident did not achieve the goal of three bowel movements on multiple days, and the staff failed to notify the provider as required. This resident had a diagnosis of alcoholic cirrhosis. Interviews with staff revealed a lack of communication and tracking of bowel movements, contributing to the failure in following the prescribed bowel management protocols.
Staffing Deficiency in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents during April and May 2024. The Facility Assessment outlined specific staffing levels required for direct care staff, including one nurse and two LNAs during the day and evening shifts, and one nurse and one LNA during the night shift. However, a review of the Daily Staffing Sheets revealed multiple instances where these staffing levels were not met, with significant shortages in LNA staffing across several shifts. This deficiency was confirmed by the Director of Nursing during an interview. Interviews with staff members highlighted the challenges faced due to inadequate staffing. Staff reported that LNAs were overworked, often unable to take breaks, and that nurses had to assist LNAs despite having their own responsibilities. The lack of sufficient LNAs led to long wait times for residents, particularly during mealtimes and when residents required assistance with lifts, which necessitated two staff members. Staff expressed that the administration seemed to consider only the census and not the acuity of residents when scheduling staff. Residents also reported negative experiences due to the staffing shortages. They described long wait times for assistance, with some residents experiencing waits of up to 45 minutes. One resident mentioned instances of soiling themselves due to delayed responses to call bells. Another resident expressed concerns about safety when being changed in bed by only one aide. The Resident Council meetings also highlighted chronic staffing issues, with reports of staff turnover exacerbating the problem. Overall, the deficiency in staffing levels significantly impacted the quality of care provided to residents.
Failure to Ensure Proper Hair Restraints in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety and did not ensure that staff were wearing proper hair restraints in the main kitchen. During an observation, a cook was seen serving scrambled eggs without wearing a facial hair restraint, despite having facial hair. The cook confirmed that he/she did not wear a facial hair restraint when serving food. The facility's policy requires all staff to have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. This policy aligns with the FDA food code, which mandates that food employees wear hair restraints to prevent hair from contacting exposed food and clean equipment.
Failure to Follow Physician Orders and Document Resident Injury
Penalty
Summary
The facility failed to follow physician orders for a resident who was reviewed for falls. An observation revealed that the resident had a gauze border dressing on their right elbow without a date. The resident indicated that the injury might have been a result of a recent fall. However, a review of the resident's orders, skin/wound assessments, change in condition report, treatment records, care plans, and progress notes showed no documentation of the right elbow injury. This indicates a lack of proper documentation and adherence to physician orders regarding the resident's care following the fall. Interviews with the Director of Nursing confirmed that there was no documentation or order for the dressings on the resident's right elbow. Additionally, the facility's policy on skin integrity and wound management requires nursing assistants to observe and report skin changes to the nurse, and for the nurse to evaluate and document any skin changes or wounds. The failure to document and follow up on the resident's injury represents a deficiency in meeting professional standards of quality care.
Inaccurate Medical Records for Wound Care
Penalty
Summary
The facility failed to ensure medical records were accurate for one resident reviewed for pressure ulcers. Specifically, a review of the resident's current orders revealed a wound care order dated 4/8/24 for the left posterior thigh, which was not documented in the April 2024 Treatment Administration Record (TAR). An interview with a Registered Nurse confirmed that the treatment had not been added to the TAR. Additionally, the resident's wound evaluations incorrectly listed the location as the rear right thigh instead of the left posterior thigh. The Director of Nursing confirmed these findings and the error in the wound evaluations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
