Lafayette Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franconia, New Hampshire.
- Location
- 93 Main Street, Franconia, New Hampshire 03580
- CMS Provider Number
- 305077
- Inspections on file
- 16
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lafayette Center during CMS and state inspections, most recent first.
A resident developed pressure ulcers that were not promptly reported to a provider, resulting in delayed treatment orders and incomplete documentation of wound size and care. Nursing staff did not consistently follow physician orders or facility policy for wound assessment and treatment, leading to worsening of the wounds and lack of regular monitoring.
Staff did not follow infection control protocols during wound care for two residents, including failing to use clean field barriers and required PPE under Enhanced Barrier Precautions. Additionally, the facility lacked a water management plan specific to its actual water system, as required by policy.
The facility did not keep residents informed about the status or resolution of ongoing concerns raised in Resident Council Meetings regarding LNAs discussing residents and being loud, nor did it document responses or actions taken in meeting minutes, as required by facility policy.
Two residents with pressure ulcers did not have their care plans updated or developed to address new or existing wounds. In both cases, staff confirmed that new wounds were not reflected in the care plans, and necessary interventions were not documented or implemented as required.
A resident with bipolar disorder and Tardive Dyskinesia received multiple medications, including Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion, significantly later than scheduled on numerous occasions. The resident, who was cognitively intact, reported frequent late medication administration, which was confirmed by audit reports and staff interview. This practice did not comply with facility policy requiring medications to be given within 60 minutes of the scheduled time.
A resident with a history of hearing impairment and a documented need for hearing aids requested an audiology consult due to worsening hearing, but the facility did not arrange the appointment as requested. The resident continued to experience communication difficulties, and staff confirmed the request was not fulfilled, contrary to facility policy.
A resident missed a scheduled knee x-ray and physician visit because staff failed to arrange necessary transportation, despite appointment paperwork being present at the nurses station and communication between staff about the appointment. The resident was not provided the required assistance, resulting in the missed medical appointment.
A resident with dementia and a low BIMS score was repeatedly subjected to inappropriate sexual behavior by other residents. Despite having care plans in place, the facility failed to implement effective interventions to prevent these incidents, resulting in a deficiency in resident safety and protection from abuse.
The facility failed to report alleged abuse incidents to the SSA within the required timeframe. In one case, an LNA observed inappropriate touching between two residents, which was reported internally but not to the SSA until the next day. In another case, a resident reported being attacked, but the incident was not reported to the SSA for several days. A third incident involving inappropriate touching was not reported to the SSA at all.
The facility failed to update care plans for two residents involved in abuse incidents. One resident exhibited increased sexual and wandering behaviors, while another allegedly caused a fall. Despite these incidents, their care plans lacked new interventions addressing these behaviors.
A resident with a history of trauma was re-traumatized when another resident entered their room without consent and allegedly assaulted them, resulting in physical injuries. Despite the resident's known traumatic past and expressed fears, the facility failed to document care plan interventions to prevent such incidents.
A facility failed to accurately document an abuse incident involving two residents. A LNA witnessed inappropriate contact and reported it to an LPN, who documented the event. However, the note was struck out and moved to a non-medical record system by the DON, leaving no evidence of the incident in the official medical record.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels due to the facility's failure to implement necessary interventions for pressure redistribution. Despite being identified as at risk, the resident's care plan lacked specific measures for offloading and repositioning. Staff interviews revealed a lack of awareness regarding the implementation of these interventions, and the DTIs were confirmed to be facility-acquired by the DON.
The facility failed to secure chemical cleaning solutions, leaving them accessible to wandering residents in the Birch and Spruce Units. Observations confirmed by staff interviews revealed that chemicals were not stored according to facility policy, posing potential health risks. The DON acknowledged the presence of 13 wandering residents, emphasizing the need for proper chemical storage.
The facility failed to properly store and label medications in the Birch Unit Medication Room and Pine Unit Medication Cart. The Birch Unit's medication refrigerator was found at an incorrect temperature, and the temperature log was incomplete. In the Pine Unit, insulin pens and vials were not labeled with open or expiration dates, and one vial was beyond its expiration period. These deficiencies were confirmed by LPNs during observations.
A dietary aide failed to perform proper hand hygiene during dishwashing procedures. The aide was observed handling both dirty and clean dishes without washing hands in between, contrary to the facility's policy. This was confirmed during an interview with the aide.
The facility did not follow CDC guidelines for PPE use for two residents. One resident receiving IV medication and with a wound did not have proper gown use by a nurse. Another resident on contact precautions for viral herpes had staff unaware of the precautions' reasons, leading to improper PPE use. Facility policies and CDC guidelines were not adhered to.
The facility failed to develop and update care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident with PTSD lacked a care plan for trauma-related interventions, while another on Coumadin for Atrial Fibrillation had no care plan for anticoagulation therapy. Additionally, a resident with new heel injuries did not have an updated care plan, despite facility policy requiring revisions upon status changes.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer prevention and treatment for one resident. Upon admission, the resident had no pressure ulcers, but subsequently developed open areas on the right and left buttocks. The right buttock wound was first noted as a small open area, but there was no documentation that the provider was notified or that a physician's order was obtained for treatment for six days. During this period, the wound worsened and was later assessed as an unstageable pressure ulcer. Treatment orders were not obtained until several days after the wound was identified, and the treatment was not documented as completed until two days after the order was written. For the left buttock, a stage 2 pressure ulcer was identified, but there was no treatment ordered or documented for a period of three weeks. Additionally, there was a lack of weekly documentation of the size and measurements of both the right and left buttock pressure ulcers for extended periods after their identification. Interviews with nursing staff confirmed that wounds were not measured or documented as required, and that treatment orders were delayed or not followed according to physician instructions. During wound care observations, staff did not follow physician's orders for wound treatments and failed to take measurements of wounds at the time of dressing changes. Facility policies required wound treatment to be provided in accordance with physician orders, prompt notification of providers for new wounds, and regular documentation of wound characteristics and measurements. These policies were not followed, resulting in incomplete and delayed care for the resident's pressure ulcers.
Failure to Implement Infection Control and Water Management Policies
Penalty
Summary
Surveyors observed that staff failed to follow established infection prevention and control policies during wound care for two residents. Specifically, the infection preventionist and an advanced practice registered nurse gathered wound care supplies on an uncleaned clipboard without using a clean field barrier, and entered rooms marked for Enhanced Barrier Precautions (EBP) without donning isolation gowns. During wound care, contaminated items such as scissors were placed on the clipboard and then returned to the treatment cart without proper cleaning. These actions were confirmed by staff interviews and were not in accordance with the facility's policies, which require the use of gowns and gloves for high-contact care activities like wound care, and the establishment of a clean field for dressing changes. Additionally, the facility failed to develop and implement a water management program tailored to its actual water system. The provided water management plan described a four-story building, while the facility is only one story, and did not accurately reflect the flow of the water system. The administrator confirmed the absence of a water management plan specific to the facility, despite policy requirements for such a program as part of the infection prevention and control program.
Failure to Communicate and Document Resident Council Grievance Responses
Penalty
Summary
The facility failed to keep residents informed about the progress and resolution of concerns raised during Resident Council Meetings, and did not maintain documentation demonstrating the response and rationale to these grievances. Over a three-month period, meeting minutes consistently documented resident complaints regarding LNAs discussing other residents in front of them and being loud in hallways and at nurse's stations. Despite these ongoing concerns, residents reported that no follow-up or communication about actions taken was provided to them. Interviews with staff confirmed that while concerns from Resident Council Meetings were verbally relayed to department heads, there was no written follow-up or evidence of actions taken documented in subsequent meeting minutes. The facility's policy requires that concerns and recommendations from the Resident Council be acted upon and that decisions be communicated back to the Council, but this process was not followed as required.
Failure to Update and Develop Comprehensive Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop and update comprehensive care plans for two residents with pressure ulcers. For one resident, a provider note documented a new open area on the sacrum, but no new treatment orders were written, and the care plan for skin had not been updated since a previous date. Interviews with staff confirmed that the new wound was not addressed in the care plan and that treatments had not been completed as required. The medication administration record also did not reflect any new orders for the newly identified wound area. For another resident, progress notes indicated the development of multiple pressure ulcers, including an unstageable area, a stage 2 ulcer, and a deep tissue injury. Observation confirmed the presence of these wounds, but the care plan, which was initiated earlier, had not been updated to include interventions for the new pressure areas. Staff interviews confirmed the absence of care plan interventions for the pressure ulcers that developed subsequently.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality in medication administration for one resident. Multiple instances were identified where medications were administered outside of the prescribed time frames. Specifically, medications such as Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion were given significantly later than their scheduled times, with delays ranging from over an hour to several hours past the ordered administration times. These findings were confirmed through review of the Medication Administration Audit Report and interviews with both the resident and an Advanced Practice Registered Nurse. The resident involved had a diagnosis of bipolar disorder and Tardive Dyskinesia, and was prescribed several medications to be administered at specific times, including early morning and evening doses. The resident was cognitively intact, as evidenced by a Basic Interview for Mental Status (BIMS) score of 15 out of 15, and reported that medications were often given late, a statement corroborated by the audit report covering the previous 30 days. The late administration of medications included both time-critical and non-time-critical drugs, with some doses being administered several hours after the scheduled time. Facility policy required that medications be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. The observed practice did not align with this policy, as numerous medications were administered well outside the acceptable window. The failure to adhere to scheduled medication times was confirmed by staff interview and documentation review, establishing a deficiency in meeting professional standards and following physician orders for medication administration.
Failure to Assist Resident in Accessing Hearing Services
Penalty
Summary
A resident who had been diagnosed with abnormal auditory perceptions in the left ear and was identified as a good candidate for bilateral hearing aids requested to be seen by an audiologist due to worsening hearing. Despite the resident's expressed concerns and a documented need for hearing services, the facility failed to make an appointment with the audiologist as requested. The resident's Durable Power of Attorney confirmed ongoing communication difficulties, and staff acknowledged that the request for a hearing consult was not acted upon. Facility policy required that outside clinical services be provided as ordered and available, but this was not followed in this instance.
Failure to Arrange Transportation for Scheduled X-ray Appointment
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident in arranging transportation for a scheduled x-ray appointment. The resident, who had been admitted in December 2024, was supposed to have a knee x-ray at an orthopaedic clinic. The resident reported being upset after being informed by the staff member responsible for transportation arrangements that they were unaware of the appointment and had not set up transportation. Another staff member confirmed seeing paperwork regarding the appointment at the nurses station and communicated this to the transportation coordinator. Further interviews confirmed that the resident had been given paperwork with the appointment details during a previous clinic visit, but the necessary transportation was not arranged, resulting in the resident missing the scheduled x-ray and physician visit. The report is based on interviews with the resident and staff, as well as a review of the resident's medical record and communication with the orthopaedic clinic, all of which confirmed the missed appointment due to the lack of transportation arrangements.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, involving multiple incidents with other residents. Resident #5, who has unspecified dementia and a Brief Interview for Mental Status (BIMS) score of 3, was involved in several inappropriate interactions. On 5/5/24, a staff member observed Resident #2 with their hand down Resident #5's pants. Staff A, the Activities Director, was aware of multiple incidents of Resident #2 being sexually inappropriate with cognitively impaired residents. Additionally, on 7/27/24, Staff H, an LNA, witnessed Resident #2 rubbing Resident #5's genital area. Further incidents involved Resident #1, who was seen touching Resident #5 inappropriately on 8/13/24 and again on another occasion by Staff L. Resident #2, with a BIMS score of 12, had a care plan addressing potential physical behaviors and sexually inappropriate behavior, but interventions were not effectively preventing these incidents. Resident #1, with a BIMS score of 3 and similar diagnoses to Resident #5, had a care plan for potential verbal/physical behaviors, but it lacked specific interventions to prevent inappropriate sexual behavior. The facility's failure to implement effective interventions and protect Resident #5 from repeated abuse incidents constitutes a deficiency in ensuring resident safety and freedom from abuse.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse to the State Survey Agency (SSA) within the required timeframe for three out of four reviewed cases. In the first case, a Licensed Nursing Assistant (LNA) observed a resident with their hands on another resident's genital area. The incident was reported to a nurse, who left a note for the Assistant Director of Nursing. However, the incident was not reported to the SSA until the following day, exceeding the two-hour reporting requirement for abuse allegations. In the second case, a resident reported being attacked by another resident, resulting in a fall. The incident was witnessed by a Registered Nurse who heard a commotion and found the resident on the floor. Despite the incident occurring on one day, it was not reported to the SSA until several days later. In the third case, an LNA witnessed inappropriate touching between two residents and reported it to a Licensed Practical Nurse. This incident was not reported to the SSA at all, further demonstrating the facility's failure to adhere to reporting protocols.
Failure to Revise Care Plans Following Abuse Incidents
Penalty
Summary
The facility failed to revise care plans for two residents involved in incidents of abuse. Resident #1 was observed by a Licensed Nursing Assistant with their hand on the genital area of another resident. A progress note indicated increased sexual behaviors and wandering, but the care plan, last revised on 7/15/24, did not include new interventions for these behaviors. The care plan only included an evaluation for a Psych/Behavioral Health consultation. Resident #3 was involved in an incident where they allegedly hit another resident, causing them to fall. Despite this incident, Resident #3's care plan, initiated on 8/23/23, did not include any new interventions for aggressive behaviors. The existing care plan focused on verbal behaviors and included interventions such as discouraging head shaving and providing a consistent caregiver, but it did not address the recent physical aggression.
Failure to Protect Trauma Survivor from Re-traumatization
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma was free from re-traumatization. An incident occurred where a resident was found on the floor with a hematoma on the head, a skin tear on the elbow, and complaints of rib pain after another resident entered their room without consent and allegedly hit them. The affected resident had previously disclosed a traumatic past to the social services staff and had expressed fear of the other resident, even wearing a whistle for protection. Despite this, there were no care plan interventions documented in the medical record to address the resident's history of trauma.
Failure to Accurately Document Abuse Incident in Medical Record
Penalty
Summary
The facility failed to maintain an accurately documented medical record for a resident involved in an alleged abuse incident. On 8/13/24, a Licensed Nursing Assistant (Staff K) witnessed an inappropriate interaction between two residents, where one resident was seen touching another resident's inner thigh. Staff K immediately separated the residents and reported the incident to a Licensed Practical Nurse (Staff M). Staff M documented the incident in a nurse's note on the same day. However, this note was later struck out by someone other than Staff M, as directed by the Director of Nursing (Staff F), who claimed it was placed in the wrong section of the medical record. The incident was instead recorded in the Risk Management System, which is not part of the official medical record. A review of the medical record confirmed the absence of documentation regarding the incident.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide appropriate care and services to prevent an avoidable pressure ulcer for a resident identified as being at risk. The facility's policy on Pressure Injury Prevention and Management required the development of a care plan with measurable goals and evidence-based interventions for residents at risk of pressure injuries. Despite this, the care plan for the resident, who was assessed with a Braden Scale score indicating risk for pressure ulcers, lacked specific interventions for offloading and repositioning. The resident's care plan included goals to prevent skin breakdown and interventions such as weekly skin checks and daily observation during ADL care, but it did not address the need for pressure redistribution. The deficiency was further highlighted by the development of deep tissue injuries (DTIs) on the resident's left and right heels, which were noted in physician documentation. The task for offloading the resident's heels was only initiated after the left heel DTI was identified. Interviews with staff revealed a lack of awareness and implementation of the necessary interventions, with discrepancies in the understanding of when the resident's heels were supposed to be floated. The Director of Nursing confirmed that the DTIs on the resident's heels were acquired within the facility, indicating a failure to adhere to the facility's pressure injury prevention policy.
Chemical Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that the residents' environment was free from accident hazards, specifically regarding the storage of chemical cleaning solutions. Observations were made on multiple occasions in the Birch Unit Tub Room, where a bottle of Rapid Multi Disinfectant Spray was found hanging on the wall within reach of wandering residents. Similarly, in the Spruce Unit Tub Room, a container of Super Sani-Cloth Germicidal wipes was observed on top of a portable cart, also within reach of wandering residents. These observations were confirmed by interviews with staff members, including a Licensed Practical Nurse and a Licensed Nursing Assistant. The facility's policy mandates that any area used for storing chemicals should be locked at all times, which was not adhered to in these instances. The Director of Nursing confirmed the presence of 13 wandering residents in the facility, highlighting the potential risk posed by the unsecured chemicals. The Safety Data Sheets for the chemicals indicated potential health effects, such as eye irritation and respiratory tract irritation, underscoring the importance of proper storage to prevent resident exposure.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed in the Birch Unit Medication Room and the Pine Unit Medication Cart. In the Birch Unit, the temperature log for the medication refrigerator was incomplete, with missing entries on multiple dates. During an observation, the refrigerator was found to be at 50 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees Fahrenheit for storing medications such as Sanofi High-Dose Influenza Vaccinations, Insulin Flex Touch Pens, and Purified Protein Derivative (PPD). This was confirmed by a Licensed Practical Nurse (LPN) present during the observation. In the Pine Unit, an open Lispro Insulin Pen and Lantus Insulin Pen were found without an open or expiration date, and an open vial of Lispro Insulin was beyond its 28-day expiration period. The facility's policy requires medications to be labeled with a 'date opened' sticker and to adhere to manufacturer-recommended expiration dates. The LPN confirmed these findings during the observation. The facility's failure to adhere to proper storage and labeling protocols for medications was evident in these observations.
Failure in Hand Hygiene During Dishwashing
Penalty
Summary
The facility failed to ensure proper hand hygiene by dietary staff during dishwashing procedures, as observed on 5/14/24. Staff K, a Dietary Aide, was seen stacking plate warmers, bowls, and plates onto racks and rinsing food debris off the dishes with ungloved hands before sanitizing them through a high-temperature dish machine. After wiping their hands with a paper towel, Staff K did not perform hand hygiene before handling clean and sanitized dishes and utensils. This action was confirmed during an interview with Staff K at the time of observation. The facility's policy on cleaning dishes and using the dish machine, which was reviewed on the same day, specifies that the person loading dirty dishes should not handle clean dishes unless they change into a clean apron and wash their hands thoroughly before transitioning from handling dirty to clean dishes.
Failure to Follow PPE Protocols for Infection Control
Penalty
Summary
The facility failed to adhere to CDC guidelines for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for two residents. Resident #25, who was receiving intravenous medication and had a wound, was observed with an EBP sign on the door and PPE available outside the room. However, a registered nurse, Staff J, did not wear a gown while administering IV medications to the resident, which was confirmed during an interview. For Resident #212, who was on contact precautions due to a diagnosis of viral herpes, there was a lack of awareness among staff regarding the reason for these precautions. Staff B, an LPN, entered the resident's room without donning PPE while administering medications, despite a contact precaution sign being present. Interviews with Staff B, Staff G, and the Director of Nursing revealed a lack of understanding of the precautions required for Resident #212. The facility's policy on isolation precautions and CDC guidelines emphasize the need for gown and gloves during high-contact care activities, which was not followed in these instances.
Care Plan Deficiencies for Residents with PTSD, Anticoagulation Therapy, and Skin Breakdown
Penalty
Summary
The facility failed to develop, implement, and revise care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #2, diagnosed with Post Traumatic Stress Disorder (PTSD) upon admission, did not have a care plan that included focus areas or interventions related to PTSD. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed a lack of awareness regarding the resident's trauma, indicating a gap in communication and care planning. Resident #58, who was prescribed Coumadin for Atrial Fibrillation, did not have a care plan addressing anticoagulation therapy and monitoring for side effects. The facility also lacked a policy related to anticoagulation therapy, as confirmed by the Administrator. Additionally, Resident #48, who developed a new left heel Deep Tissue Injury and a blister on the right heel, had a care plan that was not updated to reflect these changes, despite the facility's policy requiring care plan revisions upon status changes. The Director of Nursing confirmed that the care plan had not been updated to include the actual skin breakdown identified.
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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