Lebanon Center, Genesis Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, New Hampshire.
- Location
- 24 Old Etna Road, Lebanon, New Hampshire 03766
- CMS Provider Number
- 305050
- Inspections on file
- 19
- Latest survey
- October 6, 2025
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Lebanon Center, Genesis Healthcare during CMS and state inspections, most recent first.
A resident was hospitalized and tested positive for Legionella, but the facility did not follow its own water management plan by failing to test or remediate the water system, nor did it document control measures as required. Staff confirmed that a humidifier, which was prohibited by policy, was used in the resident's room, and water samples from the device were not tested. These lapses in infection control procedures exposed all residents to potential Legionella risk.
The facility did not obtain written authorization from three residents to manage their personal funds, resulting in direct deposit of social security benefits and automatic withdrawals for care costs without proper consent. Review of financial records and fund management forms showed that required authorizations were missing or incomplete for each resident involved.
The facility did not provide two residents or their representatives with required quarterly written statements of personal funds, as confirmed by record review and interviews. Instead, statements were signed only by the administrator, and both residents and their legal representatives reported not receiving the statements.
A resident was not notified when their personal fund account balance exceeded the SSI resource limit for several consecutive months. Despite facility policy and regulatory requirements mandating monthly notification when a resident's account approaches the Medicaid eligibility threshold, the required notifications were not provided or documented.
The facility failed to maintain sufficient nursing staff levels on weekends, as determined by their facility assessment. The required Hours Per Patient Day (HPPD) for nurse aides was set at 1.63, but several weekend dates showed staffing below this level, with HPPD ranging from 1.43 to 1.57. Staff M confirmed these findings, highlighting a pattern of inadequate staffing on weekends.
The facility failed to provide nourishing bedtime snacks, resulting in a 15-hour gap between dinner and breakfast. Interviews with residents and the Resident Council revealed that most did not receive bedtime snacks, despite requests for more substantial options. The facility's policy requires bedtime snacks, but the available options were limited to juice and cookies, and some residents reported not being offered snacks at all.
The facility did not provide necessary training on abuse, neglect, exploitation, and misappropriation of resident property to a Licensed Nursing Assistant. The staff member's education file lacked documentation of such training, and the Director of Nursing confirmed the absence of training prior to the staff member's start date. This was in violation of the facility's policy requiring such training during orientation and annually.
A resident did not receive the correct dosage of Heparin as ordered by the physician. An LPN administered 50 units instead of the prescribed 100 units intravenously for flushing a PICC line. This error was confirmed during an interview with the LPN and was identified through a review of the resident's MAR.
A facility failed to follow CDC guidance for Enhanced Barrier Precautions when an LPN accessed a resident's IV site without wearing a gown, despite signage indicating the requirement. The facility's infection preventionist confirmed the expectation for gown use, aligning with CDC guidelines to prevent MDRO transmission during high-contact care activities.
The facility did not follow its antibiotic use protocols as part of its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for UTIs in April and June 2024. This was confirmed by the Infection Preventionist, who acknowledged the prescriptions did not meet the facility's criteria.
A facility failed to limit psychotropic drug orders to 14 days for a resident. The resident's MAR showed an order for Ativan without a stop date, resulting in 10 doses administered beyond the 14-day limit. This was confirmed by the DON, and the facility's policy requires PRN psychotropic medications to be ordered for no more than 14 days.
The facility did not have a qualified professional directing the activities program for its 88 residents. An Activities Aide and the Administrator confirmed the absence of a Director since February 2024. The job description and policy review indicated that the Director of Recreation Services is responsible for overseeing the recreation services and ensuring the inclusion of various programs.
The facility did not ensure that the required members of the QAA Committee attended meetings quarterly, as per policy. The Medical Director missed the first and second quarter meetings, and the Infection Preventionist missed the fourth quarter meeting. This was confirmed through interviews and a review of attendance sheets.
The facility did not update the daily nurse staffing information to reflect actual hours worked at the beginning of each shift. A review showed discrepancies between posted information and actual schedules from June 9 to July 10. Staff M confirmed the postings were not updated, despite the facility's policy requiring daily adjustments to reflect staffing changes.
A facility failed to notify a resident and their representative of quarterly care plan meetings, as required for participation in their person-centered care plan. The resident's DPOA reported attending only two meetings since the resident's admission. Medical records confirmed attendance at two meetings, but no documentation of additional meetings was available. Staff from Social Services confirmed the lack of documentation, highlighting the deficiency.
The facility inaccurately coded the MDS for four residents, indicating daily use of bed rails as restraints when they were used for mobility assistance. Staff interviews and documentation confirmed the inaccuracies.
Failure to Implement Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Legionella prevention and response. After a resident, who had been admitted since November 2024, was transferred to the hospital with acute respiratory failure and subsequently tested positive for Legionella, the facility did not conduct required testing or remediation of its water system as outlined in its Water Management Plan. Staff interviews confirmed that neither the water system nor equipment where Legionella could proliferate were tested following the confirmed case, despite the facility's policy and CDC guidance requiring such actions after a healthcare-associated Legionnaires' disease diagnosis. Additionally, the facility did not document the results of control measures as required by its Water Management Plan. The maintenance supervisor acknowledged that water heater temperatures were checked but not logged, and there was no documentation to show which portable air conditioning units had been cleaned. The facility's water management plan also did not identify humidifiers as a risk for waterborne pathogens, and routine Legionella monitoring was not performed, contrary to the plan's requirements for outbreak investigation and control. Furthermore, a humidifier was found in the affected resident's room, which was against the facility's own procedures for Legionnaires' disease prevention. Staff were unaware of the prohibition on humidifiers until after the resident's hospitalization. Although a water sample from the humidifier was collected, it was not tested. These failures in following established policies and procedures exposed the facility's residents to the potential spread and growth of Legionella.
Failure to Obtain Written Authorization for Management of Resident Funds
Penalty
Summary
The facility failed to obtain written authorization from three residents to act as fiduciary of their personal funds and to manage, safeguard, and account for those funds deposited with the facility. For each of the three residents reviewed, their social security benefits were direct deposited into their resident fund accounts, and significant amounts were automatically transferred to the facility for care costs. However, a review of the Resident Fund Management Service forms for each resident revealed that none had authorized the facility to either direct deposit their social security benefits or to automatically transfer payments for care costs. Specifically, the forms for all three residents were either unsigned or did not include authorization for the facility to manage these financial transactions. The records showed repeated automatic withdrawals for care costs without the required written consent from the residents or their guardians. These actions were identified through record review and interviews conducted on 7/7/25, and the lack of proper authorization was consistently documented across all three cases.
Failure to Provide Quarterly Personal Fund Statements to Residents or Representatives
Penalty
Summary
The facility failed to provide written quarterly statements of personal funds to residents or their representatives within 30 days after the end of the quarter, as required. For two residents reviewed, the quarterly statements for multiple quarters were signed by the facility administrator rather than the residents or their legal representatives. Record reviews showed that the statements for both residents were not acknowledged by the appropriate parties, and interviews confirmed that neither the residents nor their representatives had received the required statements. Specifically, one resident's guardian reported not receiving any quarterly statements for the resident's personal fund account, and another resident and their activated power of attorney both stated they had not received any such statements. The administrator confirmed during interview that the statements had not been provided to the residents or their representatives, substantiating the deficiency in managing and communicating residents' personal fund information.
Failure to Notify Resident of Exceeding SSI Resource Limit
Penalty
Summary
The facility failed to notify a resident when their personal fund account balance reached or exceeded $200 less than the Supplemental Security Income (SSI) resource limit, as required by state and federal regulations. Record review showed that the resident's account consistently exceeded the $2,500 SSI resource limit from January through June, with monthly balances ranging from $3,604.10 to $5,784.29. Interviews with the Regional Business Office Manager and the Administrator confirmed that the resident was not notified of exceeding the SSI resource limit during this period. The facility's own policy requires monthly notification and documentation when a resident's account approaches the Medicaid eligibility threshold, but this was not followed for the resident in question.
Insufficient Weekend Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff as determined by their facility assessment. A review of the facility's Payroll Based Journal Staffing Data report for Quarter 2, 2024, revealed excessively low weekend staffing. The facility assessment determined that the required Hours Per Patient Day (HPPD) for nurse aides was 1.63 HPPD. However, a review of the nursing staff punch reports from June 9, 2024, to July 10, 2024, showed that on several weekend dates, the staffing levels for nurse aides were below the required HPPD. Specifically, on June 9, 2024, nurse aides were staffed at 1.57 HPPD; on June 22, 2024, at 1.49 HPPD; on June 23, 2024, at 1.45 HPPD; on June 29, 2024, at 1.49 HPPD; on July 6, 2024, at 1.47 HPPD; and on July 7, 2024, at 1.43 HPPD. An interview with Staff M, the Scheduler/Human Resources, confirmed these findings, indicating a consistent pattern of insufficient staffing on weekends, which did not meet the facility's own assessment requirements.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to provide nourishing bedtime snacks to residents, resulting in a 15-hour gap between the evening meal and breakfast. An interview with the Resident Council, consisting of 13 residents, revealed that most attendees did not receive bedtime snacks. The Resident Council President had previously requested more substantial snacks, such as tuna, egg salad, or chicken salad, to be available in the kitchenettes. However, the facility's snack offerings, as confirmed by the Food Service Director, were limited to items like cranberry juice, apple juice, oatmeal creme cookies, chocolate creme cookies, and crackers. Further interviews with individual residents highlighted the deficiency. One resident reported not being offered a snack in the evening, while another stated they were not offered snacks at any time during the day or night. The facility's policy, revised in October 2022, mandates that bedtime snacks be provided for all residents, with the Dining Services Department collaborating with residents, nursing, and management to identify necessary snack items. Nursing Services is responsible for delivering and offering these snacks, but the policy was not adhered to, leading to the deficiency.
Failure to Provide Required Training on Abuse and Neglect
Penalty
Summary
The facility failed to provide necessary training and education to staff on abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified for one of the five staff members reviewed, specifically a Licensed Nursing Assistant (Staff L). Upon reviewing Staff L's education file, it was found that there was no documentation of training or education on these critical topics. An interview with the Director of Nursing (Staff D) confirmed that Staff L had not received the required training prior to their start date in April 2024. The facility's policy, titled 'Abuse Prohibition' and revised in October 2022, mandates that training and reporting obligations be provided to all employees during orientation, through Code of Conduct training, and at least annually. However, this policy was not adhered to in the case of Staff L, leading to the identified deficiency.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered, specifically involving the administration of Heparin. During an observation, a Licensed Practical Nurse (LPN) administered 50 units of Heparin intravenously to a resident, contrary to the physician's order which specified 100 units to be administered twice daily for flushing a right arm PICC line. This discrepancy was confirmed during an interview with the LPN, who acknowledged administering the incorrect dose. The physician's order had been in place since June 19, 2024, and the error was identified on July 9, 2024, during a review of the resident's Medication Administration Record (MAR).
Failure to Follow Enhanced Barrier Precautions for IV Access
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidance for Enhanced Barrier Precautions (EBP) for a resident with an intravenous (IV) access. During an observation, it was noted that a Licensed Practical Nurse (LPN) accessed the resident's IV site without wearing a gown, despite signage on the resident's room door indicating that EBP was required. This action was confirmed through an interview with the LPN, who acknowledged the failure to wear a gown while accessing the IV site. Further interviews and policy reviews revealed that the facility's infection preventionist expected staff to wear a gown when accessing an IV. The facility's policy on Enhanced Barrier Precautions, revised in January 2024, aimed to reduce the transmission risk of epidemiologically significant microorganisms through direct or indirect contact. The CDC guidelines, updated in July 2022, specify that gown and gloves should be used during high-contact resident care activities, especially for residents with wounds or indwelling medical devices, to prevent the spread of multidrug-resistant organisms (MDROs).
Failure to Adhere to Antibiotic Use Protocols
Penalty
Summary
The facility failed to adhere to its antibiotic use protocols, which are part of its Antibiotic Stewardship Program (ASP), during the period from March 2024 to June 2024. Specifically, the facility did not meet its criteria for determining appropriate antibiotic use in two out of the four months reviewed. In April 2024, one resident was prescribed antibiotics for a urinary tract infection (UTI) without meeting the facility's criteria. Similarly, in June 2024, six residents were prescribed antibiotics for UTIs without meeting the established criteria. This was confirmed during an interview with the Infection Preventionist, who acknowledged that the antibiotics were prescribed without adhering to the facility's criteria. The facility's policy, titled IC402 Antibiotic Stewardship, mandates the implementation of an ASP that includes protocols and systems for monitoring antibiotic use, which were not followed in these instances.
Failure to Limit Psychotropic Drug Orders to 14 Days
Penalty
Summary
The facility failed to ensure that orders for psychotropic drugs were limited to 14 days for a resident reviewed for psychotropic/opioid side effects. The review of the resident's Medication Administration Record (MAR) revealed a physician's order for Ativan Oral Tablet 0.5 mg to be given every 4 hours as needed for anxiety/nausea, starting on 6/16/24, with no stop date indicated. The resident received 10 doses of the as-needed Ativan after 14 days of the order being initiated. This finding was confirmed during an interview with the Director of Nurses. The facility's policy on psychotropic medication use, revised on 10/24/22, states that PRN psychotropic medications should be ordered for no more than 14 days.
Lack of Qualified Director for Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional for its census of 88 residents. During an interview, an Activities Aide revealed that there was no Director of the Activities program at the facility. This was confirmed by the Administrator, who stated that the previous Director left the position in February 2024. A review of the facility's job description for the Director of Recreation Services indicated that this role is responsible for the development, implementation, and supervision of the full scope of recreation services in the nursing center. Additionally, the facility's policy on Recreation Program Components outlined that the Recreation Director is responsible for ensuring the inclusion of various recreation programs.
Failure to Ensure Required QAA Committee Attendance
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assessment and Assurance (QAA) Committee attended meetings at least quarterly, as mandated by their policy. Specifically, the Medical Director was absent from the meetings in the first and second quarters, and the Infection Preventionist was absent in the fourth quarter of 2023/24. This deficiency was confirmed through an interview with the Administrator and a review of the QAPI meeting attendance sheets. The facility's policy, revised in March 2024, stipulates that the QAA Committee must include the Director of Nursing Services, the Medical Director, the Administrator, at least two other staff members, and the infection control and prevention officer.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to update the posted daily nurse staffing information to reflect the actual hours worked at the beginning of each shift on a daily basis. A review of the facility's daily nursing staff postings from June 9, 2024, through July 10, 2024, revealed discrepancies between the posted information and the actual daily nursing schedules. During an interview on July 11, 2024, Staff M, who is responsible for scheduling and human resources, confirmed that the postings were not updated to reflect the actual staffing. The facility's policy, revised on August 7, 2023, requires that the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff be posted and adjusted daily to reflect any staffing changes.
Failure to Notify Resident of Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to notify a resident and/or their representative of quarterly care plan meetings, which is a requirement for resident participation in their person-centered plan of care. Specifically, the deficiency involved a resident whose activated alternate Durable Power of Attorney (DPOA) reported being invited to only two care plan meetings since the resident's admission in April 2023. A review of the resident's medical record confirmed the presence of two quarterly care plan attendance sheets dated April 26, 2023, and February 27, 2024, indicating that both the DPOA and the alternate DPOA were in attendance. However, Staff K from Social Services was unable to provide documentation of any additional quarterly care plan meetings, confirming the deficiency.
Inaccurate MDS Coding for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of four residents regarding the use of bed rails. For Resident #11, the Quarterly MDS indicated daily use of bed rails as a restraint, while a Bed Rail Evaluation showed that the resident requested the use of two half upper rails for mobility and transfer assistance, not as a restraint. This discrepancy was confirmed by the MDS Coordinator during an interview. Similarly, for Residents #53, #76, and #24, the MDS inaccurately coded the bed rails as restraints used daily. Interviews with staff, including a Licensed Practical Nurse and the MDS Coordinator, confirmed that the bed rails for these residents were not restraints. Resident #24's Consent for Use of Bed Rails also indicated that the rails were used as a mobility enabler, not a restraint. These inaccuracies in the MDS submissions were acknowledged by the staff involved.
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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