Mineral Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in North Conway, New Hampshire.
- Location
- 1251 White Mountain Highway, North Conway, New Hampshire 03860
- CMS Provider Number
- 305084
- Inspections on file
- 24
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mineral Springs during CMS and state inspections, most recent first.
A resident with dysphagia was not provided with the prescribed pureed fruits and vegetables, instead receiving whole sliced pears and cut watermelon on multiple occasions. Staff confirmed these items were not pureed, despite clear physician orders, care plan interventions, and facility policy requiring pureed foods for this resident.
The facility failed to ensure accurate advance directives for two residents. One resident had conflicting documentation between a Full Code order and a DNR form, while another had discrepancies between a DNR order and a Full Code care plan. These inconsistencies were confirmed by nursing staff.
A facility failed to inform a resident and their DPOA about the option to use an outside pharmacy and the associated charges for services not covered by Medicaid/Medicare. The resident was admitted and provided an outside pharmacy prescription card, but the facility required the use of its own pharmacy, resulting in unexpected monthly co-pay charges. The facility's policy allows for noncontract pharmacy use, but this was not communicated, leading to the deficiency.
A resident received more doses of Acetaminophen than prescribed within a 48-hour period without notifying the physician, as required by the PRN order. The resident frequently reported pain levels above the mild pain threshold, yet was administered medication outside the prescribed parameters. Staff interviews confirmed the lack of documentation and notification to the provider.
The facility did not have an RN on duty for 8 consecutive hours on four days in September 2024. A review of staffing data showed no RN hours for these days, and the DON confirmed the lack of documentation for RN presence.
The facility failed to label and date medications properly, as observed in two medication carts. A medication cup with unlabeled pills and inhalers without open dates or resident identifiers were found. Staff confirmed the findings, with one unable to identify the owner of a Symbicort inhaler.
A facility failed to accurately document a resident's PTSD diagnosis in their medical record. Despite the resident having a documented diagnosis of PTSD, a social worker incorrectly marked that the resident had no history of trauma in the Social Services Assessment. The social worker admitted to not asking the resident about trauma, leading to the inaccurate assessment. This failure to follow the facility's Trauma Informed Care policy resulted in a deviation from proper documentation procedures.
The facility did not follow infection control guidelines for water management, failing to monitor control measures to minimize Legionella risk. The Infection Preventionist was unaware of any monitoring system, and logs showed inconsistent documentation of temperature and pressure checks. This deficiency potentially affected 48 residents, as there was no evidence of a system to ensure water safety.
The facility failed to provide adequate nursing staff, resulting in delayed care and medication administration for residents. Interviews with residents and staff revealed that low staffing levels led to increased incontinence incidents, missed showers, and delayed assistance. The facility's staffing assessment and daily staffing sheets confirmed consistent understaffing, impacting resident care.
The facility failed to follow physician orders and provide timely medication administration for several residents. A resident received medications like Ativan and Eliquis outside prescribed timeframes, while another's wound care was not documented as performed. Additionally, a resident's weight monitoring for CHF was not conducted, and another did not receive prescribed Lotrisone Cream and eye drops. Staff interviews confirmed these deficiencies, indicating non-compliance with medication management protocols.
The facility failed to ensure the activities program was directed by a qualified professional. The Director of Activities, promoted in September 2024, had been an activities aide since June 2024 and lacked necessary certifications, degrees, or experience. The facility's job description requires specific qualifications, which the Director did not meet, as confirmed by the Administrator.
The facility failed to designate a qualified Infection Preventionist with specialized training in infection prevention and control. Staff D, hired as the Infection Preventionist, lacked evidence of such training, as confirmed by interviews with Staff D and the DON. The facility's job description and policy required specialized training within 90 days of hire, which was not met.
A resident's needs were not accommodated as their call bell was consistently out of reach, hanging over a roommate's light fixture. The resident, unable to access the call bell, indicated they would have to yell for assistance. Observations confirmed the call bell's position remained unchanged, leaving the resident without a means to call for help.
The facility failed to maintain a clean environment on one unit, where smeared brown substances were observed on the carpet. Two residents were seen walking on these areas. A staff member confirmed the substance was from a resident's loose stools the previous evening.
A resident did not receive any showers over a three-month period, despite the facility's policy requiring showers as per request or schedule. The resident's family had previously raised concerns about the lack of weekly showers. The Clinical Nursing Officer confirmed the absence of documentation for showers during this time.
The facility did not provide weekend activities for residents in September 2024, as confirmed by the Resident Council and activity calendars. Residents expressed dissatisfaction with the lack of activities, and the Director of Activities confirmed no plans were made for weekends, with supplies locked away.
A resident with a pressure ulcer did not receive necessary treatment and services, as the facility failed to document weekly wound assessments. The resident developed a pressure ulcer around the Achilles tendon after having a cast placed on their left leg. Despite the facility's policy requiring weekly documentation, wound measurements were only recorded sporadically over a month, which was confirmed by the DON.
A resident's insulin regimen was not administered timely, with doses given significantly late, contrary to physician orders. Additionally, low blood glucose events were not properly treated or documented, and providers were not notified, as confirmed by staff interviews.
A facility failed to maintain a medication error rate below 5%, resulting in a 5.56% error rate. A resident was prescribed Olanzapine 2.5 mg for borderline personality disorder and Metoprolol Succinate ER 100 mg for hypertension. A nurse administered Olanzapine 5 mg instead of the prescribed dose and omitted Metoprolol. The nurse confirmed these errors, violating the facility's policy on the six rights of medication administration.
The facility failed to maintain proper storage and labeling of medications, with expired and unlabeled vials found in the medication room and cart. A resident self-administered nasal sprays without secure storage, and an unlocked medication cart was left unattended in a hallway. Staff confirmed these deficiencies, including improper disposal of medications.
The facility did not have a documented Quality Assurance and Performance Improvement (QAPI) plan. An interview with the Administrator revealed the absence of a written QAPI plan, indicating a failure to establish formalized procedures for QAPI and QAA activities.
A resident on Coumadin for atrial fibrillation did not receive the medication for five days due to a missed INR test and lack of follow-up orders. The resident showed symptoms of complications and was sent to the hospital, where they were diagnosed with bilateral pulmonary embolisms.
Failure to Provide Prescribed Pureed Diet for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia had a physician's order for a regular/liberalized dysphagia advanced texture diet, specifically requiring pureed fruits and vegetables. The resident's care plan identified them as being at nutritional risk due to dysphagia, with interventions in place to provide a dysphagia diet as ordered. Despite these orders and care plan interventions, observations on two separate occasions revealed that the resident was served whole sliced pears and cut pieces of watermelon, rather than pureed fruits as required. Staff interviews confirmed that these items were not pureed and did not meet the dietary requirements specified for the resident. Further review of the resident's speech therapy discharge summary confirmed the ongoing need for pureed fruits and vegetables due to swallowing issues. The facility's own Diet and Nutrition Care Manual and policy on therapeutic diet orders also specified that foods for residents on a dysphagia puree diet must be provided in pureed form. Both dietary and nursing staff were responsible for ensuring therapeutic diets were provided as prescribed, but failed to do so in this instance, resulting in the resident not receiving the appropriate diet texture as ordered.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure the residents' right to formulate advance directives for two residents. For Resident #102, there was a discrepancy between the physician's order for Full Code, dated 2/15/25, and a Portable Do Not Resuscitate (DNR) form, dated 7/11/22, which indicated the resident was a DNR. Additionally, the care plan for advanced directives confirmed the resident's code status as DNR. This inconsistency was confirmed by a Registered Nurse during an interview. Similarly, for Resident #152, there was a conflict between the physician's order for DNR, dated 2/18/25, and the care plan for advanced directives, which indicated a Full Code status, dated 2/14/25. This discrepancy was confirmed by a Nurse Manager during an interview.
Failure to Inform Resident of Pharmacy Options and Charges
Penalty
Summary
The facility failed to inform a resident and their Durable Power of Attorney (DPOA) about the option to use an outside pharmacy and the associated charges for services not covered by Medicaid/Medicare. The resident was admitted in December 2024, and during the admission process, the facility did not discuss the option of using an outside pharmacy with the resident or their DPOA. The DPOA provided the facility with an outside pharmacy prescription card, but the facility required the use of its own pharmacy, resulting in monthly co-pay charges that would not have occurred with the resident's preferred pharmacy. The facility's policy allows residents to request medications from a noncontract pharmacy, but this information was not communicated to the resident or their DPOA, leading to unexpected charges.
Failure to Follow Physician's Orders for Pain Management
Penalty
Summary
The facility failed to adhere to physician's orders for pain management for Resident #44, as identified through interviews and record reviews. The resident had a physician's order for Acetaminophen 325 mg, to be administered as needed for mild pain, with a stipulation to notify the physician if more than three doses were given within 48 hours. However, the Medication Administration Record (MAR) showed that the resident received four doses within 48 hours on two separate occasions, and there was no documentation that the physician was notified as required. Additionally, the resident frequently reported pain levels of 5 or above on a numeric pain scale of 1 to 10, which was outside the parameters for mild pain as defined by the facility. Despite this, the resident was administered Acetaminophen outside of the PRN order parameters without notifying the provider. Interviews with the Nurse Manager and the Advanced Practical Registered Nurse confirmed the lack of documentation and notification to the provider regarding the deviation from the prescribed pain management plan.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for four specific days in September 2024. A review of the Facility's Payroll Based Journal Staffing Data Report for Quarter 4 2024 revealed that there were no RN hours submitted for the dates of September 1, 15, 28, and 29, 2024. An interview with the Director of Nursing confirmed these findings and indicated that the facility could not provide documentation to show that an RN was on duty during these dates.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and dated according to currently accepted professional principles, as observed in two medication carts. During an observation, a small clear plastic medication cup containing three unlabeled and undated pills was found in the top drawer of a medication cart, which was confirmed to belong to a resident. Additionally, another medication cart contained a Symbicort inhaler without a box, bag, resident identifier, or open date, and an Advair Diskus inhaler in a box for another resident without an open date or expiration date. The pharmacy instructions indicated that the Advair Diskus should be discarded one month after opening, and the manufacturer's instructions for Symbicort stated it should be discarded within three months after removal from the pouch. Staff interviews confirmed the findings, with one staff member unable to identify the owner of the Symbicort inhaler.
Inaccurate Documentation of PTSD in Resident's Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). A review of the resident's medical record showed a diagnosis of PTSD, but the Social Services Assessment and Documentation, completed by a social worker, inaccurately indicated that the resident had no history of trauma or PTSD. The social worker admitted during an interview that they did not ask the resident about trauma, leading to the inaccurate completion of the assessment. The facility's policy on Trauma Informed Care outlines a multi-pronged approach to identifying a resident's history of trauma, including asking residents about triggers and using various assessment tools. However, this policy was not followed in the case of the resident with PTSD, as the social worker did not conduct a thorough assessment to identify the resident's trauma history. This oversight resulted in a failure to document the resident's condition accurately, which is a deviation from the facility's established procedures.
Failure to Monitor Legionella Control Measures
Penalty
Summary
The facility failed to adhere to established infection control guidelines for water management, specifically in monitoring control measures to minimize the risk of Legionella and other opportunistic pathogens. During an interview, the Infection Preventionist was unaware of any system in place to monitor these control measures. A review of the facility's Legionella Water Management policy from 2017 indicated that domestic water tanks were designed to be inhospitable to Legionella bacteria due to high temperature and volume use, and were purged monthly by maintenance staff. However, the facility's documentation did not support consistent monitoring of these measures. The facility's boiler room daily inspection and maintenance logs revealed significant gaps in monitoring temperature and pressure, with only 10 out of 31 days in August and 4 out of 14 days in September being documented. The Maintenance Director confirmed these findings, indicating a lack of evidence for consistent control measures to prevent the introduction and spread of Legionella. This deficiency potentially affected the facility's census of 48 residents, as there was no documented system to ensure the safety of the water supply.
Staffing Deficiencies Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple interviews and record reviews. Residents reported delays in receiving care and medications due to staff being too busy. One resident mentioned waiting for 45 minutes for assistance while on the toilet, highlighting the impact of staffing shortages on resident care. Staff interviews corroborated these accounts, revealing that low staffing levels led to delayed medication administration, increased incontinence incidents, and missed showers for residents. Staff members, including Licensed Nursing Assistants (LNAs) and Medication Nursing Assistants (MNAs), reported that at times, only one LNA was available for 25 residents, making it challenging to provide necessary care. They also noted that during certain shifts, there was only one nurse available for 50 residents, further exacerbating the issue. The facility's staffing assessment indicated that there should have been more staff on duty, but the daily staffing sheets revealed numerous instances where staffing levels were below the required numbers. The facility's daily staffing sheets from July 1, 2024, to September 11, 2024, showed consistent understaffing, with many shifts lacking the necessary number of LNAs and nurses. This staffing deficiency was confirmed by the facility's scheduler. Additionally, an Advanced Practice Registered Nurse expressed concerns about residents not receiving consistent wound care due to staffing issues, indicating that the deficiency affected various aspects of resident care.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders and provide timely medication administration for several residents, leading to deficiencies in care. Resident #47 experienced multiple instances where medications such as Ativan and Eliquis were administered outside the prescribed timeframes, with some doses given hours late or too close together. This was confirmed by staff interviews, indicating a lack of adherence to scheduled medication times. Resident #1's treatment for skin breakdown was not documented as performed on several occasions, despite a physician's order to change dressings daily. The Director of Nursing confirmed the lack of documentation, suggesting a failure in following through with prescribed wound care. Similarly, Resident #34 received medications, including Lantus and Hydralazine, at incorrect times, with some doses administered hours late or inappropriately close together. The Advanced Practice Registered Nurse was unaware of these discrepancies, highlighting a communication gap in medication administration. Resident #17's weight monitoring for congestive heart failure was not conducted as ordered, with missed weight recordings and a lack of notification to the provider about significant weight gain. Resident #26 did not receive prescribed Lotrisone Cream due to unavailability and missed doses of eye drops following cataract surgery. Staff interviews confirmed these omissions, indicating a failure to ensure medication availability and administration. These deficiencies reflect a pattern of non-compliance with physician orders and medication management protocols.
Unqualified Director of Activities
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, affecting a census of 78 residents. An interview with the Director of Activities, who was promoted in September 2024, revealed that they had been working as an activities aide since June 2024 and lacked prior certifications, degrees in recreation, or experience in an activity program. The facility's job description for the Director of Recreation Services requires certification by the National Certification Council of Activity Professionals or the National Council of Therapeutic Recreation Certification, a bachelor's degree in therapeutic recreation, or two years of experience in a social or recreational program, with one year in a patient activity program in a healthcare setting. An interview with the Administrator confirmed that the Director of Activities did not meet these qualifications.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist who had completed specialized training in infection prevention and control. During a record review on September 11, 2024, it was found that the facility could not provide evidence of such training for Staff D, who was hired on May 23, 2024, and was currently serving as the Infection Preventionist. An interview with Staff D confirmed the lack of specialized training. Additionally, an interview with Staff E, the Director of Nursing, corroborated these findings. The facility's job description for the Infection Preventionist, revised on August 3, 2020, required the completion of specialized training within 90 days of hire. Furthermore, the facility's policy on the Infection Prevention and Control Program, revised on July 1, 2024, outlined the responsibilities of the Infection Preventionist, which included developing, implementing, monitoring, and maintaining the program.
Resident's Call Bell Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring their call bell was within reach. During an observation, it was noted that the resident's call bell was hanging over their roommate's light fixture, making it inaccessible to the resident. The resident, who was unable to reach the call bell, stated in an interview that they would have to yell for help if needed. Subsequent observations confirmed that the call bell remained in the same inaccessible position, with the resident either sitting in a wheelchair or napping in bed, unable to reach it.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of its units. During an observation on the [NAME] Unit, three large areas of a smeared brown substance were found adhered to the carpet. One area, approximately 4 feet long and 1 foot wide, was located in the hallway, while two other areas, each approximately 2 feet long and 1 foot wide, were in front of the nursing station. Two residents were observed walking on these areas. An interview with a Licensed Nursing Assistant revealed that the substance was from a resident who had loose stools the previous evening.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #42, as part of their Activities of Daily Living (ADL) care. A review of the facility's policy on resident showers revealed that showers should be provided as per request or according to the facility's schedule, ensuring resident safety. However, documentation from July, August, and September 2024 showed that Resident #42 did not receive any showers, and there was no record of the resident refusing showers. This was confirmed during an interview with the Clinical Nursing Officer, who acknowledged the lack of documentation for showers during the specified period. Additionally, a Care Plan Meeting Note from July 2024 indicated that the resident's family had expressed concerns about the resident not receiving weekly showers.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide facility-sponsored groups and individualized activities to support residents based on their preferences, interests, and needs during weekends in September 2024. An interview with the Resident Council, consisting of eight residents, revealed complaints about the absence of weekend activities for the past two weekends, with nothing scheduled on the September activities calendar for weekends. One resident reported watching television all day, while seven others stated there was nothing for them to do. A review of the September 2024 activity calendars confirmed the lack of documented activities on Saturdays and Sundays throughout the month. Interviews with two residents indicated their willingness to attend weekend activities. The Director of Activities, who works Monday through Friday, confirmed these findings and stated that no activities were planned for weekends when they were not working, and the activity supplies were inaccessible as the office was locked.
Failure to Ensure Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, as evidenced by the lack of weekly documentation of wound assessments. The resident, who had a cast on their left leg, developed a pressure ulcer around the Achilles tendon. Despite the facility's policy requiring weekly reviews and documentation of skin assessments and pressure injury progression, the resident's wound measurements were only recorded on five occasions over a period of more than a month. This was confirmed by the Director of Nursing during an interview, acknowledging that the required weekly measurements were not conducted.
Failure in Timely Insulin Administration and Monitoring
Penalty
Summary
The facility failed to ensure timely administration and adequate monitoring of a diabetic resident's insulin regimen. The resident expressed concerns about inconsistent blood sugar levels and questioned the accuracy of insulin administration. A review of the resident's medical records revealed multiple instances where insulin doses were administered significantly later than the scheduled times, including doses of Fiasp and Lantus insulins. These delays ranged from 1.5 to over 3 hours late, which did not align with the physician's orders for administration before meals. Additionally, the facility's policy required medications to be administered within 60 minutes of the scheduled time, which was not adhered to in these cases. Furthermore, the facility did not adequately respond to instances of low blood glucose levels. On two occasions, the resident's capillary blood glucose (CBG) levels were recorded as low, but the necessary treatment with Insta-Glucose Gel was not documented as administered, nor were repeat CBGs conducted as required. There was also no documentation of provider notification regarding these low blood sugar events. Interviews with staff confirmed the lack of documentation and notification, indicating that the necessary actions were not taken to address the resident's low blood sugar levels.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent during medication administration, resulting in a 5.56 percent error rate. This deficiency was identified during an observation of medication administration for a resident. The resident had physician's orders for Olanzapine 2.5 mg to be taken in the morning for borderline personality disorder and Metoprolol Succinate ER 100 mg to be taken once daily for hypertension. However, a registered nurse was observed administering Olanzapine 5 mg instead of the prescribed 2.5 mg and omitting the administration of Metoprolol Succinate ER 100 mg. The nurse confirmed these errors during an interview. The facility's medication administration policy requires adherence to the six rights of medication administration, including the right dosage, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain proper storage and labeling of medications, as observed in both the medication room and medication cart. In the [NAME] Medication Room, an open vial of Tuberculin PPD-Aplisol was found without an open date or expiration date, and another vial was expired. The manufacturer's instructions specify that vials in use for more than 30 days should be discarded. Staff M, a Registered Nurse, confirmed these findings. Additionally, the Brettonwoods Medication Cart contained a medication cup with pre-poured pills lacking a resident identifier and an open Insulin Basaglar (Lantus) Qkwikpen without an open date or expiration date, contrary to the manufacturer's instructions that the pen should not be used for more than 28 days after opening. Staff L, a Medication Nursing Assistant, confirmed these observations. Further deficiencies were noted with Resident #26, who self-administered nasal sprays without a secure place to store them in the room. An unlocked medication cart was observed in the hallway of the [NAME] Woods Unit, with no staff present and residents nearby, violating the facility's policy that all drugs and biologicals must be stored in locked compartments. Additionally, Resident #34's Lantus was found expired, and Staff N, a Registered Nurse, was observed improperly disposing of an Olanzapine tablet in an uncovered trash receptacle attached to the medication cart, contrary to the facility's policy on hazardous waste pharmaceuticals. Staff N confirmed the medication cart was left unlocked and the Lantus was expired.
Failure to Maintain a Comprehensive QAPI Plan
Penalty
Summary
The facility failed to develop, implement, and maintain an effective comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) plan. During an interview with the Administrator, it was revealed that the facility was unable to provide documentation of a written QAPI plan. This indicates a lack of formalized procedures and documentation necessary for conducting QAPI and Quality Assessment and Assurance (QAA) activities.
Failure to Administer Anticoagulation Therapy
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving anticoagulation therapy. The resident, who was on Coumadin for atrial fibrillation, did not receive the medication for five days due to a lapse in monitoring and follow-up. The resident's medical record indicated an order for Coumadin to be administered until April 25, with a follow-up INR test scheduled for April 26. However, the INR test was not conducted, and no new orders for Coumadin were obtained, resulting in the resident not receiving the medication. On May 1, the resident exhibited symptoms of potential complications, including cyanotic lips, elevated heart rate, and low oxygen saturation. A nurse practitioner's note confirmed that the resident had not received Coumadin since April 25 and was sent to the emergency room due to concerns of acute pulmonary embolism. The resident was subsequently admitted to the hospital with bilateral pulmonary embolisms, highlighting the facility's failure to ensure proper anticoagulation management.
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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