Mountain Ridge Center, Genesis Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, New Hampshire.
- Location
- 7 Baldwin Street, Franklin, New Hampshire 03235
- CMS Provider Number
- 305075
- Inspections on file
- 19
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mountain Ridge Center, Genesis Healthcare during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident care needs, often assigning LNAs on light duty as full-duty staff and resulting in inadequate coverage for tasks such as showers, transfers, and timely response to call lights. Staff and residents reported long waits for care, missed showers, and frequent closure of the dining room due to insufficient staffing, with some residents left in bed or grouped together for meals.
Two residents did not receive care and services as ordered, including lack of administration of PRN bowel medications for constipation and failure to schedule or complete specialist referrals and diagnostic procedures for a resident with a non-healing wound. Staff interviews and record reviews confirmed these deficiencies, including missed appointments and lack of documentation of required interventions.
A resident experienced significant weight loss over a one-month period, with records showing consistently low meal intake and no documentation that the dietitian or physician was notified as required by the care plan. The last dietitian assessment was several months prior, and staff confirmed that necessary notifications regarding the resident's nutritional decline were not made.
Surveyors found that multiple opened inhalers on two medication carts were not labeled with open or expiration dates as required by manufacturer instructions and facility policy. LPNs confirmed the lack of labeling for inhalers such as Incruse Ellipta, Breztri, Spiriva, and Trelegy, resulting in a deficiency for improper medication labeling and storage.
A resident's urinalysis was delayed after the initial specimen was forgotten in the refrigerator and not sent to the lab, requiring recollection several days later. Staff interviews confirmed that such oversights occur frequently, resulting in delays in laboratory testing and treatment.
The facility's assessment did not include staffing needs for each resident unit, instead listing only overall RN/LPN and LNA hours for the entire census. The Administrator confirmed that unit-specific requirements were not considered.
The facility did not consistently include two residents and their DPOAs in care plan meetings, as required by policy. One DPOA had not been invited to a meeting in about two years, and another attended only one meeting since admission, with no documentation of additional meetings. Staff confirmed the lack of invitations and documentation.
A resident was administered PRN Morphine Sulfate multiple times despite documentation of a pain level of 0, contrary to physician orders specifying administration only for pain rated at 5/10 or higher. The Unit Manager confirmed the medication was given without clinical indication, representing a failure to follow professional standards for medication administration.
Surveyors found that expired IV antibiotics and opened, undated multi-dose vials of vaccines were stored in the medication room refrigerator. A nurse confirmed that the vials had been used and the antibiotics were expired, in violation of manufacturer instructions and facility policy requiring removal of outdated medications and proper dating of opened vials.
The facility did not maintain adequate nursing staff coverage for most days reviewed, leading to residents experiencing long waits for assistance with daily care, missed activities, and delays in responding to call bells. Staff, including LNAs, RNs, and the Infection Preventionist, frequently had to cover additional shifts and roles, and residents requiring extensive assistance were particularly affected by the staffing shortages.
The facility did not provide required Medicare beneficiary notices to two residents, including failing to give a NOMNC with 48-hour notice and not issuing SNF ABNs when coverage ended, as confirmed by record review and staff interview.
A facility failed to follow physician-ordered medication parameters for a resident's pain management. The resident's MAR indicated that Oxycodone 5 mg was administered multiple times without documenting the pain level, contrary to the physician's order requiring administration for pain rated 5/10 or greater. This was confirmed by the Unit Manager, highlighting a deviation from professional standards of care.
A facility failed to provide a resident with education and an offer for the Pneumococcal vaccine upon admission. The resident's medical record lacked documentation of immunization history, education, consent, or declination for the vaccine. An interview with the Infection Preventionist confirmed the oversight, which was against the facility's policy requiring vaccination history and administration for eligible adults.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record reviews, staff interviews, and direct observations. Staffing schedules showed that Licensed Nursing Assistants (LNAs) on light duty with lifting restrictions were counted as full-duty staff and assigned full workloads. On multiple occasions, there were shifts where only one LNA was present on a unit, or where two LNAs on light duty were scheduled together, resulting in inadequate coverage for the number of residents, including those requiring two-person assistance for transfers. Staff interviews consistently reported that the number of LNAs was insufficient to complete required tasks such as showers, transfers, and timely response to call lights, with some staff refusing to work due to unsafe staffing levels. Direct observations and staff accounts indicated that residents were not receiving necessary care, such as showers and assistance with transfers, due to the lack of available staff. Residents dependent on mechanical lifts or two-person assists often had to wait extended periods for care, and some were left in bed or in geriatric chairs for prolonged times. The dining room was frequently closed because of inadequate staffing, and residents were grouped together in rooms for meals instead. Staff also reported an increase in resident falls and that residents were missing outside specialist appointments and meaningful activities because there were not enough staff to assist them. Resident council minutes and interviews with residents confirmed ongoing concerns about insufficient staffing, long waits for care, and missed showers. Residents expressed frustration with the lack of available staff, particularly during evening and night shifts, and reported going extended periods without showers. The facility's failure to adjust staffing assignments to account for light duty restrictions and to ensure adequate coverage for resident care needs directly contributed to these deficiencies.
Failure to Provide Ordered Care and Ensure Specialist Referrals
Penalty
Summary
The facility failed to provide necessary care and treatment according to physician orders and residents' needs for two residents. For one resident, documentation showed prolonged periods without a bowel movement, specifically nine days and six days on separate occasions. Despite physician orders for as-needed administration of Milk of Magnesia and Dulcolax suppositories if no bowel movement occurred in three days, there was no documentation that these interventions were offered or administered during the periods of constipation. The Director of Nursing confirmed that no interventions were documented as provided during these times. For another resident, the facility did not ensure that specialist referrals and diagnostic procedures were scheduled or completed as ordered by the physician. The resident had a persistent, non-healing neck wound with ongoing concern for malignancy, and multiple referrals to dermatology and an MRI were ordered. However, there was no documentation that the dermatology appointment or MRI was scheduled or completed, and the resident missed several specialist appointments, often due to lack of transportation or appointments not being made. The medical record repeatedly noted the need for specialist evaluation and follow-up, but these were not carried out as ordered. Interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, confirmed the lack of documentation and follow-through on physician orders for both residents. The deficiencies were identified through record review and staff interviews, which revealed failures in providing care and ensuring timely access to necessary medical services as ordered.
Failure to Notify Dietitian and Physician of Resident's Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident experienced significant weight loss, dropping from 154.6 to 144.0 pounds over approximately one month. The resident's last documented assessment by a dietitian occurred several months prior, and there was no evidence that the dietitian or physician was notified of the recent weight loss or the resident's low meal intake, despite care plan interventions requiring such notifications. Meal intake records showed frequent days with only one or two meals documented as eaten, and some days with no meals documented. Staff confirmed that there was no documentation of required notifications to the dietitian or physician regarding the resident's nutritional decline. The care plan for nutritional risk included interventions to monitor intake at all meals, offer alternate choices, and alert the dietitian and physician to any decline in intake, but these interventions were not followed as documented in the resident's records.
Failure to Label Opened Inhalers with Required Dates
Penalty
Summary
Surveyors observed that medications, specifically inhalers, were not labeled with open or expiration dates on two of three medication carts inspected. During the inspection, multiple opened inhalers belonging to several residents were found without the required labeling, including Incruse Ellipta, Breztri, Spiriva, and Trelegy inhalers. Licensed Practical Nurses present at the time confirmed that these inhalers were opened and not labeled as per manufacturer instructions. A review of the manufacturer's instructions for each inhaler indicated that labeling with the date opened and discard date is required to ensure proper use and disposal. The facility's own policy also mandates that medications and biologicals be stored according to manufacturer or pharmacy recommendations to maintain their integrity and support safe administration. The failure to label these medications as required constitutes a deficiency in following professional standards for medication storage and labeling.
Delayed Laboratory Testing Due to Specimen Mismanagement
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who had a physician's order for a urinalysis (UA) with culture and sensitivity due to delusions. The order was written on 5/6/25, and the urine specimen was initially collected on 5/7/25. However, there were no laboratory results for this date, and a subsequent nursing note indicated that the specimen was not tested because it was forgotten in the refrigerator. As a result, the specimen had to be recollected on 5/13/25 and then sent to the laboratory. Staff interviews confirmed that specimens are often forgotten in the refrigerator, leading to delays in treatment.
Facility Assessment Lacked Unit-Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit for a census of 68 residents. Record review of the Mountain Ridge Facility Assessment for 2025 showed that staffing requirements were listed only in aggregate for the entire facility, specifying total hours for RN/LPN and LNA staff per shift, but did not break down staffing needs by individual resident units. Further review confirmed that the assessment did not address unit-specific requirements. During an interview, the Administrator acknowledged that the facility assessment did not consider the needs of each resident unit.
Failure to Include Residents and Representatives in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and their representatives were included in the development and implementation of person-centered care plans for two residents. For one resident, the Durable Power of Attorney (DPOA) reported not being notified or invited to a care plan meeting for approximately two years, and there was no documentation of care plan meetings after the resident's admission in 2023. The Director of Social Services confirmed that although the resident was scheduled for care plan meetings, there was no documentation or recollection of the meetings or of the DPOA being invited. For another resident, the DPOA attended only one care plan meeting since the resident's admission, with no documentation of additional meetings before or after that date. The DPOA expressed a desire to be present to understand the goals being set for the resident. Facility policy requires invitations to be sent in advance and documentation of care plan meetings, but records and staff interviews confirmed these steps were not consistently followed.
Failure to Follow Physician-Ordered Pain Parameters for PRN Medication
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident, as evidenced by the administration of Morphine Sulfate without following physician-ordered pain parameters. Specifically, the physician's orders required that Morphine Sulfate 30 mg be given by mouth every four hours as needed for pain rated at 7/10 or greater, and later for pain rated at 5/10 or greater. However, review of the resident's Medication Administration Record (MAR) for March and April revealed multiple instances where the medication was administered despite documentation of a pain level of 0, indicating no pain at the time of administration. Interview with the Unit Manager confirmed that the resident received the medication on these occasions with a documented pain level of 0. This failure to follow the seven rights of medication administration, specifically the right indication, resulted in the administration of a controlled substance without clinical justification as per the physician's orders.
Failure to Remove Expired Medications and Date Opened Vials
Penalty
Summary
Surveyors observed that the facility failed to properly manage medications and biologicals in the medication room. Specifically, an opened bottle of Tuberculin Purified Protein Derivative and an opened bottle of Afluria Influenza Vaccine were found in the vaccine refrigerator without any open date or open expiration date, despite both vials having been used. Additionally, three bags of IV Vancomycin and three bags of IV Zosyn, both antibiotics, were found in the medication room refrigerator with expiration dates that had already passed. These findings were confirmed by a registered nurse present during the observation. Further review of manufacturer instructions indicated that multi-dose vials of Afluria should be discarded within 28 days of being opened, and Tuberculin vials should be discarded after 30 days of use. The facility's own policy requires that outdated, contaminated, discontinued, or deteriorated medications be immediately removed from stock and disposed of according to established procedures. The failure to date opened vials and remove expired medications from stock led to the deficiency cited by surveyors.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents for 24 out of 30 days reviewed, resulting in delays in care and unmet resident needs. Multiple residents reported waiting extended periods for assistance with activities of daily living, such as getting out of bed, dressing, and toileting. One resident, admitted for short-term rehabilitation following a back fracture, experienced incontinence while waiting for staff to respond to a call bell. Another resident reported waiting over an hour to be assisted back to bed, and the resident council expressed concerns about long call bell wait times, particularly on the 3-11 shift and weekends, when only one LNA was often responsible for up to 30 residents per unit. Staff interviews confirmed frequent short staffing, with LNAs and RNs regularly covering additional shifts and roles outside their primary responsibilities, including the Infection Preventionist missing key meetings due to covering direct care shifts. Staff members, including the Scheduling Coordinator, LNAs, RNs, and the Infection Preventionist, consistently reported ongoing short staffing, especially on evening shifts. The Director of Nurses confirmed that a significant number of residents required extensive assistance, including mechanical lifts and two-person assists, yet staffing levels were insufficient to meet these needs. Documentation from resident council meetings and interviews with residents and their representatives further corroborated the persistent issue of inadequate staffing, leading to delays in care and missed activities. The facility's matrix showed 14 new admissions in the past 30 days, further straining available staff resources.
Failure to Provide Timely Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide timely and appropriate beneficiary notices regarding Medicare coverage and potential financial liability for services not covered. For one resident, the Notice of Medicare Non-Coverage (NOMNC) was not given with the required 48-hour notice prior to the last covered day, as the resident was notified only one day in advance. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) was not provided to this resident. For another resident, the SNF ABN was also not provided, despite the resident remaining in the facility after Medicare Part A coverage ended. These deficiencies were confirmed through record review and staff interview.
Failure to Document Pain Levels for PRN Medication
Penalty
Summary
The facility failed to adhere to physician-ordered medication parameters for a resident reviewed for pain management. The physician's order specified that Oxycodone 5 mg should be administered at bedtime for pain management and every six hours as needed for pain rated 5/10 or greater. However, the Medication Administration Record (MAR) for June 2024 showed that the resident received the PRN Oxycodone 5 mg tablet on multiple occasions without documentation of the pain level. This discrepancy was confirmed during an interview with the Unit Manager, who acknowledged that the medication was administered without recording the pain level, which is a deviation from the physician's orders and professional standards of quality care.
Failure to Educate and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were offered and provided education on the risks and benefits of Pneumococcal immunization. Specifically, for one resident reviewed for immunizations, there was no record of Pneumococcal immunization history, nor was there documentation of education, consent, or declination for the vaccine. This resident was admitted to the facility in February 2024, and by the time of the review in June 2024, these requirements had not been fulfilled. An interview with the Infection Preventionist confirmed that the resident had not been offered or educated about the pneumonia vaccines, which should have occurred upon admission. The facility's policy mandates obtaining pneumococcal vaccination history upon admission and administering the vaccine to adults aged 65 years or older who have not previously received it or whose vaccination history is unknown.
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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