Nashua Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Nashua, New Hampshire.
- Location
- 55 Harris Road, Nashua, New Hampshire 03062
- CMS Provider Number
- 305005
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Nashua Post Acute Care during CMS and state inspections, most recent first.
Multiple units and a kitchenette were found with unsafe and unclean conditions, including lifting and loose floor tiles, exposed drywall, soiled furniture, and dust accumulation on medical equipment. Staff confirmed these findings, and a resident was observed traversing uneven flooring in the kitchenette.
The facility was cited for deficiencies in food safety practices, including failure to use beard restraints by dietary staff and improper food labeling and storage. Observations revealed that staff did not wear beard restraints while preparing food, and several food items in the kitchen lacked proper date markings or were past their use-by dates. Additionally, temperature logs for kitchenettes were incomplete, indicating inconsistent monitoring.
The facility did not follow infection control guidelines for water management, potentially affecting 220 residents. Unit 4 was not in use, and the facility's Legionella Surveillance required hot water storage above 140°F. The Water Management Plan called for regular temperature checks and flushing of little-used outlets. However, the Maintenance Director confirmed that Unit 4 had been closed for a long time, with random flushes performed but no documentation or temperature monitoring.
A resident with a self-care deficit related to dementia did not receive necessary assistance for personal hygiene, including bathing and shaving, as required by their care plan. Observations showed the resident with disheveled hair and stubble, and staff interviews confirmed a lack of documented care. The facility's policy on ADLs was not followed, leading to unmet hygiene needs.
The facility failed to label and date opened multi-dose medications on a medication cart and in a medication room. An LPN confirmed that a Lispro Insulin Quik Pen was found without necessary labeling, contrary to facility policy. Additionally, a medication refrigerator contained a Tuberculin Purified Protein Derivative with unclear opening and expiration dates, which an LPN could not verify.
A resident with severe dental issues, including broken and decaying teeth, was not provided with necessary dental services or assistance in making appointments, despite multiple requests and a care plan intervention. The facility failed to follow up on a treatment plan for extractions and dentures, as confirmed by staff interviews and medical record reviews.
The facility failed to accommodate dietary allergies for two residents, leading to the provision of meals containing allergens. A resident with allergies to chocolate and tomatoes was served chocolate frosting, while another resident with a beef allergy was repeatedly served beef. These actions were contrary to the facility's policy requiring dietary preferences and allergies to be recorded and respected.
A resident did not receive a pneumococcal vaccine despite having signed consent, as confirmed by the Infection Preventionist. The facility's policy, which aligns with CDC guidelines, was not adhered to in this case.
The facility failed to notify two residents or their representatives of the bed hold policy upon transfer to a hospital, as required by their policy. This oversight was confirmed through record reviews and staff interviews, revealing that the facility only provides the bed hold policy upon admission, not at the time of transfer. The Administrator confirmed the lack of documentation and adherence to the policy.
The facility failed to complete comprehensive MDS assessments within 14 days for two residents admitted to hospice care. One resident's MDS was completed 28 days after admission to hospice, while another's was completed 21 days later. These delays were confirmed by the MDS Coordinator.
A resident with atherosclerosis and DM II did not receive necessary podiatry care, despite requests and a note from the Dialysis Center. The resident's toenails were overgrown, and the facility failed to assist in making podiatry appointments, as confirmed by the DON.
Failure to Maintain Safe and Clean Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment across several units and a kitchenette. On Unit #6, rooms were found with black tape covering uneven and lifting floor thresholds, dust accumulation on an oxygen concentrator, exposed drywall, brown substances on bed rails and privacy curtains, peeling surfaces on bedside tables, and visibly soiled furniture. Additional observations included cracked walls, multiple scrapes and discoloration, and further instances of lifting flooring at room entrances. Staff interviews confirmed these findings. On Unit #5, rooms had floor tiles that were curled, lifted, and loose, with some tiles able to be moved with light pressure. There was also missing trim on a bedside table. Staff confirmed the presence of these hazards. In Unit #1 West, the kitchenette had missing tiles resulting in uneven flooring, with black tape covering the edges of remaining tiles. A resident was observed walking over this uneven surface. Staff interviews corroborated the observations of missing tiles and uneven flooring.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility was found to have deficiencies in food safety practices, specifically related to the use of facial hair restraints and proper food labeling and storage. During observations, it was noted that dietary staff, including a cook and a dietary aide, were not wearing beard restraints while preparing and serving food. This was confirmed through interviews with the staff involved and the Director of Culinary, who acknowledged that staff with beards should always wear restraints to prevent hair from contacting food. Additionally, the facility failed to adhere to professional standards for food labeling and storage. Observations in the main kitchen revealed several food items, such as mayonnaise, pasta salad, sliced tomatoes, and shredded cheese, that were either past their use-by dates or lacked proper date markings. Similar issues were found in the dessert refrigerator, where items like pizza slices and cheese were not properly dated or covered, posing a risk of contamination. The report also highlighted missing temperature logs for several kitchenettes, indicating a lack of consistent monitoring of refrigerator and freezer temperatures. This was observed across multiple units, with several days in September missing temperature recordings. Interviews with staff confirmed these findings, and the facility's policy on date marking for food safety was reviewed, which emphasized the importance of clearly marking food to indicate consumption or discard dates.
Failure to Follow Water Management Infection Control Guidelines
Penalty
Summary
The facility failed to adhere to established infection control guidelines concerning water management, which could potentially affect the 220 residents residing there. An observation revealed that Unit 4 was not in use. A review of the facility's Legionella Surveillance indicated that hot water should be stored above 140 degrees Fahrenheit. The Water Management Plan Overview specified that the supply temperature at the hot water heater outlet should not be lower than 140 degrees Fahrenheit and that little-used outlets should be flushed twice weekly. However, an interview with the Maintenance and Environmental Services Director confirmed that Unit 4 had been closed for a long time, and although random flushes were performed, there was no documentation of these flushes or temperature monitoring for the water heater.
Failure to Provide Necessary ADL Assistance for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADL) received the necessary services to maintain good personal hygiene. This deficiency was identified for one resident, who was observed on multiple occasions with disheveled hair and long dark stubble on their face and chin. The resident, who had a self-care deficit related to dementia, was coded as dependent for showers and personal hygiene in their care plan. Despite this, the resident was not provided with the required assistance for bathing and shaving, as confirmed by staff interviews and documentation reviews. The resident's care plan indicated the need for one staff member to assist with bathing and personal hygiene tasks, yet records showed that scheduled weekly baths were not documented for several dates in September. Interviews with the resident's nurse and LNAs revealed uncertainty about when the resident last received a shower or shave, and it was confirmed that these services had not been provided in the past week. The facility's policy on ADLs, which mandates care and services for bathing and grooming, was not adhered to, resulting in the resident's unmet hygiene needs.
Failure to Label and Date Medications
Penalty
Summary
The facility failed to properly label and date opened multi-dose medications, as observed in one of the six medication carts and one of the five medication rooms. During an observation of the 5 East Medication Cart, an opened Lispro Insulin Quik Pen was found without a name, open date, or expiration date. This was confirmed by an LPN present at the time. The facility's policy requires insulin pens to be clearly labeled with the resident's name, type of insulin, amount to be given, frequency, and expiration date, and states that pens without labels should not be used. Additionally, in the 100's Medication Room, an observation of the medication refrigerator revealed an influenza vaccine and a vial of Tuberculin Purified Protein Derivative with two handwritten dates, but it was unclear when the vaccine had been opened or when it expired. An LPN confirmed these findings and was unsure about the vaccine's opening or expiration date. Manufacturer instructions for the Tuberculin Purified Protein Derivative specify that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services and assistance in making dental appointments for a resident with significant dental health issues. The resident, identified as having multiple decaying teeth and roots, expressed that their teeth were broken and had been requesting to see a dentist. Despite these requests, the facility did not facilitate a dental appointment. Observations confirmed the resident's teeth were nearly all broken and black, indicating a severe dental condition. The resident's care plan, initiated in May 2023, included interventions to coordinate dental care and transportation. However, the resident's dental visit notes revealed a history of dental issues dating back to April 2021, with multiple referrals to an oral surgeon for extractions and denture fabrication. Despite a treatment plan established in November 2021, there was no follow-up recorded. Interviews with facility staff confirmed the lack of additional dental visits and the absence of documented follow-up actions, highlighting a failure to adhere to the facility's dental services policy.
Failure to Accommodate Resident Dietary Allergies
Penalty
Summary
The facility failed to adhere to dietary requirements for two residents, resulting in the provision of meals that did not accommodate their documented allergies. Resident #4 reported receiving meal trays containing chocolate and tomatoes, to which they are allergic, causing them to feel sick. This was confirmed during an observation where Resident #4 was served vanilla cake with chocolate frosting, despite their meal ticket indicating an allergy to chocolate and tomatoes. Similarly, Resident #49 was consistently served beef, despite having an allergy to it noted on their meal ticket. The facility's policy mandates that resident preferences and allergies be recorded during the assessment process and reflected on dietary tray cards, but this was not followed in these instances.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal immunization to one resident, identified as Resident #73, who was reviewed for pneumococcal vaccination. The resident's immunization record indicated a historical pneumococcal vaccine was given in 2017, but the type was unknown. A consent for a pneumococcal vaccine was signed by the resident in April 2023, yet the vaccine was not administered. This was confirmed during an interview with the Infection Preventionist, who acknowledged that the resident had not received the consented second pneumococcal vaccine. The facility's policy, revised in May 2023, outlines the administration of pneumococcal vaccines according to CDC guidelines, but this protocol was not followed for Resident #73.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy upon transfer to a hospital, as required by their own policy. This deficiency was identified during a review of records and interviews with staff members. Specifically, two residents were affected by this oversight. Resident #75 was sent to the hospital on April 27, 2024, and it was confirmed through an interview with the Social Services Office Coordinator that the facility only provides the bed hold policy upon admission, not at the time of transfer. Similarly, Resident #97 was hospitalized twice, on August 11, 2024, and September 9, 2024, without receiving the required bed hold policy notification. The facility's policy, titled "Bed Hold Notice Upon Transfer," mandates that written notice of the bed hold policy be provided to residents or their representatives at the time of transfer for hospitalization or therapeutic leave. This policy was not followed in the cases of the two residents reviewed. The Administrator confirmed the lack of documentation and adherence to the policy during an interview. The facility's failure to comply with its own policy resulted in a deficiency being noted by the surveyors.
Failure to Timely Complete MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change in condition was determined for two residents who were admitted to hospice care. Resident #165 was admitted to hospice on July 5, 2024, but the Significant Change MDS was not completed until August 2, 2024, which is 28 days after the determination of the significant change. Similarly, Resident #11 was admitted to hospice on September 13, 2024, and the Significant Change MDS was completed on October 4, 2024, 21 days after the determination of the significant change. These findings were confirmed during an interview with the MDS Coordinator, Staff Z, on October 10, 2024. The delay in completing the MDS assessments for these residents indicates a failure to adhere to the required timeline for assessing significant changes in residents' conditions.
Failure to Provide Necessary Foot Care Services
Penalty
Summary
The facility failed to provide necessary foot care services or assist a resident in making appointments to maintain good foot health. A resident, who had been requesting to see a podiatrist for overgrown toenails, was found to have not received appropriate care. The resident's medical record indicated a previous podiatry visit where routine care was deemed medically necessary due to atherosclerosis of the extremities and Diabetes Mellitus Type 2, which increased the risk of bone infection and potential limb loss. However, no further podiatry visit notes were found in the resident's medical record. Additionally, a communication from the Dialysis Center to the facility highlighted the need for the resident's toenails to be trimmed as they were too long and posed a risk of cutting the toes. An observation confirmed that the resident's toenails on the left foot were overgrown, with one toenail curled under the toe. The Director of Nursing confirmed these findings and noted that the resident had missed the podiatrist's visit due to being at dialysis. The facility's policy on podiatry services emphasized the importance of assisting residents in making appointments for necessary services, which was not adhered to in this case.
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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