Pheasant Wood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Peterborough, New Hampshire.
- Location
- 50 Pheasant Road, Peterborough, New Hampshire 03458
- CMS Provider Number
- 305059
- Inspections on file
- 16
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pheasant Wood Center during CMS and state inspections, most recent first.
Two residents reported grievances regarding delayed call bell responses and prolonged periods in soiled briefs, but staff failed to document these concerns or follow the facility's grievance policy. As a result, the grievances were not logged, investigated, or resolved according to established procedures.
A resident received PRN Lorazepam for anxiety without a required 14-day stop date, and the order remained active beyond the policy limit. The DON confirmed that the order lacked a stop date and was not extended by a physician, contrary to facility policy.
The facility did not notify the provider of significant weight changes or missed daily weights for two residents with CHF, despite physician orders requiring notification for specific weight gains. Documentation and staff interviews confirmed that the provider was not informed as required.
The facility did not provide enough nursing staff on one floor to meet residents' needs, leading to long call bell wait times, episodes of incontinence, and missed opportunities for activities and outdoor time. Multiple residents and staff reported that delays were worse during certain shifts and on weekends, with some residents left in soiled briefs or unable to get assistance for basic needs.
A resident received incorrect doses of Hydromorphone on multiple occasions, and staff failed to accurately document the receipt and administration of controlled drugs. The facility did not follow its policy for reporting and investigating discrepancies in controlled substance records, as confirmed by the DON.
Surveyors found that two medication carts contained improperly labeled and stored medications, including open eye drops and inhalers without open or expiration dates, and ear drops stored with eye drops. LPNs confirmed these findings, which were not in accordance with manufacturer instructions or facility policy requiring proper labeling, separation by route, and timely removal of outdated medications.
The facility did not provide the required Medicare beneficiary notices, such as the NOMNC and SNF ABN, to three residents whose Medicare Part A coverage ended while they still had benefit days remaining. This deficiency was confirmed by the administrator, who was unable to produce the necessary documentation for these residents.
The facility failed to sanitize dishes according to the manufacturer's instructions, as staff did not check the dish machine's temperature gauge during operation. The rinse temperatures recorded were inconsistent with the required minimum of 180°F, violating both the FDA Food Code and facility policy.
The facility failed to maintain cleanliness of wheelchairs and tube feeding pumps for three residents. A resident's wheelchair had dried food-like substances, another's had built-up dust, and a third's tube feeding pump was covered in dried substances. Staff confirmed that cleaning schedules were not followed, and the facility's policies and manufacturer's instructions for regular maintenance and cleaning were not adhered to.
A facility failed to ensure controlled medications were stored under double lock as required. An inspection revealed that a medication refrigerator was not locked, containing a bottle of Lorazepam labeled for a resident. This was confirmed by an LPN and the DON, despite the facility's policy mandating double lock storage for controlled substances.
A resident's medication regimen was not adjusted according to the pharmacy's recommendation for a Gradual Dose Reduction of Benzotropine, despite the provider's acceptance of the recommendation. The medication order remained unchanged, as confirmed by the DON, contrary to the facility's policy on acting upon MRR recommendations.
The facility failed to ensure accurate MDS assessments for three residents. One resident's MDS incorrectly listed multiple treatments not received, another's inaccurately noted restraint use, and a third's omitted anticoagulant medication use. These errors were confirmed by staff interviews.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to follow its established grievance policy for two residents who reported concerns regarding their care. According to the facility's policy, staff are required to initiate a Grievance/Concern Form upon receipt of a grievance, document it on the Grievance Concern Log, investigate the grievance, take corrective action if needed, and notify the person filing the grievance in a timely manner. However, interviews and record reviews revealed that grievances reported by two residents were not documented or processed according to this policy. One resident reported filing multiple grievances about excessive wait times for call bell responses and issues with an LNA's attitude, but these grievances were not found on the facility's grievance log, and staff confirmed they had not completed the required documentation. The resident's care plan note did mention grievances and weekly check-ins with the Unit Manager, but no formal grievance forms were completed. Another resident reported having filed multiple grievances since admission, including an incident where the resident waited over two hours in a soiled brief and reported this to an LNA. The LNA stated that the grievance was reported to the Unit Manager, but again, there was no documentation of this grievance on the facility's grievance log. The Administrator confirmed that these grievances were not forwarded or documented as required by policy. As a result, the facility did not make prompt efforts to resolve the grievances or ensure the residents' rights to voice concerns without discrimination or reprisal.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, as required by policy, for one resident. Record review showed that a resident had an active PRN order for Lorazepam 0.5 mg to be given every 4 hours as needed for increased anxiety, starting from 5/9/25, with no stop date indicated. The medication administration record confirmed that the resident received doses of Lorazepam beyond the 14-day limit without a documented stop date or physician extension. The Director of Nursing confirmed these findings during an interview. Facility policy requires PRN psychotropic medication orders, excluding antipsychotics, to be limited to 14 days unless extended by the prescribing practitioner.
Failure to Notify Provider of Significant Weight Changes in Residents with CHF
Penalty
Summary
The facility failed to ensure that physicians were notified of significant weight changes for two residents with orders for daily weights related to congestive heart failure (CHF). For one resident, the treatment administration record showed a physician's order to notify the provider if there was a weight gain of more than 2 pounds in one day or 5 pounds in a week. Documentation revealed that on one occasion, the resident's weight increased by 11.8 pounds over two days, but there was no evidence that the provider was notified as required. Additionally, there were missing weight entries on certain days, and no documentation indicated that the provider was informed of these omissions. For the second resident, the record indicated a similar physician's order for daily weights with notification parameters for weight gain. However, weights were not obtained or were refused on multiple consecutive days, and again, there was no documentation that the provider was notified of the missed weights or refusals. Interviews with the Director of Nursing and the Nurse Practitioner confirmed that the provider was not notified of these findings as ordered.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on the 2nd floor, as determined by their own facility assessment, to meet the needs of 47 residents. Multiple residents reported excessive wait times for call bell responses, with one resident stating they waited up to 30 minutes for assistance to use the bathroom, resulting in episodes of incontinence. Another resident expressed concern about not being able to go outside to smoke, particularly on weekends when staffing was lower. Staff interviews confirmed that there were not enough staff to meet residents' needs, leading to delays in care, including residents being left in soiled briefs for up to two hours and not being able to attend activities due to lack of assistance. Resident Council meeting minutes and interviews with both residents and staff indicated that the issue was more pronounced during the 3-11 and 11-7 shifts, as well as on weekends, when staffing levels were reduced. Residents reported being put to bed in their day clothes or left up until the next shift due to insufficient staff. The care plan review for one resident showed interventions for bowel incontinence, but the resident still experienced long waits for assistance. Overall, the deficiency was evidenced by consistent reports and documentation of unmet care needs and delayed responses due to inadequate staffing.
Failure to Accurately Record and Reconcile Controlled Drug Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically Hydromorphone, for one resident. The resident expressed concern about receiving the wrong dose of pain medication. Review of the Medication Administration Records (MAR) and Individual Patient's Narcotic Records revealed multiple instances where the resident was administered an incorrect dose of Hydromorphone, including full 2 mg tablets instead of the prescribed 1 mg (0.5 tablet) dose. These errors were confirmed by the Director of Nursing during interviews. Additionally, there was a documented discrepancy in the quantity of Hydromorphone tablets received, with conflicting documentation by two nurses regarding the number of tablets accepted by the facility. The facility did not follow its own policy for managing controlled substances when the discrepancy was identified. The nursing supervisor was not notified, a Controlled Drug Discrepancy Investigation Form was not completed, and no investigation into the discrepancy was initiated. The facility's policy requires that any discrepancies in controlled drug receipt or administration be reported and investigated immediately, but this process was not followed in this case.
Failure to Properly Label and Store Medications in Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to follow accepted professional principles for labeling and storing drugs and biologicals in two of three medication carts reviewed. Specifically, an open bottle of Brimodine eye drops was found without an open date, expiration date, or resident identifier. A box of Cipro ear drops labeled with an expiration date of 6/6 was stored in the medication cart alongside eye drops, contrary to facility policy requiring separation of medications by route of administration. Additionally, an open Breyna inhaler and an open Incruse Ellipta inhaler were found without open dates or open expiration dates. These findings were confirmed by interviews with LPNs responsible for the medication carts. Review of manufacturer instructions and facility policy indicated that these medications require labeling with open dates and must be discarded after specific periods post-opening. The facility's policy also mandates that eye and ear medications be stored separately and that outdated medications be immediately removed from stock. The observed deficiencies demonstrate non-compliance with both professional standards and facility policy regarding medication labeling and storage.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to three residents who either remained in the facility or were discharged home after their last covered day of Medicare Part A services. Specifically, for each of the three residents reviewed, the facility could not produce the Notice of Medicare Non-Coverage (NOMNC) and, where applicable, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). Documentation reviewed indicated that these residents had benefit days remaining at the time their Medicare coverage ended, yet the necessary notifications regarding coverage termination and potential financial liability were not given. This was confirmed during an interview with the facility administrator, who acknowledged the absence of the required notices.
Failure to Sanitize Dishes According to Manufacturer's Instructions
Penalty
Summary
The facility failed to ensure that dishes were sanitized according to the manufacturer's instructions for food service safety in the main kitchen. During an observation and interview with the Dietary Manager and Dietary Aide, it was revealed that the facility used a high-temperature dish machine to sanitize utensils and dishes. However, the staff did not check the wash and rinse temperature gauge on the dish machine while it was running. The rinse temperatures recorded during multiple cycles were 170, 175, 176, 178, and 180 degrees Fahrenheit, which did not consistently meet the required minimum temperature of 180 degrees Fahrenheit as specified by the manufacturer's instructions and the FDA Food Code 2017. The facility's policy on machine warewashing and sanitizing, effective from May 1, 2023, requires that the final rinse temperature for a high-temperature machine be a minimum of 180 degrees Fahrenheit. If temperatures fall below the standard, the Director of Dining Services or Maintenance Department should be notified immediately, and warewashing should be discontinued until the issue is corrected. Despite these guidelines, the staff continued to use the dish machine without verifying the temperatures, leading to a failure in maintaining proper sanitization standards.
Failure to Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to maintain wheelchairs and tube feeding pumps according to the manufacturer's instructions for three residents. Resident #65 was observed sitting in a wheelchair with yellow dried liquid splatters and clumps of dried yellow food-like substance on various parts of the wheelchair. Staff confirmed that wheelchairs were supposed to be cleaned weekly on residents' shower days, but there was no current schedule for cleaning wheelchairs. The facility's protocol indicated that Resident #65's wheelchair should have been cleaned on a specific day, but it was not. Resident #3's wheelchair was found to have built-up dust and a dark substance. The resident reported having asked for the wheelchair to be cleaned, but the LNA only cleaned the seat. The facility's policy required wheelchairs to be sprayed down and dried during shower times, but this was not done for Resident #3. The manufacturer's instructions emphasized the importance of regular maintenance and cleaning to prevent wear and damage. Resident #2 was observed with a tube feed kangaroo pump that had a dried off-white substance covering the top and screen, and a dried brown substance in the grooves. The facility's policy required cleaning and disinfecting of frequently touched items and surfaces, following the manufacturer's recommendations. The manufacturer's manual for the pump recommended cleaning after each feeding set use to prevent bacterial contamination, which was not adhered to in this case.
Controlled Medication Storage Deficiency
Penalty
Summary
The facility failed to comply with the requirement to store controlled medications under double lock, as observed in one of the medication rooms. During an inspection, it was found that a medication refrigerator on the second floor was not locked, and it contained a 30 ml bottle of Lorazepam, a controlled substance, labeled with a resident's name. This was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that controlled substances should be double locked. The Director of Nursing (DON) also confirmed the finding. The facility's policy, last revised on April 1, 2022, mandates that all controlled substances must be stored under double lock, separate from other medications.
Failure to Implement Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act upon the Medication Regimen Review (MRR) recommendations for a resident who was receiving an anticholinergic medication, Benzotropine, three times a day. The pharmacy consultation report recommended a Gradual Dose Reduction (GDR) of Benzotropine to two times a day with the goal of eventual discontinuation. This recommendation was accepted by the provider on a specified date. However, upon review of the resident's active physician orders, it was found that the Benzotropine medication order remained at three times a day, contrary to the pharmacy's recommendation. This discrepancy was confirmed during an interview with the Director of Nursing. The facility's policy on Medication Regimen Review emphasizes the importance of acting upon recommendations, yet in this instance, the necessary changes were not implemented.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents as reflected in their Minimum Data Set (MDS) evaluations. For one resident, the MDS inaccurately indicated that the resident was receiving multiple special treatments, including chemotherapy and IV therapy, despite no documentation supporting these treatments during the assessment period. This error was confirmed by the Director of Nursing during an interview. Another resident's MDS incorrectly noted the use of a trunk restraint, which was not used at any time during the resident's stay, as confirmed by both a Licensed Practical Nurse and the Assistant MDS Coordinator. Additionally, a third resident's MDS failed to document the use of an anticoagulant medication, Apixaban, which was prescribed and administered during the assessment period. This oversight was confirmed by the Director of Nursing, who acknowledged that the anticoagulant use should have been recorded in the MDS. These inaccuracies in the MDS assessments highlight a failure in the facility's processes to ensure that residents' statuses are accurately documented.
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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