Pleasant View Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, New Hampshire.
- Location
- 239 Pleasant Street, Concord, New Hampshire 03301
- CMS Provider Number
- 305045
- Inspections on file
- 30
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Pleasant View Center during CMS and state inspections, most recent first.
The facility did not follow its antibiotic stewardship program, as antibiotic use protocols such as the Loeb Minimum Criteria were not documented or utilized for a resident receiving antibiotics for UTI prophylaxis. The Infection Preventionist could not provide evidence of protocol use, and antibiotic use data was not discussed in QAPI meetings, as required by facility policy.
Two residents had conflicting documentation regarding their advance directives and code status, with discrepancies between physician orders, care plans, and other medical record sections. Staff confirmed the inconsistencies, and the facility did not ensure that the residents' current code status was accurately reflected and communicated as required by policy.
A resident was placed in a pedal broda chair with two wheels locked, restricting movement and causing agitation. Staff confirmed the wheels were locked to limit the resident's mobility, but there were no physician orders or care plan interventions authorizing this restraint.
Two newly admitted residents did not receive multiple prescribed medications for serious conditions such as COPD, heart failure, depression, hypertension, hypokalemia, atrial fibrillation, diabetes, and infection because the medications were not available in the facility. Staff did not notify a provider or document alternative orders as required by facility policy.
Multiple residents did not have care plans addressing their assessed needs, including activity preferences, supervised smoking, mobility and transfer assistance, skin integrity interventions, smoking status changes, complex medical regimens, and communication barriers. Staff interviews and observations confirmed that these omissions led to unaddressed resident needs and lack of staff awareness regarding required interventions.
A resident with repeated falls, including incidents from bed and wheelchair resulting in a fractured clavicle, did not have post-fall reviews or root cause analyses completed as required by facility policy. The DON confirmed that no assessments or care plan updates were made to prevent further falls.
A resident with PTSD did not have a completed trauma assessment or a care plan addressing trauma triggers and interventions. Staff, including an LNA, LPN, and Social Worker, were unaware of the PTSD diagnosis, and the Social Worker had not completed the required assessment or consulted the resident's guardian. The DON confirmed the care plan lacked trauma-informed interventions, despite facility policy requiring such measures.
The facility did not follow its pneumococcal vaccine policy for two residents, including missing documentation of vaccine history, lack of eligibility assessment, and failure to provide required education before or after vaccine refusal. Staff confirmed these documentation and process gaps.
Three residents did not receive COVID-19 vaccination and education as required by facility policy. Two residents over 65 received only one dose of the 2024-2025 vaccine with no record of a second dose or education, despite signed consent. Another resident under 65 had consent for vaccination but no documentation of vaccine administration, history, or eligibility assessment. The Infection Preventionist confirmed these lapses, and there was no vaccine shortage.
A resident with a high risk of infection recurrence did not receive a required CT scan after leaving the initial appointment and refusing a rescheduled one, with no further attempts made to complete the imaging or provide results to the ordering practitioner.
The facility did not provide required transfer/discharge and bed-hold notices to two residents who were hospitalized, as confirmed by record review and staff interviews. Facility policy mandates these notifications and documentation, but they were not present in the residents' files.
Three residents experienced significant changes in hospice care status, but the facility did not complete the required Significant Change in Status MDS assessments within the mandated timeframe. In one case, the assessment was completed late after hospice admission; in another, no assessment was done after hospice discharge; and for a third, no assessment was completed within 14 days of hospice admission. These deficiencies were confirmed through staff interviews and record reviews.
A resident in a LTC facility was hospitalized after receiving incorrect medications intended for another resident. The error involved multiple medications, including Ativan and Zyprexa, instead of the resident's prescribed Atenolol and others. The resident, with a history of hypertension and chronic kidney disease, became lethargic and hypotensive, requiring Narcan and emergency transfer to the hospital for further management.
A resident received incorrect medications due to a nurse's error, leading to lethargy and hospital admission. The facility delayed reporting the incident to the SSA, violating its policy requiring immediate notification for alleged abuse or serious injury.
The facility failed to administer medications timely for two residents, leading to deficiencies in care. A resident's insulin was administered late, affecting their blood sugar management, while another resident experienced multiple delays in receiving their prescribed intravenous antibiotic for Staph aureus septicemia. These delays were confirmed by staff interviews.
A facility failed to ensure that a Registered Nurse, who was assigned through an agency, had the necessary competencies to care for residents. The nurse did not receive orientation or skills assessment and was unfamiliar with the facility's electronic medical record system and medication administration procedures. The Night Supervisor had to provide basic guidance after their shift. The Administrator confirmed the absence of orientation for agency staff working a single shift.
A facility failed to maintain accurate records for a resident's controlled drugs, specifically Dilaudid 2 mg tablets. Discrepancies were found between the narcotic count and the documented count, with no investigation conducted. The narcotic book and medication administration record showed multiple discrepancies, and facility policies requiring accurate accountability and immediate reporting of discrepancies were not followed.
A facility failed to improve performance in reporting alleged violations, as evidenced by a medication error where a nurse administered incorrect medications to a resident. The error was recognized during verification, and the resident was assessed with no allergic reaction noted. The facility's QAPI agenda lacked documentation for improvement projects, and the deficiency had been cited in four consecutive surveys.
Two residents experienced significant delays in medication administration, with medications given more than two hours past their scheduled times. The Director of Nursing confirmed the expectation for timely administration but could not provide a facility policy on timing.
A facility failed to report an alleged abuse incident and investigation results within the required timeframe. A resident was found with a bruise of unknown origin, and during an interview, implicated a Licensed Nursing Assistant (LNA) as the alleged perpetrator. The initial report was delayed, and the interview findings were not reported to the State Survey Agency (SSA) as required by the facility's policy.
A facility failed to notify a resident's DPOA-H of significant changes in the resident's condition and treatment, including the introduction of new medications like Azithromycin and Oxycodone. Despite the resident's refusal of a chest x-ray and medications, and the DPOA-H's later concerns about Oxycodone, the facility did not document any notification to the DPOA-H, violating their policy on required notifications.
A resident with dementia and psychotic disturbance eloped from the facility without staff knowledge and was found consuming alcohol at a nearby hotel. Despite the incident, the facility failed to report the elopement to the State Survey Agency, violating its policy on abuse, neglect, and exploitation.
The facility failed to follow infection control guidelines for water management and Enhanced Barrier Precautions (EBP). It lacked documentation and control measures to prevent Legionella spread. Additionally, a nurse did not wear a gown while administering medication to a resident with a PICC line, contrary to CDC guidelines for preventing MDRO spread.
The facility failed to maintain accurate records for controlled drugs, with missing staff signatures and discrepancies in narcotic counts. A resident's methadone count was miscalculated, and corrections were undocumented, as confirmed by staff interviews.
The facility failed to properly label and store medications, with expired insulin pens found on a medication cart and a cart left unlocked and unattended. A resident had inhalers at their bedside without proper storage or documentation, contrary to facility policy.
A resident was found to be self-administering two inhalers without staff supervision, despite facility policy requiring an assessment for self-administration. The resident had physician orders for unsupervised use of one inhaler, but the other was to be clinician-administered. No assessment or care plan was documented, and staff were unaware of the resident's self-administration.
The facility failed to report alleged abuse and neglect incidents involving two residents to the State Survey Agency within the required timeframe. One resident felt bullied by a nurse, while another reported neglect by an LNA. The incidents were not reported as per facility policy.
A resident experienced significant pain due to missed doses of Hydrocodone-Acetaminophen 7.5-300 mg after the facility ran out of the medication. The resident's scheduled doses were missed over two days, and no emergency dose was available. This deficiency was confirmed through interviews and record reviews, highlighting a failure in pain management.
A resident with wounds on the abdomen and groin did not receive daily wound care as per physician orders. The Treatment Administration Record showed that the wounds were not cleaned on multiple days in June and July. Interviews with staff confirmed the expectation for daily cleaning, and the facility's policy required adherence to physician orders for wound care.
The facility did not provide the required SNF Advance Beneficiary Notice (ABN) to two residents who were discharged from Medicare Services but remained in the facility. The Business Officer confirmed that the SNF ABN forms were not completed for these residents, indicating a lapse in the notification process.
The facility failed to notify residents of the bed hold policy before hospital transfers. A resident discharged on a specific date had no evidence of receiving the policy, confirmed by the Director of Social Services. Another resident's record also lacked this information, confirmed by a Business Office staff member. The facility's policy requires providing this information before transfers, but it was not followed.
The facility failed to create comprehensive care plans for two residents, one requiring supervised smoking and another on anticoagulant medication. Despite assessments and physician orders, the care plans lacked necessary documentation and monitoring measures, as confirmed by the DON and ADON.
The facility failed to report alleged misappropriation/diversion of medications. An anonymous individual noticed a pattern of narcotics being signed out of the narcotic book but not recorded in the eMAR for several residents, indicating potential drug diversion. The issue was reportedly being handled by the unit manager and administration, but the allegation was not reported to the Administrator. The Administrator and DON were unaware of any allegations of misappropriation/diversion of residents' medications.
The facility failed to ensure accurate accounting for controlled medications for four residents. Discrepancies were found between the eMAR and the narcotic book, with medications being signed out more times than documented as administered. Interviews with residents and staff confirmed these findings.
Failure to Implement Antibiotic Stewardship Program and Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program and antibiotic use protocols as outlined in its policy. Review of the June 2025 antibiotic line list showed that while the list included resident names, infections, antibiotics, and start/end dates, it did not indicate whether antibiotics were appropriate for use or if the Loeb Minimum Criteria was utilized. Specifically, a resident was prescribed Bactrim DS and Nitrofurantoin for urinary tract infection prophylaxis, but there was no documentation in the medical record of the Loeb's minimum criteria evaluation prior to the initiation of antibiotics. Interviews with the Infection Preventionist revealed an inability to explain or provide documentation that the Loeb's criteria were used for antibiotic initiation during the month in question. The Infection Preventionist also confirmed that data regarding resident infections and antibiotic use had not been discussed in QAPI meetings since their employment began. The Administrator corroborated that there had been no discussion of these topics in recent QAPI meetings, confirming the facility's failure to monitor and discuss antibiotic use as required by its own protocols.
Failure to Accurately Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status were accurately documented and consistently communicated across all relevant sections of the medical record for two residents. For one resident, the medical record contained conflicting information, with the resident header and physician's order indicating Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) status, while the care plan and special instructions listed Full Code status. The code status binder also contained both a Full Code face sheet and a portable DNR form for this resident. Staff interviews confirmed the presence of these discrepancies and clarified that the resident's current code status was DNR, not Full Code. For the second resident, the physician's order indicated DNR status, but the care plan listed Full Code status. Documentation from the resident's guardian authorized a DNR/DNI order, but the care plan was not updated to reflect this change. Staff interviews confirmed that the care plan did not match the physician's order. These inconsistencies demonstrate a failure to adhere to facility policy regarding the accurate and timely documentation and communication of residents' advance directives and code status.
Use of Physical Restraint Without Medical Authorization
Penalty
Summary
A deficiency was identified when a resident was observed in a pedal broda chair with the leg rest elevated and two of the four wheels locked, which restricted the resident's ability to move freely. The resident was seen struggling to propel the chair and appeared agitated. Staff interviews confirmed that the wheels were intentionally locked to prevent the resident from moving around due to restlessness. Review of the resident's medical records, including physician's orders, assessments, and care plan, revealed no documentation or interventions authorizing the use of the locked wheels as a restraint. The Director of Rehab confirmed that the chair was provided for mobility, not restraint.
Failure to Provide and Administer Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered to two newly admitted residents. For one resident, multiple medications for conditions including COPD, heart failure, depression, hypertension, hypokalemia, and atrial fibrillation were not given on the first and second days after admission due to the medications not being received from the pharmacy. The resident reported not receiving all prescribed medications, and medical record review confirmed the missed doses. The facility's emergency medication supply did not contain all required medications, and there was no documented communication with a provider regarding the missed doses. For the second resident, essential medications for cardiac conditions, diabetes, hypertension, and infection were not administered on the day of admission because they were unavailable. Progress notes indicated the medications were not on hand, and there was no evidence that a provider was notified about the missed doses. The facility's emergency supply only included a lower dose of one of the required medications. Facility policy required staff to notify a physician and obtain alternative orders when medications were unavailable, but this was not documented in either case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for seven residents, as identified through record review, observation, and staff interviews. For one resident, the care plan did not address individual or group activity preferences, despite the resident expressing strong interests in reading, music, animals, news, favorite activities, and religious services. Staff confirmed the absence of a care plan for these preferences, and the Activities Director acknowledged this omission. Another resident, who required supervised smoking per assessment and facility policy, did not have a care plan addressing supervised smoking, and the Unit Manager confirmed this gap. A resident dependent on a wheelchair for mobility and requiring assistance with eating, hygiene, and transfers did not have a care plan addressing these needs, as confirmed by staff. Another resident with physician orders to offload heels to prevent skin breakdown was repeatedly observed in bed with heels directly on the mattress, and staff were unaware of the care plan intervention or physician order. Additionally, a resident who had smoking privileges revoked did not have a care plan addressing smoking status or the removal of privileges, as confirmed by the Director of Nursing. Further deficiencies included a resident on hemodialysis and multiple medications who required assistance with activities of daily living but only had care plans for code status and nutritional risk, with no interventions for other identified needs. Lastly, a resident whose primary language was Cambodian and who only understood simple English commands did not have a care plan addressing communication barriers, and staff were unaware of the resident's language needs. These findings demonstrate multiple failures to develop and implement care plans that address the comprehensive needs of residents as identified in their assessments.
Failure to Investigate and Address Causes of Resident Falls
Penalty
Summary
The facility failed to determine the causes or contributing factors for multiple falls experienced by a resident, and did not revise the resident's plan of care or facility practices to reduce the likelihood of further falls. The resident, who had a history of repeated falls from both bed and wheelchair, sustained a fractured clavicle as a result of one of these incidents. Progress notes documented several falls over a period of time, including incidents where the resident slid out of bed, was found on the floor next to the bed, was found on the floor in the dining room (resulting in an emergency room visit for shoulder pain), and was found sitting on the floor in the hallway. Review of post-fall documentation revealed that for each of these falls, there was either no post-fall review completed or no description of what occurred and no root cause identified. The facility's policy required completion of a post-fall assessment, incident report, care plan review, and documentation of all assessments and actions following a fall. However, interviews and record reviews confirmed that these steps were not followed for the resident's falls, and no interventions were identified or implemented to prevent further incidents.
Failure to Identify and Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) had identified triggers and interventions in place to eliminate or mitigate the risk of re-traumatization. Review of the resident's medical record showed an incomplete Social History and Trauma Assessment, which had been initiated but not completed. The resident's care plan did not address PTSD, nor did it include any identified triggers or interventions related to trauma. Interviews with facility staff, including a Licensed Nursing Assistant, an LPN, and the Social Worker, revealed that they were unaware of the resident's PTSD diagnosis and that the Social Worker had not completed the necessary assessment or interviewed the resident's guardian regarding trauma history and triggers. The Director of Nursing confirmed the absence of a care plan addressing PTSD triggers and interventions for this resident. Facility policy requires a multi-pronged approach to identifying trauma history, including direct inquiry about triggers and the development of individualized care plan interventions to minimize or eliminate re-traumatization. Despite these policy requirements, the facility did not complete the trauma assessment or incorporate trauma-informed care planning for the resident with PTSD. This resulted in a lack of staff awareness and absence of documented strategies to address the resident's trauma-related needs.
Failure to Implement Pneumococcal Vaccine Policy for Two Residents
Penalty
Summary
The facility failed to implement its pneumococcal vaccine policy for two residents. For one resident, there was no documentation of pneumococcal vaccine history or assessment of eligibility upon admission, despite a signed consent from the resident's guardian for vaccine administration. There was also no record that the vaccine was administered, and staff were unable to provide documentation of any assessment for vaccine eligibility. For the second resident, the immunization record showed no history of receiving a pneumococcal vaccine, and although the vaccine was refused, there was no documentation that education about the vaccine was provided to the resident or their representative before or after the refusal. Staff confirmed the absence of required documentation and education for both residents, indicating noncompliance with the facility's policy and CDC guidelines regarding pneumococcal immunizations.
Failure to Implement COVID-19 Vaccination Policy and Documentation
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy for three of five residents reviewed for immunizations. According to the facility's policy, residents and staff are to be educated about the COVID-19 vaccine, offered the vaccine, and have their vaccination status properly documented. For residents aged 65 and older, the policy requires two doses of the 2024-2025 COVID-19 vaccine, while those aged 12-64 require one dose. Review of records revealed that two residents in their 70s and 80s received only one dose of the 2024-2025 vaccine, with no documentation of a second dose being administered or offered, despite signed consent forms. Additionally, there was no documentation of education provided to one of these residents or their representative. Another resident, in their 60s and under 65, had a signed consent form for the COVID-19 vaccine but no documentation of vaccine administration, history, or assessment of eligibility. Interviews with the Infection Preventionist confirmed these findings and clarified that there was no shortage of vaccine supply, as doses could be ordered from the pharmacy as needed. The lack of documentation and follow-through on vaccine administration and education for these residents constitutes a failure to follow the facility's established COVID-19 vaccination policy.
Failure to Obtain Ordered Radiology Services
Penalty
Summary
A deficiency occurred when the facility failed to obtain radiology services as ordered for a resident who was at high risk for recurrence of infection and required a CT scan of the abdomen and pelvis with contrast. The resident initially went to an appointment for the CT scan but left before it could be completed and did not recall the reason. The scan was rescheduled at another location, but the resident refused to attend the second appointment, and no further appointment was made. Review of the medical record showed no results or follow-up for the required imaging, despite ongoing orders and the resident's continued need for assessment related to infection risk. Staff interviews confirmed that the imaging was not completed and that the ordering practitioner had not received results.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required notifications and documentation regarding transfer, discharge, and bed-hold policies for two residents who were hospitalized. For one resident, medical record review showed two separate hospital transfers, but there was no documentation that a bed hold notice was provided for either event. Staff interviews confirmed the absence of this documentation. For the second resident, the medical record indicated a hospital transfer, but there was no evidence that a transfer/discharge notice or bed hold notice was given. Staff interviews further confirmed that these notifications were not provided. Facility policy requires that a signed and dated copy of the bed-hold notice be kept in the resident's file and that transfer/discharge notices be provided in an understandable manner to the resident and their representative, with evidence that the notice was sent to the Ombudsman. Review of the records and staff interviews confirmed that these requirements were not met for the two residents involved.
Failure to Complete Timely Significant Change MDS Assessments for Residents with Hospice Status Changes
Penalty
Summary
The facility failed to ensure timely completion of Significant Change in Status Minimum Data Set (MDS) assessments for three residents who experienced significant changes in their hospice care status. For one resident, the MDS assessment was completed late after the resident was admitted to hospice care, as confirmed by the MDS Coordinator. Another resident was discharged from hospice services, but no Significant Change in Status MDS was completed following the end of hospice care, as verified by the Director of Nursing. Additionally, a third resident was admitted to hospice care, but no Significant Change in Status MDS was completed within the required 14-day period following the change. These findings were confirmed through interviews with facility staff and review of resident records, which documented the changes in hospice status and the lack of timely or completed MDS assessments as required.
Significant Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors, resulting in the resident requiring hospitalization. During a morning medication round, a registered nurse inadvertently administered the incorrect medications to a resident, giving them another resident's medications instead of their prescribed ones. The medications administered in error included Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, while the resident was supposed to receive Atenolol, Lactobacillus, and Omeprazole. The nurse recognized the error upon verifying the medication administration record and immediately assessed the resident, notified the attending physician, and informed the family. The resident, who had a medical history of hypertension, hyperlipidemia, bladder cancer, chronic hypoxemic respiratory failure, and chronic kidney disease, became lethargic and was later found to have hypotension. The physician ordered frequent monitoring of vital signs and PRN Naloxone spray. Despite these interventions, the resident's condition worsened, leading to the administration of Narcan and subsequent transfer to the hospital via emergency medical services. At the hospital, the resident required brief bag mask ventilation and was admitted for observation and medical management due to hypotension caused by the medication error.
Failure to Timely Report Medication Error and Alleged Abuse
Penalty
Summary
The facility failed to report an alleged violation of abuse immediately to the State Survey Agency (SSA) as required. A registered nurse (RN) inadvertently administered incorrect medications to a resident, including Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, instead of the prescribed Atenolol, Lactobacillus, and Omeprazole. The error was recognized during the medication administration round, and the attending physician was notified. The resident was assessed, and the family was informed. Despite no initial allergic reaction, the resident became lethargic, and Narcan was administered following a telehealth provider's order. The resident was eventually sent to the hospital via emergency services. The Director of Nursing confirmed the resident's hospital admission, and the facility administrator began investigating the incident the day after it occurred. However, the incident was not reported to the SSA until two days later, which was not in compliance with the facility's policy. The policy mandates that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after the allegation is made. In this case, the delay in reporting the incident to the SSA constituted a deficiency in the facility's adherence to its reporting policy.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to administer medications timely for two residents, leading to deficiencies in care. For Resident #4, a delay in administering scheduled insulin was observed. The resident's blood sugar was recorded at 177, and the insulin, which was supposed to be administered before breakfast at 7:00 a.m., was not given until 8:51 a.m. This delay was confirmed during an interview with Staff H, a Registered Nurse, who acknowledged the late administration. Resident #1 experienced multiple delays in receiving their prescribed intravenous antibiotic, Cefazolin, which was ordered to be administered every 8 hours for Staph aureus septicemia. The medication was consistently administered late on several occasions, with delays ranging from over an hour to several hours past the scheduled time. These delays were confirmed by the Director of Nursing, Staff A, during an interview. The repeated late administration of this critical medication highlights a significant lapse in adhering to prescribed medication schedules.
Lack of Competency Assessment for Agency Nurse
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to meet residents' needs, as evidenced by the experience of a Registered Nurse (Staff E) who was assigned to a shift through an agency. Upon arrival, Staff E did not receive any orientation or skills assessment, despite being unfamiliar with the facility's electronic medical record system and the location of the medication room. During the shift, Staff E encountered difficulties administering antibiotics to a resident due to a lack of knowledge about the intravenous pump required for the medication. The Night Supervisor (Staff G) confirmed that Staff E expressed concerns about their unfamiliarity with the electronic medical record system, and Staff G had to stay after their shift to provide basic guidance. The facility's Administrator (Staff B) acknowledged that there was no orientation or skills assessment for agency staff working a single shift.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for a resident's Dilaudid 2 mg tablets. On February 23, 2025, a discrepancy was discovered during a narcotic count reconciliation by a registered nurse and the night shift nurse. The count of narcotics did not match the documented count in the narcotic book. The night supervisor adjusted the narcotic book to match the physical count without conducting an investigation into the discrepancy. Further interviews confirmed that there was no investigation into the missing narcotics, and the director of nursing was not informed of the discrepancy as required by the facility's policy. A review of the narcotic book and the resident's medication administration record revealed multiple discrepancies in the number of tablets documented as administered on various dates in February 2025. Additionally, there were illegible entries in the narcotic book for medication administration and the amount received from the pharmacy on February 21, 2025. The facility's policies require accurate accountability of controlled substances and immediate reporting and investigation of any discrepancies, which were not followed in this case.
Medication Error and Reporting Deficiency
Penalty
Summary
The facility failed to take actions aimed at performance improvement and measure its success in reporting alleged violations of abuse and neglect. A specific incident involved a registered nurse inadvertently administering incorrect medications to a resident during a morning medication round. The medications given included Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, instead of the prescribed Atenolol, Lactobacillus, and Omeprazole. The nurse recognized the error while verifying the medication administration record and immediately assessed the patient, notified the attending physician, and informed the family. No allergic reaction was noted, and the physician ordered PRN Naloxone spray. The facility's Quality Assurance and Performance Improvement (QAPI) agenda lacked documentation for performance improvement projects related to reporting alleged violations. The administrator confirmed the findings and began investigating the incident two days after it occurred, reporting it to the SSA on the same day as the survey review. The facility's survey history revealed that the deficiency related to the reporting of alleged violations had been cited in the last four consecutive surveys, indicating a pattern of non-compliance in this area.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, leading to a deficiency in meeting professional standards of quality. For Resident #5, there was a delay in administering Sevelamer, a phosphate binder, which was scheduled for 7:30 a.m. but given at 11:59 a.m., and Fluticasone-Salmetrol, an inhalation medication for wheezing, scheduled for 4:00 p.m. but administered at 9:16 p.m. These medications were administered more than two hours past their scheduled times, which is outside the acceptable window for non-time-critical medications. Similarly, Resident #6 experienced delays in medication administration. Humalog, an insulin sliding scale to be given with meals, was scheduled for 8:00 a.m. but administered at 11:08 a.m. Additionally, Depakote, an anticonvulsant, and Midodrine, for hypotension, both scheduled for 9:00 a.m., were administered at 11:09 a.m. The Director of Nursing confirmed these findings and stated the expectation was to administer medications within one hour before or after the scheduled time, but was unable to provide a facility policy on medication administration timing.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to report an alleged violation of abuse within the required 24-hour timeframe and did not report the results of the investigation to the State Survey Agency (SSA) for one resident. A nurse initially reported a bruise of unknown origin on a resident's right forearm, which was first noted on a provider's note. The Social Service Director interviewed the resident, who mentioned a tall black man, and the facility identified the alleged perpetrator as a Licensed Nursing Assistant (LNA). The initial report about the bruise was sent to the SSA two weeks after it was first noted, and the interview findings implicating the LNA were not reported to the SSA. The facility's policy requires reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, which was not adhered to in this case. The Assistant Director of Nursing confirmed the findings and stated that the LNA's contract was terminated.
Failure to Notify DPOA-H of Resident's Condition and Treatment Changes
Penalty
Summary
The facility failed to notify the activated Durable Power of Attorney for Healthcare (DPOA-H) of a resident's change in condition and medication alterations. The resident, who was being monitored for hypoxia and nasal congestion, refused a chest x-ray and was subsequently prescribed Azithromycin and Oxycodone, while Morphine was discontinued. Despite these significant changes in treatment, the DPOA-H was not informed, as confirmed by the Assistant Director of Nursing during an interview. The resident continued to exhibit symptoms, including difficulty breathing and increased congestion, and refused medications and meals. The DPOA-H later contacted the facility, expressing concern over the administration of Oxycodone, which they were unaware had been started. The facility's policy mandates notification of significant changes in a resident's condition or treatment, which was not adhered to in this case, as there was no documentation of the DPOA-H being informed.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident of elopement involving a resident with dementia and psychotic disturbance to the State Survey Agency. On the evening of July 28, 2024, a nurse discovered that the resident was missing from the facility, having not signed out at the check-out book or reception desk. The administration was notified, and a statement was given to the police. The resident was eventually found at a nearby Holiday Inn, where they had consumed alcohol at the bar, and was returned to the facility later that night. The resident involved in the incident was diagnosed with unspecified dementia with psychotic disturbance and was on several medications, including Clorazepate Dipotassium, Gabapentin, Depakote sprinkles, and Venlafaxine. Despite the seriousness of the situation, the facility's administrator confirmed that no report was made to the State Survey Agency regarding the elopement. This failure to report was in violation of the facility's policy on abuse, neglect, and exploitation, which mandates reporting such incidents to the appropriate authorities within specified timeframes.
Infection Control Deficiencies in Water Management and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to established infection control guidelines concerning water management and Enhanced Barrier Precautions (EBP). During a review of the facility's Water Management Program, it was found that the facility lacked essential documentation, such as a plumbing map or schematic, to monitor and control measures against Legionella. Interviews with the Infection Preventionist and Maintenance Director confirmed the absence of a system to prevent the introduction and spread of Legionella, as well as a lack of control measures in place. Additionally, the facility did not follow the CDC guidelines for Enhanced Barrier Precautions for a resident with a peripherally inserted central catheter (PICC). During medication administration, a registered nurse was observed wearing gloves but not a gown, which is required for high-contact resident care activities involving indwelling medical devices. The facility's policy and CDC guidelines specify the use of gowns and gloves to prevent the spread of multidrug-resistant organisms (MDROs) during such activities, but these precautions were not followed in this instance.
Controlled Drug Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, which led to discrepancies in narcotic counts. Specifically, the facility's policy on Controlled Substance Administration & Accountability was not adhered to, as evidenced by missing staff signatures in the Controlled Substances Book for various dates on both the 4th and 3rd Floor South Side Medication Carts. Interviews with staff confirmed these findings, indicating a lack of compliance with the policy requiring two licensed nurses to account for all controlled substances and access keys at the end of each shift. Additionally, the facility failed to properly document and reconcile the narcotic count for a resident receiving methadone for chronic pain. The resident's narcotic count showed discrepancies, including a miscalculation of the remaining methadone available and a lack of documentation for corrections made to the narcotic count. Interviews with nursing staff confirmed these discrepancies and the failure to document the transfer of medication appropriately, resulting in an inaccurate account of the controlled drug.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to professional standards. During an observation of a medication cart on the third floor, it was found that a resident's Insulin Aspart Flex pens had expired, and another resident's Humulin Regular U-500 insulin pen was open without an open expiration date on the label. A registered nurse confirmed these findings. The manufacturer's instructions for both medications specify that they should be disposed of after 28 days of being opened, which was not adhered to in this case. Additionally, a medication cart on the fourth floor was observed to be unlocked and unattended in the hallway for approximately 15 minutes, with residents present in the area. This was confirmed by a registered nurse. Furthermore, a resident was found to have two inhalers at their bedside without a lock box or locked storage compartment, contrary to the facility's policy. The resident had no orders for the inhalers to be kept at bedside, and there was no documentation of instructions provided to the resident regarding proper storage. The Director of Nursing confirmed these findings.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medication for a resident. During an observation, it was noted that the resident had two inhalers on their bedside table: an Albuterol Sulfate Aerosol Solution inhaler and a Combivent Respimat Inhalation Aerosol Solution inhaler. The resident confirmed that they self-administered these inhalers without staff supervision. A review of the resident's active physician orders showed an order for unsupervised self-administration of the Combivent inhaler, but the Albuterol Sulfate inhaler was to be administered by a clinician. Further investigation revealed that there was no assessment conducted to determine the resident's ability to self-administer the inhalers, nor was there a care plan in place for the self-administration of these medications. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the lack of awareness and documentation regarding the resident's self-administration of inhalers. The facility's policy requires an interdisciplinary team assessment for residents who wish to self-administer medications, but this was not conducted for the resident in question.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations of abuse or neglect to the State Survey Agency (SSA) within the required timeframe for two residents. Resident #49 reported feeling scared, bullied, and harassed by a registered nurse, Staff N, to the Assistant Director of Nursing, Staff D. Despite being informed that Staff N would no longer provide care to Resident #49, the incident was not reported to the SSA. The Administrator, Staff P, was unaware of the incident until several days later and had not reported it to the state. Similarly, Resident #22 filed grievances regarding neglect by a Licensed Nursing Assistant, Staff O, who allegedly refused to assist with personal care tasks and failed to clean a urine collection device. These grievances were not reported to the SSA, and Staff O was no longer employed at the facility. The facility's policy requires immediate investigation and reporting of all alleged violations, which was not adhered to in these cases.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #19, who was part of a sample of 31 residents reviewed for pain management. The deficiency was identified through an interview and record review. The resident reported being awake and in pain all night in early July 2024 because the facility ran out of their prescribed pain medication, Hydrocodone-Acetaminophen 7.5-300 mg. A progress note from a registered nurse on July 7, 2024, confirmed that the resident's morning dose was missed, and no emergency dose was available from the E-Kit. The resident's Medication Administration Record showed missed doses on July 7 and July 8, 2024. A nurse practitioner documented on July 8, 2024, that the resident reported significant pain due to the missed doses.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for wound care for a resident with skin conditions. The resident, identified as having wounds on the abdomen and groin, reported that the wounds were supposed to be cleaned daily but had not been cleaned since the previous week. A review of the resident's physician orders indicated a specific regimen for wound care, including cleansing with wound cleaner, applying skin prep, Medi honey, and silicone bordered foam dressing, to be performed every shift and as needed. However, the Treatment Administration Record (TAR) showed that the resident's wounds were not cleaned on 13 out of 30 days in June and 17 out of 23 days in July. Interviews with facility staff, including a Nurse Practitioner and a Wound Care Nurse, confirmed the expectation that the resident's wounds should be cleaned daily according to the physician's orders. The facility's policy on Wound Treatment Management, revised in January 2024, also stipulated that wound treatments should be provided in accordance with physician orders, including the method of cleansing, type of dressing, and frequency of dressing changes. The failure to follow these orders resulted in a deficiency in the care provided to the resident.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for two residents. Resident #49 was discharged from Medicare Services on July 5, 2024, but remained in the facility without receiving the required SNF ABN form. Similarly, Resident #139 was discharged from Medicare Services on May 25, 2024, and also remained in the facility without the SNF ABN form being provided. During an interview on July 25, 2024, Staff C, the Business Officer, confirmed that the SNF ABN forms for both residents had not been completed, acknowledging the oversight in the notification process.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transfers to the hospital for three residents in a sample of 31. Resident #77 was discharged to the hospital on 7/17/2024, and there was no evidence in their medical record that the bed hold policy was provided at the time of transfer. Similarly, Resident #146 was discharged to the hospital on 6/18/2024, and their medical record also lacked evidence of the bed hold policy being provided. An interview with the Director of Social Services confirmed that the bed hold policy was not being provided at the time of transfer. Resident #5 was discharged to the hospital on 4/14/2024, and their medical record showed no evidence of the bed hold policy being provided upon transfer. An interview with a staff member from the Business Office confirmed that the bed hold policy was not provided to residents transferred to the hospital. The facility's policy, dated 7/2021, requires that residents or their representatives be given written information about the bed hold policy before a transfer to the hospital or therapeutic leave, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #48, who required supervised smoking, did not have a care plan addressing this need. Despite an assessment indicating the necessity for supervision, the care plan lacked documentation of safe smoking measures, which should have been communicated to all responsible parties. This oversight was confirmed by the Director of Nursing during an interview. Similarly, Resident #5, who was prescribed Eliquis for nonrheumatic aortic valve stenosis, did not have a care plan for monitoring the side effects of the anticoagulant medication. The absence of a care plan for this critical aspect of the resident's treatment was confirmed by the Assistant Director of Nursing. The facility's policy on comprehensive care plans mandates that care plans describe the services necessary to maintain the resident's highest practicable well-being, which was not adhered to in these cases.
Failure to Report Alleged Drug Diversion
Penalty
Summary
The facility failed to report alleged misappropriation/diversion of medications. An interview with an anonymous individual revealed a pattern of narcotics being signed out of the narcotic book but not recorded in the resident's electronic Medication Administration Record (eMAR) for several residents. This practice could indicate drug diversion. The anonymous individual was informed by a staff member that the issue was being handled by the unit manager and administration, but the allegation was not reported to the Administrator. Interviews with the Administrator and the Director of Nursing confirmed that they were unaware of any allegations of misappropriation/diversion of residents' medications.
Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accounting for all controlled medications for four residents. The policy review revealed that after administering medication, it should be documented in the Medication Administration Record (MAR), Treatment Administration Record (TAR), and controlled substance sign-out record. However, discrepancies were found in the documentation and administration of Oxycodone HCL for Residents #1, #2, #3, and #7. For instance, Resident #1's eMAR showed no documentation of Oxycodone administration, yet the narcotic book indicated it was signed out six times. Resident #1, who is moderately impaired, reported not using extra pain medication and preferred Tylenol instead. Similarly, Resident #2's eMAR showed only one instance of Oxycodone administration, but the narcotic book indicated it was signed out 23 times. Resident #2, who is cognitively intact, reported rarely using Oxycodone and did not recall recent usage. Resident #3's eMAR documented multiple administrations of Oxycodone, but the narcotic book showed an extra 19 instances of signing out the medication. Resident #3, who is also cognitively intact, confirmed receiving Oxycodone as needed, mostly during nighttime hours. Lastly, Resident #7's eMAR showed two instances of Oxycodone administration in February and one in March, but the narcotic book indicated 12 sign-outs in February and 37 in March. Interviews with the Administrator and Director of Nursing confirmed these findings.
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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