Saint Teresa Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, New Hampshire.
- Location
- 519 Bridge Street, Manchester, New Hampshire 03104
- CMS Provider Number
- 305071
- Inspections on file
- 16
- Latest survey
- March 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saint Teresa Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to administer medications and treatments as ordered for two residents. A resident did not receive a prescribed lidocaine patch for pain management, despite it being documented as administered. Another resident with a skin tear did not receive proper wound care due to a failure to transcribe the physician's order to the Treatment Administration Record, resulting in the wound not being covered as prescribed.
The facility failed to remove expired medications and properly label multi-dose vials. Observations revealed expired medications on a medication cart and improperly labeled vials in the medication room. Staff confirmed the findings, and a review of policies indicated that outdated medications should be removed immediately.
The facility failed to follow CDC guidance for Transmission Based Precautions (TBP) for five residents with suspected Norovirus. Staff were observed not using proper hand hygiene, PPE was not consistently used, and residents were taken off precautions prematurely. The facility's outbreak line list did not consistently track symptoms, and there was a lack of education provided to staff on proper infection control measures.
The facility failed to implement policies and procedures to ensure staff screening was conducted prior to working. Specifically, an LNA from a staffing agency worked without an employee record or background check, and the facility had used staff from the same agency on multiple dates without background checks.
The facility failed to complete a PASARR screening for a resident admitted with bipolar disease and major depression. Staff confirmed the absence of the required documentation, which is mandated by the facility's policy.
The facility failed to follow physician orders for a resident during a medication pass. Staff L did not administer the prescribed saline nasal spray, and the omission was confirmed upon review of the resident's Medication Administration Record (MAR) and an interview with Staff L.
The facility failed to provide a written notice of transfer/discharge to a resident or their representative and did not send a copy to the LTC Ombudsman. This issue was confirmed through staff interviews and a review of the resident's medical record, which lacked the required documentation.
The facility failed to notify a resident of the bed hold policy before their transfer to the hospital. The omission occurred due to a switch to a new electronic medical system, as confirmed by staff interviews. The facility's policy requires providing bed hold information at admission and before hospital transfers.
The facility failed to ensure accurate MDS documentation for two residents. One resident's MDS incorrectly indicated the use of antianxiety medication instead of antidepressant and anticoagulant medications. Another resident's discharge MDS incorrectly stated that the resident was discharged to a hospital instead of home. These errors were confirmed through interviews and record reviews.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered as ordered for two residents. Resident #197 did not receive a prescribed lidocaine patch for pain management on their right shoulder, despite the medication being documented as administered in the Medication Administration Record (MAR). An interview with the resident and observation by the Unit Manager confirmed the absence of the patch. The physician's order specified the application of the patch to the right knee and shoulder, but this was not adhered to, indicating a discrepancy between the MAR and the actual administration of the medication. Resident #29 had a skin tear on the right forearm that was not properly treated according to the physician's orders. The order required cleansing with normal saline, application of bacitracin, and covering with a dry dressing and kerlix, but these instructions were not transcribed to the Treatment Administration Record (TAR). Observations revealed the wound was not covered as prescribed, and interviews with nursing staff confirmed the lack of documentation and treatment. This oversight in transcribing the order to the TAR resulted in the resident not receiving the necessary wound care.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility failed to ensure that expired medications were removed from stock and that multi-dose vials were labeled with an open expiration date. During an observation of the medication cart, expired medications were found, including a bottle of Carbamine Peroxide ear drops for a resident with a manufacturer's expiration date of February 2025, and a Tiotropium Bromide Monohydrate Capsule inhaler for another resident with a manufacturer's expiration date of September 2024. It was confirmed through interviews with staff that these medications were expired, and the order for the Tiotropium Bromide Monohydrate Capsule had been discontinued in May 2024. Additionally, an observation of the medication room revealed that there were opened multi-dose vials of Tuberculin Purified Protein Derivative (Mantoux) in two refrigerators. One vial had an opened date of January 2025, and another had a manufacturer's expiration date of December 2024. Interviews with staff confirmed these findings, and a review of the manufacturer's instructions indicated that a vial in use for 30 days should be discarded. The facility's policy on medication storage also stated that outdated, contaminated, or discontinued medications should be immediately removed from stock.
Failure to Follow Norovirus Precautions
Penalty
Summary
The facility failed to follow CDC guidance for Transmission Based Precautions (TBP) for five residents with suspected Norovirus. Staff G, responsible for infection prevention, confirmed that Resident #21 was placed on precautions due to norovirus. However, Staff K, a housekeeper, was observed using alcohol-based hand sanitizer instead of washing hands with soap and water after cleaning Resident #21's room, indicating a lack of proper education on norovirus precautions. Staff K confirmed that they were not educated on the correct hand hygiene protocol until the morning of 3/27/24, several days after the outbreak began. Resident #9 was also not properly managed under TBP. Staff entered Resident #9's room without PPE, and there was no signage indicating the need for precautions. Despite Resident #9 showing symptoms of a gastrointestinal bug, including vomiting and loose stools, the resident was taken off contact precautions prematurely. Staff G and Staff N confirmed that Resident #9 should have remained on precautions during the observed period. Similar issues were observed with Residents #30, #17, and #13. Resident #30 was on TBP for suspected norovirus, but there was a lack of accurate documentation and tracking of symptoms. Resident #17, who continued to have loose stools, was observed walking around the facility and interacting with other residents without proper precautions. Resident #13 was taken off contact precautions before the required 48-hour symptom-free period. The facility's outbreak line list did not consistently track symptoms, and there was a lack of education provided to staff, including housekeeping, on proper infection control measures during the norovirus outbreak.
Failure to Implement Staff Screening Procedures
Penalty
Summary
The facility failed to implement policies and procedures to ensure the screening of staff was conducted prior to working. Specifically, Staff H, a Licensed Nursing Assistant (LNA) from a staffing agency, worked at the facility without an employee record or background check. This was confirmed through observation, interviews, and record reviews. Staff H worked on the [NAME] Unit on 3/26/24 from 7:00 a.m. to 3:00 p.m. without the necessary background check, as confirmed by the Regional Clinical Director and the Director of Nursing. Further review revealed that the facility had used staff from the same agency on multiple dates without having background checks for any of these staff members. The Scheduler confirmed that the facility did not have background checks for staff from the agency that employed Staff H. The facility's policy on Abuse/Staff Treatment of Residents, revised on 3/25/11, mandates procedures for screening potential employees for a history of abuse, neglect, or mistreatment of residents, which was not followed in this case.
Failure to Complete PASARR Screening
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was completed for one of the two residents reviewed for PASARR in a sample of twelve residents. Resident #2, who was admitted in June 2023 with diagnoses of bipolar disease and major depression, did not have a Level I PASARR screening in their medical record. This was confirmed through interviews with the Director of Social Services and Medical Records staff, both of whom could not find the required PASARR documentation. The facility's policy, dated 11/16/17, mandates that all residents be screened for mental disorders or intellectual disabilities prior to admission, but this procedure was not followed for Resident #2.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for one resident, identified as Resident #32, during a medication pass. The physician's order dated 2/26/24 specified that Resident #32 was to receive saline nasal spray, 2 sprays two times a day and as needed. However, on 3/27/24 at 9:03 a.m., Staff L, a Medication Nursing Assistant, was observed administering medications to Resident #32 but did not administer the saline nasal spray as ordered. This was confirmed by Staff L during an interview at 9:47 a.m. on the same day. A review of Resident #32's March Medication Administration Record (MAR) revealed that the saline nasal spray had not been signed off as administered. The facility's policy on Medication Administration, dated January 2021, states that medications should be administered in accordance with written orders of the prescriber. The failure to administer the saline nasal spray as ordered constitutes a deficiency in following physician orders and adhering to the facility's medication administration policy.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge to Resident #14 or the resident's representative when the resident was discharged to the hospital. Additionally, the facility did not send a copy of the written notice to the Long-Term Care (LTC) Ombudsman. This deficiency was confirmed through interviews with the Director of Social Services, a Registered Nurse, and the Regional Clinical Director, who acknowledged that since the facility changed electronic medical records in August 2023, the required notices were not being provided. The incident was identified during a review of Resident #14's medical record, which lacked documentation of the written notice for the discharge on 10/7/23.
Failure to Notify Resident of Bed Hold Policy Before Hospital Transfer
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transfer for one resident reviewed for hospitalization. The medical record of the resident revealed they had been discharged to the hospital, but there was no evidence that the bed hold policy was provided upon transfer. An interview with a Registered Nurse confirmed that the bed hold policy was not provided at the time of transfer due to the facility switching to a new electronic medical system. The Regional Clinical Director confirmed these findings. The facility's policy stated that residents and their representatives should be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the residents' status for two residents. For Resident #35, the quarterly MDS indicated that the resident had received an antianxiety medication during the last seven days, which was incorrect. The Medication Administration Record (MAR) showed that the resident was prescribed Citalopram for depression and Eliquis for pulmonary embolism, but no antianxiety medication. Interviews with the Registered Nurse and the Director of Clinical Reimbursement confirmed that the MDS was incorrectly coded and should have included antidepressant and anticoagulant medications instead of antianxiety medication. For Resident #42, the discharge MDS indicated that the resident was discharged to a short-term general hospital, which was incorrect. A progress note and an interview with the Director of Social Services confirmed that the resident was actually discharged to home. The Director of Clinical Reimbursement also confirmed that the MDS was incorrectly coded. These inaccuracies in the MDS assessments reflect a failure to ensure accurate documentation of the residents' statuses.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
