Saint Vincent Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berlin, New Hampshire.
- Location
- 29 Providence Avenue, Berlin, New Hampshire 03570
- CMS Provider Number
- 305066
- Inspections on file
- 18
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Saint Vincent Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident was prescribed Sertraline and Seroquel for depression and delusions, but there was no evidence of a gradual dose reduction (GDR) attempt or documentation of clinical necessity for continued use. Facility policy requires GDRs for psychotropic medications unless contraindicated, but this was not followed, as confirmed by a corporate nurse.
A resident with bilateral heel wounds did not receive the required weekly wound assessments, as documentation was inconsistent and missing key details such as measurements and wound stage. Staff interviews confirmed that weekly monitoring was not performed, contrary to facility policy.
A resident with respiratory conditions was observed receiving continuous oxygen therapy via nasal cannula and portable tank, but review of clinical records and confirmation from the unit manager revealed that no physician order for oxygen had been obtained.
A resident on contact precautions for C. diff continued to have loose, uncontained bowel movements, yet staff failed to follow required infection control procedures. A laundry staff member entered and exited the resident's room without proper hand hygiene and was unaware of the contact precautions, while other staff were unclear about the resident's status. Facility policy required use of gowns, gloves, and handwashing, but these were not consistently followed.
Four residents who previously received a COVID-19 booster were not documented as having been offered or educated about the next recommended vaccine dose, as required by CDC guidelines and facility policy. This was confirmed by record review and staff interview.
Two residents who remained in the facility after Medicare coverage ended were not given written notice of the specific services and charges they could be liable for, as required. Instead, the SNF ABN forms provided to them stated 'No cost estimate available' rather than a good faith estimate of costs, which was confirmed as standard practice by a Social Services staff member.
The facility did not maintain the required RN staffing levels, failing to have an RN on duty for 8 consecutive hours a day, 7 days a week, for 7 days within a 92-day period. Specific days lacked RN coverage, as confirmed by staffing reports and interviews with HR staff.
The facility did not follow its antibiotic use protocols, failing to monitor, track, and review antibiotic use for six months. Despite having residents on antibiotics, there was no documentation of monthly monitoring or adherence to criteria. The facility's policy assigns the Infection Preventionist and DON to oversee the Antibiotic Stewardship Program, but they could not provide evidence of regular reporting on antibiotic use and resistance to staff.
The facility failed to provide adequate activities for residents, impacting their well-being. A resident with vascular dementia was often left without activities, leading to decreased participation. Another resident with dementia had limited engagement due to cognitive impairments, despite a care plan indicating interests. A third resident with Alzheimer's expressed boredom and agitation, with no individualized activity program in place. Staff confirmed infrequent activities and lack of tailored plans.
The facility failed to offer and document influenza and pneumococcal vaccinations for two residents. One resident was not offered the influenza vaccine for the 2023/2024 season, and another resident, admitted in June 2023, did not receive the pneumococcal vaccine despite signing a consent. These deficiencies were confirmed by interviews with the Regional Clinical Director and the DON.
The facility failed to timely inform two residents of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). The NOMNC and ABN were signed on the last covered day of Medicare Part A Skilled Services, and the facility lacked a policy for issuing beneficiary notices.
The facility did not ensure that required members attended the Quality Assessment and Assurance group meetings quarterly. In Quarter 2, the Medical Director and Infection Preventionist were absent, and in Quarter 3, another staff member was missing. This was confirmed by the DON.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications underwent a gradual dose reduction (GDR) or had documentation supporting the clinical necessity for continued use of these medications. Record review showed that the resident had physician orders for Sertraline, an antidepressant, and Seroquel, an antipsychotic, both prescribed for depression and delusions. However, there was no evidence in the medical record of any attempts to perform a GDR or documentation indicating a contraindication to GDR for either medication. This was confirmed during an interview with the corporate nurse, who acknowledged the absence of required documentation. Facility policy requires that residents on psychotropic medications receive GDRs unless clinically contraindicated, but this was not followed in this case.
Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency was identified when a resident with two heel wounds did not receive the required weekly assessments, including measurements and descriptions of the pressure ulcers. Review of the resident's medical record showed inconsistent documentation, with wound assessments recorded on non-weekly intervals and some assessments missing key information such as wound stage and measurements. Interviews with the Director of Nursing and the Unit Manager confirmed that weekly wound monitoring was not performed as required. Facility policy mandates completion of weekly pressure ulcer documentation immediately after skin rounds, but this was not followed for the resident in question, who had an unstageable pressure ulcer on the right heel.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A resident who returned from the hospital with diagnoses including acute bronchitis, urinary tract infection, early pneumonia, and reactive airway disease was observed on multiple occasions using oxygen via nasal cannula, both in bed and in a wheelchair with a portable oxygen tank. Clinical notes indicated the resident was on 1 liter of oxygen via nasal cannula and that orders would be initiated with the physician notified. However, review of the resident's physician orders revealed that no orders for oxygen had been obtained. This was confirmed by the unit manager, who acknowledged that the resident was receiving continuous oxygen without a physician's order.
Failure to Implement Contact Precautions for Resident with C. diff
Penalty
Summary
The facility failed to implement its policies and procedures for Transmission Based Precautions (TBP) for a resident on contact precautions for Clostridioides difficile (C. diff). Observation revealed that a staff member from the laundry department entered and exited the resident's room, which was clearly marked for Enteric Contact Isolation, without washing hands with soap and water as required. The staff member was unaware that the resident was on contact precautions. Additionally, another staff member, a Licensed Nursing Assistant, believed that the contact precautions had been removed, while a Registered Nurse confirmed that the resident was still on contact precautions due to ongoing loose and/or watery bowel movements that were difficult to contain. Interviews with the Director of Nursing and the Infection Preventionist confirmed that the resident had completed treatment for C. diff but remained on contact precautions because of persistent symptoms. Facility policy required all staff and visitors to wear gloves and a disposable gown upon entering the room and to wash hands before entering and exiting. The failure to follow these procedures was confirmed through observation, staff interviews, and review of facility policy.
Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine. Specifically, for four residents reviewed for immunizations, there was no documentation that they were offered or educated about the next recommended dose of the COVID-19 vaccine, despite having previously received the COVID-19 Bivalent Booster (Pfizer) in the prior year. This lack of documentation was confirmed through record review and interview with the Infection Preventionist. Facility policy required that all residents be considered eligible for COVID-19 vaccination per CDC guidelines and that ongoing updates be monitored to adjust vaccination schedules accordingly. However, the records for the four residents did not reflect any offer or education regarding the updated CDC recommendations for additional COVID-19 vaccine doses. The deficiency was identified through review of vaccination records and staff interview, which confirmed the absence of required documentation.
Failure to Provide Required Cost Estimates on SNF ABN Forms
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the specific items and services offered by the facility, the charges for those services, and the amount of potential liability for services not covered by Medicare. For two residents who were discharged from Medicare services but remained in the facility, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) forms did not include the required estimated costs for ongoing care and services. Instead, the forms stated 'No cost estimate available' for the per day/item or service, which did not meet the requirement for a good faith cost estimate as outlined in the SNF ABN form instructions. Interview with a staff member from Social Services confirmed that it was their practice to write 'No cost estimate available' rather than providing an estimated cost. Review of the official SNF ABN form instructions indicated that while it is permissible to state that no cost estimate is available in rare circumstances, this should not be a routine or frequent practice. The deficiency was identified through record review and staff interview, and it affected two residents who remained in the facility after their Medicare coverage ended.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 out of 92 days reviewed between October 1, 2023, and December 30, 2023. A review of the facility's Payroll Based Journal Staffing Data Report for Quarter 1 2024 revealed that there were no RN hours for specific days, including October 7, October 21, December 16, and December 17, 2023. Additionally, the facility's daily nursing time sheets indicated that on October 7, only 6 RN hours were worked, and on October 8, October 21, October 22, December 16, December 17, and December 31, there were either no RN hours documented or significantly fewer hours worked than required. Interviews with Staff J from Human Resources confirmed these findings.
Failure in Antibiotic Use Monitoring and Reporting
Penalty
Summary
The facility failed to adhere to its antibiotic use protocols, specifically in monitoring, tracking, and reviewing antibiotic use for six out of the twelve months reviewed. From December 2023 through April 2024, the facility did not track antibiotic use, as confirmed by the Director of Nursing during an interview. The facility had residents with infections who were on antibiotics during this period, yet there was no documentation of monthly antibiotic monitoring, tracking, or review, nor evidence that antibiotics met the criteria for use. The facility's policy on Antibiotic Stewardship, revised in February 2022, outlines that the Infection Preventionist, along with the Director of Nursing, is responsible for overseeing the Antibiotic Stewardship Program. This includes tracking antibiotics, ensuring adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. However, the facility could not provide documentation or evidence of regular reporting on antibiotic use and resistance to relevant staff, such as prescribing clinicians and nursing staff, as confirmed by the Director of Nursing.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that meet the interests and support the well-being of residents, as evidenced by observations and interviews. Resident #45 was frequently observed sitting in a wheelchair in the hallway with no activities occurring on the unit. Despite having a history of being active in activities, Resident #45's participation had significantly decreased, with no documented activities attended in May 2024. Staff interviews revealed that activities on the Second Floor Unit were infrequent, occurring only once every other week, and residents needed to be transported to other floors for activities. Resident #55, who has dementia, was observed sitting in a wheelchair with no engagement in activities. Although the resident's care plan indicated an interest in music, arts, and crafts, among other activities, there was no documentation of participation in May 2024. The resident's representative expressed concerns about the lack of engaging activities, noting that Resident #55 was unable to operate an iPad purchased for music due to cognitive impairment. Staff confirmed that Resident #55 attended activities primarily when accompanied by a spouse. Resident #63, diagnosed with Alzheimer's disease and dementia with agitation, was observed expressing boredom and agitation, with no activities documented in April or May 2024. Despite a leisure interest assessment indicating preferences for activities such as fishing, chess, and religious services, there was no individualized activity program in place. Staff acknowledged the resident's behaviors and lack of participation in group activities but could not provide a tailored activity plan.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and provided education on the risks and benefits of the Pneumococcal and Influenza vaccinations. For Resident #29, a review of the medical record revealed no documentation that the influenza vaccination had been offered for the 2023/2024 flu season. This was confirmed by an interview with the Regional Clinical Director, Staff G. The facility's policy, dated 2015, stated that all residents, staff, and volunteers should be offered the influenza vaccine from October through the end of March each year. For Resident #59, the medical record review showed that the resident was admitted in June 2023 and had signed a consent for the pneumococcal vaccine upon admission. However, there was no documentation that the vaccine had been administered. The Quarterly Minimum Data Set (MDS) indicated that the pneumococcal vaccination was not up to date. This was confirmed by an interview with the Director of Nursing, Staff A, who acknowledged that the resident had not received the pneumococcal vaccine. The facility's policy, revised in 2022, required informed consent and administration of the vaccine according to standing orders, which was not followed in this case.
Failure to Timely Inform Residents of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in a timely manner about the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). This deficiency was identified for two residents. For one resident, the last covered day of Medicare Part A Skilled Services was documented, and the facility initiated the discharge from Medicare Part A Services before benefit days were exhausted. The NOMNC and ABN were signed on the last covered day. Similarly, for another resident, the last covered day of Medicare Part A Skilled Services was noted, and the facility initiated the discharge before benefit days were exhausted, with the NOMNC signed on the last covered day. Interviews with facility staff, including a social worker, regional clinical director, and director of clinical reimbursement, confirmed the findings. It was revealed that the facility did not have a policy for issuing beneficiary notices. According to the instructions for the NOMNC, the notice must be delivered at least two calendar days before Medicare-covered services end, which was not adhered to in these cases.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assessment and Assurance group attended meetings at least quarterly. Specifically, during the review of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets, it was found that in Quarter 2, the Medical Director and Infection Preventionist were not in attendance. Additionally, in Quarter 3, another required member of the facility's staff was absent. These findings were confirmed through an interview with the Director of Nursing.
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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