The Elms Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, New Hampshire.
- Location
- 71 Elm Street, Milford, New Hampshire 03055
- CMS Provider Number
- 305068
- Inspections on file
- 18
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Elms Center during CMS and state inspections, most recent first.
The facility failed to review its water management plan annually, with the last review conducted 18 months ago. The plan's committee lacked an Infection Preventionist, and the plan did not specify a frequency for flushing dead legs. The Maintenance Director confirmed flushing dead legs and running water in infrequently used areas monthly, contrary to the plan's weekly requirement. The Infection Preventionist had not reviewed the plan, and the Director of Nursing was unfamiliar with it. The plan referenced CDC protocols, which recommend weekly flushing.
A facility failed to ensure a resident was fully informed of their care and treatment in their primary language, Spanish. Staff used personal translator apps to communicate, and the resident's MDS assessment indicated a preference for an interpreter. The medical record lacked signed consents in the resident's language, and the DON confirmed no interpreter services were available.
A facility failed to ensure a resident's right to formulate advance directives, as a discrepancy was found between a physician's order for DNR status and the resident's care plan, which indicated Full Code status. Interviews revealed that the code status change was made without consulting the resident, their representative, or the NP.
The facility did not hold routine interdisciplinary care plan meetings for two residents. One resident had no meetings for about a year, and another had only one meeting since admission. This was against the facility's policy requiring regular care plan discussions.
The facility failed to label and remove expired medications properly. An Aplisol TB vial in the medication room refrigerator was past its expiration date, and a Timolol Maleate Ophthalmic Solution bottle on a medication cart lacked an open date. Staff confirmed these findings.
The facility failed to label food and maintain a clean kitchen environment. Unlabeled containers of coffee creamer were found in the milk refrigerator, and a dusty fan was observed pointing towards the food preparation area. These issues were confirmed by the Food Service Director and a cook, indicating non-compliance with the facility's policies on food storage and kitchen cleanliness.
The facility failed to ensure the Infection Preventionist attended QAPI meetings at least quarterly, missing two meetings in 2024. This was confirmed by the DON, who acknowledged the absence despite having an Infection Preventionist in October.
The facility did not post daily nurse staffing information as required. An observation on a specific day revealed the absence of this information at all facility entrances. Interviews with the Unit Manager and Nursing Scheduler confirmed that the posting had not been done since the Nursing Scheduler assumed the role in October 2024.
The facility's assessment did not include specific staffing needs for day, evening, and night shifts. This deficiency was confirmed during an interview with the Administrator.
The facility failed to complete comprehensive MDS assessments within 14 days after a significant change in condition for two residents admitted to hospice. One resident did not have a significant change MDS assessment completed, while another resident's assessment was completed five days late. These deficiencies were confirmed by a staff interview.
Failure to Implement and Review Water Management Plan
Penalty
Summary
The facility failed to implement and review its water management plan annually, affecting the census of 46 residents. The last review of the water management plan was conducted in June 2023, which is 18 months prior to the current review. The water management plan committee, responsible for oversight and implementation, did not include an Infection Preventionist. The plan outlined control measures and monitoring for dead legs and infrequently used areas, but did not specify a frequency for flushing dead legs. Staff J, the Maintenance Director, confirmed flushing dead legs monthly and running water in infrequently used areas monthly, contrary to the plan's weekly requirement. Interviews revealed that the Infection Preventionist, who started in November 2024, had not reviewed the water management plan. Staff J, who developed the plan, could not recall the standards used for its development. The Director of Nursing was unfamiliar with the plan and did not remember reviewing it. The facility's plan referenced CDC protocols for control measures, which recommend flushing low-flow piping and dead legs at least weekly. The lack of adherence to these guidelines and the absence of an annual review contributed to the deficiency.
Failure to Provide Language Interpreter Services
Penalty
Summary
The facility failed to ensure that a resident was fully informed of their care and treatment in a language they understand. Resident #44, whose primary language is Spanish, was not provided with language interpreter services. Interviews revealed that staff members used personal translator applications on their phones to communicate with the resident, and the resident also used a personal translator application to initiate communication. The resident's Admission Minimum Data Set (MDS) assessment indicated a preference for an interpreter, and a review of the medical record showed no signed consents for treatments in the resident's language. The Director of Nursing confirmed the absence of language interpreter services for the resident's primary language.
Failure to Ensure Resident's Right to Formulate Advance Directives
Penalty
Summary
The facility failed to uphold a resident's right to formulate advance directives, as evidenced by a discrepancy in the code status of a resident. A review of the medical record for a resident revealed a physician's order for Do Not Resuscitate (DNR) status, dated January 8, 2025. However, the resident's care plan still indicated Full Code status. An interview with an Advanced Practice Nurse confirmed that no order had been given to change the resident's code status to DNR. Additionally, the Director of Nursing disclosed that the code status was altered without any discussion with the resident, their representative, or the Nurse Practitioner.
Failure to Conduct Routine Care Plan Meetings
Penalty
Summary
The facility failed to conduct routine interdisciplinary care plan meetings for two residents, leading to a deficiency in care planning. For Resident #24, the Durable Power of Attorney reported that no care plan meetings had occurred for about a year, and the last documented meeting was on May 1, 2024. This was confirmed by the Director of Nursing. For Resident #44, who was admitted in May 2024, there were no care plan meetings documented between May and November 2024, with the only meeting occurring on November 27, 2024. The facility's policy requires care plan discussions at regular intervals, initially, and after significant changes, which was not adhered to in these cases.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired medications, as observed during a survey. In the medication room refrigerator, a vial of Aplisol TB was found with an open date of 11/22/24, which should have been discarded by 12/22/24 according to the manufacturer's instructions. This was confirmed by Staff G, the Unit Manager. Additionally, a medication cart inspection revealed a bottle of Timolol Maleate Ophthalmic Solution 0.5% without an open date, despite manufacturer guidelines stating that opened bottles should be discarded after 28 days. Staff I, a Registered Nurse, confirmed that the Timolol Maleate was actively in use.
Failure to Label Food and Maintain Clean Kitchen Environment
Penalty
Summary
The facility failed to ensure proper labeling and cleanliness in the main kitchen, as observed during a survey. Individual plastic containers containing white liquid, identified as coffee creamer, were found in the milk refrigerator without any labeled identifiers or dates. This was confirmed by the Food Service Director, Staff F, who acknowledged the oversight. Additionally, a fan with accumulated dust on its blades and cage was observed pointing directly towards the food preparation area, which was confirmed by Staff K, a cook, who stated that the fan was used during meal preparation. The facility's policies on food storage and kitchen environment, which require labeling of all foods and maintaining a clean and sanitary kitchen, were not adhered to, as evidenced by these observations.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required committee members attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly, as mandated. Specifically, the Infection Preventionist, a required member of the QAPI committee, was absent from two of the four quarterly meetings reviewed for the year 2024. The absence was noted in the second quarter meeting held in July 2024 and the third quarter meeting held in October 2024. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged that although there was an Infection Preventionist in October, they did not attend the QAPI meeting.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required. On January 9, 2025, at approximately 9:45 a.m., an observation of all facility entrances revealed that there was no nurse staffing information posted. This was confirmed by an interview with Staff G, the Unit Manager, at the same time. Further investigation through an interview with Staff H, the Nursing Scheduler, at approximately 2:00 p.m. on the same day, revealed that the daily posting of nurse staffing information had not been done since Staff H took over the position in October 2024.
Facility Assessment Lacks Shift-Specific Staffing Details
Penalty
Summary
The facility failed to ensure that its assessment included specific staffing needs for each shift, such as day, evening, and night. This deficiency was identified during a review of the facility assessment, which was dated but not specified in the report. The assessment lacked detailed information on the staffing levels required for different shifts. This finding was confirmed during an interview with the facility's Administrator, Staff E, on January 9, 2025, at approximately 8:15 a.m.
Failure to Timely Complete MDS Assessments After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within the required 14 days after a significant change in condition was identified for two residents. Resident #47 was admitted to hospice on November 1, 2024, but a significant change MDS assessment was not completed. Similarly, Resident #24 was admitted to hospice on April 18, 2024, and although a significant change MDS assessment was initiated, it was completed five days late, on May 7, 2024. These findings were confirmed through interviews with Staff D, who acknowledged that the assessments were not completed in a timely manner as required by the MDS Resident Assessment Instrument Manual.
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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