Lebanon Center, Genesis Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, New Hampshire.
- Location
- 24 Old Etna Road, Lebanon, New Hampshire 03766
- CMS Provider Number
- 305050
- Inspections on file
- 19
- Latest survey
- October 6, 2025
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Lebanon Center, Genesis Healthcare during CMS and state inspections, most recent first.
A resident was hospitalized and tested positive for Legionella, but the facility did not follow its own water management plan by failing to test or remediate the water system, nor did it document control measures as required. Staff confirmed that a humidifier, which was prohibited by policy, was used in the resident's room, and water samples from the device were not tested. These lapses in infection control procedures exposed all residents to potential Legionella risk.
The facility did not obtain written authorization from three residents to manage their personal funds, resulting in direct deposit of social security benefits and automatic withdrawals for care costs without proper consent. Review of financial records and fund management forms showed that required authorizations were missing or incomplete for each resident involved.
The facility did not provide two residents or their representatives with required quarterly written statements of personal funds, as confirmed by record review and interviews. Instead, statements were signed only by the administrator, and both residents and their legal representatives reported not receiving the statements.
A resident was not notified when their personal fund account balance exceeded the SSI resource limit for several consecutive months. Despite facility policy and regulatory requirements mandating monthly notification when a resident's account approaches the Medicaid eligibility threshold, the required notifications were not provided or documented.
The facility failed to maintain sufficient nursing staff levels on weekends, as determined by their facility assessment. The required Hours Per Patient Day (HPPD) for nurse aides was set at 1.63, but several weekend dates showed staffing below this level, with HPPD ranging from 1.43 to 1.57. Staff M confirmed these findings, highlighting a pattern of inadequate staffing on weekends.
The facility failed to provide nourishing bedtime snacks, resulting in a 15-hour gap between dinner and breakfast. Interviews with residents and the Resident Council revealed that most did not receive bedtime snacks, despite requests for more substantial options. The facility's policy requires bedtime snacks, but the available options were limited to juice and cookies, and some residents reported not being offered snacks at all.
The facility did not provide necessary training on abuse, neglect, exploitation, and misappropriation of resident property to a Licensed Nursing Assistant. The staff member's education file lacked documentation of such training, and the Director of Nursing confirmed the absence of training prior to the staff member's start date. This was in violation of the facility's policy requiring such training during orientation and annually.
A resident did not receive the correct dosage of Heparin as ordered by the physician. An LPN administered 50 units instead of the prescribed 100 units intravenously for flushing a PICC line. This error was confirmed during an interview with the LPN and was identified through a review of the resident's MAR.
A facility failed to limit psychotropic drug orders to 14 days for a resident. The resident's MAR showed an order for Ativan without a stop date, resulting in 10 doses administered beyond the 14-day limit. This was confirmed by the DON, and the facility's policy requires PRN psychotropic medications to be ordered for no more than 14 days.
A facility failed to follow CDC guidance for Enhanced Barrier Precautions when an LPN accessed a resident's IV site without wearing a gown, despite signage indicating the requirement. The facility's infection preventionist confirmed the expectation for gown use, aligning with CDC guidelines to prevent MDRO transmission during high-contact care activities.
The facility did not follow its antibiotic use protocols as part of its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for UTIs in April and June 2024. This was confirmed by the Infection Preventionist, who acknowledged the prescriptions did not meet the facility's criteria.
The facility did not have a qualified professional directing the activities program for its 88 residents. An Activities Aide and the Administrator confirmed the absence of a Director since February 2024. The job description and policy review indicated that the Director of Recreation Services is responsible for overseeing the recreation services and ensuring the inclusion of various programs.
The facility did not update the daily nurse staffing information to reflect actual hours worked at the beginning of each shift. A review showed discrepancies between posted information and actual schedules from June 9 to July 10. Staff M confirmed the postings were not updated, despite the facility's policy requiring daily adjustments to reflect staffing changes.
The facility did not ensure that the required members of the QAA Committee attended meetings quarterly, as per policy. The Medical Director missed the first and second quarter meetings, and the Infection Preventionist missed the fourth quarter meeting. This was confirmed through interviews and a review of attendance sheets.
A facility failed to notify a resident and their representative of quarterly care plan meetings, as required for participation in their person-centered care plan. The resident's DPOA reported attending only two meetings since the resident's admission. Medical records confirmed attendance at two meetings, but no documentation of additional meetings was available. Staff from Social Services confirmed the lack of documentation, highlighting the deficiency.
The facility inaccurately coded the MDS for four residents, indicating daily use of bed rails as restraints when they were used for mobility assistance. Staff interviews and documentation confirmed the inaccuracies.
Failure to Implement Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Legionella prevention and response. After a resident, who had been admitted since November 2024, was transferred to the hospital with acute respiratory failure and subsequently tested positive for Legionella, the facility did not conduct required testing or remediation of its water system as outlined in its Water Management Plan. Staff interviews confirmed that neither the water system nor equipment where Legionella could proliferate were tested following the confirmed case, despite the facility's policy and CDC guidance requiring such actions after a healthcare-associated Legionnaires' disease diagnosis. Additionally, the facility did not document the results of control measures as required by its Water Management Plan. The maintenance supervisor acknowledged that water heater temperatures were checked but not logged, and there was no documentation to show which portable air conditioning units had been cleaned. The facility's water management plan also did not identify humidifiers as a risk for waterborne pathogens, and routine Legionella monitoring was not performed, contrary to the plan's requirements for outbreak investigation and control. Furthermore, a humidifier was found in the affected resident's room, which was against the facility's own procedures for Legionnaires' disease prevention. Staff were unaware of the prohibition on humidifiers until after the resident's hospitalization. Although a water sample from the humidifier was collected, it was not tested. These failures in following established policies and procedures exposed the facility's residents to the potential spread and growth of Legionella.
Failure to Obtain Written Authorization for Management of Resident Funds
Penalty
Summary
The facility failed to obtain written authorization from three residents to act as fiduciary of their personal funds and to manage, safeguard, and account for those funds deposited with the facility. For each of the three residents reviewed, their social security benefits were direct deposited into their resident fund accounts, and significant amounts were automatically transferred to the facility for care costs. However, a review of the Resident Fund Management Service forms for each resident revealed that none had authorized the facility to either direct deposit their social security benefits or to automatically transfer payments for care costs. Specifically, the forms for all three residents were either unsigned or did not include authorization for the facility to manage these financial transactions. The records showed repeated automatic withdrawals for care costs without the required written consent from the residents or their guardians. These actions were identified through record review and interviews conducted on 7/7/25, and the lack of proper authorization was consistently documented across all three cases.
Failure to Provide Quarterly Personal Fund Statements to Residents or Representatives
Penalty
Summary
The facility failed to provide written quarterly statements of personal funds to residents or their representatives within 30 days after the end of the quarter, as required. For two residents reviewed, the quarterly statements for multiple quarters were signed by the facility administrator rather than the residents or their legal representatives. Record reviews showed that the statements for both residents were not acknowledged by the appropriate parties, and interviews confirmed that neither the residents nor their representatives had received the required statements. Specifically, one resident's guardian reported not receiving any quarterly statements for the resident's personal fund account, and another resident and their activated power of attorney both stated they had not received any such statements. The administrator confirmed during interview that the statements had not been provided to the residents or their representatives, substantiating the deficiency in managing and communicating residents' personal fund information.
Failure to Notify Resident of Exceeding SSI Resource Limit
Penalty
Summary
The facility failed to notify a resident when their personal fund account balance reached or exceeded $200 less than the Supplemental Security Income (SSI) resource limit, as required by state and federal regulations. Record review showed that the resident's account consistently exceeded the $2,500 SSI resource limit from January through June, with monthly balances ranging from $3,604.10 to $5,784.29. Interviews with the Regional Business Office Manager and the Administrator confirmed that the resident was not notified of exceeding the SSI resource limit during this period. The facility's own policy requires monthly notification and documentation when a resident's account approaches the Medicaid eligibility threshold, but this was not followed for the resident in question.
Insufficient Weekend Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff as determined by their facility assessment. A review of the facility's Payroll Based Journal Staffing Data report for Quarter 2, 2024, revealed excessively low weekend staffing. The facility assessment determined that the required Hours Per Patient Day (HPPD) for nurse aides was 1.63 HPPD. However, a review of the nursing staff punch reports from June 9, 2024, to July 10, 2024, showed that on several weekend dates, the staffing levels for nurse aides were below the required HPPD. Specifically, on June 9, 2024, nurse aides were staffed at 1.57 HPPD; on June 22, 2024, at 1.49 HPPD; on June 23, 2024, at 1.45 HPPD; on June 29, 2024, at 1.49 HPPD; on July 6, 2024, at 1.47 HPPD; and on July 7, 2024, at 1.43 HPPD. An interview with Staff M, the Scheduler/Human Resources, confirmed these findings, indicating a consistent pattern of insufficient staffing on weekends, which did not meet the facility's own assessment requirements.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to provide nourishing bedtime snacks to residents, resulting in a 15-hour gap between the evening meal and breakfast. An interview with the Resident Council, consisting of 13 residents, revealed that most attendees did not receive bedtime snacks. The Resident Council President had previously requested more substantial snacks, such as tuna, egg salad, or chicken salad, to be available in the kitchenettes. However, the facility's snack offerings, as confirmed by the Food Service Director, were limited to items like cranberry juice, apple juice, oatmeal creme cookies, chocolate creme cookies, and crackers. Further interviews with individual residents highlighted the deficiency. One resident reported not being offered a snack in the evening, while another stated they were not offered snacks at any time during the day or night. The facility's policy, revised in October 2022, mandates that bedtime snacks be provided for all residents, with the Dining Services Department collaborating with residents, nursing, and management to identify necessary snack items. Nursing Services is responsible for delivering and offering these snacks, but the policy was not adhered to, leading to the deficiency.
Failure to Provide Required Training on Abuse and Neglect
Penalty
Summary
The facility failed to provide necessary training and education to staff on abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified for one of the five staff members reviewed, specifically a Licensed Nursing Assistant (Staff L). Upon reviewing Staff L's education file, it was found that there was no documentation of training or education on these critical topics. An interview with the Director of Nursing (Staff D) confirmed that Staff L had not received the required training prior to their start date in April 2024. The facility's policy, titled 'Abuse Prohibition' and revised in October 2022, mandates that training and reporting obligations be provided to all employees during orientation, through Code of Conduct training, and at least annually. However, this policy was not adhered to in the case of Staff L, leading to the identified deficiency.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered, specifically involving the administration of Heparin. During an observation, a Licensed Practical Nurse (LPN) administered 50 units of Heparin intravenously to a resident, contrary to the physician's order which specified 100 units to be administered twice daily for flushing a right arm PICC line. This discrepancy was confirmed during an interview with the LPN, who acknowledged administering the incorrect dose. The physician's order had been in place since June 19, 2024, and the error was identified on July 9, 2024, during a review of the resident's Medication Administration Record (MAR).
Failure to Limit Psychotropic Drug Orders to 14 Days
Penalty
Summary
The facility failed to ensure that orders for psychotropic drugs were limited to 14 days for a resident reviewed for psychotropic/opioid side effects. The review of the resident's Medication Administration Record (MAR) revealed a physician's order for Ativan Oral Tablet 0.5 mg to be given every 4 hours as needed for anxiety/nausea, starting on 6/16/24, with no stop date indicated. The resident received 10 doses of the as-needed Ativan after 14 days of the order being initiated. This finding was confirmed during an interview with the Director of Nurses. The facility's policy on psychotropic medication use, revised on 10/24/22, states that PRN psychotropic medications should be ordered for no more than 14 days.
Failure to Follow Enhanced Barrier Precautions for IV Access
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidance for Enhanced Barrier Precautions (EBP) for a resident with an intravenous (IV) access. During an observation, it was noted that a Licensed Practical Nurse (LPN) accessed the resident's IV site without wearing a gown, despite signage on the resident's room door indicating that EBP was required. This action was confirmed through an interview with the LPN, who acknowledged the failure to wear a gown while accessing the IV site. Further interviews and policy reviews revealed that the facility's infection preventionist expected staff to wear a gown when accessing an IV. The facility's policy on Enhanced Barrier Precautions, revised in January 2024, aimed to reduce the transmission risk of epidemiologically significant microorganisms through direct or indirect contact. The CDC guidelines, updated in July 2022, specify that gown and gloves should be used during high-contact resident care activities, especially for residents with wounds or indwelling medical devices, to prevent the spread of multidrug-resistant organisms (MDROs).
Failure to Adhere to Antibiotic Use Protocols
Penalty
Summary
The facility failed to adhere to its antibiotic use protocols, which are part of its Antibiotic Stewardship Program (ASP), during the period from March 2024 to June 2024. Specifically, the facility did not meet its criteria for determining appropriate antibiotic use in two out of the four months reviewed. In April 2024, one resident was prescribed antibiotics for a urinary tract infection (UTI) without meeting the facility's criteria. Similarly, in June 2024, six residents were prescribed antibiotics for UTIs without meeting the established criteria. This was confirmed during an interview with the Infection Preventionist, who acknowledged that the antibiotics were prescribed without adhering to the facility's criteria. The facility's policy, titled IC402 Antibiotic Stewardship, mandates the implementation of an ASP that includes protocols and systems for monitoring antibiotic use, which were not followed in these instances.
Lack of Qualified Director for Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional for its census of 88 residents. During an interview, an Activities Aide revealed that there was no Director of the Activities program at the facility. This was confirmed by the Administrator, who stated that the previous Director left the position in February 2024. A review of the facility's job description for the Director of Recreation Services indicated that this role is responsible for the development, implementation, and supervision of the full scope of recreation services in the nursing center. Additionally, the facility's policy on Recreation Program Components outlined that the Recreation Director is responsible for ensuring the inclusion of various recreation programs.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to update the posted daily nurse staffing information to reflect the actual hours worked at the beginning of each shift on a daily basis. A review of the facility's daily nursing staff postings from June 9, 2024, through July 10, 2024, revealed discrepancies between the posted information and the actual daily nursing schedules. During an interview on July 11, 2024, Staff M, who is responsible for scheduling and human resources, confirmed that the postings were not updated to reflect the actual staffing. The facility's policy, revised on August 7, 2023, requires that the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff be posted and adjusted daily to reflect any staffing changes.
Failure to Ensure Required QAA Committee Attendance
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assessment and Assurance (QAA) Committee attended meetings at least quarterly, as mandated by their policy. Specifically, the Medical Director was absent from the meetings in the first and second quarters, and the Infection Preventionist was absent in the fourth quarter of 2023/24. This deficiency was confirmed through an interview with the Administrator and a review of the QAPI meeting attendance sheets. The facility's policy, revised in March 2024, stipulates that the QAA Committee must include the Director of Nursing Services, the Medical Director, the Administrator, at least two other staff members, and the infection control and prevention officer.
Failure to Notify Resident of Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to notify a resident and/or their representative of quarterly care plan meetings, which is a requirement for resident participation in their person-centered plan of care. Specifically, the deficiency involved a resident whose activated alternate Durable Power of Attorney (DPOA) reported being invited to only two care plan meetings since the resident's admission in April 2023. A review of the resident's medical record confirmed the presence of two quarterly care plan attendance sheets dated April 26, 2023, and February 27, 2024, indicating that both the DPOA and the alternate DPOA were in attendance. However, Staff K from Social Services was unable to provide documentation of any additional quarterly care plan meetings, confirming the deficiency.
Inaccurate MDS Coding for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of four residents regarding the use of bed rails. For Resident #11, the Quarterly MDS indicated daily use of bed rails as a restraint, while a Bed Rail Evaluation showed that the resident requested the use of two half upper rails for mobility and transfer assistance, not as a restraint. This discrepancy was confirmed by the MDS Coordinator during an interview. Similarly, for Residents #53, #76, and #24, the MDS inaccurately coded the bed rails as restraints used daily. Interviews with staff, including a Licensed Practical Nurse and the MDS Coordinator, confirmed that the bed rails for these residents were not restraints. Resident #24's Consent for Use of Bed Rails also indicated that the rails were used as a mobility enabler, not a restraint. These inaccuracies in the MDS submissions were acknowledged by the staff involved.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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