Merrimack County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Boscawen, New Hampshire.
- Location
- 325 Daniel Webster Highway, Boscawen, New Hampshire 03303
- CMS Provider Number
- 305056
- Inspections on file
- 17
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Merrimack County Nursing Home during CMS and state inspections, most recent first.
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.
Medication administration was not performed according to orders and facility procedures for three residents. An RN gave morphine to one resident outside the ordered respiratory-rate and pain parameters, an LPN administered multiple G-tube meds by pushing them with the syringe plunger instead of gravity delivery, and an RN gave a Breyna inhaler without offering mouth rinsing afterward.
Failure to provide adaptive eating equipment for a resident with a care plan for built-up utensils, a sip cup, a lip plate, and a non-slip mat. The resident was observed using standard utensils and no non-slip mat during meals in bed and in the dining room, with food dropping onto the clothing protector and soup spilling. The resident stated the foam on the spoon and other adaptive items had not been available in a long time, and staff confirmed the resident’s adaptive devices were not in place.
A resident who had declined from being ambulatory to no longer able to ambulate wanted to work with PT again after coming off hospice. Although the UM emailed a rehab screen request to the rehab dept and the care plan noted a referral, the Rehab Director confirmed that no rehab screen was completed for the resident.
Late Significant Change MDS Assessments for Hospice Admission and Discharge: The facility failed to complete Significant Change in Status MDS assessments within the required timeframe for multiple residents when they were admitted to or discharged from hospice. An MDS Coordinator confirmed that several assessments were completed late after hospice status changes.
The facility failed to remove expired medications and properly label multidose vials in medication storage areas. Observations revealed expired Omeprazole, Synthroid, and Lipitor bottles, as well as unlabeled Refresh Tears bottles on a medication cart. The facility's policy on medication storage was not followed, resulting in these deficiencies.
The facility did not follow its Enhanced Barrier Precautions (EBP) policy for a resident with a suprapubic catheter. Observations revealed no EBP signage or PPE at the resident's door. Interviews confirmed that EBP was not followed, despite the facility's policy requiring it for residents with indwelling medical devices.
The facility failed to ensure accurate MDS assessments for four residents. A resident's MDS incorrectly indicated insulin injections, while another's showed hospice care and conditions not documented in their medical record. Two residents' MDS were inaccurately coded for anticoagulant use, with one actually on Plavix. Staff confirmed these errors.
The facility failed to supervise a resident during and after a fire alarm, resulting in the resident eloping and suffering from hypothermia. Staff did not conduct a required resident census check after the alarm was cleared, leading to a delay in locating the resident, who was found outside the facility hours later and required hospital treatment.
A facility failed to follow proper infection control practices during a wound dressing change for a resident. A nurse did not change gloves or perform hand hygiene between removing the old dressing and applying a new one, contrary to facility policy. This was confirmed by the nurse, the DON, and the Infection Preventionist.
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.
Medication Administration Not Performed per Orders and Facility Procedures
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of quality for Resident #287. Review of the February MAR showed orders for Morphine Sulfate Concentrate 20 mg/mL to be given only for breakthrough moderate pain or dyspnea with a respiratory rate of 26–28 at 0.5 mL, or for breakthrough severe pain or dyspnea with a respiratory rate greater than 29 at 1 mL. The MAR documented morphine administrations outside those ordered parameters on 2/7/26 at 12:47 p.m., 2/7/26 at 8:58 p.m., and 2/8/26 at 4:00 a.m.; in each instance 1 mL was given when the documented respiratory rate was 22, 18, and 22 respectively, and one entry also had no pain level recorded. The physician confirmed the medication was administered outside the ordered parameters. The facility also failed to follow medication administration procedures for two other residents observed during medication pass. For Resident #16, Staff A administered multiple medications through the G-tube by pushing them with the syringe plunger, including Senna Liquid, Oxybutnin Chloride, Hyfiber liquid, Amlodipine, Acidophillus capsule, Tizanidine, and Amoxicillin, with 15 mL sterile water flushes pushed before and after each medication. Staff A confirmed the observation. For Resident #296, Staff D administered a Breyna inhaler and did not offer the resident water to rinse the mouth afterward; Staff D confirmed this observation. The facility policy for feeding tube medication administration called for gravity delivery through a piston syringe, and the inhaler manufacturer and facility policy directed mouth rinsing after steroid inhaler use.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating utensils and adaptive eating equipment for Resident #91, who had a care plan to use built-up utensils, a sip cup, a lip plate, and a non-slip mat when eating. Review of the resident’s meal ticket on the breakfast tray showed that a divided plate, foam on spoon, non-slip mat, and sip cups were indicated. However, during breakfast observation, the resident was eating in bed with a standard utensil, standard plate, and no non-slip mat, and crumbs from the muffin and eggs were noted on the clothing protector. The resident stated that foam on the spoon, a divided plate, and a non-slip mat had not been available in a long time and that the foam on the spoon made it easier to feed self. Later observation during lunch showed the resident in the dining room using a standard spoon with the plate placed directly on the linen tablecloth without a non-slip mat. The resident attempted to eat yellow beans with the standard spoon and dropped them on the clothing protector. Additional observation later that day showed the resident eating lunch in bed with a standard spoon and spilling soup. Staff interviews confirmed that the lunch tray contained food and beverages in sippy cups, but there were no foam on spoon or non-slip mat. The 3 North Unit Manager stated the resident had a care plan for adaptive eating devices, and the ADON stated the facility did not have a policy for the use of adaptive equipment.
Failure to Complete Requested Rehab Screen
Penalty
Summary
The facility failed to provide a specialized rehabilitation evaluation for Resident #196, who reported being ambulatory when admitted in 2023 but later declined and was no longer able to ambulate. During interview, the resident stated a desire to work with rehab to walk again. A plan of care note dated 1/15/26 documented that, per request, the resident wanted to work with PT again after coming off hospice and that a referral had been made. Staff H, the Unit Manager, stated that a rehab screen request dated 1/6/26 had been emailed to the rehabilitation department, but Staff M, the Rehabilitation Director, confirmed that a rehabilitation screen was not completed for the resident. The facility policy titled Rehabilitation Screen stated that any resident requiring a rehabilitation screen would be seen within seven days of the submitted request.
Late Significant Change MDS Assessments for Hospice Admission and Discharge
Penalty
Summary
The facility failed to ensure that Significant Change in Status MDS assessments were completed timely for residents when they were admitted to or discharged from hospice services. Review of records showed that Resident #43 was admitted to hospice on 12/4/25 and had a Significant Change in Status MDS with an ARD of 12/12/25 that was signed completed on 12/23/25, five days late. Resident #128 was admitted to hospice on 11/8/25 and had a Significant Change in Status MDS with an ARD of 11/14/25 that was signed completed on 11/24/25, two days late. Resident #173 was admitted to hospice on 12/8/25 and had a Significant Change in Status MDS with an ARD of 12/19/25 that was signed completed on 1/2/26, eleven days late. Resident #221 was admitted to hospice on 1/31/26 and had a Significant Change in Status MDS with an ARD of 2/6/26 that was signed completed on 2/19/26, six days late. Resident #279 was admitted to hospice on 1/2/26 and had a Significant Change in Status MDS with an ARD of 1/9/26 that was signed completed on 1/23/26, seven days late. Resident #196 was discharged from hospice on 12/31/25, and the Significant Change in Status MDS with an ARD of 1/9/26 was signed completed on 1/23/26, nine days late. Staff G, the MDS Coordinator, confirmed that the MDS assessments for Residents #43, #128, #173, #221, and #279 were completed late, and later confirmed the findings for Resident #196.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility failed to ensure that expired medications were removed from stock and that multidose vials were labeled with an open or expiration date. During an observation in the Young Adult/Hospice medication room, a bottle of Omeprazole suspension for a resident was found with an expiration date of 2/15/25, yet it was still in the medication refrigerator. The resident's medical record indicated an ongoing order for this medication, and the Medication Administration Record confirmed administration on the day of observation. Additionally, in the 3rd floor medication room, a bottle of Synthroid with an expiration date of 12/25/24 was found, although it was not being used for the resident it was intended for, and had not been removed from stock. Further observations revealed that in the 4 South medication room, three bottles of Lipitor with past use-by dates were still present, and two unopened bottles of house stock Geri Mox with expiration dates of 11/24 were also found. On a medication cart, three open bottles of Refresh Tears for three residents lacked open or expiration dates. The facility's policy on medication storage, which mandates the removal and destruction of expired medications, was not adhered to, leading to these deficiencies.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling suprapubic catheter. The physician's order for the catheter was dated 5/28/24, yet during an observation on 2/26/25, there was no signage at the resident's door indicating EBP, nor was there Personal Protective Equipment (PPE) available for use. Interviews with the Infection Preventionist and a Licensed Nursing Assistant confirmed that EBP was not being followed for this resident. Additionally, a Licensed Practical Nurse confirmed the presence of the catheter. The facility's policy, dated 7/2024, requires EBP for residents with indwelling medical devices, such as urinary catheters, which was not implemented in this case.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for four residents. For Resident #9, the quarterly MDS indicated that the resident received insulin injections, but a review of the January 2025 Medication Administration Record and physician's orders showed no such orders or documentation of insulin administration. Staff A confirmed that the MDS was incorrectly coded. Similarly, Resident #27's MDS was inaccurately coded for hospice care, foot infection, and diabetic ulcer, none of which were documented in the resident's medical record. Staff A confirmed these inaccuracies during an interview. Resident #103's MDS was incorrectly coded to reflect the use of anticoagulant medications, which were neither ordered nor administered according to the medical record. Staff A confirmed this error. Additionally, Resident #157's MDS was coded for anticoagulant medication use, but the review of physician orders revealed no such orders during the look-back period. Instead, the resident was on Plavix, an antiplatelet medication. Staff A confirmed these findings, indicating a pattern of inaccurate MDS coding for multiple residents.
Failure to Supervise Resident During Fire Alarm Leads to Elopement and Hypothermia
Penalty
Summary
The facility failed to ensure that residents received adequate supervision during and after a fire alarm, resulting in a resident eloping and a delay in locating the resident. On the night of the incident, the fire alarm sounded due to smoke from a resident room, causing the locking mechanisms of the locked doors to disengage. Video recordings showed the resident exiting the unit via the stairwell exit door and leaving the facility. The fire alarm was cleared, but staff did not conduct a resident census check. The resident was found missing hours later and was eventually located outside the facility, suffering from hypothermia and requiring hospital treatment. Interviews with staff revealed that they did not perform a resident census check after the fire alarm was cleared. The resident's hospital records indicated that the resident was found in a ditch, wearing inadequate clothing for the weather, and was hypothermic upon arrival at the hospital. The facility's policies on fire procedures and elopement required a census check and monitoring of doors during a fire alarm, but these procedures were not followed. The facility updated its policies and conducted staff education and mock drills following the incident.
Removal Plan
- Updated the facility's fire procedure and elopement policy
- Initiated staff education on the updated policies and procedures
- Planned for mock drills which will be reviewed and monitored in Quality Assurance
- Completed in-service staff education on the facility's updated fire procedure and elopement policy
- Completed a Code Red (fire procedure) mock drill
Infection Control Lapse During Wound Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a wound dressing change for a resident. During an observation, a registered nurse was seen removing the old dressing, cleansing the wound, and attempting to apply a new dressing without changing gloves or performing hand hygiene. This action was confirmed by the nurse during an interview immediately following the procedure. Further interviews with the Director of Nursing and the Infection Preventionist confirmed that the facility's policy requires changing gloves and performing hand hygiene between removing the old dressing and applying a new one. A review of the facility's hand hygiene policy also supported this requirement, indicating that hand hygiene must be performed before donning gloves and after removing them, as well as when moving from a contaminated body site to a clean body site.
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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