Alpine Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Keene, New Hampshire.
- Location
- 298 Main Street, Keene, New Hampshire 03431
- CMS Provider Number
- 305062
- Inspections on file
- 19
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Alpine Healthcare Center during CMS and state inspections, most recent first.
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.
Surveyors identified multiple environmental deficiencies in the memory care unit, including chipped and missing paint on doorways, missing laminate on a closet, exposed and crumbling sheetrock, lifted floor tiles, a hole in hallway tile, and rough, exposed wood on handrails. Staff interviews confirmed these issues, and only one work order had been placed for the lifted tiles, with no work orders for the other deficiencies.
A resident with multiple wounds did not consistently receive wound care as ordered by the physician, with several missed treatments and no documentation of care completion or refusals. The DON confirmed that the medical record and TAR lacked required documentation for both completed and refused wound care.
A resident with a history of trauma and PTSD experienced distress after witnessing a confrontation, but their care plan did not include known trauma triggers such as loud noises and confrontation, despite staff awareness and facility policy requiring such documentation.
Surveyors found that expired and discontinued medications, including controlled substances and insulin pens, were not removed from use on two medication carts. Two residents' medications were involved, with staff confirming the presence of expired Morphine, Lorazepam, and insulin pens that were either unlabeled or past their in-use expiration dates.
Dishware was not properly sanitized because the chemical sanitizer solution in the three-compartment sink was not tested before use and was found to be below the required concentration. Documentation of testing was also missing, and staff confirmed the solution was not checked prior to washing dishware, contrary to facility procedures and manufacturer instructions.
A resident's care plan did not include the most recent hospice plan of care or a description of services provided by the hospice agency. The hospice binder lacked required documentation, and staff interviews revealed confusion about the resident's hospice status and missing details in the care plan.
Two residents and/or their representatives were not given timely SNF Advance Beneficiary Notices (ABN) regarding the end of Medicare Part A coverage. In one case, the ABN was not provided at all, and in another, notification was given only one day in advance instead of the required two days, as confirmed by staff and record review.
The facility did not follow its antibiotic stewardship program for May, June, and July 2024, failing to track or trend antibiotic use and appropriateness. Despite having protocols to optimize infection treatment and reduce adverse events, there was no data on antibiotic appropriateness or infection rates. This was confirmed by the Clinical Consultant and DON. Reports showed multiple antibiotics prescribed without systematic review.
The facility failed to secure lighters and cigarettes for two residents who required supervision with smoking. One resident kept smoking materials in their room, while another kept them in their jacket pocket, both contrary to their care plans. Staff interviews confirmed the residents were supposed to return these items to nursing staff, indicating a lapse in policy implementation.
The facility failed to maintain proper temperature documentation for medication storage and did not dispose of expired medications. In the Unit 2 Medication Room, temperature logs were incomplete, and recorded temperatures were outside the acceptable range. Additionally, an expired Lispro U-100 Insulin Kwikpen was found in the Unit 1 Treatment Cart, exceeding the manufacturer's 28-day usage guideline once opened.
The facility did not follow CDC guidelines for Enhanced Barrier Precautions for two residents with indwelling medical devices. One resident with an indwelling catheter had no PPE available, and another with a gastrostomy tube was attended to by an RN who only used gloves, despite orders requiring gowns, gloves, and masks. The facility's policy and CDC guidelines require gown and glove use during high-contact care activities to prevent MDRO spread.
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 Maintain Safe and Homelike Environment in Memory Care Unit
Penalty
Summary
Surveyors observed multiple deficiencies in the memory care unit related to the physical environment. Several resident room doorways were found to be chipped, scraped, and missing paint. In one room, the closet was missing a laminate piece in the lower corner, and a section of the lower wall had exposed sheetrock that was crumbling onto the floor due to the absence of a baseboard. Additionally, the floor in another room had 3-4 tiles lifting up in front of the bed, and a hole was noted in the hallway tile outside a resident room. The handrails along the main hallway were also observed to have faded paint and exposed wood, resulting in a rough surface. Interviews with staff confirmed these observations. A Licensed Medication Nursing Assistant acknowledged the conditions of the benches in the hallway and the issues in one of the rooms. The maintenance staff reported that a work order had been placed for the lifted tiles in one room since the previous month, but there were no work orders for the other observed deficiencies in the memory care unit. No information was provided regarding the medical history or condition of the residents in the affected rooms at the time of the deficiency.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care for a resident with multiple wounds, as evidenced by missing documentation of wound care completion on several dates. The resident reported not always receiving daily wound care, and review of the Treatment Administration Record (TAR) for May and June showed multiple instances where wound care was not documented as completed for both left and right wounds, including specific treatments such as cleansing, application of santyl, collagen, medi-honey, and dressing changes. There was also no documentation indicating that the resident refused care on these dates. During an interview, the Director of Nursing confirmed the findings and acknowledged that the resident occasionally refused care, but the medical record and TAR did not reflect refusals or provide explanations for missed treatments. The lack of documentation and failure to follow physician's orders for wound care constituted a deficiency in meeting professional standards of quality for the resident's pressure ulcers.
Failure to Identify and Document Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to ensure that trauma triggers were properly identified and documented for a resident with a known history of trauma and PTSD. Interviews and record reviews revealed that the resident experienced distress after witnessing an altercation between other residents, specifically being upset by hearing threatening language. The resident's social history and social services assessments both indicated a history of trauma and the presence of trauma triggers, but did not specify what those triggers were, despite the resident exhibiting symptoms such as anxiety, fear, irritability, mood changes, and sleep disturbances. Further investigation showed that staff were aware of the resident's trauma triggers, including loud noises and confrontation, but these were not included in the resident's care plan. The care plan referenced the resident's history of trauma and noted an incident where PTSD was triggered by a verbal argument, but failed to identify loud noises as a specific trigger. The facility's own policy requires that trauma triggers be identified and included in care plans to prevent re-traumatization, but this was not followed in this case.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from use on two of four medication carts inspected. For one resident, expired Morphine Sulfate IR and Lorazepam tablets were found on the medication cart, despite both medications having been discontinued in the previous year. Staff confirmed the presence of these expired and discontinued medications during the inspection, and a review of physician orders verified that these drugs were no longer prescribed for the resident. Additionally, another resident's insulin and treatment cart contained an open Lispro insulin pen with no documented open or expiration date, and an open Lantus Solostar insulin pen that had exceeded the manufacturer's recommended in-use period of 28 days. Staff confirmed these findings, and a review of manufacturer instructions supported that both insulin pens should have been discarded after 28 days of use. These observations indicate that the facility did not ensure proper labeling and timely removal of expired or discontinued medications from active medication storage areas.
Failure to Ensure Proper Dishware Sanitization Due to Inadequate Chemical Testing
Penalty
Summary
The facility failed to ensure proper sanitization of dishware in the kitchen, as observed when a cook tested the chemical sanitizer solution in the three-compartment sink and found it to be at 150 ppm, which is below the required 200-400 ppm for effective sanitization. There was no documentation on the Three-Compartment Sink Logs indicating that the sanitizer solution was tested prior to use that morning. The cook confirmed that the solution was not tested before washing dishware, and the log for that day was incomplete. Facility procedures and manufacturer instructions both require that the sanitizer be tested and within the specified range before use, but these steps were not followed.
Failure to Include Hospice Plan of Care and Service Details in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's written plan of care included both the most recent hospice plan of care and a description of the services provided by the hospice agency. Review of the resident's hospice binder revealed the absence of hospice certification, a hospice plan of care, and schedules of services furnished by the hospice agency. The resident's nursing home care plan for hospice did not contain a schedule or description of hospice services. During interviews, a registered nurse was unaware that the resident was still receiving hospice services and confirmed that the care plan lacked details about services provided by the hospice agency. The social services staff member, who coordinates services between the hospice agency and the facility, confirmed that the resident was currently receiving hospice services.
Failure to Provide Timely SNF Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) to residents and/or their representatives for two of three residents reviewed. For one resident, the last covered day of Medicare Part A skilled services was identified, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted; however, the SNF ABN was not signed by the resident, and staff confirmed that the notice was not provided. For another resident, the spouse was notified of the SNF ABN by telephone only one day prior to the last covered day of Medicare Part A services, rather than the required two days in advance, as confirmed by staff interview. Review of the facility's policy on Advanced Beneficiary Notices indicated that notices should be provided at least two days before the end of a Medicare covered Part A stay to allow residents or their representatives sufficient time to make decisions regarding services and financial responsibility. The failure to provide timely and properly documented ABNs for these residents constituted noncompliance with both facility policy and regulatory requirements.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to adhere to its established antibiotic stewardship program and system of monitoring antibiotic use for the months of May, June, and July 2024. The facility's policy, revised on May 23, 2023, outlines the purpose of the program to optimize infection treatment while reducing adverse events associated with antibiotic use. It includes protocols for using CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tools to define infections, and the Loeb Minimum Criteria to determine the necessity of antibiotic treatment. The policy also mandates monitoring the response to antibiotics and reviewing antibiotic orders for appropriateness upon admission or from consulting providers. However, a review of the facility's Line List/Antibiotic Stewardship binder revealed a lack of tracking or trending of antibiotics for the specified months, with no data on antibiotic appropriateness, facility or healthcare-acquired information, or infection rates. This deficiency was confirmed during an interview with the Clinical Consultant and the Director of Nursing. Additionally, a report from Pharmscript indicated that one resident was on antibiotic treatment for a urinary tract infection starting July 11, 2024, and previous reports showed 15 antibiotics prescribed in June and 9 in May, highlighting the absence of a systematic review process during these months.
Failure to Secure Smoking Materials for Residents
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not securing lighters and cigarettes for two residents who were identified as requiring supervision with smoking. Resident #7 was observed with a pack of cigarettes and a lighter on their overbed table, despite their care plan indicating that smoking materials should be returned to the nurses' desk after use. Interviews with the resident and staff confirmed that the resident kept smoking materials with them at all times, contrary to the facility's policy and the resident's care plan. Similarly, Resident #68 was found to keep cigarettes and a lighter in their jacket pocket, and they reported going to the smoking area alone. The resident's care plan required them to return smoking materials to the nursing staff after use, but this was not being followed. Staff interviews confirmed that the resident was supposed to return these items to the nursing staff, indicating a failure in implementing the facility's smoking safety policy.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to maintain proper documentation and temperature control for medication storage, as observed in the Unit 2 Medication Room. Specifically, the temperature logs for the medication refrigerator were incomplete, with missing entries on several dates in June and July 2024. Additionally, recorded temperatures on certain dates were outside the acceptable range of 36 to 46 degrees Fahrenheit, as specified by both the facility's policy and the manufacturer's instructions for Aplisol, a Tuberculin Purified Protein Derivative. This discrepancy was confirmed through interviews with facility staff, including a Med Tech and a Clinical Consultant. Furthermore, the facility did not dispose of expired medications as required. During an observation of the Unit 1 Treatment Cart, an open Lispro U-100 Insulin Kwikpen was found with an expiration date that had passed. The insulin, which was opened on 6/16/24, had an open expiration date of 7/14/24, exceeding the manufacturer's guideline of a 28-day usage period once opened. This finding was confirmed by a Registered Nurse during the inspection.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to CDC guidance for Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident #16, who had an indwelling catheter, was observed without any Personal Protective Equipment (PPE) available in or near their room. Staff H, a Licensed Nursing Assistant, confirmed that Resident #16 was not on EBP, and a review of the resident's care plan showed no EBP interventions for the indwelling catheter. Additionally, Resident #18, who had a gastrostomy tube, was observed being attended to by Staff C, a Registered Nurse, who donned only gloves while accessing the gastrostomy tube to administer medications. The physician's orders for Resident #18 included EBP, which required the use of gowns, gloves, and masks during high-contact care activities involving device care. The facility's policy and CDC guidelines both emphasize the necessity of using gown and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms (MDROs), especially for residents with indwelling medical devices.
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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