Derry Center For Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Derry, New Hampshire.
- Location
- 20 Chester Road, Derry, New Hampshire 03038
- CMS Provider Number
- 305095
- Inspections on file
- 22
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Derry Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
A survey of a medication cart in an LTC facility revealed multiple instances of improperly labeled multi-dose medications, including insulin pens and vials without open or discard dates. Some medications also lacked resident identifiers, violating the facility's labeling policy and manufacturer's instructions. An LPN confirmed these findings.
A facility failed to assess a resident's ability to self-administer medication. An albuterol inhaler was found in the resident's room, and the resident reported using it as needed. However, there was no physician's order or self-administration assessment in the medical record. An LPN confirmed these findings, which were contrary to the facility's policy requiring an interdisciplinary team assessment for self-administration safety.
The facility failed to notify residents of the bed hold policy before hospital transfers, as required by their policy. Two residents were transferred without receiving this notification, confirmed by a review of medical records and an interview with the Business Office Manager. The facility's policy mandates written notification at the time of transfer or within 24 hours in emergencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a history of ESBL colonization and another with a pressure ulcer. Observations revealed the absence of EBP signs and PPE, and interviews confirmed non-compliance with CDC guidelines and facility policy, which require gown and glove use during high-contact care activities.
The facility failed to implement care plans for two residents requiring meal supervision. One resident with mobility and weakness issues was observed eating alone in bed, contrary to their care plan. Documentation showed they ate independently multiple times without supervision. Another resident with mobility, vision, and cognitive deficits was also observed eating alone, despite their care plan requiring supervision. The DON expected staff to visually supervise residents during meals, which was not done.
A resident with dysphagia and a self-care performance deficit was observed eating alone in bed, contrary to their care plan which required staff supervision after meal setup. Despite a previous choking incident, documentation showed multiple instances of the resident eating without supervision, highlighting a failure to provide adequate supervision during meals.
The facility failed to maintain appropriate food temperatures, resulting in cold meals being served to residents. Despite initial compliance with temperature guidelines, food temperatures dropped significantly by the time of service. Residents had previously complained about cold food, and staff interviews revealed a lack of necessary equipment to maintain food temperature.
A resident was observed eating breakfast without the necessary assistive devices, such as a nosey cup and built-up silverware, which were specified on their meal ticket. The Dietary Manager confirmed these items should have been provided, as per the facility's policy on adaptive devices for residents who need them.
The facility failed to ensure dietary staff used facial hair restraints, maintain a clean kitchen environment, and properly store food. A cook was observed preparing and serving food without a beard restraint, and the kitchen had accumulated food debris and sticky floors. Additionally, Vanilla Mighty Shakes in the kitchenette lacked thawed or use-by dates, contrary to storage guidelines.
Failure to Document Post-Fall Assessments and Vital Signs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not documenting required post-fall assessments for two residents. For Resident #1, a registered nurse (Staff C) reported that after a fall on 1/21/26, the resident was found on the floor leaning against the wall, complaining of head pain and groin pain. Staff C stated the resident had a lump on the back of the head and groin sensitivity, and that the resident was transferred from the floor to a chair with a licensed nursing assistant and then to bed with assistance from Staff B. Once in bed, the resident had increased right leg pain. Staff C acknowledged performing an assessment after the fall but did not document any of these findings in the medical record. Record review for Resident #1 showed a progress note by Staff B at 1:50 p.m. stating the resident was found on the floor complaining of severe pain in the right parietal scalp and right leg/hip/pelvis, unable to extend the leg due to pain, and that the provider was notified and the resident sent to the ER. An IDT note the following day stated the resident had a small abrasion on the right side of the head, a full body assessment was done with no other injuries noted, the resident would not extend the leg straight, and pain prevented assessment of the right lower extremity for shortening or rotation; x‑rays were ordered but not completed due to pain, and the resident was sent to the ER. Despite these narrative notes, there was no documentation of vital signs, no neurological checks, and no documentation by Staff C of the assessment performed while the resident was on the floor, even though the resident remained at the facility for approximately two hours before hospital transfer. The DON confirmed the absence of documented vital signs and neuro checks and stated the resident should not have been moved while complaining of pain. For Resident #2, the medical record contained a progress note dated 1/19/26 indicating the resident was found on the floor next to the bed, stated they did not want to wait for help, had no skin issues, and was moved from the floor to a wheelchair. An IDT note dated 1/20/26 documented that the resident had a fall in the room while trying to transfer from bed to chair, that no injuries were noted on a full body assessment by the unit manager, and that the resident was assisted back to bed. There were no additional progress notes or documentation of the resident’s assessment after the fall, and Staff B confirmed there was no documentation of the full body assessment referenced in the IDT note. Review of facility policies on assessing falls and accident/incident reporting showed that post-fall documentation was required to include assessment data, vital signs, obvious injuries, and the condition of the resident, which was not completed for these two residents.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that multi-dose medications were labeled appropriately, as observed during a survey of the East Medication Cart. The survey revealed multiple instances where insulin pens and vials, as well as other medications, were not labeled with open or discard dates. Specifically, medications for several residents, including Humalog, Lispro, Lantus, Lyumjev, Tresbia, Basaglar, Admelog, and Apidra insulin pens, were found without proper labeling. Additionally, some medications lacked resident identifiers, such as an open bottle of Systane gel eye drops and Prednisolone eye drops. The facility's policy on labeling medication containers, revised in April 2019, requires that individual resident medications include necessary information such as the resident's name, expiration date, and directions for use. However, the survey findings indicated non-compliance with this policy, as confirmed by an interview with Staff A, a Licensed Practical Nurse. The manufacturer's instructions for the medications observed also specify discard dates after opening, which were not adhered to in the facility's practice.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to determine if self-administration of medications was appropriate for a resident. During an observation, an albuterol inhaler was found on the resident's bedside table, and the resident confirmed using it as needed. However, a review of the resident's medical record showed no physician's order for the inhaler and no completed self-administration assessment. A Licensed Practical Nurse confirmed these findings. The facility's policy requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and clinically appropriate.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transferring them to a hospital, as required by their own policy. This deficiency was identified during a review of medical records and interviews, which revealed that two residents were transferred to the hospital without being informed of the bed hold policy. Resident #8 was discharged to the hospital on April 15, 2024, and Resident #47 was discharged on August 20, 2024, and again on September 21, 2024, without receiving the necessary notification. Additionally, Resident #51 was transferred to the hospital on July 29, 2024, without being informed of the bed hold policy. An interview with the Business Office Manager confirmed that the facility did not provide the bed hold policy at the time of transfer, although it was included in the admission packet. The facility's policy, revised in March 2022, mandates that residents be given written information about bed hold policies at the time of transfer or within 24 hours in emergency situations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to the CDC guidance for Enhanced Barrier Precautions (EBP) for two residents, leading to a deficiency in infection prevention and control. Resident #4, who had a history of colonization with Extended Spectrum Beta-Lactamase (ESBL) in their urine, did not have an EBP sign or Personal Protective Equipment (PPE) outside their room. Despite having a care plan that included maintaining EBP due to the colonization, the Unit Manager confirmed that Resident #4 was not on EBP. This oversight was identified during an observation and confirmed through interviews with staff. Similarly, Resident #10, who had an open wound on the right heel upon admission, was not placed on any precautions. The Director of Nursing confirmed the presence of a pressure ulcer, yet no EBP sign or PPE was observed inside or outside the resident's room. Interviews with the resident and the Infection Preventionist confirmed that staff only wore gloves during wound care, without the use of protective gowns, which is contrary to the facility's policy and CDC guidelines. The facility's policy, revised in August 2023, mandates the use of gown and gloves for high-contact care activities, which was not followed in these cases.
Failure to Implement Meal Supervision Care Plans
Penalty
Summary
The facility failed to implement the care plans for two residents who required supervision during meals. Resident #1, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. Despite the care plan specifying the need for staff supervision after meal setup and encouraging the resident to get out of bed for meals, documentation over the last 30 days showed that the resident ate independently seven times and received only setup or cleanup assistance 35 times. Interviews with the resident and a Licensed Nursing Assistant confirmed that the resident always eats alone in their room after meal setup. Similarly, Resident #2, who has a self-care performance deficit related to declined mobility, poor vision, and declined cognition, was also observed eating breakfast alone in their room. The care plan for this resident also required staff supervision after meal setup. However, documentation from the last 30 days indicated that the resident ate independently five times and received setup or cleanup assistance 24 times. An interview with the Director of Nursing revealed that the expectation for supervision at meals was for staff to maintain a visual on the residents, which was not adhered to in these cases.
Inadequate Supervision During Meals for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision to prevent choking accidents during meals for a resident with a diagnosis of dysphagia. The resident, who has a self-care performance deficit related to declined mobility, deconditioning, and weakness, was observed eating breakfast alone in bed. The care plan for the resident indicated that staff supervision was required after meal setup, and the resident was encouraged to get out of bed for meals as tolerated. However, interviews with the resident and a Licensed Nursing Assistant (LNA) revealed that the resident always eats alone in his room after meal setup. A review of the resident's medical record and nursing notes indicated a previous choking incident on a dinner meal, where the resident began to choke and required assistance to be sat up and expel the food. Despite this incident, documentation over the last 30 days showed that the resident had meals without supervision multiple times, with seven instances of eating independently and 35 instances of only setup or cleanup assistance. This lack of supervision during meals is a direct violation of the resident's care plan and poses a significant risk given the resident's medical condition.
Deficiency in Food Temperature Control
Penalty
Summary
The facility failed to provide food that is palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. The U.S. Food and Drug Administration Food Code requires that time/temperature control for safety food be maintained at specific temperatures, but the facility did not adhere to these guidelines. During a food service observation, it was noted that while the holding temperatures of scrambled eggs, toast, and cream of wheat were initially within acceptable ranges, the temperatures significantly dropped by the time the food was served to residents. A test tray showed that scrambled eggs, toast, and cream of wheat were served at unappetizing low temperatures, which were confirmed by staff interviews. Residents had previously raised concerns about cold food during Food Council and Resident Council meetings, but these grievances were not addressed. Interviews with staff revealed that the facility lacked equipment such as a plate warmer or heated food cart, which contributed to the issue of cold food being served, especially for breakfast in resident rooms. Observations also showed that meal carts were left open during service, further contributing to the temperature drop. Residents expressed dissatisfaction with the temperature of their meals, confirming the deficiency in food service quality.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide a resident with the necessary assistive devices for eating, as observed during a survey. On the morning of June 4, 2024, a resident was seen eating breakfast alone in bed without the required assistive devices, specifically a nosey cup and built-up silverware, which were indicated on the resident's meal ticket. An interview with the Dietary Manager confirmed that these items should have been included on the resident's breakfast tray. A review of the facility's policy on assistance with meals, revised in March 2022, stated that adaptive devices should be provided for residents who need or request them, including items like silverware with enlarged handles and specialized cups.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure that dietary staff used facial hair restraints while cooking and serving food, as observed in the kitchen. Staff E, a cook, was seen preparing and serving food without a beard restraint, despite having a beard over an inch long. Interviews with Staff E and the Dietary Director confirmed that the facility did not provide beard restraints, and Staff E admitted to never wearing one. This lack of compliance with the facility's policy on employee hygiene and sanitary practices was evident during meal service observations. Additionally, the facility did not maintain a clean kitchen environment. Observations revealed food particles and debris accumulated under counters and the steam table, with sticky floors and dried liquid stains present. Staff E confirmed that the floors were supposed to be swept after each meal and mopped at night, but often remained dirty the following morning. A review of the cleaning schedule showed no documentation of nightly mopping, and the Dietary Director confirmed these findings. The facility also failed to store food according to professional standards. In the kitchenette, ten Vanilla Mighty Shakes were found without thawed or use-by dates, and Staff F was unaware of when they were thawed. This oversight contradicts the manufacturer's instructions, which require thawed products to be used within 14 days and kept refrigerated. The lack of proper date marking and storage practices poses a risk of foodborne illness, as confirmed by the facility's policy review.
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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