Elm Wood Center At Claremont
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, New Hampshire.
- Location
- 290 Hanover Street, Claremont, New Hampshire 03743
- CMS Provider Number
- 305041
- Inspections on file
- 15
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Elm Wood Center At Claremont during CMS and state inspections, most recent first.
Staff members engaged in emotionally abusive behavior by mocking and ridiculing three residents, recording these actions on video, and sharing the videos via social media with a third party. The incidents involved staff lying in a resident's bed, making derogatory comments, and laughing at residents' cognitive or communicative limitations. The abusive actions were not reported until months later, after the videos were shown to a nurse who then notified facility leadership.
Residents were not served their meals at the same time as others seated at their table, resulting in some eating while others waited without food or drink. Multiple observations showed residents expressing hunger and frustration, and staff confirmed there was no process to ensure coordinated meal service. The Food Service Director acknowledged ongoing issues with meal service timing.
Two residents with documented mental health conditions, including PTSD, major depression, and anxiety, had inaccurate Level I PASARR screenings that failed to reflect their diagnoses. The errors were confirmed by the Social Service Director, and one resident was later identified as needing a Level II evaluation.
Two residents did not receive meals in accordance with their stated preferences: one did not receive the requested chocolate milk needed for a dialysis diet, and another repeatedly received scrambled eggs despite expressing a dislike and was not offered an alternative. Facility policy requiring alternatives for refused meals was not followed.
A resident admitted to hospice did not have a hospice certification or plan of care in their records, and required hospice visits were not documented. Facility staff, including an LNA and RN, were unaware of hospice visit schedules or the care being provided, and the staff member responsible for coordination confirmed that no schedule or plan of care was received from the hospice provider.
Staff failed to follow facility policies on Enhanced Barrier Precautions (EBP) and cleaning of a glucometer. Two residents requiring EBP due to wounds, a PICC line, and a Foley catheter received high-contact care from staff who wore gloves but not gowns, contrary to policy. Additionally, a glucometer was observed with dried residue, indicating it was not disinfected after use as required.
The facility did not include specific staffing requirements for each unit and shift in its facility assessment, instead providing only overall staff numbers and general notes about adjustments based on census and acuity. The assessment failed to reflect the building's two units or detail staffing for day, evening, and night shifts, as confirmed by the Administrator.
The facility failed to provide necessary audiology services to residents, resulting in missed appointments. Despite requests being sent, the facility did not complete the necessary paperwork, leading to the cancellation of clinics. This highlights a deficiency in managing resident care and coordination with external service providers.
The facility experienced insufficient staffing levels on weekends during January, February, and March 2024, as confirmed by PBJ Staffing Data and staff interviews. Staffing levels for licensed nurses and nurse aides were consistently below the facility's assessment requirements, leading to forced additional shifts for staff due to call-outs.
The facility failed to follow physician's orders for three residents regarding the administration of Metoprolol Tartrate. A resident received the medication despite having a systolic blood pressure (SBP) below the prescribed threshold, while another resident was given the medication without documented blood pressure readings. These actions were confirmed by the Unit Manager and an LPN, indicating a lapse in medication management protocols.
A resident admitted with a high pain level did not receive prescribed Oxycodone until the next morning due to a lack of a written prescription and difficulty reaching an on-call provider. The facility's policy for emergency authorization of Schedule II substances was not effectively followed, resulting in the resident experiencing prolonged pain.
The facility failed to maintain accurate records of controlled substances, as required by policy, due to missing dual nurse signatures on narcotic shift count sheets. Interviews with LPNs confirmed the oversight, and the DON acknowledged the need for proper documentation.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN prepared the wrong dose of Folic Acid and the incorrect probiotic for a resident, contrary to the physician's orders. The errors were confirmed through observation and interview, indicating a lapse in following the facility's medication administration policy.
The facility failed to provide timely Medicare non-coverage notices to two residents. One resident did not receive the SNF ABN when Medicare Part A services ended, and another was discharged without receiving the NOMNC. Staff confirmed these oversights.
Staff Emotional Abuse and Exploitation of Residents via Social Media
Penalty
Summary
Staff members engaged in emotionally abusive and exploitative behavior toward three residents by recording videos in which they mocked and ridiculed the residents. In one instance, a licensed nurse aide was recorded lying in a resident's bed, talking about cuddling, and mocking the resident, while another staff member filmed and both giggled. In other cases, a staff member was recorded sitting on the edge of a resident's bed, mocking the resident's cognitive state, and in another, standing next to a resident's bed and mocking the resident's speech. These videos were shared via social media with a third party, specifically the daughter of a registered nurse at the facility. The incidents were not immediately reported; the videos were shown to the registered nurse months after they were created, who then reported them to the facility's administrator and director of nursing. The residents involved were later interviewed, but did not recall the incidents, and telepsychology assessments found no identified trauma. The staff members involved were identified through investigation and their actions were confirmed through interviews and record review.
Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring that all residents seated at the same table in the main dining room were served their meals together. Multiple observations across several meals revealed that some residents were eating while others at the same table were left waiting without food or drink. For example, one resident was nearly finished with breakfast while another at the same table had not received any food or drink. Similar patterns were observed during lunch, where some residents waited for extended periods while others at their table had already been served and finished eating. In one instance, a resident waiting for their meal took food from another resident who had already been served, and another resident repeatedly attempted to leave the dining room while waiting for their meal. Staff interviews confirmed there was no process in place to ensure simultaneous meal service for all residents at the same table. The Food Service Director acknowledged that the facility was aware of ongoing issues with meal service timing in the main dining room. Residents were observed expressing hunger and frustration, with some verbally stating they were hungry or asking for their meals while waiting. These repeated delays and lack of coordinated meal service directly impacted the residents' dining experience and dignity.
Inaccurate PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Level I Pre-admission Screening and Resident Review (PASARR) for two residents with documented mental health diagnoses. For one resident, the medical record listed diagnoses of Post Traumatic Stress Disorder, Anxiety, Major Depression, and a personal history of suicidal behavior, but the PASARR Level I screening indicated no mental illness. For the second resident, the medical record included diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, Anxiety Disorder, and Borderline Personality Disorder, yet the initial PASARR did not indicate any mental illness diagnoses. A subsequent PASARR for this resident later identified the need for a Level II face-to-face evaluation. These inaccuracies were confirmed by the Social Service Director during interviews.
Failure to Accommodate Resident Meal Preferences and Provide Alternatives
Penalty
Summary
The facility failed to provide meals that accommodated the individual preferences of two residents. One resident, who is on dialysis and requires extra protein, repeatedly did not receive the requested chocolate milk with meals as indicated on their meal ticket. Observations over multiple meals confirmed that chocolate milk was not provided, nor was any substitution offered. The Food Service Director later confirmed that chocolate milk was unavailable due to financial and vendor issues, and acknowledged that an alternative should have been offered. Another resident consistently received scrambled eggs for breakfast despite expressing a dislike for them to the Food Service Director. Observations showed that the resident refused to eat the eggs and was not offered an alternative meal. The resident's food preference assessment did not list scrambled eggs as a dislike, but the Food Service Director confirmed being informed of the resident's preference. Facility policy requires that alternative food be offered if a resident refuses a meal or desires something else, but this was not followed in these cases.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate hospice care for a resident who had been admitted to hospice services. Record review showed that the resident was admitted to hospice, but there was no hospice certification or plan of care available in the hospice binder. The resident's care plan listed several hospice interventions, including visits from hospice nursing, a licensed nursing assistant, a social worker, and a volunteer. However, the resident sign-in sheet only documented an admission visit and a spiritual care visit, with no evidence of other required visits. Interviews with facility staff, including a licensed nursing assistant and a registered nurse, revealed that they were unaware of when hospice staff were scheduled to visit or what care was being provided. The staff member responsible for coordinating hospice care confirmed that the hospice provider had not supplied a schedule or plan of care for the resident.
Failure to Implement Enhanced Barrier Precautions and Device Disinfection
Penalty
Summary
The facility failed to implement its own policies regarding Enhanced Barrier Precautions (EBP) and the cleaning and disinfection of a point-of-care device. During observation, a glucometer was found on top of a medication cart with a dried pink/red smear on its back, and a Licensed Practical Nurse confirmed that the glucometer should be cleaned after each use with EPA-approved disinfectant wipes, as per facility policy. Review of the policy confirmed the requirement to clean and disinfect the blood glucose meter after each use, but the observed condition of the glucometer indicated this was not done. Additionally, the facility did not follow its EBP policy for two residents who required these precautions due to chronic wounds, a PICC line, and an indwelling Foley catheter. In one case, a Registered Nurse provided perineal care to a resident with wounds and a PICC line while wearing only gloves and not a gown, despite an active physician's order and care plan for EBP. In another case, a Licensed Nursing Assistant provided personal hygiene to a resident with an indwelling Foley catheter while wearing gloves but not a gown, and initially stated the resident was not on EBP, which was later contradicted by another staff member and the resident's medical record. The Infection Preventionist confirmed that the facility policy required both gown and gloves for high-contact care activities for residents on EBP.
Facility Assessment Lacks Specific Staffing by Unit and Shift
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit and for each shift, such as day, evening, and night. Record review showed that the facility assessment did not specify staffing levels by unit or shift, despite the building having two units. The assessment only listed total numbers of staff needed and included general notes about staffing adjustments based on census and acuity, but did not provide detailed breakdowns for each unit or shift. An interview with the Administrator confirmed these findings.
Deficiency in Audiology Services for Residents
Penalty
Summary
The deficiency involves a failure to provide necessary audiology services to residents at the facility. The report highlights that a resident, along with others, was not seen by an audiologist despite having been scheduled for appointments. The facility had not ensured that the resident received the required audiology services, which was a concern given the resident's condition. The facility had not responded to the audiology company's requests for necessary paperwork, leading to the cancellation of scheduled clinics. The report indicates that the facility had not adequately communicated with the audiology company, resulting in missed appointments for the residents. Despite the requests being sent, the facility did not complete the necessary paperwork, leading to the cancellation of the clinics. This lack of communication and follow-up resulted in the residents not receiving the required audiology services, highlighting a deficiency in the facility's management of resident care and coordination with external service providers.
Insufficient Weekend Staffing in Winter Months
Penalty
Summary
The facility failed to provide sufficient staffing levels to meet the needs of residents on weekends during the months of January, February, and March 2024. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2 2024 indicated excessively low weekend staffing. Interviews with staff, including a Unit Manager and a Staff Scheduler, confirmed that short staffing was a significant issue during these months, particularly on weekends. The facility's assessment outlined specific staffing levels for licensed nurses and nurse aides, but the Daily Staffing Sheets revealed that actual staffing levels were consistently below these requirements on multiple weekend shifts. The deficiency was further corroborated by interviews with staff members, including an LNA and an LPN, who reported being forced to work additional shifts due to call-outs, especially during the winter months. The Director of Nursing confirmed that a staffing action plan was developed in response to these concerns. Despite some reported improvements in staffing levels in recent months, the documented staffing shortages during the specified period indicate a failure to meet the required staffing levels to adequately care for the residents.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, resulting in the administration of Metoprolol Tartrate despite contraindicated blood pressure readings. Resident #25 had a physician's order to hold the medication if the systolic blood pressure (SBP) was less than 100. However, the medication was administered on multiple occasions when the SBP was below this threshold, as confirmed by both the Unit Manager and the Licensed Practical Nurse involved. Similarly, Resident #22 received Metoprolol despite blood pressure readings below the specified limit of 100/60, with documented instances of administration when the blood pressure was 84/55 and 93/56. Resident #64's records revealed a failure to document blood pressure readings prior to administering Metoprolol on several occasions, contravening the physician's order to hold the medication for SBP less than 100. The Unit Manager confirmed these findings, indicating a systemic issue in following physician's orders and documenting necessary vital signs before medication administration. These deficiencies highlight a lapse in the facility's adherence to professional standards of quality in medication management.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who was admitted with a pain level of 7 out of 10. Upon admission, the resident was in pain and did not receive their prescribed pain medication, Oxycodone, until the following morning. The delay in administering the medication was due to the absence of a written prescription for the Schedule II narcotic from the hospital and difficulty in reaching an on-call provider to authorize the prescription. This process took approximately 3-4 hours, during which the resident remained in pain. The facility's Unit Manager acknowledged awareness of the resident's pain upon admission and noted that the nurse should have notified the pharmacy once the prescription was obtained. This would have allowed access to the Emergency Medication Kit to provide the resident with the necessary medication. The facility's policy on new orders for Schedule II controlled substances indicates that verbal authorization should be provided in emergency situations, which was not effectively executed in this case.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records in order. This deficiency was identified in two out of three narcotic books reviewed. The facility's policy on Controlled Substance Management requires that two licensed nurses perform a shift count and maintain an ongoing inventory of all Schedule II-IV controlled substances at shift changes or when narcotic keys are transferred between nursing staff. However, during the review of Medication Cart #1 and Medication Cart #2, it was found that on several occasions, only one nurse had signed the narcotic shift count sheets, indicating a failure to comply with the policy. Interviews with nursing staff confirmed these findings. Staff A, a Licensed Practical Nurse, admitted to forgetting to sign the controlled inventory count sheet for Medication Cart #1. Similarly, Staff K, another Licensed Practical Nurse, confirmed the lack of dual signatures for Medication Cart #2. The Director of Nursing acknowledged that the Controlled Substance Inventory Count Sheets should be signed and dated by the nursing staff at the time of the actual counts, and all required information should be documented on the form. This oversight in documentation and adherence to policy led to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during medication administration. This deficiency was identified during an observation of medication administration for a resident, where a Licensed Practical Nurse (LPN) prepared and intended to administer the incorrect dose of Folic Acid and the wrong probiotic. The resident's Medication Administration Record (MAR) indicated a physician's order for 1 mg of Folic Acid and a Lactobacillus probiotic, but the LPN prepared 400 mcg of Folic Acid and Saccharomyces Boulardii instead. The LPN confirmed the error during an interview, acknowledging the preparation of the wrong medications. The facility's policy on medication administration requires staff to verify the correct medication and dose before administration. However, this protocol was not followed, leading to two medication errors out of 25 opportunities. The errors were documented through observation, interview, and record review, highlighting a failure to adhere to established medication administration procedures.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notification to residents or their representatives regarding the termination of Medicare Part A Skilled Services, resulting in a deficiency. For Resident #33, the facility did not issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN), Form CMS-10055, when the resident's Medicare Part A services were discontinued on February 28, 2024, despite the resident remaining in the facility. This oversight was confirmed by Staff J, the Business Officer, who acknowledged that the SNF ABN was not completed for Resident #33. Similarly, for Resident #217, the facility did not provide the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, before the resident's last covered day of Medicare services on February 12, 2024. Resident #217 was discharged home without receiving the required notice, as confirmed by Staff J. The NOMNC is mandated to be delivered at least two calendar days before the end of Medicare-covered services, which was not adhered to in this case.
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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