Epsom Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Epsom, New Hampshire.
- Location
- 901 Suncook Valley Highway, Epsom, New Hampshire 03234
- CMS Provider Number
- 305080
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Epsom Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect EMR Privacy: Staff were observed leaving laptops open with resident identifiable information visible on 100 and 200 Halls, including while stepping away from the computer. During med pass, an RN and an LPN partially closed laptop screens and left the carts or computers out of sight while resident health information remained on the screen. Facility policy requires staff to lock the screen or use the walk-away button when away from the computer.
Missed care plan meetings and no resident invitation documented. A resident who was his/her own decision maker was not invited to attend routine interdisciplinary care plan meetings, and the most recent care conference showed no attendance or declination documentation. The resident had quarterly comprehensive MDS assessments, but no care plan meetings were documented after later assessments, and the SS staff confirmed the meetings were missed.
The facility failed to follow professional standards for medication administration and weight monitoring. An LPN discontinued Eliquis for a resident without a new order, and another resident missed Pyridostigmine doses without documented hold parameters or provider notification. The facility also did not re-weigh residents after a large weight gain and a large weight loss, including a resident with severe protein-calorie malnutrition.
A resident with autonomic hypotension and medication induced hypertension had an order for Pyridostigmine 30 mg BID, but multiple doses were not given because the medication was reported unavailable. The record showed no documentation that the provider was notified when the medication was unavailable, and an LPN confirmed the doses should have been administered because the medication was in the facility. An APRN was unaware the resident had missed doses or whether the medication was available.
A resident’s consultant pharmacist MRR recommended changing lisinopril to losartan, and an APRN agreed and signed the recommendation, but the order was not updated in the resident’s chart. The resident’s physician orders still showed lisinopril with no change, and the APRN confirmed the EHR was not updated to reflect the recommended order change.
A resident’s self-administered inhalers and nasal spray were repeatedly observed unsecured on the bedside table and dresser instead of being kept in a locked storage area, despite care plan and physician orders allowing bedside storage. An LPN confirmed the meds were not locked, and another LPN noted there was a resident on the unit with a history of wandering into other residents’ rooms.
Kitchen equipment was found unclean in the main kitchen and a second-floor kitchenette. A fryolator had yellow-brown debris, cloudy dark oil with visible crumbs, and grease-like grime on the basket and tank area, while a microwave had dried food particles on the interior surfaces. The FSD confirmed both observations, and the fryolator cleaning log showed it had been cleaned every two weeks despite manufacturer instructions calling for daily maintenance and cleaning.
Failure to follow EBP PPE requirements was identified for two residents. One resident had EBP orders due to open wounds and a pressure injury, and staff were observed assisting with dressing and transfers while wearing gloves but no gown despite signage requiring both for high-contact care. Another resident with a history of ESBL and an EBP care plan was observed during linen care and dressing assistance with gloves only, and the LNA confirmed the gown was not worn.
The facility failed to implement a comprehensive water management program to prevent waterborne pathogens, affecting 102 residents. Key staff were unable to describe the water system or identify risk areas, and the required Legionella testing was incomplete. This lack of understanding and oversight led to deficiencies in pathogen control.
The facility failed to follow the seven rights of medication administration for two residents. A Medication Nursing Assistant administered an incorrect dose of Calcium to a resident, while an LPN did not check the apical pulse before administering Metoprolol to another resident, contrary to the physician's order and facility policy.
The facility failed to revise care plans for two residents. One resident's care plan lacked interventions for monitoring adverse drug reactions for an anticoagulant medication, and another resident's care plan did not include an intervention to encourage going to bed if they fall asleep in their wheelchair. These deficiencies were confirmed by the DON and an LPN, respectively.
A registered nurse failed to instruct a resident to rinse their mouth after using a corticosteroid inhaler, contrary to physician's orders and manufacturer warnings, increasing the risk of infection. The DON confirmed the findings.
Failure to Protect Electronic Medical Record Privacy
Penalty
Summary
The facility failed to provide privacy of electronic medical records for residents on 100 and 200 Halls and during medication administration. On 200 Hall, a Licensed Nursing Assistant was observed documenting on a laptop computer placed on a bench on the short hall and then walking away into a resident room while identifiable information remained visible on the screen. The same computer was later observed open on the bench with a blank screen, but resident identifiable information could be seen when the keyboard was touched, and no staff were nearby. On 100 Hall, a laptop computer was observed open on a movable computer stand near a bench with resident identifiable information visible when the keyboard was touched, and no nursing staff were nearby. During medication administration on the East Hall and North Hall, a Registered Nurse and a Licensed Practical Nurse were observed partially closing laptop screens and walking away from the medication cart or leaving the computer out of sight while resident health information remained visible on the screen. Staff confirmed these observations, and facility staff stated that policy requires staff to lock the screen or use the walk-away button when stepping away from the computer.
Missed interdisciplinary care plan meetings and no resident invitation documented
Penalty
Summary
The facility failed to hold routine interdisciplinary care plan meetings and failed to include the resident in the care planning process for one resident reviewed for care planning. Resident #27 stated in interview that he/she had not been invited to attend care plan meetings. Record review showed quarterly comprehensive MDS assessments completed on 8/13/25, 11/5/25, and 1/22/26, and the resident was identified as his/her own decision maker. The Care Conference Report showed the most recent care plan meeting was held on 8/19/25, with Resident #27 not listed as attending and no documentation that he/she had been invited. There were no documented care plan meetings after the 11/5/25 and 1/22/26 MDS assessments. Staff L confirmed that the most recent care plan meeting was on 8/19/25, that Resident #27 was not documented as attending or declining, and that the facility missed care plan meetings for the later quarterly comprehensive MDS assessments. The facility policy stated that the resident and/or legal representative are encouraged to attend and participate in assessment and person-centered care plan development, and that the social services director or designee is responsible for notifying the resident/representative and maintaining records of such notices.
Medication Administration and Weight Monitoring Failures
Penalty
Summary
The facility failed to follow professional standards related to medication administration for Resident #8 and Resident #24. For Resident #8, a progress note documented that the nurse practitioner wanted Eliquis decreased from 5 mg twice daily to 5 mg once daily, but the medication was discontinued after the morning dose on 2/26/26 without a new physician order to restart it. The March 2026 MAR showed no Eliquis order from 3/1/26 through 3/11/26, even though later physician and NP notes stated to continue Eliquis for chronic atrial fibrillation. Staff E confirmed the resident should have been on Eliquis 5 mg daily, and Staff D confirmed the verbal order was not entered and the medication was discontinued instead. For Resident #24, the MAR showed Pyridostigmine Bromide 30 mg twice daily ordered for orthostatic hypertension, but the medication was not administered on multiple dates because of "condition" or elevated blood pressure comments. One entry had no documentation of what the condition was, and the order did not include parameters to hold the medication. Staff D confirmed the medication was not given as ordered and that there were no hold parameters, and also confirmed there was no documentation that the provider had been notified when the medication was not administered. Staff E stated they were not aware the resident had missed the medication on those dates. The facility also failed to follow its weight policy for Resident #5 and Resident #65. Resident #5 had a documented weight increase from 135.4 lbs. to 148 lbs. in 7 days, but no re-weigh was done to verify the accuracy of the weight and the dietician was not notified. Resident #65 had a documented weight loss from 123.8 lbs. to 108 lbs. in 11 days, with no documentation verifying the accuracy of the weight loss and no re-weigh recorded after 3/8/26. Resident #65 was admitted with severe protein-calorie malnutrition and had nutritional interventions in place, including therapeutic diet, snacks between meals, Megace, and house supplements twice daily.
Missed Pyridostigmine Doses for Resident With Autonomic Hypotension
Penalty
Summary
The facility failed to provide routine medications to meet the needs of one resident reviewed for choices, Resident #24. An outside cardiology progress note dated 2/26/26 documented a recommendation to consider starting Pyridostigmine 30 mg twice daily for autonomic hypotension with medication induced hypertension. A physician's order was entered for Pyridostigmine Bromide 30 mg twice daily with a start date of 2/27/26, but the medication was not administered on 2/27/26, 2/28/26, 3/2/26, 3/3/26, 3/6/26, and 3/7/26 because it was not available. The record contained no documentation that the provider was notified on 2/27/26 or 2/28/26 that the medication was unavailable. The facility pharmacy delivery form showed the medication was delivered on 2/28/26 at 10:44 p.m., and an LPN confirmed the medication should have been administered on the missed dates because it was available in the facility. An APRN stated he/she was not aware the resident had missed the doses or whether the medication was available at the facility.
Failure to Act on Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to act on a provider-approved pharmacy medication regimen review recommendation for Resident #95. On 2/16/26, the consultant pharmacist completed a Medication Regimen Review and recommended that the prescriber consider changing lisinopril to losartan. Staff E, an APRN, agreed with the recommendation and signed the form, but the resident’s physician orders still showed no change to lisinopril on 3/12/26. During interview, Staff E confirmed agreement with the recommendation but stated that the electronic health record was not updated to reflect the recommended order change. The facility policy stated that written or electronic pharmacy findings and recommendations are given to the attending physician, DON, medical director, and others as appropriate to ensure the findings are acted upon.
Unsecured Self-Administered Medications in Resident Room
Penalty
Summary
The facility failed to ensure self-administered medications were properly secured for Resident #53. On 3/10/26, observation in the resident’s room found three prescription medication boxes with pharmacy labels on the bedside table and not secured in a locked storage area. The medications observed were Breztri inhaler, Albuterol Sulfate inhaler, and Ipratropium Bromide nasal spray. At that time, Resident #53 was in bed sleeping. Review of the resident’s care plan showed that the inhalers and nasal spray could be kept in the resident’s room, and the active physician orders also indicated that these medications could be kept at bedside. However, on 3/11/26, the Breztri inhaler and Ipratropium Bromide nasal spray were again observed on the bedside table and the Albuterol Sulfate inhaler was on top of the bedside dresser, still not secured in a locked storage area. An LPN confirmed the medications were not locked. On 3/12/26, an LPN stated there was a resident on the unit with a history of wandering into other residents’ rooms, and the medications were again observed unsecured in Resident #53’s room while the resident was not present.
Kitchen Equipment Not Kept Clean
Penalty
Summary
The facility failed to ensure kitchen equipment was clean for 1 of 1 kitchen and 1 of 2 kitchenette observed. During a kitchen tour, a fryolator was observed with yellow-brown, food-like debris on the top surface, cloudy dark oil with visible crumbs inside, and a thick layer of yellow-brown, grease-like grime on the upper portion of the fryolator, including the basket and the top area of the tank. Staff G, the Food Service Director, confirmed the observation and stated the fryolator had last been cleaned two weeks earlier and was cleaned every two weeks. In the second floor kitchenette, a microwave was observed with multiple dried food particles scattered across the interior surfaces, including the bottom, side walls, and top interior area. Staff G confirmed the condition of the microwave. Review of the fryolator cleaning log showed it was last cleaned on 2/28/26, and the manufacturer’s instructions stated that daily preventative maintenance and daily cleaning, including filtering the oil and removing loose debris, were required. The FDA 2022 Food Code was also reviewed and stated that equipment food-contact surfaces and utensils shall be clean to sight and touch and that cooking equipment food-contact surfaces shall be kept free of encrusted grease deposits and other soil accumulations.
Failure to Follow EBP PPE Requirements
Penalty
Summary
The facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed. Resident #65 had a care plan and physician order for EBP due to open wounds, and the record also showed a pressure injury to the right scapula that was present on admission. On 3/10/2026, an EBP sign outside the resident’s room indicated that gloves and a gown were required for high-contact care activities such as dressing and transfers, but Staff M, a Certified Occupational Therapy Assistant, was observed assisting the resident with dressing while wearing gloves and no gown. Staff M confirmed not wearing a gown during the dressing assistance. On 3/11/2026, Staff M was again observed in Resident #65’s room assisting the resident while seated in a wheelchair, wearing gloves and no gown. Staff M confirmed assisting with dressing and transferring from bed to wheelchair without a gown. Resident #90 had a care plan intervention for EBP and a history of ESBL. On 3/11/2026, an EBP sign outside the resident’s room indicated gloves and gown were required for high-contact activities including dressing, toileting, and changing linens. Staff N, a Licensed Nursing Assistant, was observed changing blue soak pads on the resident’s bed while wearing gloves and no gown, then going into the bathroom and appearing to assist the resident. Staff N later confirmed assisting Resident #90 with dressing in the bathroom while not wearing a gown.
Deficient Water Management Program for Pathogen Control
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to prevent the growth of waterborne pathogens, affecting a census of 102 residents. The review of the facility's undated water management program revealed several deficiencies, including the absence of a detailed description or diagram of the water system, and a lack of identification of areas where Legionella and other opportunistic pathogens could grow and spread. Additionally, the facility did not conduct the required second Legionella testing in 2024, and there were no control measures or procedures for monitoring and intervening when control limits were not met. Interviews with key staff members, including the Director of Maintenance and Environmental Services, the Director of Nursing, the Infection Preventionist, and the Administrator, confirmed these findings. Staff members were unable to describe the facility's water system or identify areas at risk for pathogen growth. They also could not explain the measures in place to minimize the risk of Legionella and other pathogens, indicating a lack of understanding and oversight of the water management program. This lack of knowledge and implementation contributed to the facility's failure to adequately manage and control waterborne pathogens.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to adhere to the seven rights of medication administration for two residents. For Resident #6, Staff E, a Medication Nursing Assistant, administered 375 mg of Calcium Extra Strength instead of the prescribed 200 mg chewable Calcium. This discrepancy was confirmed during an interview with Staff E, who acknowledged the error in medication dosage. For Resident #37, Staff F, an LPN, did not follow the physician's order to check the apical pulse before administering Metoprolol Succinate 100 mg extended release. Instead, Staff F used a pulse oximeter to measure the resident's pulse, which did not comply with the facility's policy on Apical Pulse Monitoring. The policy requires the use of a stethoscope to determine the apical pulse, and the medication should be held if the apical pulse is less than 60. Staff F confirmed during an interview that they did not check the apical pulse as required.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in their care. For Resident #63, the medical record showed a provider order for Eliquis, an anticoagulant, starting on 12/22/23 for atrial fibrillation. However, the care plan did not include interventions for monitoring adverse drug reactions related to the anticoagulant medication. This was confirmed by the Director of Nursing during an interview on 3/7/24. The facility's policy on Anticoagulant Medications, dated 9/1/22, requires assessment for any signs or symptoms of adverse drug reactions, which was not followed in this case. For Resident #31, a nurse's note dated 3/4/24 indicated that the resident fell asleep in their wheelchair and fell forward to the floor on 2/27/24. The note stated that the care plan was updated to include an intervention to encourage the resident to go to bed if they fall asleep in their wheelchair. However, a review of the care plan on 3/6/24 revealed that this intervention was not included, and the care plan for falls was last updated on 1/18/24. This discrepancy was confirmed by an LPN during an interview on 3/7/24. The facility's policy on Comprehensive Care Planning, dated 9/1/22, mandates ongoing assessments and revisions of care plans as residents' conditions change, which was not adhered to in this instance.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to follow professional medication administration standards for a resident. During an observation, a registered nurse did not instruct the resident to rinse their mouth after inhaling a corticosteroid medicine, despite the physician's orders specifying this instruction. The review of the physician's orders and the manufacturer's warnings indicated that rinsing the mouth after use is necessary to reduce the risk of Candida albicans infections. The Director of Nursing confirmed these findings during an interview.
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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