Lafayette Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franconia, New Hampshire.
- Location
- 93 Main Street, Franconia, New Hampshire 03580
- CMS Provider Number
- 305077
- Inspections on file
- 16
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lafayette Center during CMS and state inspections, most recent first.
A resident developed pressure ulcers that were not promptly reported to a provider, resulting in delayed treatment orders and incomplete documentation of wound size and care. Nursing staff did not consistently follow physician orders or facility policy for wound assessment and treatment, leading to worsening of the wounds and lack of regular monitoring.
Staff did not follow infection control protocols during wound care for two residents, including failing to use clean field barriers and required PPE under Enhanced Barrier Precautions. Additionally, the facility lacked a water management plan specific to its actual water system, as required by policy.
The facility did not keep residents informed about the status or resolution of ongoing concerns raised in Resident Council Meetings regarding LNAs discussing residents and being loud, nor did it document responses or actions taken in meeting minutes, as required by facility policy.
Two residents with pressure ulcers did not have their care plans updated or developed to address new or existing wounds. In both cases, staff confirmed that new wounds were not reflected in the care plans, and necessary interventions were not documented or implemented as required.
A resident with bipolar disorder and Tardive Dyskinesia received multiple medications, including Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion, significantly later than scheduled on numerous occasions. The resident, who was cognitively intact, reported frequent late medication administration, which was confirmed by audit reports and staff interview. This practice did not comply with facility policy requiring medications to be given within 60 minutes of the scheduled time.
A resident with a history of hearing impairment and a documented need for hearing aids requested an audiology consult due to worsening hearing, but the facility did not arrange the appointment as requested. The resident continued to experience communication difficulties, and staff confirmed the request was not fulfilled, contrary to facility policy.
A resident missed a scheduled knee x-ray and physician visit because staff failed to arrange necessary transportation, despite appointment paperwork being present at the nurses station and communication between staff about the appointment. The resident was not provided the required assistance, resulting in the missed medical appointment.
A resident with dementia and a low BIMS score was repeatedly subjected to inappropriate sexual behavior by other residents. Despite having care plans in place, the facility failed to implement effective interventions to prevent these incidents, resulting in a deficiency in resident safety and protection from abuse.
The facility failed to report alleged abuse incidents to the SSA within the required timeframe. In one case, an LNA observed inappropriate touching between two residents, which was reported internally but not to the SSA until the next day. In another case, a resident reported being attacked, but the incident was not reported to the SSA for several days. A third incident involving inappropriate touching was not reported to the SSA at all.
The facility failed to update care plans for two residents involved in abuse incidents. One resident exhibited increased sexual and wandering behaviors, while another allegedly caused a fall. Despite these incidents, their care plans lacked new interventions addressing these behaviors.
A resident with a history of trauma was re-traumatized when another resident entered their room without consent and allegedly assaulted them, resulting in physical injuries. Despite the resident's known traumatic past and expressed fears, the facility failed to document care plan interventions to prevent such incidents.
A facility failed to accurately document an abuse incident involving two residents. A LNA witnessed inappropriate contact and reported it to an LPN, who documented the event. However, the note was struck out and moved to a non-medical record system by the DON, leaving no evidence of the incident in the official medical record.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels due to the facility's failure to implement necessary interventions for pressure redistribution. Despite being identified as at risk, the resident's care plan lacked specific measures for offloading and repositioning. Staff interviews revealed a lack of awareness regarding the implementation of these interventions, and the DTIs were confirmed to be facility-acquired by the DON.
The facility failed to secure chemical cleaning solutions, leaving them accessible to wandering residents in the Birch and Spruce Units. Observations confirmed by staff interviews revealed that chemicals were not stored according to facility policy, posing potential health risks. The DON acknowledged the presence of 13 wandering residents, emphasizing the need for proper chemical storage.
The facility failed to properly store and label medications in the Birch Unit Medication Room and Pine Unit Medication Cart. The Birch Unit's medication refrigerator was found at an incorrect temperature, and the temperature log was incomplete. In the Pine Unit, insulin pens and vials were not labeled with open or expiration dates, and one vial was beyond its expiration period. These deficiencies were confirmed by LPNs during observations.
A dietary aide failed to perform proper hand hygiene during dishwashing procedures. The aide was observed handling both dirty and clean dishes without washing hands in between, contrary to the facility's policy. This was confirmed during an interview with the aide.
The facility did not follow CDC guidelines for PPE use for two residents. One resident receiving IV medication and with a wound did not have proper gown use by a nurse. Another resident on contact precautions for viral herpes had staff unaware of the precautions' reasons, leading to improper PPE use. Facility policies and CDC guidelines were not adhered to.
The facility failed to develop and update care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident with PTSD lacked a care plan for trauma-related interventions, while another on Coumadin for Atrial Fibrillation had no care plan for anticoagulation therapy. Additionally, a resident with new heel injuries did not have an updated care plan, despite facility policy requiring revisions upon status changes.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer prevention and treatment for one resident. Upon admission, the resident had no pressure ulcers, but subsequently developed open areas on the right and left buttocks. The right buttock wound was first noted as a small open area, but there was no documentation that the provider was notified or that a physician's order was obtained for treatment for six days. During this period, the wound worsened and was later assessed as an unstageable pressure ulcer. Treatment orders were not obtained until several days after the wound was identified, and the treatment was not documented as completed until two days after the order was written. For the left buttock, a stage 2 pressure ulcer was identified, but there was no treatment ordered or documented for a period of three weeks. Additionally, there was a lack of weekly documentation of the size and measurements of both the right and left buttock pressure ulcers for extended periods after their identification. Interviews with nursing staff confirmed that wounds were not measured or documented as required, and that treatment orders were delayed or not followed according to physician instructions. During wound care observations, staff did not follow physician's orders for wound treatments and failed to take measurements of wounds at the time of dressing changes. Facility policies required wound treatment to be provided in accordance with physician orders, prompt notification of providers for new wounds, and regular documentation of wound characteristics and measurements. These policies were not followed, resulting in incomplete and delayed care for the resident's pressure ulcers.
Failure to Implement Infection Control and Water Management Policies
Penalty
Summary
Surveyors observed that staff failed to follow established infection prevention and control policies during wound care for two residents. Specifically, the infection preventionist and an advanced practice registered nurse gathered wound care supplies on an uncleaned clipboard without using a clean field barrier, and entered rooms marked for Enhanced Barrier Precautions (EBP) without donning isolation gowns. During wound care, contaminated items such as scissors were placed on the clipboard and then returned to the treatment cart without proper cleaning. These actions were confirmed by staff interviews and were not in accordance with the facility's policies, which require the use of gowns and gloves for high-contact care activities like wound care, and the establishment of a clean field for dressing changes. Additionally, the facility failed to develop and implement a water management program tailored to its actual water system. The provided water management plan described a four-story building, while the facility is only one story, and did not accurately reflect the flow of the water system. The administrator confirmed the absence of a water management plan specific to the facility, despite policy requirements for such a program as part of the infection prevention and control program.
Failure to Communicate and Document Resident Council Grievance Responses
Penalty
Summary
The facility failed to keep residents informed about the progress and resolution of concerns raised during Resident Council Meetings, and did not maintain documentation demonstrating the response and rationale to these grievances. Over a three-month period, meeting minutes consistently documented resident complaints regarding LNAs discussing other residents in front of them and being loud in hallways and at nurse's stations. Despite these ongoing concerns, residents reported that no follow-up or communication about actions taken was provided to them. Interviews with staff confirmed that while concerns from Resident Council Meetings were verbally relayed to department heads, there was no written follow-up or evidence of actions taken documented in subsequent meeting minutes. The facility's policy requires that concerns and recommendations from the Resident Council be acted upon and that decisions be communicated back to the Council, but this process was not followed as required.
Failure to Update and Develop Comprehensive Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop and update comprehensive care plans for two residents with pressure ulcers. For one resident, a provider note documented a new open area on the sacrum, but no new treatment orders were written, and the care plan for skin had not been updated since a previous date. Interviews with staff confirmed that the new wound was not addressed in the care plan and that treatments had not been completed as required. The medication administration record also did not reflect any new orders for the newly identified wound area. For another resident, progress notes indicated the development of multiple pressure ulcers, including an unstageable area, a stage 2 ulcer, and a deep tissue injury. Observation confirmed the presence of these wounds, but the care plan, which was initiated earlier, had not been updated to include interventions for the new pressure areas. Staff interviews confirmed the absence of care plan interventions for the pressure ulcers that developed subsequently.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality in medication administration for one resident. Multiple instances were identified where medications were administered outside of the prescribed time frames. Specifically, medications such as Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion were given significantly later than their scheduled times, with delays ranging from over an hour to several hours past the ordered administration times. These findings were confirmed through review of the Medication Administration Audit Report and interviews with both the resident and an Advanced Practice Registered Nurse. The resident involved had a diagnosis of bipolar disorder and Tardive Dyskinesia, and was prescribed several medications to be administered at specific times, including early morning and evening doses. The resident was cognitively intact, as evidenced by a Basic Interview for Mental Status (BIMS) score of 15 out of 15, and reported that medications were often given late, a statement corroborated by the audit report covering the previous 30 days. The late administration of medications included both time-critical and non-time-critical drugs, with some doses being administered several hours after the scheduled time. Facility policy required that medications be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. The observed practice did not align with this policy, as numerous medications were administered well outside the acceptable window. The failure to adhere to scheduled medication times was confirmed by staff interview and documentation review, establishing a deficiency in meeting professional standards and following physician orders for medication administration.
Failure to Assist Resident in Accessing Hearing Services
Penalty
Summary
A resident who had been diagnosed with abnormal auditory perceptions in the left ear and was identified as a good candidate for bilateral hearing aids requested to be seen by an audiologist due to worsening hearing. Despite the resident's expressed concerns and a documented need for hearing services, the facility failed to make an appointment with the audiologist as requested. The resident's Durable Power of Attorney confirmed ongoing communication difficulties, and staff acknowledged that the request for a hearing consult was not acted upon. Facility policy required that outside clinical services be provided as ordered and available, but this was not followed in this instance.
Failure to Arrange Transportation for Scheduled X-ray Appointment
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident in arranging transportation for a scheduled x-ray appointment. The resident, who had been admitted in December 2024, was supposed to have a knee x-ray at an orthopaedic clinic. The resident reported being upset after being informed by the staff member responsible for transportation arrangements that they were unaware of the appointment and had not set up transportation. Another staff member confirmed seeing paperwork regarding the appointment at the nurses station and communicated this to the transportation coordinator. Further interviews confirmed that the resident had been given paperwork with the appointment details during a previous clinic visit, but the necessary transportation was not arranged, resulting in the resident missing the scheduled x-ray and physician visit. The report is based on interviews with the resident and staff, as well as a review of the resident's medical record and communication with the orthopaedic clinic, all of which confirmed the missed appointment due to the lack of transportation arrangements.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, involving multiple incidents with other residents. Resident #5, who has unspecified dementia and a Brief Interview for Mental Status (BIMS) score of 3, was involved in several inappropriate interactions. On 5/5/24, a staff member observed Resident #2 with their hand down Resident #5's pants. Staff A, the Activities Director, was aware of multiple incidents of Resident #2 being sexually inappropriate with cognitively impaired residents. Additionally, on 7/27/24, Staff H, an LNA, witnessed Resident #2 rubbing Resident #5's genital area. Further incidents involved Resident #1, who was seen touching Resident #5 inappropriately on 8/13/24 and again on another occasion by Staff L. Resident #2, with a BIMS score of 12, had a care plan addressing potential physical behaviors and sexually inappropriate behavior, but interventions were not effectively preventing these incidents. Resident #1, with a BIMS score of 3 and similar diagnoses to Resident #5, had a care plan for potential verbal/physical behaviors, but it lacked specific interventions to prevent inappropriate sexual behavior. The facility's failure to implement effective interventions and protect Resident #5 from repeated abuse incidents constitutes a deficiency in ensuring resident safety and freedom from abuse.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse to the State Survey Agency (SSA) within the required timeframe for three out of four reviewed cases. In the first case, a Licensed Nursing Assistant (LNA) observed a resident with their hands on another resident's genital area. The incident was reported to a nurse, who left a note for the Assistant Director of Nursing. However, the incident was not reported to the SSA until the following day, exceeding the two-hour reporting requirement for abuse allegations. In the second case, a resident reported being attacked by another resident, resulting in a fall. The incident was witnessed by a Registered Nurse who heard a commotion and found the resident on the floor. Despite the incident occurring on one day, it was not reported to the SSA until several days later. In the third case, an LNA witnessed inappropriate touching between two residents and reported it to a Licensed Practical Nurse. This incident was not reported to the SSA at all, further demonstrating the facility's failure to adhere to reporting protocols.
Failure to Revise Care Plans Following Abuse Incidents
Penalty
Summary
The facility failed to revise care plans for two residents involved in incidents of abuse. Resident #1 was observed by a Licensed Nursing Assistant with their hand on the genital area of another resident. A progress note indicated increased sexual behaviors and wandering, but the care plan, last revised on 7/15/24, did not include new interventions for these behaviors. The care plan only included an evaluation for a Psych/Behavioral Health consultation. Resident #3 was involved in an incident where they allegedly hit another resident, causing them to fall. Despite this incident, Resident #3's care plan, initiated on 8/23/23, did not include any new interventions for aggressive behaviors. The existing care plan focused on verbal behaviors and included interventions such as discouraging head shaving and providing a consistent caregiver, but it did not address the recent physical aggression.
Failure to Protect Trauma Survivor from Re-traumatization
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma was free from re-traumatization. An incident occurred where a resident was found on the floor with a hematoma on the head, a skin tear on the elbow, and complaints of rib pain after another resident entered their room without consent and allegedly hit them. The affected resident had previously disclosed a traumatic past to the social services staff and had expressed fear of the other resident, even wearing a whistle for protection. Despite this, there were no care plan interventions documented in the medical record to address the resident's history of trauma.
Failure to Accurately Document Abuse Incident in Medical Record
Penalty
Summary
The facility failed to maintain an accurately documented medical record for a resident involved in an alleged abuse incident. On 8/13/24, a Licensed Nursing Assistant (Staff K) witnessed an inappropriate interaction between two residents, where one resident was seen touching another resident's inner thigh. Staff K immediately separated the residents and reported the incident to a Licensed Practical Nurse (Staff M). Staff M documented the incident in a nurse's note on the same day. However, this note was later struck out by someone other than Staff M, as directed by the Director of Nursing (Staff F), who claimed it was placed in the wrong section of the medical record. The incident was instead recorded in the Risk Management System, which is not part of the official medical record. A review of the medical record confirmed the absence of documentation regarding the incident.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide appropriate care and services to prevent an avoidable pressure ulcer for a resident identified as being at risk. The facility's policy on Pressure Injury Prevention and Management required the development of a care plan with measurable goals and evidence-based interventions for residents at risk of pressure injuries. Despite this, the care plan for the resident, who was assessed with a Braden Scale score indicating risk for pressure ulcers, lacked specific interventions for offloading and repositioning. The resident's care plan included goals to prevent skin breakdown and interventions such as weekly skin checks and daily observation during ADL care, but it did not address the need for pressure redistribution. The deficiency was further highlighted by the development of deep tissue injuries (DTIs) on the resident's left and right heels, which were noted in physician documentation. The task for offloading the resident's heels was only initiated after the left heel DTI was identified. Interviews with staff revealed a lack of awareness and implementation of the necessary interventions, with discrepancies in the understanding of when the resident's heels were supposed to be floated. The Director of Nursing confirmed that the DTIs on the resident's heels were acquired within the facility, indicating a failure to adhere to the facility's pressure injury prevention policy.
Chemical Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that the residents' environment was free from accident hazards, specifically regarding the storage of chemical cleaning solutions. Observations were made on multiple occasions in the Birch Unit Tub Room, where a bottle of Rapid Multi Disinfectant Spray was found hanging on the wall within reach of wandering residents. Similarly, in the Spruce Unit Tub Room, a container of Super Sani-Cloth Germicidal wipes was observed on top of a portable cart, also within reach of wandering residents. These observations were confirmed by interviews with staff members, including a Licensed Practical Nurse and a Licensed Nursing Assistant. The facility's policy mandates that any area used for storing chemicals should be locked at all times, which was not adhered to in these instances. The Director of Nursing confirmed the presence of 13 wandering residents in the facility, highlighting the potential risk posed by the unsecured chemicals. The Safety Data Sheets for the chemicals indicated potential health effects, such as eye irritation and respiratory tract irritation, underscoring the importance of proper storage to prevent resident exposure.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed in the Birch Unit Medication Room and the Pine Unit Medication Cart. In the Birch Unit, the temperature log for the medication refrigerator was incomplete, with missing entries on multiple dates. During an observation, the refrigerator was found to be at 50 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees Fahrenheit for storing medications such as Sanofi High-Dose Influenza Vaccinations, Insulin Flex Touch Pens, and Purified Protein Derivative (PPD). This was confirmed by a Licensed Practical Nurse (LPN) present during the observation. In the Pine Unit, an open Lispro Insulin Pen and Lantus Insulin Pen were found without an open or expiration date, and an open vial of Lispro Insulin was beyond its 28-day expiration period. The facility's policy requires medications to be labeled with a 'date opened' sticker and to adhere to manufacturer-recommended expiration dates. The LPN confirmed these findings during the observation. The facility's failure to adhere to proper storage and labeling protocols for medications was evident in these observations.
Failure in Hand Hygiene During Dishwashing
Penalty
Summary
The facility failed to ensure proper hand hygiene by dietary staff during dishwashing procedures, as observed on 5/14/24. Staff K, a Dietary Aide, was seen stacking plate warmers, bowls, and plates onto racks and rinsing food debris off the dishes with ungloved hands before sanitizing them through a high-temperature dish machine. After wiping their hands with a paper towel, Staff K did not perform hand hygiene before handling clean and sanitized dishes and utensils. This action was confirmed during an interview with Staff K at the time of observation. The facility's policy on cleaning dishes and using the dish machine, which was reviewed on the same day, specifies that the person loading dirty dishes should not handle clean dishes unless they change into a clean apron and wash their hands thoroughly before transitioning from handling dirty to clean dishes.
Failure to Follow PPE Protocols for Infection Control
Penalty
Summary
The facility failed to adhere to CDC guidelines for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for two residents. Resident #25, who was receiving intravenous medication and had a wound, was observed with an EBP sign on the door and PPE available outside the room. However, a registered nurse, Staff J, did not wear a gown while administering IV medications to the resident, which was confirmed during an interview. For Resident #212, who was on contact precautions due to a diagnosis of viral herpes, there was a lack of awareness among staff regarding the reason for these precautions. Staff B, an LPN, entered the resident's room without donning PPE while administering medications, despite a contact precaution sign being present. Interviews with Staff B, Staff G, and the Director of Nursing revealed a lack of understanding of the precautions required for Resident #212. The facility's policy on isolation precautions and CDC guidelines emphasize the need for gown and gloves during high-contact care activities, which was not followed in these instances.
Care Plan Deficiencies for Residents with PTSD, Anticoagulation Therapy, and Skin Breakdown
Penalty
Summary
The facility failed to develop, implement, and revise care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #2, diagnosed with Post Traumatic Stress Disorder (PTSD) upon admission, did not have a care plan that included focus areas or interventions related to PTSD. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed a lack of awareness regarding the resident's trauma, indicating a gap in communication and care planning. Resident #58, who was prescribed Coumadin for Atrial Fibrillation, did not have a care plan addressing anticoagulation therapy and monitoring for side effects. The facility also lacked a policy related to anticoagulation therapy, as confirmed by the Administrator. Additionally, Resident #48, who developed a new left heel Deep Tissue Injury and a blister on the right heel, had a care plan that was not updated to reflect these changes, despite the facility's policy requiring care plan revisions upon status changes. The Director of Nursing confirmed that the care plan had not been updated to include the actual skin breakdown identified.
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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