Mountain Ridge Center, Genesis Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, New Hampshire.
- Location
- 7 Baldwin Street, Franklin, New Hampshire 03235
- CMS Provider Number
- 305075
- Inspections on file
- 19
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mountain Ridge Center, Genesis Healthcare during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident care needs, often assigning LNAs on light duty as full-duty staff and resulting in inadequate coverage for tasks such as showers, transfers, and timely response to call lights. Staff and residents reported long waits for care, missed showers, and frequent closure of the dining room due to insufficient staffing, with some residents left in bed or grouped together for meals.
Two residents did not receive care and services as ordered, including lack of administration of PRN bowel medications for constipation and failure to schedule or complete specialist referrals and diagnostic procedures for a resident with a non-healing wound. Staff interviews and record reviews confirmed these deficiencies, including missed appointments and lack of documentation of required interventions.
A resident experienced significant weight loss over a one-month period, with records showing consistently low meal intake and no documentation that the dietitian or physician was notified as required by the care plan. The last dietitian assessment was several months prior, and staff confirmed that necessary notifications regarding the resident's nutritional decline were not made.
Surveyors found that multiple opened inhalers on two medication carts were not labeled with open or expiration dates as required by manufacturer instructions and facility policy. LPNs confirmed the lack of labeling for inhalers such as Incruse Ellipta, Breztri, Spiriva, and Trelegy, resulting in a deficiency for improper medication labeling and storage.
A resident's urinalysis was delayed after the initial specimen was forgotten in the refrigerator and not sent to the lab, requiring recollection several days later. Staff interviews confirmed that such oversights occur frequently, resulting in delays in laboratory testing and treatment.
The facility's assessment did not include staffing needs for each resident unit, instead listing only overall RN/LPN and LNA hours for the entire census. The Administrator confirmed that unit-specific requirements were not considered.
The facility did not consistently include two residents and their DPOAs in care plan meetings, as required by policy. One DPOA had not been invited to a meeting in about two years, and another attended only one meeting since admission, with no documentation of additional meetings. Staff confirmed the lack of invitations and documentation.
A resident was administered PRN Morphine Sulfate multiple times despite documentation of a pain level of 0, contrary to physician orders specifying administration only for pain rated at 5/10 or higher. The Unit Manager confirmed the medication was given without clinical indication, representing a failure to follow professional standards for medication administration.
Surveyors found that expired IV antibiotics and opened, undated multi-dose vials of vaccines were stored in the medication room refrigerator. A nurse confirmed that the vials had been used and the antibiotics were expired, in violation of manufacturer instructions and facility policy requiring removal of outdated medications and proper dating of opened vials.
The facility did not maintain adequate nursing staff coverage for most days reviewed, leading to residents experiencing long waits for assistance with daily care, missed activities, and delays in responding to call bells. Staff, including LNAs, RNs, and the Infection Preventionist, frequently had to cover additional shifts and roles, and residents requiring extensive assistance were particularly affected by the staffing shortages.
The facility did not provide required Medicare beneficiary notices to two residents, including failing to give a NOMNC with 48-hour notice and not issuing SNF ABNs when coverage ended, as confirmed by record review and staff interview.
A facility failed to follow physician-ordered medication parameters for a resident's pain management. The resident's MAR indicated that Oxycodone 5 mg was administered multiple times without documenting the pain level, contrary to the physician's order requiring administration for pain rated 5/10 or greater. This was confirmed by the Unit Manager, highlighting a deviation from professional standards of care.
A facility failed to provide a resident with education and an offer for the Pneumococcal vaccine upon admission. The resident's medical record lacked documentation of immunization history, education, consent, or declination for the vaccine. An interview with the Infection Preventionist confirmed the oversight, which was against the facility's policy requiring vaccination history and administration for eligible adults.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record reviews, staff interviews, and direct observations. Staffing schedules showed that Licensed Nursing Assistants (LNAs) on light duty with lifting restrictions were counted as full-duty staff and assigned full workloads. On multiple occasions, there were shifts where only one LNA was present on a unit, or where two LNAs on light duty were scheduled together, resulting in inadequate coverage for the number of residents, including those requiring two-person assistance for transfers. Staff interviews consistently reported that the number of LNAs was insufficient to complete required tasks such as showers, transfers, and timely response to call lights, with some staff refusing to work due to unsafe staffing levels. Direct observations and staff accounts indicated that residents were not receiving necessary care, such as showers and assistance with transfers, due to the lack of available staff. Residents dependent on mechanical lifts or two-person assists often had to wait extended periods for care, and some were left in bed or in geriatric chairs for prolonged times. The dining room was frequently closed because of inadequate staffing, and residents were grouped together in rooms for meals instead. Staff also reported an increase in resident falls and that residents were missing outside specialist appointments and meaningful activities because there were not enough staff to assist them. Resident council minutes and interviews with residents confirmed ongoing concerns about insufficient staffing, long waits for care, and missed showers. Residents expressed frustration with the lack of available staff, particularly during evening and night shifts, and reported going extended periods without showers. The facility's failure to adjust staffing assignments to account for light duty restrictions and to ensure adequate coverage for resident care needs directly contributed to these deficiencies.
Failure to Provide Ordered Care and Ensure Specialist Referrals
Penalty
Summary
The facility failed to provide necessary care and treatment according to physician orders and residents' needs for two residents. For one resident, documentation showed prolonged periods without a bowel movement, specifically nine days and six days on separate occasions. Despite physician orders for as-needed administration of Milk of Magnesia and Dulcolax suppositories if no bowel movement occurred in three days, there was no documentation that these interventions were offered or administered during the periods of constipation. The Director of Nursing confirmed that no interventions were documented as provided during these times. For another resident, the facility did not ensure that specialist referrals and diagnostic procedures were scheduled or completed as ordered by the physician. The resident had a persistent, non-healing neck wound with ongoing concern for malignancy, and multiple referrals to dermatology and an MRI were ordered. However, there was no documentation that the dermatology appointment or MRI was scheduled or completed, and the resident missed several specialist appointments, often due to lack of transportation or appointments not being made. The medical record repeatedly noted the need for specialist evaluation and follow-up, but these were not carried out as ordered. Interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, confirmed the lack of documentation and follow-through on physician orders for both residents. The deficiencies were identified through record review and staff interviews, which revealed failures in providing care and ensuring timely access to necessary medical services as ordered.
Failure to Notify Dietitian and Physician of Resident's Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident experienced significant weight loss, dropping from 154.6 to 144.0 pounds over approximately one month. The resident's last documented assessment by a dietitian occurred several months prior, and there was no evidence that the dietitian or physician was notified of the recent weight loss or the resident's low meal intake, despite care plan interventions requiring such notifications. Meal intake records showed frequent days with only one or two meals documented as eaten, and some days with no meals documented. Staff confirmed that there was no documentation of required notifications to the dietitian or physician regarding the resident's nutritional decline. The care plan for nutritional risk included interventions to monitor intake at all meals, offer alternate choices, and alert the dietitian and physician to any decline in intake, but these interventions were not followed as documented in the resident's records.
Failure to Label Opened Inhalers with Required Dates
Penalty
Summary
Surveyors observed that medications, specifically inhalers, were not labeled with open or expiration dates on two of three medication carts inspected. During the inspection, multiple opened inhalers belonging to several residents were found without the required labeling, including Incruse Ellipta, Breztri, Spiriva, and Trelegy inhalers. Licensed Practical Nurses present at the time confirmed that these inhalers were opened and not labeled as per manufacturer instructions. A review of the manufacturer's instructions for each inhaler indicated that labeling with the date opened and discard date is required to ensure proper use and disposal. The facility's own policy also mandates that medications and biologicals be stored according to manufacturer or pharmacy recommendations to maintain their integrity and support safe administration. The failure to label these medications as required constitutes a deficiency in following professional standards for medication storage and labeling.
Delayed Laboratory Testing Due to Specimen Mismanagement
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who had a physician's order for a urinalysis (UA) with culture and sensitivity due to delusions. The order was written on 5/6/25, and the urine specimen was initially collected on 5/7/25. However, there were no laboratory results for this date, and a subsequent nursing note indicated that the specimen was not tested because it was forgotten in the refrigerator. As a result, the specimen had to be recollected on 5/13/25 and then sent to the laboratory. Staff interviews confirmed that specimens are often forgotten in the refrigerator, leading to delays in treatment.
Facility Assessment Lacked Unit-Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit for a census of 68 residents. Record review of the Mountain Ridge Facility Assessment for 2025 showed that staffing requirements were listed only in aggregate for the entire facility, specifying total hours for RN/LPN and LNA staff per shift, but did not break down staffing needs by individual resident units. Further review confirmed that the assessment did not address unit-specific requirements. During an interview, the Administrator acknowledged that the facility assessment did not consider the needs of each resident unit.
Failure to Include Residents and Representatives in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and their representatives were included in the development and implementation of person-centered care plans for two residents. For one resident, the Durable Power of Attorney (DPOA) reported not being notified or invited to a care plan meeting for approximately two years, and there was no documentation of care plan meetings after the resident's admission in 2023. The Director of Social Services confirmed that although the resident was scheduled for care plan meetings, there was no documentation or recollection of the meetings or of the DPOA being invited. For another resident, the DPOA attended only one care plan meeting since the resident's admission, with no documentation of additional meetings before or after that date. The DPOA expressed a desire to be present to understand the goals being set for the resident. Facility policy requires invitations to be sent in advance and documentation of care plan meetings, but records and staff interviews confirmed these steps were not consistently followed.
Failure to Follow Physician-Ordered Pain Parameters for PRN Medication
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident, as evidenced by the administration of Morphine Sulfate without following physician-ordered pain parameters. Specifically, the physician's orders required that Morphine Sulfate 30 mg be given by mouth every four hours as needed for pain rated at 7/10 or greater, and later for pain rated at 5/10 or greater. However, review of the resident's Medication Administration Record (MAR) for March and April revealed multiple instances where the medication was administered despite documentation of a pain level of 0, indicating no pain at the time of administration. Interview with the Unit Manager confirmed that the resident received the medication on these occasions with a documented pain level of 0. This failure to follow the seven rights of medication administration, specifically the right indication, resulted in the administration of a controlled substance without clinical justification as per the physician's orders.
Failure to Remove Expired Medications and Date Opened Vials
Penalty
Summary
Surveyors observed that the facility failed to properly manage medications and biologicals in the medication room. Specifically, an opened bottle of Tuberculin Purified Protein Derivative and an opened bottle of Afluria Influenza Vaccine were found in the vaccine refrigerator without any open date or open expiration date, despite both vials having been used. Additionally, three bags of IV Vancomycin and three bags of IV Zosyn, both antibiotics, were found in the medication room refrigerator with expiration dates that had already passed. These findings were confirmed by a registered nurse present during the observation. Further review of manufacturer instructions indicated that multi-dose vials of Afluria should be discarded within 28 days of being opened, and Tuberculin vials should be discarded after 30 days of use. The facility's own policy requires that outdated, contaminated, discontinued, or deteriorated medications be immediately removed from stock and disposed of according to established procedures. The failure to date opened vials and remove expired medications from stock led to the deficiency cited by surveyors.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents for 24 out of 30 days reviewed, resulting in delays in care and unmet resident needs. Multiple residents reported waiting extended periods for assistance with activities of daily living, such as getting out of bed, dressing, and toileting. One resident, admitted for short-term rehabilitation following a back fracture, experienced incontinence while waiting for staff to respond to a call bell. Another resident reported waiting over an hour to be assisted back to bed, and the resident council expressed concerns about long call bell wait times, particularly on the 3-11 shift and weekends, when only one LNA was often responsible for up to 30 residents per unit. Staff interviews confirmed frequent short staffing, with LNAs and RNs regularly covering additional shifts and roles outside their primary responsibilities, including the Infection Preventionist missing key meetings due to covering direct care shifts. Staff members, including the Scheduling Coordinator, LNAs, RNs, and the Infection Preventionist, consistently reported ongoing short staffing, especially on evening shifts. The Director of Nurses confirmed that a significant number of residents required extensive assistance, including mechanical lifts and two-person assists, yet staffing levels were insufficient to meet these needs. Documentation from resident council meetings and interviews with residents and their representatives further corroborated the persistent issue of inadequate staffing, leading to delays in care and missed activities. The facility's matrix showed 14 new admissions in the past 30 days, further straining available staff resources.
Failure to Provide Timely Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide timely and appropriate beneficiary notices regarding Medicare coverage and potential financial liability for services not covered. For one resident, the Notice of Medicare Non-Coverage (NOMNC) was not given with the required 48-hour notice prior to the last covered day, as the resident was notified only one day in advance. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) was not provided to this resident. For another resident, the SNF ABN was also not provided, despite the resident remaining in the facility after Medicare Part A coverage ended. These deficiencies were confirmed through record review and staff interview.
Failure to Document Pain Levels for PRN Medication
Penalty
Summary
The facility failed to adhere to physician-ordered medication parameters for a resident reviewed for pain management. The physician's order specified that Oxycodone 5 mg should be administered at bedtime for pain management and every six hours as needed for pain rated 5/10 or greater. However, the Medication Administration Record (MAR) for June 2024 showed that the resident received the PRN Oxycodone 5 mg tablet on multiple occasions without documentation of the pain level. This discrepancy was confirmed during an interview with the Unit Manager, who acknowledged that the medication was administered without recording the pain level, which is a deviation from the physician's orders and professional standards of quality care.
Failure to Educate and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were offered and provided education on the risks and benefits of Pneumococcal immunization. Specifically, for one resident reviewed for immunizations, there was no record of Pneumococcal immunization history, nor was there documentation of education, consent, or declination for the vaccine. This resident was admitted to the facility in February 2024, and by the time of the review in June 2024, these requirements had not been fulfilled. An interview with the Infection Preventionist confirmed that the resident had not been offered or educated about the pneumonia vaccines, which should have occurred upon admission. The facility's policy mandates obtaining pneumococcal vaccination history upon admission and administering the vaccine to adults aged 65 years or older who have not previously received it or whose vaccination history is unknown.
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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