Saint Vincent Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berlin, New Hampshire.
- Location
- 29 Providence Avenue, Berlin, New Hampshire 03570
- CMS Provider Number
- 305066
- Inspections on file
- 18
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saint Vincent Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident was prescribed Sertraline and Seroquel for depression and delusions, but there was no evidence of a gradual dose reduction (GDR) attempt or documentation of clinical necessity for continued use. Facility policy requires GDRs for psychotropic medications unless contraindicated, but this was not followed, as confirmed by a corporate nurse.
A resident with bilateral heel wounds did not receive the required weekly wound assessments, as documentation was inconsistent and missing key details such as measurements and wound stage. Staff interviews confirmed that weekly monitoring was not performed, contrary to facility policy.
A resident with respiratory conditions was observed receiving continuous oxygen therapy via nasal cannula and portable tank, but review of clinical records and confirmation from the unit manager revealed that no physician order for oxygen had been obtained.
A resident on contact precautions for C. diff continued to have loose, uncontained bowel movements, yet staff failed to follow required infection control procedures. A laundry staff member entered and exited the resident's room without proper hand hygiene and was unaware of the contact precautions, while other staff were unclear about the resident's status. Facility policy required use of gowns, gloves, and handwashing, but these were not consistently followed.
Four residents who previously received a COVID-19 booster were not documented as having been offered or educated about the next recommended vaccine dose, as required by CDC guidelines and facility policy. This was confirmed by record review and staff interview.
Two residents who remained in the facility after Medicare coverage ended were not given written notice of the specific services and charges they could be liable for, as required. Instead, the SNF ABN forms provided to them stated 'No cost estimate available' rather than a good faith estimate of costs, which was confirmed as standard practice by a Social Services staff member.
The facility did not maintain the required RN staffing levels, failing to have an RN on duty for 8 consecutive hours a day, 7 days a week, for 7 days within a 92-day period. Specific days lacked RN coverage, as confirmed by staffing reports and interviews with HR staff.
The facility did not follow its antibiotic use protocols, failing to monitor, track, and review antibiotic use for six months. Despite having residents on antibiotics, there was no documentation of monthly monitoring or adherence to criteria. The facility's policy assigns the Infection Preventionist and DON to oversee the Antibiotic Stewardship Program, but they could not provide evidence of regular reporting on antibiotic use and resistance to staff.
The facility failed to provide adequate activities for residents, impacting their well-being. A resident with vascular dementia was often left without activities, leading to decreased participation. Another resident with dementia had limited engagement due to cognitive impairments, despite a care plan indicating interests. A third resident with Alzheimer's expressed boredom and agitation, with no individualized activity program in place. Staff confirmed infrequent activities and lack of tailored plans.
The facility failed to offer and document influenza and pneumococcal vaccinations for two residents. One resident was not offered the influenza vaccine for the 2023/2024 season, and another resident, admitted in June 2023, did not receive the pneumococcal vaccine despite signing a consent. These deficiencies were confirmed by interviews with the Regional Clinical Director and the DON.
The facility failed to timely inform two residents of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). The NOMNC and ABN were signed on the last covered day of Medicare Part A Skilled Services, and the facility lacked a policy for issuing beneficiary notices.
The facility did not ensure that required members attended the Quality Assessment and Assurance group meetings quarterly. In Quarter 2, the Medical Director and Infection Preventionist were absent, and in Quarter 3, another staff member was missing. This was confirmed by the DON.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications underwent a gradual dose reduction (GDR) or had documentation supporting the clinical necessity for continued use of these medications. Record review showed that the resident had physician orders for Sertraline, an antidepressant, and Seroquel, an antipsychotic, both prescribed for depression and delusions. However, there was no evidence in the medical record of any attempts to perform a GDR or documentation indicating a contraindication to GDR for either medication. This was confirmed during an interview with the corporate nurse, who acknowledged the absence of required documentation. Facility policy requires that residents on psychotropic medications receive GDRs unless clinically contraindicated, but this was not followed in this case.
Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency was identified when a resident with two heel wounds did not receive the required weekly assessments, including measurements and descriptions of the pressure ulcers. Review of the resident's medical record showed inconsistent documentation, with wound assessments recorded on non-weekly intervals and some assessments missing key information such as wound stage and measurements. Interviews with the Director of Nursing and the Unit Manager confirmed that weekly wound monitoring was not performed as required. Facility policy mandates completion of weekly pressure ulcer documentation immediately after skin rounds, but this was not followed for the resident in question, who had an unstageable pressure ulcer on the right heel.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A resident who returned from the hospital with diagnoses including acute bronchitis, urinary tract infection, early pneumonia, and reactive airway disease was observed on multiple occasions using oxygen via nasal cannula, both in bed and in a wheelchair with a portable oxygen tank. Clinical notes indicated the resident was on 1 liter of oxygen via nasal cannula and that orders would be initiated with the physician notified. However, review of the resident's physician orders revealed that no orders for oxygen had been obtained. This was confirmed by the unit manager, who acknowledged that the resident was receiving continuous oxygen without a physician's order.
Failure to Implement Contact Precautions for Resident with C. diff
Penalty
Summary
The facility failed to implement its policies and procedures for Transmission Based Precautions (TBP) for a resident on contact precautions for Clostridioides difficile (C. diff). Observation revealed that a staff member from the laundry department entered and exited the resident's room, which was clearly marked for Enteric Contact Isolation, without washing hands with soap and water as required. The staff member was unaware that the resident was on contact precautions. Additionally, another staff member, a Licensed Nursing Assistant, believed that the contact precautions had been removed, while a Registered Nurse confirmed that the resident was still on contact precautions due to ongoing loose and/or watery bowel movements that were difficult to contain. Interviews with the Director of Nursing and the Infection Preventionist confirmed that the resident had completed treatment for C. diff but remained on contact precautions because of persistent symptoms. Facility policy required all staff and visitors to wear gloves and a disposable gown upon entering the room and to wash hands before entering and exiting. The failure to follow these procedures was confirmed through observation, staff interviews, and review of facility policy.
Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine. Specifically, for four residents reviewed for immunizations, there was no documentation that they were offered or educated about the next recommended dose of the COVID-19 vaccine, despite having previously received the COVID-19 Bivalent Booster (Pfizer) in the prior year. This lack of documentation was confirmed through record review and interview with the Infection Preventionist. Facility policy required that all residents be considered eligible for COVID-19 vaccination per CDC guidelines and that ongoing updates be monitored to adjust vaccination schedules accordingly. However, the records for the four residents did not reflect any offer or education regarding the updated CDC recommendations for additional COVID-19 vaccine doses. The deficiency was identified through review of vaccination records and staff interview, which confirmed the absence of required documentation.
Failure to Provide Required Cost Estimates on SNF ABN Forms
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the specific items and services offered by the facility, the charges for those services, and the amount of potential liability for services not covered by Medicare. For two residents who were discharged from Medicare services but remained in the facility, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) forms did not include the required estimated costs for ongoing care and services. Instead, the forms stated 'No cost estimate available' for the per day/item or service, which did not meet the requirement for a good faith cost estimate as outlined in the SNF ABN form instructions. Interview with a staff member from Social Services confirmed that it was their practice to write 'No cost estimate available' rather than providing an estimated cost. Review of the official SNF ABN form instructions indicated that while it is permissible to state that no cost estimate is available in rare circumstances, this should not be a routine or frequent practice. The deficiency was identified through record review and staff interview, and it affected two residents who remained in the facility after their Medicare coverage ended.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 out of 92 days reviewed between October 1, 2023, and December 30, 2023. A review of the facility's Payroll Based Journal Staffing Data Report for Quarter 1 2024 revealed that there were no RN hours for specific days, including October 7, October 21, December 16, and December 17, 2023. Additionally, the facility's daily nursing time sheets indicated that on October 7, only 6 RN hours were worked, and on October 8, October 21, October 22, December 16, December 17, and December 31, there were either no RN hours documented or significantly fewer hours worked than required. Interviews with Staff J from Human Resources confirmed these findings.
Failure in Antibiotic Use Monitoring and Reporting
Penalty
Summary
The facility failed to adhere to its antibiotic use protocols, specifically in monitoring, tracking, and reviewing antibiotic use for six out of the twelve months reviewed. From December 2023 through April 2024, the facility did not track antibiotic use, as confirmed by the Director of Nursing during an interview. The facility had residents with infections who were on antibiotics during this period, yet there was no documentation of monthly antibiotic monitoring, tracking, or review, nor evidence that antibiotics met the criteria for use. The facility's policy on Antibiotic Stewardship, revised in February 2022, outlines that the Infection Preventionist, along with the Director of Nursing, is responsible for overseeing the Antibiotic Stewardship Program. This includes tracking antibiotics, ensuring adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. However, the facility could not provide documentation or evidence of regular reporting on antibiotic use and resistance to relevant staff, such as prescribing clinicians and nursing staff, as confirmed by the Director of Nursing.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that meet the interests and support the well-being of residents, as evidenced by observations and interviews. Resident #45 was frequently observed sitting in a wheelchair in the hallway with no activities occurring on the unit. Despite having a history of being active in activities, Resident #45's participation had significantly decreased, with no documented activities attended in May 2024. Staff interviews revealed that activities on the Second Floor Unit were infrequent, occurring only once every other week, and residents needed to be transported to other floors for activities. Resident #55, who has dementia, was observed sitting in a wheelchair with no engagement in activities. Although the resident's care plan indicated an interest in music, arts, and crafts, among other activities, there was no documentation of participation in May 2024. The resident's representative expressed concerns about the lack of engaging activities, noting that Resident #55 was unable to operate an iPad purchased for music due to cognitive impairment. Staff confirmed that Resident #55 attended activities primarily when accompanied by a spouse. Resident #63, diagnosed with Alzheimer's disease and dementia with agitation, was observed expressing boredom and agitation, with no activities documented in April or May 2024. Despite a leisure interest assessment indicating preferences for activities such as fishing, chess, and religious services, there was no individualized activity program in place. Staff acknowledged the resident's behaviors and lack of participation in group activities but could not provide a tailored activity plan.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and provided education on the risks and benefits of the Pneumococcal and Influenza vaccinations. For Resident #29, a review of the medical record revealed no documentation that the influenza vaccination had been offered for the 2023/2024 flu season. This was confirmed by an interview with the Regional Clinical Director, Staff G. The facility's policy, dated 2015, stated that all residents, staff, and volunteers should be offered the influenza vaccine from October through the end of March each year. For Resident #59, the medical record review showed that the resident was admitted in June 2023 and had signed a consent for the pneumococcal vaccine upon admission. However, there was no documentation that the vaccine had been administered. The Quarterly Minimum Data Set (MDS) indicated that the pneumococcal vaccination was not up to date. This was confirmed by an interview with the Director of Nursing, Staff A, who acknowledged that the resident had not received the pneumococcal vaccine. The facility's policy, revised in 2022, required informed consent and administration of the vaccine according to standing orders, which was not followed in this case.
Failure to Timely Inform Residents of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in a timely manner about the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). This deficiency was identified for two residents. For one resident, the last covered day of Medicare Part A Skilled Services was documented, and the facility initiated the discharge from Medicare Part A Services before benefit days were exhausted. The NOMNC and ABN were signed on the last covered day. Similarly, for another resident, the last covered day of Medicare Part A Skilled Services was noted, and the facility initiated the discharge before benefit days were exhausted, with the NOMNC signed on the last covered day. Interviews with facility staff, including a social worker, regional clinical director, and director of clinical reimbursement, confirmed the findings. It was revealed that the facility did not have a policy for issuing beneficiary notices. According to the instructions for the NOMNC, the notice must be delivered at least two calendar days before Medicare-covered services end, which was not adhered to in these cases.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assessment and Assurance group attended meetings at least quarterly. Specifically, during the review of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets, it was found that in Quarter 2, the Medical Director and Infection Preventionist were not in attendance. Additionally, in Quarter 3, another required member of the facility's staff was absent. These findings were confirmed through an interview with the Director of Nursing.
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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