Bel Aire Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport, Vermont.
- Location
- 35 Bel-aire Drive, Newport, Vermont 05855
- CMS Provider Number
- 475049
- Inspections on file
- 19
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Bel Aire Center during CMS and state inspections, most recent first.
Three residents experienced multiple unwitnessed falls due to the facility's failure to maintain assistive devices, provide adequate supervision, and implement timely, effective interventions. One resident suffered serious injuries after falling from a wheelchair with a broken seat belt, while two others with cognitive impairments had repeated falls without prompt care plan updates or new preventive measures. Documentation and monitoring of interventions were inconsistent, contributing to ongoing accident hazards.
A resident with severe cognitive impairment and a history of falls was placed in a buckle seat belt that they could not remove independently, without a physician order, proper documentation, or consent. Staff interviews revealed confusion about restraint use, and facility policy requirements for assessment, monitoring, and care planning were not followed.
A resident with multiple health conditions was discharged from the hospital with a 30-day order for Enoxaparin to prevent blood clots, but due to a medication reconciliation error, only received the medication for 10 days. The failure to properly verify and transcribe the order resulted in the resident developing a DVT, requiring emergency care. Staff interviews revealed confusion about the medication reconciliation process and a lack of required double-checking.
Expired medications, including Docusate Sodium and Guaifenesin, were found stored in a medication cart, and multiple medication carts were observed left unlocked or with medications unattended. Staff, including the DON and an RN, confirmed that carts and medications should have been secured according to facility policy. These incidents occurred in areas accessible to staff and residents, including those with dementia.
The facility did not properly obtain or document consents for influenza and pneumococcal vaccines for three residents. In one case, a resident received the flu vaccine despite a prior documented refusal and without updated consent. For two other residents, pneumococcal vaccine forms were either unsigned by the resident or incorrectly completed by nursing staff, with a nurse signing in place of a resident and again as the nurse. The DON confirmed these documentation issues.
Two residents with cognitive impairment and a history of falls did not receive adequate post-fall interventions or care plan updates after experiencing multiple falls. In both cases, care plans were not revised following new incidents, and required documentation and monitoring were missing. The DON confirmed that the facility did not follow its own policies for post-fall care planning and intervention.
Multiple residents experienced prolonged delays in call light responses, sometimes waiting up to an hour for assistance, resulting in unmet hygiene needs and episodes of incontinence. Staff and family interviews confirmed that LPNs and LNAs frequently worked overtime, missed breaks, and struggled to complete care tasks due to low staffing. Grievances from residents and family members highlighted ongoing concerns about insufficient staff, delayed care, and lack of timely assistance, particularly during shift changes and nighttime hours.
A resident who was dependent on staff for ADLs and not cognitively impaired was observed multiple times with an uncovered Foley catheter bag, despite the care plan and facility policy requiring a privacy bag. The resident expressed a desire for the bag to be properly covered, and staff confirmed the lack of coverage, but the issue persisted over several days.
A resident with arthritis and neck pain did not receive a prescribed Lidocaine patch for pain management due to unavailability, and there was no documentation that the physician was notified or that non-pharmacological interventions were attempted. The DON confirmed that required notifications and alternative pain management were not documented.
A resident did not have a completed COVID-19 vaccine consent form in their immunization records, as confirmed by the DON during record review and interview.
A facility failed to report an alleged abuse incident involving a resident in a timely manner. An LNA witnessed another LNA forcing a resident to the bathroom, causing distress, but did not report it immediately due to uncertainty about the procedure. The Nurse Educator, informed the next day, also failed to report the incident to the DON or ADM. The DON learned of the allegations only when Adult Protective Services arrived three days later.
The facility failed to promptly investigate and prevent further potential abuse after a resident was allegedly mishandled by an LNA. Despite the facility's policy requiring immediate investigation and removal of the involved staff, the incident was not reported to the DON until an Adult Protective Services investigator arrived days later. The LNA continued to care for the resident during this period.
A resident with a care plan for cardiovascular risk was administered Metoprolol 16 times despite their systolic blood pressure and/or heart rate being below physician-prescribed parameters. The facility failed to document reasons for this deviation or notify the physician, as confirmed by the DON.
The facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as staff were unaware of the requirement and did not use PPE during care. EBP signage and staff education were only initiated after surveyors arrived, indicating a deficiency in the infection prevention program.
The facility failed to honor resident preferences for daily routines, resulting in delays for three residents in receiving care and meals. A resident was left waiting in bed for breakfast due to staff shortages, another could not use the bathroom before breakfast, and a third was moved to the hallway and delayed in receiving care and meals. Despite complaints, no resolution was provided.
The facility failed to update care plans for three residents with a history of falls, resulting in repeated incidents without new interventions. One resident experienced multiple falls, including a contusion and facial bruising, while another had three falls in three weeks. A third resident had 22 falls, with care plans revised only four times. A LNA expressed concerns about insufficient staffing to prevent falls, highlighting a lack of adequate supervision and interventions.
The facility failed to identify and address trauma histories and triggers for two residents with PTSD. One resident's care plan did not include PTSD or trauma interventions despite experiencing flashbacks, while another resident's triggers were not documented. The social service assessment tool used was inadequate, only asking about recent trauma consequences, leading to deficiencies in trauma-informed care.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. Several residents reported long wait times for assistance with toileting, leading to incontinence. During dinner service, an LPN was unable to check blood sugars for all residents due to being busy with others. Observations showed residents waiting for morning care and breakfast due to limited staff. Interviews confirmed that staffing shortages impacted the ability to meet residents' needs, affecting their care and safety.
The facility did not ensure that LNAs and nurses were assessed for competencies required to care for residents, with missing or outdated evaluations for 4 out of 5 sampled LNAs and nurses. The designated wound care nurse had not been evaluated since 2020. These issues were confirmed by the Market Clinical Lead and Market Operations Advisor.
The facility failed to accurately monitor residents using psychotropic drugs, as behavior and side effect documentation was inconsistent and incomplete. Residents with mood disorders, anxiety, depression, and delusions were not properly monitored by licensed staff, leading to discrepancies in behavior flow sheets and delayed side effect monitoring in MARs. The Market Clinical Lead confirmed these deficiencies, highlighting a lack of adherence to facility policy.
The facility failed to report an allegation of staff-to-resident abuse to the State Licensing Agency. A resident with a BIMS score of 14 reported that a night aide had ripped off their necklaces. The incident was reported to the DON, but the allegation was not reported to the State Licensing Agency. The DON was unaware of the reporting requirement but has since been educated.
The facility failed to create timely baseline care plans for two residents upon admission, leading to deficiencies in person-centered care. One resident's care plan did not initially address existing skin breakdown, while another resident's plan lacked provisions for mood and dementia management. These omissions were confirmed by facility staff.
A facility failed to provide appropriate wound care for a resident with a non-pressure-related injury, not conducting initial or weekly assessments as required by the care plan. The resident, with conditions including osteomyelitis and diabetes, had a wound that was not properly monitored, leading to necrotic tissue. The wound care nurse did not assess the wound until a skin check revealed issues, and the care plan was not updated to reflect these findings.
A facility failed to provide appropriate pain management for a resident admitted for rehabilitation after falls. The care plan required non-pharmacological interventions before PRN medications, but the MAR lacked documentation of these interventions. Pain assessments consistently showed a pain level of zero, with no assessments conducted before administering PRN medications. The DON confirmed the need for documented pain assessments and interventions.
Failure to Prevent Resident Falls Due to Inadequate Supervision and Device Maintenance
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible, specifically related to falls, for three sampled residents by not maintaining assistive devices, providing adequate supervision, or implementing timely and effective interventions. One resident, who had a history of falls and moderate cognitive impairment, was care planned to use a wheelchair seat belt as a fall reminder. Despite staff and maintenance being aware that the seat belt was broken and improperly secured for several days, no effective intervention was implemented, and the resident suffered a fall resulting in multiple fractures and significant pain. The maintenance log system was not properly utilized, and the broken equipment was not tracked or repaired in a timely manner, with the resident left without a functioning seat belt until after the incident. Another resident with mild dementia and a history of falls experienced nine unwitnessed falls over a short period. Despite repeated incidents, the care plan was not updated with new interventions after each fall, and changes were delayed by up to 28 days. Documentation and monitoring of interventions were lacking, and the resident continued to fall without evidence of effective preventive measures being implemented or tracked in a timely manner. A third resident, dependent on staff for self-care and with severe cognitive impairment, experienced four unwitnessed falls in one month. Although some interventions were added to the care plan, they were often repeats of previous measures and not new or tailored to the resident's changing needs. The resident was left unattended in high-risk areas despite a known history of getting up unassisted, and after a fall resulting in a facial laceration and ER transfer, no new interventions were created. The DON confirmed that care plans were not updated as required after each fall, and there was no evidence of consistent implementation or monitoring of fall prevention strategies.
Failure to Ensure Resident Was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically regarding the use of a seat belt that the resident could not remove independently. The resident, who had diagnoses including dementia, schizophrenia, and seizure disorder, was assessed as being dependent on staff for self-care and mobility, with severely impaired cognitive skills. The care plan initially included a Velcro seat belt for safety, but after multiple unwitnessed falls, the seat belt was changed to a buckle type, which the resident was unable to remove on their own. Despite the change to a buckle seat belt, there was no physician order specifying the medical symptom, frequency of use, release times, or activities to be performed during release. The care plan was updated to reflect the change in seat belt type, but there was no documentation on how the restraint would treat a medical symptom, nor was there evidence of direct monitoring, recommendations for gradual reduction, or assessment of risks related to restraint use. Additionally, there was no documentation of consent obtained from the resident's representative for the use of the buckle seat belt, and no completed restraint assessments after the initial evaluation. Interviews with facility staff revealed a lack of clarity and communication regarding the use and type of seat belt, with some staff unaware of the change or the requirements for restraint use. The facility's own policy requires a specific process for restraint use, including physician orders, consent, regular reassessment, and care planning, none of which were followed in this case. The DON confirmed that the restraint policy was not adhered to because the seat belt was not considered a restraint by the facility.
Medication Reconciliation Failure Leads to DVT
Penalty
Summary
A significant medication error occurred when a resident with a history of right femur fracture, muscle weakness, anxiety, and atrial fibrillation was discharged from the hospital with an order for Enoxaparin 40 mg subcutaneously every 24 hours for 30 days to prevent blood clots. Upon admission to the facility, the medication was transcribed incorrectly, and the resident received Enoxaparin for only 10 days instead of the prescribed 30 days. The medication administration record reflected this shortened duration, and three licensed nursing staff administered the medication over the 10-day period. The facility's medication reconciliation policy required verification of orders and clarification with the transferring hospital if discrepancies were found, but this process was not properly followed. The error was discovered after the resident developed pain, redness, and swelling in the thigh, leading to an emergency department transfer where a deep vein thrombosis (DVT) was diagnosed by ultrasound. Interviews with facility staff revealed that the order was not checked a second time as required, and the nurse responsible for transcribing the order was unclear about the process and did not ensure a proper handoff. The Director of Nursing confirmed that the usual double-check process was not completed due to the absence of the unit clerk, resulting in the medication error and subsequent adverse event.
Expired Medications and Unsecured Medication Storage
Penalty
Summary
Expired medications were found stored in a medication cart, including Docusate Sodium 100 mg tablets that expired in January 2025 and Guaifenesin 16 fl oz with an expiration date of May 2025. The nurse assigned to the cart confirmed the presence of these expired medications. Facility policy requires that medication rooms, cabinets, and supplies remain locked when not in use or attended by authorized personnel, and that medication carts are kept closed and locked when out of sight of the medication nurse. Multiple instances were observed where medication carts were left unlocked and medications were left unattended. On one occasion, a medication treatment cart was found unlocked, and the DON confirmed it should have been locked. In another instance, an RN left a Senna pill and a medication pack of Benzonatate tablets unattended on a medication cart while walking away to retrieve more medication and to administer medications to a resident. Additionally, a medication treatment cart was observed unlocked with a drawer partially open in a hallway with staff and two self-propelling residents with dementia present. The nurse responsible for the cart confirmed it should have been locked.
Deficient Consent and Documentation for Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to obtain required consents and maintain accurate records for influenza and pneumococcal vaccinations for three residents. For one resident, the representative declined the influenza vaccine and signed the informed consent form, but the resident later received the vaccine without an updated consent form in the electronic health record. Another resident's pneumococcal vaccine form was not signed by the resident, nor was there documentation indicating the resident's wishes regarding the vaccination, although the provider signed and dated the form. For a third resident, the pneumococcal vaccine form was not signed by the resident; instead, a nurse signed in the resident's place and also signed again in the section designated for a licensed nurse. The Director of Nursing confirmed that the consent forms and documentation for these vaccinations were incomplete or incorrectly filled out.
Failure to Revise Care Plans and Implement Adequate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that two residents received adequate interventions to prevent accidents, specifically falls, despite their known high risk and history of previous incidents. One resident with significant cognitive impairment, muscle weakness, and a history of falls experienced multiple falls within a short period. After the first fall, which resulted in a skin tear and a subsequent hospital evaluation revealing a brain hemorrhage, the care plan was updated with general safety interventions. However, following a second fall that resulted in another head injury and bleeding, the care plan was not revised to include any new or additional interventions, and there was no documentation of further neurological checks or post-fall assessments as required by facility policy. Another resident, also identified as high risk for falls due to impaired mobility, cognitive impairment, and a history of stroke, experienced a fall that was witnessed by staff. Although an incident report was completed and a physical therapy evaluation was ordered as an intervention, the resident refused therapy, and no alternative interventions were considered or implemented. The care plan was not updated to reflect the attempted intervention or to address the continued risk of falls, and the effectiveness of the intervention was not evaluated. Interviews with the Director of Nursing confirmed that in both cases, the facility did not follow its own policies regarding post-fall care planning and intervention. The care plans were not reviewed or revised after subsequent falls, and required documentation and monitoring were lacking. These failures resulted in a lack of adequate supervision and accident prevention measures for residents at high risk for falls.
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 its residents, as evidenced by multiple observations, interviews, and record reviews. Residents experienced significant delays in call light responses, with documented wait times ranging from 23 to 45 minutes, and in some cases up to an hour. Several residents, all with unimpaired cognitive status, reported frequent and prolonged waits for assistance, leading to episodes of incontinence and unmet hygiene needs. Staff interviews confirmed that nursing personnel were required to work overtime or extra shifts regularly, often foregoing breaks, and struggled to complete their duties due to inadequate staffing levels. Staff also reported that care tasks such as hygiene and meal service were delayed or rushed because of insufficient personnel. Family members and residents filed grievances regarding the lack of timely care and insufficient staff presence, particularly during shift changes and nighttime hours. One family representative noted that residents were not always repositioned as needed, and staff confirmed that there were not always enough personnel to safely operate equipment such as Hoyer lifts. Grievances documented that some staff refused to answer call lights at night, citing facility rules, and residents continued to express concerns about staffing even after grievances were filed. These findings collectively demonstrate a pattern of inadequate staffing that compromised residents' physical, mental, and psychosocial well-being.
Failure to Provide Privacy for Resident's Foley Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity regarding the management of personal medical equipment, specifically a Foley catheter. According to the resident's care plan, staff were required to provide privacy and comfort by covering the Foley catheter bag with a privacy bag. Despite this directive, multiple observations over three consecutive days revealed that the resident's Foley bag was not covered with a privacy bag and was visibly draining yellow urine. The resident, who was dependent on staff for activities of daily living and hygiene, was not cognitively impaired and expressed a desire for the Foley bag to be properly covered, especially in public settings. Interviews with staff confirmed the absence of the privacy bag, and the issue persisted despite acknowledgment from an LPN that the bag needed to be covered. The facility's policy emphasized treating each resident with respect and dignity, and the care plan specifically instructed staff to provide a privacy bag for the Foley catheter. The repeated failure to follow these instructions resulted in the resident not being afforded the privacy and dignity outlined in both facility policy and the resident's care plan.
Failure to Provide Ordered Pain Management and Notify Physician
Penalty
Summary
A resident with a diagnosis of arthritis affecting multiple sites, including a pinched nerve in the neck, reported ongoing neck pain and was prescribed a Lidocaine 4% patch to be applied to the left posterior neck each morning for ten days. Despite this physician order, the resident did not receive the pain patch for at least two consecutive days, as confirmed by both the resident's statement and review of the Medication Administration Record (MAR), which indicated the medication was unavailable on one of those days. Nursing notes documented the resident's complaint of pain but did not show that any non-pharmacological interventions were attempted to relieve the pain. Further review of the resident's care plan revealed instructions to administer medications as ordered, monitor for effectiveness and side effects, and report to the physician as indicated. However, there was no documentation that the physician was notified about the unavailability of the pain medication or that alternative pain management strategies were implemented. The Director of Nursing confirmed that the physician should have been notified in such situations, but this was not done, and no non-pharmacological interventions were documented.
Missing COVID-19 Vaccine Consent Form for Resident
Penalty
Summary
The facility failed to obtain a COVID-19 vaccine consent form for one resident. Record review showed that the resident's immunization records did not include the required consent form for the COVID-19 vaccine. During an interview, the DON confirmed that the consent form had not been completed and acknowledged that it was needed. This deficiency was identified through both record review and staff interview, with direct confirmation from facility leadership regarding the missing documentation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving a resident in a timely manner, as required by their Abuse Prohibition Policy. The incident involved a Licensed Nurse's Aide (LNA) who allegedly forced a resident to walk to the bathroom against their will, causing the resident to express pain and distress. The incident was witnessed by another LNA, who did not report it immediately due to being unable to find a nurse and not knowing the proper steps to take. The following day, the witness discussed the incident with the Nurse Educator, who failed to report the allegations to the Director of Nursing (DON) or the Administrator (ADM) and did not ensure that the incident was reported to the required agencies. The DON only became aware of the abuse allegations when an Adult Protective Services investigator arrived at the facility three days after the incident. The facility's policy requires immediate reporting of suspected abuse to the charge nurse or, if unavailable, to the DON at any time. The DON confirmed that the Nurse Educator should have reported the allegations after being informed by the witness. The failure to follow the proper procedure resulted in a delay in reporting the incident to the appropriate authorities and responsible parties.
Failure to Investigate and Prevent Further Abuse
Penalty
Summary
The facility failed to immediately investigate allegations of abuse and prevent further potential abuse for a resident. According to the facility's Abuse Prohibition Policy, an investigation should be initiated within 24 hours of an allegation, and the employee involved should be immediately removed from duty pending investigation. However, a Licensed Nurse's Aide (LNA) provided a witness statement regarding an incident that occurred four days prior, involving another LNA who allegedly forced a resident to walk to the bathroom and raised their voice when the resident did not cooperate. The resident expressed pain and distress during the incident. The witness reported the incident to the facility's Nurse Educator the following day, but the Nurse Educator did not report it to the Director of Nursing (DON) or Administrator, nor did they follow up to ensure the allegation was reported to the required agencies. The DON only became aware of the abuse allegations when an Adult Protective Services investigator arrived at the facility three days after the incident. During this time, the alleged perpetrator, LNA #2, was not removed from duty and continued to provide care to the resident involved in the incident. The facility's investigation into the abuse allegation was only launched after the arrival of the investigator. The DON confirmed that the investigation should have been initiated immediately after the alleged event, and the staff member involved should have been taken off duty to prevent further potential abuse, but these actions were not taken.
Failure to Adhere to Medication Orders for a Resident
Penalty
Summary
The facility failed to implement care plan interventions regarding medication administration for a resident. The resident was admitted with physician orders for Metoprolol, a medication used to treat high blood pressure, with specific instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 65. Despite these parameters, the medication was administered 16 times when the resident's systolic blood pressure and/or heart rate were below the prescribed limits. The care plan for the resident identified a risk for cardiovascular symptoms or complications related to heart failure, with interventions including administering medications as ordered. However, there was no documentation in the resident's medical record explaining why the medication was given contrary to the physician's orders, nor was there any indication that the physician was notified of the deviation. The Director of Nursing confirmed the failure to adhere to the medication order during an interview.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an infection prevention and control program specifically related to Enhanced Barrier Precautions (EBP) for residents identified as at risk. Observations and interviews revealed that several residents with wounds or indwelling medical devices were not placed under EBP, which involves the use of gowns and gloves during high-contact care activities. Staff were unaware of the requirement for EBP and were not observed using personal protective equipment (PPE) during direct care of these residents. Upon further investigation, it was found that EBP signage was not present on the doors of the relevant resident rooms until after the survey team arrived. The Infection Preventionist confirmed that the necessary precautions, including signage, staff education, and placement of PPE, were only initiated after the surveyors' arrival. This indicates a lack of prior implementation of EBP for residents who required it, leading to a deficiency in the facility's infection prevention and control program.
Failure to Honor Resident Preferences in ADLs
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice in their daily routines, specifically in the timing of activities of daily living (ADLs) such as getting out of bed, eating meals, and using the bathroom. Resident #43 expressed a desire to be up and eating breakfast in the dining room earlier, but due to staff shortages, they were left waiting in bed until staff were available. This delay resulted in Resident #43 eating breakfast much later than desired, which was a frequent occurrence. Similarly, Resident #209 was unable to use the bathroom before breakfast as preferred, due to staff being too busy, leading to frustration and a delayed breakfast. Resident #15 also experienced issues with their daily routine, as they were moved out of their room and left waiting in the hallway while their roommate was cared for. This resident preferred to eat breakfast at 7:00 AM but was often left waiting until 10:00 or 11:00 AM. Despite complaints to staff and the Social Service Director, no resolution was provided, and the resident continued to experience delays in receiving care and meals. These incidents highlight the facility's failure to provide care based on resident preferences, as confirmed by interviews with staff and the Director of Nursing.
Failure to Update Care Plans Leads to Repeated Falls
Penalty
Summary
The facility failed to review and revise care plans related to falls for three residents, leading to multiple incidents of falls without updated interventions. Resident #36, diagnosed with Alzheimer's Disease and a history of falls, experienced multiple falls at the facility, including incidents on 2/17/24 and 3/8/24, resulting in a contusion and facial bruising. Despite these falls, the care plan for Resident #36 was not updated with new interventions to prevent future falls, as confirmed by the Director of Nursing and the Corporate Compliance Director. Similarly, Resident #37, with diagnoses including Alzheimer's Disease and fractures, suffered three falls within three weeks, yet no new interventions were added to the care plan after these incidents. Resident #47, with a history of falls and other medical conditions, had 22 documented falls, but the care plan was revised only four times. A Licensed Nursing Assistant expressed concerns about insufficient staffing to prevent falls for Resident #47, indicating a lack of adequate supervision and interventions. The facility's failure to update care plans as per their 'Falls Management' policy contributed to the repeated falls experienced by these residents.
Failure to Address Trauma Histories and Triggers
Penalty
Summary
The facility failed to identify and address the past history of trauma and potential triggers for two residents, leading to deficiencies in providing trauma-informed care. Resident #26, who has a history of PTSD and is on Olanzapine for this condition, did not have PTSD or trauma addressed in their care plan. Despite the resident experiencing flashbacks related to military service, the care plan lacked interventions to manage these episodes. The social service assessment used to screen for PTSD was inadequate, as it only asked about recent trauma consequences and did not explore past trauma experiences. The Social Service Director was unaware of Resident #26's PTSD history, relying solely on the limited screening tool. Similarly, Resident #11, who also has PTSD and a history of live combat, reported triggers such as sudden loud noises and loud male voices, which were not documented in their care plan. Although the care plan acknowledged the resident's PTSD, it failed to identify specific triggers. The social service assessment for Resident #11 also used the same two-question tool, which was insufficient for a comprehensive trauma history. The Director of Social Services confirmed the lack of additional screening tools, indicating a systemic issue in identifying and addressing trauma histories and triggers for residents.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several deficiencies. Resident #20, who is at risk for decreased ability to perform ADLs and falls, reported having to wait for assistance with toileting, leading to instances of incontinence. Similarly, Resident #36, also at risk for falls and skin breakdown, expressed frustration over long wait times for assistance, which sometimes resulted in soiling themselves. Resident #8, with a history of a leg fracture and altered mental status, experienced delays in response to call bells at night, leading to episodes of incontinence. These incidents highlight the facility's inability to provide timely assistance to residents, compromising their dignity and care. During dinner service, several residents, including Resident #51, had their blood sugar checks delayed due to insufficient staffing, as reported by an LPN who was unable to attend to all residents in a timely manner. Observations on B hall revealed that most residents were not dressed and had to wait for assistance with morning care and breakfast due to limited staff availability. Interviews with staff confirmed that the shortage of aides resulted in delays in providing necessary care, such as helping residents with toileting, dressing, and eating, as well as monitoring those at risk for falls. This staffing inadequacy directly impacted the quality of care and safety of the residents.
Failure to Assess Nursing Competencies
Penalty
Summary
The facility failed to ensure that the competencies of licensed nursing assistants (LNAs) and nurses were assessed in accordance with regulatory requirements. Specifically, 4 out of 5 sampled LNAs and 4 out of 5 nurses did not have documented evidence of competency evaluations for the skills necessary to meet resident care needs as outlined in their care plans. Among the LNAs, two files lacked any evidence of competency evaluation, one had no updates since 2022, and another only included hand hygiene and PPE competencies without any other resident care evaluations. Similarly, two nurse files had no competency evaluations since 2022, and one nurse had only been assessed for medication pass and IV therapy skills, with no other competencies evaluated since March 2022. Additionally, the designated wound care nurse had not undergone a competency evaluation since 2020. These deficiencies were confirmed during interviews with the Market Clinical Lead and the Market Operations Advisor, who acknowledged the lack of compliance with regulatory requirements for nursing competencies.
Inadequate Monitoring of Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure accurate monitoring of residents using psychotropic drugs, as evidenced by the lack of proper documentation and monitoring of behaviors and side effects for five residents. The facility's policy requires that all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. However, the facility did not adhere to this policy, as behavior monitoring was not accurately completed by the licensed nursing staff, and side effect monitoring was not consistently documented in the Medication Administration Records (MAR). Resident #26, diagnosed with mood disorder, major depressive disorder, and delusional disorder, was not accurately monitored for behaviors despite having daily episodes of anger, yelling, and aggression. The behavior flow sheets did not reflect the actual frequency of behaviors as reported by the Licensed Practical Nurse (LPN). Similarly, Resident #3, with anxiety and depression, had side effect monitoring added to their MAR only on the day of the survey, despite being on psychotropic medications since early April 2024. Other residents, including Resident #36, Resident #6, and Resident #47, also experienced deficiencies in monitoring. Resident #36, with major depressive disorder, had side effect monitoring added to their MAR only on the survey date, despite being on medication since December 2022. Resident #6, with delusions and agoraphobia, and Resident #47, with depression, had behavior monitoring sheets that did not accurately reflect their daily behaviors. The Market Clinical Lead confirmed that behavior monitoring was not being completed by licensed nursing staff, leading to inaccurate documentation of resident behaviors.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was reported to the State Licensing Agency as required. A Licensed Nursing Assistant reported that a few weeks prior, a resident with a BIMS score of 14 (indicating cognitive intactness) had informed them that a night aide had ripped off their necklaces and broken them. This incident was reported to the Director of Nursing (DON). However, a review of the investigation revealed no evidence that the allegation was reported to the State Licensing Agency. The DON admitted to being unaware of the requirement to report such allegations but has since been educated on the matter.
Failure to Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in providing effective and person-centered care. Resident #49 was admitted with existing skin breakdown requiring treatment on the sacrum and bilateral feet. However, the baseline care plan created on the day of admission did not reflect the actual skin breakdown or identify necessary interventions. It was only updated three days later to include the specific areas of skin breakdown and related conditions such as CKD, COPD, and T2DM. A Registered Nurse confirmed that the baseline care plan should have addressed the actual skin breakdown and provided appropriate interventions. Resident #3 was admitted with diagnoses including anxiety and depression, and was undergoing short-term rehabilitation for diabetes and dementia management. Despite these conditions, the facility did not develop a baseline care plan addressing mood and dementia within the first 48 hours of admission. It took 21 days for the care plans related to mood symptoms, cognitive loss, and dementia to be created. The Director of Nursing confirmed that these care plans should have been included in the baseline care plan upon admission.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide treatment and care to a resident with a non-pressure-related injury in accordance with professional standards of practice and the person-centered care plan. The resident, who was admitted with acute osteomyelitis of the left ankle and foot, an amputation of the left great toe, Type 2 Diabetes, and peripheral artery disease, had a care plan that required weekly wound assessments. However, the facility did not perform an initial wound assessment upon admission, nor did it conduct weekly assessments as required by the care plan. The wound care nurse admitted that surgical wounds were not assessed on admission and that the responsibility for documenting the wound condition was left to the nurse changing the dressings. The facility's policy required daily monitoring of wounds for complications or declines, but the wound care nurse did not assess the wound until a skin check revealed necrotic tissue. There was no documentation of the wound's condition from the time of admission until this assessment, and the care plan was not revised to reflect the findings of necrotic tissue. The Director of Nursing confirmed these failures, acknowledging that the facility did not adhere to its policy of performing initial and ongoing wound assessments and did not document the wound's status during dressing changes until the surgeon intervened to remove dead tissue.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, consistent with professional standards of practice and the comprehensive person-centered care plan. The resident was admitted for rehabilitation services following repeated falls at home and had a care plan indicating a risk for alterations in comfort due to advanced age and history of falls. The care plan included interventions to evaluate pain characteristics and monitor for pain, with a focus on attempting non-pharmacological interventions before administering PRN pain medications. However, the Medication Administration Record (MAR) for the resident showed that PRN pain medications were administered without documentation of non-pharmacological interventions being attempted first. Additionally, the MAR and pain assessments documented the resident's pain level as zero throughout their stay, with no indication of pain assessments being conducted prior to administering PRN medications. The Director of Nursing confirmed that there should have been an indication for the need based on a pain assessment and documentation of non-pharmacological interventions before administering PRN medications.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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