Bennington Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 2 Blackberry Lane, Bennington, Vermont 05201
- CMS Provider Number
- 475027
- Inspections on file
- 31
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bennington Health & Rehab during CMS and state inspections, most recent first.
The facility failed to ensure timely availability of ordered medications, leading to multiple residents missing critical drugs for extended periods. One resident went several days without prescribed venlafaxine XR and pregabalin, was later found on the floor with severe headache, markedly elevated BP, and seizure-like activity, and had a post-procedure prednisolone eye-drop order started late. Another resident’s Depakote for mood disorder was placed on hold when a switch to sprinkles was ordered, but the new formulation was not implemented for 20 days, during which no Depakote was given. A third resident’s pregabalin was repeatedly unavailable, and when painful urination developed, newly ordered Keflex and Pyridium were delayed while noted as awaiting pharmacy. The DON confirmed ongoing pharmacy-related delays and an audit showing missing medications for dozens of residents.
A resident with multiple psychiatric and neurologic conditions missed several days of Effexor XR and Lyrica due to pharmacy non-delivery, and also experienced delayed transcription and administration of prescribed Prednisolone eye drops after laser iridotomy; during this period the resident had an unwitnessed fall, severe headache, markedly elevated BP, and seizure-like activity requiring hospital evaluation and treatment. Another resident with bipolar disorder had Depakote held when a diet change required conversion to sprinkles, but the new formulation was not implemented for 19 days, resulting in no Depakote being given. A third resident with neuropathy missed multiple doses of Lyrica due to unavailability without documented provider notification or increased monitoring, and later had ordered Keflex and Pyridium for suspected UTI delayed in implementation, with Keflex started two days late and Pyridium still awaiting pharmacy. The DON confirmed ongoing issues with the contracted pharmacy and that these medication errors occurred.
A resident with a mood disorder was admitted on multiple psychotropic medications, and documentation showed that the representative was not informed of the benefits, risks, or alternatives to these drugs until weeks after admission. Later, an anti-anxiety medication (Buspirone) was started for the resident without any documented evidence that the responsible party was informed of its benefits, risks, or alternative treatments, or that consent was obtained prior to initiation. The responsible party reported only learning of the new medication after it had already been started and then requested that it be discontinued, and the DON confirmed there was no documentation of informed consent before Buspirone was begun.
Surveyors identified multiple failures in food storage, labeling, and date marking in the kitchen, including wet dishware set out as ready for use, open dry goods without dates, and refrigerated items such as lemonade, cranberry sauce, coleslaw, diced chicken, and egg substitute that were not labeled or dated. Expired tortillas and another expired food item were left in storage, and freezer items such as ravioli and hamburger patties were open to the air and undated. A resident reported receiving a hot dog bun with green-gray discoloration, and the Chef acknowledged ongoing challenges managing bread stock due to limited freezer space. The Dietary Manager confirmed these practices were inconsistent with the facility’s date-marking policy, which requires all stored foods to be covered or containerized, labeled, and dated.
A resident with ESRD, anemia in CKD, and dependence on hemodialysis had a central venous catheter and a care plan intervention requiring smooth catheter clamps to be maintained at the bedside and with the resident when out of bed in case of catheter breakage or excessive bleeding. During surveyor observations, no smooth clamps were found at the bedside, and although an emergency kit was present, it did not contain the clamps. The UM and DON confirmed that the emergency kit lacked the required clamps and that the kit was supposed to remain with the resident at all times, including during off-site dialysis treatments.
A resident with new-onset gross hematuria, a history of recent GI bleeds, and low Hgb levels was evaluated via telemedicine, and the practitioner ordered a CBC/BMP, conditional holding of Eliquis, and clinician notification for any change in condition. Review of the record showed the ordered CBC was not completed, no lab results were obtained, and the physician was not notified that the labs were not done. The DON confirmed that the ordered labs were never carried out and that the practitioner was not informed, resulting in a deficiency related to failure to provide or obtain ordered laboratory services and to notify the ordering practitioner.
Surveyors identified that the facility's food service department lacked sufficient staff with documented training and competency in essential dietary functions. Multiple grievances were filed regarding food quality and preparation, and record review showed that several dietary staff had no recent or relevant training or competency assessments. The Administrator was unaware of the training status, and the issue was confirmed through interviews and documentation review.
Surveyors identified multiple deficiencies in kitchen sanitation and food storage, including the presence of fruit flies, uncovered food and utensils, improper storage of raw chicken without dates, and refrigeration units operating above safe temperatures. The Dietary Manager and regional Dietary Manager confirmed these issues, and the facility Administrator acknowledged concerns about kitchen cleanliness.
A resident who was recently moved to a new room was found to be living in an environment that was not safe or homelike. The room contained an unmade bed with various items piled on it, including a wet floor sign and wheelchair parts, as well as four wheelchairs that did not belong to the resident. The space was cluttered with personal belongings, linens, and uncovered pillows, and the resident's items had not been unpacked.
A resident receiving lithium for schizoaffective disorder did not have required blood levels monitored as ordered, and staff failed to notify the physician or hold the medication despite multiple signs of toxicity. Documentation was inaccurate and untimely, with late entries added after the resident's transfer. The resident continued to receive lithium, developed severe toxicity, and died after transfer to the hospital.
A resident with a history of schizoaffective disorder and diabetes was admitted on lithium therapy, which requires close lab monitoring. Despite physician orders for lithium level checks, nursing staff failed to obtain the required labs and continued administering lithium without lab confirmation. The resident developed symptoms of lithium toxicity, including altered mental status and seizures, which were not consistently reported to the physician. The resident was eventually hospitalized with severe lithium toxicity and died. Facility leadership confirmed that critical lab monitoring was not completed, physician notification was lacking, and the medication was not held despite the absence of lab results.
A resident receiving lithium therapy did not have required blood levels obtained due to the facility's lack of a laboratory services policy and insufficient involvement of the Medical Director in policy development and implementation. The resident continued to receive lithium without appropriate monitoring, and the Medical Director was unaware of the absence of a relevant policy.
The facility did not ensure that LPNs were assessed for medication administration competency, as required by its own facility assessment. Review of staff files showed missing documentation for this skill, and the checklist used to evaluate nurse competencies did not cover medication administration except for injections and Narcan. The DON and Administrator confirmed that medication administration was not included in competency evaluations.
The facility failed to assess continence for three residents upon admission, leading to inadequate care. A resident was admitted with incontinence, but no urinary or bowel continence assessment was documented. Staff were misinformed about the resident's continence status, resulting in significant gaps in toileting assistance. The facility's policy requires a continence evaluation and management diary, but these were not completed for the affected residents.
A facility failed to notify a resident's representative of a worsening wound, abnormal lab results, and a hospital transfer. The resident's pressure ulcer progressed from stage 2 to stage 3, and despite a care plan directive, there was no documentation of notification. The resident was also lethargic, leading to blood work that revealed elevated sodium levels, but the representative was not informed of these results or the hospital transfer.
The facility failed to monitor and verify significant weight changes for multiple residents, as required by its policy. Several residents experienced notable weight fluctuations without documented reweighs or appropriate notifications to healthcare providers. Interviews confirmed that the facility's procedures were not consistently followed, leading to unverified weight changes and potential oversight of residents' clinical conditions.
A facility failed to consistently document pain management for a resident with chronic pain and opioid dependence. Despite receiving routine opioid medication, the resident's pain levels and medication effectiveness were not regularly monitored or documented, contrary to the care plan and facility policy. The DON confirmed the lack of regular pain monitoring.
The facility failed to provide adequate training for staff to meet the behavioral health needs of residents with OUD, SUD, and PTSD. Training files revealed that two LNAs lacked training in OUD and SUD, and one LNA had no training in PTSD and trauma-informed care. Additionally, an RN had no evidence of training in these areas. A recently hired RN confirmed the absence of resident-specific training and was unaware of residents with these diagnoses, leading to unmet behavioral health needs for a resident.
A resident's dignity and rights were compromised when a letter containing personal information was posted at the nurse's station, visible to others. The resident felt humiliated and targeted. Additionally, staff actions led to escalated emotions and behaviors, resulting in police involvement when the resident was denied outdoor access and scheduled pain medication.
A resident with type 2 diabetes did not receive necessary foot care, as required by their care plan, leading to a severe toe infection and partial amputation. Despite reporting severe toe pain, the resident's condition was not properly assessed, and daily diabetic foot checks were not documented. The issue was discovered by a family member, resulting in the resident's hospitalization and diagnosis of osteomyelitis.
Widespread Delays and Omissions in Providing Ordered Medications
Penalty
Summary
The facility failed to ensure timely acquisition and availability of ordered medications, resulting in omitted or delayed physician-ordered drugs for multiple residents. One resident had an order for venlafaxine XR 300 mg daily for depression and did not receive the medication for four days because it was not available, as documented on the MARs and in progress notes. The same resident also had an order for pregabalin 25 mg daily for pain that was not available and not administered for eight days. During this period, a progress note described staff finding the resident on the floor, crying with a pounding headache and left hand pain, with a blood pressure of 206/104, pulse 98, oxygen saturation 97%, and seizure activity observed twice, leading to transfer to the ED. Hospital records showed suspicion for organic seizure, elevated troponin and lactic acid, and a discharge plan that referenced possible missed medications at the facility. The resident later returned from an outpatient laser iridotomy with an order for prednisolone 1% eye drops daily for seven days, but the order was not implemented until two days after the prescribed start date, and there was an additional documented day when venlafaxine was again unavailable. Another resident had a long-standing order for Depakote DR totaling 1500 mg daily for mood disorder. When the resident’s diet was changed to pureed and they were unable to swallow the Depakote tablets due to size and coating, an on-call provider ordered a change to Depakote sprinkles with dosing to be determined by pharmacy. The original Depakote order was placed on hold pending the new formulation, and the MAR showed that the Depakote sprinkles order was not implemented for 20 days. During this time, the resident did not receive any Depakote, as confirmed by the DON, because the new formulation and dosing were not obtained and started in a timely manner. A third resident had a physician’s order for pregabalin 50 mg three times daily, with progress notes indicating that the medication was not available over several days. This resident later developed painful urination, and the provider ordered diagnostic tests, IV fluids, and new medications including Keflex 500 mg twice daily for five days and Pyridium 100 mg twice daily for three days. Review of the MAR showed that the Keflex order was not implemented until two days after it was written, and Pyridium remained documented as awaiting pharmacy on that same date. In an interview, the DON confirmed that some medications had not been available for administration as ordered, reported ongoing issues with the pharmacy not delivering medications on time, and identified that an internal audit found 35 of 81 residents with missing medications.
Significant Medication Omissions Due to Pharmacy Delays and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including frequent omissions related to medication unavailability and transcription issues. One resident with multiple psychiatric and neurologic diagnoses, including panic disorder, anxiety disorder, dissociative identity disorder, major depressive disorder, tremor, and hypertension, had a physician’s order for Effexor XR 300 mg daily for depression. Review of progress notes and MARs showed this resident did not receive Effexor for several days spanning late December and early January. The same resident also had an order for Pregabalin (Lyrica) 25 mg daily for pain, which was not available and not administered for multiple days. During this period of missed doses, the resident was found on the floor crying, reporting a pounding headache and left hand pain, with a blood pressure of 206/104, pulse 98, and oxygen saturation of 97%, and was noted to have seizure activity twice before being sent to the emergency department. At the hospital, the resident was admitted for observation with seizure-like activity and elevated troponin and lactic acid levels, and was started on Keppra to prevent further seizure activity. The discharge summary documented suspicion for organic seizure and noted that the patient would be going back on all standard medications, with mention that there was some question about missed medications at the facility based on information from a friend. The resident later returned to the facility with no new orders, and a subsequent communication note documented that Effexor and Lyrica still had not arrived from the pharmacy despite multiple contacts. Additionally, after the resident underwent bilateral laser iridotomy, the surgeon ordered Prednisolone 1% eye drops once daily in each eye for seven days starting the day after the procedure. The January MAR showed that this order was not transcribed until two days after the intended start date and not implemented until the following day, and an SBAR later documented the resident’s complaint of right eye pain and throbbing. Another resident with anxiety disorder and bipolar disorder had a long-standing order for Depakote DR totaling 1500 mg daily for mood disorder. When this resident’s diet was changed to pureed and staff reported the resident could not swallow the Depakote tablets, an on-call provider ordered a change to Depakote sprinkles with dosing to be determined by pharmacy. The original Depakote order was placed on hold the same day, but the Depakote sprinkles were not implemented for 19 days, resulting in the resident receiving no Depakote during that period. A third resident had an order for Pregabalin (Lyrica) 50 mg three times daily for neuropathy, but progress notes documented that the medication was not available for several days, with no documentation that the physician was notified of the missed doses or that monitoring for adverse reactions to abrupt cessation occurred. This same resident later had an SBAR for painful urination, with provider orders for Keflex and Pyridium for suspected UTI; however, the MAR showed that Keflex was not implemented until two days after the order and Pyridium remained awaiting pharmacy on that date. The DON confirmed ongoing issues with the contracted pharmacy not providing prescribed medications and confirmed that these medication errors occurred. Overall, across these three residents, the survey findings show repeated failures to administer ordered medications as prescribed due to unavailability and delays in transcription and implementation of new orders. These failures included omissions of psychotropic, anticonvulsant, neuropathic pain, ophthalmic, and antibiotic medications over multiple days. Documentation gaps included lack of timely transcription of orders, lack of timely implementation of ordered therapies, and lack of evidence that providers were notified or that residents were monitored for adverse reactions when medications such as Lyrica were abruptly not given. The DON acknowledged the medication omissions and the facility’s ongoing problems with the contracted pharmacy, which contributed to the significant medication errors identified by surveyors.
Failure to Obtain Informed Consent Before Initiating Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a resident’s representative was fully informed and provided informed consent prior to the initiation of an anti-anxiety medication. Resident #2 was admitted on 5/27/2025 with physician orders for Depakote (anticonvulsant), Vistaril (antihistamine), and Zoloft (antidepressant) for a mood disorder, and there was no documented evidence that the resident’s representative was informed of the benefits, risks, or alternatives to these medications until a consent form was completed by the Unit Manager on 6/20/2025, indicating verbal consent from the responsible party. On 7/17/2025, a physician ordered Buspirone 10 mg by mouth twice daily for anxiety, and record review showed no documentation that the responsible party was informed of the benefits, risks, alternative treatments, or the initiation of this medication. A progress note dated 7/25/2025 documented that Buspirone was discontinued per provider and guardian request and that the responsible party was aware at that time, but in an interview the responsible party stated they had not been made aware when Buspirone was started and requested its discontinuation once informed. In a separate interview, the Director of Nursing confirmed there was no evidence that informed consent had been obtained from the resident’s representative prior to starting Buspirone.
Improper Food Storage, Labeling, and Date Marking in Dietary Services
Penalty
Summary
The deficiency involves failure to store, label, and handle food in accordance with professional standards and the facility’s own date-marking policy. During an initial kitchen tour, surveyors observed dishware, including cups flipped upside down, that were still wet but had been deemed ready for use by the Dietary Manager, who acknowledged they had not been dried correctly and should have remained on a drying rack to air dry. In the dry storage area, an open brownie mix and a package of elbow pasta were found without any dating, and the Dietary Manager confirmed these items should have been labeled with the dates they were opened. In the refrigerators, multiple food items, including a pitcher of lemonade, cranberry sauce, coleslaw, and diced chicken, were not labeled with product names or dates of production or expiration, despite posted signage indicating the requirement to label and date items. Additionally, eleven packages of flour tortillas and a container of an item identified as [NAME] were found past their expiration dates, and the Dietary Manager confirmed expired items should have been removed and discarded. Further observations on a subsequent kitchen tour with the Chef revealed an open, undated egg substitute carton in the refrigerator, which he confirmed should have been dated when opened. The Chef also acknowledged awareness of a resident’s complaint about a hot dog bun with green-gray discoloration, consistent with mold, and stated that the kitchen had been contacted during service and the meal was remade, noting ongoing difficulty balancing bread stock due to limited freezer space. In the freezer, an open, undated ravioli package and a box of hamburger patties left open to the air and undated were identified, and the Dietary Manager confirmed these items should have been dated and stored in closed containers per facility policy. Review of the facility’s “Date Marking” policy showed that foods are required to be date marked with the product name and date of production or opening, with discard dates determined by a reference list, and the Dietary Manager confirmed that practice and policy require all stored items to be covered or containerized, labeled, and dated.
Failure to Maintain Required Emergency Dialysis Catheter Clamps at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related care consistent with professional standards and the resident’s care plan for a resident with end stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis. The resident had a central venous catheter in place and a care plan focus identifying risk for worsening impaired renal function and complications related to hemodialysis, initiated on 10/7/25. The care plan included an intervention, also initiated on 10/7/25, to maintain smooth catheter clamps at the bedside and on the resident when out of bed in case of catheter breakage or excessive bleeding. During an observation on 12/8/25 at 1:00 PM, surveyors noted that no smooth clamps were located at the bedside in the resident’s room. In a subsequent interview on 12/9/25 at 2:30 PM, the Unit Manager stated the resident should have an emergency kit at the bedside that includes smooth clamps and directed a nurse to check the kit; the nurse reported that while the kit was present, it did not contain the clamps. A further observation on 12/9/25 at 3:16 PM with the DON and Unit Manager confirmed that the emergency kit in the resident’s room did not include the required smooth clamps, and the DON acknowledged that the clamps needed to be added and that the emergency kit should be with the resident at all times, including when off-site for dialysis.
Failure to Complete Ordered Labs and Notify Physician for Resident With Gross Hematuria
Penalty
Summary
Facility staff failed to obtain ordered laboratory tests and notify the physician of missing results for a resident with new-onset gross hematuria. A telemedicine eye health note documented that the resident, who was on Eliquis and had a history of two recent hospitalizations for gastrointestinal bleeding, was evaluated for visible blood in the urine. The note referenced recent hemoglobin levels of 8.2 and 10.9, and the assessment/plan identified gross hematuria as an acute, worsening problem. The practitioner ordered that the A.M. Eliquis be held if hematuria recurred overnight, a CBC and BMP be checked in the morning, and that a clinician be notified of any change in condition. Review of the resident’s medical record showed no documentation that the CBC ordered on that date was ever completed, that results were obtained, or that the physician was notified about the lack of completed labs. The DON confirmed in an interview that the ordered labs for this resident were never completed and that the physician was not notified. This failure to carry out the physician’s lab order and to communicate about the uncompleted labs constituted the deficiency identified by surveyors.
Insufficient Dietary Staff Training and Competency Documentation
Penalty
Summary
The facility failed to ensure that the contracted food service department employed sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. During a kitchen observation, multiple concerns were noted regarding cleanliness, food storage, safety, and sanitization. A review of the facility's grievance log from April to July revealed five grievances related to food quality, temperature, and the preparation of various meats, including issues with undercooked and overcooked foods. Interviews with the Regional Dietary Manager (RDM) and review of training records showed a lack of documented training and competency assessments for both cooks and dietary aides. Several staff members had no evidence of recent or relevant training, and there was no documentation that any dietary staff had been assessed for competency in key areas such as food storage, preparation, cooking, and serving. The facility Administrator confirmed that the consulting food service agency was responsible for staff training and competency but was unaware of the current status, and acknowledged that the concerns had been reported through the grievance process.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and kitchen sanitation practices. Upon entering the main kitchen, fruit flies were seen flying around the food preparation and cooking areas, and the Dietary Manager (DM) confirmed their presence for about a week. The DM reported attempts to address the issue by flushing drains with bleach and cleaning the kitchen daily. In the dish room, additional fruit flies were present, and fly tape with dead flies was hanging from the ceiling, being blown by a fan. Inspectors also found a large bin of flour uncovered, two bins of kitchen utensils left uncovered, dead fruit flies on a rack under the juice dispenser, live fruit flies in the dry storage area, and open boxes of potatoes and watermelons. The large mixer was left uncovered with dried debris in the bowl. Further inspection of the walk-in refrigerator revealed an open bag of cheddar cheese and a cardboard box containing two bags of raw chicken with a significant build-up of liquid from thawing. There were no dates on the chicken bags or box to indicate when they were thawed or their expiration. A two-door refrigerator containing desserts, juices, and condiments was found to have external moisture, and both thermometers read above safe temperatures (46°F and 48°F). The DM attributed the high temperatures to frequent door openings. The regional Dietary Manager (RDM) later confirmed the presence of fruit flies, uncovered utensil bins, and the improper storage of raw chicken. The facility Administrator acknowledged concerns regarding kitchen cleanliness.
Resident Room Lacked Safe and Homelike Environment After Transfer
Penalty
Summary
A deficiency was identified when a resident who had recently been transferred to a new room was not provided with a safe, clean, and homelike environment. Upon observation, the resident's room contained two beds, one of which was unmade with a bare mattress and piled with a wet floor sign, wheelchair leg rests, a cushion, a bare pillow, several papers, and an unattached foot board. Four wheelchairs, which did not belong to the resident, were also present in the room. Additionally, the room was cluttered with a dresser, a desk with a laundry basket of personal items, shopping bags, a chair with a large plastic bag of linens, and three uncovered pillows. The facility Administrator confirmed that the room was not homelike, the resident's belongings had not been unpacked, and the extra equipment and items should not have been present.
Failure to Monitor and Respond to Lithium Toxicity Leading to Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services provided met professional standards of quality for a resident receiving lithium carbonate for schizoaffective disorder. Upon admission, the resident was alert and oriented, with a history of regular monthly blood work to monitor lithium levels during a prior hospital stay. The physician at the facility ordered a baseline lithium level, but the required blood draw was not completed as ordered. Nursing staff documented the blood draw as completed, but there was no evidence that it was actually performed, and no lab results were available. Attempts to obtain the blood sample were not documented in a timely manner, and late entries were added to the medical record over a month later, after the resident had been transferred out of the facility. There was also no documentation that the physician was notified of the failed blood draws or that any action was taken to address the lack of lab results. Despite the absence of required lithium level monitoring, the resident continued to receive daily doses of lithium. Over time, the resident exhibited multiple signs and symptoms consistent with lithium toxicity, including altered mental status, agitation, hallucinations, delusions, low blood pressure, nystagmus, and eventually unresponsiveness and seizure activity. These symptoms were documented in the medical record, but there was no evidence that the physician was notified of these significant changes in condition or that the medication was held in response to the observed symptoms. The facility had the option to send the resident to a hospital for the blood draw but did not do so after multiple failed attempts. Ultimately, the resident was transferred to the hospital in a severely compromised state, where laboratory testing revealed a critically high lithium level and acute renal failure. The resident was diagnosed with severe lithium toxicity, experienced multiple seizures, and suffered irreversible brain injury, leading to death. The facility's Director of Nursing Services confirmed failures in following physician orders, monitoring for toxicity, timely and accurate documentation, and appropriate communication with the physician regarding the resident's condition and lab work.
Failure to Monitor and Respond to Lithium Toxicity Leading to Resident Death
Penalty
Summary
A resident with a history of schizoaffective disorder and diabetes was admitted to the facility on lithium therapy, a medication with a narrow therapeutic range requiring regular blood level monitoring. Prior to admission, the resident had been receiving monthly lithium level checks during a prolonged hospital stay, with levels remaining mostly within the therapeutic range. Upon admission to the facility, a physician ordered a baseline lithium level, and nursing staff documented that the blood draw was completed; however, there was no evidence that the lab was actually obtained, and a late entry note was added to the record over a month later indicating unsuccessful attempts to draw blood. Despite the absence of lithium level results, the resident continued to receive daily doses of lithium. Over the following weeks, the resident exhibited multiple signs and symptoms consistent with lithium toxicity, including altered mental status, agitation, hallucinations, delusions, and eventually unresponsiveness and seizure activity. Nursing documentation showed that these changes in condition were not consistently reported to the physician, and there was no documentation of holding the lithium or seeking urgent evaluation as recommended in the presence of such symptoms. Multiple attempts to obtain a lithium level were unsuccessful, and the facility did not send the resident to an outside facility for the required blood draw, despite this being an available option. The resident continued to receive lithium without laboratory confirmation of safe levels, even after telemedicine consultation recommended obtaining a lithium level prior to further recommendations. Ultimately, the resident's condition deteriorated to the point of requiring emergency transfer to the hospital, where severe lithium toxicity, acute renal failure, and toxic encephalopathy were diagnosed. The resident's lithium level was found to be critically elevated, and the resident expired after a period of unresponsiveness and seizure activity. Interviews with facility leadership confirmed that critical lab monitoring was not completed as ordered, that there was a lack of timely physician notification regarding changes in the resident's condition, and that the facility failed to hold the medication or seek alternative means of obtaining necessary laboratory data.
Failure to Implement and Coordinate Laboratory Services Policy
Penalty
Summary
The facility failed to ensure that the Medical Director assisted with the development and implementation of resident care policies, specifically regarding laboratory services. A resident with a diagnosis of schizoaffective disorder was admitted with physician orders for lithium, including an order to obtain a lithium blood level. Despite this order, there was no evidence in the resident's medical record that the lithium level was obtained prior to the resident's transfer to the hospital for altered mental status. Additionally, there was no documentation that the physician was notified of the inability to complete the blood draw until after the resident had already been transferred. The resident continued to receive lithium daily during this period. Interviews and record reviews revealed that the facility did not have a policy or written process in place for laboratory services at the time of the incident, and the Medical Director was unaware of the absence of such a policy. The facility's Lab Draw Collection Policy was implemented only after the incident occurred. Documentation showed that the Medical Director had not reviewed nursing policies and procedures for an extended period prior to the event. The lack of a laboratory services policy and the Medical Director's lack of involvement in policy development contributed to the failure to obtain necessary laboratory monitoring for the resident.
Lack of Medication Administration Competency Assessment for Licensed Nurses
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies to meet residents' needs as identified through assessments and care plans. A review of five licensed nurses' education files revealed that three LPNs did not have documented assessments for medication administration competency. The facility's own assessment identified medication administration as a required competency for licensed nursing staff. However, the Nurse Skills Day Checklist used to evaluate nurse competencies did not include medication administration skills, except for injections and Narcan administration. The DON was unable to provide evidence of medication administration competency checks for licensed nurses, and the Administrator confirmed that such competencies were not included in the evaluation process.
Failure to Assess Continence on Admission
Penalty
Summary
The facility failed to assess residents for urinary and bowel incontinence upon admission, which led to inadequate care for three residents. Resident #105 was admitted in October 2024, and although the care plan indicated incontinence, there was no documented evidence of a urinary or bowel continence assessment. The Licensed Nursing Assistant (LNA) reported that staff were initially informed that Resident #105 was continent, but this was not the case. The LNA also mentioned that there was no specific schedule for checking the resident's brief, leading to significant gaps in toileting assistance, as evidenced by the documentation showing long intervals between toileting. The facility's Continence Management policy requires a urinary incontinence evaluation and a Three Day Continence Management Diary for residents who are incontinent upon admission. However, the Unit Manager confirmed that the urinary continence evaluations for Residents #105, #31, and #48 were not completed, indicating non-compliance with the facility's policy. This lack of assessment and adherence to policy resulted in the failure to provide appropriate treatment and services to restore continence to the extent possible for the affected residents.
Failure to Notify Resident's Representative of Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, including a worsening wound, abnormal laboratory results, and a transfer to the hospital. The resident, admitted with a stage 2 pressure ulcer and venous stasis ulcers, experienced a deterioration of the wound to a stage 3 pressure ulcer. Despite the care plan's directive to inform the resident or their healthcare decision-maker of any change in status, there was no documented evidence that the representative was notified of the wound's progression. Additionally, the resident was noted to be lethargic, prompting a physician to order blood work. Although the representative was informed of the resident's condition and the blood work order, they were not notified of the elevated sodium level found in the results or the subsequent transfer to the hospital for treatment. The Assistant Director of Nursing confirmed the lack of documentation regarding these notifications.
Failure to Monitor and Verify Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and verify significant weight changes for five out of six residents sampled. Resident #2 experienced a 12.60% weight loss over one month and a 10.82% loss over six months, with no evidence of reweighing after significant fluctuations. Similarly, Resident #3 had a 6.72% weight loss over one month and a 10.39% loss over six months, with no documented reweighs. Resident #4, who was at risk for unplanned weight changes, had significant daily weight fluctuations without reweighs on several occasions. Resident #5 showed a significant weight gain of 5.52% over one month, and Resident #6 had a gradual weight loss of 11 lbs over several months, followed by an 8.4 lb loss in one month, with no reweighs documented for either resident. The facility's policy requires reweighing residents if their weight is not as expected and mandates that significant weight changes be reviewed by a licensed nurse, with notifications to the physician and dietitian. However, interviews with the dietitian and the Director of Nursing confirmed that these procedures were not consistently followed. The lack of reweighing and documentation indicates a failure to adhere to the facility's policy, resulting in unverified weight changes and potential oversight of residents' clinical conditions.
Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to ensure consistent pain management for a resident with chronic pain syndrome, opioid dependence, opioid use disorder, and arthritis. The resident had been receiving opioid medications for pain control since admission, with specific physician's orders for Buprenorphine HCl Sublingual tablets. Despite the routine administration of pain medication, the facility did not consistently document the monitoring of the resident's pain levels or evaluate the effectiveness of the medication. The care plan for the resident included interventions such as attempting non-pharmacologic interventions, administering pain medication as ordered, and documenting the effectiveness and side effects, but these were not consistently followed. The facility's policy on pain management required daily evaluation of pain presence and monitoring for effectiveness and side effects of pain interventions. However, a review of the resident's documented pain level summary for April, May, and June 2024 showed that pain ratings were documented only a few times each month. The Director of Nursing confirmed that there was no regular pain monitoring or evaluation for effectiveness performed for the resident, indicating a failure to adhere to the facility's pain management policy and the resident's care plan.
Inadequate Staff Training for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff members were adequately trained and possessed the necessary competencies to care for residents with behavioral health needs, specifically those with diagnoses of opioid use disorder (OUD), substance use disorder (SUD), and post-traumatic stress disorder (PTSD). This deficiency was identified through the review of training files for three Licensed Nursing Assistants (LNAs) and three Staff Nurses. It was found that two of the three LNAs had not received any training related to OUD or SUD, and one LNA had no evidence of training related to PTSD and trauma-informed care. Additionally, one Registered Nurse (RN) had no evidence of training in these areas. During an interview, a recently hired RN confirmed that they had not received any resident-specific training regarding SUD, OUD, PTSD, and trauma-informed care, and were unaware of any residents with these diagnoses in their assignment. This lack of training and awareness contributed to the facility's failure to meet the behavioral health needs of a resident with these diagnoses.
Failure to Respect Resident's Dignity and Rights
Penalty
Summary
The facility failed to maintain a resident's right to dignity and respect, as evidenced by the posting of a letter at the nurse's station that contained personal and sensitive information about a resident. The letter specified which Licensed Nursing Assistants (LNAs) should not provide care to the resident and included details about the resident's personal care needs and behaviors. This letter was visible to anyone at the nurse's station, including other residents and visitors, which led to the resident feeling humiliated and targeted. The resident expressed feeling that their rights as a person were lost, and they were visibly upset about the situation. Additionally, the facility's staff actions on two occasions led to the escalation of the resident's emotions and behaviors. On one occasion, the resident was prevented from going outside alone, which resulted in the police being called after the resident became verbally aggressive. On another occasion, the resident was denied their scheduled pain medication due to a timing issue, leading to further escalation and another police call. These incidents highlight the facility's failure to appropriately manage the resident's care and rights, contributing to the resident's distress and feelings of being targeted.
Failure to Provide Diabetic Foot Care Leads to Amputation
Penalty
Summary
The facility failed to provide necessary foot care for a resident with type 2 diabetes, leading to a serious health issue. Upon admission, the resident had no wounds, but the care plan identified them as at risk for skin breakdown and required daily diabetic foot checks. However, there was no documented evidence that these checks were performed. On a later date, the resident reported severe pain in their left great toe, but the nurse only administered Tylenol without further assessing the cause of the pain. This lack of assessment and documentation contributed to the development of a toe wound and subsequent infection. The situation escalated when a family member discovered a black wound on the resident's toe, prompting a demand for hospital transfer. The hospital diagnosed the resident with cellulitis and osteomyelitis, leading to a partial toe amputation. Interviews with the Director of Nursing confirmed the absence of documentation for both the pain assessment and the diabetic foot checks. The American Diabetes Association recommends daily foot examinations for diabetics, which were not adhered to in this case, resulting in severe consequences for the resident.
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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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