Birchwood Terrace Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Vermont.
- Location
- 43 Starr Farm Rd, Burlington, Vermont 05408
- CMS Provider Number
- 475003
- Inspections on file
- 16
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Birchwood Terrace Rehab & Healthcare during CMS and state inspections, most recent first.
Surveyors found that frozen vegetables were stored uncovered and without expiration dates in the facility's freezer. Both the Assistant Dietary Manager and the Dietary Manager confirmed that food items should be covered, labeled, and dated according to facility policy.
Eight residents requiring feeding assistance were not provided with individualized attention during meals, as each staff member was responsible for feeding two residents at the same time. Staff also referred to these residents as 'feeders,' a term the Administrator confirmed was inappropriate and not respectful of resident dignity.
A resident with Alzheimer's and bipolar disorder was involved in a physical altercation with another resident, resulting in a small skin tear. Despite some improvement with medication, the resident continued to exhibit aggressive behaviors. The facility's investigation confirmed the abuse, highlighting a deficiency in protecting residents from such incidents.
The facility failed to implement effective infection control measures during a COVID-19 outbreak, resulting in 42 residents testing positive. Testing was limited, and staff did not consistently wear PPE. A COVID-19 positive resident was not isolated properly, and the facility did not follow CDC guidelines for ending transmission-based precautions. Inadequate staffing and cross-contamination further contributed to the outbreak.
The facility failed to maintain safe water temperatures below 120°F in resident bathrooms, with several instances of temperatures ranging from 121.2°F to 127.3°F. This poses a risk of burns, especially to residents with cognitive impairments. The Environmental Services Director checks temperatures weekly, but the survey found multiple instances of elevated temperatures, indicating a failure to adhere to the facility's policy.
The facility failed to provide a dignified dining experience and adequate care for residents, as evidenced by delayed meal service, lack of assistance with soiled clothing, and inadequate supervision during meals. Residents were observed with soiled clothing, food on their faces, and without timely assistance for activities of daily living (ADLs), compromising their dignity and quality of life.
The facility failed to provide detailed care plans for residents with ADL self-care performance deficits, affecting their ability to achieve or maintain their highest practicable well-being. Observations showed residents were not given necessary assistance, and interviews confirmed care plans lacked specific interventions for feeding, transferring, ambulation, and hygiene care.
The facility failed to provide adequate assistance to residents with ADL needs, leaving them unattended during meals and neglecting personal hygiene. Residents with swallowing difficulties were left alone with food, and several had long, dirty fingernails. Additionally, residents lacked access to call bells or timely assistance, resulting in prolonged periods without necessary care.
The facility failed to provide engaging activities for residents, including a resident who expressed interest in music and audio books but was not supported. Multiple residents on Unit B wanted to spend time outdoors, but their preferences were not accommodated due to limited staffing and lack of specific interventions in care plans. Additionally, there were no scheduled activities on weekends, and the facility was short-staffed, impacting the activities program.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident lacked an assessment for triggers and a care plan to prevent re-traumatization, while another resident was observed in distress without a care plan addressing their PTSD history. Staff interviews revealed a lack of awareness and incomplete psychosocial assessments.
The facility failed to provide adequate nursing staff, resulting in delayed care and assistance for residents. A resident experienced a 32-minute delay in receiving pain medication, while others faced late medication administration due to insufficient staffing. Several residents lacked access to call bells, leading to prolonged waits for assistance. Additionally, residents requiring help with eating were left unattended for significant periods, highlighting systemic staffing issues.
The facility experienced a high medication error rate of 72% due to delayed administration of medications for several residents. Medications for two residents were administered over an hour late due to the large unit size and high volume of medications. Additionally, two other residents received their medications late because the LPN was interrupted by staffing shortages and the need to assist aides.
A resident in an LTC facility experienced an unwitnessed fall and refused assessment and care for apparent injuries. Despite a request from the resident's POA to send them to the ER, the staff did not act due to the resident's initial refusal. The following morning, the resident was found in a compromised state and was emergently transferred to the hospital with altered mental status and other medical issues. The facility failed to notify the DON or on-call provider about the resident's condition, not adhering to policy and advance directives.
The facility failed to remove expired medications and biologicals from use. In the A-Wing medication storage room, expired glucose control solution and BinaxNow COVID tests were found. In the B-Wing, a Diabetic Hypoglycemic Emergency Kit contained expired Glucagon. A RN confirmed the expired items and stated that checking for expired medications is a shared responsibility among nurses.
A resident with cognitive intactness was not notified in writing of their involuntary discharge or their right to appeal, despite being their own guardian. The facility only informed the resident's family member, leading to the resident's confusion and continued hospital stay while awaiting long-term placement.
Failure to Properly Store Frozen Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. During an initial kitchen tour, three uncovered boxes containing frozen vegetables were found open to air in the freezer room, and none of the items had expiration dates. The Assistant Dietary Manager confirmed that items should be covered in the storage area. A review of the facility's Food Safety Requirements policy, revised in February 2024, indicated that food should be kept covered or in tight containers. The Dietary Manager also confirmed in an interview that items in storage should be covered or in a container, labeled, and dated.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to provide dignity and respect to residents requiring feeding assistance, as observed during a meal service where four staff members were feeding eight residents, with each staff member feeding two residents simultaneously. During interviews, a Licensed Nursing Assistant (LNA) acknowledged that due to insufficient staffing, it was common practice for one staff member to feed more than one resident at a time. The LNA also referred to residents needing assistance as 'feeders,' a term confirmed by the Administrator as inappropriate and not in line with respecting residents' dignity. All eight sampled residents requiring feeding assistance were affected by this practice.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse during a resident-to-resident altercation. Resident #1, who was admitted to the Memory Care Unit with Alzheimer's disease and dementia with behavioral disturbances, threw a clipboard at Resident #2, hitting them in the elbow and causing a small skin tear. Resident #2, who was admitted for nursing and rehabilitative services with Alzheimer's disease and bipolar disorder, retaliated by throwing the clipboard back. The incident was observed by staff, and the facility's investigation confirmed the occurrence of physical abuse between the two residents. Resident #2 had a history of verbal and physical aggression towards other residents, including Resident #1, which was documented in a physician's note. Despite some improvement with an increased dosage of an SSRI, Resident #2 continued to exhibit behaviors that posed a safety risk to themselves and others. The facility's policy on abuse, neglect, and exploitation, which was last revised in January 2024, defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish, including certain resident-to-resident altercations. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from abuse.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in accordance with CDC and state health department guidelines during a COVID-19 outbreak. The outbreak began on 7/13/2024, and by the time of the survey, 42 residents had tested positive. The facility did not conduct broad-based testing of all residents and staff, as recommended, to identify and contain the spread of the virus. Instead, testing was limited to symptomatic individuals and those with known close contact, which was insufficient to control the outbreak. The Infection Control Nurse admitted there was no process in place to monitor close contacts or symptoms effectively. Staff on Units B and C were observed not consistently wearing facemasks, and there was a lack of adherence to PPE protocols, particularly in the Special Care Unit (SCU) for dementia patients. Resident #9, who was symptomatic and COVID-19 positive, was not isolated properly, and staff did not use appropriate PPE when interacting with the resident. The resident was observed in communal areas without a mask, potentially exposing other residents. The facility's policy required the use of N95 masks and other PPE for confirmed COVID-19 cases, but this was not followed. The facility's approach to ending transmission-based precautions was also inadequate. The Medical Director confirmed that the facility ended precautions after one negative test, contrary to CDC guidelines that require two consecutive negative tests. Additionally, there was no dedicated staffing for affected units, leading to potential cross-contamination. The facility's failure to follow recommended testing and isolation protocols, along with inconsistent use of PPE, contributed to the uncontrolled spread of COVID-19 among residents and staff.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident environments were free of accident hazards by not maintaining safe water temperatures below 120 degrees Fahrenheit. During an observation on the Special Care Unit, which houses residents with dementia or cognitive impairments, water temperatures in several resident bathroom sinks were found to exceed the facility's policy limit of 120 degrees Fahrenheit. Temperatures ranged from 121.2 to 127.3 degrees Fahrenheit, posing a risk of burns to residents, particularly those with cognitive impairments who may not recognize the danger of scalding water. The Environmental Services Director (ESD) stated that water temperatures are checked weekly in random resident bathrooms, and adjustments are made if temperatures are high. However, during the survey, multiple instances of elevated water temperatures were recorded, indicating a failure in maintaining consistent safe water temperatures. The facility's policy on safe water temperatures was not adhered to, as evidenced by the repeated findings of water temperatures exceeding the maximum allowable limit, which could potentially lead to accidents or injuries among the residents.
Failure to Provide Dignified Dining Experience and Adequate Care
Penalty
Summary
The facility failed to provide a respectful and dignified dining experience for residents, as evidenced by several observations of neglect and inadequate care. Residents were not served meals at the same time, leading to some residents observing others eat without having their own meals. Additionally, there were instances where residents were left soiled and unattended for extended periods. For example, one resident was observed with visibly soiled pants and was not assisted until much later, despite expressing discomfort and needing help. Another resident was found with coffee spilled on the floor and wet socks, yet remained in the same position for a significant time without assistance. Further observations revealed that residents were not adequately supervised or engaged during meal times, with some residents left with food on their faces and clothes from previous meals. There were also instances where residents were not assisted with their activities of daily living (ADLs), such as a resident with bowel movement on their hands and another with food caked in their teeth and a white film at the gum line. The lack of timely assistance and supervision during meals and ADLs compromised the residents' dignity and quality of life.
Inadequate Resident Care Plans for ADL Support
Penalty
Summary
The facility failed to ensure that resident care plans were adequately detailed to describe the specific care and services required for residents to achieve or maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified for 10 of 40 sampled residents who had deficits in activities of daily living (ADL) self-care performance. The care plans for these residents lacked specific interventions, such as the type of assistance needed for feeding, transferring, ambulation, and hygiene care. For instance, Resident #65 required constant supervision and verbal cues while eating, and was dependent on staff for all ADLs, but this information was not included in the care plan. Similarly, Resident #109 was on aspiration precautions and required supervision while eating, yet these details were omitted from the care plan. Observations during the recertification survey revealed that the residents were not provided with the necessary assistance to complete ADL tasks. Interviews with facility staff, including a Nurse Consultant, confirmed that care plans should be person-centered and specify the type of assistance required for proper ADL care. However, the care plans reviewed did not meet these standards, as they failed to include resident-specific interventions for hygiene task support and other ADL needs. This lack of detailed care planning contributed to the deficiency identified by the surveyors.
Inadequate Assistance and Supervision for Residents with ADL Needs
Penalty
Summary
The facility failed to provide adequate assistance to residents who were unable to perform activities of daily living (ADLs) independently. Multiple residents with swallowing difficulties and cognitive impairments were left unattended during meals, despite care plans indicating the need for constant supervision and assistance. For instance, one resident with dysphagia was observed alone in the dining room and in their room with food in front of them, without receiving the necessary verbal cues or physical assistance to eat safely. Another resident with Parkinson's disease struggled to feed themselves due to the timing of their medication, yet staff left them unattended with their meal. In addition to meal-related deficiencies, the facility neglected to maintain proper hygiene for several residents. Observations revealed that multiple residents had long, dirty fingernails, despite expressing a desire for them to be cut. This lack of attention to personal care needs was consistent across several residents, indicating a broader issue with the facility's ability to meet the basic hygiene requirements of its residents. Furthermore, the facility failed to ensure that residents had access to call bells or assistance when needed. Several residents were observed calling out for help to use the bathroom or to be repositioned, but staff did not respond in a timely manner. In one case, a resident was left in a reclined wheelchair for an extended period, calling out for assistance to use the bathroom, but was not attended to for over 40 minutes. These observations highlight significant lapses in the facility's ability to provide necessary care and assistance to its residents, as outlined in their care plans.
Deficiency in Resident Activities and Outdoor Access
Penalty
Summary
The facility failed to provide engaging activities for residents, as evidenced by the case of a resident who was observed in bed without stimulation and expressed interest in more independent and one-on-one activities. Despite the resident's care plan indicating a need to break the cycle of inactivity and establish a list of enjoyable activities, the Activities Director was unaware of these interventions and did not track participation or refusals. The resident's interest in music and audio books was not adequately addressed, and there were no specific interventions in the care plan to support these preferences. Multiple residents on Unit B expressed a desire to spend time outdoors, but the facility did not support this interest. Record reviews and interviews revealed that residents had preferences for outdoor activities, but their care plans lacked specific interventions to facilitate this. The Activities Director acknowledged the issue of limited outdoor access and insufficient staffing to accommodate residents' preferences, with only three outdoor activities scheduled over two months. The facility also failed to provide weekend activities, as observed on a Sunday when no activities took place on Unit B. The activity calendars for July and August showed no scheduled activities on weekends, and the Activities Director confirmed that the department was short-staffed, making it difficult to maintain the activities program. The SCU Unit Manager noted that nursing staff attempted to provide activities when none were scheduled, but there was no consistent presence in the dining room to engage residents.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD. Resident #92 was admitted with PTSD and dementia, but there was no evidence of an assessment for triggers that could re-traumatize the resident. The resident's care plan lacked information on how staff could avoid re-traumatizing the resident. Interviews with staff revealed a lack of awareness about the resident's PTSD diagnosis and triggers. The Medical Social Worker admitted that psychosocial assessments were not up to date and that there was no specific trauma care plan in place for Resident #92. Similarly, Resident #18, who also had a history of PTSD related to abuse, was observed in distress, asking for help, and showing signs of discomfort. Despite a completed psychosocial assessment indicating PTSD, there was no care plan addressing the resident's trauma history or identifying triggers. The Director of Social Services confirmed the absence of an active care plan for Resident #18, acknowledging the importance of having such a plan to guide staff in providing appropriate care.
Staffing Deficiencies Lead to Delayed Care and Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents of delayed assistance and care. Resident #79 experienced a significant delay in receiving pain medication, waiting 32 minutes after initially calling for help. The delay was attributed to the LPN being occupied with other residents' medication administration. Similarly, medication administration for four other residents was delayed due to the large unit size and insufficient staffing, causing interruptions in medication passes. Several residents were observed without access to their call bells, leading to prolonged periods without assistance. Resident #34 was unable to reach the bathroom for 40 minutes due to the lack of a call bell, resulting in distress. Resident #76 also lacked access to a call bell and was unable to reach the common area for lunch, waiting 2.5 hours before receiving assistance. These incidents highlight the facility's failure to ensure residents have the means to request help and receive timely assistance. Residents requiring assistance with eating were also neglected. Resident #50, who needs supervision due to aspiration precautions, was left without assistance for 26 minutes during a meal. Similarly, Resident #65, who requires constant supervision and prompting while eating, was left unattended for significant periods during meals. These observations indicate a systemic issue with staffing levels and the facility's ability to meet the care needs of its residents, particularly those requiring assistance with activities of daily living.
High Medication Error Rate Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that medication error rates were below 5%, with a calculated error rate of 72% for four of ten sampled residents. During observations, it was noted that medications for two residents were administered over an hour late. For Resident #13, medications including Tylenol, Aspirin, Vitamin D, Apixaban, Gabapentin, a multivitamin, and Oxycodone were scheduled for 8:00 AM but were administered between 10:15 AM and 10:30 AM. Similarly, Resident #45's medications, including Allopurinol, Amlodipine, Zoloft, Hydrochlorothiazide, and Metformin, were also administered late. The RN attributed the delay to the large unit size and the high volume of medications to be administered. Further observations revealed that Resident #50 received Carbidopa-Levodopa and Entacapone over an hour late, and Resident #20 received Ensure and Artificial Tears late as well. These medications were scheduled for 5:00 PM but were administered at 6:28 PM and 6:52 PM, respectively. The LPN explained that the unit was very busy, and medication passes were interrupted due to insufficient staffing, as aides required assistance. These delays contributed to the high medication error rate observed during the survey.
Failure to Assess and Respond to Resident's Fall and Subsequent Condition
Penalty
Summary
The facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and facility policy after sustaining a fall. Resident #22, who was admitted for short-term rehabilitation, experienced an unwitnessed fall while attempting to use the bathroom. Despite having apparent injuries, including bruising and a skin tear, the resident refused a head-to-toe assessment and care for the injuries. The staff noted the resident's refusal and aggressive behavior, but did not take further action to ensure the resident's safety and well-being. On the morning following the fall, Resident #22 was observed in a compromised state, slumped in a wheelchair, unable to control their upper body, and eventually vomiting. Despite these concerning signs, there was no staff monitoring the resident in the dining/activity area. The resident was emergently transferred to the hospital with altered mental status and low blood pressure, where they were diagnosed with pyelonephritis, dehydration, and low blood pressure. The facility's staff, including the LPN and RN, failed to notify the Director of Nursing or the on-call provider about the resident's change in mental status. The resident's Power of Attorney had requested that the resident be sent to the emergency room, but this was not acted upon due to the resident's initial refusal. The facility's policy on notification of changes and the resident's advance directive were not adequately followed, leading to a delay in necessary medical intervention.
Expired Medications and Biologicals Found in Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were removed from use when expired. During an observation on 8/29/2024, a vial of glucose control solution with an expiration date of 8/3/24 was found in the A-Wing medication storage room, labeled as opened on 7/9/24. Additionally, one opened BinaxNow COVID test with an expiration date of 1/7/2024 and two with expiration dates of 2/14/2024 were present. The Unit Manager confirmed these items were expired. In the B-Wing medication storage room, a Diabetic Hypoglycemic Emergency Kit contained a tube of Glucagon 1mg Emergency Injection Kit and Glucose Gel 40% with an expiration date of 6/2024. A Registered Nurse confirmed the Glucagon was expired and stated that it is the responsibility of all nurses to check for expired medications.
Failure to Notify Resident of Discharge
Penalty
Summary
The facility failed to provide timely written notification of a transfer or discharge to a resident, who was identified as their own guardian, following an incident. The resident, admitted for rehabilitation after a fall, was diagnosed with Down syndrome, anxiety, mild intellectual disabilities, and obsessive-compulsive behavior. Despite having a BIMS score indicating cognitive intactness, the resident was not informed in writing about the involuntary discharge or their right to appeal. Instead, the facility only communicated the discharge to the resident's family member by phone and email. The deficiency was confirmed through interviews and record reviews, which revealed no evidence of a written discharge notice given to the resident. The resident expressed confusion about the discharge and stated they were unaware of the facility's decision, indicating they would have preferred to return to the facility. The resident remained in the hospital while awaiting long-term placement, highlighting the facility's failure to adhere to proper notification procedures for discharge or transfer.
Latest citations in Vermont
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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