Center For Living & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 160 Hospital Drive, Bennington, Vermont 05201
- CMS Provider Number
- 475029
- Inspections on file
- 22
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Center For Living & Rehabilitation during CMS and state inspections, most recent first.
A resident was repeatedly addressed by an LPN using a term of endearment instead of their preferred name during a request for pain medication. The resident indicated discomfort with this form of address, and the LPN acknowledged using such terms as a general habit rather than based on the resident's preference. The administrator confirmed that staff are expected to use residents' preferred names or pronouns.
A resident with chronic pain and osteoarthritis reported severe back pain and requested both repositioning and pain medication. Staff delayed transferring the resident to bed and did not provide PRN pain medication or offer non-pharmacological interventions, despite standing orders and documented options. The resident's pain was not adequately addressed until much later, and the DON and Administrator confirmed that the response was insufficient.
A resident with multiple medical conditions, including chronic pain and lymphedema, was observed unable to reach the call bell while in their room. The call bell was pinned to the bed out of reach, and the resident had to use a cell phone to contact a friend for help, who then called the nurse's station. An LPN confirmed the incident and noted the resident's need for two-person assistance with transfers.
Two residents with intact cognition and behavioral health diagnoses were involved in repeated physical altercations, including one incident where a resident sustained a bloody nose after being struck by another. Despite a prior similar event, staff did not update care plans or implement interventions to keep the residents apart, and the DON confirmed no specific measures were in place to prevent recurrence. This resulted in actual physical and psychosocial harm.
Following two altercations between residents with intact cognition and behavioral health diagnoses, the facility did not update care plans or the Kardex to include interventions such as separation or monitoring. Staff relied on informal redirection, and there was no documentation to guide prevention of further incidents, resulting in physical and psychosocial harm to a resident.
A resident who required two-person assistance for transfers and protective skin devices was transferred by a single staff member, resulting in a significant skin tear. Facility records and staff interviews confirmed that the transfer was not performed according to the care plan, leading to the injury.
A resident with a history of a diabetic foot ulcer on the left heel was re-admitted without any right heel wounds documented. Despite being at high risk for skin breakdown, no interventions were in place to protect the right heel. Nursing staff later identified a Stage 2 pressure ulcer on the right heel, and the care plan was only updated with protective measures after the ulcer developed. The DON confirmed that the right heel wound occurred in the facility and that preventive interventions were not implemented beforehand.
Three residents with significant mobility and cognitive impairments experienced falls, but the facility did not complete required fall risk assessments or update care plans with new interventions after each incident, despite repeated falls and a policy mandating these actions. The DON confirmed that these steps were not taken as required.
Surveyors observed that medications and biologicals were left unattended on medication carts, expired medications and supplies were present in medication storage rooms and carts, and some medications had missing or illegible expiration dates. Staff confirmed these findings, and a pill cutter with medication debris and food items were also found in medication carts.
Staff did not follow infection control protocols for a resident on contact isolation, including failing to wear PPE and perform hand hygiene after resident contact and handling soiled linens. During a medication pass, a nurse handled medications with bare hands and did not perform hand hygiene between administrations to two residents, contrary to infection prevention standards.
A resident with advanced dementia had a notarized advance directive requesting comfort care only, but subsequent COLST forms listed the resident as Full Code without signatures from the resident or POA, and there was no documented consultation with the POA regarding this change. The DON confirmed the lack of communication with the family and absence of required signatures.
A resident with cancer and swallowing difficulties, identified as at risk for malnutrition, did not receive physician-ordered nutritional supplements and an appetite stimulant on multiple occasions. Documentation incorrectly stated these items were unavailable, despite confirmation from pharmacy and dietary staff that they were accessible. The resident experienced significant weight loss during this period, and the DON confirmed the failure to administer the ordered interventions.
A resident's medical chart was missing required documentation of monthly medication regimen reviews for several months, despite pharmacist recommendations being made. Facility policy requires these records to be maintained and easily retrievable, but staff confirmed the documents were not available during review.
Significant maintenance issues, including broken shower stalls, missing tiles, leaking fixtures, standing water, and a non-functional toilet, persisted for months in multiple resident units. Despite having an electronic maintenance tracking system and recent staff training, these problems were not reported or tracked, resulting in a lack of documentation or repair efforts.
A resident with diabetic neuropathy and a prior foot wound did not receive timely foot assessments or interventions as required by their care plan. Staff failed to inspect the resident's feet or address concerns about the bed footboard causing injury, resulting in the development and worsening of a new foot wound that showed signs of infection before being properly assessed and managed.
The facility failed to maintain a safe, clean, and homelike environment across all nursing units, with issues such as broken electrical outlets, delaminating wall coverings, and missing baseboard trim. Additional problems included broken tiles posing infection control concerns and signs of leaking toilets. The administrator confirmed these issues, citing room occupancy and admissions as reasons for incomplete repairs.
The facility did not adhere to its policy of conducting annual criminal background checks for staff, as four out of five sampled direct care staff lacked these checks despite being employed for over a year. The Human Resource Staff acknowledged the absence of a system to ensure these checks were completed.
The facility failed to ensure proper management and documentation of psychotropic medications for residents, including lack of gradual dose reductions, absence of specific diagnoses for medication use, and inadequate monitoring of behaviors and side effects. Observations revealed residents experiencing symptoms like tremors, hallucinations, and distress, which were not accurately documented. The Unit Manager confirmed the lack of structured documentation, and the facility could not provide additional evidence during the survey.
A resident with a history of verbal aggression reported that an LNA swore at them during an interaction, which was confirmed by the LNA. The resident, who has high cognitive function, was upset by the incident but did not wish to stop working with the LNA, as they usually have a positive relationship. The facility's administrator substantiated the allegation of undignified treatment.
A facility failed to report an alleged verbal abuse incident involving a resident within the required 24-hour timeframe. A staff member accused the resident of tampering with their ostomy appliance, causing emotional distress. An LPN documented the event and reported it to a supervisor, but the incident was not promptly reported to the Administrator or DON. The Unit Manager did not conduct a thorough investigation, and the accused staff member continued working with the resident.
A facility failed to prevent further potential abuse after a resident was verbally accused by a staff member of tampering with their ostomy appliance, causing emotional distress. Despite the LPN's report of the incident, the Unit Manager did not conduct a thorough investigation, and the accused staff member continued to work with the resident. The Director of Nursing confirmed that the facility did not follow its policy, as a full investigation was delayed.
The facility failed to document education on COVID-19 vaccine benefits and side effects for a resident before administration and did not ensure another resident received the vaccine. The Infection Preventionist confirmed the lack of documentation and consent, attributing the delay to ongoing Power of Attorney arrangements.
A resident with Alzheimer's, hypothyroidism, and dementia experienced a significant weight loss of 16.3% over a month, dropping from 126.4 to 105.8 pounds. Despite the facility's policy requiring notification of the physician for such changes, the physician was not informed. Interviews confirmed the oversight.
A resident with a history of falls was not consistently laid down after meals as per their care plan, leading to multiple falls and injuries. Staff, including the assigned nurse and LNAs, were unaware of this intervention, resulting in the resident being left in a wheelchair, tired and at risk of further falls.
The facility failed to update care plans for two residents, leading to deficiencies in fall prevention and IDT reviews. One resident experienced multiple falls without effective intervention updates, while another resident's care plan lacked a required quarterly review. The facility did not follow its policy for fall risk evaluation and care plan revisions.
A resident with dementia and incontinence was observed with long, dirty fingernails, contrary to their care plan's intervention to keep nails short. The resident was seen tugging at their brief, indicating discomfort. An LNA assumed a Nurse Practitioner was responsible for nail care, while the Unit Manager confirmed that nursing staff could and should have trimmed the nails.
A resident with a hearing deficit was unable to obtain new hearing aids due to the facility's failure to reschedule a canceled audiology appointment. Despite the resident's expressed frustration and documented need for new hearing aids, the appointment was not rescheduled, as confirmed by the Scheduler and DON.
The facility failed to prevent falls for two residents, leading to multiple injuries. One resident, with a history of falls, was inaccurately assessed for fall risk, and their care plan was not updated with effective interventions. Another resident experienced falls due to staff's lack of awareness of the care plan, which required laying the resident down after meals. The deficiencies highlight the facility's failure to implement and monitor effective fall prevention strategies and ensure staff adherence to care plans.
A resident with Alzheimer's, hypothyroidism, and dementia experienced significant weight loss due to the facility's failure to adhere to its weight monitoring protocol. The resident was not weighed weekly as required, resulting in a 16.3% body weight loss over five weeks. The Unit Manager confirmed the oversight in an interview.
A resident with a history of trauma was observed in distress, crying in bed, and expressing incoherent concerns. Despite screening positive for trauma, their care plan lacked specific interventions to address their trauma or triggers. Interviews revealed that trauma-informed interventions might have been accidentally removed from the care plan, contrary to the facility's policy.
A facility failed to prevent a significant medication error when an anticoagulant was administered to a resident with a diagnosed brain bleed. The resident had sustained an unwitnessed fall and was sent to the ER, where a brain bleed was identified. Despite a physician's order to hold anticoagulation, the resident received a dose of apixaban the following morning. The Director of Nursing confirmed the error.
Failure to Address Resident by Preferred Name
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) addressed a resident by the term 'Boo' multiple times during an interaction in response to the resident's request for pain medication. The resident expressed that their name was not 'Boo' and questioned why the LPN used that term. In an interview, the LPN stated that 'Boo' was not the resident's nickname but rather a general figure of speech used for everyone. The facility administrator confirmed that it is not appropriate for staff to use terms of endearment and that residents should be addressed by their preferred name or pronoun. This incident demonstrates a failure to honor the resident's right to dignity and respect, as the resident was not addressed according to their preference during the interaction.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with chronic pain syndrome and osteoarthritis, who was cognitively intact, experienced inadequate pain management during their stay. The resident repeatedly expressed severe back pain, rating it as 9 out of 10, and requested to be transferred to bed for relief. Staff initially denied the request, instructing the resident to remain in their chair for dinner. When the resident was eventually transferred to bed, they continued to report severe pain and requested pain medication. The resident stated that the scheduled Tylenol was ineffective and that they were not receiving it as needed. Upon assessment, the LPN confirmed that there were no PRN pain medications available and that the next scheduled dose of Tylenol was not due for several hours. Although the resident's pain was assessed and the provider was notified, no immediate pharmacological or non-pharmacological interventions were offered at the time, despite standing orders for topical pain relief and documented non-pharmacological options such as repositioning, back rubs, music, or diversional activities. The DON and Administrator later confirmed that a pain level of 9 should be addressed promptly and that non-pharmacological interventions should have been implemented.
Resident Unable to Access Call Bell in Room
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, morbid obesity, lymphedema, and osteoarthritis did not have access to the call bell while in their room. The resident, who was cognitively intact per their MDS assessment, was observed sitting in a wheelchair and calling out for help with increased volume. The call bell was found pinned to the top sheet of the resident's bed, out of their reach. The resident reported that after being brought to their room following an activity, they requested to go to bed, but staff said they would return and did not provide the call bell within reach. Unable to summon assistance, the resident used their cell phone to contact a friend, who then called the facility's nurse's station to request help. Upon staff intervention, the resident was repositioned and the call bell was placed within their reach. An LPN confirmed that the resident's friend or family member had called the facility, prompting staff to assist the resident. The LPN also stated that the resident requires two-person assistance for transfers and had provided re-education to the resident regarding this requirement. The deficiency was identified through both observation and interviews, demonstrating that the facility failed to ensure the resident had access to the call bell as required.
Failure to Prevent Resident-to-Resident Abuse Following Prior Altercation
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by not implementing effective interventions following a prior altercation between two residents. Despite a previous incident where one resident pushed and kicked another, resulting in a reported injury, the facility did not update care plans or establish measures to keep the residents apart or address the ongoing risk of further altercations. Both residents had documented histories of behavioral and mental health issues, including anxiety, depression, and bipolar disorder, and were assessed as having intact cognition. On a subsequent occasion, the same two residents were involved in another physical altercation. Staff, including the ADON and NP, observed the residents exchanging words in a negative tone and attempted to intervene, but were unable to prevent the escalation. One resident repeatedly rammed their wheelchair into the other, who then responded by striking the first resident in the face, causing a bloody nose and requiring emergency department evaluation for blunt trauma. The incident was witnessed by staff, and both residents expressed distress following the event. Record reviews and interviews confirmed that after the initial altercation, there were no specific interventions or care plan updates to prevent further incidents between the two residents. The DON acknowledged that neither resident's care plan or Kardex included instructions to keep them apart or protect them from each other, even after two documented altercations. This lack of action resulted in actual physical and psychosocial harm to the residents involved.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents following significant changes in their conditions after two resident-to-resident altercations. Despite documented incidents where one resident physically assaulted another, resulting in physical and psychosocial harm, the care plans and Kardex for both residents were not updated to include interventions to prevent recurrence, such as separation or increased monitoring. Staff interviews confirmed that interventions were limited to informal redirection rather than documented, individualized strategies. Both residents involved had intact cognition, as indicated by BIMS scores of 15, and diagnoses including anxiety and mood disorders. The first altercation involved one resident pushing and kicking another, while the second incident escalated to physical violence and threats, resulting in one resident sustaining blunt trauma to the nose and expressing fear and distress. Despite these events, there was no documentation in the care plans or Kardex to guide staff in preventing further incidents, and staff were unaware of any specific interventions or risks related to these residents.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had a care plan requiring two staff members to assist with stand pivot transfers and the use of Dermasaver skin tubes while out of bed, was transferred by a single staff member. The resident was found in bed with a large skin tear on the right lower leg after being out of bed in a wheelchair for dinner. Facility records and staff statements confirmed that the assigned LNA transferred the resident out of bed to a chair alone and did not transfer the resident back to bed. The skin tear was discovered by the primary LNA upon the resident's return to bed, and the facility's internal investigation determined that the injury occurred during the unsupervised transfer, which was not in accordance with the resident's care plan.
Failure to Prevent Development of Avoidable Pressure Ulcer
Penalty
Summary
A resident was re-admitted to the facility with a diabetic foot ulcer on the left heel, but there was no documentation of any wound on the right heel at the time of admission. The resident's care plan included interventions for skin integrity, such as the use of an air mattress, but did not specify protective measures for the right heel. On a later date, nursing staff observed blood on the resident's right sock and identified an open area on the right heel, described as a 5x5 cm broken blister with red inner tissue, white soft tissue, and dark pink edges. The supervisor and family were notified, and the resident was transferred to the hospital the same day. Upon return, the right heel wound was documented as a Stage 2 pressure ulcer. The care plan was not updated to include specific interventions for the right heel until after the pressure ulcer had developed. Prior to the identification of the right heel wound, there were no documented interventions to protect the right heel from pressure ulcers. The Director of Nursing confirmed that the right heel wound developed in the facility and that protective measures for the right heel were not implemented until after the wound was discovered.
Failure to Update Care Plans and Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and timely, effective interventions to prevent future falls, as required by their own Fall Prevention and Protocol policy. For one resident with Parkinson's Disease, impaired mobility, and visual deficits, a fall occurred while attempting to transfer to bed, and the resident was found with saturated clothing and had reportedly refused care. Despite a high fall risk score and a policy requiring a fall risk evaluation and care plan update after each fall, no such evaluation or care plan revision was completed following the incident. The Director of Nursing confirmed that these steps should have been taken but were not. Similarly, another resident with hemiplegia, aphasia, and a history of multiple falls did not have a fall risk assessment or care plan update after a fall, despite repeated incidents and a policy mandating these actions. A third resident, who required a Hoyer lift and experienced a fall, also did not have any new interventions added to their care plan after the event. In all cases, the Director of Nursing acknowledged that care plans should have been updated after each fall, but this was not done, resulting in a failure to implement effective measures to reduce the likelihood of future accidents.
Improper Storage and Expired Medications Found in Medication Carts and Storage Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, as evidenced by multiple observations of improper medication storage and the presence of expired medications and supplies. On several occasions, nurses left medications unattended and unsupervised on top of medication carts, including blister packs, over-the-counter medications, and a bottle of Metamucil. Additionally, expired blood culture vials and expired topical creams were found in medication storage rooms, with staff confirming their availability for use. Medication carts were also found to contain expired medications, a pill cutter with visible medication debris, and a container of food items, all of which were confirmed by staff interviews. Further observations revealed that some medications had missing or illegible expiration dates, and expired medications were present in multiple medication carts. Staff interviews consistently confirmed the presence of these expired or improperly stored medications and supplies. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency, but the findings indicate a systemic failure to maintain proper medication storage and labeling practices throughout the facility.
Failure to Implement Infection Control Measures for Isolation Precautions and Medication Pass
Penalty
Summary
Facility staff failed to implement required infection control measures for a resident on contact isolation precautions. Observations revealed that staff entered the resident's room without donning gowns or gloves, handled the resident and their personal items, and removed soiled linens with bare hands. Staff did not perform hand hygiene after leaving the isolation room and were seen carrying used linens down the hall. The Infection Preventionist confirmed that these actions did not comply with the facility's contact isolation protocols, which require the use of personal protective equipment and hand hygiene after resident contact and PPE removal. Additionally, during a medication pass, a nurse was observed pouring tablets from blister packs directly into his ungloved hand and then placing the medications into cups for administration to two residents. The nurse did not perform hand hygiene between medication administrations. In an interview, the nurse acknowledged these actions and stated he believed gloves were not permitted in the hallway. These practices were not consistent with infection control standards for medication administration.
Failure to Involve POA in Advance Directive and Code Status Decisions
Penalty
Summary
The facility failed to ensure that a resident's power of attorney (POA) was involved in developing and updating advanced directives in accordance with the resident's previously stated wishes. The resident had a notarized advanced directive specifying a desire for comfort care only and authorizing the agent to decline or terminate life-prolonging treatments in the event of a terminal condition with no reasonable prospect of recovery. Despite this, subsequent Clinicians Orders for Life Sustaining Treatment (COLST) forms indicated the resident was a Full Code, and these forms were not signed by the resident or the POA. There was no documented evidence that the resident or POA was consulted regarding the change to full code status. Physician notes indicated awareness of the need to review the resident's health care proxy and discuss goals of care and code status, especially in light of the resident's decline and inability to make medical decisions due to advanced dementia. The Director of Nursing confirmed that the COLST forms were not signed by the resident or POA and acknowledged that the family had not been contacted about the code status change, citing disagreements and hope that the resident would regain decision-making capacity.
Failure to Administer Ordered Nutritional Supplements and Appetite Stimulant
Penalty
Summary
A resident with diagnoses including prostate and bone cancer and difficulty swallowing was identified as being at risk for malnutrition due to increased nutritional needs, poor appetite, and altered skin integrity. The resident's care plan included interventions such as providing nutritional supplements and an appetite stimulant as ordered by the physician. Physician orders specified a daily house shake and Megestrol Acetate Oral Suspension for appetite stimulation. However, review of the Medication Administration Record (MAR) revealed that the resident did not receive the Megestrol Acetate Oral Suspension on multiple dates, with nursing notes incorrectly documenting the medication as unavailable, despite pharmacy records confirming its delivery and availability. Additionally, the resident did not receive the ordered house shake supplement on several dates, with nursing notes again indicating it was not available, while the Dietary Manager confirmed that house shakes were always prepared and distributed daily. During this period, the resident experienced a 6.9-pound weight loss, representing a 4.3% decrease in total body weight. The Director of Nursing confirmed that both the medication and supplement were available but were not administered as ordered.
Missing Medication Regimen Review Documentation
Penalty
Summary
The facility failed to maintain complete drug regimen review (MRR) documentation for one out of five sampled residents. For this resident, medication regimen reviews were conducted by the pharmacist in several months, and recommendations were made. However, copies of the MRRs for three specific months were missing from the resident's medical chart. According to the facility's own policy, all drug regimen review recommendations and prescriber's responses should be maintained in an easily retrievable location and filed with the permanent medical record. During interviews, the Director of Nursing, MDS Coordinator, and an RN confirmed that the MRRs for the specified months were not present in the resident's chart and were not available in the facility for review.
Failure to Maintain Safe and Clean Resident Environment Due to Unaddressed Maintenance Issues
Penalty
Summary
The facility failed to provide necessary maintenance services to ensure a safe, clean, comfortable, and homelike environment for residents in four of six resident units. Observations revealed significant maintenance issues in communal shower rooms, including an open hole in a shower wall exposing wooden studs, missing tiles, a leaking handheld showerhead, standing water on the floor not draining, and missing grout along shower floors. Additionally, a toilet in one shower room was marked as out of order, contained standing water and a large amount of wadded toilet paper, and was still being used despite not flushing. These environmental issues were confirmed by both staff and the Director of Maintenance (DM) during facility tours and interviews. The DM reported that the facility uses the TELS electronic maintenance tracking system, which is accessible to all staff and was recently the subject of staff education. However, the DM confirmed that the identified maintenance issues had existed for months and had not been entered into the TELS system, resulting in no documentation regarding the duration of the issues, whether maintenance was aware, or if any repairs had been attempted. The DM acknowledged that the maintenance department did not implement the TELS system as intended to identify, report, assign, track, and complete necessary repairs, despite its availability and recent staff training.
Failure to Provide Timely Skin Assessment and Intervention for Resident with Diabetic Neuropathy
Penalty
Summary
A resident with diabetic neuropathy and a history of a right plantar foot wound was admitted to the facility. Upon admission, the care plan identified the resident as having an actual impairment to skin integrity and required daily foot inspections. Despite this, interviews and record reviews revealed that staff did not remove the resident's socks or assess the feet until several weeks after admission. The resident reported that their feet had been rubbing against the bed's footboard since admission, and this concern was communicated to staff and maintenance but not addressed until after a new wound developed. Initial documentation of a 'skin issue' to the right foot was made by an LPN, but the assessment lacked detail and no further evaluation was performed at that time. The wound was not assessed by the facility's Wound Nurse Practitioner until a week after the initial documentation, by which time the wound had deteriorated into a large blister with open edges and signs of infection. The care plan was not updated with new interventions to address the current skin issue or prevent further complications until after the wound had worsened. The Director of Nursing confirmed that the resident was at risk for skin impairment and that concerns about the bed footboard and skin issues were not evaluated or addressed until after the development of the new, in-house acquired wound.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide necessary maintenance services to ensure a safe, clean, comfortable, and homelike environment for residents across all six nursing units. Observations revealed multiple functional and cosmetic issues in several resident rooms, including broken electrical outlets with exposed wiring, delaminating plywood wall coverings, and missing baseboard trim exposing peeling paint and broken sheetrock. Additionally, numerous rooms had unrepaired holes, scratches, peeling wallpaper, or unpainted spackle on the walls, contributing to an overall neglected environment. Further issues included a broken wardrobe drawer, a broken fluorescent light cover, and large scratches and missing paint on walls. In one bathroom, broken tiles in front of the toilet posed an infection control concern due to cleaning difficulties. Signs of leaking at the base of a toilet in an unoccupied room were also noted, with black liquid partially dried on the floor. The facility administrator acknowledged these issues during an interview, stating that some repairs had been identified but not completed due to room occupancy and admissions.
Failure to Conduct Annual Background Checks
Penalty
Summary
The facility failed to implement its policy for screening employees by not completing the required criminal background checks for four out of five sampled staff. The facility's policy, titled 'Background Checks, Arrests, and Conviction Notification,' mandates that criminal background checks be conducted for all current employees at least annually. However, a review of employee human resource files revealed that four of the five sampled direct care staff, who have been employed at the facility for over a year, did not have their annual federal background checks completed. During an interview, the Human Resource Staff admitted that there was no system in place for obtaining these annual national background checks for staff who have been employed for over a year.
Deficiencies in Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, as required by regulations and facility policy. Specifically, for one resident with major depressive disorder and schizophrenia, there was no evidence of a GDR attempt in the past year for any of the prescribed psychotropic medications. The resident exhibited symptoms such as tremors and repetitive movements, which were not adequately documented or monitored for potential medication side effects. Another resident, diagnosed with Alzheimer's disease and dementia, was prescribed Risperidone without a documented diagnosis justifying its use. Despite pharmacist recommendations to assess the necessity of the medication and consider a tapering schedule, no changes were made to the resident's diagnoses or medication orders. Observations during the survey revealed the resident experiencing hallucinations and agitation, yet these behaviors were not accurately documented in the progress notes. A third resident with dementia, anxiety, and major depressive disorder was observed exhibiting distress and crying, with incoherent phrases about family members. The facility's documentation did not reflect these behaviors or potential medication side effects. The Unit Manager acknowledged the lack of structured documentation for behaviors and side effects, confirming that the progress notes did not accurately capture the residents' conditions. The facility was unable to provide additional evidence of proper documentation during the survey.
Resident Dignity Violation by LNA
Penalty
Summary
The facility failed to ensure that all residents were treated with respect and dignity by staff, as evidenced by an incident involving a resident and a Licensed Nursing Assistant (LNA). Resident #87, who has a care plan addressing verbal aggression and poor impulse control, reported that a staff member swore at them during an interaction approximately a month prior to the interview. The resident, who has a high cognitive function as per a recent MDS assessment, expressed that the incident was upsetting but did not wish to discontinue working with the LNA, as they generally have a positive relationship. The LNA admitted to swearing at the resident under their breath during a disagreement over the handling of the resident's urinal. The facility's administrator confirmed the allegation of undignified treatment was substantiated.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident within the required 24-hour timeframe. On the date of the incident, a staff member was witnessed accusing a resident of tampering with their ostomy appliance, which caused the resident to become visibly upset. The resident, who was lying naked and soiled, was berated by the staff member, leading to emotional distress. A Licensed Practical Nurse (LPN) present during the incident documented the event and reported it to their supervisor. However, the supervisor and the Unit Manager did not take immediate action to report the incident to the Administrator or the Director of Nursing, as required by regulations. The Unit Manager's statement, recorded three days after the incident, indicated a lack of thorough investigation into the abuse allegation. The Unit Manager did not interview the accused staff member or review the LPN's witness statement. Furthermore, the accused staff member continued to work with the resident throughout the night. The Director of Nursing later confirmed that the verbal abuse allegation was not reported to the mandated agencies within the required timeframe, highlighting a failure in the facility's reporting protocol.
Failure to Address Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment after an allegation of verbal abuse was made against a staff member by a resident. On the date of the incident, a Licensed Practical Nurse (LPN) witnessed a staff member accusing a resident of tampering with their ostomy appliance, which caused the resident to become visibly upset. Despite the resident's denial and emotional distress, the staff member continued to berate the resident. The LPN reported the incident to their supervisor, who then informed the Unit Manager (UM). However, the UM did not conduct a thorough investigation, as they did not speak with the accused staff member, the LPN, or any other witnesses, nor did they review the LPN's written statement. The Director of Nursing (DON) confirmed that the facility did not adhere to its Abuse, Neglect, and Exploitation policy, as the accused staff member was allowed to continue working with the resident after the incident. The full investigation into the abuse allegation was not initiated until two days after the incident, despite the LPN's report of potential verbal abuse. This delay in action and failure to remove the alleged perpetrator from the resident's care compromised the resident's safety and well-being.
Deficiencies in COVID-19 Vaccination Documentation and Administration
Penalty
Summary
The facility failed to document that a resident or their representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine before administration. Specifically, Resident #100 received the Fall 2023 COVID-19 immunization without any evidence in the medical record that education was provided. The facility's Infection Preventionist confirmed the absence of documentation during an interview, indicating a lapse in the facility's protocol for informed consent and education prior to vaccination. Additionally, the facility did not ensure that another resident, Resident #6, received the COVID-19 vaccine. There was no documentation of education or signed consent for the immunization, despite the resident having signed consent for the influenza vaccine two days prior. The Infection Preventionist acknowledged that Resident #6 could have consented to the COVID-19 vaccine at the same time as the influenza vaccine. The delay was attributed to the ongoing process of obtaining a Power of Attorney for Resident #6, who lacked the capacity to consent, yet the facility failed to address this in a timely manner.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician of significant weight loss, which was identified during a survey. The resident, who has diagnoses including Alzheimer's disease, hypothyroidism, and dementia, was noted to have a nutrition care plan that required monitoring of weight and notifying the physician of any significant changes. The resident's weight dropped from 126.4 pounds to 105.8 pounds over approximately one month, indicating a 16.3% weight loss, which is considered significant. Despite this, there was no evidence that the physician was informed of this change. Interviews with the resident's physician and the Unit Manager confirmed that the physician had not been notified, contrary to the facility's policy on weight assessment monitoring.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for fall prevention for a resident, leading to multiple falls and injuries. The resident, who had a history of falls and was admitted after a significant fall at a Senior Living facility, experienced two falls within the facility. The care plan, updated after the second fall, included an intervention to lay the resident down after meals. However, this intervention was not consistently implemented by the staff. On observation, the resident was seen with multiple bruises on their face and was found sitting in a wheelchair, appearing tired and nodding off after lunch. Despite the care plan's directive, the resident was not laid down after meals, and staff members, including the assigned nurse and LNAs, were unaware of this requirement. This lack of awareness and implementation of the care plan contributed to the resident's continued risk of falls and injuries.
Deficiencies in Care Plan Review and Fall Prevention
Penalty
Summary
The facility failed to adequately review and revise care plans for two residents, leading to deficiencies in fall prevention and interdisciplinary team (IDT) care plan reviews. For one resident, who was admitted with conditions including Parkinsonism, dementia, and a history of falls, the facility did not update the care plan with new interventions after multiple falls occurred. Despite the resident experiencing several falls resulting in injuries, the care plan was not revised to include effective fall prevention strategies. The facility's policy required a fall risk evaluation and care plan review after each fall, but this was not consistently followed, as evidenced by repeated falls and ineffective interventions such as grip strips. Additionally, the facility failed to ensure that the IDT reviewed and revised another resident's care plan quarterly as required. The resident's care plan was not reviewed in October 2023, as there was no documented evidence of an IDT meeting or care plan revision during that period. The Long Term Care Manager confirmed the absence of necessary documentation, indicating a lapse in the required quarterly review process for the resident's care plan.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance to a resident who was unable to perform activities of daily living independently. The resident, who has dementia and incontinence, was observed with long and dirty fingernails, despite a care plan intervention to keep nails short to prevent skin impairment. On two separate occasions, the resident was seen tugging at their brief and groin area, indicating discomfort. A Licensed Nursing Assistant (LNA) acknowledged the resident's nails were long and dirty but assumed that a Nurse Practitioner was responsible for cutting them. The Unit Manager later confirmed that the nursing staff could cut the resident's nails and agreed they should have been trimmed.
Failure to Assist Resident in Rescheduling Audiology Appointment
Penalty
Summary
The facility failed to assist a resident in making audiology appointments, resulting in a deficiency. The resident, who has a communication problem related to a hearing deficit, expressed frustration over the inability to obtain new hearing aids. The resident had an audiology appointment scheduled, which was canceled by the provider, and no follow-up was made to reschedule it. A care plan meeting note indicated the need for an appointment to get new hearing aids, and a progress note confirmed that the resident missed an appointment due to transportation issues. Despite the facility's responsibility to reschedule, the appointment had not been rescheduled, as confirmed by the Scheduler and the Director of Nursing, who acknowledged that the appointment should have been rescheduled promptly.
Failure to Prevent Falls and Ensure Staff Adherence to Care Plans
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for two residents, leading to multiple falls and injuries. Resident #62, who was admitted with Parkinsonism, dementia, and a history of falls, was inaccurately assessed for fall risk, with evaluations not conducted after each fall as required by the facility's policy. Despite being at high risk, the resident's care plan was not updated with effective interventions after several falls, and some falls were not documented as incidents. The use of grip strips as a preventive measure was ineffective, and the facility did not evaluate or implement new interventions after repeated falls, resulting in injuries such as skin tears and abrasions. Resident #266, admitted after a significant fall, experienced multiple falls within the facility. After a fall, the care plan was updated to include toileting every 2-3 hours and laying the resident down for a nap after meals. However, during an observation, the resident was found nodding off in a wheelchair, and staff were unaware of the care plan's requirement to lay the resident down after meals. Despite the resident's visible fatigue and attempt to stand unassisted, staff did not ensure the resident was laid down as per the care plan. The deficiencies highlight the facility's failure to implement and monitor effective fall prevention strategies and ensure staff awareness and adherence to care plans. The lack of consistent documentation and evaluation of interventions contributed to the residents' repeated falls and injuries, indicating a need for improved oversight and communication within the facility.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status by not obtaining weights as care planned. According to the facility's policy on Weight Assessment Monitoring, nursing staff are required to weigh residents weekly or as ordered for the first four weeks after admission, and continue weekly if the resident is at risk for weight loss. However, the records show that the resident, who was admitted with diagnoses including Alzheimer's disease, hypothyroidism, and dementia, was not weighed weekly as required. The resident's care plan, which included monitoring weights and notifying the medical doctor of significant weight changes, was not followed. The resident's documented weights show a significant weight loss of 20.6 pounds, or 16.3% of their body weight, between February 5, 2024, and March 8, 2024. This weight loss occurred over a five-week period during which the resident was not weighed weekly as per the care plan. The Unit Manager confirmed in an interview that the resident should have been weighed weekly but was not, indicating a failure to adhere to the facility's weight monitoring protocol.
Failure to Provide Trauma-Informed Care for a Resident
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a personal history of trauma. Observations on multiple occasions revealed the resident in distress, crying in bed, and expressing incoherent concerns about their parents' skin. Despite the resident's evident distress and a positive screening for trauma, the care plan lacked specific focus, goals, or interventions addressing the resident's trauma or identifying, mitigating, or eliminating their triggers. Interviews with the Unit Manager and the resident's physician confirmed the absence of trauma-informed interventions in the care plan. The Unit Manager was unaware of the specifics of the resident's trauma, and the physician acknowledged that interventions related to trauma might have been accidentally removed from the care plan. The facility's policy on trauma-informed care requires the development of a care plan aimed at mitigating or eliminating triggers, but this was not implemented for the resident in question.
Medication Error: Anticoagulant Administered to Resident with Brain Bleed
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the administration of an anticoagulant to a resident with a brain bleed. Resident #266 sustained an unwitnessed fall and was sent to the emergency room, where a brain bleed was diagnosed. Despite the physician's order to hold anticoagulation due to the brain bleed, the resident received a dose of apixaban, an anticoagulant, on the morning following the fall. The medication was not placed on hold until later that morning, and the Director of Nursing confirmed the administration of the anticoagulant against medical recommendations.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
