Crescent Manor Care Ctrs
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 312 Crescent Blvd, Bennington, Vermont 05201
- CMS Provider Number
- 475033
- Inspections on file
- 23
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Crescent Manor Care Ctrs during CMS and state inspections, most recent first.
The facility did not have a clear process or policy in place to allow residents to file grievances anonymously. Two residents and the Social Worker confirmed that the grievance forms required a signature and that there was no documented or communicated option for submitting grievances without revealing the resident's identity.
Surveyors found that food items, including condiments, baking mixes, bread, hot dog rolls, and fish sticks, were stored without expiration dates, and original packaging had been discarded. Kitchen equipment such as a can opener and meat slicer were observed to be unclean with visible residues. Additional issues included unlabeled food containers and snacks in unit kitchenettes, with staff confirming the lack of proper labeling and storage practices.
Surveyors found that a sharps container in the memory care unit's shower room was overfilled and could not close, with uncovered disposable razors left unsecured on top. Additionally, the dining/activity room had a baseboard radiator with missing covers, exposing sharp fins. An LPN and the Unit Manager confirmed these issues during interviews.
Surveyors found expired and undated medications and medical supplies in all medication and treatment rooms inspected. Expired IV tubing kits, sterile water, injectable medications, auto injectors, blood collection sets, needleless connectors, foley care wipes, skin protectant ointments, and a catheter kit were confirmed by the Unit Manager, Nursing Manager, and an LPN. Items without expiration dates, such as glucose tablets and Vitamin B-Complex, were also present and acknowledged as needing removal.
Staff did not consistently or correctly wear required face masks during a COVID-19 outbreak, with multiple instances of masks being worn incorrectly or not at all on two units. Interviews confirmed that universal masking was required, but staff failed to adhere to this protocol, resulting in a repeat deficiency.
Surveyors found that multiple residents did not have accessible call lights while in bed, with call bells often out of reach, hidden, or removed entirely. Some residents were unable to locate or use their call bells, despite care plans requiring accessibility. In one case, a resident with dementia had their call light removed due to behavioral issues, but no alternate communication method was provided. Staff interviews confirmed awareness of the requirement for call lights to be within reach, yet deficiencies persisted.
A resident with a critical sodium level was not promptly reported to the provider as required by facility policy. Nursing staff became aware of the abnormal lab value but did not immediately notify the provider or DON. The resident was only sent to the emergency department after a Nurse Practitioner was informed of the result, and staff interviews confirmed the delay in notification.
A resident with limited mobility and moderate cognitive impairment, who was care planned to use wheelchair leg rests at all times, was observed without them attached. Staff interviews confirmed the resident could not self-propel and that facility policy required footrests for such residents, but the intervention was not implemented, resulting in a fall.
A resident with multiple sclerosis and moderate cognitive impairment, who required staff assistance and used a wheelchair, suffered a fall and injuries when staff failed to use required leg rests during transport. The DON confirmed that staff had not been educated on the facility's practice of using leg rests for non-self-propelling residents, contributing to the incident.
A resident with dementia and cognitive impairment was physically struck on the forehead by another cognitively impaired resident, as witnessed by an LNA. The incident was confirmed by facility investigation, and the DON acknowledged the failure to ensure the resident's right to be free from physical abuse.
A resident with a stage 2 pressure ulcer experienced worsening of their condition due to the facility's failure to obtain a recommended Flexi Seal system to manage fecal contamination. Despite multiple recommendations from the wound care team and physician orders, the device was not secured, leading to the ulcer progressing to stage four and becoming infected. The resident required hospitalization and surgical debridement as a result.
The facility failed to provide effective skin and wound care for several residents, with deficiencies in documentation and management. A resident's care plan required weekly documentation of skin injuries, but inconsistencies were found in the records. Another resident's fungal rash was not addressed in the care plan, causing pain during care. A third resident lacked weekly skin evaluations, and a fourth had no completed evaluations despite having multiple lesions. Additionally, a resident expressed concerns about staff's knowledge of using a wound vac, which was observed unattached to suction for hours. The facility lacked a system for accurate skin assessments and wound evaluations.
The facility failed to implement an effective infection prevention and control program, as staff did not wear required PPE while assisting residents on precautions. Observations showed LNAs assisting residents with MRSA, ESBL, and open areas without gowns, despite being on contact and enhanced barrier precautions. The Infection Preventionist confirmed the need for gowns and gloves during personal care.
The facility failed to ensure that licensed nurses had the necessary competencies to care for residents with wound vacs. Two residents with wound vacs were affected, and a review showed that none of the direct care staff had documented competencies for using the device. The Nurse Educator acknowledged the absence of a competency checklist for wound vac use, despite some staff receiving informal instruction.
The facility did not conduct annual performance evaluations for LNAs who have been employed for over a year. This was confirmed through a review of employee files and an interview with the Administrator.
A resident with a history of falls reported an unwitnessed fall to an LNA, who informed a nurse. The nurse instructed the LNA to notify the RN responsible for the resident, but the RN was not informed, resulting in no assessment for injuries. Five days later, a bruise was found on the resident's head, confirming the lack of immediate assessment.
Failure to Provide Anonymous Grievance Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, as required by regulation. Observations revealed that the grievance policy and procedure posted in the lobby only displayed the first page, which included the grievance officer's contact information but did not provide instructions for filing grievances anonymously. The grievance forms and the facility's written policy required a resident's signature, and there was no indication on the forms or policy that anonymous grievances were permitted. Interviews with three residents confirmed that they were unaware of any process to file grievances without revealing their identity, and they reported using the facility-provided form and submitting it to the Social Worker. The Social Worker, identified as the Grievance Official, stated that while envelopes were available for anonymous grievances, the posted policy and procedure did not include this option, and she was unable to locate any documentation of an anonymous grievance process in the facility's policies. She acknowledged the difficulty in handling anonymous grievances and confirmed that providing an option for anonymous grievance submission is a requirement.
Deficient Food Storage, Labeling, and Equipment Cleanliness
Penalty
Summary
Surveyors identified multiple failures in food storage, labeling, and equipment cleanliness within the facility's food service operations. During a tour of the kitchen's dry storage area, boxes of condiments and various baking mixes were found without expiration dates, as the original packaging had been discarded. Bread racks in the storage area also lacked expiration dates. The Food Service Manager (FSM) confirmed the absence of expiration dates and was unable to provide this information. In the kitchen, a commercial can opener and meat slicer were observed to be unclean, with visible residues and substances present. The FSM acknowledged that these items had not been properly cleaned after use. Further observations revealed additional deficiencies in food labeling and storage. In the freezer, packages of hot dog rolls and a box of fish sticks were found without expiration dates, which was confirmed by both the FSM and the dietician. In a unit kitchenette refrigerator freezer, a cup containing a pink substance was found unlabeled and covered with a paper towel, with the Activities Director confirming it did not belong to any resident and should be discarded. Another unit kitchenette contained containers of food and a loaf of bread without preparation or expiration dates, as well as bins of individual-sized condiments and snacks lacking expiration dates. An LPN confirmed these findings during the inspection.
Unsafe and Unclean Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents on the licensed memory care unit. During an initial tour, a sharps container in the shower room was found to be full and unable to close properly, with a bundle of disposable razors—three of which had no covers—left unsecured on top of the container. An LPN confirmed that the sharps container should have been removed and that razors should not have been left exposed. Additionally, in the dining/activity room, the baseboard radiator had three areas where the covers were missing, exposing sharp fins. The Unit Manager confirmed the exposed areas, and the Maintenance Director noted that the radiator covers frequently get bumped off.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
The facility failed to ensure that medications and biologicals were removed from storage areas once their expiration dates had passed, as required by facility policy and professional standards. During observations and interviews, expired items were found in all three medication and treatment rooms inspected. In the west wing medication room, the Unit Manager confirmed the presence of expired IV tubing kits, sterile water for injection, Piperacillin and Tazobactam for injection, Epinephrine auto injectors, a blood collection set, and needleless connectors. Additionally, a bottle of glucose tablets was found without an expiration date, and the Unit Manager acknowledged that undated items should be discarded. In the north wing medication room, an LPN confirmed that a bottle of Vitamin B-Complex lacked an expiration date and should be thrown out. In the medication treatment room near the south/west nursing station, the Nursing Manager identified expired foley care wipes, skin protectant ointments, and a catheter kit. These findings demonstrate that the facility did not consistently remove expired or undated medications and supplies from storage, contrary to its own policy and accepted professional principles.
Repeat Failure to Ensure Proper PPE Use During COVID-19 Outbreak
Penalty
Summary
Staff failed to consistently and correctly wear required personal protective equipment (PPE), specifically face masks, during an active COVID-19 outbreak in the facility. Observations on two separate units revealed multiple instances where staff, including licensed nursing assistants and registered nurses, were either not wearing masks at all, wearing masks under their chins, or wearing masks below their noses. These observations occurred both at the nurse's station and in the memory care unit. Interviews with staff and the Infection Preventionist confirmed that universal masking was required at the time due to the outbreak, but staff were not adhering to this protocol. The deficiency was further substantiated by staff interviews, where it was acknowledged that masks were required and that staff were not following the correct procedures. The Infection Preventionist confirmed multiple observations of improper mask use, which did not provide adequate protection against infection for residents or staff. This issue was noted as a repeat deficiency, having been cited in previous recertification surveys.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that a working call system was accessible to residents in their beds or other sleeping accommodations in five out of six rooms where residents were care planned for call bell use. Observations revealed that call bells were often out of reach, such as being hung on walls, hidden behind curtains, or placed on the floor under beds. Interviews with residents confirmed that some were unable to locate or access their call bells when needed, despite care plans specifying that call lights should be within reach and residents encouraged to use them. Staff interviews corroborated that call bells were not always accessible, and that staff were aware of the expectation to keep call lights within reach. In one case, a resident with dementia and behavioral issues had their call light removed due to repeated disconnection and aggressive behavior when staff attempted to restore it. The care plan and Kardex for this resident indicated that staff should anticipate needs because the resident could not use the call bell appropriately, but no alternate means of communication was provided after the call light was removed. The resident's medical history included dementia, wandering, delusional and adjustment disorders, depression, and anxiety, and the care plan noted risks related to communication and self-care deficits. Additional observations included a resident whose call light was found on the floor and another whose bed placement made the call light inaccessible. Staff confirmed these situations during interviews. The Staff Development Coordinator stated that staff are educated to ensure call lights are within reach and to respond promptly, and confirmed that call light cords should not be pinned up or removed. Despite these policies, the deficiency persisted across multiple rooms and residents.
Failure to Promptly Notify Provider of Critical Lab Result
Penalty
Summary
The facility failed to promptly notify the provider of a critical laboratory result for one resident. According to facility policy, staff are required to immediately inform the ordering practitioner of laboratory results that fall outside the clinical reference range. In this case, a progress note documented that the resident had a critical sodium level of 161, but there was no evidence that the provider was notified immediately after nursing staff became aware of this result. Interviews with both an LPN and the Director of Nursing confirmed that the provider was not made aware of the critical lab value at the appropriate time. The delay in notification was further substantiated by a Nurse Practitioner note, which identified the resident's severe hypernatremia and documented that the resident was sent to the emergency department only after the Nurse Practitioner became aware of the critical lab value. The LPN confirmed during interview that both the provider and DON were not immediately informed, and acknowledged that critical lab values should be reported to the provider right away, as per facility policy.
Failure to Implement Wheelchair Leg Rest Care Plan Intervention
Penalty
Summary
The facility failed to implement care plan interventions for a resident with multiple sclerosis, dementia, anxiety disorder, and major depressive disorder, who had moderate cognitive impairment and limited physical mobility. The resident's care plan required extensive assistance from one staff member for locomotion using a standard wheelchair with bilateral footrests as needed. After a fall incident in which the resident's foot became caught under the wheelchair while being pushed, the care plan was revised to ensure leg rests were always attached when the resident was in the wheelchair. Despite this revision, observation revealed that the resident was seated in the wheelchair without leg rests attached. Interviews with the resident, an LPN, and the DON confirmed that the resident was not self-propelling and that facility policy required footrests for residents unable to self-propel. The staff failed to follow the care plan and facility policy, resulting in the resident being without the required leg rests at the time of observation and at the time of the fall.
Failure to Provide Wheelchair Leg Rests and Supervision Leads to Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with multiple sclerosis, dementia, and moderate cognitive impairment remained as free from accidents as possible. The resident, who was dependent on staff for activities of daily living and used a wheelchair, had a care plan indicating the need for extensive assistance and the use of bilateral footrests as needed. Despite this, the resident was being transported by a Licensed Nursing Assistant (LNA) without the required leg rests in place. During transport, the resident's foot became caught under the wheelchair, resulting in a fall that caused abrasions and swelling to the left knee and right hand. Interviews and record reviews confirmed that the facility's practice was to use leg rests for residents who do not self-propel, but there was no evidence that staff had been educated on this requirement. The Director of Nursing (DON) acknowledged that the resident required assistance and did not self-propel, and could not provide documentation of staff education regarding the use of wheelchair leg rests. The failure to implement and educate staff on appropriate interventions and assistive devices directly contributed to the resident's fall and subsequent injuries.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. According to the report, both residents involved had diagnoses of dementia and cognitive impairment, with BIMS scores indicating they were unable to answer questions to determine their cognitive functional level. Despite these impairments, regulations clarify that cognitive impairment does not preclude a resident from engaging in deliberate actions. On the date of the incident, a Licensed Nursing Assistant (LNA) witnessed one resident standing over another resident's bed. When questioned, the first resident turned and struck the second resident on the forehead with a closed fist. The resident who was struck was unable to communicate their needs. The incident was immediately witnessed and reported by the LNA, and the facility's investigation confirmed the occurrence of physical abuse. The Director of Nursing (DON) acknowledged that the facility did not ensure the resident's right to be free from physical abuse, as required by regulation. The report specifically notes that the abuse was verified and that the facility failed in its responsibility to protect the resident from harm.
Failure to Obtain Fecal Management System Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services to Resident #87, leading to the worsening of a pressure ulcer. Initially admitted with a stage 2 pressure ulcer, the resident's condition deteriorated due to inadequate management of fecal contamination. Despite recommendations from the wound care team and physician orders for a Flexi Seal system to manage fecal contamination, the facility did not obtain the device, resulting in the ulcer progressing to stage four and becoming infected. Resident #87, who was cognitively intact and frequently incontinent of urine, was admitted with an existing stage 2 pressure ulcer. The wound care team identified moisture-associated skin damage and recommended a Flexi Seal system to prevent stool contamination. However, the facility did not secure the device, and the resident's condition worsened, with the ulcer becoming unstageable and infected, necessitating hospitalization and surgical debridement. Throughout the period from early August to mid-September, multiple progress notes from nurse practitioners and physicians highlighted the need for the Flexi Seal system, yet it remained unavailable. The resident's condition continued to decline, with increased necrosis, malodor, and infection, ultimately leading to a hospital admission for surgical intervention. The Director of Nursing confirmed the facility's failure to obtain the recommended fecal management system, contributing to the resident's deteriorating condition.
Deficiencies in Skin and Wound Care Documentation and Management
Penalty
Summary
The facility failed to provide safe and effective skin and wound care for several residents, as evidenced by the lack of regular and accurate documentation of weekly skin checks and non-pressure ulcer wound evaluations. Resident #25's care plan indicated a need for weekly treatment documentation of skin injuries, yet there were inconsistencies in the documentation of skin evaluations and wound assessments. Observations revealed compromised skin on Resident #25's thigh and bottom, with visible open spots, contradicting the medical record that lacked recent wound assessments. Resident #30's care plan did not address a fungal rash in the groin area, despite observations of a red rash causing pain during incontinence care. The care plan and skin evaluations failed to document this condition, even though a physician had ordered treatment for the rash. Similarly, Resident #34 did not have weekly skin evaluations, and there was no documentation of multiple bruises and scabs observed on the resident's body. Resident #51, admitted after hip surgery, also lacked completed weekly skin evaluations, despite having multiple open lesions documented in a nurse practitioner's note. The facility lacked a system to ensure accurate weekly skin assessments and wound evaluations, with no written procedures for staff to follow. Interviews with the Director of Nursing and other staff confirmed the absence of comprehensive skin assessments and documentation. Additionally, Resident #291 expressed concerns about staff's knowledge of using a wound vac, and observations showed the device was not properly attached to suction for several hours. The facility did not have a standard of practice for using the wound vac, and staff had not completed competencies for its use, leading to inadequate wound care for the resident.
Failure to Implement Infection Control Protocols
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for residents on precautions. Observations revealed that a Licensed Nursing Assistant (LNA) assisted two residents, one with a diagnosis of MRSA and the other with ESBL, without wearing the required gown. This was confirmed by a Licensed Practical Nurse who acknowledged that the LNA should have been wearing a gown while providing personal care to these residents. Additionally, another observation noted that two LNAs assisted a resident with diabetes and neuropathy, who was on Enhanced Barrier Precautions due to open areas on the lower left extremity, without wearing gowns. The Infection Preventionist confirmed that the residents were on precautions and that the LNAs should have been wearing gowns and gloves during personal care activities. These actions demonstrate a failure to adhere to the infection control protocols designed to prevent the transmission of communicable diseases.
Lack of Competency in Wound Vac Use
Penalty
Summary
The facility failed to ensure that all licensed nurses possessed the necessary competencies and skill sets to care for residents' needs as identified through assessments and care plans. Specifically, two residents with wound vacs, which are devices that promote wound healing using suction, were affected. A review of records revealed that none of the direct care staff responsible for these residents had documented competencies for using a wound vac. During an interview, the facility's Nurse Educator admitted that the facility had not developed a competency checklist for wound vac use, although some staff nurses had been shown how to change the dressing and use the required materials.
Failure to Conduct Annual LNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Licensed Nursing Assistants (LNAs) received annual performance evaluations. This deficiency was identified through a review of employee files for LNAs who have been employed at the facility for over a year. It was found that no performance evaluations had been completed for these LNAs within the past year. During an interview, the Administrator confirmed that the annual performance evaluations for the LNAs had not been conducted.
Failure to Assess Resident After Reported Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed for injuries and complications after reporting an unwitnessed fall, which is a deficiency in meeting professional standards of quality care. The resident, who had a history of falling at home, informed a licensed nursing assistant (LNA) about the fall. The LNA reported the incident to a nurse, who then instructed the LNA to inform the registered nurse (RN) responsible for the resident's care. However, the RN was not made aware of the fall and, as a result, did not assess the resident for any injuries or complications on the day of the incident. Five days later, a nursing progress note documented a large bruise of unknown origin on the back of the resident's head. The facility's incident report and witness statements confirmed that the resident had reported the fall, but no assessment was conducted. The Director of Nursing (DON) confirmed during an interview that the resident should have been assessed immediately following the fall, as per the facility's policy, but this did not occur.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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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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