Elderwood At Burlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Vermont.
- Location
- 98 Starr Farm Rd., Burlington, Vermont 05408
- CMS Provider Number
- 475030
- Inspections on file
- 41
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Elderwood At Burlington during CMS and state inspections, most recent first.
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.
A resident’s record lacked required documentation showing they were educated about, offered, and either received or declined influenza and pneumococcal vaccines. The EMR listed the flu status only as historical without supporting details and did not show any pneumococcal vaccination information. The Infection Preventionist could not produce a consent/declination form and confirmed that documentation of vaccine education, offer, and acceptance or refusal was not available, contrary to facility policies requiring such records.
Surveyors found that a resident’s EMR lacked required documentation showing they had been educated about, offered, and either received or declined the COVID-19 vaccine. The EMR immunization report listed a historical COVID-19 vaccination date, but there was no supporting record of the immunization, consent, or declination. The Infection Preventionist could not provide the facility’s consent/declination form or any other documentation confirming that COVID-19 vaccination education and consent procedures, as required by facility policy, had been completed for this resident.
An LPN was found to have misappropriated multiple controlled pain medications for ten residents by falsifying controlled drug logbooks and related documentation. A nurse first noticed a drastic change in a resident’s PRN medication count and altered documentation during a shift-to-shift controlled count, prompting review of logbooks and MARs. The review revealed overwritten and out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of medications without corresponding MAR entries for several controlled drugs, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine. Handwriting comparisons linked the irregular entries to the LPN, who did not hold an active nursing license, and facility leadership confirmed that medications were removed but believed not to have been administered to the intended residents.
An LPN’s multistate compact license, which had allowed practice in the survey state, expired and was not renewed for that state, leaving the nurse with only a single-state North Carolina license that was not valid where care was being provided. Despite this, the LPN continued to work 11 shifts, including 6 shifts administering medications as an LPN Team Leader, a role requiring a current state LPN license. The Administrator acknowledged awareness of the licensing issue, cited a vacant HR position and an outdated license-tracking spreadsheet, and the former DON reported that review of the personnel file had revealed the expired state license.
An LPN with an expired state nursing license was assigned to pass medications and was later found, through audits of controlled medication logbooks and MARs, to have falsified sign-outs, forged staff signatures, altered dates, and removed controlled pain medications (including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine) without corresponding MAR documentation for ten residents on two units. The issue came to light after a nurse reported that a resident had not received a PRN medication for several months, and subsequent review and staff interviews confirmed that the LPN failed to follow facility policies for controlled substance counts, medication administration, and documentation.
The facility did not send written transfer notices to residents or their representatives when three residents were transferred to outside facilities, nor were copies of these notices sent to the LTC Ombudsman as required. Interviews confirmed that the process for providing these notifications was not followed.
A resident with cognitive impairment and multiple medical conditions was prescribed PRN Lorazepam for itching and anxiety without a required 14-day stop date. The medication was administered multiple times, and the DON confirmed the omission of the stop date in the order.
A resident with multiple chronic conditions and cognitive impairment was given Lisinopril by a nurse despite a systolic blood pressure below the ordered threshold. The medication was administered when the resident's blood pressure was 89/54 mmHg, contrary to the physician's order to hold the medication if systolic blood pressure was under 100 mmHg. The resident subsequently experienced further hypotension and was transferred to the emergency department. There was no documentation of IV normal saline administration prior to transfer, as ordered.
A resident reported allegations of staff misconduct and possible abuse to a State Surveyor, who notified facility leadership and Adult Protective Services. The facility did not report the allegations to the State Survey Agency or document an investigation until a week later, after Adult Protective Services intervened. Interviews confirmed the lack of timely reporting and investigation documentation.
After a resident reported allegations of employee misconduct and possible abuse involving a roommate and a nurse aide, the facility did not document an investigation or implement protective measures. Staff allegedly involved continued to work and had contact with the resident and the alleged victim until Adult Protective Services began an investigation several days later.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. Multiple residents reported long waits for assistance with ADLs, such as toileting and transferring, and some experienced falls due to lack of timely help. Staff interviews confirmed the facility's staffing shortages, with supervisory staff often covering shifts. A review of schedules showed numerous unfilled shifts, highlighting the facility's inability to meet residents' needs.
Several residents in the LTC facility experienced significant delays in receiving assistance with ADLs due to staffing shortages. A resident with mobility impairments waited over an hour for incontinence care, while another resident experienced a fall after attempting to use the bathroom independently due to delayed staff response. Additionally, residents reported missed showers and long waits for transfers, with LNAs confirming insufficient staffing to meet care needs.
The facility failed to monitor adverse effects of psychotropic medications for three residents. A resident with Alzheimer's was lethargic and sleepy due to multiple psychotropic drugs, with no evidence of monitoring or provider notification. Another resident on RisperiDONE and a third on Lorazepam and Zoloft also lacked documented monitoring. The facility's policy requires such monitoring, but it was not followed.
A facility failed to ensure accurate review of a resident's care plan during required visits. The resident, with Alzheimer's and behavioral issues, had discrepancies in physician notes regarding prescribed medications. Despite Seroquel being discontinued, it was still listed in notes. The DON confirmed the inaccuracies, indicating a failure to review the resident's care plan as required.
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.
Failure to Document Influenza and Pneumococcal Vaccination Status for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s documentation of influenza and pneumococcal vaccinations for one resident. Record review on 03/25/2026 showed that Resident #124 was admitted on an unspecified date, and the EMR contained no documentation that the resident or their representative had been educated about, offered, and had either received or declined influenza and pneumococcal vaccines. An Immunizations Report from the EMR listed the resident’s influenza status as historical but did not include supporting documentation of the immunization, nor did it indicate whether the resident had received a pneumococcal vaccination. During interviews on 03/25/2026, the Infection Preventionist was unable to provide a Vaccination Review: Consent/Declination SNF Resident Form for this resident and confirmed that documentation of offering, educating, and either receiving or declining the influenza and pneumococcal vaccinations was not available. This lack of documentation was inconsistent with the facility’s written policies, which require education, completion of consent/declination forms, and placement of immunization documentation or reasons for non-immunization in the resident’s record.
Failure to Document COVID-19 Vaccination Education and Status for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for COVID-19 vaccination education, offering, and documentation for one of six sampled residents. Record review on 03/25/2026 showed that Resident #124, admitted on an unspecified date, had no documentation in the EMR indicating that the resident or representative had been educated about, offered, received, or declined the COVID-19 vaccine. An Immunizations Report from the EMR listed the resident’s COVID-19 vaccination status as “historical” with a date of 12/5/24, but there was no supporting documentation of the immunization itself. During interviews on 03/25/2026, the Infection Preventionist was unable to produce the facility’s Vaccination Review: Consent/Declination SNF Resident Form for this resident and confirmed that documentation of offering education and obtaining consent or declination for COVID-19 vaccination was not available, despite the facility’s written policy requiring written affirmation for declinations, provision of vaccination fact sheets, and informed consent (written or verbal) for all individuals being vaccinated. This lack of documentation for Resident #124’s COVID-19 vaccination education, offer, consent/declination, and administration status constituted the cited deficiency.
Misappropriation and Falsified Documentation of Controlled Medications by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to ensure accurate, non-fraudulent documentation of controlled drug administration. A concern was first raised when a nurse, during a change-of-shift controlled drug count, noticed that the count for a resident’s PRN medication had drastically changed since her prior shift, and that her own documentation had been altered. Subsequent review of controlled medication logbooks and MARs for multiple residents revealed overwritten entries, out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding MAR documentation. These irregularities involved six different controlled pain medications, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine, and affected ten residents across two units. Interviews and handwriting comparisons identified an LPN as the individual responsible for the irregular logbook entries. The Administrator confirmed that the LPN’s handwriting matched the questionable entries and that the LPN was involved in ten incidents of removing medications believed not to have been administered to the prescribed residents. The DON and other nursing staff reported that the controlled medication counts themselves were correct, but the signatures and dates in the logbooks did not match staff who had actually worked the shifts, and the sequence of dates was inconsistent with proper administration. The LPN was described as visibly shaky when asked to provide a handwriting sample and did not clearly deny involvement when questioned. It was also confirmed that this LPN did not hold an active state nursing license, and the facility acknowledged a failure to protect residents from this LPN’s misappropriation of medications.
Unlicensed LPN Worked Multiple Shifts and Administered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by a nurse holding an active state license as required for the position. Review of credentials for an LPN under investigation for misappropriation of medications showed that the nurse’s multistate compact license, which had permitted practice in the survey state, had expired on a specified date. A nursys.com search confirmed that the LPN then only held an active single-state license in North Carolina, which was not valid for practice in the survey state. Despite this, the LPN continued to be scheduled and worked 11 shifts after the compact license expiration, including 6 shifts in which medications were administered in the role of an LPN Team Leader, a position whose job description requires a current state LPN license in good standing for the state of employment and includes administering medications and treatments as an essential function. Interviews and record review further showed that the Administrator was aware that the LPN’s license status had changed and stated that the LPN had selected the wrong option during renewal, resulting in a single-state license rather than a multistate compact license that included the survey state. The Administrator also reported that the Human Resources position was vacant and that the spreadsheet used to track staff license expiration dates had not been updated. The former DON stated that during a review of the LPN’s personnel file, it was identified that the LPN’s state nursing license needed for the position had expired, and that the Administrator had taken on the task of researching the expired license. Despite the facility’s stated expectation that staff must have an active license in the state to work, the LPN continued to work multiple shifts without a valid license for that state.
Unlicensed LPN and Falsified Controlled Medication Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff administering medications maintained current licensure and followed required procedures for controlled substances. A concern was raised when an oncoming medication nurse reported that a resident had not received a PRN medication for three months, which the nurse confirmed with the resident. In response, the facility reviewed all controlled medication logbooks and medication administration records and identified irregularities involving one LPN on two units and affecting ten residents. The irregularities included falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding documentation on the medication administration records. During the facility’s investigation, it was discovered that the LPN suspected of these irregularities had been working with an expired state nursing license, despite being assigned to medication administration duties. Interviews with the Administrator and the former DON confirmed that the LPN did not hold a current state license required for the position and that the LPN had fraudulently removed controlled medications, including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine, without following facility policies for administration and documentation. Facility policies required that a licensed nurse administer medications in compliance with state and federal laws, that controlled substances be counted and verified at shift change, and that documentation corrections be made properly by the original author, but these procedures were not followed by the LPN.
Failure to Provide Required Transfer Notifications and Ombudsman Notices
Penalty
Summary
The facility failed to provide required written documentation and notifications regarding resident transfers to outside facilities. Specifically, for one resident who was transferred for geriatric psychiatric care, there was no written notice sent to the resident or their representative. Additionally, for two other residents who were transferred to the hospital, there was no record of written transfer information being sent to their family representatives. Review of the facility's policy indicated that such notifications should be sent following any emergency discharge or planned transfer, but this was not done in these cases. Furthermore, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman for any of the three residents involved. The transfer forms had a designated section for documenting that a copy was sent to the Ombudsman, but this section was left blank for all three cases. Interviews with the Ombudsman and the DON confirmed that the required notifications were not sent, and the process for doing so was not being followed at the time of the incidents.
Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications by prescribing an as-needed Lorazepam order for a resident with vascular dementia, chronic kidney disease, and COPD, who was cognitively impaired with a BIMS score of 9. The physician's order for Lorazepam 0.5 mg every 6 hours as needed for itching and anxiety did not include a required 14-day stop date. The resident received Lorazepam eight times over a period of approximately three weeks. The DON confirmed during interview that the order lacked the appropriate stop date documentation.
Significant Medication Error: Lisinopril Administered Despite Low Blood Pressure
Penalty
Summary
A significant medication error occurred when a resident with a history of Type II Diabetes, Alzheimer's Disease, schizoaffective disorder, and anxiety, who was cognitively impaired with a BIMS score of 4, was administered Lisinopril despite a documented systolic blood pressure of 89/54 mmHg. The physician's order clearly stated that Lisinopril should be held if the systolic blood pressure was under 100 mmHg and the provider should be notified. The medication was administered by a licensed nurse during the morning medication pass, contrary to the order and facility policy. Following the administration, the resident experienced hypotension with blood pressure readings dropping as low as 77/45 mmHg. The resident was found on the floor by a CNA, assessed for injury, and subsequently transferred to the emergency department as ordered by an advanced practice nurse. There was no documentation that normal saline was administered via IV prior to the transfer, as ordered. The Director of Nursing confirmed the medication error and the lack of IV administration before hospital transfer.
Failure to Timely Report Alleged Abuse and Initiate Investigation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime as required by section 1150B of the Act. A resident reported allegations of employee misconduct and possible abuse involving their roommate and a Licensed Nursing Assistant to a State Surveyor, who then informed both the facility's former Administrator and Assistant Director of Nursing, as well as Adult Protective Services, on the same day. Despite this, the facility did not report the allegations to the required State Survey Agency until seven days later, when Adult Protective Services arrived to investigate. Interviews with the current Administrator, Director of Nursing, and Assistant Director of Nursing confirmed that there was no documentation of an investigation or timely reporting to the State Survey Agency prior to the involvement of Adult Protective Services. No additional evidence of timely reporting or investigation was provided by the facility.
Failure to Implement Immediate Protective Measures After Abuse Allegation
Penalty
Summary
The facility failed to take immediate action after being notified of allegations of employee misconduct and possible abuse involving a resident and their roommate by a Licensed Nurse's Aide. The State Surveyor reported these allegations to the former Administrator and Assistant Director of Nursing on the same day they were made, and also notified Adult Protective Services. Despite this notification, there was no documentation of an investigation being conducted by the facility prior to the arrival of Adult Protective Services seven days later. During this period, the staff members allegedly involved in the incident continued to work and had contact with both the resident who made the allegation and the alleged victim. The current administrative staff confirmed that no protective measures were implemented following the initial report of the allegations.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents reported delays in receiving assistance with activities of daily living (ADLs), such as toileting and transferring, which are critical for their well-being. For instance, one resident with cerebral palsy and schizoaffective disorder was left in soiled conditions for over an hour, despite having a care plan that required prompt incontinent care. Another resident, who is always incontinent, reported waiting for hours for assistance, with multiple staff members acknowledging the delay but failing to provide the necessary care. The deficiency extended to other areas of care, including meal assistance and fall prevention. A resident with a history of falls and moderate cognitive impairment attempted to use the bathroom independently after waiting for staff assistance, resulting in a fall. Additionally, residents expressed dissatisfaction with the frequency of showers and the timeliness of call bell responses, indicating a systemic issue with staffing levels. Interviews with staff confirmed that the facility was understaffed, with licensed nursing assistants (LNAs) and unit managers frequently covering shifts outside their usual roles. The facility's staffing challenges were further highlighted by a review of schedules, which revealed numerous unfilled shifts and reassignments. The Director of Nursing and other supervisory staff often had to step in to cover for absent nurses, indicating a persistent shortage of direct care staff. This shortage impacted the facility's ability to provide timely and adequate care, as evidenced by the unmet needs of residents across various units. The report underscores the facility's failure to maintain adequate staffing levels to ensure the health and safety of its residents.
Inadequate Assistance with ADLs Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to significant delays in care. Resident #7, who is cognitively intact but has mobility impairments, reported soiling themselves and waiting over an hour for assistance, with their call light going unanswered for extended periods. Similarly, Resident #10, who requires assistance for incontinence care, experienced delays in receiving care, with multiple staff members acknowledging the need but failing to provide timely assistance. These incidents highlight a pattern of inadequate response to residents' needs, particularly in toileting and incontinence care. Resident #1, who is dependent on staff for eating and prefers to dine in a common area, was consistently left to eat in bed, contrary to their care plan and the wishes of their representative. Resident #8, with moderate cognitive impairment, experienced a fall after attempting to use the bathroom independently due to delayed staff response to their call light. This lack of timely assistance not only contravenes the care plans but also poses safety risks to residents. The facility's staffing issues are further underscored by Resident #4 and Resident #5, who reported long waits for assistance with transfers due to insufficient staff. A confidential resident interview and a Power of Attorney for another resident also highlighted missed showers and inadequate care due to staffing shortages. Interviews with LNAs confirmed the facility's staffing challenges, with insufficient personnel to meet the needs of residents requiring two-person assistance for ADLs, exacerbating delays and compromising care quality.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to monitor three residents for adverse side effects related to psychotropic medications. Resident #9, diagnosed with Alzheimer's and dementia with behavioral disturbances, was prescribed multiple psychotropic medications, including Haloperidol, Lorazepam, and Zyprexa, which have significant side effects such as drowsiness. There was no documented evidence of monitoring for adverse effects prior to medication administration. Observations revealed that Resident #9 was lethargic and often sleepy, with no evidence that providers were notified or that symptoms were addressed. Despite recommendations for medication adjustments, Resident #9 was restarted on antipsychotic medications without documented evidence of following the recommendations. Resident #5 was prescribed RisperiDONE for agitation and behaviors, but there was no documentation of monitoring for side effects or adverse reactions since the medication was started. Similarly, Resident #10 was prescribed Lorazepam and Zoloft, with no documented evidence of monitoring for adverse effects or an interdisciplinary team meeting. The facility's policy requires monitoring for efficacy and adverse consequences of psychotropic drugs, but interviews with the Director of Nursing confirmed the lack of documented monitoring for these residents.
Failure to Accurately Review Resident's Care Plan During Visits
Penalty
Summary
The facility failed to ensure that physicians and other providers reviewed the total program of care, including medications and treatment plans, for a resident during required visits. Specifically, for one resident with Alzheimer's disease and behavioral issues, the physician notes from multiple visits inaccurately reflected the medications the resident was actually prescribed. For instance, a physician note dated June 4, 2024, mentioned that the resident was on Seroquel, Haldol, and Ativan, despite Seroquel having been discontinued on May 23, 2024. Similarly, subsequent notes on July 20, 2024, and August 5, 2024, continued to list medications that did not match the resident's actual orders at the time. The discrepancies in the physician notes were confirmed by the Director of Nursing during an interview on August 14, 2024. The Director acknowledged that the provider visits did not accurately review the resident's total program of care, as required by regulations. This oversight resulted in a failure to ensure that the resident's care plan was appropriately reviewed and updated during regulatory visits, potentially impacting the resident's treatment and care.
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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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