Green Mountain Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Colchester, Vermont.
- Location
- 475 Ethan Allen Avenue, Colchester, Vermont 05446
- CMS Provider Number
- 475040
- Inspections on file
- 15
- Latest survey
- June 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Green Mountain Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain an effective QAPI program, failing to identify and address issues in pressure ulcer prevention, physician supervision, administration, and Medical Director oversight. As a result, a resident developed a facility-acquired stage II pressure ulcer that worsened and required two surgeries due to delayed care. The facility lacked a tracking system for pressure ulcers, did not consistently discuss these issues in QAPI meetings, and failed to monitor mandatory staff training. Medication audits showed widespread late or missed doses, including significant medication errors.
Several residents with existing or high risk for pressure ulcers did not receive timely wound care, regular skin assessments, or preventive interventions as ordered by wound care consultants and providers. Wound care orders were often not implemented for days or weeks, and documentation of wound assessments and care plan updates was lacking. This led to the development and worsening of pressure injuries, including cases requiring hospitalization for infection and surgical intervention.
A review of HR files and education records showed that most sampled direct care staff, including LNAs and LPNs, lacked documented completion of required QAPI training. The Administrator confirmed that no additional evidence of training was available beyond what was in the employee files.
A resident was found with a bruise on their face, which was not reported to the state agency as required. The incident was not communicated during shift change, and no internal report was completed. The facility's policies mandate immediate reporting of such incidents, but the administrator confirmed the state agency was not informed in time. The RN on duty was unaware of the bruise until the family reported it, and no investigation was initiated.
A resident sustained a bruise of unknown origin after sliding out of bed, which was not reported or investigated by the facility staff. The incident was only noted after the resident's family requested hospital evaluation. Interviews revealed that the staff failed to communicate the incident to the DON or Administrator, leading to a deficiency.
A facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident. The care plan was not signed or dated and lacked documentation of the resident's admission goals, functional abilities, fall status, code status, and other essential care needs. Additionally, it did not include the resident's daily preferences or family involvement in care discussions.
A resident with severe cognitive impairment developed a stage 2 pressure ulcer that worsened to a stage III with infection due to the facility's failure to provide timely wound care, update the care plan, and ensure consistent treatment and monitoring. The care plan was not updated for 56 days, and the resident missed multiple wound treatments as ordered by the physician.
The facility failed to notify residents and their representatives in writing before transferring them to the hospital, as required by regulations. This deficiency was identified for four residents, and staff interviews confirmed the lack of proper documentation and adherence to procedures.
The facility failed to store food in accordance with professional standards, with multiple items found without dates or labels in the refrigerator/freezer and dry storage areas. Additionally, the milk cooler recorded temperatures above the acceptable range, and the milk was stored in an unplugged refrigerator without temperature monitoring. These practices indicate significant lapses in food safety protocols.
The facility failed to implement and maintain an effective training program for all new and existing staff related to QAPI, communication, and emergency preparedness. None of the sampled staff had completed the required training, and new hires worked assignments without evidence of onboarding education. Interviews revealed gaps in the training process and lack of follow-up on training completion.
The facility failed to provide a homelike environment during meals, as six residents, including two on puree diets, received their lunch on paper plates. The Registered Dietitian confirmed a month-long shortage of regular plates, which were later found in storage by the administrator.
The facility failed to update the care plans for two residents following significant changes in their conditions. One resident's care plan was not updated for 24 days after a fall resulting in severe rib pain, and another resident's care plan was not updated to include G-tube care after hospitalization for sepsis.
The facility failed to prepare a comprehensive discharge summary and post-discharge plan for a resident, as required by their policy. The discharge instructions provided did not include most of the required elements, and the staff were unaware of the detailed requirements.
The facility failed to maintain complete and accurate records, including missing physician notes, x-ray results, and medication reviews. Additionally, care plan meetings for several residents were not documented as required.
The facility failed to develop a comprehensive, person-centered care plan for a resident with depression, demoralization, and apathy, who frequently refused care. Despite staff reapproaching multiple times to provide care, the care plan did not include goals or interventions to address the resident's refusals, as required by facility policy.
A resident with a documented allergy to Tramadol was administered the medication following a physician's order. The DON confirmed the administration despite the known allergy.
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents. One resident with Alzheimer's and a history of falls did not have their care plan updated after multiple falls, and another resident with mobility issues did not have a fall risk care plan prior to an unwitnessed fall. The facility did not follow its own policies for post-fall evaluations and care plan updates.
A resident with a urinary catheter did not receive appropriate care to prevent infections. The LNA failed to follow infection control standards and facility policies during a catheter bag change, putting the resident at risk. The DON confirmed that the correct procedures were not followed.
The facility failed to ensure residents maintain acceptable nutritional status, evidenced by lack of weight monitoring for one resident with Congestive Heart Failure and inadequate follow-up on significant weight loss for another resident with metabolic encephalopathy and Diabetes. Both residents' care plans lacked necessary interventions.
A facility failed to provide proper care and treatment for a resident with a g-tube. The resident's medical record lacked a care plan, physician orders, and documentation of g-tube site care for over nine months. Additionally, the facility did not obtain necessary orders after the resident returned from a hospital visit for g-tube repair.
The facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses were completed and documented for a resident taking Digoxin. A pharmacy recommendation for lab work was not reviewed by the physician, and the required blood work was delayed.
A resident with depression continued to receive Citalopram 40 mg daily despite a pharmacist's recommendation for a gradual dose reduction. The physician did not review or attempt the GDR until nearly two months later, as confirmed by the Director of Nursing.
A facility failed to maintain proper infection control during catheter care for a resident with Flaccid Neuropathic Bladder. Observations revealed exposed, unlabeled leg bags with residual urine, improper handling of the foley bag, and lack of hand hygiene and alcohol cleaning of catheter ends. The LNA and DON confirmed these lapses against facility policy.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon discharge to the hospital. This deficiency was identified for four residents, with no documentation of the bed hold policy being provided during multiple hospital transfers. The RN Unit Manager, Social Worker, and Administrator confirmed the absence of such documentation.
Failure to Implement Comprehensive QAPI Program and Oversight
Penalty
Summary
The facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed all systems of care, resulting in significant deficiencies. Specifically, the facility did not identify or address problems related to the prevention and treatment of pressure ulcers, physician supervision of resident care, administration, and oversight by the Medical Director. This lack of oversight led to a resident developing a facility-acquired stage II pressure ulcer that worsened and required two surgical interventions due to delayed identification and treatment. The facility also had other cases of facility-acquired pressure ulcers and had no tracking system in place to monitor skin issues or pressure ulcer progression, despite this being a repeat deficiency. Additionally, the facility's QAPI meetings did not consistently address critical issues such as pressure ulcers, as confirmed by both the Administrator and Medical Director, with no evidence of discussion or subcommittee meetings on these topics since the previous year. The facility also failed to monitor and track mandatory staff training in key areas, including communication, resident rights, abuse, neglect, QAPI, infection control, compliance, and behavioral health. Medication administration audits revealed that approximately 50 residents experienced late or missed medications, with about 2,900 instances of late or missed doses and 15 significant medication errors. These deficiencies were identified during a recertification survey, which also found multiple repeat deficiencies and cited the facility at the immediate jeopardy level for QAPI non-compliance.
Failure to Prevent and Treat Pressure Ulcers Resulting in Harm and Immediate Jeopardy
Penalty
Summary
Multiple residents experienced significant lapses in pressure ulcer prevention and treatment, resulting in the development and worsening of pressure injuries. Residents with existing wounds or at high risk for pressure ulcers did not receive timely or appropriate wound care interventions as ordered by wound care consultants and medical providers. In several cases, wound care orders were not implemented for days or weeks after being written, and there was a lack of documentation of wound assessments, pain evaluations, and care plan updates. For example, one resident was admitted with multiple pressure ulcers and wounds, but wound treatments were not documented as completed until several days after admission, and subsequent wound care recommendations were repeatedly not implemented in a timely manner. Another resident developed a new deep tissue injury and experienced delays in both wound care and recommended diagnostic workups for possible infection, with the wound care consultant unaware that her recommendations were not being followed due to lack of access to the electronic health record. Other residents at risk for pressure ulcers did not receive regular skin assessments or preventive interventions such as offloading heels, despite care plans indicating their risk. In one case, a resident with a history of heel redness did not have weekly skin assessments or heel offloading interventions in place until after deep tissue injuries were discovered during a facility-wide skin sweep. Another resident developed a stage 1 pressure ulcer and later a suspected deep tissue injury, but did not receive a full wound assessment or pain evaluation until days after the ulcer was identified, and offloading interventions were delayed. A resident admitted for rehabilitation with a pressure ulcer on the coccyx experienced worsening of the wound without additional assessment or documentation, even as the wound increased in size and a new heel ulcer developed. Across these cases, the facility failed to follow its own policies for pressure injury prevention and management, including prompt evaluation, care plan development, and communication among staff and providers. The lack of coordination and documentation led to missed or delayed treatments, unaddressed wound deterioration, and, in one case, a resident requiring hospitalization for osteomyelitis and sepsis related to a pressure ulcer.
Failure to Ensure Staff Completion of Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that all staff completed mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. A review of employee Human Resources files and the Education Tracking spreadsheet revealed that there was no evidence of QAPI training for nine out of ten sampled permanent and contracted direct care staff, including both LNAs and LPNs. During an interview, the Administrator confirmed that the reviewed employee files contained the only available documentation for staff training and competencies, and was unable to provide evidence that the required QAPI training had been completed by the identified staff members.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state licensing agency as required for a resident. The incident involved a resident who was found with a bruise on their face, which was noticed by their family representative. The resident mentioned falling out of bed but was unsure how the bruise occurred. The incident was not reported to the oncoming nurse during the shift change, nor was it communicated to the nursing supervisor. The injury was only noted after the family representative called the facility and requested the resident be sent to the hospital. The facility's policies require immediate reporting of suspected abuse or incidents of unknown injuries to the administrator and the state agency. However, there was no documentation of the incident in the clinical record, and no internal incident report was completed. The facility administrator confirmed that the state agency was not informed within the specified time frame. Additionally, the RN on duty was unaware of the bruise or the reported fall until informed by the family, and no investigation was initiated into the bruise of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who sustained a bruise of unknown origin. The resident, who was assisted back into bed by three staff members after sliding out of bed, was found to have a bruise on the face. The incident was not reported to the oncoming nurse during the shift change, nor was it communicated to the nursing supervisor. The injury was only noted after the resident's family representative called the facility and requested that the resident be sent to the hospital for evaluation. The resident was subsequently admitted to the hospital with severe posterior thigh pain and an abrasion on the forehead, which the family confirmed was new. Interviews with facility staff revealed that the incident was not reported to the Director of Nursing Services or the Administrator, and no investigation was initiated into the bruise of unknown origin. The Registered Nurse on duty confirmed being unaware of the bruise or the reported fall until informed by the family. This lack of communication and failure to follow the facility's policy on reporting and investigating injuries of unknown origin led to the deficiency identified in the report.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident. The baseline care plan was neither signed nor dated by the resident or the staff responsible for completing it. Additionally, the care plan lacked documentation of the resident's admission goals, functional abilities, fall status, code status, initial/admission goals, educational needs, and social service needs. There was also no documentation regarding the resident's status on eating, oral hygiene, transfers, ambulation, therapy goals, and social services. Furthermore, the care plan did not include the resident's daily preferences, such as choosing clothes, caring for personal belongings, bathing preferences, and family involvement in care discussions.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for a resident with a pressure ulcer. The resident, who has severe cognitive impairment and is at risk of developing pressure ulcers, was admitted with no pressure ulcers but developed a stage 2 pressure ulcer on the left gluteal area. The facility did not update the resident's care plan to reflect the new pressure ulcer until 56 days after it was identified. Additionally, the care plan did not include necessary interventions such as weekly wound assessments, wound treatment orders, or frequent monitoring of wounds and/or dressings. The resident did not receive treatment for the pressure ulcer on multiple occasions as ordered by the physician, and there was no evidence of daily monitoring for complications. The resident's pressure ulcer worsened over time, progressing to a stage III pressure injury with infection. The wound increased in size and caused significant pain to the resident. The facility's failure to provide timely and appropriate wound care, update the care plan, and ensure consistent treatment and monitoring led to the deterioration of the resident's condition. The Assistant Director of Nursing confirmed the deficiencies in wound assessment, treatment, and care plan updates during an interview.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to notify residents and their representatives in writing before transferring them to the hospital, as required by regulations. This deficiency was identified for four residents. Resident #21 was transferred to the hospital twice without any documentation of a discharge/transfer notice being provided. Similarly, Resident #39 was sent to the hospital for evaluation and treatment due to sudden onset of pain, but there was no documentation of a transfer/discharge notice. Resident #52 was also sent to the hospital following a fall, and again, no transfer/discharge notice was documented. Resident #167 reported being transferred to the hospital twice without receiving any notice, and record reviews confirmed the absence of such documentation for both transfers. Interviews with staff, including Registered Nurse Unit Managers and the Social Worker, confirmed that the facility did not provide the required transfer notices. Additionally, it was discovered that blank transfer notices with pre-signed Administrator signatures were kept in residents' charts, but these were not used appropriately. The Administrator acknowledged that the facility's current practice for handling transfer notices did not meet regulatory requirements.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to consistently store food in accordance with professional standards for food service safety. During an initial tour of the facility kitchen, several items in the refrigerator/freezer were found without dates or labels, including packages of donuts, English muffins, mixed iced tea, baked cake layers, hash browns, pepperoni, fish, beef teriyaki, mayonnaise, and pickles. Additionally, there were issues with food storage in the dry food storage area, where a large bag of dry pancake mix and racks of muffins were found without dates or labels. The dietary manager was unable to confirm when the pancake mix was opened, and the bag was not properly secured shut. Furthermore, there were instances of improper food storage in metal pans covered with aluminum foil that had tears, exposing the food inside to potential contamination. A review of refrigerator temperatures revealed that the milk cooler had recorded temperatures above the acceptable range on multiple occasions in August and November. The milk was removed and stored in an unplugged refrigerator in the basement, but the temperature of this refrigerator was not monitored while the milk was stored there. Interviews with the kitchen manager and maintenance supervisor confirmed these practices, indicating a lack of consistent monitoring and adherence to food safety standards. These deficiencies highlight significant lapses in the facility's food storage and safety protocols, potentially compromising the safety and quality of food served to residents.
Failure to Implement and Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff related to QAPI, communication, and emergency preparedness. This deficiency was identified for 10 of 10 sampled direct care staff and 3 of 3 sampled contracted staff. The facility's policy required all staff to participate in initial orientation and annual in-service training, including effective communication, QAPI, and emergency preparedness. However, a review of direct care staff education files revealed that none of the sampled staff had completed the required training. Additionally, three staff members hired within the past year did not have evidence of onboarding education in their files. Interviews with the Staff Educator and Human Resource Specialist further highlighted the deficiencies. The Staff Educator, who is also the Director of Nursing, indicated that onboarding education consists of new staff reading handouts and taking quizzes, but there was no communication training, and the educator was not responsible for emergency preparedness and QAPI training. The Human Resource Specialist confirmed that new employees receive handouts and quizzes but admitted there was no system to ensure quizzes were reviewed or followed up on. Contracted staff did not return quizzes, and employees could work assignments without completing the required training. The lack of evidence of completed training for new hires and the absence of specific training in the onboarding packet were also confirmed.
Failure to Provide Homelike Environment During Meals
Penalty
Summary
The facility failed to provide a homelike environment during meals, as observed on 3/25/24. Six out of twelve residents in the main dining room received their lunch on paper plates, including two residents on puree diets. The paper plates for the puree diets appeared wet and weakened by the liquid food. Other residents in the dining room had regular plates. The Registered Dietitian confirmed that the facility had been experiencing a shortage of regular plates for about a month, leading to the use of paper plates. The facility administrator later found two cases of regular plates in the storage area, confirming the use of paper plates for the past month.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised for two residents. Resident #6, who was admitted with diagnoses including heart failure and chronic respiratory failure, experienced a fall resulting in severe right rib pain. Despite the facility's policy requiring care plans to be updated with changes in a resident's condition, Resident #6's care plan was not updated until 24 days after the fall. The Director of Nursing confirmed that the care plan should have been updated immediately following the incident. Resident #1, admitted with diagnoses including ALS and paraplegia, was hospitalized for sepsis and had a G-tube inserted during the hospital stay. Upon returning to the facility, the care plan for Resident #1 was not updated to include the G-tube care, contrary to the facility's policy. The Director of Nursing confirmed that the care plan should have been updated to reflect the new medical intervention and care requirements.
Failure to Provide Comprehensive Discharge Summary and Plan
Penalty
Summary
The facility failed to prepare a discharge summary that included a final summary of the resident's status and a post-discharge plan of care for one resident. The facility did not have a system in place to prepare a discharge summary that included all the required elements for any resident with the potential for discharge. This deficiency was identified during a review of Resident #64's records, who was admitted for therapy related to a fractured femur and discharged home. The review revealed that the discharge instructions provided to the resident did not include most of the required elements as stated in the facility's policy. The Resident Family Service Coordinator (RFSC) confirmed that the discharge instructions form used for all residents did not contain the required elements and that they were unaware of the detailed requirements outlined in the facility's discharge summary and plan policy. The facility's policy, adopted in September 2022, mandates that a discharge summary and post-discharge plan be developed and provided to the resident when a discharge is anticipated. The policy specifies that the discharge summary should include a comprehensive summary of the resident's status, including current diagnosis, medical history, functional status, and other relevant details. The post-discharge plan should outline the resident's discharge goals, caregiver availability, and support for the transition to post-discharge care. However, the facility's current practice of using a discharge instructions form and a medication list did not meet these requirements, leading to the deficiency identified in the report.
Deficiencies in Record Keeping and Documentation
Penalty
Summary
The facility failed to ensure that records were complete, accurately documented, readily accessible, and systematically organized. For Resident #63, the physician's note from a visit on 1/11/2024 and the x-ray results from 1/12/2024 were missing from both the electronic medical record and the paper chart. The resident had shown respiratory symptoms and was confirmed positive for RSV before passing away on 1/12/2024. The Administrator confirmed the absence of these critical documents. Additionally, Resident #56's records showed no evidence of provider visits after 9/5/2023, and the Unit Manager admitted to not knowing how the facility was managing the transfer of resident information from paper charts to the electronic health record (EMR). Furthermore, 25 documents containing provider information were missing from both the paper chart and the EMR, and a Licensed Practical Nurse (LPN) reported not having access to the EMR system, Prism. The Unit Manager confirmed that the facility was not maintaining medical records in a systematically organized manner that was readily accessible. The facility also failed to maintain accurate medication reviews and care plan revision notes. Resident #35's monthly Consultant Pharmacist's Medication Regimen Review recommendations for September and October of 2023 were not available in the medical record, which was confirmed by the Director of Nursing (DON). Additionally, care plan meetings for Residents #52, #39, and #35 were not documented as required in February 2024. The last documented care plan meetings for these residents were in November 2023. The DON confirmed the absence of the required care plan review and revision documentation for February 2024.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan that is person-centered and addresses the specific needs and preferences of Resident #30. The resident, who was admitted with diagnoses including depression, demoralization, and apathy, frequently refuses care such as dressing changes and assistance with bathing and dressing. Despite the resident's consistent refusal of care, the care plan did not include any goals or interventions to address this issue. Observations and interviews with staff and family members revealed that the resident often requires multiple attempts before accepting care, but this approach was not documented in the care plan. On multiple occasions, staff members, including a Licensed Nursing Assistant and a wound care nurse, noted that Resident #30 did not respond to requests for care and often pushed away attempts to assist. The facility's policy on comprehensive, person-centered care plans requires that refusals of care be documented and addressed in the care plan, but this was not done for Resident #30. The Director of Nursing confirmed that the care plan lacked documentation regarding the resident's refusal of care, indicating a failure to comply with the facility's own policies and regulatory requirements.
Administration of Medication Despite Known Allergy
Penalty
Summary
The facility failed to ensure that a resident did not receive a medication listed as a known drug allergy in their medical record. Resident #29 had Tramadol documented as an allergy. Despite this, a physician's order dated 3/23/2024 prescribed Tramadol 25 mg to be administered every 8 hours as needed for pain. On the same day, the resident received a dose of Tramadol for pain rated as 5 on a 10-point scale. The Director of Nursing confirmed that the resident was administered Tramadol despite the known allergy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents. Resident #1, who has Alzheimer's dementia and a history of falls, was admitted to the facility after a hip fracture surgery. Despite suffering a fall two days after admission and another incident where staff prevented a fall, the resident's care plan was not updated with new interventions to prevent future falls. Additionally, there was no immediate assessment or notification to the physician after the second fall, and no incident report or fall risk evaluation was completed as required by the facility's policies and procedures. Resident #3, who has Alzheimer's disease, major depressive disorder, and other mobility issues, experienced an unwitnessed fall resulting in a right frontal scalp contusion. The resident did not have a care plan addressing fall risk prior to the incident, and a care plan for falls was only initiated after the fall occurred. The Assistant Director of Nursing confirmed that the resident should have had a fall risk care plan in place before the incident. The facility's failure to implement and document appropriate fall prevention measures and to follow their own policies and procedures for post-fall evaluations and care plan updates contributed to the deficiencies observed. Both residents experienced pain and injury due to the lack of adequate supervision and timely interventions to prevent falls.
Failure to Adhere to Catheter Care Protocols
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter received appropriate treatment and services to prevent urinary tract infections. Resident #14, who has a diagnosis of Flaccid Neuropathic Bladder and requires an indwelling Foley catheter, was observed on 3/26/24 at 1:05 pm during a catheter bag change. The Licensed Nurse Aide (LNA) did not adhere to infection control standards and the facility's policy/procedure, which included washing and drying hands, applying clean gloves, cleaning the catheter/bag junction with an alcohol wipe before disconnecting, and keeping the collection bag below the level of the resident's bladder. These lapses put the resident at risk for infection, as evidenced by the resident's history of urinary tract infections and inflammatory reactions due to the indwelling urethral catheter. The Director of Nursing confirmed in an interview on 3/26/24 at 3:30 pm that the facility's policies should have been followed during the provision of urinary catheter care. The failure to adhere to these policies and procedures during the catheter bag change was a direct cause of the deficiency noted in the report.
Failure to Monitor and Address Nutritional Status
Penalty
Summary
The facility failed to ensure that residents maintain acceptable parameters of nutritional status, as evidenced by the lack of weight monitoring for one resident and a lack of follow-up on significant weight loss for another. Resident #16, diagnosed with Congestive Heart Failure, had no documented order for regular weights after 12/20/23, despite a care plan requiring monthly weight monitoring. The resident regularly refused to get out of bed for weight measurements, and there was no evidence of any efforts by the facility to assess these refusals or explore ways to increase compliance. The dietitian confirmed that there was no provider documentation to support the discontinuation of weight monitoring, and the family had refused meal supplementation for the resident in the past. Resident #56, diagnosed with metabolic encephalopathy and Diabetes, experienced a significant weight loss of 14.6% over 180 days. Despite this, there was no documentation in the care plan addressing the weight loss or interventions to monitor and prevent it. The resident's weight loss was noted by the dietitian and the DON, but no nutrition assessment was performed, and the care plan lacked interventions for weight loss. Observations and interviews with staff indicated that the resident often had poor oral intake and consumed dietary supplements inconsistently.
Failure to Provide Proper G-Tube Care
Penalty
Summary
The facility failed to provide care and treatment of a gastrostomy tube (g-tube) consistent with professional standards for one resident. The resident returned to the facility after a hospital stay that required the placement of a g-tube. However, for over nine months, the resident's medical record lacked a care plan related to g-tube site care, physician orders for site care, documentation of g-tube site care, site assessment, or how the resident tolerated the site care. This is contrary to the facility's policy, which requires a physician order for site care, a care plan review, and documentation of the g-tube site care and assessment by licensed nursing staff. The policy aims to promote cleanliness and protect the g-tube site from irritation, breakdown, and infection. Additionally, the resident experienced complications when the g-tube broke during medication administration, necessitating a hospital visit for repair. Upon the resident's return to the facility, there was no evidence that the facility contacted the provider to obtain orders related to the care and monitoring of the g-tube. An LPN confirmed that the resident did not have physician orders for g-tube care prior to a specific date and acknowledged that such orders should have been in place at the start of care. The LPN also confirmed that the procedure would be to contact the provider to obtain the necessary orders for the resident's g-tube care, which was not done in this case.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses were completed and documented in the resident record for one of the sampled residents. Specifically, a pharmacy recommendation dated 10/24/23 for a resident taking Digoxin stated that lab work for digoxin levels should be obtained every six months, with the most recent lab work recorded on 3/09/2023. However, there was no documented evidence in the resident's medical record that the physician reviewed or addressed the pharmacy recommendations. The Director of Nursing confirmed during an interview that the physician had not reviewed the recommendations and that the required blood work was not performed until 12/20/23.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who uses psychotropic drugs received gradual dose reductions (GDR), unless clinically contraindicated. Resident #6, diagnosed with depression, had a physician's order for Citalopram 40 mg daily. On 10/24/2023, a pharmacist recommended a GDR from 40 mg to 30 mg. However, there was no evidence that a physician reviewed this recommendation or attempted a GDR until 12/15/2023. The resident continued to receive the 40 mg dose daily during this period. The Director of Nursing confirmed that the physician did not review the pharmacy recommendations or attempt a GDR until 12/15/2023.
Infection Control Lapses During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control procedures during catheter care for a resident diagnosed with Flaccid Neuropathic Bladder. The resident required a foley catheter to drain urine, which was connected to a collection bag. During an observation, it was noted that two leg bags in the bathroom were exposed, unlabeled, undated, and had residual urine without caps on the spouts or connectors. The Licensed Nurse Aide (LNA) lifted the foley bag above the resident's bladder, causing a risk of urine backflow, and placed a container on the floor without a barrier, leading to urine spraying on the floor, which was not cleaned up. Additionally, the resident handled the catheter tubing without sanitizing hands or wearing gloves, and the LNA did not clean the catheter ends with alcohol before reconnecting the tubes. The LNA confirmed the lapses in procedure, including the absence of a barrier on the floor, failure to notice and clean the urine on the floor, and not having alcohol wipes handy to clean the catheter ends. The Director of Nursing (DON) confirmed that the facility's policy required rinsing, capping, labeling, and covering unused catheter leg bags, using a barrier when emptying the bag, and cleansing the connector with an alcohol sponge. The DON also confirmed that the resident should have practiced hand hygiene and worn gloves during the procedure.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives received written notification of the bed hold policy upon discharge to the hospital. This deficiency was identified for four residents. Resident #21 was discharged to the hospital twice, on 12/5/23 and 1/29/24, and readmitted on later dates without any documentation of the bed hold policy being provided. The RN Unit Manager confirmed the absence of such documentation. Similarly, Resident #39 was sent to the hospital on 3/24/24, and there was no record of the bed hold policy being given to the resident or their representative, as confirmed by the RN Unit Manager. Resident #52 was also sent to the hospital on 12/28/23 due to a fall, and no documentation of the bed hold policy being provided was found, which was confirmed by the RN Unit Manager. Resident #167 reported being transferred to the hospital twice since their initial admission and did not recall receiving a bed hold notice. Record reviews confirmed that no bed hold notice was provided for transfers on 2/28/24 and 3/15/24. Interviews with the Social Worker and the resident's nurse confirmed the absence of bed hold notices. The Administrator acknowledged that the facility's current practice for bed hold notices does not meet regulatory requirements.
Latest citations in Vermont
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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