Greensboro Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, Vermont.
- Location
- 47 Maggie's Pond Road, Greensboro, Vermont 05841
- CMS Provider Number
- 475043
- Inspections on file
- 17
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Greensboro Nursing Home during CMS and state inspections, most recent first.
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.
Three cognitively impaired residents, all dependent on staff for ADLs and prescribed psychotropic medications for conditions such as Alzheimer's disease and depression, did not have signed consent forms for these medications in their records. The facility also lacked a policy for obtaining psychotropic medication consent, as confirmed by the DON.
Two residents were subjected to verbal abuse by a visitor, specifically a spouse, who confronted and intimidated them in the hallway and in a resident's room. Witnesses reported that one resident became visibly upset and cried, while the other appeared fearful and withdrawn after the incident. The facility did not document the incident, investigate the matter, or implement care plan interventions to protect the residents from further abuse.
Staff and visitors observed a resident's spouse verbally abusing two residents, causing distress and emotional upset. Although one incident was reported to APS, neither incident was reported to the State Licensing Agency as required. Facility leadership confirmed they were unaware of the obligation to report to both APS and the State Licensing Agency.
Two residents were involved in an incident where one resident's spouse verbally confronted another resident, causing distress. The facility did not document the event in the affected resident's record, failed to investigate the allegation of abuse, and did not report the incident to the State Licensing Agency as required. Interviews confirmed that staff were unaware of the need to report such incidents to both APS and the State agency.
Expired Spectrum Hand Sanitizer and Sani-cloth germicidal wipes were discovered in the medication storage area and had not been removed after their expiration. An LPN confirmed the expired status of these items.
The facility did not follow professional standards for food storage and kitchen sanitation, as expired food was found in storage, melted plastic was present on a kitchen wall, and personal items along with a dirty mop bucket were stored in a freezer room, as confirmed by food service staff.
The facility did not complete a required risk assessment to identify areas in the water system where Legionella could grow, as outlined in its own Legionella Water Management Program policy. Both the Administrator and Director of Maintenance confirmed that no such assessment was performed, and areas at risk for Legionella growth were not identified.
A resident exhibiting aggressive behaviors was struck by an LNA with a package of wipes during an altercation, as witnessed by another LNA. The witnessing LNA delayed reporting the incident to administration and authorities, resulting in a failure to promptly notify the proper agencies about the suspected abuse.
A resident receiving hospice and comfort care was administered lorazepam without a documented end date or proper prescriber justification for extending the PRN order beyond 14 days, contrary to facility policy and regulatory requirements. The DON relied on pharmacist review, which did not address the medication, and failed to provide the necessary documentation for continued use.
A resident was transferred to the hospital, but the facility did not provide or document the required bed-hold notice to the resident or their representative, as confirmed by record review and the DON.
A resident with Alzheimer's dementia and a history of multiple falls did not have their care plan properly reviewed, revised, or implemented after repeated incidents. Required interventions such as non-skid strips and a fall mat were not present in the room, and there was no documentation of completed screenings, evaluations, or OT referrals as outlined in facility policy. The DON confirmed that a fall mat should have been in place, but no further assessment results were provided.
A resident receiving hospice services did not have hospice care orders, progress notes, or care plan updates documented in the medical record. The DON confirmed that communication with the hospice provider was only verbal and that no written documentation or records from hospice had been received, resulting in a lack of coordinated and documented hospice care measures.
The facility did not ensure that monthly Medication Regimen Reviews (MMRs) were completed and documented for a resident, and failed to act on a pharmacist's recommendation and physician's order for a digoxin level test for another resident. The DON was unable to provide evidence of the required MMR or the completion of the ordered lab test, despite repeated pharmacist requests.
The facility did not obtain or document laboratory results as ordered for two residents, including a basic metabolic panel and a digoxin level, despite repeated reminders from the consulting pharmacist and physician orders. The DON was unable to locate the required lab results in the records or confirm that the tests were completed as ordered.
The facility failed to assess the competency and skill sets of its nursing staff, including LNAs and LPNs, to ensure they could meet residents' individualized needs. A review revealed that one LNA and two LPNs lacked evidence of required competency evaluations. The Administrator confirmed these findings.
The facility did not employ a full-time or part-time dietitian and lacked a certified Director of Nutrition Services. The Dietary Manager's file showed no certification, and the administrator confirmed these staffing deficiencies.
The facility did not establish a water management program to minimize Legionella risk. The DON, maintenance director, and administrator were unaware of such a program, and no assessment of the building's water system had been conducted.
A resident with severe cognitive impairment was exposed in a common area during medication administration, violating privacy and dignity standards. Additionally, the facility's locked environment restricted residents' autonomy, requiring staff supervision for outdoor access. The facility lacked policies for assessing residents' independence and managing a locked facility, causing frustration among residents and visitors.
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 Obtain Psychotropic Medication Consent for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that three residents with cognitive impairment were fully informed and able to make treatment decisions regarding their prescribed psychotropic medications. Record review showed that all three residents had significant cognitive deficits, as indicated by low BIMS scores, and were dependent on staff for activities of daily living and hygiene. Each resident had been prescribed psychotropic medications, including quetiapine fumarate and lorazepam, for conditions such as Alzheimer's disease, dementia, depression, anxiety, and related symptoms. Despite these prescriptions, there were no signed psychotropic medication consent forms in the medical records of any of the three residents. Additionally, the facility did not have a policy in place regarding obtaining consent for psychotropic medications from residents or their representatives. The DON confirmed during interviews that the facility lacked both the required consent forms and a related policy.
Failure to Protect Residents from Verbal Abuse by Visitor
Penalty
Summary
The facility failed to protect residents from verbal abuse by a visitor, specifically the spouse of one resident, affecting two residents. According to progress notes and interviews, the spouse was reported to have verbally abused their partner and another resident in the hallway, including pointing a finger and making aggressive statements. Witnesses described the affected resident as visibly upset and crying, and noted that the spouse's behavior had been problematic on previous occasions. After the incident, the resident who was verbally abused appeared distressed and hesitant to leave their room. Record reviews revealed that there were no care plan interventions in place to address or prevent further abusive behavior by the visitor toward either resident. Additionally, there was no documentation of the incident or its psychosocial impact on the second resident, nor evidence of an investigation into the event. The Director of Nursing confirmed the occurrence of the verbal abuse and the resulting fear experienced by the resident.
Failure to Timely Report Suspected Abuse Incidents
Penalty
Summary
The facility failed to report incidents of suspected abuse involving two residents. According to interviews and record reviews, a staff member and a visitor reported that a resident's spouse was verbally abusive to both their spouse and another resident. The spouse confronted another resident in the hallway, pointed a finger, and made aggressive statements, causing the second resident to become visibly upset and cry. The spouse then took their partner into a room and closed the door, after which the resident appeared distressed and expressed a desire to leave the room. These events were witnessed by staff and visitors, and were documented in progress notes by the Social Worker and DON. Despite these documented incidents and witness statements, the facility did not submit incident reports to the State Licensing Agency for either resident. While a report was filed with Adult Protective Services (APS) regarding the incident between the resident and their spouse, no report was made to APS or the State Licensing Agency regarding the incident involving the second resident. During interviews, the DON and Administrator confirmed their lack of awareness of the requirement to report to both APS and the State Licensing Agency, and acknowledged that no such reports had been made.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving two residents and a visitor. According to progress notes and interviews, a visitor reported that the spouse of one resident verbally confronted another resident in the hallway, pointing a finger and using aggressive language, which caused the second resident to become visibly upset and cry. The visitor also noted that the spouse had a history of similar behavior and that the affected resident appeared distressed after the incident. Despite this, there was no documentation in the second resident's medical record regarding the altercation, nor evidence that the incident was investigated as an allegation of abuse. Further review revealed that the incident was not reported to the State Licensing Agency, and no summary of an investigation was sent as required. While the facility did file a report with Adult Protective Services (APS) concerning the interaction between the resident and their spouse, no such report was made regarding the incident involving the second resident. Interviews with the DON and Administrator confirmed that they did not investigate or report the incident as abuse, and were unaware of the requirement to report such allegations to both APS and the State Licensing Agency.
Expired Medications and Biologicals Found in Medication Storage
Penalty
Summary
During an observation of the medication cart, an 8 oz bottle of Spectrum Hand Sanitizer and a package of three Sani-cloth germicidal disposable wipes were found with expiration dates that had already passed. These expired items were located in the medication storage room and had not been removed after their expiration. An LPN confirmed the presence of the expired medications and biologicals and acknowledged that they were expired.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store food in accordance with professional standards and did not maintain a sanitary kitchen environment. During observation, four packages of cream of wheat with expiration dates that had already passed were found in dry storage, and a food service staff member confirmed that these items were expired. Additionally, melted plastic was observed on the wall behind the toaster, which the food service worker stated had been present for about a year. In a room containing two large freezers, hats were found hanging from pipes on the ceiling, coats were hung on the wall, and a dirty mop bucket with mop water was on the floor. The food service staff member confirmed that these storage practices were typical for the area.
Failure to Conduct Legionella Risk Assessment in Water Management Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program specifically related to Legionella prevention. Record review revealed that the facility's water management program did not include a risk assessment to identify areas within the building where Legionella bacteria could potentially grow and spread. The facility's own Legionella Water Management Program policy requires identification of such areas, including storage tanks, water heaters, filters, aerators, showerheads, hoses, and other equipment, as well as specific control measures, monitoring systems, and documentation. However, these steps were not completed as required by the policy. During an interview, both the Administrator and the Director of Maintenance confirmed that a risk assessment had not been conducted, and areas in the building where Legionella could reside had not been identified. The Director of Maintenance stated that they did not believe there were any areas in the facility where Legionella could grow, further confirming the lack of compliance with the facility's policy and regulatory expectations.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported promptly to facility administration, Adult Protective Services, and the State Licensing Agency. A resident who had been admitted in May 2025 and was exhibiting aggressive behaviors required staff intervention and an emergent hospital transfer. On 5/8/2025, a Licensed Nursing Assistant (LNA) witnessed another LNA hit the resident with a package of wipes during an incident where the resident was hitting the staff member and then lunged at her. However, the witnessing LNA did not report the incident until 5/22/2025, resulting in a delay in notifying the appropriate authorities about the suspected abuse.
Failure to Ensure Proper Documentation and Duration for PRN Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's dementia, major depressive disorder, and anxiety disorder was administered lorazepam (Ativan) without proper indication for use and without a documented discontinuation date. The resident was dependent on staff for activities of daily living and was receiving hospice and comfort-directed care. The physician's order requested continuation of lorazepam for anxiety and agitation, but did not specify an end date. The order was entered into the electronic health record by the DON as a PRN medication to be given every four hours as needed until a specified date, but this did not align with the original physician's order. Facility policy required that PRN psychotropic medications not be continued beyond 14 days unless the prescriber documented the rationale and specified the duration. Review of the records showed no documentation from the prescriber justifying the extension or specifying the number of days for continued use. The DON relied on the pharmacist's monthly review as justification, but the review did not address the lorazepam order. Additionally, a reference document provided by the pharmacist clarified that there is no exception to the 14-day rule for comfort care or hospice orders, yet the required documentation was still not present.
Failure to Provide Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required documentation regarding bed-hold policies to a resident or their representative following the resident's transfer to the hospital. Record review showed that the resident was admitted and later transferred to the hospital, but there was no documented evidence that a bed-hold notice was given at the time of transfer. The facility's own bed-hold policy states that residents or their responsible parties must be notified of their right to return and that this notification should be documented in the medical record. During an interview, the DON confirmed that there was no documentation of the bed-hold notice for this resident and was unable to locate the required document.
Failure to Review, Revise, and Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to review, revise, and implement care plans for a resident with a history of falls. The resident, who has diagnoses including Alzheimer's dementia, major depressive disorder, and anxiety disorder, was dependent on staff for activities of daily living and required assistance with food and fluid intake. Despite multiple documented falls over several months, there was no evidence that the facility completed screenings, reviews, evaluations, or occupational therapy (OT) referrals as interventions following these incidents. The facility's own policies require staff and physicians to reevaluate and reconsider interventions for residents who continue to fall, and to monitor and document responses to interventions, but these steps were not documented as completed for this resident. Additionally, the resident's care plan included interventions such as non-skid strips by the bed and a fall mat on the right side of the bed, but observations on multiple dates revealed that these items were not present in the resident's room. The DON confirmed that a fall mat should have been in place when the resident was in bed. Although a printed copy of an OT referral was provided, there was no further documentation regarding the results of assessments or referrals. These failures demonstrate that the facility did not follow its own policies or ensure that care plan interventions were implemented and maintained for the resident at risk for falls.
Failure to Coordinate and Document Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate and implement hospice care measures for a resident who had been receiving hospice services. Although there was a physician's order for hospice care, the resident's medical record did not contain any additional hospice care orders, hospice progress notes, updates to the care plan regarding hospice interventions, or documentation indicating when hospice care was provided. The facility's own hospice policy requires coordination with the hospice provider, documentation of communication, and inclusion of the hospice plan of care in the resident's care plan, none of which were present in this case. Interviews with the DON revealed that the facility had not received any medical records or documentation from the hospice agency for the resident, and that communication with hospice was only verbal. The DON acknowledged that it often takes time to receive information from the hospice provider and that there was no written documentation to guide the facility's implementation of hospice interventions for the resident.
Failure to Complete and Act on Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MMRs) were completed and acted upon as required by policy. For one resident, there was no evidence that the MMR was completed for the month of March 2025, and the Director of Nursing (DON) confirmed that she could not produce the required documentation. This indicates that the process for ensuring regular pharmacist reviews and documentation was not followed for this resident. Additionally, for another resident, the pharmacist identified the need for a one-time digoxin level test during the MMR, which was subsequently ordered by the physician. However, there was no evidence that the facility acted on this order, as the required digoxin level was not obtained or documented in the resident's record in a timely manner. The pharmacist repeatedly noted the absence of the test result in subsequent monthly reviews, and the DON was unable to provide evidence that the order was carried out as directed.
Failure to Obtain and Document Ordered Laboratory Results
Penalty
Summary
The facility failed to obtain and document laboratory results as ordered by physicians for two residents. For one resident, a basic metabolic panel (BMP) was drawn as ordered, but there was no evidence in the medical record that the results were obtained, reviewed, or acted upon. The consulting pharmacist noted the missing results during a medication regimen review and requested that the results be obtained and scanned into the electronic health record, but this was not completed. The Director of Nursing (DON) confirmed that the BMP results could not be located in the resident's chart or the laboratory's record system. For another resident, the pharmacist identified the need for a one-time digoxin level test, which the physician approved and ordered. Despite repeated monthly reminders from the pharmacist in subsequent medication regimen reviews, there was no evidence that the digoxin level was obtained or documented as ordered. The only available digoxin level result was from a later date, and the DON was unable to provide evidence that the laboratory service was obtained as initially ordered or that the pharmacist's recommendations were followed.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets necessary to provide care and respond to each resident's individualized needs. This deficiency was identified through a review of employee training files and interviews. Specifically, one out of three sampled Licensed Nursing Assistants (LNAs) had no evidence of any competency evaluation to demonstrate the necessary skills for resident care. Additionally, two out of three Licensed Practical Nurses (LPNs) lacked evidence of annual competency evaluations. The Administrator confirmed the absence of competency evaluations for these staff members during an interview.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time or part-time dietitian and a certified Director of Nutrition Services, as required for the food and nutrition service. A review of the Dietary Manager's employee file revealed no documented evidence of the necessary certification for Dietary Managers. During an interview, the facility's administrator confirmed the absence of a full-time dietitian and a certified Director of Nutrition Services.
Failure to Establish Water Management Program
Penalty
Summary
The facility failed to establish and maintain a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water systems. During an interview, the Director of Nursing (DON), who is also the Certified Infection Preventionist, admitted to having no knowledge of a water management program specific to the facility. Additionally, both the maintenance director and the administrator confirmed their lack of awareness regarding the existence of such a program. They also acknowledged that an assessment of the building had not been performed, and a program to minimize the risk of Legionella and other opportunistic pathogens in the water system had not been developed.
Privacy and Autonomy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident with severe cognitive impairment and multiple diagnoses, including dementia and parkinsonism. An LPN administered medication in a common area, exposing the resident's abdomen and undergarments to others, which violated the facility's policy on resident privacy. The LPN acknowledged the mistake, and the Director of Nursing and Administrator confirmed that the resident's privacy was not respected according to the facility's guidelines. Additionally, the facility maintained a locked environment, restricting residents' ability to exercise their right to self-determination and access to the outside. Residents could only go outside with staff supervision, and visitors faced challenges entering and exiting the facility due to locked doors. The facility lacked a policy for assessing residents' ability to go outside independently and did not have a procedure for operating a completely locked facility. This situation caused frustration among residents and their families, as they were dependent on staff availability to access the outdoors.
Latest citations in Vermont
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
