Menig Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Randolph Center, Vermont.
- Location
- 215 Tom Wicker Lane, Randolph Center, Vermont 05061
- CMS Provider Number
- 475058
- Inspections on file
- 13
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Menig Nursing Home during CMS and state inspections, most recent first.
The facility did not provide a way for residents to file anonymous grievances, as grievance forms were only available through staff at the nurses' station or administration office. Interviews with residents and staff confirmed that residents could not access forms without staff assistance, despite the facility's policy allowing for anonymous complaints.
The facility did not ensure that the food and nutrition services manager had the necessary certifications, education, or experience required for the position. Interviews and record reviews confirmed that the manager lacked appropriate credentials, and the certified dietician and dietary manager associated with the facility did not meet the required on-site hours.
Surveyors found that food items in the kitchen's freezer, cooler, and dry storage were not consistently dated, sealed, or removed when expired. The Kitchen Manager confirmed that several opened and expired items were present, and that proper food storage protocols were not followed, potentially affecting all residents.
The facility did not address Legionella monitoring in its water management policies and failed to update key infection control policies annually. Additionally, a resident with a chronic pressure ulcer was not promptly placed on Enhanced Barrier Precautions as required by CDC guidance and facility policy, due to uncertainty among staff.
A resident alleged that an LNA was mean, hit, and swore at them, but the facility did not report this abuse allegation to the State Agency as required by policy. The DON confirmed that the incident and subsequent investigation were not submitted to the state.
A resident with chronic pressure ulcers did not receive consistent weekly wound assessments or thorough documentation of wound characteristics, including measurements and descriptions. The wounds increased in size during periods when documentation was limited or absent, and the DON confirmed that required assessments and documentation were not consistently performed.
A resident with PTSD did not have trauma triggers identified in their care plan, despite a documented history of trauma and a positive PTSD screening. The social worker and administrator confirmed the absence of these triggers in the care plan, and the facility lacked a specific trauma-informed care policy.
The facility restricted residents' rights to receive visitors by imposing visiting hours from 10:00 AM to 7:00 PM, with additional restrictions during meal times. A resident and a family member reported difficulties with these restrictions, which were confirmed by a posted sign and facility policy. The facility claimed accommodations could be made, but the existence of preferred visiting hours was confirmed by the Administrator.
The facility failed to maintain safe handwashing water temperatures, with readings exceeding 120°F, posing a risk to residents with cognitive impairments. Additionally, residents with Alzheimer's disease exhibited wandering behaviors without adequate supervision, and the facility lacked an elopement prevention policy. A resident identified as a fall risk had no documented fall care plan, and the facility did not have a fall prevention policy, compromising resident safety.
The facility failed to include necessary staff trainings and patient care policies in their facility-wide assessment, affecting the care provided to residents. Required regulatory training topics were not documented for staff, and nurse aides lacked evidence of completing mandatory in-service hours. Additionally, the Medical Director was unaware of missing patient care policies, and the facility assessment did not evaluate the necessary policies and procedures for resident care.
The facility did not ensure the Medical Director assisted in developing and implementing resident care policies, affecting all 27 residents. During a survey, the facility could not provide policies on fall prevention, weight management, and elopement prevention. The Administrator confirmed the absence of these policies, and the Medical Director was unaware of this deficiency.
The facility failed to maintain an effective training program for staff, lacking necessary training in QAPI, communication, compliance, ethics, and behavioral health. There was no evidence of the required 12 hours of annual training for LNAs. Interviews revealed a lack of documentation and tracking systems for training, and the onboarding packet for new hires was incomplete.
The facility did not provide mandatory training on effective communication for direct care staff, including LNAs, RNs, and an LPN. Training records showed no evidence of such training, and interviews confirmed that any communication training is informal and not systematically documented.
The facility failed to provide mandatory training on the QAPI program for its staff. A review of training records for several staff members, including LNAs and RNs, showed no evidence of such training. Interviews with LNAs and facility administrators confirmed the absence of mandatory QAPI training.
The facility did not provide mandatory compliance and ethics training to its staff. A review of training records for several direct care staff, including LNAs, RNs, and an LPN, showed no evidence of such training. Interviews with staff confirmed the absence of training, and facility administrators acknowledged the deficiency in the training program.
The facility did not have a system to document the required 12 hours of annual training for nurse aides, as revealed by a review of training records for four staff members. Interviews with LNAs and facility staff confirmed the lack of a documentation system, leaving them unable to account for the training hours.
The facility failed to provide behavioral health training for its staff, despite having residents with psychiatric and mood disorders. The facility's assessment indicated the need for such training, but records showed no evidence of it for seven direct care staff members. Interviews confirmed the absence of a training program, potentially affecting care quality for residents with behavioral health needs.
The facility's practice of keeping doors locked 24/7 restricts residents' rights to self-determination and access to external services. Observations showed that visitors needed staff assistance to enter and exit, and interviews revealed residents felt confined and confused about visiting hours. The facility's policy confirmed the locked status, acknowledged by the administrator and VP of Quality and Compliance.
The facility failed to update care plans for residents at risk, including one with Alzheimer's and significant weight loss, and another with multiple falls. Despite recommendations and risk assessments, care plans were not revised, and a fall prevention policy was lacking. The Clinical Coordinator confirmed these deficiencies.
The facility failed to adhere to food safety standards, as observed during a kitchen tour where expired and improperly stored food items were found. Additionally, uncovered deviled eggs were left on a hand washing sink and transported uncovered through the facility for a picnic. Staff confirmed these practices did not meet professional standards.
A resident with Alzheimer's and other conditions experienced significant weight loss and behavioral decline, but the facility delayed completing a SCSA MDS for six weeks. Despite policy requirements, the resident's consistent pattern of change was not addressed in a timely manner.
A resident with Alzheimer's and other health issues was not weighed as frequently as required by their care plan, which specified weekly monitoring. Over a 28-week period, the resident was weighed only 15 times, with no documentation of refusals or reattempts. The Clinical Coordinator confirmed frequent refusals by the resident, but these were not documented by the nursing staff.
The facility failed to provide sufficient supervision for two residents with aggressive and disruptive behaviors, leading to repeated altercations and potential harm. Despite care plan revisions and staff interventions, the behaviors persisted, and staff reported insufficient personnel to provide necessary supervision, especially during peak hours.
The facility failed to report an abuse incident involving a resident and an LNA within the required timeframe. The LPN delayed reporting due to fear of negative repercussions. Additionally, the facility's abuse policy lacked necessary elements for ensuring the reporting of a reasonable suspicion of a crime.
The facility failed to develop comprehensive policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy lacked essential components such as screening, training, prevention, identification, investigation, protection, reporting, and coordination with the QAPI program. The Administrator confirmed the policies did not meet specific regulatory requirements.
Failure to Provide Anonymous Grievance Filing System
Penalty
Summary
The facility failed to provide a system that enables residents to file anonymous grievances, as required by their own policy and regulatory standards. Observations revealed that grievance forms were not publicly available in common areas where grievance information is posted. Instead, forms were only accessible at the nurses' station and administration office, requiring residents to request them directly from staff. Interviews with the Director of Nursing (DON) and other staff confirmed that there was no process in place for residents to submit grievances anonymously without staff involvement. Interviews with six residents during a Resident Council meeting indicated that residents were unaware of how to file an anonymous grievance, with several stating they would need to ask staff for a form. Record reviews showed that these residents had no cognitive impairment, as indicated by their BIMS scores. The facility's grievance policy allows for anonymous complaints, but in practice, residents could not access forms without staff assistance. Staff interviews further confirmed that grievance forms were kept in locations inaccessible to residents without staff involvement.
Unqualified Food and Nutrition Services Manager
Penalty
Summary
The facility failed to ensure that the individual managing the food and nutrition services possessed the required qualifications. Review of the Chef Manager's personnel record revealed that the Chef Manager did not have certification as a dietary manager or food service manager, nor did they hold a similar national certification or an associate's or higher degree in food service management or hospitality. Additionally, the Chef Manager lacked two or more years of experience as a director of food and nutrition services in a nursing facility setting and had not completed a relevant course of study in food safety and management. Interviews with the Chef Manager, Administrator, and DON confirmed that the Chef Manager was not certified and that the certified dietician and certified dietary manager associated with the facility did not work at least 35 hours per week on site.
Failure to Properly Store and Date Food Items
Penalty
Summary
Surveyors observed multiple instances where food items in the facility's kitchen were not stored according to professional standards for food service safety. In the walk-in freezer, several opened food items, including cinnamon rolls, fish sticks, sausage patties, and dinner rolls, were found without expiration dates and were not properly sealed. The Kitchen Manager confirmed that these items should have been sealed and dated after opening. Additionally, an expired quart of basil pesto sauce was found in the freezer. In the walk-in cooler, several containers of horseradish, cream cheese spread, and black beans were identified as expired, and other items such as pizza sauce, cream cheese, various soup bases, bacon, and miso were found without expiration dates. The Kitchen Manager acknowledged these deficiencies during interviews. Further observations in the dry storage area revealed two unopened packages of dried coconut that were expired, as well as opened bags of coconut, macaroni, walnuts, and cashews that were either not dated or not properly sealed. The Kitchen Manager confirmed that these items were expired, improperly sealed, or not dated. These findings indicate a failure to consistently follow professional standards for food storage, including proper dating, sealing, and removal of expired items, which has the potential to impact all residents receiving food from the facility.
Deficiencies in Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices, specifically regarding Legionella monitoring and annual updates to infection control policies. The Water/Wastewater Distribution System policy did not address Legionella, and the water management binder lacked identification of areas within the nursing home at risk for Legionella growth. Both the Infection Preventionist and Maintenance Director confirmed that there was no documentation or facility-specific information related to Legionella, and the binder contained only generic materials not tailored to the nursing home. Additionally, two infection control policies, the Antimicrobial Stewardship Program and the Antibiotic Stewardship Program, had not been updated annually as required. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic pressure ulcer. According to CDC guidance and the facility's own policy, EBP should be used for residents with chronic wounds such as pressure ulcers. However, the DON was initially unsure if EBP was necessary for the resident with a stage 1-2 wound and relied on the Infection Preventionist, who did not think EBP was needed. This resulted in a delay in placing the resident on Enhanced Barrier Precautions.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who stated that a Licensed Nursing Assistant (LNA) was mean, hit, and swore at them. According to the facility's policy, all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, are to be reported immediately to the Director of Nursing (DON) or Administrator, the State Survey Agency, Adult Protective Services, and other agencies as required. However, record review showed no evidence that this allegation was reported to the State Agency. The DON confirmed in an interview that the allegation was not reported to the state, and although an investigation was completed, it was not submitted to the state surveying agency.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and document the condition of a resident with chronic pressure ulcers. Nursing notes and skin assessments over an extended period showed that the resident's pressure ulcers were not consistently assessed on a weekly basis as required. The wound assessments that were present in the record lacked consistent documentation of wound characteristics, including measurements and descriptive details. There were several periods where the wounds increased in size, but the records contained limited or no wound measurements and insufficient descriptions of the wounds' characteristics during these times. According to the facility's own policy, pressure ulcer assessments should include daily monitoring and weekly documentation of wound type, location, staging, descriptive characteristics, measurements, progress toward healing, and signs of infection or complications. The policy also requires documentation of dressing status and interventions for pain. The Director of Nursing confirmed that weekly wound assessments, measurements, and thorough documentation of wound characteristics were not consistently performed, and acknowledged that the resident's wound had increased in size during this period.
Failure to Include Trauma-Informed Interventions in Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure that care plans included trauma-informed interventions for a resident diagnosed with PTSD. The resident, who is cognitively intact and has a history of trauma from both sexual abuse and war zone service, was screened for PTSD and found to have some symptoms. Despite this, the resident's care plan did not identify any specific triggers related to PTSD, and the resident reported not discussing these triggers with the social worker. The absence of identified triggers in the care plan was confirmed by both the social worker and through record review. Additionally, the facility did not have a specific trauma-informed care policy in place. The administrator acknowledged that there was no dedicated trauma-informed policy, and the existing person-centered care plan policy only briefly mentioned that care plans should be trauma-informed and culturally competent, without providing further guidance on identifying or addressing trauma triggers. This lack of detailed policy and omission of PTSD triggers in the care plan contributed to the deficiency.
Failure to Allow Unrestricted Visitation
Penalty
Summary
The facility failed to honor residents' rights to receive visitors of their choosing at any time, as required by regulations. Observations and interviews revealed that the facility imposed restricted visiting hours from 10:00 AM to 7:00 PM, with additional restrictions during meal times from 12:00 PM to 1:00 PM and 5:00 PM to 6:00 PM. This policy was confirmed by a sign posted at the facility entrance and was corroborated by interviews with a resident and a family member, who expressed difficulties with the restricted visiting hours. The facility's policy, effective May 6, 2024, outlined that all visitors must ring a doorbell to gain entry, and staff would facilitate their entry and exit. Despite the facility's claim that accommodations could be made for visits outside the posted hours, the existence of preferred visiting hours and the requirement to avoid visiting during meal times were confirmed by the facility Administrator and Quality and Compliance Officer. This restriction on visitation has the potential to affect all residents and their visitors, including family, legal representatives, and advocates.
Deficiencies in Safety and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure that resident environments were free from accident hazards, particularly concerning safe handwashing water temperatures. Observations revealed that water temperatures in various locations, including common area bathrooms and resident rooms, exceeded the facility's policy limit of 120 degrees Fahrenheit, with readings as high as 126 degrees Fahrenheit. The facility's maintenance procedures did not include monitoring water temperatures in resident-accessible areas, and the Administrator confirmed that the existing policy was not specific to the nursing home facility. This oversight posed a significant risk to residents, especially those with cognitive impairments or neuropathy, who may not be able to feel pain from scalding. The facility also failed to provide adequate supervision to prevent accidents for several residents, particularly those with Alzheimer's disease who exhibited wandering behaviors. Resident #28, for example, was observed wandering unsupervised and attempting to exit the facility, yet was not assessed as an elopement risk. Similarly, Resident #24's elopement risk assessments were incomplete, lacking risk scores, and Resident #22, despite being assessed with poor safety awareness, was observed trying to open doors without staff supervision. The facility lacked an elopement prevention policy, and staff were unable to explain the criteria for assessing elopement risk. Additionally, the facility did not have a fall prevention or management policy, which contributed to inadequate care planning for Resident #20, who was identified as a fall risk. Despite experiencing multiple falls, there was no documented evidence of a fall care plan or revisions following these incidents. The Clinical Coordinator acknowledged the absence of an active fall care plan and explained that the post-fall check-off sheet did not include reviewing or revising the care plan. This lack of a structured approach to fall prevention and management further compromised resident safety.
Deficiency in Staff Training and Policy Evaluation
Penalty
Summary
The facility failed to address necessary staff trainings and policies in their facility-wide assessment, which is crucial for providing the required level and types of care for their residents. During a review of employee education records, it was found that the facility could not provide evidence of required regulatory training topics for all seven staff members reviewed, including communication, QAPI, compliance and ethics, and behavioral health. Additionally, four nurse aides did not have evidence of completing the required 12 hours of in-service training. The facility assessment dated 2024 did not include an evaluation of the training program. Furthermore, the Medical Director was unaware of the absence of patient care policies for fall prevention and management, obtaining weights, weight loss prevention and management, and elopement prevention. The facility assessment also failed to evaluate the necessary policies and procedures to care for the patient population. The Administrator and the VP of Quality and Compliance Officer confirmed that the facility assessment did not address staff training and patient care policies needed for the identified population.
Lack of Resident Care Policies
Penalty
Summary
The facility failed to ensure that the Medical Director assisted with the development and implementation of resident care policies, which had the potential to affect all 27 residents. During an annual recertification survey, surveyors requested multiple patient care policies related to fall prevention and management, obtaining weights, weight loss prevention and management, and elopement prevention. The Clinical Care Coordinator and the Administrator were unable to provide these policies. The Administrator confirmed that the facility did not have written procedures for these concerns. The Medical Director, during an interview, acknowledged awareness of issues with falls, weight loss, and elopement but was unaware of the absence of related patient care policies.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members. This deficiency was identified through record reviews and staff interviews, revealing that the facility did not provide necessary training related to Quality Assurance and Performance Improvement (QAPI), communication, compliance and ethics, and behavioral health for all sampled direct care staff. Additionally, the facility did not establish a system to demonstrate the required 12 hours of annual training for Licensed Nurse Aides (LNAs). The facility's assessment indicated that competency standards were created and implemented, with department managers responsible for ensuring competencies were met during the introductory period and annually thereafter. However, upon reviewing employee files, there was no evidence of the required training for several LNAs and RNs. Interviews with the Director of Nursing, who was a temporary employee, revealed a lack of knowledge about how LNA training and competencies were documented. The Director mentioned that the facility shared software systems with a hospital, but was unable to produce evidence of documented training. Further interviews with the Administrative Assistant and Clinical Coordinator confirmed the absence of a system to track the required annual LNA training hours. The onboarding packet provided to new hires, including temporary staff, also lacked the necessary training components.
Lack of Mandatory Communication Training for Staff
Penalty
Summary
The facility failed to provide mandatory training for direct care staff on effective communication, which includes speaking in a way that others can understand, active listening, and observing verbal and nonverbal cues. A review of training records for seven sampled staff members, including LNAs, RNs, and an LPN, revealed no evidence of such training. Interviews with the Administrative Assistant and the Clinical Coordinator confirmed the absence of mandatory communication training, noting that any training provided is informal and discussed at morning meetings without recorded attendance to ensure all staff receive the information.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training for its staff on the Quality Assurance and Performance Improvement (QAPI) program. A review of training records for seven sampled staff members, including Licensed Nursing Assistants (LNAs) and Registered Nurses (RNs), revealed no evidence of training on the facility's QAPI program. Interviews with three LNAs confirmed that they had not received any training on the QAPI program. Additionally, an interview with the Administrative Assistant and the Clinical Coordinator confirmed that the facility does not provide mandatory training for staff regarding its QAPI program.
Lack of Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory training on compliance and ethics to its staff, as required by regulations. A review of training records for seven sampled direct care staff members, including LNAs, RNs, and an LPN, revealed no evidence of training on the Compliance and Ethics program. Interviews with an LPN and two LNAs confirmed that they did not recall attending any training or in-service on ethics. Additionally, an interview with the Administrative Assistant and the Clinical Coordinator confirmed that the employee training program lacked the mandatory compliance and ethics component.
Failure to Document Nurse Aide Training Hours
Penalty
Summary
The facility failed to establish a system to document the required minimum of 12 hours of annual training for nurse aides, which is necessary to ensure their continuing competence. A review of training records for four sampled staff members revealed no evidence that they had completed the required training hours. During interviews, a Licensed Nursing Assistant (LNA) expressed uncertainty about how their education hours were documented, and another LNA was unsure if they met the annual training standard. Additionally, the Clinical Coordinator and Administrative Assistant confirmed the absence of a system to document the mandatory training hours, and they were unable to account for or provide information on how these hours were being tracked.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, specifically in the area of behavioral health care and services. This deficiency was identified through staff interviews and record reviews, which revealed that none of the seven sampled staff members had received training on behavioral health care. The facility's assessment, last updated in January 2024, indicated that the facility was equipped to provide care for individuals with psychiatric and mood disorders, including managing medical conditions and medication-related issues causing psychiatric symptoms and behavior. However, the lack of a training program meant that staff were not equipped with the necessary competencies and skills to provide appropriate care for residents with behavioral health needs. The facility assessment identified eight residents with behavioral health needs during the assessment period, highlighting the importance of having trained staff to manage these needs. Despite this, the education records of seven direct care staff members, including LNAs, RNs, and an LPN, showed no evidence of behavior health training. Interviews with the Administrative Assistant and the Clinical Coordinator confirmed the absence of a training program that included behavioral health as part of the direct care staff training program. This lack of training could potentially impact the quality of care provided to residents with behavioral health needs.
Facility's Locked Doors Restrict Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to self-determination and access to external persons and services by maintaining a locked facility 24/7. This practice restricts residents' ability to exercise their rights as citizens or make personal choices about going outside without interference. Observations during the survey revealed that the main entrance doors were locked, requiring staff intervention for entry and exit. Visitors had to use a doorbell to alert staff for access, and staff were needed to unlock the doors for them to leave. This system was in place throughout the survey period. Interviews with residents and family members highlighted the impact of this policy. A resident mentioned feeling like they were in jail initially due to the locked doors, while another resident expressed confusion about visiting hours. A family member noted that visitors were discouraged from coming during meal times due to staff being occupied, and visiting hours ended at 7:00 PM. The facility's policy confirmed that all doors were secured with badge access only, and the facility administrator and VP of Quality and Compliance Officer acknowledged the 24/7 locked status of the facility.
Failure to Update Care Plans for Residents at Risk
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to deficiencies in addressing their needs. Resident #15, diagnosed with Alzheimer's dementia and other conditions, experienced a decline in condition, including refusal of care and significant weight loss. Despite a dietician's recommendation to discontinue dietary restrictions and provide preferred snacks, the care plan was not updated to reflect these changes. Additionally, after a fall, Resident #15's care plan was not revised to include new interventions. The Clinical Coordinator confirmed these omissions during interviews. Resident #21, at risk for falls due to Alzheimer's disease, experienced multiple falls without subsequent updates to their care plan. The facility lacked a fall prevention or management policy, and the check-off sheet used by staff did not include care plan revisions. Resident #20, identified as a fall risk, had no documented fall care plan or revisions after falls. The Clinical Coordinator acknowledged the absence of a current fall care plan, which had been discontinued earlier in the year. These failures highlight the facility's inability to maintain accurate and responsive care plans for residents at risk.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food safety. During an initial kitchen tour, surveyors observed an open box of pasta, two tubs of cream cheese icing, and one tub of chocolate fudge icing with expired dates on a food storage shelf. Additionally, a cardboard box containing a bag of lentils was found open and spilling out. The dietary supervisor confirmed the icing was expired, and the pasta and lentils were open. In a separate observation, a plate of uncovered deviled eggs was found placed on a hand washing sink in the kitchenette off the main dining room, with no staff present. A dietary aide later confirmed that the deviled eggs should not have been left uncovered on the sink. The same dietary aide was observed transporting the uncovered deviled eggs through the facility hall to an outside area for a resident and staff picnic, confirming again that the eggs should have been covered during transport. The Food Service Manager also confirmed that the eggs should have been covered.
Failure to Complete Timely SCSA MDS for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a significant change in condition. The resident, diagnosed with Alzheimer's dementia, recurring urinary tract infections, emphysema, and heart failure, showed a consistent pattern of decline, including significant weight loss and increased behavioral issues. Despite these changes, the SCSA MDS was not completed until approximately six weeks after the initial signs of deterioration. The resident's weight loss was documented as 11.57% over six months and 8.06% over one month, which, according to the facility's policy, should have triggered a SCSA MDS. Additionally, the resident began refusing meals, medications, and care, and exhibited increased aggressive behaviors and incontinence. The Clinical Coordinator acknowledged the resident's decline and significant weight loss, confirming that these changes warranted a SCSA MDS, but admitted to not considering it at the time.
Failure to Monitor Resident's Weight as Care Planned
Penalty
Summary
The facility failed to adequately monitor the weight of a resident, identified as Resident #15, who has multiple diagnoses including Alzheimer's dementia, recurring urinary tract infections, emphysema, and heart failure. The resident's care plan, effective from November 3, 2023, required weekly weight monitoring, charting of weights, and reweighing if there was a weight change of 3 pounds. However, from January 1, 2024, to July 22, 2024, the resident was weighed only 15 times out of the 28 weeks, with no documentation of refusals or reattempts to weigh the resident for the 13 weeks they were not weighed. The Clinical Coordinator confirmed that the resident frequently refused to be weighed, but these refusals were not documented by the nursing staff as required.
Inadequate Supervision of Residents with Aggressive Behaviors
Penalty
Summary
The facility failed to provide sufficient supervision for residents with a history of aggressive, disruptive, and intrusive behaviors, specifically for two residents diagnosed with dementia. Resident #1 exhibited behaviors such as wandering, touching other residents, and attempting to assist them inappropriately, which were documented in multiple nursing notes. Despite interventions like redirection and medication adjustments, these behaviors persisted, and staff reported that there were not enough personnel to provide the necessary supervision, especially during peak hours. Observations confirmed that Resident #1 was often left unsupervised, leading to continued intrusive and potentially harmful interactions with other residents. Resident #2 also displayed aggressive behaviors, including pushing, dragging, and cursing at other residents and staff. Nursing notes detailed several incidents where Resident #2 physically interacted with other residents inappropriately. Although the care plan was revised to include additional interventions, staff interviews revealed concerns about insufficient staffing to provide one-on-one supervision during times of increased agitation. The lack of effective supervision and intervention led to repeated altercations involving Resident #2. Interviews with various staff members, including RNs, LNAs, and LPNs, highlighted a consistent concern about the inability to adequately supervise residents with aggressive behaviors due to staffing shortages. These deficiencies in supervision and intervention were not adequately addressed in the residents' care plans, leading to ongoing risks of resident-to-resident altercations and potential harm.
Failure to Report Abuse and Inadequate Reporting Policies
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the Administrator and other officials in accordance with State law for one resident. An incident occurred where an LPN witnessed a staff-to-resident altercation involving a resident and an LNA. The altercation, which included yelling and physical contact, was not reported to the Administrator, State Survey Agency, Adult Protective Services, or local law enforcement until two days after the event. The LPN admitted to delaying the report due to fear of negative repercussions. Additionally, the facility's policy on Adult Abuse and Reporting, effective since 2017, did not include the required elements to ensure the reporting of a reasonable suspicion of a crime. The policy lacked specific procedures for immediate reporting, orientation for new and temporary staff, annual notifications, identification of barriers to reporting, and collaboration with law enforcement. The Administrator confirmed that the policy did not meet the necessary requirements for reporting a reasonable suspicion of a crime.
Deficient Policies and Procedures for Abuse Prevention
Penalty
Summary
The facility failed to develop written policies and procedures that include all the required topics to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. The facility's policy titled 'Adult Abuse and Reporting,' effective 11/28/2017, was found lacking in several critical areas. Specifically, the policy did not address necessary components related to screening, training, prevention, identification, investigation, protection, reporting/response, and coordination with the Quality Assurance and Performance Improvement (QAPI) program. These deficiencies were identified through a review of the facility's policy and staff interviews, which confirmed that the policies did not meet specific regulatory requirements. The missing components included written procedures for screening prospective residents, comprehensive training for staff on abuse prevention and recognition, protocols for preventing sexual abuse, and detailed procedures for identifying and investigating abuse and neglect. Additionally, the policy lacked measures to protect residents during and after investigations, immediate reporting requirements, and coordination with the QAPI program. The Administrator confirmed that while the facility's policies acknowledged these topics generally, they did not include the specific regulatory requirements necessary to ensure the safety and well-being of the residents.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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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