Mountain View Center Genesis Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Rutland, Vermont.
- Location
- 9 Haywood Avenue, Rutland, Vermont 05701
- CMS Provider Number
- 475012
- Inspections on file
- 16
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mountain View Center Genesis Healthcare during CMS and state inspections, most recent first.
A resident with severe mobility limitations and legal blindness, who required two-person assistance for ADL care, was left in the care of a single LNA. While the LNA attempted to change bed linens and reposition the resident alone, the resident fell from the bed, resulting in hospitalization for a fractured hip and pelvic injuries. The care plan's requirement for two-person assistance was not followed, as confirmed by staff interviews.
A resident with multiple medical conditions and intact cognition was verbally abused by an LNA after an incontinence episode. The LNA made disparaging remarks about the resident's continence, which were confirmed by the resident, a roommate, and another staff member. The facility's investigation substantiated the verbal abuse.
The facility failed to maintain a homelike environment on Unit D due to continuous loud call bell alarms affecting approximately 50 residents. Observations during a survey revealed alarms going off for extended periods during meals, louder than the TV volume. Residents and staff confirmed the disruptive nature of the alarms, with the Administrator acknowledging the issue.
The facility failed to create comprehensive care plans for three residents, leading to unmet needs. A resident experienced significant weight loss without updated nutritional assessments or care plan interventions. Another resident's preference for bi-weekly shaving was not documented, and staff were unaware of this need. A third resident with Parkinson's disease did not have a care plan addressing her need for hand exercises to manage contractures.
The facility failed to provide adequate personal hygiene and nail care for residents unable to perform activities of daily living. One resident had long, dirty fingernails and facial hair, while another was not shaved according to their preference due to staff being too busy. A third resident had excessively long toenails, and a resident with a pressure ulcer had worsening nail conditions due to lack of podiatry services. The facility lacked a system to track residents needing podiatry care.
The facility failed to meet the activity needs of several residents, including those with cognitive impairments and mobility limitations. Residents reported a lack of engagement and variety in activities, with some expressing a desire for more in-room activities and opportunities to go outside. Activity logs and care plans were outdated or incomplete, and there was no formal process for determining or documenting one-on-one visits.
The facility failed to provide adequate nursing staff, resulting in delayed assistance for residents' basic needs and personal care. Residents reported long waits for help with toileting, walking, and personal grooming. Staff confirmed the difficulty in managing care with insufficient aides, especially on weekends. Additionally, a resident at risk for malnutrition did not receive timely meal assistance, highlighting the impact of staffing shortages on resident care.
A facility failed to monitor behaviors and side effects in residents using psychotropic drugs. One resident with anxiety and depression was given Hydroxyzine without behavior documentation. Another resident with schizophrenia and bipolar disorder was not monitored for behaviors despite being on Paroxetine and Risperidone. A third resident with dementia received Seroquel and Trazadone without monitoring for adverse effects, despite frequent sleepiness. The DON and LPN confirmed the lack of monitoring.
The facility failed to serve meals that were palatable and timely to three residents. A resident with Alzheimer's and other conditions did not receive a meal for 40 minutes, resulting in non-palatable food. Additionally, two residents were left without meals while another resident at their table was served, due to late food cart arrival.
The facility failed to maintain safe refrigerated food temperatures in the Cherry Tree Country Kitchen. A refrigerator storing resident drinks and snacks was found open, with temperatures recorded at 56 degrees, despite logs showing 41 degrees. An LNA noted the refrigerator had been broken for some time, and the Dietary Manager confirmed the issue. The administrator was unaware of the ongoing problem with the refrigerator seal.
A facility failed to consistently follow physician orders for a resident with anxiety and major depressive disorder. The resident's care plan required non-pharmacological interventions before administering PRN Hydroxyzine, but these were documented only 5 out of 22 times. The DON confirmed the oversight, highlighting a lapse in adhering to professional standards of care.
The facility failed to conduct and document weekly skin and wound assessments for two residents, leading to unaddressed and worsening skin conditions. One resident with morbid obesity and diabetes had a bleeding wound on the thigh, with no assessments since February, despite a care plan and treatment order. Another resident with venous insufficiency had a coccyx wound treated without a care plan or physician order until days later, and inaccurate documentation of skin status. The DON confirmed the lack of required assessments.
A facility failed to follow pharmacy recommendations for monitoring heart rate before administering digoxin to a resident with atrial fibrillation. The pharmacy review required checking the apical pulse and withholding the medication if the pulse was below 60 bpm. However, these instructions were not documented in the medication order, and there was no evidence that the pulse was checked before administration, as confirmed by the Unit Manager.
Two residents were not treated with dignity and respect in a facility. A resident with dementia was distressed after an LNA forcefully cut their food and ignored their inquiry. Another resident, at risk for malnutrition, was left without meal assistance while others were served. The resident attempted to eat without help, and their food was found unpalatable after being left out. An LPN confirmed the resident required assistance.
A facility failed to report a resident-to-resident altercation involving potential verbal abuse to the State Survey Agency. The incident occurred when a resident exhibited aggressive behavior towards their roommate due to frustration over bathroom usage, leading to incontinence. Staff intervened to prevent further escalation, but the incident was not reported as required by the facility's Abuse Prohibition policy.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, legal blindness, and a history of chronic conditions including epilepsy and normal pressure hydrocephalus, was not provided the required level of assistance during activities of daily living (ADL) care. The resident's care plan specified the need for two-person assistance for ADL care due to limited mobility and other health conditions. Despite this, a Licensed Nursing Assistant (LNA) provided care alone, attempting to change bed linens and reposition the resident without additional help. During this unsupervised care, the LNA rolled the resident to the side of the bed, resulting in the resident falling to the floor. The incident led to the resident experiencing pain and being hospitalized for a fractured hip and pelvic injuries. Interviews confirmed that the care plan intervention requiring two-person assistance was not followed at the time of the incident, and the unit manager acknowledged that adherence to the care plan would have prevented the fall.
Resident Subjected to Verbal Abuse by LNA Following Incontinence Episode
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute respiratory failure with hypoxia, congestive heart failure, and chronic kidney disease, who was cognitively intact and independent with activities of daily living, was subjected to verbal abuse by a Licensed Nursing Assistant (LNA). The incident took place after the resident experienced an episode of incontinence. The LNA entered the resident's room and made disparaging remarks, questioning why the resident was incontinent in the facility and whether they soiled themselves at home. These statements were confirmed by both the resident and their roommate during interviews conducted as part of the facility's internal investigation. Further documentation from the internal investigation included an admission from the LNA that she raised her voice and made comments about the resident's incontinence not being helpful in the rehabilitation setting. Another LNA reported that the staff member was visibly upset after cleaning the resident and expressed her displeasure to colleagues, using inappropriate language regarding the resident's condition. The facility's internal investigation confirmed the occurrence of verbal abuse, and the administrator acknowledged that the resident was not free from abuse.
Continuous Loud Alarms Disrupt Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment on Unit D, where approximately 50 residents reside, due to continuous loud call bell alarms. During the recertification survey conducted from April 9 to April 11, 2024, it was observed that call bell alarms were repeatedly going off for extended periods, ranging from 10 to 40 minutes, during meal times. The alarms were loud enough to be heard over the surveyors' speaking voices and louder than the television volume in the common area, which serves as both a living and dining area. Interviews with residents and staff confirmed the disruptive nature of the alarms. One resident expressed that the alarms were bothersome, while another stated they hated the loudness of the call bells. Staff, including a Licensed Nurse Aide and a Licensed Practical Nurse, acknowledged that the alarms were going off non-stop throughout the day. The facility's Administrator also confirmed the loudness of the alarms in an area frequently used by residents, indicating a failure to maintain a comfortable and homelike environment.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. Resident #72 experienced significant weight loss, dropping from 175.2 pounds to 139.0 pounds, yet the care plan did not include goals or interventions to address nutritional needs. The nutritional assessment was outdated, based on a weight from 2022, and did not reflect the resident's current risk for malnutrition. The Director of Nursing confirmed the care plan's inadequacy in addressing nutrition and weight loss risk. Resident #3 expressed dissatisfaction with not having his face shaved for three weeks, despite his preference for bi-weekly shaving due to his inability to perform this task independently. The care plan lacked specific interventions to accommodate this preference, and staff were unaware of where such preferences were documented. Similarly, Resident #83, who has contractures due to Parkinson's disease, did not have a care plan addressing her need for assistance with hand exercises to maintain function. The care plan failed to include interventions for her contractures, despite her expressed importance of maintaining independence.
Failure to Provide Adequate Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents unable to perform activities of daily living, resulting in poor hygiene and unmet personal care needs. Resident #102 was observed with long, dirty fingernails and facial hair, despite their care plan indicating a need for extensive assistance with personal hygiene. The Unit Manager confirmed the expectation for staff to maintain residents' nail and facial hair care, which was not met in this case. Resident #3 expressed dissatisfaction with not having their face shaved for three weeks, although their preference was to be shaved twice a week. The care plan did not reflect this preference, and staff cited being too busy due to short staffing as the reason for not fulfilling this need. An LNA confirmed the workload prevented them from completing the shaving task, leading to Resident #3's distress. Resident #83 had excessively long toenails, with no interventions in their care plan addressing nail care, despite being dependent on staff for personal hygiene. Additionally, a resident with a pressure ulcer on their right great toe had progressively worsening nail conditions due to the lack of podiatry services. The facility did not have a podiatrist available, and there was no system in place to track residents needing podiatry care, as confirmed by an LPN and RN.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to ensure that the activities program met the needs of each resident, as evidenced by the lack of engagement and stimulation for several residents. Resident #91, who has Parkinson's Disease and Dementia, was observed spending days in their room with no activities other than watching TV. Despite having a care plan that emphasized the importance of engaging in favorite activities, there was no record of activity participation, and the resident's family was not involved in discussions about their care preferences. The activities assistant and director confirmed that there was no formal process for determining which residents should receive one-on-one visits, and these visits were not documented. Resident #19, who is unable to leave their room due to poor upper body strength, reported having no activities provided in their room and expressed a desire for more engagement. Their activity logs showed limited participation in independent activities, and their care plan did not reflect any recent updates to address their preferences for in-room activities. Similarly, Resident #95 expressed a desire for more varied activities beyond watching TV and playing bingo, but their care plan had not been updated since 2022, and their activity logs showed minimal engagement. Residents #72 and #15 also reported dissatisfaction with the available activities, noting a lack of variety and opportunities to go outside. Resident #72's care plan had not been revised since 2020, and their activity logs showed no participation in activities for several months. Resident #15's care plan emphasized the importance of engaging in meaningful activities, but their logs indicated only receiving newsletters, with no record of additional engagement. The facility's failure to provide adequate activities and engagement for these residents highlights a significant deficiency in meeting their individual needs and preferences.
Staffing Shortages Lead to Delayed Care and Meal Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, impacting two of four units. Multiple residents expressed frustration over the lack of staff, leading to delays in receiving assistance for basic needs. One resident reported waiting 45 minutes for help to get off the toilet, while another could not receive assistance to walk daily, resulting in prolonged periods in a wheelchair. Residents also reported unmet personal care needs, such as nail cutting, hand exercises, and shaving, due to staff shortages. Staff interviews corroborated the residents' concerns, with Licensed Nurse Aides (LNAs) stating that it is challenging to complete all patient care tasks with insufficient staffing levels. On weekends, the number of aides often drops to three or four, making it difficult to manage the workload. The constant ringing of call bells further indicates the high demand for assistance that the current staffing levels cannot meet. Additionally, the facility failed to provide timely meal assistance to a resident at risk for malnutrition. The resident, who requires help with meals, was left without a dining tray while others were served, and their meal was placed out of reach. It took 50 minutes for staff to address the situation, during which the resident attempted to eat a pear handed by another resident. The delay in meal service and lack of attention to the resident's needs highlight the staffing inadequacies affecting resident care.
Failure to Monitor Psychotropic Drug Use in Residents
Penalty
Summary
The facility failed to ensure proper monitoring of residents using psychotropic drugs, leading to deficiencies in care for three residents. Resident #15, diagnosed with anxiety disorder and major depressive disorder, was administered Hydroxyzine for anxiety on multiple occasions without any documentation of behaviors or monitoring orders. The care plan lacked interventions to monitor behaviors, and there was no evidence of behavior monitoring in the Medication Administration Record (MAR), Treatment Administration Record (TAR), or the point of care system. Resident #10, with diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety, was prescribed Paroxetine and Risperidone. Despite the care plan's directive to complete a behavior monitoring flow sheet, there was no documentation of behavior monitoring in the MAR, TAR, or point of care system. The Director of Nursing confirmed that behavior monitoring was not conducted for this resident, despite the expectation to monitor behaviors three times a day for residents on psychotropic medications. Resident #98, admitted with dementia and behavioral disturbances, was prescribed Seroquel and Trazadone. The resident received all scheduled doses of these medications without any documented monitoring for behaviors or adverse effects, despite the care plan's requirement to monitor for changes in mental status and functional level. Observations noted the resident frequently sleeping through meals, and the LPN Unit Manager confirmed an increase in sleepiness, potentially due to pneumonia, but acknowledged the lack of monitoring for adverse effects or increased behaviors related to the psychotropic medications.
Failure to Serve Palatable and Timely Meals
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature to three residents. Resident #99, who was admitted with Alzheimer's dementia, stroke with aphasia, and heart failure, was observed sitting at a table without being offered a meal or beverage while other residents received their trays. The meal intended for Resident #99 was left uncovered for 40 minutes, and upon checking, the food temperature was found to be non-palatable. The Dietary Manager confirmed that the meal should not be served and replaced it with a new plate. In another instance, residents #11 and #12 were observed sitting at a table with Resident #17, who was eating their dinner while the other two residents had not received their meals. The RN/Unit Manager, upon noticing the situation, instructed an LNA to serve the meals to residents #11 and #12. An LNA later explained that the food carts had arrived late, which disrupted the usual dining process where all residents at a table are served simultaneously.
Refrigerator Temperature Maintenance Failure
Penalty
Summary
The facility failed to maintain refrigerated food temperatures at a safe level in the Cherry Tree Country Kitchen. On observation, the refrigerator used to store resident drinks and snacks was found to be open approximately 2 inches, with no items obstructing the door. The temperature monitoring log indicated temperatures of 41 degrees from April 1 to April 9, but at the time of observation, the temperature was 56 degrees. A Licensed Nursing Assistant (LNA) mentioned that the refrigerator had been broken for some time, but was unsure if anyone was aware of the issue, and believed it was the kitchen's responsibility to monitor the temperature. The Dietary Manager confirmed the refrigerator was broken and the temperature inside was 58 degrees. The administrator acknowledged that the refrigerator had ongoing issues with the seal, which had been replaced several times, but was unaware of the current problem. The administrator confirmed that a new refrigerator was being purchased to replace the broken one in the Cherry Tree Country Kitchen.
Failure to Follow Physician Orders for Anxiety Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not consistently following physician orders for a resident with anxiety and major depressive disorder. The resident had physician orders for the administration of Hydroxyzine, an antianxiety medication, with specific instructions to attempt non-pharmacological interventions before administering the medication. However, the Medication Administration Record (MAR) revealed that these non-pharmacological interventions were documented only 5 out of 22 times when the PRN Hydroxyzine was administered. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to administering PRN medications. This oversight occurred despite the resident's care plan, which included a range of non-pharmacological strategies to be used before resorting to medication. The failure to adhere to these orders indicates a lapse in following professional standards of care for the resident.
Failure to Conduct Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to provide safe and effective skin and wound care for two residents by not performing and documenting weekly skin checks and wound evaluations as per professional standards and facility policy. Resident #94, who has conditions including morbid obesity, type 2 diabetes, and mixed urinary incontinence, was found with a bleeding wound on the right thigh and redness on both thighs. Despite having a care plan indicating a risk for skin breakdown and a physician order for topical treatment, the last documented skin assessment was on 2/22/2024, with no subsequent weekly assessments or wound evaluations conducted. Interviews with staff confirmed the lack of adherence to the facility's policy for weekly wound assessments. Resident #125, diagnosed with venous insufficiency and type 2 diabetes, was noted to have a dressing applied to the coccyx on 4/1/2024, yet there was no care plan, wound evaluation, or physician orders for this wound at that time. The care plan was only updated on 4/2/2024, and a physician order for treatment was initiated on 4/5/2024. However, a skin check on 4/5/2024 inaccurately reported no skin injuries or wounds. As of 4/10/2024, there were still no wound assessments for the coccyx wound. The Director of Nursing confirmed the absence of initial or weekly wound assessments for Resident #125.
Failure to Monitor Heart Rate Before Digoxin Administration
Penalty
Summary
The facility failed to adhere to pharmacy recommendations regarding the monitoring of heart rate prior to the administration of digoxin for a resident diagnosed with cerebral vascular accident and atrial fibrillation. The resident was prescribed digoxin to manage atrial fibrillation, which requires careful monitoring due to the risk of cardiac arrhythmias. The pharmacy review, signed by the provider, explicitly stated that the apical pulse should be checked before administering digoxin, and the medication should be withheld if the pulse is less than 60 beats per minute. However, there was no evidence in the resident's records that these instructions were included in the medication order or that the pulse was checked before administering the medication. During an interview, the Unit Manager confirmed that the medication parameters, including the requirement to check the pulse, were not documented in the digoxin order. The Unit Manager acknowledged that the absence of these parameters meant that nurses were not aware of the need to check the pulse before administering the medication. This oversight resulted in a failure to follow the necessary protocol for administering digoxin, as there was no documentation of the pulse being checked on the medication administration record.
Failure to Ensure Dignity and Meal Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident #66, who has dementia, was observed in the dining room expressing difficulty with eating. A Licensed Nursing Assistant (LNA) responded in a loud and forceful manner, cutting the resident's food without consent and ignoring the resident's inquiry about their drink. This interaction left the resident visibly distressed, with their head resting on the table. The LNA later acknowledged that their approach was undignified and disrespectful. Resident #99, diagnosed with Alzheimer's dementia, stroke with aphasia, and heart failure, was not provided assistance with meals despite being at risk for malnutrition. During meal service, Resident #99 was left without a tray or beverage while other residents at the table were served. The resident attempted to eat a pear handed by another resident and later tried to consume condensation from the food cover. Staff did not assist or notice the resident's actions for an extended period. When the Dietary Manager was alerted, the food was found to be unpalatable due to prolonged exposure, and a new meal was eventually provided. The LPN confirmed that Resident #99 required assistance and should have been served alongside others.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident altercation, which potentially involved verbal abuse, to the State Survey Agency. The incident involved a resident who exhibited verbal and aggressive behavior towards their roommate due to frustration over bathroom usage, which led to incontinence. The resident attempted to throw themselves out of bed while shouting threats and obscenities. Staff intervened to prevent a fall and further escalation by assisting the resident back into bed and redirecting the roommate. The facility's policy on Abuse Prohibition requires any witnessed incident of suspected abuse to be reported immediately to a supervisor and subsequently to the Administrator or designee, as well as other officials in accordance with state law. However, during an interview, the Administrator revealed that the incident was not reported to them or the State Agency, indicating a failure to adhere to the facility's reporting policy.
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.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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