Pine Heights At Brattleboro Center For Nursing & R
Inspection history, citations, penalties and survey trends for this long-term care facility in Brattleboro, Vermont.
- Location
- 187 Oak Grove Avenue, Brattleboro, Vermont 05301
- CMS Provider Number
- 475023
- Inspections on file
- 15
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pine Heights At Brattleboro Center For Nursing & R during CMS and state inspections, most recent first.
Surveyors observed a frozen turkey stored on the floor, an open bag of frozen fish left on a shelf, and clean dishes being put away while still wet. The Dietary Manager confirmed these practices did not meet professional food service safety standards.
The facility did not complete annual evaluations for two of three LNAs who had worked at the facility for over a year. Record review found no documentation of evaluations to determine appropriate education or training, and both the Administrator and DON confirmed that annual evaluations are not conducted for staff.
Surveyors found expired medications on two medication carts, including Isopto Atropine Solution 1% and Glutose 15. LPNs confirmed the presence of expired drugs and indicated that the night shift was responsible for checking for outdated medications.
A resident was not included in the development or review of their care plan and reported being unaware of care plan meetings. Documentation from a care conference did not indicate that the resident or their representative was invited, and facility leadership confirmed that invitations are limited to annual or significant change meetings.
A resident receiving IV antibiotics via a PICC line experienced resistance during medication administration due to a kinked and potentially migrated catheter. The facility failed to document the external catheter length at admission and during weekly assessments, as required by policy, resulting in a lack of evidence regarding the line's position and safety.
An LPN handled an indwelling catheter bag for a resident on enhanced barrier precautions without wearing required PPE, including gloves and a gown, as outlined in facility policy. The LPN admitted to not using PPE and was uncertain about glove availability in the resident's room. The Infection Preventionist confirmed that gloves should be worn during such care to comply with infection control protocols.
The facility failed to meet food service safety requirements. A fan above the clean dish drying area was covered in dust and circulated air over clean flatware, creating an unsanitary condition. Additionally, moldy bread was found in the 2nd floor kitchenette, and the facility lacked a process for monitoring and dating bread to prevent use beyond expiration.
A resident with dysphagia and cognitive impairment was left without meal assistance for 25 minutes, during which another resident took their drink without staff intervention. When finally attended to, the resident declined the meal, which had been left uncovered, and was not offered an alternative or reheating. The DON confirmed the resident's dependency on staff for meal assistance and acknowledged the deficiency.
A resident, dependent on staff for transfers, was found on the floor after sliding from their wheelchair due to inadequate supervision. The care plan required assistance to bed and hourly repositioning, but staff failed to perform safety checks and walking rounds, leading to the incident.
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, several residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
During a kitchen tour with the Dietary Manager (DM), surveyors observed a frozen turkey in a cardboard box stored on the floor and an open bag of frozen fish left on a shelf. The DM confirmed that the turkey had been left over from the previous Thanksgiving and had not yet been discarded, and acknowledged that the bag of fish should not have been left open. Later, clean dishes were seen being put away and placed on food carts while still wet, which the DM also confirmed was not proper procedure. These actions demonstrate failures in storing, preparing, and handling food and dishware according to professional food service safety standards. No specific residents or their medical histories were mentioned as being directly involved or affected in the report.
Failure to Complete Annual Evaluations for LNAs
Penalty
Summary
The facility failed to complete annual evaluations for two out of three Licensed Nursing Assistants (LNAs) who had been employed for over a year. Record review showed no documentation of annual evaluations for these LNAs, which would indicate what education or training was appropriate for each individual. During interviews, both the Administrator and the Director of Nursing confirmed that annual evaluations are not conducted for any staff, including LNAs.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that medications were not stored in accordance with accepted professional principles on two of four medication carts. On the Third Floor Unit, a bottle of Isopto Atropine Solution 1% was found to be expired since 4/2025. The LPN assigned to this cart confirmed the medication was expired and stated that the night shift was responsible for checking for outdated medications. On the Fourth Floor Unit, a tube of Glutose 15 was found to be expired since 6/2025, and the LPN assigned to this cart also confirmed the expired medication, again noting that the night shift was responsible for checking for outdated medications. These findings indicate that expired medications were present on medication carts and that the process for checking for outdated medications was not effectively implemented, as confirmed by staff interviews.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was involved in the care planning process, as required. During an interview, the resident stated that they were not included in the development or review of their care plan and were unaware of when their care plan was reviewed or revised. Review of documentation from a care conference showed that the section indicating whether the resident or their responsible party was invited to the meeting was left blank. Additionally, the facility administrator confirmed that residents and their responsible parties are only invited to comprehensive care plan meetings conducted annually or when there is a significant change, rather than for all care plan reviews or revisions.
Failure to Follow PICC Line Assessment and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice regarding the care and maintenance of a peripherally inserted central catheter (PICC) line for a resident with acute osteomyelitis and a chronic foot ulcer who was receiving intravenous antibiotics. During an observation, an LPN encountered resistance while attempting to administer an antibiotic through the resident's PICC line. The line was found to be excessively long and coiled, causing it to kink under the dressing and impede fluid flow. Upon uncoiling, the line measured 42 cm at the indicator, suggesting possible migration of the catheter. Record review revealed that there was no documentation of the external catheter length at the insertion site upon admission or during subsequent weekly assessments, as required by facility policy. The Assistant Director of Nursing confirmed that the line should have been measured at admission and weekly thereafter, but no such measurements were documented in the medical record. This lack of assessment and documentation meant there was no evidence to determine whether the line had migrated or if it was safe to use.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Licensed Practical Nurse (LPN) was observed handling an indwelling catheter bag for a resident on enhanced barrier precautions without wearing any personal protective equipment (PPE), specifically gloves or a gown, as required by facility policy. The LPN picked up the catheter bag from the floor without donning PPE, despite the facility's urinary catheterization policy defining enhanced barrier precautions as the use of both gown and gloves during such care. The Infection Preventionist confirmed that gloves should be worn when handling indwelling catheter bags, and the LPN acknowledged that PPE should have been used but stated she did not have gloves in her pocket and was unsure if gloves were available in the resident's bathroom. The Centers for Disease Control and Prevention guidance was referenced regarding the importance of enhanced barrier precautions to reduce the transfer of multi-drug resistant organisms.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to meet food service safety requirements as observed during a survey. On two separate occasions, a fan located above the clean dish drying area in the kitchen was found to have a significant accumulation of dark gray dust-like material on its blades and outer surface. This fan was circulating air directly over a tray of clean flatware, creating an unsanitary condition. The facility's Dietary Manager confirmed the unsanitary condition and noted that maintenance had been notified about the need for cleaning, but it had not been completed. Additionally, a bag of white bread slices with visible green mold was found in the facility's 2nd floor kitchenette. The Dietary Manager confirmed the presence of mold and acknowledged that the facility lacked a process for monitoring and dating bread to ensure it was not used beyond its expiration date.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care, specifically in maintaining good nutrition for a resident identified as having dysphagia, cognitive impairment, and a risk for weight loss and malnutrition. The resident's care plan required continual supervision and assistance during meals. However, during a meal observation, the resident was left unattended for 25 minutes without any cueing or assistance from staff, despite being seated with a meal and drink in front of them. During this time, another resident took the drink from the resident without any staff intervention. When a Licensed Nursing Assistant (LNA) finally attended to the resident, the meal had been sitting uncovered for 25 minutes, and the resident declined the food when offered. The LNA did not inquire about the resident's refusal, offer an alternative meal, or reheat the food. The Director of Nursing confirmed the resident's dependency on staff for meal assistance and acknowledged the lack of appropriate care during the observed meal, which contributed to the deficiency in providing necessary ADL support.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent a fall for a resident who was totally dependent on two staff members with a mechanical lift for transfers. The resident was found on the floor of their room at 1:45 AM, having apparently slid out of their wheelchair. The care plan for the resident indicated that they required assistance to bed by 11 PM, intentional rounding every hour for repositioning, and monitoring of positioning while in the room. However, the resident was not assisted to bed or reevaluated until they were found on the floor. The facility's internal investigation revealed that a staff member had brought the resident to their room after the evening meal, but the Licensed Nursing Assistant (LNA) assigned to the resident's care had falsely documented performing safety checks. Additionally, the evening and night shift staff failed to conduct walking rounds at the change of shift as expected. These lapses in supervision and adherence to the care plan contributed to the resident's fall.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, five residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The facility's Grievance/Concern Policy stated that forms should be available on nursing units and in the front lobby, but there was no evidence of such availability. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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