Premier Rehab And Healthcare At Berlin
Inspection history, citations, penalties and survey trends for this long-term care facility in Barre, Vermont.
- Location
- 98 Hospitality Drive, Barre, Vermont 05641
- CMS Provider Number
- 475020
- Inspections on file
- 43
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Premier Rehab And Healthcare At Berlin during CMS and state inspections, most recent first.
Multiple residents reported that meals were frequently served cold, unappetizing, and lacking in variety, with some meals not meeting specific dietary needs such as those for diabetes and dialysis. Surveyors observed food that appeared slimy, mushy, and bland, confirming resident complaints about poor food quality and temperature.
A resident with dysphagia was found with a pill and pudding left at the bedside without staff supervision, despite lacking a physician's order for self-administration. An LPN confirmed that medications, including a crushed medication and an uncrushed Protonix tablet, were left at the bedside, contrary to facility policy.
A nurse left a medication cup containing both crushed and whole medications, including a non-crushable pill, unattended at the bedside of a resident with dysphagia who did not have an order for self-administration. The medications were not under direct staff observation or secured, contrary to facility policy, and this issue has been cited in previous surveys.
A Physician's Assistant failed to perform hand hygiene after removing gloves during a dressing change for a resident with a pressure ulcer. The PA handled a used scalpel and touched personal items and the door knob with bare hands, in direct violation of the facility's hand hygiene policy.
A resident with cognitive impairment and a history of wandering, identified as an elopement risk and wearing a Wander Guard, was able to exit the facility undetected by removing a window and screen in an unmonitored room. The care plan lacked interventions for wandering or supervision, and the Wander Guard did not alarm since the window was not equipped with an alarm. The resident was later found on an adjacent property with minor injuries after a fall, and staff interviews confirmed lapses in supervision and monitoring.
Three residents did not receive necessary pressure ulcer prevention and care, including failure to implement individualized interventions, incomplete documentation, and lack of care plan updates. One resident developed a fatal unstageable pressure injury, another had an untreated open wound, and a third developed a deep tissue injury due to lack of preventive measures for a hand contracture.
A resident at high risk for pressure injury developed a sacral wound that progressed without timely intervention, despite repeated documentation and requests by the APRN for preventive measures such as an air mattress. The care plan was not updated with individualized interventions, and the DON was unaware of the wound until it had worsened. The Medical Director did not coordinate care or monitor the implementation of skin care policies, and was unaware of the resident's condition and the facility's lapses, resulting in the resident's death from complications of a pressure injury.
The facility failed to update care plans for three residents after changes in their skin and wound status. One resident developed a sacral pressure ulcer without care plan revisions for repositioning or air mattress use, another developed an untreated open wound on the shoulder with no care plan update or monitoring, and a third with a hand contracture developed a deep tissue injury without preventive interventions added to the care plan. The DON confirmed that care plans were not revised to address these issues.
Physicians and other providers did not consistently review or document residents' total care programs, including skin and wound care, during required visits. For example, a resident with a new stage 2 pressure injury did not have their care plan updated or receive timely wound assessment, and the physician was unaware of the issue during a regulatory visit. Two other residents with new or existing wounds had provider notes that failed to address these concerns, despite nursing documentation and physician orders for wound care.
Four LPNs lacked documented assessment of competencies in skin and wound care, despite facility policy and assessment identifying these as necessary skills. The competency evaluation materials used did not include skin or wound assessment, and this omission was confirmed by the DON.
A resident who was high risk for pressure injuries developed a stage 2 pressure ulcer that progressed to an unstageable wound, but the POA was not notified of the new condition or treatment plan until after the ulcer worsened. Interviews and record review confirmed that both the POA and DON were unaware of the wound at the time it was first identified, in violation of facility policy.
The facility failed to provide adequate nursing staff, leading to frequent delays in medication administration and assistance with ADLs. Multiple residents reported long wait times for care, especially on weekends and evenings, and an LPN confirmed being consistently late with medications due to having to help with non-nursing tasks. Family members also experienced difficulty reaching staff, highlighting the impact of staffing shortages on resident care and communication.
Surveyors observed unsanitary conditions in the kitchen, including food debris on equipment and surfaces, cobwebs on storage racks, and expired food items in both dry storage and the cooler. The Dietary Manager confirmed the expired items.
The facility did not complete or document a facility-wide assessment to determine necessary resources for competent care, as required. The assessment provided was incomplete, unsigned, undated, and had not been reviewed by leadership. Interviews with the DON, RDCO, and Administrator confirmed the assessment was still in progress and referenced documents that did not exist.
Staff were repeatedly observed not wearing masks properly, failing to perform hand hygiene after glove removal, and not using required PPE when entering precaution rooms. Reusable equipment, such as stethoscopes, was not cleaned between resident uses as required, and oxygen tubing for several residents was not dated or replaced according to policy. Staff interviews revealed confusion about infection control protocols, and multiple lapses in following established procedures were confirmed.
The facility did not develop or implement comprehensive care plans for two residents receiving palliative care, despite medication reviews and facility policy requiring such plans. Additionally, after a resident-to-resident altercation, another resident was placed on 15-minute checks, but documentation was incomplete and staff were unaware of the intervention, indicating failures in communication and care plan implementation.
The facility did not provide an ongoing activities program to meet residents' interests and well-being, as no group or individual activities were observed or documented for several residents. Staff confirmed activities were on hold due to Covid, but residents continued to gather in common areas without engagement. Multiple residents reported a lack of activities, and care plans indicating preferences for group events were not followed. Activity logs were missing, and the sole activities staff member had not assessed all residents' needs.
Several residents with a history of trauma did not receive trauma-informed or culturally competent care, as required by facility policy. One resident with a significant trauma history did not have their triggers or trauma addressed in their care plan, and multiple other residents lacked complete trauma assessments. Staff confirmed that appropriate assessment tools and care planning were not in place for these residents.
The facility did not provide or obtain necessary dental services for three residents, including those with ill-fitting or missing dentures, despite complaints and care plan interventions. Staff failed to arrange dental appointments or referrals, and the facility lacked a dental services contract, resulting in unmet dental needs.
A resident was found with multiple pills left at their bedside by an LPN, including medications not listed on their MAR. The resident had not been assessed for self-administration of medications, and facility policy requires observation of medication consumption. The DON confirmed no assessment had been completed for self-administration.
A resident admitted for rehabilitation was kept in bed for several days because staff would not assist with transfers until a PT assessment was completed, despite the resident's requests to get up and use the bathroom. The resident's spouse also experienced difficulty contacting staff and was not asked for contact information during admission. The DON confirmed the resident was not assessed by PT until later, resulting in the resident remaining in bed per facility policy.
A resident repeatedly requested a PRN anxiety medication after the prescription had expired, but nursing staff did not contact the on-call physician to renew the order, resulting in the resident not receiving the medication for several days. No documentation was made regarding the requests or the lack of administration, despite the resident's regular use of the medication and the facility's policy of 24/7 physician access.
A resident who was dependent on staff for personal hygiene did not receive necessary assistance with fingernail care, resulting in overgrown, dirty nails and a broken nail with a blood-like stain that went unnoticed and untreated by staff. Documentation showed no evidence of fingernail care being provided for over a month.
A resident with hearing impairment was repeatedly left without functioning hearing aids, despite physician orders and a care plan requiring daily assistance. The resident reported that staff often forgot to help with the hearing aids, leaving them unable to communicate with staff during multiple surveyor observations.
A medication error rate of 43% was observed when an LPN administered multiple medications late, failed to follow administration protocols such as instructing a resident to rinse after inhaler use, and did not provide a requested PRN medication. The LPN reported that late medication administration was routine due to staffing shortages and additional duties, resulting in several residents' medications being overdue.
A resident was found unsupervised in bed with three pills left on their lap, including medications for constipation, diabetes, and depression. Review of records showed one medication was not listed on the MAR, and an LPN confirmed leaving the medications at the bedside, which is not permitted.
A resident who did not eat facility-provided meals relied on personal food stored in a unit refrigerator. Staff discarded all of the resident's food without notification because it was not labeled, despite facility policy requiring staff to label such items and to notify residents before discarding food. Most of the discarded food was unopened and not expired, and no policy was posted on the refrigerator.
The facility operated without a state-licensed administrator after the previous administrator resigned. The DON, who does not hold a Nursing Home Administrator License, was designated as acting administrator, as confirmed by interviews with facility leadership and state licensure records.
The facility operated without a Licensed Administrator after a change in leadership and failed to notify the State Agency of changes in both the Administrator and DON, resulting in the facility's license not reflecting current leadership as required by state regulations.
A resident with a history of eye conditions received ear drops in their eyes, causing significant pain and requiring medical attention. The error involved the administration of Debrox Otic Solution, intended for ear wax removal, into the resident's eyes, leading to irritation and redness. The facility's policy defines this as a significant medication error, as it caused discomfort and required urgent medical intervention.
The facility experienced a deficiency in staffing, leading to delayed responses to residents' needs. Residents reported long wait times for call light responses, with some left in soiled conditions. Staff interviews highlighted the challenges in providing timely care due to insufficient personnel, with some staff working excessive hours. The DON and other staff had to perform duties outside their roles, and staffing decisions were based on census rather than resident acuity.
The facility failed to provide residents with meals that met their nutritional needs due to issues with the meal delivery system and produce quality. Residents reported missing or substituted food items during meal services, such as missing salads and replaced entrees. The Dietary Manager acknowledged communication lapses regarding menu changes, leading to unmet dietary requirements.
The facility did not follow the posted Dinner menu, serving penne pasta instead of the scheduled Beef Lasagna. Residents were not informed of this change, and the menu was not updated. The Dietary Manager confirmed the oversight.
The facility failed to provide and communicate meal options effectively, leading to resident dissatisfaction. Residents were not offered choices before meals, and alternatives were only given after the initial meal was declined. Short staffing and reliance on a Preference List that only recorded dislikes contributed to the issue, as confirmed by interviews with dietary staff and management.
The facility failed to maintain a clean and safe environment, with observations of disrepair and uncleanliness in resident units, including damaged radiators, unrepaired walls, and unsanitary conditions. Mold was found in the gym and other areas, and a resident's bathroom door was left unfinished, posing an infection control issue. Residents and staff reported insufficient housekeeping due to staffing shortages.
The facility failed to ensure that physicians signed and dated all physician orders for four residents. One resident's orders were unsigned 29 days after admission, another's 62 days, a third's 31 days, and a fourth's 39 days. The Market Clinical Lead confirmed the Attending Physician did not sign the required admission orders.
The facility did not conduct annual performance evaluations for three LNAs who had been employed for over a year. This was confirmed by the Market Operations Advisor, highlighting a deficiency in the facility's evaluation process.
The facility failed to maintain resident dignity and provide adequate care, as observed in several incidents. A resident was transported in a wheelchair with their feet and catheter bag dragging on the floor. Another resident was instructed to use a pull-up instead of being assisted to the bathroom, despite having a care plan for assistance. On Unit B, staff neglected to interact with residents, leaving them unattended and exposed. In one case, a resident was left wet and holding a catheter bag, calling for help while staff ignored them. Additionally, residents were left exposed in shower chairs for extended periods.
A resident transferred to the ED for a potential UTI did not receive a bed hold notice, nor was there evidence of such notice being sent to their POA. Interviews with staff confirmed the absence of the notification, despite facility policy requiring it to be provided prior to transfer.
A facility failed to assess a resident for the ability to self-administer medications, as required by policy. The resident was found to be self-administering Nystatin powder and Bio Freeze without a documented assessment, physician order, or inclusion in their care plan. The resident did not have a lockbox for medication storage, and the Clinical Market Lead confirmed these deficiencies.
A resident was found to have improperly stored medications in their room, including Nystatin powder and Bio Freeze, without a lockbox or necessary orders for self-administration. The facility's policy requires secure storage and care planning for self-administered medications, which were not provided, leading to a deficiency.
A resident in the facility was not provided with necessary dental services, including a requested teeth cleaning and assistance with teeth grinding. Despite expressing the need for dental care and having a partial plate at home, there was no evidence of follow-up or scheduled appointments. Staff interviews revealed a lack of understanding and follow-through in the process for obtaining dental services, resulting in the resident's needs being unmet.
The facility failed to employ a full-time qualified dietitian or designate a director of food and nutrition services with the required qualifications. The part-time Dietitian is present only one day a week, and the Dietary Manager, in the position for a year, has not yet obtained necessary certification. This results in a lack of qualified oversight for consistent food safety practices.
The facility was found deficient in maintaining pest control in the kitchen, as an open window without a screen was observed adjacent to food preparation areas. The Dietary Manager confirmed the lack of a screen and acknowledged its necessity to prevent pests and potential infection control issues.
The facility failed to implement care plan interventions for a resident with a suprapubic catheter, resulting in infection control risks due to improper handling of the catheter. Additionally, the facility did not have a care plan for another resident's UTI diagnosis and antibiotic therapy, leading to inadequate management of the condition.
A resident experienced severe eye pain after ear drops were mistakenly administered into their eyes. Despite treatment in the emergency department, the facility failed to revise the care plan to monitor for adverse effects, as confirmed by interviews with the Clinical Market Lead and DON.
A facility failed to maintain infection control standards for a resident with a suprapubic catheter, who is at high risk for UTIs. The resident's urine drainage bag and tubing were observed dragging on the floor during transport and while seated in the dining room. LNAs confirmed the improper positioning of the catheter bag, and the MCA acknowledged the infection control risks.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide palatable, appealing, and appropriately heated food to 10 of 19 sampled residents. Multiple residents reported that their meals were frequently served cold, with some stating that food remained cold even after attempts to reheat it. Several residents described the food as unappetizing, lacking in variety, and not meeting their dietary preferences or needs. Specific complaints included the prevalence of fish and chicken, limited beef options, and dissatisfaction with the quality and taste of the food, such as meat described as tasting like rubber and vegetables appearing slimy and mushy. One resident, who is diabetic and on dialysis, reported that meals were high in carbohydrates and snacks were sugary, which did not align with their dietary requirements. Observations by surveyors confirmed that food was served at unappetizing temperatures and appearances, such as green beans that looked slimy and mushy with a thin white sauce, and rice and asparagus that were bland and overcooked. Residents also noted a reduction in menu variety, such as the discontinuation of certain breakfast items and the lack of preferred condiments. These findings were based on direct interviews with residents and observations of meal service, indicating a pattern of inadequate food quality and service.
Failure to Assess and Supervise Medication Self-Administration
Penalty
Summary
The facility failed to determine whether it was clinically appropriate for a resident with dysphagia to self-administer medications. According to the facility's policy, medications are to be administered by licensed nurses or authorized staff as ordered by a physician. Record review showed that the resident did not have a physician's order for self-administration of medications. During observation, a pill in a medicine cup with pudding was found left at the resident's bedside without nursing staff present. Interview with the assigned nurse confirmed that medications, including a crushed medication and an uncrushed Protonix tablet, were left at the bedside, and the nurse acknowledged this should not have occurred.
Medications Left Unattended at Bedside for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a nurse left a medication cup containing both crushed and whole medications, including Protonix (Pantoprazole), on a resident's bedside table without supervision. The resident, who has dysphagia and no physician order for self-administration of medications, was left alone with the medications, and there was no nursing staff present in the room at the time of observation. Facility policy requires that medications be administered by licensed staff and remain under their direct observation or be locked away during medication passes. The incident was confirmed by the nurse assigned to the medication cart, who acknowledged that the medications should not have been left at the bedside. The observation revealed that the medication storage and administration practices did not align with the facility's policies or professional standards, as medications were not kept secure or under direct supervision. This deficiency has been cited in the facility's previous three recertification surveys.
Failure to Perform Hand Hygiene After Dressing Change
Penalty
Summary
A deficiency was identified when a Physician's Assistant (PA) failed to perform proper hand hygiene during a dressing change for a resident with an unstageable pressure ulcer on the coccyx. The PA donned gloves and conducted a wound assessment and debridement using a disposable scalpel. After completing the procedure, the PA removed the soiled gloves but did not sanitize or wash their hands before handling the used scalpel with bare hands, placing it inside a removed glove, and then touching personal items and the room's door knob. The PA confirmed in an interview that hand hygiene was not performed after glove removal. The facility's hand hygiene policy specifically requires hand hygiene immediately after removing gloves, and this incident represents a repeat deficiency from a previous survey.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a resident assessed as an elopement risk. The resident, who had impaired cognitive function, restlessness, agitation, and a traumatic brain injury, was identified as an elopement risk upon admission and was fitted with a Wander Guard device. However, the resident's care plan did not include interventions related to wandering or supervision. The resident was able to remove a window and screen in an empty room under maintenance, exit the building undetected, and was later found on an adjacent property after having fallen and sustaining scrapes to both knees and complaining of head and knee pain. The Wander Guard did not alarm because the window was not equipped with an alarm system. Interviews with staff confirmed that the resident was last seen over an hour before being found and that the Wander Guard was still in place when the resident was located. The Director of Nursing acknowledged that the window used for the exit was not alarmed, and the resident was able to leave without staff noticing. Additionally, during an observation, the same resident was seen exiting through an alarmed door while staff were preoccupied assisting another resident, and no intervention or redirection was provided by the employee present.
Failure to Prevent and Manage Pressure Injuries Resulting in Harm and Death
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure injuries for three residents, resulting in significant harm, including death. One resident, admitted with high risk factors such as impaired mobility, incontinence, and a high Braden score, did not have individualized interventions like turning and repositioning or an air mattress added to their care plan, despite repeated assessments and recommendations from an APRN. Documentation of skin assessments was incomplete, and there was no evidence of timely wound evaluation or care plan updates after the development of sacral redness and subsequent pressure injury. The resident's condition deteriorated to an unstageable, necrotic pressure injury, leading to hospitalization for osteomyelitis and sepsis, and ultimately death. The facility's policies for skin and wound assessment, care planning, and communication among staff were not followed, and the DON acknowledged lack of staff support and failure to update care plans or review clinical notes. Another resident, identified as high risk for skin breakdown, developed an open wound on the left shoulder. Although the APRN documented the wound and provided treatment orders, these were not entered into the medical record, and the care plan was not updated to reflect the new wound. There was no evidence of monitoring or treatment of the wound, and the area was not included in skin assessments or the facility's wound tracker. The DON was unaware of the wound, and the APRN did not communicate new findings during wound rounds. A third resident with cerebral palsy and a significant hand contracture developed a deep tissue injury (DTI) on the right index finger. The care plan did not include interventions to prevent pressure injury to the contracted hand, and recommendations for protective measures, such as a finger separator, were not implemented. The DON stated that the absence of a formal contracture diagnosis was the reason for not including specific preventive interventions in the care plan, despite the resident's limited range of motion and observed contracture.
Failure of Medical Director to Implement and Coordinate Skin Care Policies
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled responsibilities related to the implementation of resident care policies and coordination of medical care, specifically regarding the total skin program. A resident was admitted with a high risk for pressure injury but had no existing skin issues on the sacrum at admission. The care plan identified the risk but only included general interventions, lacking individualized measures such as turning, repositioning, or the use of an air mattress. Despite ongoing documentation by the APRN of sacral redness and pain, and repeated requests for an air mattress, no new interventions were added to the care plan, and the resident's condition was not escalated appropriately. The APRN noted the development of a sacral pressure injury and documented the need for specific wound care and an air mattress, but did not follow the process of communicating these findings to the nurse on the unit or the DON. The DON was unaware of the wound until it had worsened significantly, and there was no timely referral to the wound care specialist or updates to the care plan. The resident experienced significant pain and was eventually transferred to the hospital, where they died from complications related to the sacral pressure injury. The Medical Director, who was also the resident's physician, was not aware of the resident's skin issues or the facility's failure to implement pressure injury prevention and treatment policies. The Medical Director had not reviewed the APRN's notes or discussed concerns with her, and there was no evidence of coordination between the Medical Director, the APRN, and the facility staff regarding the resident's care. Facility policy required the Medical Director to coordinate care and monitor quality, but there was no documentation that these responsibilities were fulfilled in this case.
Failure to Revise Care Plans for Skin and Wound Management
Penalty
Summary
The facility failed to revise and update care plans for three residents following changes in their skin and wound conditions, as required by regulation and facility policy. For one resident with a history of failure to thrive and pelvic fracture, the care plan did not include specific interventions for turning, repositioning, or the use of an air mattress, despite a high Braden score indicating risk for pressure injury and subsequent development of a sacral pressure ulcer. The care plan was not updated to reflect the actual wound or prescribed treatments until after the condition worsened, contrary to the facility's own policy on pressure injury management. Another resident, identified as high risk for skin breakdown due to limited mobility, fragile skin, and diabetes, developed a new open wound on the left shoulder. Although an APRN documented the wound and provided treatment orders, there was no evidence that these orders were entered into the medical record, the care plan was updated, or the wound was monitored. The Treatment Administration Record did not reflect the new wound or its treatment, and the Director of Nursing confirmed the care plan was not revised to address the new skin issue. A third resident with cerebral palsy and a significant right hand contracture developed a deep tissue injury on the right index finger. The care plan did not include interventions to prevent pressure injury to the contracted hand, despite clinical notes recommending protective measures such as a finger separator and foam dressing. Observation confirmed the absence of a finger separator and the presence of a dressing, with the resident reporting pain and inability to use the affected hand. The Director of Nursing acknowledged that the care plan did not specifically address the contracture or related pressure prevention.
Failure to Review and Document Residents' Total Program of Care During Required Provider Visits
Penalty
Summary
The facility failed to ensure that physicians and other providers reviewed residents' total programs of care, including skin, pressure injury risk, prevention, and treatment plans at each required visit for three of seven sampled residents. For one resident admitted with a high risk for pressure injury, a stage 2 pressure injury was identified by an APRN, but the care plan was not updated, and no referral to the IWCS or wound assessment was completed until over two weeks later. The physician's regulatory visit note did not address the pressure injury, and the physician was unaware of the issue, having not reviewed prior APRN notes or discussed the resident's skin condition before the visit. The DON confirmed that the provider visit did not accurately review the resident's total program of care as required. Another resident with cerebral palsy and limited range of motion was observed to have new skin issues, including a wound and redness, documented by nursing staff. However, the physician's recertification note did not address these new skin concerns. A third resident admitted with a deep tissue pressure injury to the left knee had physician orders for wound care, but the physician's admission note did not address the wound or the treatment plan, instead documenting that exposed skin areas were clear. These findings demonstrate repeated failures to review and document residents' care programs, particularly regarding skin and wound care, during required provider visits.
LPN Competency Gaps in Skin and Wound Assessment
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies to provide appropriate care for residents, specifically in the areas of skin and wound assessment. Review of five licensed nurses' education files revealed that four LPNs did not have documented evidence of being assessed for skin or wound assessment competencies, despite the facility's policy requiring evaluation of staff competencies relevant to their job duties. The facility's own assessment identified skin integrity, pressure injury prevention and care, and wound care as services offered based on residents' needs. However, the competency evaluation packet used for licensed nurses did not include these required competencies, a fact confirmed by the DON during interviews. As a result, the facility did not ensure that staff had the specific skills necessary to meet residents' assessed needs as outlined in their care plans.
Failure to Notify POA of New Pressure Ulcer and Change in Condition
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) of a significant change in condition, specifically the development of a new stage 2 pressure ulcer on the sacrum. The resident, who was admitted with a diagnosis of failure to thrive and a history of pelvic fracture, was identified as high risk for pressure injuries and was dependent on staff for care and repositioning. The pressure ulcer was first identified by an APRN, but there was no documentation in the medical record that the POA was informed of the new wound or the need for new treatment, as required by facility policy. The resident's family was not notified until after the ulcer had deteriorated to an unstageable pressure injury with necrosis. Interviews confirmed that the POA was not made aware of the pressure injury or its treatment plan until much later, and the DON was also unaware of the wound at the time it was first identified. This deficiency is a repeat issue for the facility, having been cited in two previous recertification surveys. The lack of timely notification to the POA and family regarding the resident's change in condition and the progression of the pressure ulcer was substantiated through record review and staff and family interviews.
Insufficient Staffing Resulting in Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delays in medication administration and assistance with activities of daily living (ADLs). Multiple residents reported waiting over an hour for as-needed medications or personal care, with some stating that staff sometimes forgot to return at all. Observations confirmed that medications were frequently administered late, with a medication administration audit revealing approximately 3,400 late medications over a 15-day period for 64 residents. An LPN reported being consistently late with medication administration due to having to assist with non-nursing tasks such as passing trays and feeding residents because of short staffing. The issue was noted to be particularly severe on weekends and evenings. Several residents with care plans indicating dependence on staff for ADLs, including transfers requiring a Hoyer lift, reported that staff discouraged them from choosing their preferred bedtimes or getting up in the evening due to time constraints. Family members of a newly admitted resident were unable to reach staff by phone on the night of admission, and reported that no staff were available to take contact information during the admission process. These findings, based on interviews, observations, and record reviews, demonstrate a pattern of insufficient staffing impacting resident care and safety.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and did not maintain a sanitary kitchen environment. During an observation of the kitchen, surveyors noted food debris on the steam table, stainless-steel covers, and under the stove burners, as well as cobwebs on the coffee pot and carafe storage rack. The inside of the microwave door appeared burned, and there was food debris inside and beneath the microwave, as well as water marks and food debris on all stainless-steel counters. Additional findings included food debris on the clean plate holding device and remnants of food on the kitchen floor under all stainless-steel working surfaces and in front of the stove and grill. In the dry storage area, several containers of spices (turmeric, ground ginger, ground allspice, and dried chives) were found to be expired, as well as two plastic pitchers of juice in the cooler. The Dietary Manager confirmed the presence of expired items during an interview.
Failure to Complete and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. After a change in ownership, surveyors requested the facility assessment during the recertification entrance conference, but the document provided was incomplete, undated, unsigned, and had not been reviewed by the leadership team. Interviews with the DON, Regional Director of Clinical Operations, and Facility Administrator confirmed that the assessment was still a work in progress, had not been implemented, and referenced a staff development and training plan that did not exist. The Administrator also acknowledged that he had not reviewed the assessment and planned to do so at a later date.
Widespread Failure in Infection Control Practices and Equipment Maintenance
Penalty
Summary
The facility failed to maintain effective infection prevention and control practices, as evidenced by multiple observations of staff not adhering to established policies and procedures. Numerous staff members, including LNAs, LPNs, a Nurse Practitioner, and managers, were repeatedly observed not wearing masks properly in areas where residents with active COVID-19 were present. Staff were seen with masks below their nose, mouth, or chin, and some were not wearing masks at all while in hallways, resident rooms, and during direct care activities. Interviews with staff and managers revealed confusion and lack of clarity regarding masking requirements, despite the facility's written policies mandating proper mask use under droplet and airborne precautions. Hand hygiene and the use of personal protective equipment (PPE) were also not consistently followed. Staff were observed removing gloves after handling dirty linens and trash without performing hand hygiene, and entering precaution rooms with inadequate PPE, such as wearing only a surgical mask instead of the required N95, face shield, gloves, and gown. The Nurse Practitioner was observed using a reusable stethoscope on residents under precautions without cleaning it between uses inside the room, instead cleaning it in the hallway due to lack of available hand sanitizer in the room. Staff interviews confirmed knowledge of the correct procedures but admitted to lapses in practice, such as forgetting to perform hand hygiene or not wearing full PPE. Additionally, the facility did not ensure proper maintenance and replacement of oxygen tubing and related equipment. Multiple residents were found with oxygen tubing and nebulizer equipment that was not dated or was overdue for replacement according to facility policy, which requires weekly changes and proper dating. In some cases, tubing was found on the floor or had not been changed for several weeks, and staff confirmed these findings during interviews. These failures demonstrate a lack of consistent implementation of infection control measures, including surveillance, staff training, and adherence to established protocols.
Failure to Develop and Implement Comprehensive Care Plans for Palliative and Supervision Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who were identified as receiving palliative care. Despite medication regimen reviews recommending evaluation and possible discontinuation of certain medications due to high risk of side effects, the nurse practitioner documented that both residents were palliative care patients as the reason for not following these recommendations. However, neither resident had any focus or interventions for palliative care documented in their care plans, as confirmed by the Director of Nursing, the assigned LPN, and the nurse practitioner. The facility's own policy requires a comprehensive assessment and care plan to address the choices and preferences of residents receiving palliative care, which was not completed for these individuals. Additionally, the facility failed to implement and document care plan interventions related to supervision for a resident involved in a resident-to-resident altercation. After the incident, the resident was placed on one-to-one supervision and later on 15-minute checks, as documented in the care plan. However, review of the 15-minute check sheets revealed incomplete documentation on multiple dates, and both the assigned LPN and LNA were unaware that the resident was on 15-minute checks. This indicates a lack of communication and implementation of the care plan interventions intended to ensure resident safety.
Failure to Provide Ongoing Activities Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program to support residents' choices and interests, as evidenced by the lack of engaging activities for six of twenty sampled residents. Over a four-day survey period, no group activities were observed, and residents were seen sitting idly in hallways and public spaces without any organized engagement. Staff interviews confirmed that activities were on hold due to an active Covid outbreak, but residents continued to congregate in common areas without social distancing. Multiple residents reported that there had been no activities for an extended period, and some stated they had not been offered any bedside or alternative activity options. Record reviews revealed that several residents had care plans indicating preferences for group activities such as BINGO, musical events, arts and crafts, and resident council, but there was no evidence that these preferences were being met. Activity logs for the sampled residents were missing for several months, and the activities calendars showed only independent activities on weekends with no scheduled activities after 4 PM. The Activities Director confirmed that group activities were suspended, had not reviewed all residents' activity assessments, and was unable to produce daily activity logs. The Director also acknowledged that there were insufficient activities for residents with dementia and that she was the only staff member in the activities department. Residents interviewed expressed dissatisfaction with the lack of activities, with some stating they spent their time watching TV or engaging in self-entertainment. One resident noted that the previous activities staff had been reassigned, leaving no one to provide activities. New admissions were not informed about available activities, and there was no evidence that residents were being offered meaningful engagement in accordance with their care plans. The deficiency was further compounded by inadequate staffing and lack of documentation regarding activity provision.
Failure to Provide Trauma-Informed, Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to seven residents identified as trauma survivors. Interviews and record reviews revealed that one resident, who had a history of being held in a concentration camp, was on frequent checks due to past trauma. However, the resident's care plan did not include information about their trauma history or specific triggers, despite the facility's policy requiring identification and mitigation of such triggers through individualized care planning. The Social Worker confirmed that the resident's care plan lacked this essential information. Additionally, six other residents did not have complete trauma assessments documented in their medical records. The Social Service Director acknowledged that trauma-informed care assessments had not been completed for these residents and that the assessment tool in use did not evaluate for trauma triggers. This lack of comprehensive assessment and care planning for trauma survivors was inconsistent with the facility's own policies and professional standards of practice.
Failure to Provide or Obtain Dental Services for Residents
Penalty
Summary
The facility failed to provide or obtain routine and emergency dental services for three residents, as required by its own policy and federal regulations. One resident reported that their dentures did not fit properly, causing pain and injury, and despite repeated complaints and a care plan intervention to obtain a dental referral, no dental visit occurred as scheduled, with no documented reason for the missed appointment. Another resident lost their upper denture, and although the loss was reported and family members were involved in searching for the denture, there was no evidence of a dental referral or attempt to replace the denture. A third resident lost their dentures shortly after admission, and while staff searched for the missing dentures, there was no documentation of any referral or attempt to obtain dental services for this resident. Interviews with staff and administration confirmed that the facility had not had a contract with a dentist since late the previous year, and the administrator was unaware of the current dental needs of several residents. The facility's dental services policy outlines clear responsibilities for staff to notify supervisors, arrange appointments, and keep residents and their representatives informed, but these procedures were not followed for the affected residents. The lack of access to dental services and failure to arrange outside care when in-house services were unavailable directly contributed to the deficiency.
Failure to Assess Appropriateness of Resident Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was clinically appropriate for a resident to self-administer medications. During an observation, a resident was found sitting in bed with three pills on their lap and was asking for more water. An LPN confirmed that the pills had been left at the resident's bedside. The medications included Docusate 100 mg, Metformin 500 mg, and Bupropion ER 150 mg. Record review revealed that the resident did not have Docusate 100 mg tablets listed on their Medication Administration Record (MAR). Further review of the facility's Medication Administration policy indicated that staff are required to review the MAR, verify medication details, and observe resident consumption of medication. An interview with the DON confirmed that the resident had not been assessed for self-administration of medications and was not authorized to self-administer. This deficiency was also cited in the two previous recertification surveys.
Failure to Honor Resident Choice and Facilitate Self-Determination
Penalty
Summary
A deficiency occurred when a newly admitted resident was not provided with choices regarding significant aspects of their daily life, specifically the ability to get out of bed and use the bathroom. Upon admission, the resident requested assistance to get out of bed but was informed by staff that facility policy prohibited transfers until a physical therapy (PT) assessment was completed. As a result, the resident remained in bed for the entire weekend, relying on a bedpan for toileting, which caused distress as the resident was admitted for rehabilitation but was unable to participate in activities or therapy as desired. Additionally, the resident's spouse reported communication issues during the admission process, stating that no staff collected their contact information and that repeated attempts to reach the facility by phone went unanswered. The spouse expressed concern about the lack of staff presence and the inability to check on the resident's well-being. The DON confirmed that the resident was not assessed by PT until later in the week, which led to the resident being confined to bed over the weekend, in accordance with current facility policy.
Failure to Notify Physician of Expired PRN Medication Request
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a resident's request for a PRN (as needed) anxiety medication after the prescription had expired. The resident requested the medication multiple times over a weekend, but nursing staff informed the resident that the prescription had expired and that the prescriber was unavailable until after the weekend. No attempts were made by the nursing staff to contact the on-call physician, despite having 24/7 access, to renew the prescription. As a result, the resident did not receive the requested medication until several days later. Record review revealed that there were no nursing notes documenting the resident's requests for the medication or the reasons for not administering it. The medication administration records showed that the resident regularly requested the PRN anxiety medication, and the prescription had been consistently reordered in the past. The Director of Nursing confirmed that the nurse should have contacted the on-call physician to address the expired prescription.
Failure to Provide Assistance with Personal Hygiene and Grooming
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for personal hygiene and grooming was not provided necessary assistance with fingernail care. Observation revealed the resident's fingernails were approximately 1/2 inch long with a dirt-like substance under each nail, and one nail was broken with a red/brown blood-like stain on the fingertip. The resident reported being unable to cut their own fingernails, had requested staff assistance, and stated that staff had not noticed or addressed the broken nail, which had caused pain and bleeding after catching on a blanket. Review of the care plan indicated the resident required total assistance for personal hygiene, but there was no documentation of fingernail care being provided for a one-month period.
Failure to Provide Resident with Required Hearing Aid Assistance
Penalty
Summary
The facility failed to ensure that a resident with documented hearing impairment received proper treatment and assistive devices to maintain hearing abilities. During multiple attempts to interview the resident, the individual was unable to communicate due to not having functioning hearing aids, repeatedly stating that their hearing aids were either dead or left on the charging dock. The resident's medical record included a physician's order to apply hearing aids to both ears every morning and a care plan identifying the need for hearing aids to assist with communication. Despite these documented needs and orders, staff did not consistently assist the resident with their hearing aids, resulting in the resident being unable to communicate effectively with staff during the surveyor's observations.
Medication Error Rate Exceeds Acceptable Threshold Due to Late and Missed Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, with an observed error rate of 43% during the survey. Out of 30 medication administration opportunities, 13 errors were identified for one resident, primarily due to the late administration of 12 scheduled medications, failure to follow administration recommendations, and omission of a PRN medication when requested. Specifically, multiple medications scheduled for administration at 8:00 AM or 9:00 AM were instead given between 10:23 AM and 10:54 AM. Additionally, the LPN did not instruct the resident to rinse their mouth after using an inhaler, as required by administration guidelines, and did not provide a requested PRN medication (Milk of Magnesia) as of the time of observation. Further observations revealed that the medication administration system flagged several residents as overdue for their medications, with the LPN confirming that late administration was a daily occurrence due to staffing shortages and competing responsibilities such as assisting with meals. The facility's policy defines medication errors to include late administration, omission, and failure to follow administration protocols, all of which were observed during the survey. The DON confirmed that not administering a PRN medication when requested constitutes a medication error.
Medications Improperly Stored and Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for one resident. During observation, a resident was found sitting unsupervised in bed with three pills on their lap and requesting more water. Review of the medication administration record (MAR) revealed that one of the medications, Docusate 100 mg tablet, was not listed for the resident. An interview with the LPN confirmed that the nurse had left the medications at the resident's bedside, which is not in accordance with facility policy or professional standards. This incident was noted as a repeat deficiency, having been cited in the two previous recertification surveys. The medications involved included Docusate 100 mg tablet, Metformin 500 mg tablet, and Bupropion ER 150 mg tablet, which are used for constipation, diabetes, and depression, respectively. The resident was unsupervised at the time the medications were left at the bedside.
Failure to Ensure Safe and Sanitary Storage and Handling of Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure the safe and sanitary storage, handling, and consumption of food brought in by family or visitors for one resident. The resident reported not consuming facility-provided food and instead relied on purchasing their own food, which was stored in their room and in a unit refrigerator. The resident stated that staff were responsible for placing food requiring refrigeration into the unit fridge. The resident discovered that all of their food had been discarded from the unit refrigerator without notification, despite most items being unopened and not near expiration. At the time of the surveyor's observation, the unit refrigerator was empty and no policy regarding resident food storage was posted. Review of facility policy indicated that refrigerated food must be labeled with the resident's name and date received, and should be kept for three days before being discarded, with notification to the resident. The District Manager confirmed that the food was discarded by kitchen staff due to lack of labeling, and acknowledged that staff—not residents—were responsible for labeling. The District Manager also confirmed that residents were not informed prior to the disposal of their food, and that unopened, labeled food should have been retained until three days after its expiration date.
Failure to Appoint a Licensed Administrator
Penalty
Summary
The facility failed to appoint an administrator licensed by the state to be responsible for managing the facility, as required by its own governing body policy. After the interim administrator left the role, a new administrator briefly filled the position for several days before resigning, leaving the facility without a licensed administrator. Subsequently, the Director of Nursing (DON), who does not hold a Nursing Home Administrator License according to the state Office of Professional Regulation database, was designated to act as the interim administrator. This sequence of events was confirmed through interviews with the Chief Nursing Officer, the DON, and the facility owner, all of whom acknowledged the absence of a licensed administrator during this period. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Maintain Current License and Notify State Agency of Administrative Changes
Penalty
Summary
The facility failed to maintain a current license from the State Agency to operate as a nursing home, as required by state regulations. The Chief Nursing Officer (CNO) confirmed that after the Interim Administrator left on 1/5/25, a new Administrator was in place from 1/6/25 to 1/9/25, after which the facility operated without a Licensed Administrator. Additionally, a new Director of Nursing (DON) was hired on 1/13/25. The facility's most recent License to Operate, issued on 12/18/24, still listed the previous Administrator and DON, and the facility did not notify the State Agency of these changes as required by Vermont's Licensing and Operating Rules for Nursing Homes. Interviews with the CNO and the Facility Owner confirmed the timeline of administrative changes and the lack of notification to the State Agency regarding the changes in Administrator and DON. The Facility Owner was unaware that the required notifications had not been made. The failure to notify the State Agency and update the facility's license with the current Administrator and DON constitutes noncompliance with state licensing requirements.
Significant Medication Error: Ear Drops Administered to Eyes
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of ear drops into the resident's eyes. The resident, who had a medical history including dry eyes, artificial lenses in both eyes, and mild retinopathy, experienced significant pain and burning after receiving Debrox Otic Solution, intended for ear wax removal, in both eyes. This error was confirmed by the Advance Practice Registered Nurse (APRN) during an interview, who noted the resident's eyes were very red and painful. The medication error was identified when the resident reported the incident, and subsequent medical assessments confirmed the adverse effects, including irritation and redness of the eyes. The facility's policy defines a significant medication error as one that causes discomfort or jeopardizes health and safety, which was evident in this case. The resident required medical attention, including eye irrigation and antibiotic eye drops, and was referred to the emergency department for further evaluation.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing levels, impacting the care and response to residents' needs. Multiple residents reported significant delays in call light responses, with one resident left in urine overnight and another urinating in bed due to unaddressed call lights. Staff interviews revealed that the shortage of staff led to difficulties in providing timely care, such as assisting residents with meals and personal hygiene. The Unit Nurse and LNAs expressed concerns about the inability to perform their duties effectively due to the lack of staff, with some staff working excessive hours to cover shifts. The Director of Nursing and other staff members, including the Scheduler, confirmed the staffing issues, noting that they often had to perform duties outside their roles, such as working the medication cart or providing wound care. The facility's direct care schedules and assessments indicated a lack of unit managers and a skin health nurse, with staffing decisions based on census rather than resident acuity. This deficiency in staffing potentially affected all residents, as the facility was unable to meet the required care standards due to insufficient personnel.
Failure to Meet Residents' Nutritional Needs
Penalty
Summary
The facility failed to provide residents with meals that met their daily nutritional and dietary needs, as evidenced by multiple instances of missing or substituted food items. The Dietary Manager reported issues with the meal delivery system, which led to residents receiving duplicate meal trays, causing food shortages. Additionally, produce deliveries contained unusable items, such as rotted lettuce and ripe bananas, further contributing to the shortages and substitutions. The facility's food service operates on a strict budget, and requests for additional items must be approved by the corporate entity, which sometimes results in reduced or unapproved amounts. Observations and interviews conducted during meal services revealed that residents did not receive the scheduled food items. For instance, during lunch, residents reported not receiving items like lettuce, tomato slices, and watermelon, while during dinner, the scheduled beef lasagna was replaced with penne pasta, and salads were substituted with beets without prior notification to the residents. Breakfast service also saw residents missing items like bananas, yogurt, and oatmeal. These discrepancies were not communicated to the residents in advance, leading to dissatisfaction and unmet dietary needs. The Dietary Manager stated that menu changes and substitutions should be communicated to nursing staff during daily morning meetings, but a staff RN reported that such communications did not occur. The Dietary Manager acknowledged that residents should receive all items on their menu to fulfill their dietary requirements and that missing items should be substituted with those of similar nutritional value. However, the facility's current practices resulted in residents not receiving the necessary nutrition as per their dietary plans.
Failure to Follow and Communicate Menu Changes
Penalty
Summary
The facility failed to adhere to the posted Dinner menu on 8/5/24, which was supposed to be Beef Lasagna with marinara sauce. Instead, residents were served penne pasta with meat sauce or plain penne. This change was not updated on the menu, and residents were not informed of the substitution. Observations during the dinner service confirmed that no resident received the scheduled lasagna. Interviews with several residents revealed their expectation of lasagna and their lack of notification about the menu change. The Dietary Manager confirmed the menu change and acknowledged that it was not communicated to the residents.
Failure to Provide and Communicate Meal Options
Penalty
Summary
The facility failed to effectively provide and communicate alternate food choices and appealing meal options to residents who chose not to eat the food initially served. Observations and interviews revealed that residents were not offered choices prior to meals, and alternatives were only provided after the initial meal was declined. For instance, one resident reported that the kitchen sometimes runs out of food items, and salads are often just lettuce. Another resident expressed a desire for eggs at breakfast, which was not offered, and stated that no one ever asked about their meal preferences. Additionally, a resident who disliked grilled cheese was only offered that as an alternative, resulting in uneaten meals. The facility's dietary management practices contributed to the deficiency. The Dietary Manager claimed that residents could request meal options at any time, but a Licensed Nurse's Aide (LNA) indicated that short staffing made it difficult to ask residents about their meal preferences. The facility's Dietitian confirmed that meals were based on a Preference List that only recorded dislikes, not preferences, and there was no formal process to offer alternatives. The District Manager stated that residents had to inquire about alternative options, as the facility did not provide a printed or shared alternative menu. This lack of communication and proactive meal planning led to dissatisfaction among residents regarding their meal options.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of disrepair and uncleanliness across two nursing units. Observations included damaged baseboard radiators, unrepaired holes in walls, damaged furniture, and missing or loose closet door handles. Additionally, there were reports of stained or missing ceiling tiles, bugs in light fixtures, and unsanitary conditions such as blood or stool-like substances on toilets and sinks. Residents reported that their rooms had not been cleaned in a while, and the Housekeeping Director confirmed a lack of staff and deep cleaning since the beginning of the year. Further issues were identified in the facility's gym and social services office, where mold was discovered due to humidity. A resident reported being unable to attend therapy sessions because of mold in the gym. The Regional Environmental Services Director confirmed the presence of mold in the gym and other areas, including the tub room off of A-Wing. The facility had not conducted a comprehensive cleaning of the gym, despite the presence of mold. Additionally, a resident's bathroom door was left unfinished after modifications to accommodate an electric wheelchair. The door frame was left with bare wood and drywall, which was acknowledged as an infection control issue by the Clinical Market Advisor. The resident expressed concerns about the incomplete work, and the facility had difficulty getting the contractor to return and finish the modifications.
Physician Orders Not Signed for Multiple Residents
Penalty
Summary
The facility failed to ensure that physicians signed and dated all physician orders for four of six sampled residents. Resident #403 was admitted and had a regulatory physician admission visit, but 29 days later, the admission orders, including medications, were not signed by a physician. Similarly, Resident #11 had a regulatory physician admission visit, but 62 days later, the admission orders remained unsigned. Resident #103's admission orders were unsigned 31 days after the regulatory visit, and Resident #35's orders were unsigned 39 days after their visit. The Market Clinical Lead confirmed that the Attending Physician did not sign the admission orders for these residents, which was required.
Lack of Annual Performance Evaluations for LNAs
Penalty
Summary
The facility failed to ensure that Licensed Nursing Assistants (LNAs) received annual performance evaluations. This deficiency was identified for three LNAs who had been employed at the facility for over a year. Specifically, there were no performance evaluations completed within the past year for an LNA hired on 5/31/18, another hired on 3/28/22, and a third hired on 7/4/22. During an interview on 8/7/24, the Market Operations Advisor confirmed the absence of these evaluations.
Failure to Uphold Resident Dignity and Provide Adequate Care
Penalty
Summary
The facility failed to uphold the dignity and respect of several residents, as evidenced by multiple observations and interviews. One incident involved a Licensed Nurse's Aide (LNA) transporting a resident in a wheelchair by pulling it backward, causing the resident's feet and catheter bag to drag on the floor. The LNA admitted to this action, acknowledging that the resident did not lift their feet. Another resident expressed dissatisfaction with being instructed to use a pull-up for toileting instead of being assisted to the bathroom, despite having a care plan that included assistance for toileting. The resident's Power of Attorney (POA) had repeatedly requested that the resident be taken to the bathroom, citing an orthopedic note that allowed for weight-bearing with a CAM boot. On Unit B, staff were observed neglecting to interact with residents in the common area, instead talking over them about work duties. Residents were left without engagement, and staff were seen pushing residents into the area without communication. In one instance, a resident was left visibly wet and holding a catheter bag, calling for help, while staff walked by without addressing the situation. It was only after a significant delay that a staff member engaged with the residents by initiating an activity. Additional observations included residents being left exposed and unattended. One resident was transferred in a shower chair with inadequate covering, exposing parts of their body. Another resident was left in a shower chair outside the shower room with wet hair and minimal covering, later found in their room still exposed and in pain. The LNA attending to this resident prioritized making the bed over addressing the resident's discomfort and exposure, resulting in the resident remaining in the shower chair for an extended period before being transferred to bed.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident or their representative upon the resident's transfer to the hospital. This deficiency was identified for one of the 23 residents sampled. The resident, who had been transferred to the emergency department for a potential urinary tract infection, did not receive a bed hold notice, nor was there evidence of such a notice being sent to the resident's power of attorney in the medical record. Interviews with facility staff, including the Clinical Market Advisor, confirmed the absence of the bed hold notification. Despite efforts to locate the notification, the Clinical Market Advisor was unable to find any documentation of it being provided to the resident or their representative. The facility's policy requires that the bed hold notice be given to both the resident and their representative prior to transfer, with a copy maintained in the medical record and another provided to the Business Office Manager at the next interdisciplinary team meeting.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required by their policy. During an interview, a resident revealed that they had two topical medications, Nystatin powder and Bio Freeze, in their nightstand drawer. The resident stated that they apply these medications themselves due to chronic shoulder pain and prefer to keep them in their room. However, the resident did not have a lockbox for these medications, which is a requirement according to the facility's policy. The facility's policy mandates that residents who wish to self-administer medications must be evaluated for their capability to do so safely and appropriately. This evaluation should be documented, and a physician or advanced practice provider order is required. Additionally, self-administration and medication storage must be included in the resident's care plan. In this case, there was no documented assessment, no evidence of orders for self-administration, and the resident's care plan did not reflect self-administration of medication. The Clinical Market Lead confirmed these deficiencies during an interview.
Improper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for one resident, who was found to have two topical medications, Nystatin powder and Bio Freeze, in their nightstand drawer. The resident had requested their family to bring in Bio Freeze for shoulder pain and was self-administering both medications without a lockbox for secure storage. The facility's policy requires a physician or advanced practice provider order for self-administration, care planning for medication storage, and provision of a secure, locked area for medications, none of which were in place for this resident. Interviews revealed that the facility was unaware of the resident's self-administration of medications, as confirmed by the Clinical Market Lead. A Registered Nurse familiar with the resident's care acknowledged that the resident applied the medications daily and kept them in their room. The lack of awareness and failure to provide a lockbox or obtain necessary orders and care planning led to the deficiency in medication storage compliance.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain routine and emergency dental services for a resident, leading to a deficiency. The resident was observed grinding their teeth and expressed a desire to have a dentist check it out. They also wanted to retrieve their partial plate from home and have a teeth cleaning, which they had requested nearly a year prior. Despite these requests, there was no evidence in the resident's medical record that they had received any dental services, including a teeth cleaning or assistance with their teeth grinding issue. The resident's care plan, revised months earlier, did not include interventions for obtaining the partial plate, providing dental services, or addressing the teeth grinding. Interviews with facility staff revealed a lack of follow-through and understanding of the process for scheduling dental services. The Nurse Practitioner was aware of the resident's issues but did not know how to retrieve the partial plate or ensure follow-up dental care. They admitted to not placing the resident on the list for a dental appointment. A Licensed Nursing Assistant, who previously coordinated dental appointments, was unsure how the resident's cleaning was missed and confirmed that the referral binder, used for tracking dental referrals, did not contain any entries for the resident's dental needs.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to ensure that a qualified dietitian or other clinically qualified nutrition professional was employed full-time or that a designated director of food and nutrition services met the required qualifications. The facility's Dietitian, who works part-time and is present only one day a week, does not fulfill the full-time requirement. Additionally, the Dietary Manager, who has been in the position for the past year, has not yet obtained the necessary certification or qualifications to ensure consistent food safety practices. An interview with the Dietary Manager revealed that they are currently working on their certification and are halfway through the process. However, the lack of certification means that the facility does not have a qualified individual to oversee food safety practices consistently. The facility's Department Heads phone list, updated by the Regional Market President-Operations, lists the staff member as the Dietary Manager, indicating that the facility is aware of the current staffing situation but has not yet addressed the deficiency in qualifications.
Pest Control Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain effective pest control measures in the kitchen area. During an initial tour, a window adjacent to food preparation areas was observed to be open and lacking a screen. This deficiency was confirmed through an interview with the facility's Dietary Manager, who acknowledged the absence of a screen on the window and recognized the need for such a preventative measure to prevent insects and common pests from entering the kitchen, which could lead to infection control issues.
Failure to Implement Care Plan Interventions for Catheter Care and UTI Management
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a suprapubic catheter, leading to infection control risks. The resident's care plan required that the catheter be kept off the floor and that output be recorded. However, observations revealed that the catheter bag and tubing were dragging on the floor during transport and while the resident was seated in the dining room. Interviews with LNAs confirmed that the catheter was not being managed according to the care plan, and there was no documentation of the resident's catheter output, despite it being a care plan requirement. The Market Clinical Advisor acknowledged these lapses, confirming the infection control risks posed by the catheter's improper handling. Additionally, the facility failed to identify and implement care plan interventions for another resident who had a urinary tract infection (UTI) and was on antibiotic therapy. The resident's urinalysis indicated a UTI, and they were placed on antibiotics. However, the resident refused several doses, and the care plan did not address the UTI diagnosis or antibiotic use. The resident was later transported to the emergency department for a suspected UTI and was diagnosed with the condition. The Clinical Market Advisor could not provide a care plan specific to the UTI diagnosis or antibiotic use, indicating a lack of appropriate care planning for the resident's condition.
Failure to Revise Care Plan After Medication Error
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant medication error involving the incorrect administration of ear drops into the resident's eyes. The resident, who was admitted with diagnoses including Pseudophakia OU, mild retinopathy, and dry eyes, experienced severe pain and burning in the eyes due to this error. The resident was subsequently treated in the emergency department for chemical exposure to the eyes, where the eyes were flushed, and antibiotic eye drops were prescribed to prevent infection. Despite the facility's policy requiring care plans to be reviewed and revised after each assessment and as needed, there was no documented evidence that the care plan was updated to monitor the resident for adverse effects following the medication error. Interviews with the Clinical Market Lead and the Director of Nursing confirmed the absence of revisions to the care plan and the lack of monitoring for symptoms such as pain, redness, or burning in the eyes after the resident's return from the hospital.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control measures related to catheter care for a resident with a suprapubic catheter, who is at high risk for urinary tract infections. During an observation, the resident was seen being transported in a wheelchair by a Licensed Nursing Aide (LNA), with the urine drainage bag and tubing from the suprapubic catheter dragging on the floor. This was confirmed by the LNA. Additionally, the resident was later observed in the dining room with the catheter bag and tubing again touching the floor. Two LNAs confirmed that the catheter bag was hanging too low, allowing the bag and tubing to contact the floor. The Market Clinical Advisor (MCA) acknowledged that the situation posed infection control risks for the resident.
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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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