Premier Rehab And Healthcare At Burlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Vermont.
- Location
- 300 Pearl Street, Burlington, Vermont 05401
- CMS Provider Number
- 475014
- Inspections on file
- 35
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Premier Rehab And Healthcare At Burlington during CMS and state inspections, most recent first.
A resident with Osteogenesis Imperfecta and Osteoporosis, whose care plan required transfers with a Hoyer lift and two staff, was manually lifted from a wheelchair to a bed by an LNA who acted alone and did not use the mechanical lift despite the resident’s request. After the transfer, the resident reported a popping sensation and pain in the upper back and right shoulder, and an LPN assessment found limited range of motion with grimacing on movement. Hospital evaluation confirmed a fractured scapula. Facility leadership and the DON acknowledged that the LNA knowingly failed to follow the resident’s individualized transfer care plan and the facility’s safe handling policy, leading to the resident’s injury.
A resident recovering from hip surgery did not receive wound vac care and monitoring according to facility policy, as there was no care plan, incomplete physician orders, and a lack of staff competency. The wound vac was removed due to supply issues, and dressing changes were not performed as ordered, leading to infection and hospitalization for additional surgeries.
A resident with a wound vac following hip surgery did not receive proper care due to staff lacking training and competency in wound vac management. The wound vac was not used as required, and there was no care plan or physician orders for over three weeks. This led to the resident developing an infection that required hospitalization and further surgery. Review confirmed that none of the nurses involved had received wound vac education or competency checks, and facility leadership was unaware of required training documentation.
The facility did not have a certified food service director, as the Kitchen Manager was new and not yet certified, and the Registered Dietician was not working full-time at the facility, instead splitting her hours between two locations. This staffing deficiency was confirmed through staff interviews and timecard reviews.
The facility did not ensure that substantial snacks or meal alternatives were available to residents outside of scheduled meal times, particularly for a resident returning late from dialysis who often missed dinner and could not access adequate food options. Staff interviews and observations confirmed that kitchenettes were inconsistently stocked, the kitchen closed early, and there was confusion about staff access to food after hours. Cognitively intact residents also reported that snacks were only available if the kitchenettes were stocked, which was not always the case.
Surveyors found that food was improperly stored in the kitchen and unit kitchenettes, including boxes placed directly on the freezer floor, undated and unlabeled food items, and the presence of expired and moldy food. Facility staff, including the KM and DON, confirmed that these practices did not follow established policies for food labeling and storage.
Surveyors found that medical equipment and supply carts were contaminated with construction dust, and a mattress and pillows with compromised protective coverings were prepared for new resident use after cleaning. Staff confirmed these items could not be properly disinfected. Additional deficiencies included missing sharps containers with used needles left in a medication cart, improper storage of resident-specific ice packs in a food freezer, and undated wound and PICC line dressings for a resident post-surgery. These issues reflect failures in infection prevention and control practices.
A resident requiring hemodialysis did not receive care and services consistent with professional standards, as the Hemodialysis Communication Record was not consistently or completely filled out by facility staff or the dialysis center on multiple occasions. Required pre- and post-dialysis assessments were also not completed, and staff interviews confirmed lapses in documentation and assessment responsibilities.
A medication treatment cart was found unlocked on a unit while a resident was present in the hallway. An LPN confirmed the cart should have been locked, as required by facility policy, which mandates all drugs and biologicals be stored in locked compartments.
Surveyors found that construction dust and debris were present on medical equipment and carts, including code and treatment carts and Hoyer lifts, on one unit. Staff confirmed the dust was from ongoing construction activities and that cleaning was insufficient. Additionally, a room prepared for a new resident contained a mattress with brown stains, a worn protective lining, and pillows with holes, all of which staff acknowledged were not suitable for use but remained in place after terminal cleaning.
A resident with multiple medical conditions and no cognitive impairment alleged that staff members yelled at, pushed, and physically mistreated them. During the investigation, the facility did not remove the accused staff from the premises but reassigned them to other units, contrary to facility policy requiring protection of residents from further harm.
Two residents who required interpreter services did not have baseline care plans addressing their communication needs within 48 hours of admission. Staff were unable to communicate directly with these residents, leading to unmet needs and misinterpretation of requests. Facility leadership confirmed that appropriate care plans were not in place.
Two residents were not protected from physical abuse by other residents, as evidenced by one resident being struck in the face during a verbal altercation and another being punched in the chest while standing in a doorway. These incidents were confirmed by facility leadership and documented in progress notes.
A resident reported being hit with a wet towel by a staff member, but the facility did not report the abuse allegation to the state agency or document an investigation, as required by policy. Facility leadership was aware of the allegation but chose not to report it, citing the resident's hallucinations.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet needs for residents. A resident with a leg amputation missed activities due to late transfers, while another with a fracture waited two hours for medication. Widespread concerns about long call light response times were reported, with some residents waiting over seven hours. Residents with Parkinson's disease experienced delays in medication administration, exacerbating symptoms. These issues highlight systemic staffing deficiencies affecting resident care and safety.
The facility failed to maintain the dignity and respect of several residents, as evidenced by delayed responses to call bells, refusal to assist with bathroom needs, and staff not honoring residents' preferences for personal care. Residents reported feeling disrespected and not treated as if they were in their own home, with some staff displaying rude behavior and ignoring their requests.
The facility failed to support residents' rights to voice grievances without fear of reprisal. During a Resident Council meeting, several cognitively intact residents expressed discomfort in reporting concerns about being treated without dignity and respect due to fear of repercussions. They reported experiencing rude or rough behavior from staff and feared being yelled at or ignored if they reported such issues, despite knowing the grievance process.
Three residents experienced significant delays in receiving assistance with toileting, leading to discomfort and incontinence. One resident with a leg fracture was left on a bedpan for 45 minutes, while another with lumbar issues waited over an hour during meal times. A third resident with spinal stenosis reported long wait times, resulting in incontinence. These incidents highlight a failure to adhere to care plans for timely toileting assistance.
A resident with Parkinson's disease expressed a strong preference for outdoor activities, which was documented in their care plan. However, due to insufficient staff and weather concerns, the resident was only able to go outside once in 33 days, leading to feelings of being trapped. An Activity Aide acknowledged the issue but noted a lack of staff to ensure the resident's needs were met.
A facility failed to enforce its smoking policy and provide adequate supervision for a resident with multiple health conditions, who was found to be smoking unsupervised and keeping smoking supplies in their room, contrary to facility policy. The Unit Manager confirmed the non-compliance, noting that many residents on the floor have dementia and are ambulatory.
A facility failed to document the medical rationale for extending a PRN order of Ativan beyond 14 days for a resident. The medication was prescribed for 90 days without the necessary physician documentation or evaluation, as confirmed by the Unit Manager.
The facility failed to provide residents with drink options that accommodate their preferences, specifically the availability of ginger ale. A resident expressed frustration over the absence of ginger ale, and six active resident council members voiced concerns about its removal. Despite the facility's policy to provide drinks consistent with resident needs and preferences, an LNA confirmed that ginger ale has not been available for about six months, and the drink cart did not include any soda products. The Assistant Activities Director and the Assistant Kitchen Manager also confirmed the unavailability of ginger ale and any alternative soda or carbonated drinks for residents.
The facility failed to provide sufficient dietary staff, resulting in unsatisfactory meal service for residents. Observations and interviews revealed that meals were often cold and served late due to a shortage of staff, with only one dietary staff member available instead of the required 3-4. This led to meals being served by tray service without insulation, causing faster cooling and frequent delays.
The facility failed to provide meals that were palatable, attractive, and at an appetizing temperature. Residents reported meals being served late, cold, and unappetizing, with some relying on family for food. The kitchen was short-staffed, leading to delays and temperature issues, and food temperatures were not consistently documented. The deficiency was linked to inadequate dietary staffing.
The facility failed to offer residents appealing meal options that met their preferences and dietary needs. Multiple residents reported not being given a choice of meals, receiving food that did not align with their preferences or dietary restrictions, and experiencing poor food quality. Staff interviews revealed a lack of awareness and implementation of a process to ask residents their meal preferences, contributing to the deficiency.
The facility did not follow its policy for screening abuse for an LNA. The LNA's background check showed a misdemeanor charge for disturbing the peace with fighting before being hired, but there was no evidence that the facility or corporate HR reviewed this charge to determine employment eligibility. This was confirmed by the Market Operations Advisor.
A resident admitted for sub-acute rehabilitation after a cerebrovascular accident received Apixaban, an anticoagulant, despite hospital instructions to withhold it until after a follow-up CT scan. The facility's medication reconciliation process failed, as the admitting nurse did not clarify the conflicting orders with the physician. The DON acknowledged discrepancies in discharge information, and the admitting physician was unaware of the hold order due to reliance on nursing staff for accurate communication.
A resident experiencing numbness and pain on the left side of their body did not receive a necessary x-ray, which was ordered by a physician to address issues affecting their rehabilitation. The x-ray was not obtained due to a failure in the process to alert nursing staff to enter the order.
The facility did not involve residents and their representatives in developing baseline care plans or provide them with summaries. A resident admitted for rehabilitation after a craniotomy experienced a fall, and two other residents admitted for post-acute care and rehabilitation were not included in care planning. Interviews confirmed the lack of involvement and documentation, contrary to facility policy.
A resident's port-a-cath was neglected in an LTC facility, leading to an infection and delayed chemotherapy. The port was not identified or cared for upon admission, and staff failed to document or monitor it. Despite awareness by some staff, no care was provided, resulting in the resident's hospitalization and emotional distress.
A resident's implanted port was not identified or cared for during their stay at an LTC facility, leading to an infection and removal of the port. The resident, undergoing rehabilitation after surgery and chemotherapy for ovarian cancer, had their chemotherapy delayed due to the infection. Staff were aware of the port but did not perform necessary care, such as dressing changes or monitoring. The facility's admission assessment failed to identify the port, and there was no documentation of port care throughout the resident's stay.
Injury from Failure to Follow Mechanical Lift Transfer Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to an individualized transfer care plan for a resident with significant bone fragility. The resident had diagnoses of Osteogenesis Imperfecta and Osteoporosis, conditions that make bones weak and easily fractured. The resident’s care plan specified that transfers were to be performed using a Hoyer lift with two staff members, in accordance with the facility’s Safe Resident Handling/Transfers policy, which requires staff to follow each resident’s individual plan of care. Despite these requirements, an LNA independently performed a manual transfer of the resident from a wheelchair to a bed, lifting the resident under the arms instead of using the mechanical lift and a second staff member. During the transfer, the resident told the LNA to use the mechanical lift, but the LNA continued the manual transfer. After being placed in bed, the resident felt a pop and experienced discomfort, which was reported to the LNA. The resident later reported pain in the upper back and right shoulder area, and the LNA informed the LPN that the resident needed pain medication, initially stating the pain followed assistance with removing a sweater. Upon assessment, the LPN noted limited range of motion and grimacing with movement, and the resident reported that the LNA had lifted them into bed. The LNA confirmed to facility leadership that she had transferred the resident without the Hoyer lift and was aware of, but did not follow, the care plan. Hospital evaluation documented a fractured scapula, and both the Administrator and DON confirmed that the LNA failed to comply with the resident’s care plan and facility policy, resulting in the resident’s injury.
Failure to Provide Wound Vac Care and Monitoring per Policy
Penalty
Summary
A resident admitted for rehabilitation following a left hip replacement was identified as high risk for post-operative infection and required the use of a wound vacuum (wound vac) for surgical site management. Despite this, the facility failed to develop a care plan or obtain physician orders for the wound vac upon the resident's return from the hospital, and there was no evidence of monitoring the wound vac in accordance with facility policy. The wound vac was not included in the resident's care plan or monitored as required, and physician orders lacked necessary details such as pressure settings. The wound vac was only documented as administered for three days, and when the device became full and supplies were unavailable, it was removed and replaced with wet-to-dry dressings without appropriate orders or frequency of dressing changes. Staff interviews and record reviews revealed that nursing staff were unfamiliar with the wound vac type and lacked training or competencies to provide appropriate care. The facility did not ensure that staff were educated or competent in wound vac management, as confirmed by the review of employee education files for all licensed nursing staff who cared for the resident. Additionally, after the wound vac was removed due to lack of supplies, the resident did not receive the ordered frequency of dressing changes, and the care plan was not updated to reflect the new wound care needs. As a result of these failures, the resident developed an infection at the surgical site, which required hospitalization and two subsequent surgical interventions, including a hip revision. The lack of timely care planning, physician orders, monitoring, and staff competency directly contributed to the resident's adverse outcome. The deficiencies persisted until the care plan and physician orders were finally updated more than three weeks after the initial placement of the wound vac.
Lack of Staff Competency and Education for Wound Vac Care
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies and did not receive necessary education to care for a resident with a wound vacuum (wound vac) following a hip replacement. The resident, who was cognitively intact, required the wound vac due to drainage at the surgical site. However, there was a period when the wound vac was not in use because it became full and staff were unsure how to manage it, leading to its discontinuation. The resident did not have a care plan, physician orders, or evidence of monitoring for the wound vac for 22 days after its placement. Review of staff education files revealed that none of the three licensed nurses who cared for the resident had received wound vac training or competency assessments. The Director of Nursing confirmed that no education or competencies were provided for wound vacs, and the Nurse Educator was unfamiliar with the facility's own education and competency documentation referenced in the facility assessment. As a result of these deficiencies, the resident developed an infection at the surgical site, requiring hospitalization and two additional surgical interventions.
Lack of Qualified Food Service Director and Full-Time Dietician
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, specifically lacking a qualified food service director and a full-time qualified dietician. The Kitchen Manager, who was new to the position, did not possess certification as a dietary manager or food service manager at the time of the survey. Additionally, the Registered Dietician (RD) was not working full-time at the facility, as confirmed by both the Administrator and the RD herself; the RD worked 25 hours in the previous week and was present at the facility three times a week, splitting her full-time hours between two facilities. These findings were based on staff interviews and review of timecard records.
Failure to Provide Substantial Snacks and Meal Alternatives Outside Scheduled Meal Times
Penalty
Summary
The facility failed to provide substantial snacks or meal alternatives for residents who required food outside of scheduled meal times, particularly when there was more than 14 hours between the evening meal and breakfast. Record reviews and interviews revealed that a resident with complex medical conditions, including end stage renal disease, diabetes, and chronic heart failure, often returned from dialysis appointments late in the evening and did not consistently receive dinner or substantial snacks. Documentation of meal intake was inconsistent, and staff sometimes marked the resident as 'not available' for dinner, even though the resident returned later and required food. Observations and staff interviews confirmed that kitchenettes on the units were not consistently stocked with substantial snacks or meal alternatives, such as sandwiches or salads, after the kitchen closed in the evening. The kitchen manager and nursing staff acknowledged that after the kitchen closed, only limited snack items like pudding, crackers, and chips were available, which did not constitute a meal. There was also confusion among staff regarding their ability to access the kitchen after hours to provide food for residents, and the process for restocking snacks was not reliably followed. Additional interviews with cognitively intact residents indicated that snacks were only available if the kitchenettes happened to be stocked, which was not always the case. Observations confirmed that essential snack items and meal alternatives were missing from the units, and the kitchen manager stated that the kitchen was responsible for stocking these items but did not keep track of inventory. As a result, residents who needed food outside of traditional meal times, especially those returning late from medical appointments, did not have access to suitable and nourishing alternatives.
Food Storage and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage and handling practices. During a kitchen tour, boxes of food were found stacked directly on the floor of the walk-in freezer, obstructing access to other food items. The Kitchen Manager acknowledged that boxes should be placed on crates and not directly on the freezer floor. Despite being informed of this issue, a follow-up observation the next day revealed that the problem persisted, with boxes still on the freezer floor. The Kitchen Manager confirmed that the freezer had been organized after the initial observation but reiterated that boxes should not be on the floor. Further deficiencies were identified in all four unit kitchenettes. Observations included microwaves with visible smears, cabinets with crumbs and open, undated food items, and refrigerators containing undated or expired food, moldy bread, and containers with unknown contents. Freezers also contained undated and unlabeled food items. Interviews with the Unit Manager and DON confirmed that facility policy requires all food to be labeled and dated, and that the observed conditions did not meet these standards. The Kitchen Manager also confirmed that all food in the kitchenettes should be labeled with the resident's name and relevant dates.
Infection Control Lapses and Environmental Contamination Identified
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices on the second floor of the facility. Observations revealed that essential medical equipment and supply carts, including the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts, were covered in white/grey powder and dust, later confirmed to be construction debris. Interviews with nursing and administrative staff acknowledged the presence of dust and debris on these items, as well as on the kitchenette hood, and confirmed that cleaning had not been adequately performed. The CDC notes that environmental disturbances, such as construction dust, can release airborne infections, increasing the risk of healthcare-associated infections. Further deficiencies were observed in the handling and maintenance of resident care equipment. A mattress and pillows in a recently vacated room were found to be stained, worn, and with compromised protective coverings, yet were made up and prepared for a new resident after terminal cleaning. Housekeeping and nursing staff confirmed the compromised condition of the mattress and pillows, and administrative staff acknowledged that such items could not be properly disinfected and should not remain in use. Additionally, an out-of-service medication cart was found to be missing a sharps container, with used needles and lancets left inside, and dust-like debris was noted on other equipment and surfaces. Other infection control lapses included the improper storage of resident-specific ice packs in a kitchenette freezer used for food, as confirmed by nursing and administrative staff, and the failure to label wound and PICC line dressings with the date of last change for a resident who had recently undergone surgery. These findings collectively demonstrate a lack of adherence to established infection control protocols and equipment maintenance policies, as confirmed by staff interviews and facility policy review.
Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident requiring hemodialysis. According to facility policy, staff are required to conduct ongoing assessments of the resident's condition and monitor for complications before and after dialysis treatments, as well as maintain ongoing communication and documentation with the dialysis center. Review of the medical record for a resident with end stage renal disease and multiple comorbidities revealed that the Hemodialysis Communication Record was not consistently or completely filled out by either facility staff or the dialysis center on 23 occasions since a specified date. Additionally, on at least one occasion, the required pre- and post-dialysis assessments, including checks for bruit, thrill, vital signs, last meal, diet, and general condition, were not completed by facility staff. Interviews with nursing staff and the DON confirmed that the Hemodialysis Communication Record was not being fully completed as required, and that both facility and dialysis center staff were responsible for documenting their respective portions. The DON also confirmed that nursing staff were not consistently assessing the resident's condition before departure to dialysis and upon return, nor ensuring that the dialysis center completed its documentation. The Unit Manager was identified as responsible for ensuring the records were complete and for contacting the dialysis center when documentation was missing.
Medication Cart Left Unlocked in Resident Area
Penalty
Summary
A medication treatment cart on the second floor was observed to be unlocked during a period of observation from 10:54 AM to 11:04 AM, while a resident was present and walking in the hallway. An interview with a nurse at 11:04 AM confirmed that the cart should have been locked, in accordance with the facility's Medication Storage policy, which requires all drugs and biologicals to be stored in locked compartments. Review of the policy, last updated in September, reiterated this requirement. The unlocked cart constituted a failure to safely store medications as required.
Failure to Maintain Cleanliness and Equipment Integrity During Construction
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment on one of its units, specifically the Second Floor, due to the presence of construction dust and debris on essential medical equipment and carts. White and grey powder-like substances, identified as construction dust, were found on the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts. Multiple staff, including an LPN, the DON, the Infection Preventionist, and the Regional Nurse Consultant, confirmed the presence of dust and debris on these items. Additionally, the kitchenette hood was found to have a buildup of debris and had not been cleaned. The dust was attributed to ongoing construction activities, such as sanding and wall preparation for wallpaper installation. Further deficiencies were identified in the maintenance and readiness of resident room equipment. After a resident was discharged, a mattress with brown discoloration, a worn and chipped protective lining, and two pillows with holes in their protective coverings were found in a room that had been terminally cleaned and prepared for a new resident. Staff interviews confirmed that the mattress and pillows were compromised and not suitable for resident use, as they could not be properly cleaned or disinfected. Facility policy requires that equipment in disrepair be reported and removed from use, but this was not followed in this instance, as the compromised items remained in the room ready for the next resident.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to implement effective measures to prevent further potential abuse during the investigation of an abuse allegation involving a resident who was cognitively intact and independent with activities of daily living. The resident, who had diagnoses including COPD, anxiety disorder, major depressive disorder, and Wernicke's encephalopathy, reported that a staff member yelled at them, pushed them causing a fall, and later bounced them on the bed. The resident also indicated that another staff member had engaged in similar behavior. Documentation showed that the alleged incident occurred late in the evening, and the resident was monitored following the accusation. Despite the facility's policy requiring protection of residents from further harm during investigations, records and interviews confirmed that the accused staff members were not removed from the facility but were instead reassigned to other units. Schedule reviews indicated that both staff members continued to work in the facility during the investigation period. The administrator confirmed that the accused staff were not removed from the facility while the investigation was ongoing.
Failure to Develop Baseline Care Plans for Non-English Speaking Residents
Penalty
Summary
The facility failed to create and implement a baseline care plan addressing communication needs for two residents who did not speak English and required interpreter services. Upon admission, both residents' Minimum Data Set (MDS) assessments indicated a preferred language other than English and a need for interpreter assistance to communicate with healthcare staff. Despite this, neither resident had a baseline care plan for communication or interventions for interpreter services within 48 hours of admission, as required. For one resident, a care plan was eventually created ten days after admission, but it still lacked interventions for interpreter services. The other resident did not have any care plan related to communication or interpreter services as of the date of the survey. Interviews with facility staff, including a licensed nurse and facility leadership, confirmed that interpreter services were not available and that staff were unable to communicate directly with the residents. In one instance, staff misinterpreted a resident's attempt to communicate and administered pain medication when the resident was actually trying to indicate they were cold. The administrator and DON acknowledged that baseline care plans should have been in place to address these residents' communication needs but were unable to provide evidence that such plans existed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, one resident was involved in a verbal altercation with another resident, which escalated when the second resident hit the first resident on the side of the face after being confronted about touching personal belongings. In the second incident, another resident was standing in a doorway when a different resident approached and punched them in the left side of the chest; a subsequent skin assessment found no bruising. These events were confirmed through record review and interviews with facility leadership, and the facility's abuse policy defines such actions as abuse resulting in physical harm, pain, or mental anguish.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state licensing agency as required. According to the record review, there was no evidence that a report was submitted after a resident alleged being hit with a wet towel by a staff member. Additionally, there was no documentation of an investigation into the allegation in the resident's medical record. The facility's policy requires immediate reporting and investigation of all alleged violations to the appropriate authorities, including the state agency and adult protective services. Interviews with facility staff revealed that the incident was communicated internally through the EHR and discussed among the hospice nurse, Assistant DON, and former DON. The Administrator and DON were aware of the allegation, but the leadership team decided not to report it to the state agency, citing their belief that the resident was experiencing hallucinations. This decision was made despite the facility's policy, which mandates reporting all allegations of abuse regardless of perceived credibility.
Staffing Deficiencies and Delayed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. This deficiency was observed in the care of multiple residents, including one resident with a right leg below-knee amputation who required assistance from two staff members for transfers. The resident reported missing activities due to delays in being transferred out of bed, which affected their ability to engage in meaningful daily routines and manage mood symptoms related to anxiety and depression. Another resident with a fracture of the right tibia and fibula experienced a significant delay in receiving a muscle relaxant medication, waiting approximately two hours after requesting it, which was confirmed by the unit manager as an excessive wait time. The report also highlights widespread concerns about insufficient staffing leading to long wait times for care and excessive call light response times. Residents and their family members reported wait times of up to 45 minutes or more, with call bell history revealing wait times in excess of seven hours for some residents. Specific instances included a resident with Parkinson's disease who did not receive their medications on time, leading to increased symptoms such as tremors and difficulty speaking. Another resident with spinal stenosis and myelopathy reported long wait times for toileting assistance, resulting in episodes of incontinence and distress. Additionally, the facility's failure to administer medications in a timely manner was noted for residents with Parkinson's disease, who experienced delays in receiving their prescribed medications. This was contrary to the facility's policy, which requires medications to be administered within a two-hour window. The unit manager acknowledged the importance of timely medication administration for managing Parkinson's symptoms. Overall, the report indicates a systemic issue with staffing levels and response times, impacting the quality of care and safety of residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of several residents, as evidenced by multiple incidents. Resident #88 reported that their call bell often went unanswered for over an hour, leading to incontinence episodes. The call bell log confirmed delays in response times, with several instances exceeding 30 minutes and some over an hour. Despite having a care plan to address incontinence, the resident's needs were not met promptly, compromising their dignity and comfort. Similarly, Resident #3 was observed waiting for assistance to use the bathroom while their assigned LNA was on break. The LNA present refused to assist, leaving the resident to wait and eventually call out for help, which was only addressed after the Unit Manager intervened. During a Resident Council meeting, several residents expressed concerns about not being treated with dignity and respect. Residents reported instances where staff did not knock before entering rooms, ignored their preferences for personal care, and sometimes displayed rude behavior. One resident mentioned being rushed during care and not being allowed to participate in their own hygiene routine, while another was told to manage independently despite needing assistance. These accounts highlight a pattern of staff failing to honor residents' rights to self-determination and respectful treatment, as outlined in their care plans.
Failure to Support Resident Grievance Reporting Without Fear of Reprisal
Penalty
Summary
The facility failed to establish a grievance reporting system that adequately supports residents' rights to voice grievances without fear of discrimination or reprisal. This deficiency was identified during a Resident Council meeting attended by six residents, all of whom were cognitively intact as indicated by their BIMS scores. The residents expressed that while they were aware of the grievance process and found it effective for issues like missing personal property, they did not feel comfortable reporting concerns about being treated without dignity and respect due to fear of repercussions. The residents reported that they experienced rude, disrespectful, or rough behavior from staff and feared that reporting such behavior would result in being yelled at or ignored. This sentiment was consistently confirmed by all six residents during the conversation with the survey team. The facility's policy, which states that residents have the right to voice grievances without fear of discrimination or reprisal, was not effectively implemented, leading to a situation where residents felt unable to report their concerns about staff treatment.
Failure to Provide Timely Assistance with Toileting
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, specifically in the areas of transferring and toileting. Resident #145, who was admitted with a fracture of the right tibia and fibula, required assistance with toileting as per their care plan. However, the resident reported being left on a bedpan for 45 minutes despite using the call bell, causing significant discomfort and distress. This incident highlights a failure to adhere to the care plan's specified interventions for toileting assistance. Resident #18, with a history of lumbar spondylopathy and morbid obesity, also experienced delays in receiving assistance with toileting. The resident reported waiting an hour or longer for help, particularly during meal times, which resulted in discomfort and cold meals. Similarly, Resident #73, who has spinal stenosis and requires assistance from two staff members for toileting, reported long wait times for assistance, leading to episodes of incontinence. The resident's family member corroborated these delays, noting wait times of 1-2 hours for call bell responses. These incidents collectively indicate a systemic issue in providing timely assistance for residents' toileting needs, as outlined in their care plans.
Failure to Provide Adequate Outdoor Activities for Resident
Penalty
Summary
The facility failed to provide activities that support the physical, mental, and psychosocial well-being of a resident diagnosed with Parkinson's disease. The resident, who has a cognitive assessment score indicating intact cognitive function, expressed a strong preference for engaging in favorite activities and going outside. The resident's care plan, created in October 2023, emphasized the importance of engaging in meaningful daily routines and included an intervention for going outside when the weather permits. However, the resident reported being unable to go outside daily due to insufficient staff for supervision and being told it was too cold, despite expressing that going outside was very important. During the recertification survey, the resident was not observed outside, and activity logs showed the resident only went outside once in 33 days. An Advanced Practice Registered Nurse note from August 2024 indicated the resident felt trapped and unable to get assistance to go outside. An Activity Aide acknowledged the importance of the resident going outside but was unsure if there were enough staff to facilitate this. The deficiency was identified as the facility's failure to ensure the resident's preferences and care plan interventions were met, impacting the resident's well-being.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to smoking for a resident. The resident, who has diagnoses including osteomyelitis, peripheral vascular disease, and chronic kidney disease, was admitted and readmitted to the facility. Despite the care plan stating that the resident may not smoke per the smoking evaluation and policy, the resident has been signing out and leaving the property to smoke without staff accompaniment. The resident admitted to going out to smoke three times on a particular day without signing out of the building. The facility's smoking policy requires that smoking supplies be labeled and maintained by staff in a suitable cabinet at the nursing station. However, the resident's cigarettes and lighter were kept in their room, contrary to the policy. The Unit Manager confirmed this and noted that approximately 15 residents on the floor have dementia and are ambulatory, which could pose additional risks. This oversight in policy enforcement and supervision led to the deficiency identified by the surveyors.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper evaluation and documentation for a resident receiving PRN (as needed) psychotropic medication. Specifically, a PRN order for Ativan (Lorazepam) 0.5 mg was prescribed to be administered every 4 hours as needed for restlessness/agitation over a 90-day period. This order was initiated without the required physician documentation providing a medical rationale for extending the PRN order beyond the standard 14-day period. An interview with the Unit Manager confirmed the absence of a physician note or documented evaluation justifying the extended use of this medication for more than 14 days.
Facility Fails to Provide Preferred Beverage Options
Penalty
Summary
The facility failed to provide residents with drink options that accommodate their preferences, specifically the availability of ginger ale. Resident #40 expressed frustration over the absence of ginger ale as a beverage option. Additionally, six active resident council members voiced concerns about the removal of ginger ale from the available drink options. The facility's policy, titled FNS304 Person-Centered Choice, effective 5/1/23, states that drinks should be provided consistent with resident needs and preferences. However, a Licensed Nursing Assistant (LNA) confirmed that ginger ale has not been available for about six months, and the drink cart observed did not include ginger ale or any soda products. The Assistant Activities Director and the Assistant Kitchen Manager also confirmed the unavailability of ginger ale and any alternative soda or carbonated drinks for residents.
Insufficient Dietary Staff Leads to Meal Service Deficiencies
Penalty
Summary
The facility failed to ensure sufficient support personnel to effectively carry out the functions of the food and nutrition services, impacting all residents. Observations and interviews with multiple residents revealed complaints about unsatisfactory food quality, with meals being cold when they should be hot and served later than the posted mealtimes. During a dinner service observation, meals were served by tray service without insulated plates, leading to faster cooling. A review of dinner delivery logs from 5/21/24 to 6/26/24 showed that meals were served late 76% of the time, with only 12 out of 52 instances being on time. Interviews with the Unit Manager, DON, and Kitchen Account Manager confirmed awareness of the issues, attributing them to a shortage of dietary staff. The Kitchen Account Manager noted that the kitchen has been short-staffed since April, with only one dietary staff member available instead of the required 3-4. This staffing shortage has led to delays in meal service and contributed to the food being served cold, as meals are delivered by tray service due to insufficient staff to serve from each unit's meal service line.
Deficiency in Meal Service Quality and Timeliness
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at an appetizing temperature. Multiple residents reported that meals were often served late, cold, and unappetizing. Observations confirmed that residents were served meals at inconsistent times, with some waiting significantly longer than others. Complaints were made about the lack of meal choices and the poor quality of food, with some residents relying on family to bring in meals due to dissatisfaction with the facility's offerings. The kitchen staff was found to be short-staffed, which contributed to the delays and temperature issues with the meals. The facility's Director of Nursing and Administrator were aware of the complaints regarding food quality, temperature, and timeliness. The kitchen was operating with insufficient staff, leading to the use of tray service without insulated plate covers, which caused meals to become cold more quickly. The kitchen logs revealed that food temperatures were not consistently documented, with 20 out of 90 meals lacking temperature records. The Kitchen Account Manager confirmed that the staffing shortage had been ongoing since April, affecting the ability to serve meals on time and at the correct temperature. The deficiency was attributed to the lack of adequate dietary staff, which hindered the facility's ability to provide meals that met the required standards for palatability and temperature.
Failure to Provide Appealing Meal Options
Penalty
Summary
The facility failed to provide residents with appealing meal options that accommodated their preferences and dietary needs, as evidenced by multiple observations and interviews. Residents and their representatives reported not being offered a choice of meals, with some residents receiving meals that did not align with their expressed preferences or dietary restrictions. For instance, Resident #11, who had a pork allergy, was served a ham and cheese sandwich instead of the BBQ chicken listed on their meal ticket. Other residents expressed dissatisfaction with the quality and temperature of the food, noting that meals were often served cold and late, and that they were not given the opportunity to choose alternative options. The facility's policy, effective 5/1/23, stated that residents should be offered a choice of nourishing, palatable, well-balanced food and beverage options that meet their daily nutritional needs. However, observations and interviews revealed that this policy was not being implemented. A test tray requested by the surveyor showed that the alternative meal option, BBQ chicken, was not being served, and staff interviews indicated a lack of awareness and implementation of a process to ask residents their meal preferences. The Dietitian confirmed that residents were not offered the second choice on the menu prior to meals, and the Director of Nursing acknowledged that staff should be asking residents about their meal options daily. The deficiency was further highlighted by the dissatisfaction expressed by residents and their representatives, who reported that the food quality had declined over the past few months. Some residents relied on family members to bring in meals or snacks due to the unappealing and inadequate food options provided by the facility. The lack of a structured process to ensure residents were offered alternative, appealing meal options contributed to the deficiency, as staff did not consistently inquire about or accommodate residents' meal preferences.
Failure to Review Background Check for LNA
Penalty
Summary
The facility failed to adhere to its policy regarding the screening for abuse for a Licensed Nursing Assistant (LNA). According to the facility's policy titled HR205 Background Investigations, any applicant with a criminal conviction should be interviewed by Human Resources to assess the relevance of the conviction to the position and determine eligibility for employment. However, the facility did not follow this procedure for LNA #1, a contracted employee, whose background check revealed a misdemeanor charge for disturbing the peace with fighting prior to their hire. There was no evidence that this charge was reviewed by the facility or corporate HR team to determine the employee's eligibility for employment. This oversight was confirmed during an interview with the Market Operations Advisor.
Failure to Prevent Significant Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of anticoagulation medication. The resident, who was admitted for sub-acute rehabilitation following a cerebrovascular accident with petechiae hemorrhaging, had discrepancies in the start date for their anticoagulation medication, Apixaban. The hospital's transition of care report indicated that the medication should not be started until after a follow-up CT scan was performed and evaluated by a neurologist. However, the facility's medication administration record showed that the resident received Apixaban on the day of admission and the following day, without evidence of order clarification with the admitting physician. The Director of Nursing (DON) acknowledged that the transition of care report contained conflicting information regarding the start date for the resident's Apixaban. The facility's policy requires medication reconciliation to be performed by the admitting nurse, reviewed by a second nurse, and by the physician before administering any medication. Despite this policy, there was no evidence that the orders were clarified with the admitting physician or the sending facility. The DON stated that discrepancies in discharge and admission orders are common, and nursing staff are expected to review all discharge information and reconcile medications accordingly. The admitting physician, who is also the medical director, stated that they were not aware of the orders to withhold Apixaban until after the CT scan review. The physician relies on nursing staff to accurately communicate medication orders over the phone, as they do not have access to the transition of care report outside the facility. The physician confirmed that they would not have ordered Apixaban if they had been aware of the information in the transition of care report. This lack of communication and failure to clarify medication orders led to the significant medication error.
Failure to Obtain Ordered X-ray for Resident
Penalty
Summary
The facility failed to provide necessary radiology services for a resident who was experiencing numbness and pain on the left side of their body, which was affecting their rehabilitation. The resident reported that a provider had ordered an x-ray a couple of weeks prior, but it had not been conducted. A physician's note from 6/18/24 indicated that an x-ray was ordered for the resident's left ankle due to pain and numbness, but the medical record showed no evidence that the x-ray was obtained. The Market Clinical Lead confirmed that the x-ray was never obtained and acknowledged that the physician did not follow the process to alert nursing staff to enter the order for the x-ray.
Failure to Involve Residents and Representatives in Care Planning
Penalty
Summary
The facility failed to include residents and their representatives in the development of baseline care plans and did not provide them with a summary of these plans for three residents. Resident #1 was admitted for rehabilitation following a craniotomy due to a subdural hematoma and experienced an unwitnessed fall resulting in a hospital stay. There was no evidence that Resident #1 or their representative participated in the care plan development or received a summary. Similarly, Resident #2, admitted for post-acute care after a lumbar fracture, and Resident #3, admitted for rehabilitation after a subdural hematoma, were not involved in their care plan development, nor were they provided with a summary. Interviews with the residents' representatives confirmed that they were not invited to participate in the care planning process and did not receive copies of the baseline care plans. The facility's policy requires that residents and their representatives be given a summary of the baseline care plan and be invited to care planning conferences. However, the Social Service Specialist and Director confirmed that it was not part of the facility's process to provide these summaries unless requested, and there was no documentation of invitations to the conferences for the residents and their representatives.
Neglect of Port Care Leads to Infection and Chemotherapy Delay
Penalty
Summary
The facility failed to protect a resident from neglect by not providing necessary care for a port-a-cath, leading to an infection. The resident, who was admitted for sub-acute rehabilitation following chemotherapy and surgery for ovarian cancer, had a port that was not identified or cared for during her stay. The port became infected, resulting in its removal and a delay in the resident's chemotherapy treatment, causing her emotional distress. Upon admission, the facility did not identify the resident's port, and there were no physician orders or care plans in place for its maintenance. Despite multiple opportunities for staff to observe and assess the port during skin checks and personal care, the port was neglected. Interviews with staff revealed that some were aware of the port but assumed it was being managed by oncology, while others did not document or monitor the port site. The lack of documentation and monitoring persisted throughout the resident's stay, with no evidence of care provided to the port. The facility's investigation confirmed that the port was not documented in the resident's medical records, and staff failed to obtain necessary care orders or develop a care plan. This oversight resulted in the resident's port becoming infected, requiring hospitalization and disrupting her chemotherapy schedule.
Removal Plan
- Completed a house wide audit of skin to ensure all ports were identified and no residents were identified to have ports.
- Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port, completed.
- The DON or designee will audit all new admissions for ports and audits will be reviewed at monthly QAPI meetings.
Failure to Provide Port Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident's implanted port, which led to an infection and subsequent removal of the port. The resident, who was admitted for sub-acute rehabilitation following abdominal surgery and chemotherapy for ovarian cancer, had a port that was not identified or cared for during their stay. The facility staff did not conduct comprehensive skin assessments, obtain or implement orders for port care, or include port care in the resident's care plan. As a result, the resident's port became infected, delaying their chemotherapy treatment. Interviews and record reviews revealed that the staff were aware of the resident's port but did not perform necessary care, such as dressing changes or monitoring the port site. The resident's family representative reported that the port site appeared red, inflamed, and black, with a moldy bandage, when the resident was admitted to the hospital for chemotherapy. The hospital staff confirmed the infection and removed the port, noting that the dressing was not intended for long-term use and should have been removed upon admission to the facility. The facility's initial admission assessment failed to identify the port, and there was no documentation of port care throughout the resident's stay. The Director of Nursing and Market Clinical Lead confirmed that no staff had reported the lack of care orders or care plan for the port, and the facility's investigation highlighted the absence of comprehensive skin assessments and care planning for the port.
Removal Plan
- Admission assessment should have included removing the protective dressing over the port site and identify the port on admission
- The facility should have initiated orders for care of the port
- The facility should have a care plan for care of the port
- Completed a house wide audit of skin to ensure all ports were identified and no residents were identified to have ports
- Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port
Latest citations in Vermont
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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