Springfield Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Vermont.
- Location
- 105 Chester Road, Springfield, Vermont 05156
- CMS Provider Number
- 475025
- Inspections on file
- 35
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 16 (4 serious)
Citation history
Health deficiencies cited at Springfield Health & Rehab during CMS and state inspections, most recent first.
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.
The facility did not ensure timely submission of an abuse/neglect investigation report to the State Survey Agency. An allegation of staff-to-resident neglect/abuse was self-reported, but the investigation summary was not received by the State Survey Agency within the required five working days because the Administrator sent the report to an incorrect email address, contrary to the facility’s abuse prevention policy that requires the investigative report to be provided to the State Survey Agency, law enforcement, and the Ombudsman within five days of the incident.
The facility did not complete required state adult background checks or Adult Abuse Registry checks for two new staff members, an LPN and an LNA, prior to their employment, as mandated by facility policy. The necessary checks were only obtained after surveyor inquiry, and the Administrator confirmed the oversight during an interview.
The facility did not report multiple allegations of staff verbal abuse and inappropriate conduct involving a resident to the state agency, despite policy requiring immediate reporting of suspected abuse. The Administrator confirmed these incidents were not reported, and this is a repeat deficiency.
The facility did not investigate two separate allegations of abuse made by a resident, despite having a policy requiring immediate action and internal investigation. The complaints included reports of disrespectful and inappropriate behavior by staff, but there was no evidence that the facility initiated or documented any investigation into these incidents.
A resident with multiple mental health diagnoses had a documented care plan and grievance indicating they did not want care from a specific LPN. Despite this, the LPN provided medications and treatments to the resident, as the facility did not communicate the care plan change to the LPN in time. The administrator confirmed the care plan directive was not followed.
An unopened Lidocaine 5% patch was left unsupervised on top of a medication cart by an LPN after a resident declined the medication. Multiple residents were present in the area at the time, and the medication was not secured or under direct observation as required by facility policy.
A resident with complex medical and psychiatric needs was admitted without proper reconciliation of hospital discharge orders, resulting in missed administration of critical medications including antipsychotics, antibiotics, insulin, and pain management. The omissions led to withdrawal symptoms, unmonitored blood sugars, untreated infection risk, unmanaged pain, and multiple falls, one of which resulted in a fatal subdural hematoma.
A resident with multiple complex medical conditions was admitted for short-term rehab after a fall, but critical hospital discharge orders for antibiotics, insulin, pain management, and antipsychotic medication were not implemented due to incomplete medication reconciliation. Staff only reviewed the medication list, missing essential treatments, which led to withdrawal symptoms, repeated falls, major injuries, and ultimately death. The care plan and fall risk assessments were inaccurate and did not address the resident’s changing condition or increased risks, and the facility accepted the resident back with IV therapy orders it could not provide, resulting in further delays in care.
A resident with multiple complex conditions, including narcolepsy with cataplexy, diabetes, and schizophrenia, was admitted for short-term rehab. The facility failed to implement physician orders for critical medications and interventions, did not address safety risks or update the care plan after significant changes in condition, and omitted necessary monitoring for blood glucose and fall risk. The lack of comprehensive care planning and intervention led to repeated falls, a subdural hematoma, and ultimately the resident's death.
A resident admitted for rehabilitation after multiple fractures did not receive several critical medications due to incomplete review of hospital discharge orders, leading to hyperglycemia, recurring UTIs, and withdrawal from antipsychotic medication. The care plan and fall risk assessment failed to address key diagnoses and high-risk medications, and were not updated despite the resident's behavioral changes, wandering, and repeated falls. The resident suffered multiple falls, a subdural hematoma, and ultimately died from complications related to these events, with the facility failing to recognize or report medication errors.
A resident with multiple complex medical conditions was admitted for rehabilitation after a fall, but the facility failed to implement several essential hospital discharge orders, including antipsychotic medication, insulin, antibiotics, and pain management. This led to severe withdrawal symptoms, behavioral disturbances, unmonitored blood sugars, untreated infection, repeated falls, and ultimately a fatal head injury. The facility did not identify or report the medication errors in accordance with policy, and the errors were only discovered during a surveyor's review.
A resident was started on multiple psychotropic medications, including an antidepressant and two antipsychotics, without timely or complete informed consent from the guardian. Consent documentation was either missing, incomplete, or obtained only after the medications had already been administered.
A resident's legal representative was not properly notified of significant changes in the resident's condition, including positive lab results and treatment options. Although the nurse attempted to contact the guardian and spoke with the spouse, the necessary information was not communicated, and the facility's policy requiring notification was not followed. The resident's representative and spouse reported ongoing issues with communication from staff.
The facility was unable to provide documentation of training and competency for an agency nurse, as confirmed by the Administrator during a review of staff files. This issue was compounded by recent changes in the education department and had been previously cited.
The facility's grievance policy contained conflicting information about the Grievance Officer and lacked clear procedures for residents to file grievances, including anonymous submissions. Residents were unaware of how to file grievances or where to find information, and some expressed fear of retaliation. The Administrator confirmed the posted policy was outdated and did not meet regulatory requirements.
The facility did not ensure that two of three sampled LNAs had documented competency evaluations required to demonstrate their ability to provide individualized care. The DON confirmed that a competency assessment system was not yet in place, and the Regional DON noted that employee files from previous ownership were unavailable in hard copy, with current records only accessible online. This resulted in the facility being unable to provide evidence of competency assessments for these LNAs.
The facility did not have a system to document the required 12 hours of annual training for LNAs, with sampled staff records lacking evidence of completed training. An LNA was unaware of how training was tracked, and the Regional DON stated that the facility had not developed a tracking system and lacked access to prior records.
The facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for all sampled residents, resulting in missed or delayed review of medication orders, lack of provider responses to pharmacy recommendations, and continued use of medications without appropriate indications or stop dates. Interviews revealed systemic lapses in communication and documentation among pharmacy, nursing, and medical staff, affecting residents with complex medication needs.
Three residents who were hospitalized did not receive the required written transfer/discharge notifications, including information on appeal rights, bed hold policy, and ombudsman contact details, as confirmed by record review and the DON.
The facility did not provide written notification of the bed-hold and return policy to three residents or their representatives prior to hospital transfers, as confirmed by record review and staff interviews.
The facility did not consistently assess or document trauma histories and triggers for several residents with PTSD, anxiety, or histories of sexual assault, resulting in care plans that failed to address or mitigate trauma-related needs. Social services staff confirmed that trauma triggers were not identified or incorporated into care planning, and there was no process to ensure communication of trauma-related findings from consulting clinicians.
Physicians did not consistently review or implement care orders for three residents, resulting in delays in medication administration, lack of required follow-up labs, and missed specialist referrals. Nursing staff activated orders without provider review, and physician visits were conducted via telehealth without comprehensive review of discharge instructions or care plans.
Two residents were found to have PRN medications, including opioids and psychotropics, prescribed without required stop dates. Despite pharmacy recommendations and documentation indicating discontinuation, the MARs continued to list these medications without end dates, and the DON confirmed the omission.
Surveyors found that kitchen shelves were dirty with dried food and crumbs, and clean pots and pans were stacked directly on these surfaces. Additionally, a staff member handled the ice scoop with bare hands and returned it to the ice chest, leaving the handle in contact with the ice, despite a designated container for proper storage being available but unused. The dietary manager and a Dietary Aide confirmed these practices did not meet facility standards.
The facility did not adequately explain binding arbitration agreements to two residents or their representatives, resulting in agreements being signed without proper understanding or informed consent. In both cases, the individuals signing either did not comprehend the implications or were not the appropriate party to sign due to cognitive impairment or lack of notification to the POA.
Several residents were prescribed and administered psychotropic medications without required documentation of indications, without evidence of attempted non-pharmacological interventions, and without 14-day stop dates for PRN orders. In some cases, medications were given despite the absence of symptoms they were intended to treat, and pharmacy or psychiatric recommendations to discontinue ineffective medications were not followed.
A resident with Alzheimer's, unable to make medical decisions, was administered morphine for pain management after hip surgery despite the POA's request to use only Tylenol. The POA was not informed of the morphine order or its administration, and documentation showed morphine was given even when the pain level was zero, with no explanation. Facility staff confirmed there was no communication with the POA regarding these care changes.
A resident alleged that a nurse withheld pain medication, failed to treat wounds, and used a catheter material despite a potential allergy. After reporting the concerns, the nurse was initially reassigned but was later seen near the resident, leading to feelings of intimidation. Facility policy requires no contact between the alleged perpetrator and victim during investigations, but the nurse continued to work in the facility and was present near the resident.
A resident admitted after hip fracture surgery did not receive the correct physician orders for pain management, DVT prevention, and constipation as specified in the hospital discharge summary. Facility staff entered outdated orders from a previous hospital stay, resulting in a delay of several days before the appropriate medications were provided. Additionally, an ordered ultrasound to assess new leg swelling was not documented as completed, and the process for order verification and provider review was inconsistent.
A resident on hospice care for end-stage COPD experienced frequent, severe pain that was not adequately managed by staff. Despite high pain scores and orders for both scheduled morphine and PRN acetaminophen, there was no evidence that the PRN medication was administered between scheduled doses. Pain assessments were performed only at shift changes, and the resident was repeatedly observed calling out in pain.
A medication error rate of 12% was identified when an LPN administered multiple medications, including Omeprazole, Dulera inhaler, and Basaglar insulin, to a resident significantly later than the scheduled times. The LPN confirmed the late administration, citing unfamiliarity with the assigned area, which resulted in noncompliance with the facility's policy requiring medications to be given within one hour of the prescribed time.
A resident experiencing severe dental pain reported not having seen a dentist since admission and did not receive timely dental care or follow-up, despite facility policy requiring access to routine and emergency dental services. The resident's ongoing pain was not addressed through appointments or treatment, as confirmed by the DON.
Frequent changes in facility leadership, including the Administrator, Medical Director, and DON, resulted in inconsistent administration and oversight. This led to failures such as lack of physician notification, inadequate supervision, poor infection control, and insufficient wound care. As a result, residents experienced harm, including untreated injuries, worsening pressure ulcers, and a COVID-related death, with multiple citations issued at Immediate Jeopardy and harm levels.
Staff failed to use required PPE during high-contact care activities for a resident with a urinary catheter and open wounds, and did not follow outbreak management protocols during a COVID-19 outbreak. The facility lacked proper contact tracing, testing records, and staff awareness of infection control policies, resulting in improper isolation and PPE use for COVID-positive residents. The medical director and newly assigned infection control nurse were not informed of outbreak status or mitigation strategies.
The facility did not notify the physician of several significant events, including residents testing positive for COVID-19, a physical assault resulting in injury, and the development and progression of pressure ulcers. In each case, there was no documented evidence of physician notification or consultation, and the Medical Director confirmed not being informed. These failures involved residents with complex medical histories and resulted in a lack of timely medical intervention and monitoring.
A resident with dementia and a history of falls accessed an alarmed stairwell and fell down the stairs after staff failed to respond promptly to the alarm, while other staff were unavailable or distracted. The facility also failed to respond to repeated Wander Guard alarms and did not investigate potential elopement. Additionally, two residents were not adequately supervised, resulting in one resident entering another's room and causing injury during an altercation. Care plans were not updated, staff were not educated on managing aggressive behaviors, and required monitoring was not documented.
The facility did not ensure physician supervision or timely notification for three residents, resulting in a resident with COVID-19 not being monitored or treated, and two residents involved in a violent incident not receiving appropriate physician assessment or intervention. Documentation failed to show that the physician was notified of critical changes in condition or incidents, and the medical director confirmed she was unaware of these events.
A resident with limited mobility and visual impairment was physically assaulted in their room by another resident with a known history of aggressive behavior. The aggressive resident's care plan did not address the risk of entering other residents' rooms or require supervision, and staff were not educated on managing these behaviors. Although 15-minute checks were ordered, there was no documentation or staff awareness of their implementation, leading to repeated incidents of resident-to-resident abuse.
A resident with multiple pressure ulcers did not receive timely wound assessments or care plan updates, resulting in worsening wounds. Staff failed to document new wounds, notify the physician, or consistently perform and record weekly wound measurements. Additionally, an LPN and the DON did not use required PPE during high-contact care activities, despite the resident's need for enhanced barrier precautions due to a Foley catheter and open wounds.
A resident did not receive timely or appropriate pressure ulcer care, as staff failed to obtain prompt physician orders, did not follow care plan interventions, and did not perform accurate or complete skin and wound assessments. Multiple wounds were undocumented or untreated, and care plan updates and weekly wound assessments were delayed or incomplete, resulting in wound deterioration and the development of additional pressure ulcers.
The facility did not ensure the medical director was notified or consulted regarding multiple residents who tested positive for COVID-19, nor was she involved in developing or reviewing infection control policies during an outbreak. A resident with COVID-19 was not monitored or treated and died, and several others had no evidence of physician involvement. Additionally, the medical director was not informed about a violent incident involving a resident with a history of aggression, resulting in another resident's injury and lack of appropriate assessment or provider notification.
The facility did not ensure that the designated Infection Preventionist had specialized infection prevention and control training, leaving the facility without a qualified IP for 14 days during a COVID-19 outbreak. During this period, 11 residents and 15 staff tested positive, two residents were hospitalized with respiratory distress, and a resident died from COVID-related causes.
The facility did not maintain adequate nursing staff to meet resident needs, resulting in the DON and other specialized staff having to perform direct care duties, missed infection prevention activities, and rescheduled wound care visits. Direct care hours by LNA staff also fell below state minimum requirements for several weeks.
Two residents did not receive their prescribed COVID-19 treatments, including Paxlovid and Azithromycin, due to delays in pharmacy dispensing and missed doses. Nursing staff confirmed that medications were not administered per physician orders, the prescriber was not notified of missed doses, and the full course of treatment was not completed.
The facility failed to ensure complete and accurate medical records for two residents, resulting in missing nurse progress notes, incomplete wound assessments, and absent documentation of COVID-19 diagnosis and care. One resident's wound care documentation was inconsistent and lacked required details, while another resident's COVID-19 status and related care were not recorded or communicated to the provider. Leadership interviews confirmed gaps in documentation and oversight.
A resident sustained a skin tear and a forehead bruise after being struck with a can of soda by another resident. The facility did not report the abuse allegation to the State Agency within the required 2-hour window and delayed submission of the 5-day investigation findings, contrary to facility policy. The Administrator was unaware of the full details and reporting requirements at the time.
A resident's care plan was not updated after a physical altercation with another resident resulted in a skin tear and bruise. Despite the resident's existing risk factors for skin breakdown and expressed fear of further incidents, the care plan was not revised to include interventions for monitoring or treating the new wounds, and the DON confirmed no updates were made.
A resident with a left forearm injury did not receive daily wound dressing changes as ordered, with the same dressing remaining in place for several days despite documentation indicating otherwise. An LPN confirmed the dressing was old and that daily changes were required, and there was no documentation of a wound assessment as required by facility policy.
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.
Failure to Submit Abuse Investigation Results Within Required Timeframe
Penalty
Summary
The facility failed to submit the results of an abuse/neglect investigation to the State Survey Agency within the required five working days. An online self-report of alleged staff-to-resident neglect/abuse for an incident that occurred on 11/3/25 was submitted to the State Survey Agency on 11/5/25. However, the State Survey Agency did not receive the facility’s investigation report within five working days of the alleged incident as required. During an interview on 2/17/26, the Administrator stated that the facility’s investigation summary was sent on 11/10/26 and provided an email receipt. Review of the email receipt showed that the summary was sent to an incorrect email address, and the Administrator confirmed that the address used was not the correct one for submitting a facility’s investigation summary. The facility’s own Abuse Prevention and Prohibition Program policy, revised 12/2025, requires the Administrator to provide the State Survey Agency, law enforcement, and the Ombudsman with a copy of the investigative report within five days of the incident.
Failure to Complete Required Background Checks for New Staff
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, specifically regarding the screening of prospective employees. Record review revealed that two staff members, an LPN and an LNA, did not have the required state adult background checks or Adult Abuse Registry checks on file, despite having been employed at the facility for several weeks. The facility's policy mandates background checks for all new employees and volunteers, including checks of the Child Abuse Registry, Adult Abuse Registry, criminal convictions, and the OIG exclusions database, with all information to be maintained in the personnel file. During an interview, the Administrator confirmed that the required adult background checks for these staff members were not completed prior to their employment and stated that the agency typically conducts these checks. However, the background checks were only provided on the day of the interview, indicating they were not completed as required by policy before the staff began working. The Administrator also clarified that Human Resources is responsible for conducting background checks.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report three separate allegations of abuse involving one resident to the state agency, as required by its own Abuse, Neglect, and Exploitation policy. The policy mandates that all employees and volunteers must immediately report any actual or suspected abuse, neglect, or exploitation to Adult Protective Services (APS) through their supervisor. Despite this, grievances filed by the resident documented incidents where staff used inappropriate language and behavior, including a Licensed Nursing Assistant refusing a request for medical attention and responding with profanity, as well as a nurse telling the resident to "shut up and go to sleep" when the resident requested a popsicle at midnight. There was no evidence or record that these incidents were reported to the state agency as required. The Administrator confirmed during an interview that these events were not reported. This deficiency is a repeat violation, having been cited during a previous survey. The failure to report these allegations represents noncompliance with both facility policy and regulatory requirements.
Failure to Investigate Alleged Abuse Complaints
Penalty
Summary
The facility failed to investigate two out of four sampled allegations of abuse involving a resident, despite having a policy in place that outlines the steps for investigating such complaints. According to the facility's Abuse, Neglect, and Exploitation policy, any person witnessing or receiving an allegation is required to ensure the resident's safety, notify supervisors, and initiate an internal investigation, including written reports and notification to appropriate authorities if necessary. However, record review revealed that grievances filed by a resident on two separate occasions, which included allegations of verbal abuse and inappropriate staff behavior, were not investigated as required by facility policy. Specifically, the grievances detailed incidents where the resident reported being denied access to a nurse, being spoken to in a disrespectful manner by a Licensed Nursing Assistant, and being told by a nurse to "shut up and go to sleep" when requesting assistance. There was no documentation or evidence that these allegations were investigated internally by the facility. The administrator confirmed during an interview that no internal investigation was conducted into any of the grievances alleging abuse.
Failure to Honor Resident's Care Provider Preference
Penalty
Summary
The facility failed to honor a resident's expressed choice regarding their care provider, as documented in the resident's care plan and grievance records. The resident, who has a history of major depressive disorder, post-traumatic stress disorder, schizoaffective disorder, and borderline personality disorder, submitted a grievance stating they did not wish to receive care from a specific LPN. The care plan was updated to reflect this preference, indicating that the resident requested not to be cared for by this LPN and understood that care might be delayed if another nurse from a different wing was needed. Despite this documented preference and care plan intervention, the LPN in question provided care to the resident, including administering medications, performing treatments, and assessing pain and oxygen saturation. The administrator confirmed that the care plan specified the LPN should not care for the resident, but stated that the LPN had not been informed of the change in time due to being off work. The resident confirmed during an interview that they did not want care from this LPN and were dissatisfied when it occurred.
Medication Storage Policy Not Followed
Penalty
Summary
A deficiency occurred when an unopened Lidocaine 5% patch was found left unsupervised on top of a medication cart on the second floor during an observation. At the time, there were multiple residents present in the area, including one sitting in the hallway, one self-propelling, and eight in the dining room. According to the facility's Storage of Medications policy, medications must be either under the direct observation of the person administering them or locked in the medication storage area or cart during a medication pass. The nurse responsible confirmed in an interview that she left the patch on the cart after a resident declined the medication, and it was not secured or supervised as required.
Failure to Reconcile and Implement Admission Orders Results in Immediate Jeopardy
Penalty
Summary
The facility failed to accurately reconcile and implement physician orders upon the admission of a resident, resulting in the omission of multiple critical medications and treatments. Upon admission, the resident had a complex medical history including schizophrenia, narcolepsy with cataplexy, osteoporosis, frequent falls, recurrent UTIs, and hypertension, and was admitted for short-term rehabilitation following multiple fractures. The hospital discharge orders included Keflex for UTI, a transition to nitrofurantoin, guaifenesin, sliding scale insulin with blood sugar checks four times daily, lidocaine patches for pain, and quetiapine (Seroquel) for psychiatric management. None of these orders were implemented at the time of admission due to incomplete review of the discharge summary, as only every other page was available and reviewed by staff. As a result of the missing orders, the resident did not receive Seroquel, leading to withdrawal symptoms and a significant decline in psychiatric stability, including hallucinations, agitation, medication and care refusals, and increased wandering. The resident also did not receive appropriate blood sugar monitoring or sliding scale insulin, resulting in multiple episodes of hyperglycemia and unmonitored blood glucose levels. Additionally, the prescribed antibiotics and lidocaine patches for pain management were not administered, leaving the resident at increased risk for infection and unmanaged pain. The resident experienced a series of adverse events following these omissions, including worsening psychiatric symptoms, refusal of care, and multiple falls. One fall resulted in a subdural hematoma, which was later identified as the cause of death. The facility did not identify the missing orders until questioned by the resident's family and further review by surveyors. Interviews with facility staff and leadership confirmed that the discharge summary was not fully reviewed, and the expectation for thorough reconciliation of admission orders was not met.
Failure to Reconcile Admission Orders and Incomplete Care Planning Leads to Resident Harm and Death
Penalty
Summary
The facility failed to protect a resident from neglect by not providing necessary services to prevent physical harm, pain, mental anguish, and emotional distress. Upon admission, the resident had multiple complex medical conditions, including schizophrenia, major depressive disorder, narcolepsy with cataplexy, osteoporosis, fractures, diabetes, and a recent urinary tract infection. Hospital discharge orders included several critical medications such as antibiotics, sliding scale insulin, lidocaine patches, and a high-dose antipsychotic (Seroquel). None of these orders were implemented upon admission due to incomplete scanning and reconciliation of the discharge paperwork, resulting in the resident not receiving essential treatments for infection, diabetes management, and psychiatric stabilization. Staff interviews revealed that the medication reconciliation process was inadequate, with nurses and administrative staff only reviewing the medication list and not the full discharge summary. This led to missed orders for antibiotics, insulin, and pain management, as well as the omission of the resident’s long-term antipsychotic medication. The resident subsequently experienced withdrawal symptoms, exacerbation of psychiatric symptoms, repeated falls, and major injuries, including subdural hematomas and a fractured foot. The care plan and fall risk assessments were inaccurate and incomplete, failing to address the resident’s increased risks due to missed medications, changes in condition, and high-risk diagnoses such as narcolepsy with cataplexy and multiple fractures. Despite multiple incidents of falls, behavioral changes, and hospitalizations, the care plan was not updated with appropriate interventions to address the resident’s deteriorating condition and increased safety risks. The facility also accepted the resident back from the hospital with orders for IV antibiotic therapy, which it was not equipped to provide, resulting in further delays in care. The resident ultimately died from complications related to repeated falls and untreated medical conditions, with the manner of death listed as an accident due to blunt force trauma of the head. The facility did not implement an incident report when the medication error was discovered and failed to review the complete discharge paperwork to identify all missed orders.
Failure to Develop and Implement Comprehensive Care Plan Results in Resident Harm and Death
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, resulting in significant harm. Upon admission, the resident had multiple complex diagnoses, including narcolepsy with cataplexy, schizophrenia, diabetes requiring sliding scale insulin, osteoporosis, frequent falls, and recent fractures. Despite clear hospital discharge orders for specific medications and interventions, including antipsychotic management, blood glucose monitoring four times daily, and sliding scale insulin, these orders were not implemented. The care plan did not reflect the resident's actual urinary tract infection, omitted interventions for the treatment of the UTI, and failed to address the use of sliding scale insulin or the need for frequent blood glucose checks. As a result, the resident experienced multiple episodes of hyperglycemia without appropriate monitoring or insulin administration. The care plan also failed to identify or address safety risks associated with the resident's narcolepsy with cataplexy, the use of high-risk medications, and the complications of a subdural hematoma following a fall. The resident's fall risk assessment contained inaccuracies, underestimating the number of high-risk medications and predisposing conditions. The care plan did not include interventions for increased fall risk due to the resident's diagnoses or medication changes, nor did it address the management of withdrawal symptoms from the abrupt cessation of Seroquel, which led to behavioral changes such as hallucinations, anxiety, and wandering. Despite documentation of these changes and repeated incidents of self-ambulation and falls, the care plan was not updated to include additional safety interventions or increased supervision. Following a fall that resulted in a subdural hematoma and subsequent complications, the care plan still was not revised to address the resident's new diagnoses or increased care needs. The resident continued to experience falls, behavioral disturbances, and medical complications, including a worsening hematoma and uncal herniation, without appropriate updates to the care plan or implementation of necessary interventions. Ultimately, the resident died as a result of complications from the fall and subdural hemorrhage. This deficiency was cited as immediate jeopardy and was a repeat finding for the facility.
Failure to Prevent Falls and Address Clinical Risks Resulting in Resident Death
Penalty
Summary
The facility failed to effectively assess, implement, monitor, and modify interventions to prevent falls and address accident hazards for a resident admitted for short-term rehabilitation following multiple fractures. Upon admission, the facility did not implement several critical physician orders, including antibiotics, sliding scale insulin, lidocaine patches, and Seroquel, due to incomplete review of the hospital discharge summary. This resulted in the resident experiencing multiple episodes of hyperglycemia, recurring UTIs, and withdrawal from antipsychotic medication, all of which increased the risk of falls and behavioral disturbances. The resident's care plan and fall risk assessment contained inaccuracies and omissions, failing to address significant diagnoses such as narcolepsy with cataplexy, osteoporosis, and the use of multiple high-risk medications. Despite the resident exhibiting hallucinations, anxiety, wandering, and self-transferring behaviors, the care plan was not updated to include appropriate safety interventions or increased supervision. After a fall resulting in a subdural hematoma and foot fracture, the care plan was minimally revised, and the resident continued to self-ambulate without adequate interventions to mitigate further risk. Subsequent to the initial fall and injury, the resident experienced additional adverse events, including another fall, choking, and worsening of the subdural hematoma, ultimately leading to death. The facility did not recognize or report the medication errors in accordance with policy, nor did it conduct a thorough review of the discharge paperwork to identify all missed orders. The death certificate listed the manner of death as an accident due to complications from acute on chronic subdural hemorrhage resulting from falls.
Failure to Reconcile and Administer Critical Medications on Admission
Penalty
Summary
A significant medication error occurred when a resident was admitted for short-term rehabilitation following a fall and was not provided with several critical medications as ordered upon hospital discharge. The resident, who had a complex medical history including schizophrenia, narcolepsy with cataplexy, osteoporosis, frequent falls, and recurrent UTIs, was supposed to continue Seroquel 600 mg for schizophrenia, a sliding scale insulin regimen, antibiotics for a UTI, and lidocaine patches for pain. However, the facility failed to order and administer Seroquel, the sliding scale insulin, antibiotics, and lidocaine patches as per the hospital's discharge instructions. The omission of Seroquel, in particular, led to abrupt withdrawal, which is known to cause severe psychiatric and physical symptoms, especially at high doses. Following the missed medications, the resident exhibited a marked decline in mental and physical health. Documented symptoms included hallucinations, increased behavioral disturbances such as combativeness and medication refusals, unmonitored and untreated blood sugars, and increased risk for infections. The resident experienced repeated falls, one of which resulted in a major head injury. The facility's documentation showed that blood glucose monitoring was not performed as frequently as ordered, and hyperglycemia episodes were not properly managed due to the lack of sliding scale insulin coverage. Additionally, the prescribed antibiotics and pain management patches were not provided, leading to an untreated UTI that progressed to a hemolytic Strep Group B infection. The facility's failure to reconcile and implement all hospital discharge orders was attributed to missing pages in the discharge paperwork, which was not identified or corrected until the surveyor's review. The facility did not follow its own policy for reporting and documenting medication errors, as no incident report was completed for the missed Seroquel or other medications. The resident's condition deteriorated, culminating in a fatal fall resulting in a subdural hemorrhage. Interviews confirmed that the errors were not recognized or communicated in a timely manner, and the primary physician was not fully informed of all missed medications.
Failure to Obtain Timely Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for psychotropic medications for a resident, as required. Upon admission, the resident had physician's orders for an antidepressant (Protriptyline) and an antipsychotic (Aripiprazole). While a consent form for antipsychotic medications was completed and signed by the resident's guardian, it did not include the antidepressant Protriptyline. The consent form for antidepressant medication was found to be blank and unsigned, with no evidence that informed consent was obtained for Protriptyline prior to administration. Additionally, a new antipsychotic medication (Quetiapine) was ordered for the resident, but the documentation of verbal consent from the guardian for all psychotropic medications was not completed until after both Protriptyline and Quetiapine had already been initiated. The resident's care plan included an intervention to provide informed consent to the resident or healthcare decision maker, but this was not carried out in a timely manner. The facility administrator confirmed that the required consent documentation was not completed until after the medications had been started.
Failure to Notify Resident Representative of Change in Condition and Treatment Options
Penalty
Summary
The facility failed to notify a resident's legal representative of a significant change in condition, specifically regarding laboratory results and treatment options. The resident had a court-appointed guardian, with the guardian's spouse listed as the secondary emergency contact. On the date in question, a nurse received a urine culture result and sent it to the nurse practitioner. Occupational therapy evaluated the resident and determined that the resident was not safe to take anything orally except for minimal water for comfort. Based on this evaluation, the nurse attempted to contact the guardian to discuss the lab results and possible antibiotic treatment, leaving a voicemail but not successfully reaching the guardian. Subsequent documentation indicated that the nurse spoke with the guardian's spouse, who had questions about transferring the resident to another facility or hospital, but the nurse did not discuss the urine culture results or treatment options with the spouse, as they were not the legal guardian. During a later interview, both the guardian and spouse reported poor communication from the facility, including unreturned calls and a nurse hanging up during a call. The facility's policy requires notification of significant changes in condition or treatment to the resident's physician and representative, but the administrator confirmed that the guardian's spouse should have been updated about the positive lab results and treatment, which did not occur.
Missing Training and Competency Documentation for Agency Nurse
Penalty
Summary
The facility failed to ensure that one of five nurses, specifically an agency nurse, had received the necessary training and competency assessments required to provide care for residents. During a review of five nurses' education and training files, the facility was unable to locate the training and competency documentation for the agency nurse. An interview with the Administrator confirmed that the agency nurse was no longer employed at the facility and that a recent change in the education department contributed to the inability to find the required file. This deficiency was previously cited during a prior recertification survey.
Inconsistent and Inadequate Grievance Policy Fails to Support Resident Rights
Penalty
Summary
The facility failed to establish and maintain a consistent and accurate grievance policy that supports residents' rights to file grievances without discrimination or reprisal. Review of multiple facility documents revealed discrepancies regarding the identity of the Grievance Officer, the process for filing grievances, and the contact information provided. Some documents listed the Administrator as the Grievance Officer with an incorrect email address, while others named the Director of Social Services. The policies lacked required information such as the grievance officer's responsibilities, accurate contact details, and a clear process for residents to file grievances anonymously. During a facility tour, there was no visible signage or easily accessible forms for filing grievances, nor was there evidence of a process to maintain anonymity for residents. Interviews with residents during a Resident Council meeting indicated that none of the residents knew how to file a grievance or where to find the necessary information. One resident reported not receiving a timely response to a previously filed grievance, and several residents expressed fear of retaliation if they voiced concerns. The Administrator confirmed that the posted grievance policy contained outdated and incorrect information and acknowledged that the current policy and procedures did not meet federal requirements or support residents' rights to file grievances.
Failure to Document and Assess LNA Competencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed and were assessed for the necessary competencies to provide individualized care to residents. Specifically, a review of education records revealed that two out of three sampled licensed nursing assistants (LNAs) did not have documentation of the required competency evaluations to demonstrate their ability to deliver appropriate care. During interviews, the DON acknowledged responsibility for assessing competencies but stated that a system for doing so was still under development and not yet implemented. Additionally, the Regional DON reported that the facility lacked hard copies of employee files for staff who were employed under previous ownership, and current employee records were only accessible online. As a result, the facility was unable to produce evidence of competency assessments for two of the three sampled LNAs.
Failure to Document Required Annual LNA Training Hours
Penalty
Summary
The facility failed to establish a system to document the required minimum 12 hours of annual training for Licensed Nursing Assistants (LNAs), as evidenced by the absence of documented training hours in the records of three sampled staff members. An LNA interviewed was unaware of how training records were tracked and relied on the facility to determine compliance with training requirements. Additionally, the Regional Director of Nursing confirmed that the facility lacked complete access to previous employee records from the prior owner and had not yet implemented a tracking system for current employees. These findings indicate that the facility did not have a process in place to ensure or document that LNAs received ongoing education in areas such as dementia care and abuse prevention, as required to maintain their competence.
Failure to Complete and Document Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly drug regimen reviews (MRRs), including the review of medical charts, for all sampled residents. This deficiency was observed in 10 out of 10 residents reviewed, with missing or incomplete MRRs, lack of documentation of pharmacist recommendations, and absent or delayed physician responses to those recommendations. In several cases, there was no evidence that the MRRs had been completed for multiple months, and when recommendations were made, they were not consistently addressed or documented in the resident records. Specific examples include residents with complex medical histories, such as dementia with behavioral disturbances, terminal agitation, recent aggressive behaviors, and use of psychotropic medications without appropriate stop dates or indications. For instance, one resident received PRN Haldol and Lorazepam for terminal agitation without documentation of non-pharmacological interventions or evidence of terminal agitation, and the MRR did not address these issues. Another resident was prescribed Quetiapine PRN for terminal agitation without a stop date, and the pharmacist's recommendation to add a stop date was not acted upon in a timely manner. In several cases, residents continued to receive medications despite recommendations for discontinuation or dose adjustments, and there was no documentation of provider review or action. Interviews with facility staff, including the DON and Medical Director, revealed systemic issues such as being months behind on reviewing and signing MRRs, lack of a process to ensure completion and documentation of reviews and recommendations, and communication gaps between pharmacy, nursing, and medical staff. In some cases, pharmacy staff did not have access to complete medical records or discharge summaries, resulting in missed opportunities to identify necessary follow-up actions, such as laboratory monitoring for residents on anticoagulation therapy. The facility's failure to maintain a consistent and documented MRR process led to repeated deficiencies, as noted in previous surveys.
Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to residents and/or their representatives as required by its own policy. Specifically, three residents who were hospitalized on multiple occasions did not receive written notices detailing the reason for transfer/discharge, the effective date, the location of transfer/discharge, the right to appeal, the facility's bed hold policy, or the contact information for the State Long-term Care Ombudsman. Record reviews confirmed the absence of these notifications for all three residents, and the Regional Director of Nursing acknowledged that there was no evidence such notices were given.
Failure to Provide Written Bed-Hold Notice Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the bed-hold and return policy prior to hospital transfers or therapeutic leaves, as required by the facility's own policy. Specifically, three residents who were hospitalized on various dates did not receive the required Bed-hold Notice, and this lack of documentation was confirmed by both the facility Administrator and the Regional Director of Nursing during interviews. Record reviews for each of these residents showed no evidence that the written notice was given at the time of their transfers.
Failure to Assess and Care Plan for Trauma Histories and Triggers
Penalty
Summary
The facility failed to effectively assess and address the trauma histories and triggers of several residents, resulting in a lack of individualized trauma-informed care planning. For four residents with documented histories of trauma, including sexual assault, PTSD, and anxiety disorders, the facility did not consistently identify or document trauma triggers or incorporate them into care plans. In one case, a resident with a history of multiple traumatic events, including sexual assaults and abortions, had a psychosocial evaluation and trauma screening that identified PTSD and trauma history, but the care plan did not address these issues or potential triggers. The facility's social worker confirmed that there was no process to ensure that findings from consulting social workers were communicated or incorporated into care planning. Another resident admitted with anxiety disorder and post-traumatic stress syndrome was not assessed for trauma triggers, and no care plan was developed to mitigate or eliminate potential triggers, despite facility policy requiring such assessments upon admission. The social services staff confirmed that no assessment or care plan for trauma triggers was completed for this resident. Similarly, a resident with a diagnosis of PTSD had no documentation of trauma triggers in the care plan or in the social services assessment, as confirmed by the Director of Social Services. A fourth resident with a history of childhood sexual abuse and PTSD had documentation in medical and psychological notes referencing past trauma and recent triggering events, such as a catheterization, but the care plan and social services assessment did not mention sexual trauma or related triggers. The Director of Social Services confirmed the absence of this information in both the care plan and assessment. These findings demonstrate a pattern of failure to assess, document, and plan for trauma-related needs and triggers for residents with known trauma histories.
Failure to Ensure Timely Physician Review and Implementation of Care Orders
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' care, wrote, signed, and dated progress notes and orders at each required visit for three residents. For one resident admitted after a hip fracture repair, there was no documented evidence that discharge medications, including pain management and DVT prophylaxis, were ordered or administered until four days after admission. The admission process involved nursing staff transcribing and activating orders without provider review, and the initial physician evaluation was conducted via telehealth, which did not include a comprehensive review of the discharge summary or plan of care. The facility administrator confirmed that the correct discharge summary and admitting orders were not available at the time of admission, and incorrect orders from a previous hospital stay were entered instead. Another resident, readmitted after hospitalization for COVID, gastrointestinal bleeding, and NSTEMI, did not have required follow-up lab orders as directed in the hospital discharge instructions. There was no evidence of a required in-person physician visit after readmission, and all documented physician interactions were conducted via telehealth without review or implementation of discharge orders. The physician acknowledged that required visits were not completed, and the administrator confirmed the absence of documented physician visits or accurate admission orders for this resident. A third resident with a history of schizoaffective disorder and a traumatic brain injury had facial lesions suspected to be basal cell carcinoma, with a provider's note recommending urgent dermatology referral. Although an appointment was scheduled, the resident missed it due to an emergency department visit, and there was no documentation of rescheduling or further provider follow-up regarding the skin issue. The regional medical director confirmed that the dermatology appointment was not rescheduled and no follow-up occurred.
Failure to Ensure PRN Medications Have Required Stop Dates
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the lack of stop dates for certain PRN (as needed) medications. One resident, who was readmitted following a hip fracture and surgical repair and had a history of Alzheimer's dementia, was prescribed oxycodone and morphine for post-operative pain management. Although the consulting pharmacist recommended adding a stop date for the oxycodone and the physician signed off on discontinuing it, the medication administration record (MAR) continued to show oxycodone prescribed without an end date. Another resident had an active order for PRN lorazepam without a specific stop date, despite pharmacy recommendations and CMS guidelines prohibiting open-ended PRN psychotropic orders, even for hospice residents. The medication was reportedly discontinued according to the medication regimen review, but the MAR did not reflect a stop date for the PRN medication. The Regional Director of Nursing confirmed that PRN medications for both residents did not have stop dates as required.
Failure to Maintain Clean Kitchen Environment and Proper Ice Scoop Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean kitchen environment, as evidenced by dirty shelves under the main cooking counter and steam table, which had dried food and crumbs present. Clean pots and pans were stacked directly on these unclean shelves, and other shelves in the kitchen had food-stained paper under clean kitchenware. The dietary manager confirmed that the shelves were not clean at the time of observation. Additionally, in the first-floor kitchenette, a staff member was seen picking up the ice scoop from inside the ice chest with bare hands and returning it to the ice chest, with the scoop's handle in direct contact with the ice. Although a container was available on the counter for proper storage of the ice scoop, it was empty, and the scoop remained improperly stored inside the ice chest. A Dietary Aide confirmed that the ice scoop should not be stored in this manner.
Failure to Properly Explain and Obtain Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were properly explained and that residents or their representatives acknowledged understanding of these agreements. In one case, a resident with moderate cognitive impairment had their sibling, who lived out of state, sign the arbitration agreement via email without any explanation from the facility. The representative reported that the paperwork was described as routine admission documents and was not aware of the implications of signing the arbitration agreement, stating they would not have signed it if they had understood its meaning. In another instance, a resident with severe cognitive impairment signed their own arbitration agreement, despite having a Power of Attorney (POA) in place. The POA stated they were not informed about the arbitration agreement and did not give permission for the resident to sign it, expressing doubt that the resident could understand the agreement. The Director of Admissions confirmed that forms are emailed to families and that there is minimal training on arbitration agreements, with explanations to residents and representatives being limited and lacking clarity about the legal rights being waived.
Failure to Ensure Proper Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and did not implement required gradual dose reductions (GDR) or non-pharmacological interventions prior to initiating or continuing psychotropic medications. For several residents, psychotropic medications were prescribed and administered without proper documentation of indications, without evidence that non-pharmacological interventions were attempted first, and without required 14-day stop dates for PRN (as needed) orders. In multiple cases, there was no documentation that residents were experiencing the symptoms for which the medications were prescribed at the time of administration. One resident with dementia and mood disturbances, who was on hospice for congestive heart failure, was prescribed Aripiprazole and Haldol for sundowning and terminal agitation. The resident was observed to be calm and not in distress during meal times, and staff interviews confirmed the resident was not in the active dying phase or experiencing terminal agitation. Despite this, scheduled and PRN Haldol was administered without documentation of symptoms or attempts at non-pharmacological interventions, and the PRN order lacked a stop date. Similar issues were found with other residents, including the use of Seroquel for terminal agitation without a stop date and without evidence that the resident was experiencing terminal agitation. Additional deficiencies included the administration of Lorazepam without a documented indication, and PRN psychotropic orders for agitation/restlessness that lacked stop dates or rationale for continued use. In another case, a resident continued to receive Buspirone and Melatonin despite psychiatric recommendations to discontinue them due to ineffectiveness, and the DON confirmed these recommendations were not addressed. These findings demonstrate a pattern of non-compliance with regulations regarding the use of psychotropic medications, documentation, and the implementation of non-pharmacological interventions.
Failure to Inform POA and Obtain Consent for Pain Management
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney (POA) was fully informed and involved in decisions regarding the resident's pain management and comfort care following a hip fracture and surgical repair. The resident, diagnosed with Alzheimer's and unable to make medical decisions, was readmitted to the facility with the POA responsible for healthcare decisions. Despite the POA's explicit request to limit pain management to Tylenol and not to initiate morphine or comfort measures, the physician wrote an order for morphine and comfort measures, citing concerns about timely medication availability. The POA was not informed that morphine had been prescribed or administered, and only discovered this after observing the resident's unresponsiveness and inquiring about medications. Record review showed that morphine was administered to the resident even when the documented pain level was zero, with no explanation provided in the medication administration record or progress notes. Interviews with facility staff confirmed that there was no communication between the unit manager and the provider regarding the initiation of morphine or comfort measures, despite the care plan's directive to inform the healthcare decision maker of any changes in status or care needs. The lack of communication and documentation resulted in the POA not being given the opportunity to participate in or consent to significant changes in the resident's care.
Failure to Prevent Contact Between Resident and Accused Staff During Abuse Investigation
Penalty
Summary
The facility failed to ensure that a resident was protected from further potential abuse after an allegation was made against a licensed nurse. The resident reported that the nurse withheld pain medication, did not treat wounds, and inserted a silicone catheter despite a potential allergy. The resident stated that after reporting these concerns to other nurses, the accused nurse was initially moved to a different unit but was later seen outside the resident's door and on the same unit, causing the resident to feel intimidated. The facility's policy requires that alleged perpetrators have no contact with alleged victims during an investigation, and that staff accused of abuse be removed from access to the alleged victim and other residents. Despite this, the administrator confirmed that the accused nurse continued to work in the facility during the investigation and was present in areas near the resident. The initial investigation report confirmed that the concerns were reported to Adult Protective Services and the state licensing authority.
Failure to Obtain and Implement Accurate Admission Orders
Penalty
Summary
The facility failed to obtain and implement accurate physician orders for a resident upon admission following an acute hospitalization for a right hip fracture repair. The resident was admitted for rehabilitation and pain control, with hospital discharge orders including aspirin for DVT prevention, hydromorphone and acetaminophen for pain, and senna for constipation. These medications were not ordered or administered at the facility until several days after admission, as the initial orders entered into the electronic health record were from a previous hospital stay and not the actual discharge orders. There was no evidence that the correct medications were provided prior to four days after admission. Additionally, the resident developed right lower extremity swelling, and an ultrasound was ordered to rule out DVT, but there was no documentation that the diagnostic test was completed. Interviews with facility staff revealed that the process for transcribing and verifying orders was flawed, with orders being activated before provider review and a lack of confirmation from providers regarding order approval. The facility administrator and DON confirmed that the correct discharge summary and admitting orders were not available at the time of admission, leading to a delay in necessary care and services for the resident.
Failure to Provide Adequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident receiving hospice care for end-stage chronic obstructive pulmonary disease (COPD). The resident was observed calling out in pain on multiple occasions, and interviews revealed that the resident experienced pain almost daily, particularly between scheduled pain medication doses. The Medication Administration Record (MAR) showed that the resident reported pain levels greater than 6 on ten occasions within a 26-day period, with five instances rated as 9-10 on a 1-10 pain scale. Despite these high pain scores, there was no evidence that as-needed (PRN) acetaminophen, which was ordered for pain not controlled by scheduled morphine, was administered to address the resident's discomfort between scheduled doses. Staff interviews indicated that pain assessments were typically performed only at the start of each shift, and the unit manager stated that the resident rarely requested additional pain medication outside of the scheduled doses. The care plan included interventions to assess and medicate for pain as ordered, but the lack of PRN medication administration and infrequent pain assessments did not align with the resident's reported pain levels and hospice status. The hospice nurse confirmed that more frequent pain assessments and additional medication would be expected for a hospice patient experiencing significant pain.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as evidenced by a calculated error rate of 12% based on 25 medication administration observations with three errors identified. During observation, an LPN administered Omeprazole, Dulera inhaler, and Basaglar insulin to a resident significantly later than the scheduled times indicated on the Medication Administration Record (MAR). Specifically, Omeprazole was due at 7:00 AM, and both the insulin and Dulera inhaler were due at 9:00 AM, but all were administered at 10:12 AM. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified. The LPN confirmed the medications were late and attributed the delay to unfamiliarity with working on that side of the facility.
Failure to Provide Timely Dental Services for Resident in Pain
Penalty
Summary
The facility failed to promptly provide routine and emergency dental services to meet the needs of a resident experiencing dental pain. The resident reported not having seen a dentist since admission and described severe dental pain, rating it as 10 out of 10 at times, and expressed feeling neglected regarding their dental health. Facility policy requires providing or obtaining routine and emergency dental services, including 24-hour emergency care, and assisting residents in making dental appointments when necessary. Despite a physician telehealth appointment for tooth pain, no medication changes were made, and there was no evidence of follow-up appointments or treatment to address the resident's ongoing dental concerns, as confirmed by the Regional Director of Nursing.
Widespread Administrative Failures Lead to Immediate Jeopardy and Harm
Penalty
Summary
The facility failed to administer operations in a manner that maintained the physical well-being of residents, as evidenced by multiple leadership changes, lack of consistent administration, and insufficient oversight. There were frequent changes in key positions, including the Administrator, Medical Director, and Director of Nursing, which contributed to instability and lapses in care. Interviews with the Medical Director and a resident's responsible party confirmed that these transitions led to issues with resident care and follow-through on concerns. Record review showed repeated changes in leadership within a single year. Deficient practices were identified during investigations of facility-reported incidents and complaints, resulting in numerous citations at Immediate Jeopardy and harm levels. The facility failed to ensure timely physician notification and consultation, leading to residents not being evaluated after physical assaults, not receiving treatment for pressure ulcers, and not receiving appropriate care during a COVID-19 outbreak, including a resident who died from COVID. There was also a failure to provide adequate supervision, resulting in incidents such as a resident falling down stairs and another being assaulted, with ineffective security systems observed. These failures were repeat deficiencies, with similar violations cited in previous surveys. Additional deficiencies included lack of physician supervision of medical care, failure to implement an effective infection prevention and control program, and not designating a qualified infection preventionist. These failures led to inadequate COVID-19 management, resulting in a resident death, and poor wound care practices, causing pressure ulcers to worsen. The facility also failed to protect residents from abuse and did not implement care plan interventions, resulting in harm and persistent fear among residents. These issues were directly linked to the lack of administrative oversight and failure to follow professional standards and regulatory requirements.
Failure to Implement Infection Control Program and Outbreak Management
Penalty
Summary
The facility failed to implement and enforce its infection prevention and control program, resulting in multiple deficiencies related to the use of personal protective equipment (PPE), outbreak management, and adherence to both facility policy and state health department guidance. Staff, including the DON and LPN, were observed performing high-contact care activities such as flushing a Foley catheter and wound care for a resident with an indwelling device and open pressure ulcers, without donning the required PPE such as gowns, gloves, face masks, or eye protection. Both staff members acknowledged after the fact that they should have used PPE as per the care plan and facility protocol, but did not do so. Repeated observations showed continued non-compliance with PPE use during high-risk procedures. During a COVID-19 outbreak, the facility failed to follow its own outbreak management policy and state health department recommendations regarding contact tracing, testing, and reporting. The facility did not maintain or provide contact tracing logs or testing records for residents or staff, and there was no staff member aware of the outbreak management plan or the current status of the outbreak. The DON admitted to not being in contact with the state health department for guidance and was unaware of the number of COVID-positive residents or the current outbreak status. The newly designated Infection Control Nurse had not received training, did not possess the necessary qualifications, and was not informed about the outbreak or mitigation strategies. Observations revealed that staff were not implementing required mitigation strategies, including proper PPE use and isolation for COVID-19 positive residents. Staff entered and exited precaution rooms wearing only masks, without gowns, gloves, or eye protection, and did not perform hand hygiene. Several staff members were unaware of which residents were on precautions, the duration of isolation, or the facility's COVID-19 policies. Residents who tested positive for COVID-19 were observed outside of isolation, and the medical director was not informed of the facility's policies, guidance, or the status of COVID-positive residents, including a resident who died following hospitalization for COVID-19.
Failure to Notify Physician of Significant Changes and Incidents
Penalty
Summary
The facility failed to ensure timely and appropriate notification and consultation with the attending physician during a COVID-19 outbreak and in response to significant changes in resident conditions. Specifically, three residents who tested positive for COVID-19 did not have documented evidence of physician notification or consultation regarding their positive status or symptoms, including one resident with a history of NSTEMI and advancing dementia who became lethargic and later died. The Medical Director confirmed not being notified of these cases or consulted on the facility's COVID-19 mitigation plan. Additionally, the facility did not notify the physician following a physical altercation in which one resident assaulted another, resulting in injuries such as bruising and a skin tear. Although the incident report indicated physician notification, the Medical Director stated she was not informed and would have taken further action had she been aware. The injured resident did not receive additional monitoring after being struck in the head, and the aggressor was not evaluated for behavioral concerns as would have been expected. The facility also failed to notify the physician of significant changes in condition related to the development and progression of pressure ulcers in another resident. Documentation showed new wounds and progression from deep tissue injury to stage 2 pressure ulcer without evidence of physician notification or orders for treatment. During wound care observation, an additional wound was discovered that had not been previously documented or reported to the physician, and there was no treatment order in place until later. The Medical Director confirmed she had not been informed of these developments.
Failure to Prevent Accidents and Resident-to-Resident Assaults Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment, resulting in multiple serious incidents involving residents. One resident with dementia, Alzheimer's disease, a history of falls, and identified as an elopement risk, was able to access an alarmed stairwell and fell down a flight of eight stairs while in a wheelchair, sustaining a head injury and possible hip fracture. Staff did not respond promptly to the door alarm, which was intended to alert them to potential elopement, due to confusion with other alarms and distractions on the unit. At the time of the incident, staffing was limited, with some staff on break or off the unit, leaving only two staff members available to respond to alarms. Observation also revealed that the stairway alarm system could be easily bypassed without sounding the alarm. Additionally, the facility failed to ensure staff responded appropriately to the Wander Guard alarm system, which is used to monitor residents at risk for elopement. On multiple occasions, the alarm sounded for extended periods without staff investigation or response, and staff were observed ignoring the alarm. The Administrator confirmed that staff had become desensitized to the alarm due to frequent false activations, and staff did not follow facility policy or procedure regarding elopement risk. The facility also failed to provide adequate supervision to prevent resident-to-resident altercations. One resident with a history of aggressive behavior and multiple prior incidents entered another resident's room and caused physical harm, resulting in a skin tear and bruising. The care plan for the aggressive resident was not updated to include effective interventions or increased supervision, and staff were not educated on managing the resident's behavior. There was no documentation of required 15-minute checks, and the medical director was not notified of the incidents or injuries. Multiple staff expressed concerns about insufficient staffing to supervise the aggressive resident and prevent further incidents.
Failure to Ensure Physician Supervision and Timely Notification
Penalty
Summary
The facility failed to ensure that residents' medical care was properly supervised by a physician, resulting in significant lapses for three residents. One resident, who tested positive for COVID-19 and had underlying conditions including hypertension, diabetes, and coronary artery disease, was not monitored or treated for COVID-19 after the positive test. There was no documentation that the physician was notified of the positive result or the resident's symptoms of lethargy, nor was there evidence of physician consultation or specific treatment for COVID-19. The resident was later found unresponsive and subsequently died, with the death certificate listing COVID-19 as a cause of death. The medical director confirmed she was not notified of the resident's condition or positive test result. Another incident involved a resident with violent behaviors who entered another resident's room, causing injury by throwing cans of soda and striking the resident in the head. The injured resident did not receive immediate assessment or care from a physician for the head injury, and there was no evidence that the aggressive resident received physician evaluation for the behavior. Although facility documentation indicated that the physician had been notified, the medical director stated in interviews that she was not informed of the incident. She indicated that, had she been notified, both residents would have been sent for further evaluation and treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury and ongoing fear. One resident, who is dependent for mobility due to bilateral ankle fractures and is blind in one eye, was assaulted in their room when another resident entered and threw a 12-pack of soda, causing a skin tear on the forearm and bruising to the forehead and around the eye. Documentation did not clarify how the forehead bruise occurred. The assaulted resident expressed persistent fear of further attacks and reported difficulty sleeping due to anxiety about the incident. The resident who committed the assault had a documented history of aggressive behaviors, including previous physical altercations with other residents. Despite this, the care plan for the aggressive resident did not address the risk of entering other residents' rooms or the need for supervision, even after multiple incidents. Staff interviews revealed a lack of education on managing this resident's behaviors and concerns about insufficient staffing to monitor and redirect the resident. Although 15-minute checks were ordered for the aggressive resident, there was no evidence these checks were performed or documented, and staff were unaware of the intervention. This lack of effective interventions and supervision contributed to the failure to prevent further resident-to-resident abuse.
Failure to Implement and Document Wound Care Interventions and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and update care plan interventions related to skin and wound assessments for one resident, resulting in the worsening of multiple pressure ulcers. Observations revealed that the resident had several open wounds, including an excoriated sacrum, pressure ulcers on the right hip and right malleolus, and two open areas on the left distal foot. A large dry wound on the left lateral foot was not previously identified or documented, and there was no physician notification or treatment order for this wound until eight days after it was first observed. The care plan was not updated to include the new stage 2 pressure ulcer on the left lateral foot until several days after its identification, and weekly wound assessments were not consistently performed or documented as required by the care plan. Wound measurements and descriptions were frequently missing from the records, and the progression of wounds, including the development of additional pressure ulcers, was not promptly communicated to the physician or reflected in the care plan. Further review of the resident's care plan indicated that the resident was at risk for skin breakdown due to factors such as a Foley catheter and fragile skin, with interventions including weekly skin checks and wound assessments. However, documentation showed that these interventions were not consistently carried out, with several instances where wound measurements and descriptions were omitted. The resident developed additional pressure ulcers, including unstageable ulcers and stage 2 ulcers on the feet, which were not promptly assessed or documented. The lack of timely and thorough wound assessments and failure to update the care plan contributed to the deterioration of the resident's skin condition. Additionally, the facility failed to follow enhanced barrier precautions (EBP) for the resident, who required such precautions due to the presence of a Foley catheter and open wounds. Observations showed that both the LPN and DON entered the resident's room and performed high-contact care activities, including wound care and catheter flushing, without wearing the required personal protective equipment (PPE) such as face masks, eye protection, gloves, and gowns. Despite signage indicating the need for EBP and acknowledgment from staff that PPE should have been used, these precautions were not followed during multiple care activities.
Failure to Provide Timely and Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for pressure ulcer care for one resident. The staff did not obtain timely physician orders for wound treatment, did not follow care plan interventions, and did not perform accurate or complete skin and wound assessments. Observations revealed multiple untreated and undocumented wounds, including an excoriated sacrum, open areas on the right hip and right malleolus, and two open areas on the left distal foot. Staff were unaware of a large dry wound on the left lateral foot, and there was no documentation or treatment order for this wound until several days after it was first observed. Record review showed that wound care recommendations from a wound care consultant were not implemented promptly, and there was a delay of several days before treatment orders were obtained for newly identified wounds. The resident's care plan was not updated in a timely manner to reflect new or worsening pressure ulcers, and weekly skin checks and wound assessments were either incomplete or missing critical information such as wound measurements and descriptions. Several wounds, including unstageable and stage 2 pressure ulcers, were not documented or assessed as required, and there were gaps in weekly wound assessments. Interviews with facility staff, including the DON and Regional DON, confirmed lapses in documentation, assessment, and communication regarding the resident's wounds. The DON acknowledged that the development of new wounds was not documented and that treatment orders were delayed. The facility also experienced a gap in wound care consultant visits, further contributing to the lack of timely assessment and intervention. As a result, the resident's wounds deteriorated and additional pressure ulcers developed.
Failure to Involve Medical Director in Resident Care Coordination and Incident Response
Penalty
Summary
The facility failed to ensure that the medical director fulfilled her responsibilities to implement resident care policies and coordinate medical care, particularly in relation to COVID-19 surveillance, policy development, and resident care coordination. During a COVID-19 outbreak, 11 residents and 15 staff tested positive, but there was no documented evidence that the medical director was notified of positive cases or consulted regarding treatment and care needs for affected residents. One resident, who tested positive for COVID-19 and exhibited symptoms of lethargy, was not monitored or treated for the infection and subsequently died. The medical director confirmed she was unaware of the outbreak details, had not reviewed relevant policies, and was not involved in mitigation strategies. Additionally, records for four other residents who tested positive showed no evidence of physician notification or consultation. The facility also failed to notify or consult the medical director regarding a resident with a history of aggressive behavior who committed a violent act against another resident, resulting in injury. The medical director was unaware of the incident and stated she would have taken specific actions had she been informed. There was no documentation of assessment or provider notification for the injured resident, who sustained a head injury and a skin tear. The lack of communication and consultation with the medical director in both infection control and resident safety incidents contributed to the deficient practice.
Failure to Designate Qualified Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP) had obtained specialized infection prevention and control training beyond their initial professional training. This deficiency was a repeat occurrence, having been cited during the previous two recertification surveys. During a COVID-19 outbreak, the facility did not have a qualified IP for a period of 14 days, as confirmed by interviews with the Director of Nursing (DON) and the designated staff member, both of whom acknowledged the lack of required specialized training during this time. As a result of this failure, 11 residents and 15 staff members tested positive for COVID-19 during the outbreak. Five residents were positive at the time of the survey entrance, and two residents were hospitalized with respiratory distress. One resident died shortly after hospital transfer, with the death certificate listing cardiopulmonary arrest due to COVID as the cause of death. The absence of a qualified infection preventionist during the outbreak had the potential to impact all residents in the facility.
Insufficient Nursing Staff and Missed Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by resident assessments and care plans, and did not ensure a licensed nurse was in charge on each shift. The Director of Nursing reported frequently working the medication cart due to staff shortages. The Infection Preventionist was unable to complete necessary training or follow up on the COVID-19 outbreak mitigation plan because she was out with COVID-19 and also had to work as a staff nurse. Additionally, the Integrated Wound Care Consultant had to reschedule a visit because there was not enough staff available to assist with wound rounds, as they were occupied with medication administration. Record review showed that the hours of direct care provided by LNA staff fell below the state-required minimum for four out of eight weeks sampled.
Failure to Administer Prescribed COVID-19 Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by delays and missed doses of prescribed medications for two residents. One resident, after testing positive for COVID-19, had physician orders for Paxlovid and Azithromycin to be administered over a specified period. However, the first dose of Paxlovid was not given until three days after the prescribed start date, resulting in only four out of ten ordered doses being administered. Similarly, Azithromycin was not dispensed or administered as ordered, with the resident receiving only two doses instead of the full course. The delay in medication administration was confirmed to be due to the pharmacy not dispensing the medications until several days after the orders were written. Nursing staff confirmed that the medications were not administered per the physician's orders, the physician was not notified of the missed doses, and the missed doses were not rescheduled to complete the full treatment duration. Another resident who tested positive for COVID-19 had a physician's order for Paxlovid, but the medication was not dispensed by the pharmacy until four days after the order was written, resulting in the medication not being administered as prescribed. The DON and a registered nurse confirmed that the medication was not given according to the physician's order. These findings were based on record review and staff interviews, demonstrating a failure to ensure timely and complete administration of critical medications as ordered.
Incomplete Medical Records and Documentation for Wound Care and COVID-19
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in missing nurse progress notes, incomplete assessments, and absent wound care consultant notes. For one resident with multiple wounds, documentation was inconsistent and incomplete, with several areas of required wound evaluation forms left blank, missing wound measurements, and a lack of descriptive information about the wounds. There was also no evidence that the physician was notified of new pressure ulcers, and nurse progress notes were absent for a significant period. The DON and Regional DON confirmed gaps in documentation and delays in uploading consultant notes. Another resident who tested positive for COVID-19 had no documentation in the medical record indicating the positive test result, no nursing assessment related to the infection, and no evidence that the provider was notified. There was also no documentation of any treatment or assessment for complications related to COVID-19, despite the resident's high risk due to comorbidities. The care plan lacked interventions for monitoring and assessing for COVID-19 complications, and the facility was unable to provide documentation of physician consultation or treatment related to the infection. Interviews with facility leadership revealed a lack of awareness and oversight regarding the documentation and management of these residents' conditions. The Medical Director was not familiar with the facility's infection control policies or mitigation strategies for COVID-19, and there was no formal communication about the outbreak or resident care needs. These deficiencies were noted as repeat violations from previous surveys.
Failure to Timely Report Resident-to-Resident Abuse and Investigation Findings
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of resident-to-resident physical abuse to the State Licensing Agency. Specifically, an incident occurred in which one resident entered another resident's room and threw a can of soda, resulting in a skin tear to the left forearm and a bruise to the forehead of the affected resident. Nursing documentation and risk management notes did not provide evidence regarding how the bruise to the forehead occurred. The incident was not reported to the State Agency within the required 2-hour timeframe; instead, the report was filed over 23 hours after the facility became aware of the allegation. Additionally, the facility did not submit the required 5-day investigation findings to the State Agency within the mandated period. The investigation was submitted 15 days after the incident, well beyond the 5-day requirement. The facility's policy, last revised in January 2024, clearly states that all actual or suspected acts of abuse, neglect, or exploitation must be reported immediately, with the DON or designee responsible for reporting within 2 hours if abuse is involved. During an interview, the Administrator acknowledged being unaware of the full extent of the incident and the reporting requirements, and confirmed that both the initial and 5-day reports were submitted late.
Failure to Revise Care Plan After Resident-to-Resident Altercation and Injury
Penalty
Summary
The facility failed to revise the care plan for one resident following a resident-to-resident physical altercation that resulted in injury. Specifically, after an incident in which another resident entered the affected resident's room and threw a can of soda, causing a skin tear to the left forearm and a bruise to the forehead, there was no documented evidence that the care plan was updated to include interventions to monitor for complications related to the physical abuse or to address the new wounds. The resident expressed fear of further incidents, and the existing care plan, which noted risk factors such as advanced age, frail and fragile skin, and limited mobility, was not revised to reflect the new skin impairments or to add interventions for assessment, monitoring, or treatment of the injuries. The DON confirmed that no updates had been made to the care plan regarding the new wounds or the altercation.
Failure to Provide Ordered Wound Care and Documentation
Penalty
Summary
A deficiency occurred when a resident with a left forearm injury did not receive wound care in accordance with physician orders and facility policy. Observation revealed that the resident's dressing, dated five days prior, had not been changed as required by the daily dressing change order. The resident reported that the dressing had not been changed in several days, and the LPN confirmed the dressing appeared old and that daily changes were ordered. Documentation in the Treatment Administration Record indicated the dressing was changed, but direct observation and interview contradicted this, and there was no documentation of a wound assessment as required by facility policy. The facility's wound care policy also required specific documentation of the care provided, which was not present in the resident's medical record.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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