Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Johnsbury Health & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia with agitation, and a care plan calling for choices during care was found covered in feces and taken to the shower for hygiene. When the resident refused and became combative, staff continued the bath with multiple aides present. The resident was reported to have punched, bitten, scratched, and pulled staff hair during the process and later had multiple skin tears and bruising.
Failure to revise a care plan for aggressive behaviors: A resident with dementia, severe cognitive impairment, and repeated episodes of agitation and physical aggression toward staff had multiple incidents during care, including threats, pushing, swatting, biting, scratching, and combative behavior during hygiene assistance. The resident also sustained skin tears and bruising during these events, while staff interviews confirmed care continued despite refusal and aggression. The care plan was not revised to address the pattern of physically aggressive behavior until weeks later.
Food items were not stored according to food safety standards. In the kitchen, a dirty bucket of liquid laundry stain remover was found near the walk-in fridge, and an expired balsamic vinaigrette was observed in a kitchenette and discarded by an LPN. In an activity room freezer, staff found undated cookies, unpackaged frozen bananas, and an unidentified bucket of ice with a water bottle, and the cookies remained undated on a later check. Review of personal resident refrigerator logs showed missing entries on multiple dates and several fridges above the required temperature range, with the Housekeeping Director confirming out-of-range temps and the Maintenance Director stating he had not received reports.
A resident with dementia, falls history, and mobility impairment continued to self-transfer and fall despite care plan interventions, while the resident's wheelchair had a defective anti-rollback device and loose brake that were observed not to function properly. The resident's room also contained a lifted mat over damaged flooring, creating a trip hazard. In a separate issue, a resident with smoking privileges kept cigarettes and a lighter in the room, and a used cigarette was found on the bedside table despite the facility smoking policy requiring staff control of smoking materials.
Failure to Obtain Informed Consent for Psychotropic Medication: A resident with no cognitive impairment and diagnoses including DM2 and a BKA was prescribed Venlafaxine ER for MDD and anxiety, but interviews showed the resident was not informed about the medication, did not sign a consent form, and was not spoken to by the physician about adding Effexor. The record contained no documented evidence of informed consent, and the DON confirmed no psychotropic consent form was available.
Inaccurate code status documentation was found for a resident whose COLST indicated DNR and refusal of CPR, while the care plan, physician order, and EMR care profile all listed full code. The RN Unit Manager, an LPN, and the DON confirmed that the resident’s code status information in the record did not match the current COLST form.
A resident was sent to the hospital ED during an emergent medical event, but the chart did not contain a bed-hold notice and there was no documented evidence that the LTC Ombudsman was notified of the hospitalization. The facility’s policy required written bed-hold notice after an emergency transfer and a copy in the medical record, but the social worker and DON confirmed no bed-hold notice was found and the Ombudsman was not notified.
A resident did not have required monthly MRRs completed by the Consulting Pharmacist for several months, and the DON confirmed there was no evidence the reviews had been conducted. The facility policy stated the pharmacist must review the MAR monthly and report irregularities to the attending physician and DON for action.
Expired COVID-19 vaccines were found in Unit B’s medication room freezer, and the RN Unit Manager confirmed they were ready for use and expired. The facility also left a medication treatment cart unlocked at the nursing station with medications inside while two residents were present nearby; an LPN later confirmed the cart should be locked and secured it.
Failure to Perform Hand Hygiene During Medication Administration: An LPN administered medications to a resident without performing hand hygiene before or after the med pass and then continued medication administration with unwashed hands. The LPN confirmed the omission during interview, and the facility policy required handwashing prior to administration and hand antisepsis after administration. This was a repeat deficiency previously cited on an earlier partial survey.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure the Medical Director performed required duties, including reviewing and implementing care policies, coordinating medical care, and participating in QAPI. Two residents with insulin-dependent diabetes were admitted without proper orders or care plans, resulting in delayed or missed diabetes management and one case of acute hyperglycemia. Providers and staff reported poor communication and lack of collaboration with the Medical Director, who was unaware of key care issues, staffing shortages, and medication administration problems.
The facility did not maintain adequate LNA and RN staffing, resulting in missed and late medication administrations, unprocessed lab orders, and failure to meet required direct care hours. The DON and ADON reported being unable to keep up with resident needs due to staffing shortages, and the facility's internal agency was unable to provide additional RN staff.
The facility did not ensure an RN was present for at least 8 consecutive hours daily as required, with multiple days lacking any RN coverage and additional days without the minimum required hours. This was confirmed by the Administrator through staffing schedule review and interview.
A facility failed to administer prescribed medications and treatments in accordance with physician orders and facility policy, resulting in widespread missed and late doses for multiple residents. This included a resident with insulin-dependent diabetes who did not receive ordered insulin or blood glucose monitoring, as well as numerous other residents who missed critical medications and treatments for various chronic conditions. The DON confirmed the deficiencies, and the Medical Director was not aware of the magnitude of the issue.
The facility failed to ensure timely laboratory services and result documentation for several residents, including one with diabetes and a pressure ulcer who did not have critical labs completed or results available in the medical record. Multiple lab orders for other residents were not processed, and providers were not notified of outstanding tests. Staff interviews revealed a lack of an effective system for lab collection, result tracking, and communication, with only one staff member able to access the tracking system, leading to significant delays and missing information.
Facility leadership failed to ensure effective administration, resulting in immediate jeopardy and repeat deficiencies. A resident with diabetes did not receive necessary insulin, RN coverage was insufficient for an extended period, and thousands of medication errors were documented. Lab orders went unprocessed without provider notification, and significant staffing shortages forced the DON to work direct care shifts, impacting oversight. Leadership was also unavailable to provide timely information during a survey.
The facility did not implement a comprehensive QAPI program, resulting in multiple deficiencies including lack of required regulatory visits, insufficient RN staffing, untimely lab orders, and inadequate physician and Medical Director oversight. The QAPI team and Medical Director failed to systematically identify and address these issues, leading to repeated and immediate jeopardy-level citations.
The facility did not timely report two separate allegations of staff-to-resident abuse to the State Survey Agency. In one case, a provider informed the DON of an abuse allegation, but the DON did not report it due to lack of details. In another case, a resident reported being slapped by a CNA, but there was no evidence that the Administrator's report was received by the State.
The facility did not develop or implement baseline care plans within 48 hours of admission for several residents with complex needs, resulting in missing or incomplete instructions for care related to diabetes, pressure ulcers, falls, ADLs, and personal preferences. Communication lapses among providers and staff contributed to the lack of clear care guidance, and leadership confirmed that required care plans were not completed as needed.
The facility did not develop or implement timely, comprehensive care plans for two residents with complex needs, including diabetes management, pressure ulcer care, fall prevention, and other areas identified in MDS assessments. Despite clear documentation of diagnoses and risk factors, care plans were delayed or missing, and communication among providers was insufficient, as confirmed by interviews with the DON, LPN, and medical staff.
The facility did not update comprehensive care plans by their required due dates for multiple residents. Record reviews and staff interview confirmed that several care plans remained overdue, with the DON acknowledging the missed updates.
The facility did not notify providers when lab tests were not performed and failed to promptly communicate lab results, including a critical A1c value for a resident with diabetes. Multiple lab orders for several residents were not drawn or documented, and providers reported ongoing difficulties accessing lab results due to a lack of a structured system in the EMR.
A resident admitted with diabetes and an unstageable pressure ulcer did not have a care plan for pressure ulcer treatment or diabetes management upon admission. There was no documentation or physician oversight of the pressure ulcer until weeks later, when the resident developed a stage 2 ulcer, cellulitis, and acute hyperglycemia, requiring emergency care. The resident was not receiving prescribed insulin, and facility staff were unaware of this omission.
A resident with multiple risk factors for falls, including a history of repeated falls, dementia, and impaired mobility, was not provided with a care plan addressing fall prevention upon admission. Despite documented high fall risk and a recent fall, the care plan did not include relevant interventions until after the resident experienced another unwitnessed fall.
A resident was admitted without a physician's order and was not placed under a doctor's care at the time of admission, as required. The facility did not ensure proper medical authorization and oversight during the admission process.
A resident with multiple complex medical conditions did not receive the required physician onsite visit within 30 days of admission, as confirmed by record review and interview with the DON.
A resident with diabetes and a history of pancreatectomy experienced severe hyperglycemia, with blood sugar readings exceeding 400 mg/dL, and reported symptoms including headache, nausea, and mental confusion. Despite repeated requests for assistance, an LPN failed to check the resident's blood sugar in a timely manner, did not contact the physician, and refused to provide insulin or facilitate hospital transfer. The resident independently called 911 and was transported by EMTs to the emergency department, where a critically high blood sugar was confirmed and treated. Facility leadership acknowledged that the LPN did not follow policy or professional standards, and new physician orders from the hospital were not implemented upon the resident's return.
A resident with a history of diabetes and pancreatectomy experienced severe hyperglycemia, which was not appropriately addressed by an LPN despite repeated requests for help. The LPN delayed blood sugar checks, refused to contact a physician or arrange emergency care, and failed to provide necessary transfer documentation when the resident called 911 and was transported to the hospital. Upon the resident's return, the LPN did not document the hospital visit, implement new physician orders, or notify the physician, resulting in a significant lapse in care.
A resident was found to be self-administering Zenpep capsules despite physician orders prohibiting self-administration. The resident kept the medication personally and took it independently without informing nursing staff or documenting usage, resulting in the Medication Administration Record not accurately reflecting the actual administration of the medication.
A resident with a history of diabetes and pancreatectomy experienced severe hyperglycemia and, after repeated requests for assistance, called 911 for emergency care. The LPN on duty refused to provide standard transfer documentation to EMTs and did not supply the required written bed-hold policy notification to the resident or representative prior to transfer. Upon the resident's return, new physician orders from the hospital were not documented or implemented, and there was no evidence of physician notification or appropriate follow-up.
A resident was found in possession of prescribed Zenpep capsules and reported self-administering the medication without notifying nursing staff or following the prescribed schedule. Facility staff confirmed that the medication should not have been accessible to the resident and that nursing failed to ensure proper storage and administration.
The Medical Director failed to implement resident care policies and coordinate medical care during a COVID-19 outbreak, directing staff through the DON to stop testing residents and staff and to remove precaution carts, contrary to facility policy. Leadership confirmed these actions were not in line with established protocols, and documentation showed the Medical Director had been informed of job duties and expectations.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, including delayed and incomplete reporting to the health department, omission of staff cases from required line listings, and abrupt discontinuation of testing and precautions for both residents and staff as directed by the DON and medical director. These actions were not in accordance with facility policy or regulatory guidance.
The facility did not have a qualified Infection Preventionist (IP) in place, as the DON was temporarily acting as the IP while still working toward required CDC certification. Oversight from the corporate DON was limited to weekly visits, with documentation showing only two visits since the IP position became vacant.
Two residents with significant fall risks experienced multiple unwitnessed falls, including one resulting in a hip fracture and another causing a skin tear. The facility did not promptly update care plans or implement effective, timely interventions after these incidents, and was unable to provide evidence of adequate supervision or timely care plan revisions as required by policy and leadership expectations.
During a change of ownership, the facility failed to maintain complete and accessible medical records for all residents. For several days, staff and the Medical Director were unable to access electronic records, resulting in missing documentation for two residents, including medication administration, professional notes, and assessments. Facility leadership confirmed that information was recorded in a system that became inaccessible, and the missing records could not be provided to surveyors.
The facility did not maintain adequate nursing staff levels, resulting in multiple residents receiving medications several hours late, including critical medications for anxiety, seizures, pain, and bowel management. Staff interviews confirmed that understaffing, especially during certain shifts, led to these delays, and the DON acknowledged that high resident acuity and insufficient staff contributed to the problem.
A resident with severe cognitive impairment and a history of wandering was repeatedly observed entering other residents' rooms, staff offices, and handling items on the medication cart without adequate supervision. Multiple residents reported distressing encounters, including the resident climbing into beds, grabbing others, and holding objects. Staff were present but did not consistently supervise or redirect the resident, leading to ongoing incidents and a lack of accident prevention.
Multiple residents with mental health diagnoses, including depression, anxiety, schizophrenia, and PTSD, did not receive required behavioral health services after psychiatric providers stopped attending the facility. Although leadership claimed that talk therapy was being provided, there was no documentation to support this, and residents continued to experience behavioral symptoms and altercations without appropriate interventions.
A resident's advance directives, which specified no CPR, mechanical ventilation, or feeding tube, were not accurately reflected in the physician's orders or the electronic chart dashboard. Staff relied on incorrect code status information, and the DON confirmed the mismatch between the resident's wishes and the documented orders.
A resident did not receive scheduled showers as outlined in their care plan and personal preference, with documentation showing missed showers and only one recorded refusal. An LNA reported that staffing shortages and workload prevented consistent delivery of showers according to resident preferences.
A resident with diabetes, neuropathy, and limited mobility developed an in-house acquired pressure ulcer after staff failed to consistently provide care plan interventions such as assistance with turning, repositioning, and daily diabetic foot checks. The wound was discovered after blood was noted on the bed sheets, and nursing staff confirmed it was likely caused by pressure from the resident's foot against the bed's footboard.
A resident with anemia and end-stage chronic kidney disease experienced a significant delay in having laboratory tests performed after a provider ordered a BMP, CBC, and PT/INR following a fall. The blood sample was not received by the lab until five days after the order, and the results showed critical values, including low hemoglobin. Facility leadership confirmed the delay.
A resident with multiple medical conditions gave $400 to an LNA to fix a vehicle. Initially declined, the LNA later accepted the money, leading to a confirmed case of misappropriation of resident funds. The incident was reported to APS and the police, and the facility's internal investigation verified the deficiency.
A resident gave $400 to an LNA to fix her vehicle, which was initially declined but later accepted. The incident was overheard and reported to APS and the state agency, but the involved LNAs did not report the misappropriation immediately or within 24 hours, violating facility policy.
A facility failed to complete a required PASRR Level 1 assessment for a resident admitted with major depressive disorder and an unspecified mental disorder. The resident, who was on antipsychotic medication, expressed suicidal ideation and eloped from the facility. The necessary assessment was not conducted, despite the resident's extended stay and history of serious suicide attempts.
A resident with major depressive disorder and unspecified mental disorder expressed suicidal ideation twice, yet the facility failed to develop a timely care plan to address these needs. The resident, who was on Lurasidone, eventually eloped and required emergency psychiatric evaluation. The DON confirmed the care plan was not developed promptly, leading to the deficiency.
A resident's medication was misappropriated when an LPN altered the Controlled Substance Logbook entry, reducing the recorded amount of Oxycodone received. The facility discovered the discrepancy when attempting to reorder the medication, leading to the termination of the LPN under suspicion of narcotic diversion.
A facility failed to implement its policy to thoroughly investigate the work history of an LPN, leading to a deficiency. The LPN was involved in an incident where 60 tablets of Oxycodone were unaccounted for and had a history of narcotic discrepancies at another facility. The facility did not contact previous employers to check for performance issues, as required by their policy.
Resident’s refusal of hygiene care was not honored
Penalty
Summary
The facility failed to treat a resident in a manner that promoted dignity, self-determination, and the resident’s right to make choices when staff continued hygiene care after the resident refused and became physically aggressive. Resident #4 had diagnoses including unspecified dementia with agitation and cognitive communication deficit, and an MDS showed a BIMS score of 3, indicating severe cognitive impairment. The care plan identified that the resident was resistive to care and also included an intervention to provide opportunities for choice during care and activities to give a sense of control. Staff found the resident covered in feces and escorted the resident to the shower for hygiene care. The resident refused care and became combative during the shower, including punching, trying to bite, pulling staff hair, and digging nails into staff skin, but care was continued with assistance from multiple staff members. After the event, the resident was noted to have scattered bruising and multiple skin tears, including to the right arm, left outer knee, left lateral calf, and both forearms, along with bruising to the upper right arm, side, and right lower extremity. The DON confirmed the resident was refusing care and combative, and an LNA stated the resident was combative throughout the bathing process.
Failure to Revise Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to revise and implement a person-centered care plan for a resident with dementia with agitation and cognitive communication deficit who had a BIMS score of 3, indicating severe cognitive impairment. The resident had a documented pattern of physically aggressive behavior, including making a fist and threatening to knock a staff member out, pushing a staff member, swatting at an LNA during brief care, and becoming verbally and physically aggressive during hygiene care. Nursing notes also documented repeated episodes of agitation, refusal of care, yelling, slamming doors, and combative behavior during bathing and skin care. Record review showed that the resident sustained injuries and required multiple staff members to complete care during aggressive episodes, including a skin tear during an altercation, bruising, and skin tears to the arms and knee after being combative with care. Staff interviews confirmed that on one occasion the resident was refusing care, combative, and agitated while staff continued bathing the resident. The facility did not revise the resident’s care plan with interventions to address the pattern of physically aggressive behavior until over 6 weeks after the increase in physical behaviors.
Food Storage and Refrigerator Temperature Monitoring Deficiencies
Penalty
Summary
Food items were not stored in accordance with professional standards for food service safety. During observation of the kitchen, a very strong offensive odor was noted on entry, and a dirty bucket of liquid laundry stain remover was found on crates outside the walk-in refrigerator. The Food Service Director stated it should have been thrown away and had been used for cleaning the dishwasher. In the Wing B kitchenette, balsamic vinaigrette was observed with an expiration date of 1/18/26, and an LPN confirmed it was expired and discarded it. Additional observations showed food and other items in the activity room refrigerator and freezer that were not properly labeled or identified. A bag of cookies in the freezer had no date, unpackaged frozen bananas were present, and a bucket of ice with a water bottle was also found in the freezer; staff stated they were unsure who the items belonged to and the items were not removed at the time. The bag of cookies remained undated on a later observation. Review of temperature logs for six personal resident refrigerators showed missing documentation on multiple dates and temperatures above the required 32 to 40 degrees F range on multiple days. The Housekeeping Director confirmed the temperatures were out of range and stated staff would inform maintenance, while the Maintenance Director stated he had not received any reports of out-of-range temperatures.
Accident Hazards, Wheelchair Safety, and Smoking Control Failures
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's disease, cognitive communication deficit, gait and mobility abnormalities, lack of coordination, muscle weakness, and a history of falling was protected from accident hazards related to supervision, fall hazards, and wheelchair maintenance. The resident had care plan interventions for extensive assist of 1 with transfers and fall precautions, yet records showed repeated self-transfers and falls, including a witnessed fall while trying to stand and grab a snack cart, and later notes describing the resident transferring self to bed without staff assistance and removing the brief. During observation, the resident was seen self-propelling in a wheelchair, stating that a fall had occurred earlier that day, and later was observed walking alone in the room and being assisted back to the wheelchair by an LNA. The resident's wheelchair had safety equipment that was not functioning correctly. Observations showed the anti-rollback device did not engage when the empty wheelchair was pulled backward, and the left standard brake was loose and unable to engage properly, allowing the wheel to move freely. The DON and Regional Director of Quality and Compliance confirmed that the anti-rollback device should engage when weight is removed, and the DON acknowledged that the device had been installed before the fall but was already on the wheelchair. The Director of Maintenance stated that wheelchairs were not inspected as part of the facility's PM program and confirmed that the anti-rollback device was not working correctly. He also stated that other wheelchairs in the facility had similar issues and that the loose left brake on this resident's wheelchair had not been repaired. The resident's room also contained an accident hazard. A carpeted/rubber mat was observed between the bed and window with one corner lifted several inches on the bed, creating a trip hazard, and when the mat was lifted, damaged flooring with a large missing portion was revealed. The DON confirmed the mat should not have been positioned that way, and the Administrator stated he had not been aware of the damaged flooring. The Director of Maintenance stated he had known about the damaged floor since June 2025 and described back-and-forth communication about replacing it that did not occur. The facility also failed to ensure smoking safety for a resident with a BIMS score of 13, hemiplegia, nicotine dependence, and major depressive disorder who was independent with ADLs and allowed to smoke independently per the smoking evaluation. The resident stated that cigarettes and a lighter were kept in the room, and the resident was observed returning from smoking without handing the cigarettes or lighter to staff. The smoking policy stated that residents with independent smoking privileges shall not keep cigarettes, pipes, tobacco, or other smoking articles in their possession and that smoking paraphernalia must be maintained in a locked area and distributed by staff. A used cigarette was later observed on the resident's bedside table, and the Unit Manager confirmed the cigarettes were missing from the medication room.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was provided informed consent for Venlafaxine, a psychotropic medication. Resident #43 had a BIMS score of 15 as of 1/15/26, indicating no cognitive impairment, and had diagnoses of Type II Diabetes and a below-the-knee amputation. The resident was independent with ADLs and hygiene. The MAR showed an order for Venlafaxine ER 75 mg by mouth daily, written on 7/3/25 and discontinued on 7/21/25. A psychiatric note dated 7/2/25 stated that Venlafaxine was started for major depressive disorder and also helped with anxiety. The facility’s Psychotropic Medication Administration Disclosure form stated that residents should be fully informed about psychotropic medications, but the resident stated in interviews that they were not notified about being placed on Venlafaxine, did not sign a consent form, and were not spoken to by the physician about adding Effexor. The resident also reported noticing an extra pill during medication administration and said the medication was later removed from the medication list. The record contained no documented evidence that informed consent was provided, and the DON confirmed there was no psychotropic consent form for the resident’s Venlafaxine.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that Resident #3’s advance directive and code status information were accurate and consistent across the electronic medical record. Record review showed that the resident’s COLST form indicated a choice to decline CPR and to have DNR status, but the resident’s care plan identified the resident as full code, a physician order also read full code, and the EMR care profile code status section likewise read full code. During interview, the RN Unit Manager stated the facility uses the resident’s care profile to identify code status and confirmed that the care profile, physician order, and care plan did not match the COLST form. An LPN on the unit stated staff use the resident’s care profile to obtain and confirm code status, and the DON confirmed that the code status in the care plan, physician orders, and care profile should match the current COLST form in the EMR.
Failure to Provide Bed Hold Notice After Emergency Transfer
Penalty
Summary
The facility failed to provide notice of bed hold for Resident #22 after the resident was sent to the hospital emergency department during an emergent medical event. Record review showed a nursing progress note dated 6/15/25 documenting the transfer, but there was no bed hold notice in the resident’s chart and no documented evidence that the Long-Term Care Ombudsman was notified of the hospitalization. Review of the facility’s Bed Holds and Returns policy stated that, in the event of an emergency transfer, the facility would provide written notice of bed hold policies to the resident and/or resident representative as soon as practicable and keep a copy in the medical record. On 1/27/26, the social worker confirmed she could not find a bed-hold notice in computer or hard copy, and later that day the DON and social worker confirmed the Ombudsman was not notified and that there was no bed-hold.
Missed Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews were performed by the Consulting Pharmacist and acted on for Resident #49. Record review showed that Resident #49 did not have MRRs for January 2025, February 2025, March 2025, and May 2025. The facility’s Pharmacy Consultant Policy & Procedure stated that the pharmacist will report irregularities to the attending physician and the DON, and that these reports must be acted upon; it also stated that the pharmacy consultant will do a monthly review of the MAR to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals. During interview, the DON confirmed that there was no evidence that the MRRs for those months had been conducted.
Expired Vaccines and Unlocked Medication Cart
Penalty
Summary
Drugs and biologicals were not maintained within their expiration dates in the facility’s medication storage area. During observation, Unit B’s medication room contained five COVID-19 vaccinations in the freezer with an expiration date that had passed. The facility policy titled "Storage of Medications" states that unused medications are to be inspected by the pharmacist consultant for discontinued, outdated, defective, or deteriorated medications. During interview, the RN Unit Manager for B wing confirmed the items were ready for use and expired. The facility also failed to secure a medication treatment cart. During observation, the medication treatment cart at the nursing station was unlocked while two residents were present at the station, including one who self-propelled via wheelchair and one who walked with a rolling walker. Nursing staff later left the nursing station, and no staff were observed interacting with the cart. Medications observed in the cart included wound wash, nystatin, and medicated hemorrhoid cream. An LPN later confirmed the cart contained medications and stated it should be locked, then locked the cart. Facility policies stated that all drugs and biologicals must be stored in locked compartments and that the medication cart must be kept closed and locked when out of sight of the medication nurse or aide.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention measures for hand hygiene during medication administration for one of four residents in the sample, Resident #24. During observation on 1/27/26 at 8:37 AM, an LPN administered medications to Resident #24 without performing hand hygiene before or after the medication pass, then returned to the medication cart and continued administering medications with unwashed hands. During interview at approximately 8:45 AM, the LPN confirmed that hand hygiene was not performed before or after medication administration. Record review of the facility’s Administering Oral Medications policy stated to wash hands prior to administration and perform hand antisepsis after administration. This was identified as a repeat deficiency, with the same violation cited during a previous partial survey dated 4/25/25.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure of Medical Director to Implement and Coordinate Resident Care Policies
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled the duties outlined in the Medical Director Agreement and facility policy, specifically regarding the implementation of resident care policies and coordination of medical care. The Medical Director had not reviewed or participated in the development or revision of facility policies and procedures, including those related to diabetes management, and was unaware of key documents such as the Facility Assessment. The Medical Director also had not participated in or developed staff training or educational programs since assuming the role, and had not attended or reviewed materials from QAPI meetings, nor was he aware of the facility's outstanding citations or the extent of medication administration issues. Two residents with insulin-dependent diabetes were admitted without appropriate admission orders for insulin or blood sugar checks, as indicated in their discharge orders, and did not have care plans for diabetes management until several days after admission. There was no evidence that these residents received insulin or had their blood sugars checked in a timely manner, and one resident experienced acute hyperglycemia requiring emergency room care. Providers involved in the residents' care reported a lack of collaboration and communication with the Medical Director, and were not aware of the residents' prior medical history or the facility's protocols for diabetes management. Interviews with facility staff and contracted providers revealed that there was minimal to no collaboration with the Medical Director regarding resident care. The Medical Director was not aware of significant issues such as undrawn laboratory orders, insufficient staffing, and extensive delays or missed medication administration. The lack of oversight and coordination extended to the QAPI program, with the Medical Director not participating in meetings or reviewing relevant reports. These failures resulted in repeat deficiencies and were cited at the immediate jeopardy level.
Failure to Maintain Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide a sufficient number of Licensed Nursing Assistants (LNAs) and Registered Nurses (RNs) to meet the needs of its residents, as required by regulations and the facility's own assessment. The Assistant Director of Nursing (ADON) reported frequently working overtime to provide RN coverage and being one of only two staff members trained to draw blood, resulting in 30 outstanding lab orders that had not been processed over a two-week period. Record reviews revealed extensive missed and late medication administrations, with 2,177 pages of missed medications and treatments and 6,017 pages of late administered medications and treatments. The Director of Nursing (DON) confirmed that these medications and treatments were not administered according to prescriber orders or facility policy. A traveling LPN reported that medication passes were consistently late due to insufficient staffing and frequent interruptions to assist residents. The facility's Hours Per Patient Day (PPD) report showed that staffing levels were below the minimum required for both LNAs and overall direct care for 6 out of 10 sampled weeks. The Administrator stated that requests for additional staff from corporate were unsuccessful, as the internal agency staffing group could not provide RN staff and the company would only use this internal agency. This deficiency was noted as a repeat issue from a previous recertification survey.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as required by regulation. Review of staffing schedules revealed that on eight specific days, no RN was scheduled or present in the building, and on ten additional days, there were not 8 consecutive hours of RN coverage. This deficiency was confirmed by the facility Administrator during an interview, who acknowledged that the required RN coverage was not met on these 18 days. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Widespread Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not administering all prescribed medications and treatments in a timely manner, as required by physician orders and facility policy. One resident with insulin-dependent diabetes mellitus was discharged from the hospital with orders for daily insulin glargine and blood glucose monitoring, but upon review, there were no active orders or documentation in the electronic medical record for insulin administration or finger stick blood sugar checks. The nurse responsible for admitting the resident stated she remembered entering the orders, but they were not present in the system, resulting in the resident not receiving critical diabetes management. A comprehensive review of the facility's missed and late medication reports revealed widespread issues, with thousands of pages documenting missed and late administration of various medications and treatments for multiple residents. These included essential medications for conditions such as pain, diabetes, anticoagulation, schizophrenia, anxiety, asthma, hypertension, seizures, depression, and more. Additionally, required treatments and assessments such as wound care, vital sign monitoring, and diabetic foot checks were not completed as ordered. The DON confirmed that these medications and treatments were not administered according to prescriber orders or facility policy, and the Medical Director was unaware of the extent of the missed and late administrations.
Failure to Provide Timely Laboratory Services and Results
Penalty
Summary
The facility failed to maintain a functioning system for obtaining and processing laboratory services, impacting multiple residents. For one resident with diabetes, a history of falls, and a pressure ulcer, laboratory orders were not completed as intended, and critical results such as A1c values were missing from the medical record. The resident was later sent to the emergency department with acute hyperglycemia and infection, and the provider was unaware that insulin had been discontinued. The nurse practitioner who ordered labs was not informed that the orders had been struck out and reported ongoing issues with receiving lab results, despite ordering a significant number of tests. Other residents also experienced delays or failures in laboratory testing. Several lab orders for multiple residents were not drawn or processed, with no documentation that providers were notified of the outstanding labs. In one case, a resident on clozapine had an active order for monthly CBCs, but there was no evidence these were completed. Staff interviews confirmed that there were 30 outstanding lab orders over a two-week period, and the facility lacked a process to ensure timely collection and communication of lab results. The facility's internal tracking system for labs was only accessible by one staff member, who was unavailable, leaving the facility without access to necessary information. Providers reported having to repeatedly reorder labs and follow up with staff to obtain results, often finding that labs were not performed or results were not documented. The facility's policy required nursing staff to coordinate, review, and document lab results, but interviews with leadership confirmed the absence of a process to ensure timely lab services and result documentation.
Administrative Failures Lead to Immediate Jeopardy and Repeat Deficiencies
Penalty
Summary
The facility failed to administer its operations in a manner that ensured the effective and efficient use of resources, resulting in multiple deficiencies that directly impacted resident care and safety. Leadership actions and decisions led to immediate jeopardy findings, including neglect and lack of administrative oversight. Specifically, a resident with a long-standing diagnosis of Diabetes Mellitus did not receive insulin despite being a chronic user, as documented in hospital discharge summaries and confirmed by the resident's son. The facility also failed to ensure the presence of a Registered Nurse for at least 8 consecutive hours daily over an 18-day period, and there were significant issues with medication administration, as evidenced by thousands of pages of missed and late medication reports. Additionally, 30 outstanding lab orders were not processed, and there was no documentation that providers were notified of these missed labs. Interviews revealed that the DON was frequently required to cover nursing shifts due to staffing shortages, preventing her from fulfilling her administrative duties. The DON reported being placed in the role despite being a relatively new nurse and not wanting the position, and both the DON and Administrator acknowledged that staffing shortages were impacting resident care. During an offsite review, facility leadership was unavailable to answer questions or provide information regarding a resident's care history, and there was a delay in responding to surveyor inquiries. Multiple repeat deficiencies were noted, including issues with care planning, abuse, accidents, supervision, and medical director oversight.
Failure to Implement Comprehensive QAPI Program and Oversight
Penalty
Summary
The facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed all systems of care, resulting in multiple deficiencies across several regulatory areas. Deficiencies included failure to ensure required regulatory visits, maintain appropriate staffing levels including an RN on-site for 8 consecutive hours daily, provide physician supervision and timely laboratory orders, and prevent neglect and administrative oversight failures, including those involving the Medical Director. These issues were identified through record review and interviews, with findings showing that the QAPI program did not systematically identify or address problems and opportunities for improvement in these critical areas. During several complaint and recertification surveys, the facility was cited for repeat and immediate jeopardy-level deficiencies, including those related to comprehensive care planning, abuse, accidents and hazards, insufficient nursing staff, failure to notify providers of lab results, and lack of administrative oversight by the Medical Director. Interviews revealed that the Medical Director had not participated in QAPI meetings or reviewed relevant reports and plans of correction, and the Administrator confirmed that the QAPI team was only working on select issues. The lack of effective QAPI oversight and engagement from key leadership contributed to the ongoing and repeated deficiencies.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report two separate allegations of abuse involving residents to the State Survey Agency. In the first instance, a provider reported an allegation of staff abuse involving a resident to the DON by phone, but the DON did not receive specific details and did not believe it was necessary to report the allegation to the State agency. The incident was only reported after the survey team brought it to the facility's attention. In the second case, a resident informed a provider of an allegation that a CNA had slapped them in the face. The Administrator stated that the allegation was reported to the State, but there was no evidence in the State's complaint system or facility records to confirm that the report was received. Interviews with the State's Complaint Coordinator and review of documentation confirmed the absence of a received report.
Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for multiple residents, resulting in a lack of clear instructions for providing effective and person-centered care. For several residents, including those with complex medical histories such as diabetes, pressure ulcers, recent falls, and amputations, the baseline care plans did not address critical areas such as fall risk, diabetes management, skin care, activities of daily living (ADLs), and personal preferences. In some cases, the care plans were either missing entirely or lacked essential information needed for staff to provide appropriate care. One resident with a history of diabetes, pressure ulcers, and repeated falls was admitted without a baseline care plan addressing these conditions. Despite documentation from previous providers indicating the need for ongoing diabetes management and skin care, the facility did not include these in the resident's care plan. Communication breakdowns between medical providers and facility staff further contributed to the lack of clear care instructions, as decisions regarding medication management were not properly documented or shared. This resident subsequently experienced an emergency department visit for hyperglycemia and cellulitis, as well as an unwitnessed fall, while still lacking appropriate care plans for their conditions. Other residents admitted after hospitalizations for falls, amputations, or with multiple comorbidities also did not have timely or comprehensive baseline care plans. These omissions included failure to document ADL assistance, therapy goals, personal preferences, and care needs related to communication, behavioral symptoms, dental care, and psychotropic medication use. Interviews with facility leadership confirmed that baseline care plans were not developed or implemented within the required timeframe and did not contain the necessary information to guide staff in providing proper care.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in deficiencies related to the management of diabetes, pressure ulcers, falls, and other care needs. For one resident with type 2 diabetes, diabetic neuropathy, an unstageable pressure ulcer, and a history of repeated falls, there was no documented care plan for diabetes management, pressure ulcer prevention/treatment, or fall prevention within the required timeframe after admission. Despite clear documentation of the resident's medical history and risk factors, care plans for these critical areas were delayed by several weeks. Communication breakdowns among providers and lack of clear protocols contributed to the absence of timely and appropriate care planning, as confirmed by interviews with the medical director, nurse practitioner, and nursing staff. Another resident admitted after a fall and hospitalization with a diagnosis of chronic insulin-dependent diabetes mellitus did not have a baseline care plan addressing diabetes management upon admission. The comprehensive care plan for diabetes was not developed until nearly two weeks after the resident's admission, despite the diagnosis being clearly documented in the hospital discharge information and MDS assessment. The DON confirmed the absence of a baseline care plan for diabetes for this resident. A third resident, admitted after a recent hospital stay, had multiple care needs identified in the MDS, including communication, behavioral symptoms, activities, dental care, and psychotropic drug use. Although the facility's MDS Care Area Assessment indicated that care plans would be developed for these areas, the resident's care plan did not address them. The DON confirmed that the care plans for these identified needs were not created as documented.
Failure to Timely Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update comprehensive care plans in a timely manner for six of fourteen sampled residents. Record reviews showed that for each of these residents, the care plan review due dates and target completion dates had passed without the care plans being updated. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plans had not been updated by their respective due dates. The deficiency was identified through both record review and staff interview, with specific dates of missed updates documented for each affected resident. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Notify Providers of Outstanding and Completed Lab Results
Penalty
Summary
The facility failed to notify ordering practitioners when laboratory tests were not performed and did not promptly communicate laboratory results to providers for multiple residents. For one resident with diabetes, a comprehensive set of labs was ordered, but the A1c result was missing from the medical record and not communicated to the provider, despite being significantly elevated. The provider was not made aware of this critical result until several weeks later. Additionally, there were multiple instances where laboratory orders for other residents were not drawn or collected, and there was no documentation that providers were notified of these outstanding labs. Interviews with providers and facility staff revealed ongoing issues with the facility's process for obtaining, documenting, and communicating laboratory results. Providers reported frequent difficulties in accessing lab results, with some stating they had to repeatedly request the same labs or directly contact the facility to obtain results. The Assistant Director of Nursing confirmed that numerous lab orders remained outstanding without provider notification, and providers expressed concern about the lack of a structured system for managing laboratory information in the electronic medical record.
Failure to Provide Timely Pressure Ulcer Care and Diabetes Management
Penalty
Summary
The facility failed to provide safe and effective skin and wound care in accordance with facility policy and professional standards for a resident admitted with an unstageable pressure ulcer. Upon admission, the resident had a history of type 2 diabetes with diabetic neuropathy, an unstageable pressure ulcer to the right heel, and repeated falls. Despite these conditions, the baseline care plan did not address pressure ulcer treatment, prevention, or diabetes management. The Minimum Data Set (MDS) assessment triggered the need for care planning related to pressure ulcers, but a comprehensive care plan and physician orders for pressure ulcer management were not implemented until several weeks after admission. There was also no documentation of the resident's heel pressure ulcer or related skin assessments until a wound evaluation was completed weeks later, which noted a right heel blister present on admission and signs of infection. During the period from admission until the care plan was established, there was no evidence that a physician supervised the care of the resident's pressure ulcer, despite multiple provider visits. A nurse practitioner confirmed that a care plan for pressure ulcers should have been in place upon admission. The resident was eventually sent to the emergency department due to right leg edema, where they were found to have a stage 2 right foot ulcer, cellulitis requiring antibiotics, and acute hyperglycemia. The emergency department physician noted that the resident was not receiving prescribed insulin, and blood glucose was elevated. The nurse practitioner at the facility was unaware that insulin was not currently prescribed.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement relevant, consistent, and individualized interventions to prevent falls for a resident identified as being at risk. The resident was admitted with multiple diagnoses, including type 2 diabetes with diabetic neuropathy, dementia, a history of repeated falls, muscle weakness, hearing loss, knee pain, and constipation. Upon admission, a fall assessment indicated a high risk for falls, with a score of 10, and identified several risk factors such as prior falls, incontinence, visual impairment, impaired mobility, environmental hazards, polypharmacy, pain, and cognitive impairment. Despite these findings, the resident's baseline care plan did not address fall risk or include interventions to prevent falls as identified in the assessment. Further documentation showed that the comprehensive care plan created prior to a care plan meeting did not address fall risks, prevention, or interventions, even though the resident had a recent fall prior to admission and this was noted in the MDS and CAA triggers. The lack of a fall prevention care plan persisted until after the resident experienced an unwitnessed fall in the facility. The care plan to prevent falls was not implemented until the day after this incident, confirming that the facility did not provide adequate supervision or individualized interventions to prevent accidents for this resident.
Failure to Obtain Physician Order and Oversight at Admission
Penalty
Summary
A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring the resident was under a physician's care. The facility failed to secure the necessary medical authorization and oversight from a physician at the time of admission, as required by regulations. This lapse was directly observed and documented by surveyors during their review of the resident's admission process.
Failure to Complete Timely Physician Visit for Resident
Penalty
Summary
The facility failed to ensure that all required regulatory provider visits were completed for one resident. Record review showed that the resident, who was admitted with multiple complex diagnoses including unspecified atrial fibrillation, hypokalemia, acute on chronic diastolic heart failure, hypomagnesemia, urinary tract infection, sepsis, COPD, OSA, major depressive disorder with psychotic features, an open wound of the lower back and pelvis, presence of a prosthetic heart valve, severe sepsis without septic shock, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen, did not receive the required physician onsite visit within 30 days of admission. Practitioner notes indicated that the first physician visit occurred later than the regulatory timeframe. This was confirmed during an interview with the current DON, who acknowledged that the required 30-day physician visit did not occur.
Failure to Prevent Neglect and Respond to Critical Hyperglycemia
Penalty
Summary
A resident with a history of diabetes mellitus, hyperglycemia, and a prior pancreatectomy experienced a critical episode of elevated blood sugar while under the care of facility staff. The resident utilized a Dexcom continuous glucose monitor, which indicated a blood sugar reading above 400 mg/dL. Despite repeatedly informing the assigned LPN of the dangerously high glucose readings and associated symptoms such as headache, blurry vision, nausea, and mental confusion, the LPN initially refused to check the resident's blood sugar outside of scheduled times and dismissed the resident's concerns, instructing them to "go sleep it off." The resident continued to request assistance, including asking for a blood sugar check and for the physician to be contacted for insulin orders. The LPN eventually checked the blood sugar, which was found to be in the high 300s, but still did not contact the physician, provide insulin, or initiate further interventions. The LPN also refused to facilitate a transfer to the hospital, stating there were no orders for insulin or glucose checks after a certain time. The resident, after consulting with their representative, called 911 independently. Emergency Medical Technicians (EMTs) responded, confirmed the resident's symptoms and high glucose readings, and transported the resident to the emergency department, where a blood sugar of 563 mg/dL was documented and immediate treatment was provided. Facility leadership later confirmed that the LPN did not follow professional standards or facility policy, as there was no documentation of a change in condition, no physician notification, and no transfer documentation provided to the EMTs. Additionally, upon the resident's return from the hospital, new physician orders and discharge instructions were not entered into the medical record or implemented, and there was no documentation that the resident's physician was notified of the emergency event or the new orders.
Failure to Provide Timely and Appropriate Care for Severe Hyperglycemia
Penalty
Summary
A resident with a history of diabetes mellitus due to pancreatectomy, and prior episodes of hyperglycemic-hyperosmolar coma, experienced a critical episode of hyperglycemia while under the care of facility staff. The resident, who uses a Dexcom continuous glucose monitor, reported a blood sugar reading exceeding 400 mg/dL to the assigned LPN during the evening. Despite repeated requests from the resident to have their blood sugar checked and to be sent to the emergency room, the LPN initially refused to check the blood sugar outside of scheduled times and dismissed the resident's concerns, instructing them to 'go sleep it off.' After persistent requests, the LPN checked the blood sugar, found it to be in the high 300s, but still refused to contact a physician or arrange for emergency care. The resident, experiencing symptoms such as headaches, blurry vision, nausea, and mental confusion, contacted their representative, who advised calling 911. Emergency medical technicians responded, found the resident's blood sugar to be 563 mg/dL, and transported the resident to the emergency department. The LPN did not provide the EMTs with any transfer documentation, including medical history, medication lists, or recent medication administration records, and stated that since the facility did not initiate the transfer, no paperwork would be provided. Upon arrival at the hospital, the resident was treated for severe hyperglycemia and received discharge instructions and new physician orders for regular glucose monitoring and as-needed insulin administration. Upon the resident's return to the facility, the EMT hand-delivered the hospital discharge instructions and new physician orders to the same LPN. However, the LPN failed to document the emergency department visit, did not enter or implement the new physician orders, and did not notify the resident's physician of the incident or the elevated blood sugar levels. The facility administration later confirmed that no documentation or discharge information was present in the resident's medical record following the incident, and that required notifications and documentation were not completed.
Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
The facility failed to prevent a resident from self-administering medication despite explicit physician orders prohibiting this practice. Physician orders dated 4/14/25 specified that the resident was not permitted to self-administer medications. However, during observation and interview, the resident was found in possession of Zenpep Oral Capsule Delayed Release Particles and reported taking the medication independently whenever about to eat, without notifying nursing staff or documenting the administration. The resident also stated that this was the only medication kept personally, while all others were managed by nursing staff. Review of the Medication Administration Record (MAR) for May 2025 showed no documentation of the as-needed (PRN) doses of Zenpep from the start date through the date of the survey, despite an order for a maximum of 21 capsules per day. Facility staff, including the Administrator, Regional Director of Nursing, and President of Operations, confirmed that the resident was not supposed to self-administer Zenpep and acknowledged that the MAR did not accurately reflect the actual administration of the medication.
Failure to Provide Required Transfer Documentation and Bed-Hold Notification
Penalty
Summary
A resident with a history of diabetes mellitus, hyperglycemia, and a pancreatectomy experienced a significant increase in blood glucose levels, as indicated by their Dexcom device. The resident reported a blood sugar reading above 400 mg/dL to the assigned LPN during the evening, but was told that blood sugar checks were only scheduled before meals and not after 5:00 PM. Despite repeated requests, the LPN initially refused to check the resident's blood sugar, eventually relenting after multiple requests and confirming a high reading in the 300s. The resident, feeling their concerns were not addressed, contacted their representative and subsequently called 911 for emergency assistance. When EMTs arrived, they requested standard transfer documentation from the LPN, including the resident's medical history, current medications, allergies, and recent medication administration records. The LPN declined to provide any documentation, stating that the facility was not responsible for the transfer since the resident initiated the 911 call. The EMTs transported the resident to the emergency department, where a blood glucose reading of 563 mg/dL was recorded and the resident received treatment for severe hyperglycemia. The emergency department provided discharge instructions and new physician orders, which were hand-delivered to the LPN upon the resident's return to the facility. Upon review, there was no documentation in the resident's medical record regarding the transfer to the hospital, the information provided to the EMTs, or the receipt and implementation of new physician orders from the hospital. The facility also failed to provide the required written information to the resident or their representative regarding the facility's bed-hold policy prior to the transfer. Additionally, there was no evidence that the resident's physician was notified of the change in condition or the hospital visit, and no documentation of actions taken by the DON or LPN upon the resident's return.
Failure to Secure and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were safely stored and accessible only by authorized personnel. Physician orders and the Medication Administration Record indicated that a resident was prescribed Zenpep Oral Capsule Delayed Release Particles, with specific instructions for administration before meals and as needed with snacks. During an observation and interview, the resident was found to be in possession of multiple Zenpep capsules in a clear plastic medicine cup and reported self-administering the medication without notifying nursing staff or adhering to the prescribed schedule. Facility staff confirmed that the resident should not have had access to the medication and that nursing failed to ensure proper storage and administration as ordered.
Failure of Medical Director to Implement COVID-19 Policies and Coordinate Care
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled responsibilities related to the implementation of resident care policies and coordination of medical care, specifically regarding the management of a COVID-19 outbreak. During the outbreak, 12 residents tested positive for COVID-19 over a specified period, though there were no deaths or hospitalizations. Multiple staff interviews revealed that the Medical Director, through the DON, directed staff to stop testing residents and staff for COVID-19 and to remove all precaution carts, which were previously used for infection control. Staff reported that these directives were communicated by the DON but originated from the Medical Director, who did not adhere to the facility's COVID-19 policies. Further interviews with facility leadership, including the VP of Operations, Administrator, and DON, confirmed that the Medical Director instructed the cessation of COVID-19 testing and removal of precautions, and that these actions were not in line with established facility policy. The VP of Operations also stated that the Medical Director did not believe in COVID-19 and directed staff to treat symptoms as if they were a common cold. Documentation provided by the facility confirmed that the Medical Director was made aware of job duties and expectations, but the deficiency occurred due to the Medical Director's failure to follow facility policy during the outbreak.
Failure to Maintain Infection Prevention and Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by delayed and incomplete reporting of a COVID-19 outbreak to the state health department. Documentation shows that 12 residents tested positive for COVID-19 over a two-week period, but the facility did not notify the health department until nearly two weeks after the first case. When the line listing was eventually submitted, it included only residents and omitted staff members who had tested positive, despite explicit instructions from the health department to include both residents and staff. Interviews with facility leadership confirmed the delay in reporting and the omission of staff cases, and no written evidence was provided to support the facility's claim that staff cases did not need to be reported unless there were three or more. Additionally, the facility did not follow its own infection prevention and control policy regarding COVID-19. The policy required active monitoring of all residents for symptoms, prompt initiation of transmission-based precautions, and testing for SARS-CoV-2 in symptomatic individuals. However, multiple staff interviews revealed that, during the outbreak, the DON—reportedly following the medical director's direction—instructed staff to stop all COVID-19 testing for both residents and staff. Precautions were discontinued abruptly, and all symptoms were treated as common colds. Staff also reported that N95 masks were removed from use on the floors, and that the medical director did not believe in the necessity of COVID-19 precautions. These actions and inactions resulted in the facility failing to maintain a safe, sanitary, and comfortable environment, and not adhering to both regulatory requirements and its own policies for infection prevention and control. The failure to report cases accurately and to implement appropriate infection control measures had the potential to impact all residents and staff during the outbreak.
Lack of Qualified Infection Preventionist
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. The Director of Nursing (DON) was temporarily fulfilling the role of IP while also working toward completion of the CDC Infection Prevention and Control certification, but had not yet obtained this qualification. The corporate DON was providing oversight of the infection prevention program once per week. Documentation provided by the Administrator showed that the corporate DON had only visited the facility on two occasions since the IP position became vacant. These actions resulted in the facility not having a qualified, designated IP as required.
Failure to Provide Adequate Supervision and Timely Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible by not providing adequate supervision and not implementing effective, timely interventions to reduce the likelihood of future falls for two residents. One resident, with a history of falls, impaired mobility, Alzheimer's disease, and other conditions, experienced multiple unwitnessed falls over a period of time. After a fall resulting in a hip fracture that required surgery, the resident's care plan was not revised promptly, and interventions added were either delayed or duplicative, with no new measures to increase supervision. The resident's spouse reported concerns about insufficient staff checks and ongoing pain following the fall. Another resident, also at risk for falls due to cognitive loss, impaired mobility, Parkinson's disease, and other factors, experienced several unwitnessed falls, including one that resulted in a skin tear. The care plan for this resident was not updated following several of these incidents, and the facility could not provide evidence of timely or effective interventions after the falls occurred. Facility policy required post-fall interventions to be implemented and documented according to individual risk factors, but did not specify a timeframe for care plan updates. Interviews with facility leadership indicated that care plan interventions should be immediate or within 24 hours, but documentation showed that this expectation was not met for either resident. The facility was unable to produce evidence of timely, effective care plan interventions following multiple falls for both residents.
Incomplete and Inaccessible Medical Records During Ownership Transition
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for all residents during a change of ownership. The Medical Director confirmed that access to electronic resident medical records was unavailable for several days following the transition. Record review showed that there was no electronic or written documentation for two residents over a four-day period, including medication and treatment administration records, licensed professional notes, diagnostic service reports, and resident assessments. Interviews with the Chief Nursing Officer and Facility Administrator confirmed a gap in access and storage of resident records during the transition, with staff recording information in the previous owner's electronic system, which was no longer accessible to facility staff. The facility was unable to provide the missing documentation within 24 hours to the survey team.
Delayed Medication Administration Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide a sufficient number of licensed nurses, nurse aides, and other nursing personnel to meet the needs of all residents, resulting in delayed medication administration. According to the facility's policy, medications are to be administered within one hour before or after the prescribed time. However, review of medication administration records revealed that one resident received 52 medications outside of this window over a ten-day period, including medications for anxiety, seizures, stroke prevention, depression, respiratory issues, and vitamin supplementation. Interviews with LPNs confirmed that medications were often late due to competing care responsibilities and insufficient staffing during medication administration times. Another resident reported frequent delays in receiving medications, sometimes up to nearly five hours late. Record review confirmed multiple instances where muscle relaxants, pain medications, and bowel medications were administered several hours after the scheduled time. Staff interviews further corroborated that short staffing, particularly on weekends and night shifts, contributed to these delays. The Director of Nursing acknowledged that the late administration of medications was due to high resident acuity and inadequate nursing staff to meet residents' needs.
Failure to Supervise Resident with Dementia Resulting in Repeated Wandering and Resident Distress
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent accidents and incidents involving a resident with severe cognitive impairment and a history of wandering. The resident, diagnosed with Alzheimer's dementia and assessed with a BIMS score indicating severe cognitive impairment, was care planned for supervision during ambulation and for staff to visually monitor to prevent wandering into other residents' rooms. Despite these interventions, multiple residents reported that the resident entered their rooms without permission, sometimes climbing into their beds, grabbing them, or holding objects such as a fork, causing distress and fear. Progress notes documented repeated incidents of the resident wandering into other rooms, taking items, sitting on other residents' beds, and even physically striking another resident in the hallway. Direct observations during the survey confirmed that the resident was frequently unsupervised while wandering the halls and entering other residents' rooms and staff offices. Staff were present in the area at times but did not consistently supervise or redirect the resident, allowing the resident to access other residents' personal spaces and staff areas, handle items on the medication cart, and interact with equipment and documents without intervention. These actions and inactions by facility staff resulted in a failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents and incidents.
Failure to Provide Behavioral Health Services to Residents with Mental Disorders
Penalty
Summary
The facility failed to provide appropriate behavioral health treatment and services to multiple residents diagnosed with mental disorders, psychosocial adjustment difficulties, or a history of trauma and post-traumatic stress disorder. Several residents, including those with histories of verbal and physical outbursts, resident-to-resident altercations, and significant psychiatric diagnoses such as major depressive disorder, generalized anxiety disorder, schizophrenia, bipolar disorder, and PTSD, were identified as requiring ongoing psychiatric and behavioral health interventions. Despite care plans and psychiatric evaluations indicating the need for continued behavioral health services, these services ceased when psychiatric providers stopped attending the facility. Following the discontinuation of psychiatric services, the facility reported that talk therapy was being provided by a qualified individual. However, record reviews and staff interviews confirmed that there was no documentation of such therapy being conducted for any of the affected residents. This lack of documented behavioral health interventions persisted for at least two months after the cessation of psychiatric services, during which time residents continued to display behavioral symptoms and reported incidents of altercations and feeling unsafe. Interviews with facility leadership, including the Clinical Market Lead and the Director of Nursing, confirmed the absence of psychiatric services and the lack of alternative behavioral health interventions for the residents in question. The facility acknowledged barriers to implementing comprehensive care plans, specifically citing a lack of resources and support, and was unable to provide evidence that residents received the necessary treatment and services to attain their highest practicable mental and psychosocial well-being.
Failure to Accurately Document and Implement Advance Directives
Penalty
Summary
A deficiency occurred when a resident's advance directives, which clearly stated a desire to forgo CPR, mechanical ventilation, and feeding tubes, were not accurately reflected in the facility's documentation and physician orders. The resident's advance directive was on file and the resident personally confirmed these wishes during an interview, even showing a DNR bracelet from a recent hospitalization. Despite this, the care plan only generically referenced the existence of an advance directive, while both the physician's order and the electronic chart dashboard incorrectly listed the resident as Full Code. Nursing staff reported relying on the dashboard for code status information, and the DON confirmed that the physician's order did not match the resident's documented wishes. This discrepancy between the resident's expressed and documented preferences and the orders available to staff resulted in a failure to ensure the resident's choices regarding life-sustaining treatment were properly documented, ordered, and care planned.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
A deficiency was identified when a resident did not receive scheduled showers according to their care plan and personal preference. The resident's care plan, last revised in November 2024, specified a preference for showers and required that they be offered on Tuesdays and Fridays, with the use of a bath bench and one staff assist. Documentation review for November and December 2024 showed that out of eight scheduled shower days in November, the resident received only two showers, and no showers were documented for the first ten days of December. The care plan also included instructions for documenting refusals of care, but only one refusal was recorded during this period, with no evidence that the other missed showers were refused by the resident. An interview with an LNA familiar with the resident revealed that it was often challenging to provide scheduled showers due to understaffing and workload stress. The LNA reported that some residents preferred multiple showers per week or even daily showers, but these preferences could not be accommodated because of staffing limitations. The lack of documentation for both provided showers and refusals indicates that the resident's care plan and preferences were not consistently followed.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident admitted for short-term rehabilitation with multiple diagnoses, including type 2 diabetes with neuropathy, cerebral infarction, muscle weakness, and partial paralysis, was identified as being at risk for skin breakdown due to decreased activity and limited mobility. The resident's care plan included interventions such as assistance with turning and repositioning, daily diabetic foot checks, and observation for skin breakdown. Despite these interventions being documented in the care plan and physician orders, the resident reported that staff were not consistently assisting with repositioning or performing daily foot checks. The Treatment Administration Record confirmed that diabetic foot checks were not completed on at least one occasion and were discontinued shortly thereafter. The resident developed a wound on the foot, which was discovered after staff noticed blood on the bed sheets. Initial assessments upon admission documented no skin issues, but a change in condition form later noted a blister/skin tear, which was subsequently identified as an in-house acquired pressure ulcer. Nursing staff confirmed that the ulcer likely developed due to pressure from the resident's foot pressing against the bed's footboard when sliding down in bed. Observations during a dressing change revealed an open wound with red tissue and drainage, consistent with a stage 2 pressure ulcer as defined by CMS guidelines.
Delay in Obtaining Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered by a physician for one resident. The resident, who had diagnoses of anemia and end-stage chronic kidney disease, experienced a fall and was evaluated by an on-call provider, who ordered a basic metabolic panel (BMP), complete blood count (CBC), and prothrombin time/international normalized ratio (PT/INR) on 12/1/2024. However, the resident's blood sample was not received by the laboratory until 12/6/2024, resulting in a five-day delay in obtaining the ordered tests. The lab report from that date showed critical values, including low hemoglobin. The delay in obtaining the laboratory tests was confirmed by both the Clinical Market Consultant and the Administrator during interviews.
Misappropriation of Resident Funds by LNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal funds. A resident with multiple medical conditions, including Atrial Fibrillation, Cellulitis, Hypothyroidism, and Metabolic Encephalopathy, gave $400 to a Licensed Nursing Assistant (LNA) to fix a vehicle. Initially, the LNA declined the money, but upon a second offer, accepted the $400 from the resident. This incident was reported to Adult Protective Services and the local police department. The facility's internal investigation confirmed that the LNA accepted the money, which constituted a misappropriation of the resident's property. The facility's administrator and other staff members acknowledged that the resident was not adequately protected from this financial exploitation. The deficiency was identified through record reviews and interviews conducted during the survey process.
Failure to Report Misappropriation of Resident's Property
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the misappropriation of a resident's property. A resident gave $400 to a Licensed Nursing Assistant (LNA) to fix her vehicle, which was initially declined but later accepted by the LNA. This incident was overheard by a Unit Manager and subsequently reported to Adult Protective Services (APS) and the state agency. However, the report indicates that the involved LNAs did not report the misappropriation immediately or within the required 24-hour timeframe. The facility's policy mandates immediate reporting of suspected abuse, neglect, or misappropriation of property to a supervisor, who must then notify the Administrator and other officials as per state law. Despite this policy, the LNAs involved did not adhere to these procedures, leading to a delay in reporting the incident. The facility's internal investigation confirmed the acceptance of money by the LNA and the failure of other staff members to report the incident promptly, highlighting a lapse in following established protocols for reporting suspected criminal activity.
Failure to Complete PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a resident admitted with mental disorders was properly screened prior to admission, as required by the Pre-Admission Screening and Resident Review (PASRR) process. The resident, who was admitted with diagnoses of major depressive disorder and an unspecified mental disorder, was prescribed an antipsychotic medication, Lurasidone, prior to and during their stay at the facility. Despite these conditions, a Level 1 PASRR assessment was not completed by the discharging hospital, and the exemption reason was documented as the resident being unlikely to need admission for more than 30 days. However, the resident remained in the facility well beyond this period without the necessary assessment being conducted. During their stay, the resident expressed suicidal ideation on two occasions and eventually eloped from the facility, not returning for further care. A local mental health crisis screening revealed the resident had a history of serious suicide attempts and recent hospitalization for mental illness. The Market Operations Lead confirmed that the required Level 1 PASRR was not completed for the resident, which would have identified the need for specialized services. The lack of this assessment represents a significant oversight in the facility's admission process for residents with mental disorders.
Failure to Develop Timely Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed to meet the psychosocial needs of a resident diagnosed with major depressive disorder and unspecified mental disorder. The resident, who was prescribed the antipsychotic medication Lurasidone, expressed suicidal ideation to facility staff on two separate occasions. On the first occasion, the resident expressed a desire to 'kill themselves' and requested to go to the hospital. Despite this, there was no care plan focus or interventions developed for the resident's suicidal ideations until several days later. On the second occasion, the resident again expressed suicidal ideation and subsequently eloped from the facility, leading to their admission to the emergency department for psychiatric evaluation. The Director of Nursing confirmed that the care plan for the resident's suicidal ideations was not developed in a timely manner, failing to address their psychosocial needs promptly. This lack of timely intervention and care planning contributed to the deficiency identified by the surveyors.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation of property, specifically regarding medication. On 12/30/23, it was discovered that the facility was running low on Oxycodone for a resident, and the pharmacy could not refill the prescription as their records showed a 30-day supply had been delivered on 12/11/23. A review of the Controlled Substance Logbook revealed that an entry made by two LPNs on 12/11/23 was altered. Initially, 90 tablets were recorded, but this was overwritten to 120 tablets, with the remaining 60 tablets unaccounted for. An interview with one of the LPNs revealed that they had initially entered 90 tablets instead of the 180 received, and the discrepancy was not noticed by the second LPN, leading to the alteration. The facility reported the incident to the Board of Nursing due to suspicion of narcotic diversion by one of the LPNs, who was subsequently terminated.
Failure to Investigate LPN's Work History Leads to Deficiency
Penalty
Summary
The facility failed to implement its policy regarding the thorough investigation of the work history of prospective staff, leading to a deficiency. A Licensed Practical Nurse (LPN) was involved in an incident where 60 tablets of Oxycodone were unaccounted for. This LPN had previously been named as a person of interest in another facility for discrepancies in narcotic administrations and was terminated from employment as a result. Despite this history, the facility did not conduct a thorough background check, as required by their policy, which mandates screening potential employees for a history of abuse, neglect, or mistreatment of patients by obtaining information from previous employers and checking with appropriate licensing boards and registries. Interviews with facility staff revealed that the facility was unaware of the LPN's prior involvement with narcotics issues at another facility until the investigation into the current incident was initiated. The Clinical Marketing Advisor confirmed that the facility did not contact previous employers to determine if there were performance issues. Additionally, the Human Resources representative disclosed that the LPN had been terminated from two sister facilities for various reasons before being employed at the current facility. The Market Operations Advisor indicated that it was the responsibility of the agency placing the employee to check with prior employers for performance, but the facility did not follow their own policy in this regard.
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What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Johnsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines Rehab & Health Center | 4.8 mi | ★★★★★ | 2 | 0 |
| Greensboro Nursing Home | 16.4 mi | ★★★★★ | 10 | 0 |
| Union House Nursing Home | 18.2 mi | ★★★★★ | 11 | 0 |
| Lafayette Center | 19.5 mi | ★★★★★ | 0 | 0 |
| Morrison Nursing Home | 20.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.