The Villa Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Albans, Vermont.
- Location
- 7 Forest Hill Drive, St. Albans, Vermont 05478
- CMS Provider Number
- 475055
- Inspections on file
- 14
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at The Villa Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairment, Alzheimer’s disease, osteoarthritis, and muscle weakness, identified as at risk for falls and dependent on staff with a mechanical lift for transfers, experienced multiple falls in the room involving a wheelchair. After an initial fall with injury, the care plan was only updated to note the fall and to follow facility policy, and a later fall led to adding a vague "monitor closely" intervention without timeframes or clear staff responsibilities. No specific interventions were implemented to address wheelchair-related falls or self-transfer attempts, and supervision was not formally increased beyond 2‑hour checks. An LPN did not know how to access the care plan and confirmed the absence of targeted fall interventions, while the DON confirmed that IDT notes were not in the record and that a sleep hygiene assessment was not incorporated into the care plan. The resident ultimately sustained bilateral displaced ankle fractures after another fall.
Two residents with identified fall risk experienced multiple falls or near-falls, including incidents from wheelchairs, from bed, and onto the floor or fall mats, yet their care plans were not updated with specific fall-prevention interventions after these events. One resident with decreased mobility, pain issues, cognitive deficits, and prior lower extremity fractures had documented falls while attempting self-transfers from a wheelchair, but the care plan only noted monitoring and lacked new interventions. Another resident with bilateral lower extremity amputation, decreased mobility/balance, and a high fall-risk score had several incidents involving self-transfer attempts, floor and fall-mat findings, and skin tears, but no additional interventions were added to the care plan despite changes in monitoring and environment. An LPN reported not knowing how to access a care plan until shown, and the DON acknowledged that the care plans did not reflect the needed updates after these recurrent falls.
The facility failed to maintain safe handwashing water temperatures, with readings between 121.1 and 124.1 degrees Fahrenheit in common areas and resident rooms. These temperatures were confirmed by the Dietary Manager and LNHA, despite logs showing no temperatures above 119 degrees Fahrenheit.
The facility failed to maintain food safety standards by not documenting freezer and refrigerator temperatures properly, serving food at incorrect temperatures, and not discarding expired items. The Dietary and Housekeeping Manager confirmed these issues, indicating a lapse in food safety protocols.
The facility's 2024 assessment failed to specify necessary staff competencies for resident care. The LNHA confirmed that while staff are evaluated during orientation and annually, the assessment did not identify specific training or competencies needed. This deficiency could impact all 20 residents.
The facility failed to administer prescribed ophthalmic medications to two residents as ordered, with multiple instances of missed doses due to medication unavailability. Despite facility policy requiring physician notification for such occurrences, there was no documentation that the physicians were informed. This involved five different nurses, including the DON, who did not follow the protocol for notifying the provider about the missed medications.
The facility did not maintain an effective training program for behavioral health or trauma-informed care, as required by the facility assessment. Despite having residents with various mental health diagnoses, 4 LNAs and 3 RNs lacked documented training. The DON confirmed the absence of training records, and only one staff member attended a 2023 training session.
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. The grievance process posted in the entryway lacked details on anonymous submissions, and no grievance forms were available. Interviews with two residents revealed that grievances must be filed through the Social Services Department or the Administrator, with no anonymous option. The Administrator confirmed the absence of a process for anonymous grievance filing.
Failure to Revise Fall-Prevention Care Plan After Repeated Wheelchair Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and effective fall-prevention interventions for a cognitively impaired resident with Alzheimer’s disease, osteoarthritis of the knee, and muscle weakness, who was dependent on staff for ADLs and required a mechanical lift for transfers. Fall risk evaluations conducted on 12/30/25 and 1/13/26 identified the resident as at risk for falls. The facility’s fall policy required individualized fall-prevention strategies and ongoing monitoring and modification of interventions. The resident’s fall care plan included general interventions such as assessing for drugs that may cause falls, encouraging rest in bed when tired, involving the resident in activities as tolerated, and maintaining safety (call bell within reach, bed in lowest position, proper lighting, appropriate footwear). After a fall on [DATE] in which the resident was found on the floor with severe knee pain and sustained a head hematoma and large knee bruise, the only care plan update was to document the fall with injury and to “follow facility fall policy,” without adding specific new interventions. The resident experienced subsequent falls on 1/16/26, 2/5/26, and 2/8/26, all occurring in the resident’s room and involving the wheelchair, including one fall while attempting to self-transfer. After the 1/16/26 fall, the care plan was updated only to add “will monitor closely,” with no timeframes or clarification of staff responsibilities, and no new interventions were added after the 2/5/26 fall despite the emerging pattern of wheelchair-related falls. On 2/8/26, staff responded to the resident’s screams and found the resident on the floor in front of the wheelchair, in acute distress with right leg pain, leading to hospital evaluation and diagnosis of bilateral displaced severe ankle fractures. Interviews revealed that an LPN did not know how to access the resident’s care plan and confirmed there were no specific interventions to prevent falls from the wheelchair and no interventions added after the 1/16/26 or 2/5/26 falls. The DON confirmed that increased supervision was not implemented, the resident remained on 2‑hour checks without formal increase in supervision, IDT notes were not in the record, and the only additional intervention (a sleep hygiene assessment) was not reflected in the care plan.
Failure to Update Care Plans With Fall-Prevention Interventions After Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive care plans with appropriate fall-prevention interventions following recurrent falls for two residents. For Resident #1, the care plan dated 10/17/24 and revised 2/12/26 identified the resident as at risk for falls related to decreased mobility, pain issues, cognitive deficits, and recent falls, including a recent fall with several fractures in both lower extremities. A provider note dated 1/16/26 documented a fall without injury when the resident attempted to self-transfer and lost balance, and the care plan entry for that date only stated the resident fell out of the wheelchair in the bedroom and would be monitored closely. A subsequent health status note on 2/5/26 described staff hearing a thud and finding the resident on the floor in front of the wheelchair, denying head injury, with pain consistent with baseline and stable vital and neuro checks. Despite these recurrent falls from the wheelchair on 1/16/26 and 2/5/26, review of Resident #1’s care plan showed no added interventions specifically addressing prevention of falls from the wheelchair. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires measurable objectives, time frames, and documentation of alternative interventions as needed, as well as notification of qualified staff when changes are made. During interview, an LPN stated she did not know how to access the resident’s care plan until shown and confirmed there were no interventions implemented in the care plan to prevent the resident from falling from the wheelchair and no fall interventions added after the falls on 1/16/26 and 2/5/26. The DON confirmed that Resident #1’s care plan should have been updated with interventions for falls out of the wheelchair for those dates. For Resident #2, the care plan dated 8/27/25 and revised 1/23/26 identified the resident as at risk for falls related to bilateral left knee amputation, decreased mobility/balance, and a history of falls, with a fall risk assessment score of 17/32 indicating fall risk. An incident note dated 1/11/26 documented the resident found on the floor, covered in feces, sitting on the bottom with back against the wall near the wheelchair, unable to give a credible account of the fall, with the fall mat undisturbed; the care plan noted the resident was found on the floor after attempting to self-transfer with no injury. Another incident note on 1/23/26 documented the resident found on the floor mat beside the bed, and a 2/3/26 note described the resident found sitting on the fall mat after reporting a fall scenario, with no known injuries. A 2/1/26 note documented an attempted self-transfer from bed to get a remote, during which an LNA intervened to prevent a head-first fall, resulting in two skin tears treated and neurovitals within normal limits. Review of Resident #2’s care plan showed no additional documented interventions added for the falls that occurred on 1/11/26 and 1/23/26, and the DON confirmed that interventions such as room change, rehab referral, and frequent checks were not reflected in the care plan.
Unsafe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures. During observations, the hot water from a faucet in an unlocked, common area bathroom was found to be too hot to hold a hand under comfortably, with a thermometer reading of 124.1 degrees Fahrenheit. Further assessments revealed similar high temperatures in other common area sinks and resident rooms, with readings ranging from 121.1 to 123.4 degrees Fahrenheit. These temperatures were confirmed by the facility's Dietary Manager and the Licensed Nursing Home Administrator (LNHA), who maintained a water temperature monitoring log that did not document temperatures above 119 degrees Fahrenheit. However, rechecks of the water temperatures by the surveyor and the LNHA confirmed the elevated temperatures, indicating a discrepancy in the monitoring process.
Food Safety and Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper storage and temperature documentation of food items. Specifically, the facility did not document the temperatures of one out of three freezers and two out of three refrigerators. An abnormal temperature of -12 degrees Fahrenheit was recorded for the Meat Freezer without a documented month, and the Dietary and Housekeeping Manager was unable to confirm the month of the log. Additionally, the milk refrigerator and milk cooler had several recorded temperatures outside the facility's accepted range, with no documented corrective actions. Furthermore, the facility served food items to residents at temperatures below the facility's standards. Ground entrees were recorded at temperatures lower than the required 170 degrees Fahrenheit, and other entrees and vegetables were below the accepted 160 degrees Fahrenheit. Additionally, during a kitchen assessment, expired Magic Cup ice cream cups were found in one of the basement freezers, which should have been discarded but were not. These findings indicate a failure to maintain proper food safety protocols, potentially compromising the quality of care provided to residents.
Facility Assessment Lacks Specific Staff Competencies
Penalty
Summary
The facility failed to adequately address staff competencies in their facility-wide assessment, which is necessary to provide the level and types of care needed for the resident population. The 2024 Facility Assessment did not specify the competencies required to care for the residents, nor did it indicate which competencies would be evaluated. During an interview, the Licensed Nursing Home Administrator (LNHA) stated that licensed staff are evaluated for competency during orientation and annually, with additional training provided as needed. However, the LNHA confirmed that the facility assessment did not identify the specific training or competencies needed to provide care to the residents. This deficiency has the potential to affect all 20 residents residing in the facility.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice regarding physician orders and notification for two residents. Resident #6 had physician orders for Azithromycin Ophthalmic Solution to be administered twice daily for severe blepharitis, but the medication was not given as ordered seven times over nine days. Nursing notes indicated that the medication was unavailable and on order, but there was no documentation that the physician was notified about the missed doses. An RN confirmed that the protocol is to notify the provider if medication is unavailable, but this was not done. Similarly, Resident #17 had physician orders for Erythromycin Ophthalmic Ointment to be administered twice daily for blepharitis, but the medication was not administered as ordered nine times over eighteen days. Nursing notes again cited medication unavailability, but there was no documentation of physician notification. The DON confirmed that the facility's policy requires contacting the resident's provider for missed or unavailable medications, but this was not followed. The records showed that five different nurses, including the DON, failed to administer medications as ordered and did not notify the physician as required.
Deficiency in Behavioral Health Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program related to behavioral health or trauma-informed care and services, as determined by resident needs and the facility assessment. The 2024 Facility Assessment revealed that the facility had residents diagnosed with anxiety disorder, depression, manic depression, psychiatric disorder, and Post Traumatic Stress Disorder. However, a review of employee training and competency files showed that 4 Licensed Nursing Assistants and 3 Registered Nurses had no documented evidence of receiving behavioral health and trauma-informed care training upon hire or annually for 2024. During an interview, the Director of Nursing confirmed the absence of documented evidence of such training for the staff. Although the facility Administrator provided a training log for behavioral health and trauma completed in 2023, only one of the sampled staff members had attended the training.
Failure to Support Anonymous Grievance Filing
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, which has the potential to affect all residents. Observations revealed that the facility's entryway bulletin board displayed the grievance process, including the grievance officer's contact information, but lacked details on filing grievances anonymously. There was no evidence of grievance forms or information on submitting grievances anonymously. The facility's policy, revised on 2/2/24, mentioned that grievances could be filed anonymously but did not provide a process for doing so. Interviews with two residents indicated that grievances must be filed through the Social Services Department or the Administrator, with no system in place for anonymous submissions. One resident expressed a desire for the option to file grievances anonymously. The Administrator confirmed that the facility no longer provides grievance forms in common rooms and acknowledged the absence of a process for anonymous grievance filing.
Latest citations in Vermont
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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