Vermont Veterans' Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 325 North Street, Bennington, Vermont 05201
- CMS Provider Number
- 475032
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Vermont Veterans' Home during CMS and state inspections, most recent first.
A resident with nicotine dependence and respiratory failure, receiving continuous O2 via nasal cannula, was assessed as an unsupervised smoker allowed to keep cigarettes but required to request a lighter. Despite increasing agitation and confusion, the resident went to the smoking room with O2 in use, where another resident lit their cigarette, igniting the O2 tubing. Staff later observed soot on the resident’s nose and burned tubing, and the resident sustained a painful facial burn with redness and skin loss. The resident’s smoking status and O2-related hazards were not added to the care plan until after the injury, and required no-O2 smoking-room signage was not posted until after the incident, contrary to facility smoking policy.
Surveyors found multiple food storage and temperature control deficiencies, including opened and unlabeled sausages, smart dogs, hot dog buns, and hamburger buns in the kitchen freezer and storage areas, as well as expired instant grits and cheese queso in dry storage. Kitchen staff confirmed the items were expired or should have been discarded. Review of freezer temperature logs showed repeated elevated temperatures in two wing freezers, and the Food Service Coordinator acknowledged the temperatures were elevated but did not submit required work orders as outlined in the facility’s dietary food storage policy.
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Cardinal memory care unit. In the 500 hall bathing room, the tub had chipped paint on the seat and basin, one shower stall had damaged tiles and debris, and the toilet backrest showed cracked padding and rusted framing. On both the 500 and 600 halls, surveyors observed stained and damaged ceiling tiles, including outside a resident room. Several rooms lacked proper room number signs, with the numbers instead written on the walls in magic marker. These conditions were confirmed during a tour with the Administrator, DON, and QA Nurse.
Surveyors found multiple instances where medication and treatment carts were left unlocked and unattended in resident-accessible corridors. On one unit, a medication cart and a treatment cart containing various medications, insulins, syringes, and prescription topical products were observed unlocked with a resident ambulating nearby, and the assigned RN confirmed they were not secured. On another occasion on the same unit, the medication cart was again found unlocked, which the RN Unit Manager acknowledged was contrary to expectations. On a different unit, a medication cart was observed unlocked and unattended with a resident sitting next to it, and the assigned LPN confirmed it should have been locked. The facility’s policy requires all medication compartments and carts to be locked when not in use and not left unattended if open.
A resident with nicotine dependence and respiratory failure was admitted, and although a smoking assessment documented that the resident could smoke independently with a lighter secured by nursing, the baseline care plan did not address smoking status or concurrent O2 use. Nursing notes showed the resident frequently went to smoke and required repeated reminders about O2. The omission in the care plan preceded an incident in which the resident, wearing O2 in the smoking room, had a cigarette lit by another resident; after a few puffs, the cigarette ignited, burning the O2 tubing and causing a painful superficial facial burn, including loss of skin on the nose. The ADON later confirmed that the baseline care plan lacked smoking-related interventions until after the incident, despite facility policy requiring such issues to be care planned and communicated to staff.
Surveyors found that an LPN repeatedly failed to follow required hand hygiene practices during medication administration and glucose management for two residents. The LPN did not perform hand hygiene before and after glove use while preparing and administering oral medications, eye drops, and insulin, and while using and cleaning a glucometer and disposing of used testing supplies. In an interview, the LPN acknowledged that hand hygiene is required before and after glove use, direct resident contact, medication handling, room entry, and handling contaminated equipment, and facility policy specifies that alcohol-based hand sanitizer must be used in these situations and that gloves do not replace hand hygiene.
The facility did not provide adequate supervision to prevent altercations between residents with known behavioral risks, resulting in multiple incidents of physical aggression. Additionally, a resident repeatedly sustained injuries from a bathroom fixture after staff failed to report the hazard for maintenance, despite the resident's requests and facility policy requiring such action.
Two residents with PTSD and trauma histories were not properly assessed or care planned for trauma-informed, culturally competent care. Behavioral health assessments were incomplete, lacking documentation of trauma history, triggers, and individualized interventions. Social Services staff confirmed that trauma-specific needs and care plans were not developed, resulting in a failure to address and mitigate potential triggers for these residents.
A resident with dysphagia and no natural teeth was identified as needing permanent dentures and was seen by a dentist, who instructed the facility to contact the VA for service approval. The facility did not follow up with the VA, resulting in the resident's ongoing difficulty chewing and lack of progress toward obtaining permanent dentures.
A facility failed to report an alleged abuse incident involving an LNA and a resident to the State Licensing Agency. The resident's significant other witnessed the LNA abruptly dropping the resident's wheelchair, which startled the resident. Despite an internal investigation, the facility did not report the incident, considering it a customer service issue rather than abuse.
Failure to Prevent Oxygen-Related Smoking Injury
Penalty
Summary
The facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and did not provide adequate supervision. The resident, recently admitted to the LTC unit from residential care with diagnoses including nicotine dependence and respiratory failure, had a smoking assessment completed that identified them as an unsupervised smoker who could keep cigarettes but had to request a lighter. Nursing progress notes documented that on the night prior to the incident the resident experienced increasing agitation and confusion and was receiving 4 liters of continuous oxygen via nasal cannula. At approximately 6:20 a.m., nursing staff observed black soot on the resident’s nose and burned oxygen tubing under their nose. When questioned, the resident stated that another resident had lit their cigarette and it had caught on fire. The resident sustained a painful facial burn measuring 0.67 cm in width, 1.53 cm in length, and 0.58 cm in area, with redness and loss of skin. Review of the care plan showed that the facility had not care planned the resident’s smoking status or the hazard associated with their oxygen use until the day after the burn occurred. The facility’s smoking policy, revised previously, stated that oxygen use is prohibited in smoking areas, and the DON confirmed that the resident went to the smoking room with oxygen on and was burned when the cigarette was lit, and that a sign prohibiting oxygen in the smoking room was not posted on the door until after the injury. This deficiency was cited as a repeat violation from the prior re-certification survey.
Improper Food Storage, Labeling, and Freezer Temperature Management
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices in the facility’s kitchen and dry storage areas. During an observation of the kitchen freezer, surveyors found an opened pack of three sausages and an opened package of smart dogs that were not dated or labeled. In the dry storage area, they observed a 10-pack of instant grits and a 13.7-ounce bag of cheese queso that were past their expiration dates. A kitchen staff member confirmed that the items were expired and that the sausages and smart dogs were opened and unlabeled. On a subsequent observation of the kitchen, surveyors again found the same opened and undated sausages and smart dogs still in the freezer, along with one open and undated package of hot dog buns and two packages of hamburger buns with no date or initials. Another kitchen staff member confirmed these items should have been discarded. Surveyors also identified a deficiency related to freezer temperature monitoring and follow-up. Review of the facility’s freezer temperature logs showed that on multiple dates, the C wing and North wing freezers were recorded at elevated temperatures of 10°F and 5°F. The facility’s Dietary-Food Storage policy required that all refrigerators and freezers meet national sanitation foundation standards, follow recommended temperatures, and that elevated temperatures be immediately brought to the attention of the Dietary Manager or designee and environmental services. In an interview, the Food Service Coordinator acknowledged that these recorded freezer temperatures were elevated and stated that the process was to notify maintenance and submit a work order, but confirmed that she did not submit work orders after these elevated temperatures were documented.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, specifically the Cardinal memory care unit. During observation in the 500 hall bathing room, surveyors noted the tub had chipped paint on both the seat and the tub itself, one of the two shower stalls contained damaged tiles and debris, and the toilet backrest had cracks in the padding and rust on the framing. On both the 500 and 600 halls of the Cardinal memory care unit, there were stained and damaged ceiling tiles, including outside of one resident room. Additionally, room number signs were missing outside several rooms, and the room numbers had been written directly on the walls with a magic marker. These environmental issues were observed and confirmed during a tour and interview with the Administrator, DON, and QA Nurse.
Unlocked Medication and Treatment Carts Left Unattended in Resident Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep drugs and biologicals stored in locked compartments as required by facility policy and professional standards. On the [NAME] Unit, a medication cart and a treatment cart were observed unlocked in the hallway with no staff present, while a resident was ambulating near the medication cart. The RN assigned to the cart confirmed both carts were unlocked. The medication cart contained medications including inhalers, topical patches, syringes, topical medications, insulins, prescribed resident-specific medications, and narcotics in a separate locked compartment. The treatment cart contained wound cleansers, prescription topical creams/pastes, and prescription topical powders. On a subsequent observation on the same unit, the medication cart was again found unlocked, and the RN Unit Manager confirmed it should not have been unlocked. On the North Village Unit, surveyors observed another medication cart unlocked and unattended in the corridor, with a resident sitting next to it. The LPN assigned to that cart confirmed it was not locked as required. The RN Unit Manager and the facility’s written policy on Medication Labeling and Storage both state that compartments containing medications and biologicals must be locked when not in use and that carts used to transport such items are not to be left unattended if open or otherwise available to others.
Failure to Include Smoking and Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's smoking needs, including the resident's use of oxygen, despite documented nicotine dependence and respiratory failure. The resident was admitted with these diagnoses, and a smoking assessment indicated that the resident was capable of holding their own cigarette and smoking unsupervised, with the requirement that nursing secure the lighter and make it available as needed. Nursing progress notes documented that the resident went to smoke multiple times and had to be repeatedly reminded to wear oxygen. However, the baseline care plan in effect from the resident's prior residential care unit admission did not address the resident's smoking status or oxygen use until a later date. The deficiency culminated in an incident in which the resident, while on oxygen, went to the smoking room and had another resident light a cigarette. After taking two puffs, the cigarette caught fire in the resident's face, burning the oxygen tubing and leaving black soot on the resident's nose. The resident sustained a painful superficial burn to the face, including loss of skin from the tip of the nose, with specific measurements documented in the nursing notes. During an interview, the ADON confirmed that the residential care unit care plan served as the baseline care plan on admission and was unable to provide documentation that the baseline care plan addressed the resident's smoking needs until the day after the burn incident, contrary to the facility's smoking policy requiring smoking-related privileges, restrictions, and concerns to be noted in the care plan and communicated to staff.
Failure to Follow Hand Hygiene Protocol During Medication and Glucose Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration for two of nine sampled residents. During an observation of medication administration, an LPN had nine missed opportunities to perform required hand hygiene, failing to use hand sanitizer or soap and water before and after glove use while preparing and administering oral medications to Resident #1. The same LPN also did not cleanse hands before and after glove use when preparing eye drops and glucose testing for Resident #89, instilling eye drops, testing blood glucose with a glucometer, cleaning the glucometer, disposing of used testing supplies, preparing an insulin injection, administering the insulin injection, and upon completion of the injection. In an interview, the LPN acknowledged that hand hygiene should be performed before and after putting on gloves, direct resident contact, preparing or handling medications, visiting a resident’s room, and after handling contaminated equipment such as a glucometer. The facility’s Hand Hygiene Policy states that gloves do not replace hand hygiene and that an alcohol-based hand sanitizer with at least 62% alcohol must be used before preparing or handling medications, before and after direct resident contact, and after glove removal. These observations, interviews, and record reviews demonstrated that the facility did not ensure staff adherence to its own hand hygiene policy and infection control standards during medication preparation and administration and during the use and cleaning of a glucometer for Resident #1 and Resident #89.
Failure to Prevent Resident Altercations and Address Environmental Hazards
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and did not maintain an environment free from accident hazards for several residents. In one incident, two residents with known histories of behavioral issues and prior altercations were left unsupervised on a porch, resulting in a physical altercation. Both residents had care plans indicating risks for aggression and wandering, yet there was no evidence that staff were supervising them at the time of the incident. Facility leadership confirmed that these residents were left together without supervision despite their documented behavioral histories. Another deficiency involved a resident with a history of entering other residents' rooms and being difficult to redirect. This resident's care plan lacked interventions to address their wandering or to provide supervision. As a result, altercations occurred between this resident and another, including an incident where one resident physically assaulted the other in response to repeated room entries. These events were confirmed by facility leadership and documented in progress and incident notes. Additionally, a resident with mobility challenges and a need for physical assistance during transfers repeatedly sustained knee injuries due to a poorly placed toilet paper holder in their bathroom. Despite multiple requests to staff to have the fixture moved, no maintenance request was entered as required by facility policy. The resident expressed frustration and distress over the lack of response, and the Director of Environmental Services confirmed that no action had been taken to address the hazard, even though staff had the means and responsibility to do so.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with a history of trauma, including PTSD. For one resident, the medical record documented a diagnosis of PTSD, a history of military combat, and specific triggers such as startle responses and flashbacks. Despite this, the Behavioral Health Clinical Assessment was incomplete, lacking documentation of current mental health issues, trauma history, symptoms, triggers, identified needs, and a recommended plan of care. The resident's care plan did not address PTSD or include interventions to mitigate triggers, and the Social Services staff confirmed that the resident was not care planned for trauma-related needs. Another resident with diagnoses of PTSD, anxiety, and depression was also not fully assessed for trauma-related triggers. The Behavioral Health Clinical Assessment identified a history of trauma but did not specify the type or provide further information. There was no evidence in the resident's record or care plan regarding identification of triggers or strategies to avoid re-traumatization. Interviews with Social Services staff and the Director of Social Services revealed a lack of awareness and use of trauma assessment tools, and it was confirmed that trauma-specific triggers and care planning had not been completed for this resident.
Failure to Provide Routine Dental Services for Resident Needing Dentures
Penalty
Summary
A resident admitted with dysphagia and edentulism was assessed as having chewing difficulties and was using temporary dentures, with a need for permanent dentures identified upon admission. The resident was seen by a dentist, who noted the need for new dentures and indicated that the Veterans Administration (VA) would be contacted to determine service approval and whether the dentist could proceed with care. However, there is no documentation that the facility followed up with the VA as instructed by the dentist. The resident later reported not knowing when the next dental appointment would be and expressed concern about the lack of follow-up regarding the need for new dentures. The Unit Manager confirmed that the process to contact the VA was not completed and could not ensure that the resident's dental needs were being addressed. The resident continued to experience nutritional risk and chewing difficulties due to being edentulous with only temporary dentures.
Failure to Report Alleged Abuse to State Licensing Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Licensing Agency as required. A resident's significant other placed a camera in the resident's room during a period of restricted visitation due to COVID. On a specific date, the significant other witnessed a licensed nursing assistant (LNA) allegedly abusing the resident by abruptly dropping the resident's wheelchair into a reclined position, which startled the resident. The significant other reported this incident to the facility nearly a year later, believing the LNA had been dismissed. However, upon seeing the LNA still employed, the significant other raised the issue again. The Deputy Administrator confirmed that the LNA was placed on leave and an investigation was conducted by the Human Resource Department, but the incident was not reported to the State Licensing Agency. The facility Administrator stated that the initial report was considered a customer service or resident rights issue rather than an abuse allegation, and the second report was not submitted because the previous investigation found the claim unsubstantiated. This oversight resulted in a failure to comply with mandatory reporting requirements for suspected abuse.
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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