Vernon Green Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Vernon, Vermont.
- Location
- 61 Greenway Drive, Vernon, Vermont 05354
- CMS Provider Number
- 475008
- Inspections on file
- 19
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Vernon Green Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure that nursing staff had appropriate competencies and authorizations for resident care, particularly medication-related tasks. A resident with ordered 4% lidocaine patches to both hips had patches reportedly removed by LNAs, even though LNAs were neither trained nor certified to assist with medication administration, and the nurse did not verify or remove the patches when administering oral medications. Review of LNA job descriptions and training files for multiple LNAs showed no inclusion of or training on medication administration or assistance, and the Administrator confirmed that no LNAs were certified to assist with medications, including patch removal. Additionally, an RN hired recently had no documented skills competency assessment despite working shifts, and one LNA had no documented competency assessments for two years, with the DON acknowledging the absence of completed competency packets and training evidence.
Surveyors found that kitchen ventilation systems were not maintained in a clean condition, creating a risk of contamination to food prep and dishwashing areas. A large metal vent located above a rack of clean plate covers was covered in dust and white flaky material, which kitchen staff acknowledged could fall onto clean dishes. Additional ductwork with three vents running over food prep and dishwashing stations was observed with dark substances and dust on the vent registers. The kitchen manager confirmed the vents had the potential to contaminate these areas and could not state when they were last cleaned, and the maintenance supervisor agreed the vents needed cleaning.
The facility failed to timely revise care plans in response to significant changes in condition for multiple residents. One resident with anemia, GERD, and a chronic ulcer had a significant weight loss documented by the dietitian, but no new nutritional interventions were added to the care plan. Another resident with dementia and a history of falls experienced multiple documented falls, including head injury and falls from a wheelchair and bed, without any new fall‑prevention measures being incorporated into the care plan. A third resident at risk for falls had two subsequent falls with head injuries, yet the fall‑prevention care plan remained unchanged. A fourth resident with severe cognitive impairment and prior cerebrovascular disease developed facial droop and nonresponsiveness, and was placed on comfort measures per the POA and physician documentation, but the care plan was never updated to reflect comfort care status.
Surveyors found that an unlabeled electric shaver stored in a shared shower room was being used by staff on multiple residents for shaving, with LNAs reporting they wiped the device between residents using only an alcohol pad. A RN confirmed the shaver was shared, and review of the facility’s infection control policy showed that equipment potentially contaminated with body fluids must be handled to prevent transmission of infectious agents, including proper sterilization before reuse. The DON stated she was unaware the shaver was being used on multiple residents and acknowledged that cleaning it with an alcohol pad was not an appropriate or effective disinfection method.
Surveyors found that the memory care unit had persistent strong mildew and urine odors throughout the hallway, particularly near a resident room, with damp, musty air noted during the entire survey. The Director of Maintenance reported that some incontinent residents urinate on the carpets, which are cleaned with carpet extractors, but the rugs are difficult to dry in winter because windows are not opened and the HVAC is not run as frequently to avoid making it too cold for residents. He confirmed that the dampness and odors have been an ongoing problem and acknowledged that he does not maintain a log of ventilation system use, demonstrating a failure to ensure adequate mechanical ventilation and odor control on the unit.
A cognitively impaired resident with dementia and Alzheimer's, dependent on staff for ADLs and hygiene, required two showers after bowel incontinence. During the second shower, the resident became agitated and pulled at the shower hose and pipes. In response, an LNA, feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to pull the hose away. Both LNAs later laughed about the incident while giving report to another staff member. The resident was later found to have multiple bruises on one forearm, believed to be from staff holding the arm to prevent the resident from grabbing the hose, and the DON confirmed the abuse was substantiated.
A resident with a BIMS score indicating no cognitive impairment, medical history of NSTEMI and unspecified dementia, and independence with ADLs was discharged home with planned support services and transportation assistance. Social services documented the planned discharge and the resident’s understanding of follow-up with the PCP, and an administrative note recorded the actual discharge. However, the facility did not send a discharge notice to the LTC Ombudsman, and the social services staff member acknowledged in an interview that the Ombudsman was not informed and that she was unaware of this requirement; the facility’s transfer and discharge policy also lacked any mention of notifying the Ombudsman.
The facility failed to complete and maintain required Preadmission Screening and Resident Review (PASARR) documentation for two residents. Record review showed that neither resident’s chart contained a PASARR, which is a federal requirement used to identify serious mental illness or intellectual/developmental disabilities and the need for specialized services through a Level 1 screening. The Director of Social Services stated that all residents should have a Level 1 PASARR completed before admission and that she conducts these interviews for new community admissions, but confirmed that the PASARR documents were missing from the two residents’ charts.
A resident had an order for Lidocaine 4% patches to be applied to both hips at bedtime and removed after 12 hours, but an RN documented removal on the MAR without verifying that it had occurred and stated that LNAs remove the patches. Observation showed the RN administering oral meds without checking or removing the patches. Review of LNA job descriptions and training files showed no authorization or competency for medication administration tasks, and leadership confirmed that LNAs at the facility are not certified or trained to assist with medication administration, making the delegation of patch removal and subsequent documentation inconsistent with scope of practice, facility policy, and professional standards.
Two residents at risk for falls, both with cognitive impairment and poor safety awareness, experienced multiple documented falls over several months, including falls from bed, wheelchair, and while ambulating, some resulting in head injuries and abrasions. Despite existing care plans identifying fall risk, the facility did not add or revise interventions in response to any of these falls, and the DON acknowledged that new interventions should have been implemented after each event.
A resident with anemia, GERD, a chronic foot ulcer, and other malaise experienced a significant weight loss over a short period, despite having a care plan identifying risk for weight changes and requiring monitoring, regular weights, and reporting of significant changes to the MD and family. The dietician documented a weight warning but did not update the care plan with new interventions or document the resident’s expressed preference to decline additional interventions, and there was no evidence that the MD or family were notified of the significant weight loss, as confirmed by interviews with the DON and the dietician.
Surveyors found that the facility’s medication error rate exceeded 5% when a nurse documented removal of lidocaine patches for two residents on the MAR without actually confirming or performing the removals. For one resident, 4% lidocaine patches ordered for both hips at bedtime with scheduled removal were signed off as removed before the nurse checked for their presence, and observation showed the nurse did not assess or remove the patches during a subsequent med pass. For another resident, a 4% lidocaine patch ordered to the mid-back at bedtime with morning removal was documented as removed even though the nurse could not locate the patch during medication administration. The DON confirmed that the lidocaine patch orders for both residents were not completed as ordered and that the RN’s documentation was in error.
The facility failed to implement 14-day stop dates for PRN psychotropic medications for three residents, including those with Alzheimer dementia, Lewy body dementia, bipolar disorder, and vascular dementia. Medications such as Quetiapine, Trazodone, Risperidone, and Lorazepam were prescribed without appropriate stop dates or physician documentation, contrary to facility policy. This was confirmed by the DON and a Registered Nurse.
A resident was subjected to physical abuse by another resident who became agitated when the victim attempted to enter their own room. The perpetrator removed the victim's glasses, poured soda on their head, and moved their wheelchair until they fell. The incident was witnessed by staff and verified through investigation, highlighting a failure to prevent the abuse despite the perpetrator's known history of aggressive behaviors.
The facility failed to implement care plans for two residents, leading to deficiencies in pressure ulcer prevention and safe positioning during meals. One resident with advanced dementia developed a pressure ulcer and experienced weight loss due to lack of pressure relief boots and delayed dietary interventions. Another resident with vascular dementia was not repositioned upright during meals, increasing aspiration risk. Staff confirmed these lapses in care plan adherence.
The facility did not update care plans for two residents whose conditions changed. One resident required total assistance with eating, but their care plan contained contradictory information. Another resident suffered a major injury from a fall, yet their care plan was not revised post-incident. Staff confirmed these deficiencies.
An LNA administered medications to a resident, acting outside their scope of practice. The task was delegated by a nurse due to the LNA's rapport with the resident, despite the LNA not being trained to administer medications. The DON confirmed this action was not within the LNA's scope, as per state nursing guidelines.
A resident with a history of atrial fibrillation, depression, hypertension, and dementia, who was at risk for falls, experienced an unwitnessed fall resulting in a hip fracture. The facility failed to evaluate environmental hazards and implement individualized interventions, as required by their policy.
A facility failed to implement a dietician's recommendations for a resident experiencing significant weight loss and a stage 2 pressure ulcer. The dietician advised increasing dietary supplements and administering Centrum Silver, but these changes were delayed for over a month. The Director of Nursing confirmed the oversight.
Lack of Competent and Authorized Nursing Staff for Medication-Related Tasks and Missing Competency Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and LNAs possessed and demonstrated appropriate competencies for resident care, including medication-related tasks. State statutes require that nursing assistants be licensed and, to administer medications in a nursing home, complete a Board‑approved medication administration program, pass an examination, and be endorsed by the Board as medication nursing assistants. For one resident with an order for 4% lidocaine patches to be applied to both hips at bedtime for 12 hours on and 12 hours off, the assigned nurse stated that LNAs remove the lidocaine patches, but no LNA had reported patch removal to the nurse. During observation, the nurse entered the resident’s room to administer oral medications and did not check for or remove the lidocaine patches before or after medication administration. Review of the facility’s LNA job description showed no mention of assisting with medication administration, and review of training and competency records for five sampled LNAs revealed no training regarding medication administration or assisting with medication administration. The Administrator confirmed that no LNAs in the facility were certified or trained to assist with medication administration, including removal of lidocaine patches. The deficiency also includes a lack of documented competency assessments for nursing staff. Review of employee training and competency files showed that an RN hired in mid‑December had no proof that the facility had assessed her skills competency, even though she was already working shifts. Additionally, one of five LNA files reviewed contained no proof of completed competency assessments for two consecutive years and no evidence of related training. The DON reported that new staff are given a packet of competencies to complete with a preceptor and then return, but confirmed that the RN had not yet submitted her competencies and that the LNA had no competency documentation for the specified years.
Unclean Kitchen Vents Over Food Prep and Dishwashing Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain cleanliness of the kitchen, food preparation area, and dish storage area in accordance with professional standards. During an initial kitchen tour, a large metal box-style vent located above and to the right of a rack of clean plate covers was observed with vent grates covered in dust and several pieces of a white flaky substance. A kitchen staff member confirmed that dust and flaky material from this vent could fall onto the clean dishes and cause contamination. On a follow-up tour, surveyors observed ductwork with three vents running across the width of the kitchen over food preparation areas and dishwashing stations, with all three vent registers covered in dark substances and dust. The kitchen manager acknowledged that the dark substance and dust on these vents had the potential to contaminate food preparation and dishwashing areas and was unable to state when the vents were last cleaned. The maintenance supervisor also confirmed that the kitchen vents needed to be cleaned.
Failure to Revise Care Plans After Significant Weight Loss, Recurrent Falls, and Change to Comfort Care
Penalty
Summary
The deficiency involves the facility’s failure to timely develop, review, and revise comprehensive care plans based on residents’ changing conditions, despite an existing policy requiring an interdisciplinary team to do so. For one resident with anemia, GERD, a chronic left foot ulcer, and other malaise, a significant weight loss occurred between two recorded weights, dropping from 123.6 pounds to 114.4 pounds in 15 days, which meets CMS criteria for significant weight loss. Although this resident already had a care plan problem identifying risk for weight changes and an approach to monitor for sudden weight loss, the dietitian’s progress note later documented the weight loss and acknowledged awareness of it, yet the care plan was not updated with any new interventions. The DON stated there should have been a dietitian progress note in December addressing the significant weight loss, and the dietitian admitted awareness of the weight loss and that a note should have been written. Another resident with unspecified dementia, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem identifying fall risk related to decreased safety awareness. This resident sustained eight documented falls over a three‑month period, including unwitnessed falls in a bathroom and next to the bed, a fall with a “goose egg” or presumed hematoma to the head, a fall forward out of a wheelchair, and multiple other falls in the hallway, outside the room, and while attempting to get out of bed. Despite the repeated falls and detailed nursing progress notes describing each event and associated injuries or lack thereof, there were no new interventions documented in the resident’s care plan after any of these falls. In an interview, the DON confirmed that the care plan should have been updated after each fall but was not. A third resident identified as at risk for falls due to decreased cognition, poor safety awareness, and needing encouragement to sit or rest had four fall‑prevention interventions in the care plan, all dated the same day. Progress notes later documented that this resident fell while sleeping in a chair, leaning forward and hitting the right frontal head on the floor, resulting in a quarter‑sized bump, and then fell again two days later after a bed alarm sounded, with staff finding the resident on the floor next to the bed and noting a quarter‑sized abrasion to the forehead. Review of the care plan showed no updates or additional interventions added after either fall, and the DON confirmed the care plan was not updated following these events. A fourth resident with severe cognitive impairment (BIMS score of 99), dependent for ADLs and hygiene, and diagnoses including dementia, history of TIA and cerebral infarction, and major depressive disorder experienced an acute change with facial droop and nonresponsiveness. Nursing progress notes described right‑sided facial droop, nonverbal status, and suspicion of a stroke, with documentation that the POA did not want hospital transfer and requested comfort measures. A physician late entry progress note further documented that staff suspected a cerebrovascular infarction, that the DPOA declined hospital transfer, and that comfort measures were to be initiated and the resident remain at the facility due to advanced dementia and declining quality of life. Despite this clear shift to comfort care, review of the resident’s care plan revealed no information indicating the resident had been placed on comfort care, and the DON confirmed that the care plan was not updated to reflect this change. The facility’s own care planning policy, which requires the interdisciplinary team to develop individualized comprehensive care plans based on the comprehensive assessment, was not followed in these cases.
Inadequate Infection Control for Shared Electric Shaver
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of a shared electric shaver for multiple residents. During observation in the B-Wing shared shower room, an unlabeled electric razor was seen on a shelf by the bathtub, and a Registered Nurse confirmed that this shaver was used on multiple residents when they needed a shave. Two LNAs further stated that the shaver was used for residents who needed a quick shave after their bath and that they cleaned it between residents using only an alcohol pad. Review of the facility’s Infection Control Policy, issued 3/16/2020, showed that equipment likely to be contaminated with infectious body fluids must be handled to prevent transmission of infectious agents, including proper sterilization before use on another patient. In an interview, the DON reported she was not aware that staff were using this specific shaver or that it was being shared among residents, and she confirmed that cleaning the shaver with an alcohol pad between uses was not an appropriate or effective method, demonstrating a failure to ensure appropriate disinfection of shared resident care equipment. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Inadequate Ventilation Leading to Persistent Mildew and Urine Odors on Memory Care Unit
Penalty
Summary
Surveyors identified a deficiency related to inadequate mechanical ventilation on the licensed memory care unit (B‑Wing), where a strong odor of mildew was noted upon entering the unit and a combined mildew and urine odor was present down the entire hall near a specific resident room. The damp, musty, and urine smells persisted throughout the survey period. During an interview and walkthrough with the Director of Maintenance, he explained that some incontinent residents urinate on the carpet in various locations, and staff use carpet extractors to clean the rugs, attempting to do so immediately and more extensively in the evening. He reported difficulty getting the carpets to dry in the winter because windows cannot be opened and the HVAC system cannot be run as frequently without making the environment too cold for residents, and he confirmed that the dampness and odors have been an ongoing issue. He also stated that he does not keep a log of how often the ventilation system is run. These observations and statements show that the facility did not ensure adequate mechanical ventilation or effective odor control on the memory care unit, resulting in persistent dampness and strong mildew and urine odors in resident care areas.
Abusive Shower Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from abuse during personal care. The resident had a BIMS score of 1 and diagnoses including dementia, Alzheimer's disease, and depression, and was dependent on staff for ADLs and hygiene. According to the facility’s internal investigation and witness statements, during an evening shift the resident required two showers due to bowel incontinence. During the second shower, the resident became agitated and attempted to pull on the shower hose and pipes. In response, one LNA, who reported feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to rip the hose from the first LNA’s hands and continued pulling on the pipes. Per the witness statement, both LNAs involved in the shower incident later laughed about what had occurred while giving report to another staff member, and the resident expressed a desire to apologize to someone without knowing to whom. A subsequent addendum to the investigation documented that the resident was later noted to have five bruises on the left forearm in healing stages, which were assessed as likely related to staff holding the resident’s arm to prevent them from grabbing the water hose during the same shower incident. The resident was reported as having no recollection of the incident and no pain at the time of assessment. The DON confirmed during interview that the abuse occurred and stated that the allegation was substantiated.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to send a required discharge notice to the Long-Term Care Ombudsman for a resident who was discharged home. The resident had a BIMS score of 15, indicating no cognitive impairment, and medical diagnoses including non-ST elevated myocardial infarction and unspecified dementia, and was independent with ADLs and hygiene. Social services documented that the resident would be returning home with services, assistance from a friend, and transportation support, and that the resident and family representative were aware of the need to schedule a follow-up PCP appointment. An administrative note later documented that the resident was discharged. Review of the facility’s Documentation of Transfers and Discharges policy showed no requirement to send transfer or discharge notices to the Ombudsman, and in an interview, social services confirmed that the Ombudsman was not informed of the discharge and stated she did not know this was required.
Failure to Complete and Maintain Required PASARR Screenings
Penalty
Summary
The facility failed to ensure required Preadmission Screening and Resident Review (PASARR) documentation was completed and present in the medical records for two of five sampled residents, identified as Residents #5 and #48. Record review showed that neither resident’s chart contained a PASARR, which is a federal requirement used to ensure that individuals with serious mental illness or intellectual/developmental disabilities are appropriately screened and directed to the most suitable setting with needed specialized services. A Level 1 PASARR screening is intended to identify conditions that require specialized services. During an interview, the Director of Social Services confirmed that all residents are required to have a Level 1 PASARR screening completed before admission. She explained that for new admissions from the community, she conducts the PASARR interview starting with the Level 1 screening. She further confirmed that PASARR documents were not present in the charts of Resident #5 and another resident (also referenced as Resident #109), verifying that the required screenings and documentation had not been completed or maintained for these residents.
Improper Delegation and Documentation of Lidocaine Patch Removal
Penalty
Summary
The deficiency involves failure to ensure professional standards were maintained in the delegation and documentation of nursing duties related to medication administration for one sampled resident. The resident had a physician’s order for Lidocaine 4% external patches to be applied to the left and right hips at bedtime, to remain on for 12 hours and then be removed for 12 hours. Review of the Medication Administration Record (MAR) showed that licensed nursing staff documented application of the Lidocaine patches at 8:00 PM on January 12, 2026. On the morning of January 13, the staff nurse responsible for the resident stated that Licensed Nursing Assistants (LNAs) remove the Lidocaine patches and acknowledged having no concern about signing off on the MAR for patch removal before verifying that LNAs had actually removed them. The staff nurse also stated that no LNA had reported removing the patches, yet the nurse marked the electronic MAR order for removal of the two Lidocaine patches as completed at 7:59 AM on January 13, 2026. Observation at 9:14 AM on January 13 showed the staff nurse entering the resident’s room to administer oral medications and leaving the room without checking for or removing the Lidocaine patches. Review of the facility’s LNA job description revealed no mention of assisting with medication administration, and review of training and competencies for five sampled LNAs showed no training on medication administration or assisting with medication administration. The administrator and DON both confirmed that no LNAs in the facility were certified or trained to assist with medication administration, including removal of Lidocaine patches, and that delegating this task to LNAs was outside their scope of practice and job description. The DON further confirmed that facility policy requires medications to be administered only by persons legally authorized to do so, and that the staff nurse’s delegation of patch removal to an unqualified LNA and subsequent documentation of completion without verification violated facility policy and accepted professional standards.
Failure to Revise Fall-Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision and interventions to prevent accidents, particularly falls, for two residents. One resident had a care plan identifying fall risk related to decreased cognition, poor safety awareness, and a need for encouragement to sit or rest, with four fall-prevention interventions dated 12/5/2025. On 1/4/26, progress notes documented that this resident was sleeping in a chair, leaning forward, and fell to the floor, striking the right frontal head and developing a quarter-sized bump on the right lateral forehead. Despite this fall, no new interventions were added to the care plan. Two days later, at 4:30 a.m. on 1/6/26, the bed alarm sounded and staff found the same resident sitting on the floor next to the bed with a quarter-sized abrasion on the left forehead, and again, the care plan showed no new interventions to prevent future falls. Another resident with diagnoses including unspecified dementia with behavioral disturbance, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem stating the resident was at risk for falling due to decreased safety awareness. Between 9/29/25 and 12/27/25, this resident sustained eight documented falls, including being found sitting on the floor next to a wheelchair in a former room, on the bathroom floor of a former room, on the floor next to the bed with a head injury and headache after attempting to get into bed, on the floor on knees and forehead in front of the wheelchair, falling forward out of the wheelchair, sitting naked on the floor outside the room after incontinence, losing balance and falling while walking out of another patient’s room, and rolling out of bed while attempting to get out of bed. Record review showed no documented new interventions added to the resident’s care plan after any of these falls. In an interview, the DON confirmed that there were no new interventions implemented after the falls for either resident and acknowledged that new interventions should have been attempted after each fall.
Failure to Implement Interventions and Notify MD/Family After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions and update the care plan after a resident experienced a significant weight loss. The resident had diagnoses including anemia, GERD, a non-pressure chronic ulcer of the left foot, and other malaise, all of which present a risk for weight loss. The resident’s weight decreased from 123.6 pounds on 12/7/25 to 114.4 pounds on 12/22/25, a loss of 9.2 pounds or 7.4% in 15 days, which meets the MDS definition of significant weight loss. The resident’s care plan, dated 10/30/24, already identified risk for weight changes and altered fluid status due to variable meal intake related to physical limitations and cognitive/mood state, and included approaches to monitor for sudden weight loss, weigh per physician orders, and report significant weight changes to the physician and family. Record review showed that the dietician documented a weight warning on 12/29/25 noting the 12/22/25 weight of 114.4 pounds and the percentage changes from prior weights. However, the resident’s care plan was not updated to include any new interventions in response to the significant weight loss, and the record did not show that the physician or family were notified of the weight change as required by the care plan. During interview, the DON stated there should have been a dietitian progress note in December addressing the significant weight loss. In a separate interview, the dietician reported being aware of the weight loss and stated that, after discussing it with the resident who did not want additional interventions and preferred to wait and see if weight increased, no note was written documenting this discussion or decision.
Medication Error Rate Exceeds 5% Due to Improper Lidocaine Patch Documentation and Removal
Penalty
Summary
The deficiency involves the facility’s failure to ensure medication error rates remained below 5%, with surveyors identifying 2 errors in 32 opportunities (6.25%). Facility policy required medications to be administered safely, timely, and as prescribed, in accordance with good nursing principles and practices. For one resident, physician orders directed application of 4% lidocaine patches to the left and right hip at bedtime, to be on for 12 hours and off for 12 hours, with removal per schedule. The MAR showed that nursing staff documented application of the patches at 8:00 PM on January 12, 2026. The following morning, the staff nurse stated she had no concern signing off on removal of the lidocaine patches before checking whether the two patches were present and reported that no LNA had told her they removed the patches. She then documented completion of the removal order on the electronic MAR at 7:59 AM on January 13, 2026. Observation at 9:14 AM showed the same nurse entered the resident’s room to administer oral medications and did not check for or remove the lidocaine patches before or after the medication pass. For another resident, physician orders directed application of a 4% lidocaine patch to the mid-back at bedtime for pain, with removal every morning. The MAR showed that nursing staff documented application of the lidocaine patch at 8:00 PM on January 12, 2026. During observation the next morning at 9:24 AM, the staff nurse entered the resident’s room to administer oral medications and attempted to remove the lidocaine patch but was unable to locate it. Despite not confirming that the patch was present or removed, the nurse documented on the MAR that the removal order had been completed. In an interview, the DON confirmed that the lidocaine patch orders for both residents were not completed as ordered and that the RN erred in documenting removal of the patches on the MAR.
Failure to Implement 14-Day Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to implement 14-day stop dates on prescribed as-needed (PRN) psychotropic medications for three residents. Resident #24, diagnosed with Alzheimer dementia, was prescribed Quetiapine without a documented stop date or rationale for extending the medication. Similarly, Resident #205, with a diagnosis of Lewy body dementia, had PRN orders for Trazodone and Risperidone without stop dates. The Director of Nursing confirmed the absence of stop dates for these residents' medications, which is against the facility's policy requiring PRN psychotropic drugs to be limited to 14 days unless properly evaluated and documented by the attending physician. Resident #45, diagnosed with bipolar disorder and vascular dementia, had a PRN order for Lorazepam that extended beyond the 14-day limit without physician documentation to support the extension. A Registered Nurse confirmed the lack of physician rationale for the extended order. The facility's policy mandates that PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed without a physician's evaluation and documentation, which was not adhered to in these cases.
Resident Abuse Incident Due to Inadequate Prevention Measures
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident occurred when the resident attempted to enter their own room, which was occupied by another resident who became agitated. The agitated resident removed the victim's glasses, threw them across the room, poured soda on the victim's head, and moved the victim's wheelchair from side to side until the victim fell out of the wheelchair. The victim called for help, and staff responded promptly. The incident was witnessed by staff and verified through the facility's investigation. The facility's records indicate that the perpetrator had a history of behaviors such as grabbing, hitting, pushing, cursing, screaming, threatening, and rejecting care. These behaviors were monitored, and interventions were documented. However, the incident still occurred, indicating a failure to prevent the abuse. The facility's investigation confirmed the occurrence of the incident, and it was reported to the appropriate authorities.
Removal Plan
- The residents were separated and assessed for injuries.
- Close supervision was provided.
- Care plans for both residents were updated.
- Family, physician, and authorities were notified.
- The incident was reported to the State Agency and investigated.
- The perpetrator was psychologically evaluated and medications were adjusted.
- Res. #35 was moved off the perpetrator's unit.
- Social Services and Behavioral Health Services were involved in care and treatment for both residents.
- The facility conducted a Behavior Analysis Report regarding the perpetrator's behaviors.
- Interventions implemented to halt the behavior and new interventions implemented to prevent future incidents were documented and noted effective.
Failure to Implement Care Plans for Pressure Ulcer Prevention and Safe Positioning
Penalty
Summary
The facility failed to implement care planned interventions for two residents, leading to deficiencies in their care. Resident #25, who has advanced dementia, developed a stage 2 pressure ulcer on the left heel and experienced significant weight loss. Despite a care plan that included the use of pressure relief boots and frequent repositioning, observations revealed that the resident was not wearing the boots and was not repositioned for extended periods. Additionally, dietary recommendations made by a dietician to support wound healing and prevent further weight loss were not implemented until over a month later. Resident #30, diagnosed with vascular dementia, dysphasia, and reflux disease, was observed sitting in a reclining chair at the dining table, leaning over to the left side. The care plan required the resident to be seated upright at 90 degrees during meals to reduce the risk of aspiration and reflux. However, the resident was not repositioned before receiving a meal, and the LNA confirmed that the resident should have been repositioned and required assistance during meals. These observations and interviews with staff confirmed that the facility did not adhere to the care plans for these residents, resulting in a failure to provide necessary interventions for pressure ulcer prevention, nutritional support, and safe positioning during meals. The deficiencies highlight lapses in the implementation of care plans and the monitoring of residents' needs.
Failure to Revise Care Plans for Residents with Changing Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan for two residents as their conditions changed. For one resident, observations on two consecutive days showed that staff were assisting the resident with eating, indicating a need for total assistance. However, the resident's care plan contained contradictory information, with one approach suggesting the resident was dependent on staff for meal assistance, while another encouraged independent eating. Interviews with staff confirmed the resident was dependent on staff for all activities of daily living (ADLs), yet the care plan had not been updated to reflect this dependency. Another resident experienced an unwitnessed fall resulting in a major injury, specifically a left hip fracture with internal bleeding, requiring hospitalization and surgery. Despite the facility's policy to review and revise care plans after such incidents, the resident's care plan had not been updated following the fall. The Director of Nursing confirmed that the care plan remained unchanged after the incident, indicating a failure to address the resident's increased risk of falls and injury.
LNA Administers Medications Outside Scope of Practice
Penalty
Summary
The facility failed to meet professional standards of quality by allowing a Licensed Nursing Assistant (LNA) to act outside their scope of practice. At approximately 2:00 PM on 10/28/2024, an LNA was observed administering medications to Resident #205 at the nurse's station. A Licensed Nurse confirmed that the task was delegated to the LNA due to their good rapport with the resident, despite the LNA not being trained by the facility to administer medications. The LNA admitted to having administered medications to the resident, crushed in ice cream, and stated that this was not the first time they had been delegated such tasks by nurses. The Director of Nursing confirmed that administering medications is not within an LNA's scope of practice, as per the [NAME] State Board of Nursing guidelines, which prohibit LNAs from performing activities beyond their licensure level, including medication administration.
Inadequate Supervision and Environmental Hazard Evaluation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for Resident #15, who was at risk for falls due to decreased activity tolerance and safety awareness. The resident, admitted with conditions including atrial fibrillation, depression, hypertension, and dementia, had a care plan indicating a risk for falls. Despite this, the facility did not conduct a thorough evaluation of potential environmental hazards in the resident's room that could contribute to falls. On 9/28/24, Resident #15 experienced an unwitnessed fall in their room, resulting in a left hip fracture and a small extraperitoneal pelvic hemorrhage. The resident was subsequently transported to the hospital for surgery. The facility's internal report lacked documentation of an evaluation and analysis of hazards and risks in the resident's environment, and there were no individualized interventions implemented to mitigate these risks, as required by the facility's Falls Risk Assessment and Care Planning policy.
Failure to Implement Dietician's Recommendations for Resident Care
Penalty
Summary
The facility failed to implement the recommendations made by a Registered Dietician to support wound healing and prevent weight loss for a resident. The resident experienced a significant weight loss of 11.48% over three months and developed a stage 2 facility-acquired pressure ulcer. On 9/11/2024, the dietician recommended increasing the resident's dietary supplement to three times per day and administering Centrum Silver daily. However, a follow-up note on 10/28/2024 revealed that these recommendations had not been implemented. The resident's Medication Administration Record confirmed that the dietary changes were not initiated until 10/29/2024. The Director of Nursing acknowledged the delay in implementing the dietician's recommendations during an interview on 10/30/2024.
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The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
The facility did not follow its policy or CDC guidance requiring COVID-19 vaccination education, offers, and written consent for residents and staff. Two residents had no documentation that they were offered a 2025 COVID-19 vaccine or that they consented or refused, and another resident received a COVID-19 vaccine without any recorded informed consent. Additionally, five sampled employees had no evidence in their files that they were offered the COVID-19 vaccine for the 2025 season. The DON and Infection Preventionist confirmed that required consent and offer/refusal documentation for these residents and staff could not be produced.
A resident with COPD, Type II DM, AFib, Parkinson’s disease, severe cognitive impairment, and high fall risk experienced a fall that was inaccurately documented by a nurse, who charted a witnessed self-transfer from a wheelchair and immediate assessment without documenting required VS or neuro checks until the next day. The facility’s investigation found that the resident’s physical abilities did not match the documented account, determined the fall was unwitnessed, and learned through LNA interviews that the nurse had asked them to change their witness statements, leading to the conclusion that the medical record had been falsified and that the facility’s fall assessment and documentation policies were not followed.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to follow its Coronavirus Prevention and Control policy requiring that all residents and staff be educated about COVID-19 vaccination, be offered the vaccine unless contraindicated or already fully immunized, and that written informed consent be obtained and documented prior to administration. Record review showed that two residents’ immunization records contained no evidence that they were offered a COVID-19 vaccination for 2025, and there was no documentation of either consent or refusal in their medical records. Another resident received a COVID-19 vaccination in 2025 with no evidence in the record that the resident or resident representative had provided informed consent for that vaccination. Review of employee files revealed that five sampled staff members had no documentation that they were offered the COVID-19 vaccine for the 2025 season. The DON confirmed that consent forms should be present in the medical record for all vaccinations, including COVID-19, and was unable to provide evidence of COVID-19 consents or offer/refusal documentation for the three sampled residents for 2025. In a joint interview, the DON and the Infection Preventionist also confirmed they could not provide evidence that COVID-19 vaccinations had been offered to the five sampled employees, despite current CDC guidance emphasizing the importance of updated COVID-19 vaccination, particularly for individuals aged 65 and older and those living in LTC settings.
Falsified Fall Documentation and Failure to Complete Required Post-Fall Assessments
Penalty
Summary
The deficiency involves failure to maintain accurate and truthful documentation and to follow the facility’s fall assessment protocol for a cognitively impaired resident. The resident had COPD, Type II diabetes, atrial fibrillation, and Parkinson’s disease, a BIMS score of 3 indicating cognitive impairment, was dependent on staff for ADLs and hygiene, and was at risk for falls due to deconditioning, gait/balance problems, and Parkinson’s. A nursing progress note dated 2/19/26 documented that the resident attempted to transfer independently from a wheelchair, stood up, then sat down on the floor, and joked about going to bed and missing the floor. The note stated the resident was immediately assessed, had no complaints of pain or discomfort, and was helped up and wheeled to the nurse’s cart until dinner, with emotional support provided. However, there was no documentation of vital signs or neurological checks until the following day, 2/20/26, despite the facility’s Falls-Clinical Protocol requiring assessment and documentation of vital signs, neurological status, cognition/level of consciousness, pain, musculoskeletal function, and other fall-related factors after a fall. Further review of the facility’s internal investigation showed that an incident report identified the event as a fall and indicated the resident’s representative was notified, but a risk management report found that the incident note and nursing progress note did not match the resident’s physical capabilities. The DON reported to the State Agency that the resident was incapable of rolling on the floor or moving independently as described, and the facility determined the fall was actually unwitnessed and that the resident’s representative had not been notified. Interviews with two LNAs revealed that the nurse involved had asked them to change their witness statements about the fall. Based on staff interviews and chart reviews, the facility concluded that the information in the medical record regarding the fall was falsified, in violation of the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
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