Woodridge Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Barre, Vermont.
- Location
- 142 Woodridge Drive, Barre, Vermont 05641
- CMS Provider Number
- 475045
- Inspections on file
- 26
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Woodridge Nursing Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment was physically assaulted by a roommate with a documented history of behavioral issues and aggression. Despite care plan interventions to monitor and manage the roommate's agitation, the resident sustained facial injuries and reported pain and fear after the incident. Staff confirmed the resident was not protected from abuse.
The facility did not provide a way for residents to file grievances anonymously. Multiple residents reported not knowing how to file an anonymous grievance, and one resident expressed concern about reporting staff issues without fear of reprisal. Blank grievance forms were not accessible to residents, and staff confirmed there was no process for anonymous grievance submission. The facility's policy also lacked guidance on anonymous grievance filing.
Surveyors identified improper storage of food items, including expired and unlabeled products in the kitchen, refrigerator, freezer, and dry storage. Multiple areas of the kitchen ceiling were also found to be covered in thick dust, and staff confirmed that cleaning had not occurred for several months. These deficiencies have the potential to impact all residents.
Staff failed to provide dignified and timely meal service, with some residents waiting significantly longer than others to be served lunch. Meals were delivered individually, with warming dish lids and trash placed on the dining table, and at least two residents experienced notable delays in receiving their food due to staff shortages and tray mix-ups.
Two residents were prescribed high-risk psychotropic medications, including Lorazepam, Olanzapine, and Citalopram, without documented evidence that they or their representatives were informed of the risks, benefits, or alternatives. Facility staff confirmed that required consent forms and education were not provided or documented, contrary to facility policy.
Surveyors observed multiple wheelchairs, carts, lifts, medical machines, and bags stored along hallways, as well as large boards displaying business-related data near resident common areas. The DON confirmed that hallways should not be used for equipment storage and acknowledged the non-homelike nature of the displayed boards.
The facility did not ensure that residents with complex respiratory conditions received and had documented respiratory care in accordance with physician orders. Multiple residents requiring oxygen therapy or respiratory support devices lacked care plan interventions and documentation of oxygen administration in the MAR or EHR, despite having orders specifying oxygen use and monitoring requirements. Staff confirmed these omissions and acknowledged discrepancies in order types and documentation practices.
A resident's advance directive specifying DNR with a trial of intubation for five days was not accurately reflected in the EHR, care plan, or physician orders, which instead documented DNR/DNI. The discrepancy was confirmed by the Assistant Unit Nurse Manager.
A resident with cognitive impairment and multiple medical conditions was prescribed PRN Lorazepam for 30 days without documented rationale for exceeding the 14-day limit, contrary to facility policy. The medication was administered three times, and staff confirmed the order was extended without proper documentation.
A contracted LNA was hired and permitted to work before the required Adult Abuse Registry check was completed, contrary to facility policy. The DON confirmed the check was only performed after the LNA had already started working. This is a repeat deficiency previously cited during earlier surveys.
The facility did not update care plans for two residents after significant incidents, including falls and behavioral escalations. One resident with cognitive impairment experienced repeated falls from a wheelchair without care plan interventions addressing footrest use, while another resident with dementia and trauma history had ongoing behavioral issues and anxiety after altercations, but their care plan was not revised to address these changes.
Two residents were not adequately protected from accidents and hazards. One resident with cognitive impairment and mobility issues fell twice from a wheelchair while being pushed without footrests, resulting in injury. Another resident with dementia and behavioral issues continued to display wandering and aggression, including altercations with others, without additional interventions being implemented after repeated incidents.
Two residents with indwelling Foley catheters and complex urinary conditions did not have their urinary output tracked or documented as required by facility policy. Despite orders to monitor intake and output, staff failed to record this information in the residents' charts, and the Nurse Manager confirmed the lack of documentation. This deficiency resulted in inadequate catheter care and failure to implement necessary interventions to prevent urinary tract infections.
A resident was found to have multiple topical medications unsecured in their shared room without a completed medication self-administration assessment. Staff confirmed that facility policy requires such an assessment and the use of a lock box for in-room medications, neither of which were in place.
A resident with a history of diabetes, essential tremor, and swallowing difficulties was not consistently provided with the adaptive drinking equipment outlined in their care plan. Despite the need for two-handled mugs with spouted lids for all beverages, the resident was repeatedly given drinks in standard cups or mugs, resulting in spills and inability to consume fluids independently. Staff interviews confirmed awareness of the care plan requirements, but the adaptive equipment was not reliably supplied during meals.
The facility did not make state survey results readily accessible to all residents, as they were only posted on the first floor. A resident with full cognitive function but dependent on staff for mobility and ADLs reported being unable to access the survey results due to their location. The Activities Director confirmed the lack of posting on the resident-occupied floor.
Two nursing staff members, an RN and an LPN, were found to have been employed for several years without national background checks, as required by regulatory guidance. Review of personnel files and facility policy revealed the omission, and the DON confirmed that national checks were not performed due to unawareness of updated requirements.
A resident with significant physical disabilities and intact cognition was not protected from sexual abuse by a roommate who was repeatedly observed masturbating next to the resident's bed and rummaging through personal belongings. Despite staff intervention, the incidents recurred, causing the affected resident to feel uncomfortable and scared.
A resident was subjected to forced observation of masturbation by a roommate, causing distress and discomfort. Facility leadership, including the DON and Administrator, were aware of the incident but did not identify it as sexual abuse and failed to investigate or report it to the State Survey Agency, contrary to facility policy.
A resident with dementia was not treated with dignity and respect by a nurse, who was reported to have yelled at the resident, causing distress. A family member and staff confirmed the nurse's rude behavior towards the resident and others. The facility's investigation substantiated these allegations.
A resident at high risk for pressure injuries did not have their care plan updated to include necessary interventions, resulting in the development of deep tissue injuries. Despite being identified as high risk, the facility failed to implement measures such as frequent repositioning and heel elevation, as per their wound care protocol. The oversight was confirmed by the Unit Manager, highlighting a significant lapse in care management.
A resident at high risk for pressure injuries developed two deep tissue injuries due to the facility's failure to implement preventative measures such as turning, positioning, and heel elevation. Despite being identified as high risk, necessary interventions were not added to the care plan until after the injuries occurred, as confirmed by the Unit Manager and DON.
The facility failed to provide trauma-informed care for two residents, leading to potential re-traumatization. One resident, with a history of trauma related to molestation, reported being triggered by interactions with other residents, yet their care plan lacked identified triggers. Another resident, with a history of trauma from disasters and abuse, also had no identified triggers in their care plan, and a therapy referral was not initiated as required.
A facility failed to ensure that monthly pharmacist drug regimen reviews and physician responses were documented for a resident prescribed quetiapine. Despite recommendations to limit PRN antipsychotic orders to 14 days, there was no evidence of physician review or action on these recommendations over several months. The Clinical Nurse Coordinator confirmed the lack of documentation.
The facility failed to protect residents from physical abuse in two incidents. In one case, a resident was assaulted in their room, resulting in injuries and distress, with no subsequent care plan updates. In another case, a resident was physically and verbally abused in a common area, with no staff intervention despite a known history of altercations. The lack of preventive measures and care plan updates was confirmed by facility staff.
The facility's policies on preventing abuse, neglect, and theft were found lacking essential components such as employee and resident screening, staff training, and abuse identification. The Director of Nursing confirmed the absence of additional policies, highlighting a significant oversight in regulatory compliance.
The facility's training program for staff on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was found to be inadequate. The educational materials lacked information on recognizing signs of abuse and understanding behavioral symptoms that may increase the risk of abuse. The Nurse Educator confirmed the absence of additional materials covering these critical topics.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in physical harm. One resident, diagnosed with frontotemporal neurocognitive disorder and moderate cognitive impairment, was assaulted by their roommate, who has a history of behavioral issues including agitation, restlessness, and previous incidents of physical aggression toward both staff and other residents. The roommate's care plan included interventions to observe for mood changes, identify triggers, and minimize escalation, but these measures were not effective in preventing the incident. On the day of the incident, the resident asked their roommate to turn off the TV, which led to verbal abuse and a physical assault. The assaulted resident sustained multiple injuries, including bruising and swelling to the face, an abrasion to the lower lip, and reported pain and fear following the event. Staff confirmed that the resident was not protected from abuse and had suffered injuries as a result of the assault.
Failure to Provide Anonymous Grievance Filing for Residents
Penalty
Summary
The facility failed to ensure that residents could file anonymous grievances, as required by policy. During interviews with five residents at a Resident Council meeting, all stated they did not know how to file an anonymous grievance, and one resident expressed concern about not knowing who to approach with staff-related problems without fear of reprisal. This resident was noted to have no cognitive impairment, as indicated by a BIMS score of 15. Observations on the second floor revealed that blank grievance forms were not accessible to residents, as they were kept behind the nurses' station. Review of the facility's grievance policy showed no mention of anonymous grievance filing. Both the Unit Manager and the Activities Director confirmed in interviews that there was no way for residents or their representatives to file grievances anonymously.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and did not maintain a sanitary kitchen environment. During a kitchen tour with the Dietary Manager, multiple food items were found improperly stored or expired in various areas, including the kitchen prep area, walk-in refrigerator, walk-in freezer, and dry storage. Specific issues included undated or expired spices, containers of food without labels or use-by dates, expired prepared foods, open and uncovered packages, and undated loaves of bread. Dietary staff confirmed that bread was not labeled with expiration or use-by dates, and the Dietary Manager acknowledged that open and prepared foods should be labeled and sealed, which was not consistently done. Additionally, during observations on two separate days, multiple areas of the ceiling in the kitchen prep and dish room were found to be covered with thick dust. The Dietary Manager stated that housekeeping staff were responsible for cleaning these areas, but this had not been done in several months. These findings indicate a lack of adherence to professional standards for food storage and kitchen sanitation, with the potential to impact all residents in the facility.
Failure to Ensure Dignified and Timely Meal Service
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity during meal service on two of three units. On the Evergreen unit, seven residents were observed eating lunch together at one large table and a small side table. Meals were served individually, with warming dish lids and trash being placed in the middle of the table. One resident expressed hunger at 12:19 PM but was not served lunch until 12:43 PM, while another resident waiting in the common area was not served until 12:54 PM. The Dietary Manager stated that insufficient staffing prevented simultaneous meal delivery to all units, and the DON confirmed that residents seated together should be served at the same time. On another occasion, a resident was observed sitting at a table while others ate, and was told by an LNA that their tray was delayed. The LNA later explained that the resident's tray was mistakenly sent to their room due to a mix-up, resulting in the resident receiving their meal 27 minutes after the others at the table. These incidents demonstrate that the facility did not consistently provide dignified and timely meal service to all residents, as required.
Failure to Obtain and Document Informed Consent for High-Risk Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed about their health status, care, and treatments, specifically regarding the risks and benefits of prescribed medications and available treatment alternatives. For one resident with chronic anxiety, multiple orders for Lorazepam were present in the medical record, but there was no evidence that the resident or their representative was educated on the use, risks, or benefits of this high-risk medication. Facility policy requires education and documentation for high-risk medications, but interviews with the Unit Manager and DON confirmed that consent forms were not used for Lorazepam, and no signed consent was found in the electronic medical record. Another resident had a documented verbal consent for an antipsychotic medication, Olanzapine, at a lower dose, but when the dose was increased, there was only a note indicating a message was left for the responsible party, with no further documentation of notification or consent. Additionally, this resident was prescribed Citalopram, an antidepressant, without documented evidence that the responsible party was informed of the risks, benefits, or alternatives. Facility policies require signed consent forms and education for antipsychotic and high-risk medications, but staff interviews confirmed that these requirements were not met for the residents involved.
Failure to Maintain Homelike Environment Due to Equipment and Business Boards in Hallways
Penalty
Summary
The facility failed to provide a homelike environment for residents, as observed during a walkthrough where two hallways in the Evergreen Unit were lined with multiple wheelchairs, carts, lifts, medical machines, and bags along one side of each hall. These items remained in the hallways throughout the recertification survey period. During an interview, the DON confirmed that hallways should not be used for storing such equipment and acknowledged that there are designated areas for these items. Additionally, three large boards displaying business-related data, including resident care and staffing concerns, were observed across from nursing stations near resident common areas. Although these boards did not contain resident-specific data, they were business-oriented and not consistent with a homelike environment, as acknowledged by the DON.
Failure to Provide and Document Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for five residents with significant respiratory diagnoses, including acute and chronic respiratory failure, COPD, obstructive sleep apnea, and dependence on supplemental oxygen. For each of these residents, physician orders were in place for oxygen therapy, specifying parameters such as flow rates and oxygen saturation targets. However, the care plans for these residents did not include interventions related to oxygen use or the use of respiratory support devices such as BiPAP or CPAP machines, despite their documented need for such interventions. Record reviews revealed that the medication administration records (MARs) for these residents did not document when or how much oxygen was administered, making it impossible to verify compliance with physician orders. In several cases, residents were observed using oxygen or reported using it as needed, but there was no corresponding documentation in the MAR or care plan. Interviews with facility staff, including the Unit Manager and Nurse Manager, confirmed that care plans lacked necessary interventions for oxygen therapy and that documentation of oxygen administration was absent from the electronic health record (EHR). Additionally, staff interviews indicated that some residents were on continuous oxygen, yet their orders were written as PRN (as needed), which was acknowledged as inappropriate by the Unit Manager. The lack of documentation and care planning for oxygen therapy and respiratory support devices was consistent across all five residents reviewed, despite their complex respiratory needs and physician orders requiring close monitoring and intervention.
Failure to Accurately Document and Implement Resident Advance Directives
Penalty
Summary
The facility failed to accurately document, order, and care plan a resident's wishes regarding advance directives for life-sustaining treatment. Record review showed that the resident's signed advance directive specified a do not resuscitate (DNR) status with a trial course of intubation and ventilation for five days. However, the electronic health record (EHR), care plan, and physician orders all reflected a DNR/do not intubate (DNI) status, which did not align with the resident's documented wishes. During an interview, the Assistant Unit Nurse Manager confirmed that the resident's advance directive indicated DNR with a trial of intubation for five days, and acknowledged that the current documentation, orders, and care plan did not reflect these wishes.
Failure to Limit PRN Psychotropic Medication Orders and Prevent Chemical Restraints
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that a resident was free from chemical restraints. A resident with cognitive impairment, Type II Diabetes, CHF, anxiety disorder, and chronic pain syndrome, who required substantial to maximal assistance with ADLs and hygiene, was prescribed Lorazepam 0.5 mg to be given every 12 hours as needed for anxiety, restlessness, or agitation for a 30-day period. The order was placed without documented rationale for exceeding the 14-day limit for PRN psychotropic medications, as required by facility policy. The medication was administered three times during this period, and the Unit Manager confirmed that the order was extended to 30 days without the necessary documentation or rationale in the medical record.
Failure to Conduct Timely Abuse Registry Check for Contracted LNA
Penalty
Summary
The facility failed to implement its policies and procedures related to screening for abuse for one of five employees reviewed. Specifically, a contracted Licensed Nursing Assistant (LNA) was hired and allowed to work on the floor without evidence that the required Adult Abuse Registry check had been conducted prior to employment, as mandated by facility policy. The Director of Nursing confirmed that the registry check was only completed after the LNA had already begun working, rather than before, as required. This deficiency was identified through interview and record review, and it is a repeat violation previously cited during earlier surveys.
Failure to Update Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans with pertinent information following significant changes in the condition and incidents involving two residents. For one resident with Parkinson's Disease, cognitive impairment, and dependence on staff for activities of daily living, there were two documented falls while being transported in a wheelchair. In both incidents, the resident put their feet down while being pushed, resulting in falls and injury, including a hematoma and pain requiring an emergency department visit. Despite these events and documentation in nursing and therapy notes that the resident did not keep feet on the footrests and had poor positioning, the care plan was not updated to include interventions related to the use of footrests to prevent further falls. Another resident with dementia, behavioral disturbances, and a history of trauma experienced a physical altercation with another resident, leading to visible anxiety and fear. Progress notes documented ongoing agitation, anxiety, and behavioral issues, including requests for increased safety measures and a room transfer to address negative interactions. Despite these documented changes and continued behavioral incidents, the resident's care plan was not revised to address the psychosocial impact of the altercation, nor were new interventions added following the room transfer or subsequent behavioral escalations. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed that care plans for both residents were not updated with new interventions or information following these significant events. The lack of timely care plan revisions and failure to document appropriate interventions contributed to the deficiency identified during the survey.
Failure to Prevent Accidents and Address Behavioral Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with Parkinson's Disease, cognitive impairment, and significant dependence on staff for activities of daily living experienced two falls while being transported in a wheelchair without footrests. In both incidents, the resident placed their feet on the floor while being pushed, resulting in falls—one of which led to a hematoma and complaints of pain, requiring an emergency room visit. Staff and therapy notes confirmed that the absence of footrests contributed to both falls, and staff were aware that the resident had difficulty keeping their feet on the footrests and tended to lean forward in the wheelchair. Another resident with dementia, behavioral disturbances, and a history of agitation and trauma exhibited ongoing wandering, agitation, and aggressive behaviors, including altercations with other residents. Despite documentation of these behaviors and a care plan update following an initial incident, no new interventions were added to address the resident's increased wandering and aggression. This lack of additional interventions resulted in continued disruptive and aggressive behavior, including a physical altercation with another resident in a wheelchair.
Failure to Document and Monitor Urinary Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters received appropriate treatment and services to prevent urinary tract infections. For one resident with multiple diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, acute kidney failure, urinary retention, and chronic kidney disease, there was an order to document fluid intake and urinary output as per facility policy. However, it was found that urinary output was not being tracked or documented in the resident's chart, despite a recent UTI diagnosis following a catheter change that resulted in cloudy urine and fever. The Nurse Manager confirmed that output tracking was not occurring and was not documented in the resident's records. Similarly, another resident with diagnoses of obstructive and reflux uropathy, acute kidney failure, and urinary retention also had an order for an indwelling Foley catheter. Review of the electronic health record revealed no documentation of urinary output for this resident. The lack of documentation and monitoring of urinary output for both residents with indwelling catheters represents a failure to provide appropriate catheter care and to implement interventions necessary to prevent urinary tract infections.
Medications Improperly Stored Without Assessment or Lock Box
Penalty
Summary
Facility staff failed to store medications in accordance with accepted professional principles for one resident. During an observation, multiple topical medications, including Clotrimazole Cream, Tacrolimus Ointment, and Hydrocortisone Cream, were found unsecured in the resident's room, which the resident shared with another individual. Interviews with a Licensed Practical Nurse and the Unit Manager confirmed that the resident did not have a completed medication self-administration assessment, which is required for residents to keep medications in their rooms. Additionally, staff stated that if such an assessment had been completed, the medications should have been stored in a lock box, which was not the case.
Failure to Provide Adaptive Drinking Equipment for Resident with Tremor and Swallowing Issues
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus, essential tremor, mild cognitive impairment, and a history of swallowing problems was not consistently provided with the adaptive drinking equipment specified in their care plan. The care plan required the use of a two-handled mug with a spouted lid for all beverages, as well as other adaptive utensils, to address the resident's tremor and risk of aspiration. Observations over multiple meals showed that the resident was frequently given drinks in standard cups, mugs, or glasses without lids or straws, resulting in repeated spills and an inability to consume fluids independently. Staff were present in the dining area but did not ensure that all beverages were transferred into the appropriate adaptive cups as required by the care plan. Interviews with staff confirmed that the resident was supposed to have multiple adaptive cups for different beverages, but this was not consistently provided. The LPN acknowledged the resident's need for covered drinks and noted that only one adaptive cup was typically provided. The dietary supervisor stated that the kitchen had sufficient adaptive cups available and that it was the responsibility of the floor staff to transfer beverages and request additional cups as needed. The speech language pathologist and RN unit manager both confirmed the expectation for multiple adaptive cups to be available for residents requiring them. Despite these care plan interventions and staff awareness, the resident was observed struggling to drink and eat independently, with significant portions of meals and fluids left unconsumed due to the lack of appropriate adaptive equipment.
Survey Results Not Accessible to All Residents
Penalty
Summary
The facility failed to provide state survey results in an accessible location for residents and their representatives. During an observation, it was noted that the survey results were not posted on the second floor, where all residents reside, but only on the first floor. A resident who is dependent on staff for activities of daily living and hygiene, and who has no cognitive deficits, reported being unable to access the first floor due to mobility limitations. The Activities Director confirmed that the survey results were not available on the second floor, corroborating the resident's statement.
Failure to Conduct Required National Background Checks on Nursing Staff
Penalty
Summary
The facility failed to implement national background checks for two out of five sampled employees, specifically a registered nurse and a licensed practical nurse, who had been employed for approximately thirteen and ten years, respectively. Review of their personnel files revealed that neither had a national background check on file, despite both having worked at the facility for an extended period. The facility's Prevention of Abuse policy did not address the requirement for national background checks for all employees, focusing instead on reference checks, compliance with state CORI law, and contacting relevant licensure boards and registries. Further review of communications from the licensing agency showed that memos were sent to nursing facilities outlining the requirement for national criminal background checks prior to employment and at least annually thereafter. These memos also specified that facilities must not employ individuals with certain criminal convictions. During interviews, the DON confirmed that national background checks were not performed for the two nursing staff members and stated a lack of awareness regarding the CMS memo outlining this requirement.
Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A resident with quadriplegia, cerebral palsy, and decreased range of motion, who requires a mechanical lift and assistance from two staff members for mobility, was not protected from sexual abuse by another resident. The cognitively intact resident was unable to reposition themselves in bed and was therefore unable to move away from their roommate, who is independently mobile in a wheelchair. On multiple occasions, staff observed the roommate sitting next to the resident's bed and masturbating. The roommate was also seen rummaging through the resident's personal belongings. The affected resident reported feeling uncomfortable and scared as a result of these incidents. Facility records, including care plans and progress notes, document that staff intervened when the roommate was found engaging in inappropriate behavior but the incidents recurred. The facility's abuse prevention policy defines such actions as abuse, regardless of the mental or physical condition of those involved. Interviews with the DON and Administrator confirmed the events, and the resident's discomfort and fear were substantiated by both staff observations and the resident's own statements.
Failure to Identify and Report Sexual Abuse Incident
Penalty
Summary
The facility failed to identify, investigate, and report an incident of sexual abuse involving a resident. According to the facility's abuse prevention policy, all alleged abuse, including sexual abuse, must be reported to the appropriate authorities. Record review revealed that a resident was subjected to forced observation of masturbation by their roommate, which caused the resident to feel uncomfortable and scared. Documentation showed that the roommate was found rummaging through the resident's personal belongings and then masturbating beside the resident's bed. Despite being aware of the incident, the DON and Administrator confirmed that they did not recognize the event as sexual abuse and therefore did not investigate or report it to the State Survey Agency as required.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a staff member's inappropriate behavior. The resident, who has a diagnosis of dementia and has been residing at the facility since 2022, was reportedly yelled at by a nurse, causing the resident to cry. A family member expressed concerns about the nurse's behavior, describing the nurse as rude and blunt. The facility's investigation, which included interviews with staff, confirmed that the nurse had been loud and rude to the resident and other residents on multiple occasions. The Director of Nursing acknowledged that the nurse did not treat the resident with respect and dignity, and the allegations were substantiated.
Failure to Update Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident identified as high risk for pressure injuries. The resident, who had a history of a fractured right hip and was reliant on staff for repositioning, was assessed on 1/30/2024 with a Braden score indicating high risk for pressure injuries. Despite this assessment, the care plan was not updated to include necessary interventions such as frequent repositioning, offloading the sacrum, and heel elevation as per the facility's wound care protocol. The deficiency was further highlighted when the resident developed a deep tissue injury (DTI) to the sacrum on 2/20/2024, with no evidence of updated care plan interventions until 7/18/2024. Additionally, a second DTI was identified on the resident's right heel on 7/18/2024, yet interventions like heel off-loading devices were not implemented until after the injury occurred. The Unit Manager confirmed the lack of documented evidence for updated care plans or implemented interventions prior to the injuries, indicating a significant oversight in the resident's care management.
Failure to Implement Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to prevent pressure injuries for Resident #47, who was identified as high risk for pressure injury due to decreased mobility and reliance on staff for repositioning. Despite being assessed as high risk on 1/30/2024, the facility did not implement necessary preventative measures such as turning, positioning, and heel elevation as per their policy. The resident developed a deep tissue injury (DTI) to the sacrum on 2/20/2024, and a second DTI to the right heel on 7/18/2024, indicating a lack of timely intervention. The facility's care plan for Resident #47 was not updated with appropriate interventions until after the pressure injuries had developed. The care plan interventions for turning and repositioning were only added six months after the initial pressure injury occurred. Interviews with the Unit Manager and Director of Nursing confirmed that the facility did not follow their policy to prevent pressure injuries, as there was no documented evidence of the required interventions being implemented prior to the development of the injuries.
Failure to Provide Trauma-Informed Care for Residents
Penalty
Summary
The facility failed to provide trauma-informed care for two residents who are trauma survivors, leading to potential re-traumatization. Resident #10, who has a history of trauma related to children being molested by a spouse, reported that certain interactions with other residents trigger past traumatic experiences. Despite this, the resident's care plan lacked any identified triggers, which is contrary to the facility's policy on trauma-informed care. The Social Service Staff confirmed the absence of identified triggers in the care plan and acknowledged that specific residents are a trigger for Resident #10. Similarly, Resident #71, who has a history of trauma from natural and human-caused disasters, accidents, war, and physical and emotional abuse, also did not have identified triggers in their care plan. The care plan included interventions to respond to triggers and modify care as needed, but no specific triggers were documented. Additionally, a referral for therapy support, which was part of the care plan, had not been initiated. The Social Service Staff confirmed the lack of identified triggers and the absence of a therapy referral for Resident #71.
Failure to Document Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses were completed and documented in the resident record for one of the sampled residents. The resident had multiple physician orders for the antipsychotic medication quetiapine over the past year. A pharmacist's medication regimen review in February 2024 recommended that PRN antipsychotic orders should only be for 14 days, with reassessment and clinical rationale documented every 14 days, as per the November 2017 Medicare MEGA Rule regulations. The pharmacist recommended changing the PRN quetiapine order to a 14-day duration in March, May, June, and July 2024. However, there was no evidence in the resident's medical record that the attending physician reviewed and acted upon the pharmacist's recommendations for these months. During an interview, the Clinical Nurse Coordinator confirmed the absence of evidence that a physician reviewed and took action on the pharmacy recommendations made in February, March, May, June, and July 2024 for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by two separate incidents. In the first incident, Resident #25 entered Resident #73's room and physically assaulted them, resulting in scratches and emotional distress for Resident #73. Despite the occurrence, Resident #25's care plan was not updated with interventions to prevent future altercations. The Director of Nursing confirmed the incident and acknowledged the lack of updates to the care plan. In the second incident, Resident #21 physically and verbally abused Resident #84. Despite a history of altercations and a care plan indicating a risk for inappropriate interactions, no staff intervention occurred when Resident #21 approached Resident #84 in a common area. The Unit Manager confirmed the absence of interventions to maintain distance between the two residents, and the Administrator acknowledged the incident, confirming that Resident #84 was not free from abuse.
Deficiency in Abuse Prevention Policies and Procedures
Penalty
Summary
The facility failed to develop comprehensive written policies and procedures addressing the prevention of abuse, neglect, and theft, as required by regulations. The existing policy, titled 'Preventing, Reporting, and Investigating Resident Abuse, Mistreatment, Exploitation and Neglect,' lacked essential components such as screening potential employees for histories of abuse, neglect, or exploitation, and screening prospective residents to ensure the facility could meet their care needs. Additionally, the policy did not include necessary training for staff on recognizing, reporting, and preventing abuse and neglect, nor did it address the identification of abuse types or the establishment of a safe environment for residents. The deficiency was confirmed through a review of the facility's policy and an interview with the Director of Nursing, who acknowledged the absence of additional policies or procedures related to the required topics. The facility's failure to include these critical elements in their policies and procedures indicates a significant oversight in ensuring the safety and well-being of residents, as well as compliance with regulatory standards.
Inadequate Staff Training on Abuse and Dementia Management
Penalty
Summary
The facility failed to develop and implement an effective training program for staff on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. During the investigation of abuse allegations, it was found that the educational materials used for staff training were inadequate. The materials, which included PowerPoint presentations titled 'Preventing & Reporting Resident Abuse, Misappropriation, Exploitation, and Neglect (AMEN)' and 'Abuse and Neglect,' lacked critical information. They did not cover recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, nor did they address understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. Additionally, the training materials failed to identify behaviors constituting abuse, neglect, exploitation, and misappropriation of resident property. The Nurse Educator confirmed that these materials were the entirety of the training resources available, with no additional materials covering the missing topics.
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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