Barre Gardens Nursing And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Barre, Vermont.
- Location
- 378 Prospect Street, Barre, Vermont 05641
- CMS Provider Number
- 475037
- Inspections on file
- 26
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 13 (3 serious)
Citation history
Health deficiencies cited at Barre Gardens Nursing And Rehab, Llc during CMS and state inspections, most recent first.
The facility did not maintain clean air vents and related ceiling surfaces in three common dining areas, where 14 ceiling vents were observed with dark black, speckled, fuzzy residue covering about half to three-quarters of each vent, and multiple ceiling tiles showed brown water stains. The Maintenance Director confirmed the buildup on vents and stains, reported no records of vent cleaning and stated vents had not been cleaned during his four months in the role, while also noting dust on four sprinklers. Facility policy requires annual cleaning of vents and air handling units, and the Administrator acknowledged vents should also be cleaned when dusty. The IP confirmed the vents needed cleaning, and the DON reported that a significant number of residents had chronic respiratory diagnoses. Information from a NADCA-certified company cited by surveyors stated that dirty ducts can accumulate contaminants and, in settings with residents who have compromised respiratory status, can contribute to exacerbation of chronic respiratory illnesses.
The Medical Director did not establish or maintain systems for monitoring physician regulatory visits or for consistent communication among medical providers. The Medical Director was not familiar with attending physicians listed in the facility assessment and was not promptly notified of a COVID outbreak, learning of it only after several days had passed and multiple staff and residents had tested positive.
The facility did not provide a timely or effective system for preventing, identifying, and controlling infections, as shown by delayed notification of a COVID-19 outbreak, failure to vaccinate residents who had consented, and significant lapses in environmental cleanliness and sanitation. Staff interviews confirmed inadequate housekeeping staffing, lack of regular disinfection of high-touch surfaces, and absence of recent training or audits, all contributing to the deficiency.
Surveyors found widespread unclean and unsafe conditions throughout resident rooms, bathing areas, and common spaces, including dirty floors, soiled equipment, mold, mildew, and debris. Staff and the Administrator confirmed inadequate housekeeping staffing, resulting in persistent cleanliness and safety issues affecting all residents.
Surveyors found multiple expired food items, improper storage of ready-to-eat foods with raw meat, unsealed food containers, wet-nested kitchenware, and a dusty fan in the food prep area. A dietary staff member confirmed these unsanitary practices, which have been cited in previous surveys.
The facility did not timely offer or administer the COVID-19 vaccine to eligible residents and staff who had provided consent, resulting in several residents contracting COVID-19 before vaccination. Additionally, there was a delay in notifying the Medical Director about the outbreak, and vaccination efforts only began several days after the initial cases were identified.
The facility did not ensure that required physician regulatory visits were completed on schedule for multiple residents, with many only receiving visits from NPs or PAs, and some not having any regulatory visit documented within the required timeframes. Both the Medical Director and physician confirmed that regulatory visits were behind and that no tracking system was in place to monitor compliance.
A resident with cognitive and psychiatric diagnoses who required extensive assistance with eating was observed being fed by an LNA who stood and leaned over the resident, rather than sitting at eye level as required by facility policy. The LNA stated this was their personal practice, despite orientation and policy emphasizing the importance of maintaining resident dignity during care.
A resident with diabetes, impaired mobility, and peripheral vascular disease was found with long, thick, discolored toenails and dry feet, having not received regular nail care or a podiatry consult as required by their care plan. Staff confirmed the lack of podiatrist availability and that nail care was not being performed regularly, contrary to facility policy.
A resident with Alzheimer's disease and related conditions repeatedly became distressed after an LPN reminded them of a family member's death, contrary to the resident's care plan interventions for dementia and grief. Staff did not utilize care-planned strategies such as supportive conversation or grief assistance, resulting in repeated episodes of upset and exit-seeking behavior.
A pharmacy delivery was accepted by an LPN, who entered the medication room with the delivery person. The LPN then left the delivery person alone in the medication room for several minutes, which both the LPN and Administrator confirmed should not have occurred. This incident represents a repeat deficiency regarding unauthorized access to medication storage areas.
A review of training records revealed that an LNA did not have documentation of completing the required 12 hours of annual training, including education in dementia care and abuse prevention. The DON was unable to provide evidence of this training during the survey.
The facility did not timely review or revise care plans for two residents with falls and two residents with pressure ulcers. One resident developed a deep tissue injury that was not added to the care plan until after a hospital transfer, while another experienced repeated falls and altercations without care plan updates after the first incident. A resident with dementia and aggressive behaviors did not have care plan updates reflecting psychiatric recommendations, and another with a heel ulcer did not have required interventions documented. These deficiencies were confirmed by staff interviews and record reviews.
Two residents with histories of falls and aggressive behaviors were not provided with adequate supervision or timely interventions, resulting in repeated altercations and injuries, including a hip fracture and multiple hematomas. Despite recommendations for 1:1 supervision for a resident with dementia and aggressive tendencies, this was not implemented, and lapses in supervision and unsafe equipment use were observed, contributing to multiple falls and injuries.
A resident's hearing aids, valued at $6,495, went missing and were not documented on the admission belongings list, nor was the responsible party notified of their loss. Nursing notes indicated the hearing aids had been missing for about two weeks, but there was no evidence of communication to the DPOA, and the required inventory form was incomplete and unsigned.
A resident who was admitted with bilateral hearing aids lost both devices, and despite nursing documentation and attempts to notify social services, there was no evidence that the DPOA was informed or that a follow-up appointment with audiology was scheduled. Facility staff confirmed the lack of communication and failure to arrange necessary hearing services.
A resident's funds were not distributed to the estate administrator within the facility's required 30-day period after the resident's death. The family representative did not receive the reimbursement check, totaling about $1,400, until 85 days after the resident passed away, despite facility policy mandating timely distribution.
A resident with hemiplegia and hemiparesis was subjected to disrespectful behavior by an LNA, who placed the resident near the nurse's station and made an undignified remark. This incident was witnessed by an LPN and another LNA, and the facility confirmed the allegations of disrespectful behavior. The administrator acknowledged the incident as undignified and disrespectful.
The facility failed to honor residents' rights by keeping doors locked 24/7, requiring staff assistance for entry and exit, and not respecting residents' preferences for daily routines. A resident was forced to wake up at inconvenient times, and several residents reported missing clothing issues. Resident Council meetings were scheduled without resident input, and two residents were not served meals with dignity, highlighting a lack of attention to individual needs.
The facility failed to serve food at palatable temperatures, with residents receiving meals that were hard, dry, and cold. Observations showed that food was not maintained at appropriate temperatures due to improper tray sizes on steam tables, leading to unappetizing meals.
The facility failed to provide bedtime snacks to residents when the time between dinner and breakfast exceeded 14 hours, as required. Residents reported not being offered snacks, and a diabetic resident expressed concern about managing blood sugar levels overnight. The Resident Council was not informed or consulted about the extended meal gap, and the facility administrator was unaware of these issues.
The facility failed to adhere to food safety standards, with observations of expired and unlabeled food, dirty kitchen conditions, and the use of unpasteurized eggs. The Dietary Manager confirmed the lack of a cleaning schedule and the risk posed by serving undercooked eggs to residents.
The facility's Governing Body failed to ensure that policies were accessible to staff, potentially affecting all residents. The Administrator and other staff members, including an LPN and the Unit Manager, were unable to access policies, which are managed by the Regional Clinical Director and stored on computers without staff access. The issue was acknowledged by corporate leadership, but no resolution was provided.
The facility did not involve the medical director or governing body in developing the facility-wide assessment. The assessment was completed by the LNHA and RN, but the medical director confirmed no involvement in its development, review, or revision. The administrator also stated that the governing body was not involved, although updates were provided during compliance calls.
The facility's Medical Director failed to coordinate medical care and assist in developing resident care policies. The Director was unaware of deficiencies in regulatory visit notes, which did not meet care review standards, and lacked access to facility policies. This oversight affected multiple residents, as their comprehensive care plans were not adequately reviewed.
The facility failed to maintain an effective infection prevention and control program. A resident on contact and droplet precautions was observed without a mask in common areas, contrary to policy. Additionally, an LPN improperly cleaned a glucometer with isopropyl alcohol, which does not meet the manufacturer's disinfection guidelines.
The facility failed to maintain a safe and homelike environment, with issues including a repeatedly falling chair rail strip, inaccessible call bells for a resident, indentations in linoleum flooring, and privacy curtains tied over beds causing discomfort. Maintenance and staff were aware of these issues, but residents reported ongoing problems.
The facility failed to update care plans for two residents, leading to deficiencies in catheter use, pain management, and activity preferences. One resident's care plan did not reflect the use of a leg bag for increased independence, and their pain management plan was not adjusted despite a lack of reported pain. Another resident's activity care plan was not updated to reflect increased social engagement after a fall. These oversights resulted in care plans that did not align with the residents' current needs and preferences.
The facility failed to provide an adequate activities program, affecting several residents' well-being. A resident expressed dissatisfaction with the lack of engaging activities, and observations showed that on certain days, there were no formal activities, leaving residents with unsuitable independent activity carts. Another resident, care planned for activities due to cognitive deficits, was not offered activities consistently, failing to meet care plan objectives. A third resident expressed boredom due to insufficient activities, with logs showing limited participation, highlighting the facility's failure to provide adequate stimulation and social interaction.
The facility failed to ensure that physicians and providers reviewed the total program of care, including medications and treatments, for several residents at each required visit. Documentation did not meet regulatory standards, with discrepancies noted in medication orders. Interviews revealed a lack of awareness and monitoring by the Medical Director, contributing to the deficiency.
The facility failed to ensure face-to-face physician visits for required regulatory visits and lacked a system to track these visits. A resident was not seen in person by their physician, and another resident did not receive visits every 30 days as required. The Medical Records Specialist did not track regulatory visits, and the Medical Director assumed the Nurse Practitioner was conducting the necessary visits without verification.
The facility failed to ensure physicians documented their rationale for disagreeing with pharmacist recommendations during monthly medication reviews for several residents. Recommendations included reducing Ambien for a resident with falls, obtaining a Vitamin D level, tapering Morphine, and evaluating Oxycodone therapy. Physicians either disagreed without providing a rationale or agreed without following through, as confirmed by staff interviews.
The facility failed to ensure GDRs for psychotropic medications for three residents. A resident on Venlafaxine had no GDR consideration, with the pharmacist assuming contraindication without documentation. Another resident on Sertraline had no GDR or contraindication documentation, with the physician unaware of requirements. A third resident on clozapine and venlafaxine also lacked GDR consideration, with the Unit Manager confirming no GDRs for schizophrenia.
The facility failed to maintain complete medical records for two residents. One resident's records were missing several provider visit notes, including a hematology progress note and an emergency department note related to an opiate overdose. Another resident's records lacked physician visit notes upon admission. The absence of these records was confirmed by the Unit Manager and Medical Records Specialist.
A facility failed to develop a comprehensive care plan for a resident on anticoagulants, despite the resident's admission with a physician order for enoxaparin due to conditions like heart failure and chronic pulmonary embolism. The care plan addressing anticoagulant use was not created until months after admission, as confirmed by interviews with the Unit Manager and DON.
A resident was administered Morphine Sulfate consistently for pain and shortness of breath, despite not reporting pain since February. A pharmacist recommended evaluating the need for the medication, but the physician disagreed without providing a rationale. The resident's representative expressed concerns about unnecessary medication. The NP, new to the facility, was unaware of the family's concerns and had not evaluated the resident. The DON confirmed the NP could not disagree with the dose reduction without an evaluation.
A resident with a history of pulmonary embolism did not receive their prescribed anticoagulant, Lovenox, for 49 days due to a lapse in renewing the medication order. The resident's representative discovered the issue when reviewing facility charges, and facility staff could not provide an explanation for the discontinuation. Interviews confirmed the medication should not have been stopped, resulting in a significant medication error.
A resident was unable to access their call bell due to a short cord, despite their care plan requiring it to be within reach due to fall risk and muscle weakness. An LPN was unaware of the issue until it was pointed out during a survey, and the resident suggested attaching the call bell to the bed rail for better access.
A facility failed to ensure proper care for a resident with a Peripheral IV, lacking orders for monitoring and dressing changes. The resident was receiving intravenous antibiotics, but the care plan did not include the IV, and the dressing was not changed according to policy. The Unit Manager admitted to assuming the IV would be temporary, leading to the oversight.
The facility failed to ensure binding arbitration agreements allowed for a neutral arbitrator and a convenient location for two residents. The agreements specified that arbitrations would be administered by ADR Options, Inc. and conducted at a site chosen by the facility within ten miles. The administrator confirmed the absence of required language for neutral arbitrator selection and location convenience.
Failure to Maintain Clean Air Vents and Ceiling Surfaces in Common Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in three resident common areas by not keeping ceiling air vents and related components clean. Facility policy for Plumbing, HVAC and Related Systems, revised in 2011, requires air vents and air handling units to be cleaned at least annually. Observations of three resident common areas revealed 14 ceiling air vents with a black and brown substance that appeared dark black, speckled, and fuzzy, covering approximately 50–75% of each vent. Multiple ceiling tiles in these areas also had brown stains that the Maintenance Director identified as old water damage. In addition, four sprinklers in one dining area had a gray substance on them that the Maintenance Director believed was dust. The Maintenance Director confirmed the presence of black and brown residue on the vents and brown stains on ceiling tiles and stated he did not have records of when the vents were last cleaned, noting they had not been cleaned during his approximately four months in the role. The Administrator stated that ducts are to be cleaned annually per facility policy and that maintenance is responsible, and acknowledged that vents should also be cleaned when they become dusty. The Infection Preventionist confirmed that the ceiling vents needed to be cleaned. The DON reported that 27 of the 87 residents in the facility had chronic respiratory diagnoses. A NADCA-certified company’s information, reviewed by surveyors, stated that air ducts can accumulate dust, debris, allergens, and pathogens over time and that in hospitals and nursing homes this can pose increased risk to residents with compromised immune systems or respiratory issues, and that dirty ducts can circulate contaminants and potentially exacerbate chronic respiratory conditions such as asthma, allergies, and other respiratory illnesses.
Failure of Medical Director to Coordinate Medical Care and Oversee Resident Care Policies
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled responsibilities related to the coordination of medical care and the development and implementation of resident care policies. The Medical Director acknowledged during interview that there was no system in place to monitor regulatory visits by physicians and that a process for required regulatory visits was still being developed. Additionally, the Medical Director stated there was no consistent or scheduled communication between medical providers regarding facility issues or resident status. The Medical Director was unfamiliar with the attending physicians listed in the facility assessment and indicated reliance on the Acting Physician for updates, but no formal process for regular reporting was in place. Further, the Medical Director was not promptly notified of a COVID outbreak in the facility. The Acting Physician informed the Medical Director of the outbreak only after several days had passed since the first case was identified. Facility infection control records showed that the initial COVID cases were identified 11 days prior, and by the time of the survey, multiple staff and residents had tested positive. The lack of timely communication and absence of established processes for coordination and oversight contributed to the deficiency.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by a lack of timely identification, reporting, and management of a COVID-19 outbreak. The Medical Director was not notified of the initial COVID-19 case until 7-10 days after it was identified, despite facility records showing the first resident and staff member tested positive 11 days prior. By the time of the survey, 16 residents and 8 staff members had tested positive. Additionally, although 8 residents had provided consent for the COVID vaccine, none received it before becoming infected, and vaccination only began 10 days after the initial case was identified, despite prior planning to receive the vaccine. Environmental observations revealed significant lapses in sanitation and cleanliness throughout the facility. Surveyors noted dirty floors, debris, dust-covered bathroom fans, unclean toilets, and evidence of mold and mildew in bathrooms. Common areas and resident rooms contained soiled furniture, food debris, and unsanitary conditions such as dirty shower chairs, broken tiles, and unbagged trash cans. High-touch surfaces were not regularly disinfected, and cleaning supplies and protocols were not consistently followed. Interviews with facility staff, including the Infection Preventionist and Administrator, confirmed that housekeeping was inadequately staffed, leading to irregular cleaning schedules. Leadership team members were assisting with cleaning duties, but there was no evidence of recent education, training, or audits related to cleaning practices. The lack of routine and targeted cleaning and disinfection of high-touch and common area surfaces was inconsistent with CDC guidelines and contributed to the facility's failure to control the spread of infection.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and unsafe conditions throughout resident rooms, bathing areas, and common spaces. Surveyors observed dirty floors with loose debris, broken and jagged metal on corner beads, broken floor and wall tiles, and significant dust accumulation on fans and vents. Bathing areas contained soiled equipment, such as tub chairs with powdery and thick white and gray substances, shower chairs with residue, and rolling carts with unboxed gloves and personal care items stored inappropriately. The presence of mold, mildew, and rust was noted in several shower and bathroom areas, and some call bell pulls were makeshift and unsanitary. In addition, there were instances of unflushed toilets, brown residue on surfaces, and hair and debris in drains and on floors. Common areas, such as the sunroom and nurse's station, were also found to be unclean, with trash cans lacking liners, dirty coffee carafes, food debris, and spills on floors and furniture. Partially eaten food and dirty dishes were left out for extended periods, and residents were brought into these unclean areas for meals. The nurse's station had a thick pile of crumbs, and there were multiple reports of hair, insects, and other debris in hallways and near resident rooms. Furniture was found to be worn, with exposed stuffing and damaged surfaces, and some resident rooms had broken doors, torn pillow covers, and privacy curtains with dried substances. Interviews with staff, including LPNs, the Infection Prevention staff member, and the Administrator, confirmed the lack of adequate housekeeping staff and the inability to maintain cleanliness and safety standards. Housekeeping schedules revealed minimal staffing, with some days covered only by staff in orientation and no one available to orient them. Leadership staff were reported to be assisting with cleaning due to the shortage, but the facility remained unclean. The Administrator and other staff acknowledged the ongoing issues and confirmed that the facility was not being maintained in a clean or safe condition for residents.
Repeat Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
Surveyors observed multiple instances of improper food storage and unsanitary food handling practices in the facility's kitchen and food storage areas. In the dry food storage area, several food items were found to be expired, including gluten free pasta, baking mix, and pasta, as well as thickened juice products that were not discarded within the required timeframe after opening. The Dietary Staff Member confirmed that these items should have been discarded and acknowledged their expired status. In the walk-in refrigerator, two packages of deli ham were stored on a tray with raw hamburger and were sitting in raw meat juices, while in the walk-in freezer, a box of hamburger patties was left open and unsealed. The staff member confirmed that ready-to-eat foods should not be stored with or on raw meat and that open food containers should be sealed. Additional observations in the kitchen area included preparation trays, cups, and dishes being stored while still wet (wet nesting) and a floor fan facing the food preparation area that was covered with dust and debris. The Dietary Staff Member confirmed these unsanitary conditions. These findings represent a failure to store food safely and maintain sanitary conditions for food handling, as required by professional standards. This deficiency has been cited in the facility's previous three recertification surveys.
Delayed COVID-19 Vaccination and Notification During Outbreak
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure that all eligible residents and staff were offered the COVID-19 vaccine in a timely manner, as required. Although the facility's infection prevention and control policy referenced encouraging vaccination, it did not ensure that the vaccine was actually offered and administered to those who consented. Documentation showed that 16 residents tested positive for COVID-19 during a specified period, and interviews revealed that the Medical Director was not notified of the outbreak until several days after the initial cases were identified. The first cases were detected 11 days prior to the survey, but the Medical Director was only informed on the day of the survey, indicating a breakdown in communication and timely response. Record review indicated that, of 10 residents sampled who tested positive for COVID-19, 8 had provided consent to receive the vaccine but did not receive it before becoming infected. The facility only began vaccinating residents 10 days after the initial infection was identified, despite having documentation from a prior Quality Assurance Performance Improvement meeting that the vaccine would be received. This delay in offering and administering the vaccine to consenting residents contributed to the deficiency, as the facility did not follow through with timely vaccination despite having the necessary consents and advance notice of vaccine availability.
Failure to Complete Timely Physician Regulatory Visits
Penalty
Summary
The facility failed to ensure that physician visits for residents were conducted in accordance with regulatory requirements. Specifically, physician visits did not occur every 30 days for the first 90 days after admission and at least once every 60 days thereafter for 12 out of 25 residents reviewed. Medical record reviews revealed that several residents had not received timely in-person regulatory visits by a physician, with some only being seen by nurse practitioners or physician assistants, and others not having any regulatory visit documented within the required timeframes. Interviews with the facility's Medical Director and physician confirmed that regulatory visits were significantly behind schedule. The physician acknowledged being aware of the backlog and stated that acute care needs and crisis management had taken precedence over routine regulatory visits. The physician also clarified that acute care visits were not counted as regulatory visits, as regulatory visits are more comprehensive and must be specifically documented as such. The facility's policy requires that the medical care of each resident be supervised by a licensed physician, including conducting routine required visits in accordance with OBRA regulations. Despite this, multiple residents did not receive their initial or subsequent regulatory visits within the mandated periods. Both the Medical Director and the physician confirmed awareness of the deficiency and the lack of a tracking system for regulatory visits at the time of the survey.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, bipolar disorder, and schizophrenia, who requires extensive assistance with eating, was observed being assisted by an LNA during lunch. The LNA stood next to the resident and leaned over to place food in the resident's mouth, rather than sitting at eye level as required by facility practice and policy. The care plan for the resident specifically noted the need for staff to encourage self-feeding and to assist in a manner that promotes dignity. During an interview, the LNA stated a personal choice not to sit at eye level with residents while assisting with eating, and confirmed this was not their practice, despite facility policy and orientation training that require staff to do so. The facility's policy, revised June 2023, emphasizes the right of residents to a dignified existence and to be treated with respect and dignity. The administrator confirmed that the expectation is for staff to sit at eye level when assisting residents with eating.
Failure to Provide Proper Foot and Nail Care
Penalty
Summary
A resident with a history of impaired mobility, diabetes mellitus, and peripheral vascular disease was observed sitting barefoot with dry feet and long, discolored, thick toenails. The resident reported that their toenails had not been trimmed in a long time and that they had not seen a podiatrist. The care plan indicated a need for podiatry consults and assistance with personal hygiene, but the last documented podiatry consult was over a year prior. Facility policy requires daily cleaning and regular trimming of nails to prevent infection. Interviews with staff confirmed that the resident's toenails were long and should be trimmed, and it was noted that there was no podiatrist available, with nail care being performed by the provider, who reported being able to address only urgent needs due to workload.
Failure to Implement Dementia and Grief Care Interventions
Penalty
Summary
A resident with diagnoses of Alzheimer's disease, adjustment disorder with anxiety, and depression repeatedly requested to call a deceased family member. On multiple occasions, an LPN responded by directly telling the resident that the family member had died, which resulted in the resident becoming visibly upset, exhibiting behaviors such as yelling, crying, wandering, and exit seeking. The LPN confirmed that these reminders of the family member's death consistently led to the resident's distress, and staff documentation showed that this approach was used at least seven times, each time resulting in negative behavioral responses. Review of the resident's care plan revealed interventions for both grief and dementia, including assisting with grief, encouraging expression of feelings, observing for factors delaying the grief process, and engaging the resident in calming conversations. However, during the observed interaction, these care plan interventions were not implemented. Instead, the staff's approach did not align with the documented strategies for supporting the resident's emotional and psychological needs related to dementia and grief.
Unauthorized Access to Medication Room by Delivery Personnel
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to the medication storage rooms, as required by regulations. During an observation, a pharmacy delivery was accepted by an LPN, who then entered the medication room with the delivery person. The LPN left the medication room, leaving the delivery person alone inside for approximately five minutes before the delivery person exited. In interviews, both the LPN and the Administrator confirmed that the delivery person should not have been left alone in the medication room. This is a repeat deficiency, having been cited during the previous recertification survey.
LNA Annual Training Documentation Deficiency
Penalty
Summary
The facility failed to provide evidence that a Licensed Nursing Assistant (LNA) received the minimum 12 hours of annual training required to ensure continuing competence. Review of employee training records showed that one LNA, who started before the 2025 calendar year, did not have documentation of completing the required annual training. During an interview, the Director of Nursing (DON) was unable to produce evidence that this LNA had fulfilled the 12-hour training requirement, which includes education in dementia care and abuse prevention.
Failure to Timely Update Care Plans for Falls and Pressure Ulcers
Penalty
Summary
The facility failed to review and revise care plans in a timely manner for multiple residents, resulting in deficiencies related to falls and pressure ulcers. One resident with hemiplegia, chronic kidney disease, and osteomyelitis developed a right heel blister that progressed to a deep tissue injury, but the care plan was not updated to reflect the wound or interventions until after the resident returned from a hospital transfer. The facility's own policy required the interdisciplinary care plan to identify risks and interventions for skin impairment, but this was not followed, and the DON was unaware of the wound until the hospital admission. Another resident experienced two separate incidents involving falls and altercations with a roommate, including being struck by a wheelchair and sustaining injuries such as a hematoma and pain. Despite these events, the care plan was not revised after the first incident to include measures to prevent further injury or address the risk of resident-to-resident altercations. The care plan was only updated after the second incident, and the DON confirmed the lack of documentation regarding the previous altercation. Additionally, a resident with dementia and a history of aggressive behaviors, including harming others and refusing medications, was recommended for 1:1 supervision and IM medication by a psychiatrist. However, the care plan was not updated to reflect these recommendations or new orders. Another resident with a stage 2 pressure ulcer of the heel had a treatment plan that included offloading pressure, but this intervention was not included in the care plan. These failures to update care plans were confirmed by staff interviews and record reviews.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure that residents remained as free from accidents as possible by not providing adequate supervision and timely, effective interventions for two residents with a history of altercations and falls. One resident, with diagnoses including a history of falls, osteoporosis, and failure to thrive, was independent with ambulation prior to the incident but suffered a fall after being struck multiple times by a roommate's wheelchair. This resulted in significant injuries, including a large hematoma above the left eye and a left hip fracture requiring surgery. The resident expressed ongoing fear for personal safety and reported previous similar incidents involving the same roommate, including a prior fall and injury. The roommate involved in these altercations has a documented history of dementia with agitated and aggressive behaviors, including wandering, physical aggression toward other residents and staff, and refusal of medications. A psychiatric consult recommended 1:1 supervision due to the resident's impulsivity and risk to self and others, but this intervention was not implemented or added to the care plan. There were no documented orders for 1:1 care, and staff interviews confirmed that supervision was inconsistent and not formally assigned. Observations revealed further lapses in supervision and safety, such as the resident being left unsupervised in a wheelchair that did not allow their feet to touch the floor, despite a known history of falls and attempts to stand unassisted. The resident had experienced multiple recent falls, resulting in injuries such as skin tears and blisters. Staff interviews confirmed the resident's restlessness, wandering, and unsafe behaviors, as well as the lack of appropriate supervision and interventions to prevent further accidents.
Failure to Document and Notify Loss of High Value Personal Property
Penalty
Summary
The facility failed to follow its processes for documenting and managing high value personal property for one resident. The resident's Durable Power of Attorney (DPOA) was not notified when the resident's hearing aids, valued at $6,495.00, went missing, and only learned of the loss when collecting the resident's belongings after the resident had passed away. Nursing notes indicated the hearing aids had been missing for approximately two weeks prior to the resident's death, but there was no documentation of notification to the DPOA. Additionally, the Inventory of Personal Effects completed at admission did not list the hearing aids, nor was it signed by the resident or responsible party, despite facility policy requiring this documentation and verification.
Failure to Schedule Audiology Follow-Up After Loss of Hearing Aids
Penalty
Summary
The facility failed to assist a resident in scheduling a follow-up appointment with an audiology provider after both of the resident's hearing aids went missing. The resident, who was admitted with reprogrammable bilateral hearing aids and had a care plan intervention indicating their use, was noted in nursing documentation to have lost the right hearing aid, with subsequent notes indicating both hearing aids were missing. Despite nursing staff leaving messages for social services regarding the missing devices, there was no documentation that the Durable Power of Attorney was notified, nor was there evidence that a referral or follow-up appointment with audiology was made. Interviews with facility staff confirmed a lack of communication and follow-up regarding the missing hearing aids and the absence of any scheduled audiology appointment.
Delayed Distribution of Deceased Resident's Funds
Penalty
Summary
The facility failed to distribute a deceased resident's funds to the individual administering the resident's estate within the required 30-day period. According to interview and record review, the family representative responsible for the resident's estate requested reimbursement of the resident's funds after the resident's death but did not receive the check, totaling approximately $1,400, until 85 days after the resident passed away. Documentation confirmed the date of the check request and delivery, and the facility's own policy requires distribution of such funds and a final accounting within 30 days to the appropriate party. The administrator confirmed that the funds were not distributed within the required timeframe.
Resident Rights Violation Due to Disrespectful Behavior
Penalty
Summary
The facility failed to protect and promote the rights of a resident by not treating them with respect and dignity, which is essential for maintaining or enhancing their quality of life. The resident, who had hemiplegia and hemiparesis following a cerebral infarction, was subjected to disrespectful behavior by a Licensed Nursing Assistant (LNA). The incident involved the LNA placing the resident, who was in a wheelchair, near the nurse's station and making an undignified remark, telling the resident to 'sit down and shut the [expletive] up.' This behavior was witnessed by a Licensed Practical Nurse (LPN) and another LNA, and the facility's report to the State Agency confirmed the allegations of undignified and disrespectful behavior by the LNA toward the resident. The facility's administrator acknowledged the incident and agreed that the manner of speaking to the resident was not dignified or respectful.
Facility Fails to Honor Residents' Rights and Preferences
Penalty
Summary
The facility failed to honor residents' rights to self-determination and access to the outside world by keeping all doors locked 24/7, requiring staff assistance for entry and exit. This policy, reportedly enforced by the corporate entity Priority Health Group, was observed during the survey period, with no residents seen outside independently. Interviews with residents and their families revealed frustration and a sense of imprisonment, as they were unable to come and go freely. The facility's social worker and LNAs confirmed the policy, citing safety concerns for dementia residents, but no formal policy or procedure was found to support this practice. Additionally, the facility did not respect residents' preferences regarding their daily routines. Resident #47 was forced to choose between waking up at 5 AM or waiting until 10 AM due to staff scheduling, which was not aligned with their personal preferences. The administrator was unaware of this issue, indicating a lack of communication and oversight in ensuring residents' rights to make personal choices about their daily activities. The facility also failed to address issues related to missing clothing for several residents, with reports of unresolved cases despite promises of reimbursement or replacement. The Resident Council meetings were scheduled by staff without input from residents, limiting their ability to invite family members. Furthermore, during meal service, two residents were not treated with dignity and respect, as they were either not served in a timely manner or were not provided with necessary utensils, highlighting a lack of attention to individual needs and preferences.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at an appetizing temperature. Observations and resident interviews revealed that the food, specifically a chicken patty, was difficult to cut, hard, and unappetizing. A resident demonstrated the hardness of the patty by banging it on a table, producing a clunking sound. Test trays sampled by the surveyor confirmed that the chicken patty was very dry and hard, requiring excessive effort to cut. The facility's administrator acknowledged that the meal was not acceptable for residents. Further observations during dinner service showed that food temperatures were not maintained at appropriate levels. A resident's hamburger was served at 91.8 degrees F, which was confirmed to be cold and unappetizing. Test trays and steam table temperatures indicated that the food was not held at the required temperatures, with burgers being served at temperatures significantly below the expected range. Dietary staff confirmed that improper tray sizes allowed steam to escape, preventing the food from being kept hot. The dietary manager acknowledged the inconsistency in serving food at palatable temperatures.
Failure to Provide Bedtime Snacks and Inform Resident Council
Penalty
Summary
The facility failed to provide nourishing snacks to residents at bedtime when the time between dinner and breakfast exceeded 14 hours. Residents were served dinner at 5:00 PM and breakfast at 8:00 AM, resulting in a 15-hour gap between meals. Interviews with residents revealed that they were not offered snacks before bed, with some residents, including those with cognitive impairments, unable to recall being offered snacks. Additionally, a diabetic resident expressed concern about not being offered snacks to help manage blood sugar levels overnight. The facility also did not ensure that the Resident Council was informed or agreed to the extended time between dinner and breakfast. During a Resident Council meeting, attendees stated that snacks were not offered unless requested, and there was no discussion about the regulation concerning meal timing. The facility administrator was unaware of the lack of snack offerings and the extended meal gap, despite believing that snacks were documented in the residents' electronic health records. Meeting minutes from previous months did not show any discussions about resident rights or meal timing.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial tour of the facility kitchen, several deficiencies were observed, including a reach-in refrigerator containing a large container of bulk iced tea with an expired use-by date, and a steam table with dried, crusted food drippings and an unlabeled bag of hamburger buns with condensation. Food prep tables were found with spilled milk, dropped applesauce, and crumbs, while a small table was cluttered with food particles, an opened container of peanut butter, and other items. The kitchen floors were dirty with dried spills and trash, and oven racks were improperly stored on the floor. Clean knives were stored near a sink with an unknown orange oily substance on the walls and ceiling, and the sink contained dirty items. The walk-in refrigerator had unlabeled and undated food items, including pieces of cake, a cut watermelon, and cubed turkey pieces. The Dietary Manager confirmed these observations and acknowledged the lack of an assigned cleaning schedule or check-off list for cleaning tasks. Additionally, the facility was found to be using unpasteurized eggs, which were not labeled as pasteurized, posing a risk for foodborne illness. The Dietary Manager was under the impression that the eggs ordered were pasteurized, and it was confirmed that five residents daily were served over-easy eggs, which are undercooked. The facility's food vendor order did not include an option for pasteurized eggs approved by the corporate office. This oversight in ordering and serving unpasteurized eggs to residents further highlights the facility's failure to adhere to food safety standards.
Facility Governing Body Fails to Ensure Policy Accessibility
Penalty
Summary
The facility's Governing Body failed to ensure that facility policies were accessible to all staff members, which has the potential to affect all residents in the facility. During interviews, the Administrator admitted to being unable to access all facility policies and stated that staff would need to obtain them through the corporate leadership team. It was revealed that policies are stored on desktop computers, but staff do not have access to them. This issue was acknowledged by the corporate team, but no resolution was provided. A Licensed Practical Nurse and the Unit Manager also confirmed their inability to access or navigate the policies, indicating that they would need to contact the clinical on-call person or the Director of Nursing for assistance. Further interviews revealed that the Social Service Director was also unable to access the policies. The Administrator mentioned having quarterly calls with the Governing Body, who were aware of the access issues. When the surveyor attempted to contact the Regional President of Operations for clarification, the individual refused to answer questions, deferring to the Administrator. The Administrator explained that policies are managed by the Regional Clinical Director and are generic, not facility-specific. The only policy produced was titled 'Administrative Protocols,' which stated that manuals should be available at the facility, but the Administrator confirmed that this was not the case.
Lack of Involvement in Facility Assessment Development
Penalty
Summary
The facility failed to ensure the involvement of required individuals, including a representative of the governing body and the medical director, in the development of the facility-wide assessment. The assessment, last updated on April 9, 2024, was completed by the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (RN), but did not include input from the medical director or the governing body representative. During an interview on May 9, 2024, the medical director confirmed that they had not been involved in the development, review, or revision of the facility assessment. Additionally, the administrator acknowledged that the governing body was not involved in the assessment process, although updates on the assessment's status were reported during compliance calls with the governing body.
Deficiency in Medical Director's Coordination of Care
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled their responsibilities in coordinating medical care and assisting in the development and implementation of resident care policies. The Medical Director was not involved in administrative decisions or in organizing and coordinating physician services as required by the facility's policy. The Medical Director also did not have a system in place to monitor the performance of healthcare practitioners, including ensuring that nurse practitioners acted within regulatory requirements and the scope of practice as defined by state law. The survey revealed that multiple required regulatory visit notes for several residents did not meet the definition of a total program of care review, which includes a review of all current medications, treatments, and all aspects of the resident's comprehensive plan of care. Additionally, one resident was not seen during a regulatory visit. The Medical Director was unaware of these deficiencies and did not have access to the facility's policies, which further contributed to the lack of oversight and coordination of medical care within the facility.
Infection Control Deficiencies in PPE Use and Glucometer Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper use of personal protective equipment (PPE) and inadequate infection prevention practices. Resident #24, who was on contact and droplet precautions due to respiratory cold symptoms and a positive test for Parainfluenza III, was observed without a mask in common areas on multiple occasions. This was contrary to the facility's policy, which requires residents on droplet precautions to wear a mask when outside their room. The Infection Preventionist Nurse confirmed the lack of documentation regarding the offering or refusal of a mask to Resident #24. Additionally, the facility did not adhere to proper infection prevention practices during blood glucose monitoring. An LPN was observed cleaning a glucometer with an isopropyl alcohol swab after use on a resident, which does not meet the manufacturer's cleaning instructions for preventing the transmission of bloodborne pathogens. The Unit Manager confirmed that the use of isopropyl alcohol alone was insufficient for disinfecting the glucometer, which is used on multiple residents.
Deficiencies in Resident Environment and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on Unit 1. In one instance, a strip at chair rail level in the room of two residents was observed to be falling off the wall and lying on a bed. Both residents and a spouse confirmed that the strip repeatedly falls off and is temporarily re-glued by maintenance without a permanent fix. The maintenance staff acknowledged the issue and explained that the strip is dislodged when beds are adjusted, indicating a need for a more thorough repair. Another deficiency was noted when a resident reported not having access to their call bell, which was confirmed by observation. The call bell cord was not within reach, and the resident expressed difficulty in locating it even when clipped to their pillowcase. The LPN assisting the resident was unaware of the issue and mentioned the cord's insufficient length, which prevented the resident from accessing the call bell as care planned for their fall risk. Additionally, the facility had issues with indentations in the linoleum flooring on two wings, which were explained by maintenance as being over unused drains. Privacy curtains tied in knots over residents' beds were also a concern, as multiple residents expressed discomfort with the arrangement. The facility administrator acknowledged awareness of these issues, noting that maintenance was addressing the chair rail and floor indentations, while privacy concerns with the curtains were being considered.
Failure to Update Care Plans for Catheter Use, Pain Management, and Activity Preferences
Penalty
Summary
The facility failed to revise the comprehensive care plan for two residents, leading to deficiencies in catheter use, pain management, and activity preferences. Resident #23 was admitted for rehabilitation following a hospital stay and returned to the facility with a catheter. However, the care plan did not include any focus or interventions related to catheter use until several months later. Despite a physician's order for a leg bag to increase independence, the care plan was not updated to reflect this, and the resident continued to use a standard catheter drainage bag, limiting mobility and independence. Additionally, Resident #23's care plan for pain management was not updated despite the resident's lack of reported pain since February and a representative's request to adjust the morphine regimen. The care plan continued to reflect a need for routine morphine administration without evidence of ongoing pain or a clinical rationale for its continuation. The facility's policy on pain management was not followed, as there was no evaluation of the effectiveness of pain interventions or consideration of tapering the medication. For Resident #62, the facility failed to update the activity care plan to reflect changes in the resident's preferences and behavior. Initially noted as having little activity involvement and rarely leaving the room, the resident became more social and engaged after a fall and subsequent fracture. Observations showed the resident frequently in common areas, interacting with staff and other residents, yet the care plan remained unchanged, not reflecting the resident's increased social engagement and activity preferences.
Inadequate Activities Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program that supports residents in their choice of group, individual, and independent activities, affecting the well-being of several residents. Resident #82 expressed dissatisfaction with the lack of engaging activities, noting that some days there is not much going on, which affects the residents. Observations revealed that on certain days, such as 5/6/2024, there were no formal activities, and residents were left with independent activity carts that included items like word searches and colored pencils. The Activities Director confirmed that due to staffing issues, there were several days without formal activities, relying instead on independent activities that were not suitable for all residents. Resident #73, who is care planned for activities due to cognitive deficits, was observed not participating in activities on multiple occasions. The activity report indicated that out of 37 days, the resident was offered activities on only 14 days, participating in 13. The care plan emphasized the need for activities compatible with the resident's capabilities and interests, but the facility failed to meet these objectives, as independent activities were not observed, and the resident's care plan goals were not achieved. Resident #23 also expressed boredom due to insufficient activities. The resident's care plan, which was created to provide a program of activities that empower and interest the resident, was not effectively implemented. Activity logs showed that the resident did not participate in activities on 12 out of 36 days, and on only 5 days did the resident participate in more than one activity. An LNA confirmed that the resident often felt bored due to the lack of engaging activities, highlighting the facility's failure to provide adequate stimulation and social interaction as per the resident's care plan.
Failure to Review Residents' Total Program of Care
Penalty
Summary
The facility failed to ensure that physicians and other providers reviewed the residents' total program of care, including medications and treatments, at each required visit for six of the twenty-four sampled residents. Specifically, for Residents #2, #78, #23, #19, #47, and #53, there were no provider visit notes that met the definition of a total program of care review. This includes a comprehensive review of all current medications, treatments, and all aspects of the residents' comprehensive plan of care. For instance, Resident #23's records showed discrepancies in medication orders, such as an anticoagulant being listed as current despite being discontinued and morphine being incorrectly documented as 'as needed' rather than routine. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the Nurse Practitioner notes did not meet the required standards for a total program of care review. The Medical Director admitted to being unaware of the deficiencies in the Nurse Practitioner's documentation and acknowledged the lack of a system to monitor the performance of healthcare providers to ensure compliance with regulatory requirements. The facility's policy on physician services, which mandates a review of the resident's total program of care at each visit, was not adhered to, contributing to the deficiency.
Failure to Ensure Face-to-Face Physician Visits and Tracking System
Penalty
Summary
The facility failed to ensure that residents were seen by a physician personally, face-to-face, for required regulatory visits. Specifically, one resident was not seen in person by their attending physician during a regulatory visit, as the visit was conducted through a discussion with a Nurse Practitioner without any vital signs taken or physical examination completed. Additionally, the facility did not conduct regulatory visits every 30 days for the first 90 days after admission for another resident, as required. The attending physician did not see the resident every 30 days, and the Nurse Practitioner's visits did not meet the requirements for a comprehensive visit. The facility lacked a system to track required regulatory visits for residents. Interviews revealed that the Medical Records Specialist was responsible for tracking outside provider visits but did not track regulatory visits. The Medical Director, who was the attending physician for more than half of the residents, assumed that the Nurse Practitioner was performing the alternate required visits and did not verify if the visits met regulatory requirements. The Unit Manager confirmed that there was no system in place to monitor physician visits, and they were not responsible for tracking provider visits.
Lack of Physician Documentation on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented any rationale against, or actions taken as a result of, irregularities identified by the pharmacist during the monthly medication regimen review for four of five sampled residents. For Resident #2, the pharmacist recommended reducing or eliminating Ambien due to recent falls and the potential increased fall risk. The physician disagreed with the recommendation but did not provide a rationale in the medical record. Similarly, for Resident #23, the pharmacist suggested evaluating the continued need for Morphine and considering a trial taper. The physician disagreed without documenting a rationale. For Resident #71, the pharmacist recommended obtaining a Vitamin D level, which the physician agreed to, but there was no evidence that the lab was ordered or drawn. In the case of Resident #19, the pharmacist recommended evaluating the duration of Oxycodone therapy and considering a stop date. The physician disagreed without providing a rationale. Interviews with the Unit Manager confirmed the absence of documentation, and the Nurse Practitioner admitted to not knowing the need for additional information in the record.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents taking psychotropic medications received gradual dose reductions (GDR), unless contraindicated, for three of the five sampled residents. Resident #2 was consistently receiving Venlafaxine Extended Release Tablets without any evidence of a GDR being considered over the past year. The pharmacist did not alert the physician to consider a GDR, assuming the physician deemed it contraindicated without explicit documentation. The Medical Director was unaware of the GDR requirements, and the facility did not track GDRs for psychotropic medications prescribed for chronic conditions. Similarly, Resident #19 was on a consistent dose of Sertraline for major depressive disorder without any GDR consideration or documentation of contraindications. The attending physician, who also served as the Medical Director, was unaware of the regulatory requirement to document clinical contraindications if a GDR is not attempted. Resident #25 was receiving clozapine for schizophrenia and venlafaxine for depression, with no evidence of GDR consideration or contraindication documentation. The Unit Manager confirmed that GDRs were not considered for residents diagnosed with schizophrenia.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents. For Resident #23, several provider visit notes were missing, including a hematology progress note indicating the continuation of the anticoagulant Lovenox, which was not reordered after the initial order ended. Additionally, an emergency department note related to an opiate overdose was absent, as well as attending physician notes from two specific dates. For Resident #31, there was no evidence of physician visit notes in the medical record upon admission. The Unit Manager and Medical Records Specialist confirmed the absence of these records during interviews.
Failure to Develop Anticoagulant Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing anticoagulant use for a resident who was admitted for rehabilitation following a hospital stay due to a urinary tract infection and sepsis. The resident had diagnoses including heart failure, chronic pulmonary embolism, and a pacemaker, and was admitted with a physician order for enoxaparin, an anticoagulant, to be administered for 90 days. Despite this, the resident's care plan did not include anticoagulant use until several months after admission. Interviews with the Unit Manager and the Director of Nursing confirmed that residents on anticoagulants should have a specific care plan, which was not in place for this resident until much later.
Failure to Ensure Resident is Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary medications, specifically Morphine Sulfate. The resident had a physician order for Morphine Sulfate Oral Solution to be administered every four hours for pain and shortness of breath, which had been consistently followed since January. However, a pharmacist's medication regimen review in May recommended evaluating the continued need for the medication and suggested a trial taper. The physician disagreed with the recommendation without providing a rationale in the medical record. The resident had not reported pain since February, and there were no evaluations of the effectiveness of the morphine or a clinical rationale for its continued use. Interviews revealed that the resident's representative was concerned about unnecessary medication, as the resident did not exhibit pain as initially observed. The Nurse Practitioner, who had been at the facility for less than a month, was unaware of the family's concerns and had not yet evaluated the resident. The Director of Nursing confirmed that the NP could not disagree with the dose reduction without evaluating the resident. A follow-up interview indicated that the NP reviewed the resident's record and confirmed the need to attempt a taper of the morphine medication.
Failure to Administer Anticoagulant Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of an anticoagulant medication. The resident, who was admitted for rehabilitation following a hospital stay for a urinary tract infection and sepsis, had a medical history that included heart failure, a pacemaker, chronic pulmonary embolism, and lung cancer. The resident's representative expressed concern that the resident did not receive their prescribed anticoagulant, Lovenox, for several weeks, coinciding with a significant decline in the resident's health. The representative discovered the discontinuation of the medication while reviewing facility charges and was not informed by the facility staff about the cessation of the medication. The resident's medical records indicated that the anticoagulant was to be continued as per discharge instructions and subsequent physician notes. However, the order for Lovenox ended on December 14, 2023, and was not renewed, resulting in the resident not receiving the medication for 49 days. Interviews with the Director of Nursing and the Medical Director confirmed that the order should not have been stopped, but no explanation was provided for the lapse. This oversight in medication management led to a significant medication error, as the resident did not receive necessary anticoagulation therapy during this period.
Failure to Provide Call Bell Access
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's needs, specifically regarding access to the call bell system. During an interview, the resident expressed frustration about not having access to their call bell, which was confirmed by an observation that showed the call bell cord was not within reach. The LPN, who was present during the conversation, attempted to rectify the situation by clipping the call bell to the resident's pillowcase, but the resident still could not reach it. The resident suggested attaching the call bell to the bed rail for easier access. The LPN admitted to being unaware of the resident's inability to access the call bell and noted that the cord was too short to reach the resident effectively. The resident's care plan indicated a need for the call bell to be within reach due to their potential for falls, hemiplegia/hemiparesis, and muscle weakness. Despite this, the resident had not been provided with adequate access to the call bell, which is a critical component of their care plan.
Failure to Ensure Proper Peripheral IV Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a Peripheral IV, as observed during a survey. The resident was receiving Cefepime HCl intravenously for an infection, with orders for Normal Saline Flush before and after antibiotic administration. However, there were no orders for monitoring the IV site or for dressing changes, which are essential for maintaining the IV's integrity and preventing complications. The IV dressing was dated 5/3/24, but the facility's policy requires dressing changes every 5 to 7 days or if the dressing becomes damp, loosened, or visibly soiled. The deficiency was confirmed through interviews and record reviews, revealing that the resident's care plan did not include a focus on the Peripheral IV. The Unit Manager acknowledged the oversight, stating that they assumed the IV would not remain in place for long and did not address the missing orders. This lack of documentation and adherence to professional standards of practice for IV care led to the deficiency identified by the surveyors.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to ensure that binding arbitration agreements provided for the selection of a neutral arbitrator and a location convenient to both parties for two of the three sampled residents. For Resident #67, who was admitted to the facility, the arbitration agreement was signed by the resident's representative upon admission. The agreement stipulated that all arbitrations would be administered by ADR Options, Inc. and conducted at a local site either at the facility or a site selected by the facility within ten miles. Similarly, for Resident #41, the arbitration agreement signed by the resident's representative contained the same stipulations. During an interview, the administrator confirmed that the agreements did not include the required language for selecting a neutral arbitrator and a mutually convenient location.
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The facility failed to maintain clean, odor-free, and safe carpeted rooms on one floor, as evidenced by strong urine odors concentrated around a specific room, visible dark stains, food debris, and a wet urine spot on the carpet near a bathroom door. Multiple staff, including LPNs, housekeeping, the DON, and maintenance, confirmed that a resident in that room frequently removed briefs and urinated on the carpet, and that urine odors were sometimes noticeable from the hallway. Additional observations showed that several other carpeted rooms had tears, deterioration, brown stains, and loose tiles creating tripping hazards. Staff reported that carpets were only cleaned when issues were reported verbally, and there was no routine or tracked schedule for deep cleaning or shampooing, despite a written policy requiring periodic deep cleaning of carpets.
Surveyors found that the facility failed to remove expired medications from a medication storage room and a medication cart, including expired ibuprofen, cranberry pills, lorazepam, and liquid acetaminophen, despite a policy requiring expired drugs to be returned to the pharmacy or destroyed. They also observed multiple instances where an LPN left medication carts unlocked and unattended while entering resident rooms to administer medications, with residents present near the carts, contrary to the facility’s policy that medication carts not be left unattended if open or accessible.
A resident with a history of wandering and elopement was moved from a room without a mesh gate to a room with a mesh gate on the door and was later observed yelling and unable to open the gate, which prevented exit from the room. A roommate reported that this resident often had difficulty opening the gate and called for help. The DON stated that residents who wander generally do not have mesh gates, that both roommates should be able to open any gate on their door, and that an assessment and care plan entry should exist for each resident using a mesh gate. The DON was unable to produce an assessment for this resident, confirmed the resident was not care planned for the mesh gate, and acknowledged that if an ambulatory resident cannot open a gate, it could be considered a restraint, contrary to the facility’s resident rights policy prohibiting restraints used for discipline or convenience.
Surveyors found that the facility failed to revise care plans after falls for two residents with multiple conditions including weakness, peripheral neuropathy, unsteadiness, Parkinsonism, heart disease, CHF, and mood disorders. In both cases, nursing notes documented falls related to weakness and self-transfer, and existing care plans already identified fall risk. However, the care plans had not been updated with new fall-prevention interventions following the incidents, despite an IDT meeting note stating that one care plan had been updated as needed. The DON confirmed that care plans are expected to be revised after each fall and that this did not occur for these residents.
A resident on comfort care with multiple chronic conditions received incorrect morphine doses when staff failed to verify that the concentration on the morphine bottle matched the physician’s order. The order specified Morphine 20 mg/5 ml with a 1 ml (4 mg) PRN dose, but the bottle was labeled Morphine 20 mg/1 ml. Nursing staff administered multiple 1 ml doses (20 mg each) and later 2.5 ml doses (50 mg each) from this higher-concentration bottle, contrary to the ordered doses. The DON, ADON, and Administrator confirmed that this occurred despite a facility policy requiring adherence to the 5 Rights of medication administration, including verifying that the medication concentration on the container matches the provider’s order.
The facility did not maintain clean air vents and related ceiling surfaces in three common dining areas, where 14 ceiling vents were observed with dark black, speckled, fuzzy residue covering about half to three-quarters of each vent, and multiple ceiling tiles showed brown water stains. The Maintenance Director confirmed the buildup on vents and stains, reported no records of vent cleaning and stated vents had not been cleaned during his four months in the role, while also noting dust on four sprinklers. Facility policy requires annual cleaning of vents and air handling units, and the Administrator acknowledged vents should also be cleaned when dusty. The IP confirmed the vents needed cleaning, and the DON reported that a significant number of residents had chronic respiratory diagnoses. Information from a NADCA-certified company cited by surveyors stated that dirty ducts can accumulate contaminants and, in settings with residents who have compromised respiratory status, can contribute to exacerbation of chronic respiratory illnesses.
The facility did not verify or document required competencies for a large number of contracted nursing staff, including licensed nurses and LNAs obtained through staffing agencies. Record review showed missing resident-care competencies for a contracted LNA, despite the facility assessment requiring skills such as wound management, dementia care training, behavioral interventions, infection prevention, safe lift/transfer, and emergency response preparedness. The DON reported that new and agency staff often did not receive facility training, that agency staff were only required to read policies through the agency system, and that competency was informally monitored after assignment rather than verified beforehand. A contracted LNA described starting work by going directly to the nurse’s station, receiving an assignment, and beginning work without task-specific orientation.
Two residents’ rights to privacy were not maintained during personal and incontinence care. In one instance, a resident received incontinence care from an LNA with the hall door open and the privacy curtain between beds not drawn, while a roommate and visiting family members were present and the resident remained visible. In another instance, a resident was exposed in bed while three LNAs provided personal care with the hall door wide open, and the door was only closed after staff noticed surveyors. The DON later confirmed that LNAs were expected to ensure privacy by using the curtain and/or closing the door.
A resident with several weeks of itching and self-inflicted scratches to the arms and hands was observed actively scratching with deep scratches present, while documentation showed repeated episodes of pruritus and open skin areas. Nursing staff had previously obtained a short course of Triamcinolone cream and later left messages for the physician requesting systemic medication (cetirizine) and reporting continued scratching and inflamed areas, but no new orders or documented physician response were received despite multiple calls and faxes. This resulted in the resident not being under timely physician supervision or receiving updated treatment in response to ongoing symptoms.
Surveyors found that physicians did not complete required total program of care reviews for two residents. One resident with multiple complex conditions, including dementia, cachexia, pressure ulcers, malnutrition, and dysphagia, had regulatory visit notes over an extended period that lacked documentation of a comprehensive care review, listed two medications that were not actually ordered, and failed to reflect documented MASD and pressure injuries noted in nursing progress notes. The DON confirmed the absence of a total care review and reported difficulty obtaining such documentation from some providers. Another resident admitted earlier in the year had no provider visit notes that met the definition of a total program of care review, including review of all current meds, treatments, and the comprehensive care plan.
Failure to Maintain Clean, Odor-Free, and Safe Carpeted Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the second floor, particularly in and around one resident room and several other carpeted rooms. Upon entrance, surveyors detected a strong urine-like odor on the East Wing’s second level, concentrated around a specific room where the carpet had several large dark spots and visible food particles and debris on the floor. Multiple staff, including LPNs, the DON, housekeeping staff, and the Maintenance Supervisor, confirmed that urine odors were present at times in and around this room and that a resident in that room frequently removed briefs and urinated on the carpeted floor. On a later observation, the carpet in the same room had a wet spot by the bathroom door, which housekeeping staff identified as urine and confirmed could be smelled from outside the room. Review of facility conditions showed that 6 of 13 resident rooms with carpeted flooring had safety and/or sanitary concerns, including white spots, carpet deterioration by doors, large carpet tears, smaller tears, brown stains, and tile coming up and creating tripping hazards. One room with two large tears and staining near the bathroom door also smelled of urine. The Maintenance Supervisor stated that carpets were cleaned only when maintenance was informed of a need by word of mouth, and the DON and Housekeeping Supervisor confirmed there was no established or tracked schedule for deep cleaning or carpet shampooing, despite a written policy stating carpets should be deep cleaned approximately once per month or more often as needed. These observations and staff interviews demonstrated that the facility did not follow its own carpeting policy and did not have a routine process to ensure carpets were regularly cleaned and maintained in a sanitary and safe condition.
Expired Medications and Unsecured Medication Carts
Penalty
Summary
Surveyors identified that the facility did not ensure medications were properly stored and removed when expired, as required by its Medication Labeling and Storage policy. During an observation of a second-floor medication cart, the nursing supervisor confirmed the presence of multiple expired medications, including ibuprofen 200 mg tablets that expired in June 2025, cranberry pills 450 mg that expired in May 2024, lorazepam 1 mg tablets that expired in September 2025, and liquid acetaminophen 160 mg/5 mL that expired in November 2025. In a separate observation of the first-floor medication storage room, an LPN confirmed that a bottle of liquid pain relief (Tylenol) 160 mg/5 mL cherry flavor had expired in November 2025. The facility’s policy, revised in February 2023, states that medications should be returned to the pharmacy or destroyed when expired, but these expired medications remained in active storage areas. Surveyors also found that staff failed to keep medication carts locked when unattended, contrary to facility policy. On one occasion, a medication cart on the [NAME] Wing was observed unlocked and unattended while an LPN left to assist a resident; the LPN acknowledged that the cart should have been locked when unattended. During two separate medication administration observations on the East Wing, an LPN walked away from the medication cart, leaving it unlocked and out of sight while entering resident rooms to administer medications. In one instance, two residents were near the unattended cart, and in another, one resident was near the cart. The LPN confirmed in both instances that the medication cart should be locked when left unattended, and the facility’s policy specifies that carts used to transport medications and biologicals are not to be left unattended if open or otherwise potentially available to others.
Failure to Prevent Use of a Physical Restraint Without Assessment or Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when not required for medical treatment. Resident #36 was care planned for wandering and elopement and had a history of attempting to elope. The resident was moved from a room without a mesh gate to a room with a mesh gate on the door. During observation, the resident was seen in their room yelling and unable to open the mesh gate, which prevented them from leaving the room. Another resident sharing the room reported that the roommate sometimes had difficulty opening the mesh gate and would call for help. The DON stated that some residents request mesh gates to keep out other residents who wander into their rooms and that both residents in a room should be able to access and open the mesh gate, with an assessment documented in the system and the gate included on the care plan. The DON acknowledged that residents who wander typically do not have mesh gates on their doors, that Resident #36 was not assessed for the use of the mesh gate when moved to the new room, and that there was no assessment documentation for this resident. The DON also confirmed that Resident #36 was care planned for elopement and wandering but not for the mesh gate, and that if an ambulatory resident could not open a gate, it could be considered a restraint. The facility’s Resident Rights Policy states that residents have the right to be free from physical restraints imposed for discipline or convenience and not required to treat medical symptoms.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to review and revise care plans after resident falls, as required. One resident with diagnoses including anxiety disorder, major depressive disorder, peripheral neuropathy, atherosclerotic heart disease, weakness, and the presence of an artificial hip experienced an unwitnessed fall in the bathroom on 3/25/2026. Nursing progress notes documented the fall, and the resident’s care plan already identified a risk for falls related to weakness and peripheral neuropathy. However, the care plan, last updated on 3/18/2026, did not include any new interventions or revisions in response to the 3/25/2026 fall. A second resident, with diagnoses including muscle weakness, unsteadiness on feet, other drug-induced secondary Parkinsonism, hypertensive heart disease with heart failure, CHF, major depressive disorder, anxiety disorder, and difficulty walking, experienced a fall on 3/21/2026 while attempting to self-transfer. Nursing progress notes documented this fall, and the resident’s care plan identified a risk for falls related to weakness. The IDT met on 3/25/2026 and documented that the care plan had been updated as needed regarding this most recent fall. However, the care plan had last been revised on 3/8/2026 and did not reflect any new fall-prevention measures related to the 3/21/2026 incident. The DON confirmed in both cases that care plans are supposed to be revised and updated after each fall and acknowledged that this was not done for these two residents.
Failure to Verify Morphine Concentration Before Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when staff did not verify that the morphine concentration on the bottle matched the physician’s written order. The resident, who had dementia, hypertensive heart disease, anxiety, depression, lymphedema, and unspecified seizures, was placed on comfort care. The physician ordered Morphine 20 mg/5 ml, with a dose of 1 ml (4 mg) by mouth every 2 hours as needed for pain or shortness of breath. The DON reported that this order was sent to the pharmacy and the medication was received, with the prescribed concentration (20 mg/5 ml) printed on a label attached to the bag in which the medication arrived. However, the morphine bottle itself was labeled with a different concentration of Morphine 20 mg/1 ml. Per review of the individual narcotic record and MAR, staff administered 1 ml doses from the bottle labeled Morphine 20 mg/1 ml (20 mg per dose) on multiple occasions, instead of the ordered 4 mg dose, on several dates. On one date, after a new order was written to increase the morphine to 20 mg/5 ml, 2.5 ml (10 mg) every 6 hours for pain or shortness of breath, staff administered two doses of 2.5 ml from the same bottle labeled Morphine 20 mg/1 ml, resulting in 50 mg per dose. During interviews, the DON, ADON, and Administrator confirmed that the morphine concentration on the bottle label was 20 mg/1 ml and acknowledged that their medication administration policy requires following the 5 Rights, including confirming that the medication concentration and dosage on the container match the provider’s order before administration.
Failure to Maintain Clean Air Vents and Ceiling Surfaces in Common Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in three resident common areas by not keeping ceiling air vents and related components clean. Facility policy for Plumbing, HVAC and Related Systems, revised in 2011, requires air vents and air handling units to be cleaned at least annually. Observations of three resident common areas revealed 14 ceiling air vents with a black and brown substance that appeared dark black, speckled, and fuzzy, covering approximately 50–75% of each vent. Multiple ceiling tiles in these areas also had brown stains that the Maintenance Director identified as old water damage. In addition, four sprinklers in one dining area had a gray substance on them that the Maintenance Director believed was dust. The Maintenance Director confirmed the presence of black and brown residue on the vents and brown stains on ceiling tiles and stated he did not have records of when the vents were last cleaned, noting they had not been cleaned during his approximately four months in the role. The Administrator stated that ducts are to be cleaned annually per facility policy and that maintenance is responsible, and acknowledged that vents should also be cleaned when they become dusty. The Infection Preventionist confirmed that the ceiling vents needed to be cleaned. The DON reported that 27 of the 87 residents in the facility had chronic respiratory diagnoses. A NADCA-certified company’s information, reviewed by surveyors, stated that air ducts can accumulate dust, debris, allergens, and pathogens over time and that in hospitals and nursing homes this can pose increased risk to residents with compromised immune systems or respiratory issues, and that dirty ducts can circulate contaminants and potentially exacerbate chronic respiratory conditions such as asthma, allergies, and other respiratory illnesses.
Lack of Verified Competencies for Contracted Nursing Staff
Penalty
Summary
The facility failed to ensure that contracted nursing staff, including licensed nurses and LNAs obtained through staffing agencies, had documented competencies matching residents' assessed needs and care plans. Review of two LNA employee records, one permanent and one contracted through Clipboard Health, showed that required competencies for resident care were missing for the contracted LNA. The facility assessment dated 3/9/26 identified required nursing staff competencies such as wound management skills, dementia care training, behavioral intervention training, infection prevention practices, safe lift and transfer training, and emergency response preparedness, but these were not verified for agency staff. A staffing list showed 48 nursing staff identified as contract/agency, and the DON confirmed that agency staff made up a large part of the nursing workforce. In interviews, the DON stated that the facility did not always provide facility training to new staff, especially agency staff, because of uncertainty about how long they would stay and challenges in hiring new staff. The DON explained that Clipboard Health staff were required to read facility policies in the agency system before picking up a shift, and that facility staff would monitor them, but there was no verification of competency before they worked with residents and no documentation of competencies by the facility. A contracted LNA reported that upon starting work, the process was to enter through the front door, go to the nurse's station, receive an assignment, and "jump right in" without orientation to new tasks. The DON confirmed that the listed competencies in the facility assessment were not verified for contracted nursing staff.
Failure to Maintain Privacy During Personal and Incontinence Care
Penalty
Summary
The deficiency involves failure to maintain residents’ privacy and confidentiality during provision of personal and incontinence care for two sampled residents. On 4/13/2026 at 1:40 PM, one resident (Resident #33) was observed receiving incontinence care from an LNA with the door to the hallway open and the privacy curtain between beds not drawn, while their roommate (Resident #4) was in the other bed. Another LNA entered and closed the door, but when two family members of the roommate entered the room, the privacy curtain remained open and Resident #33 was visible. On 4/14/2026 at approximately 3:30 PM, Resident #4 was observed in bed receiving personal care from three LNAs with the door to the hallway wide open and the resident exposed on the bed until one LNA noticed the surveyors and closed the door. Per interview on 4/15/2026 at 12:30 PM, the DON confirmed that LNAs should have provided privacy to the residents by drawing the privacy curtain and/or closing the door, indicating that the observed practices did not align with the facility’s expectations for maintaining resident privacy during personal care.
Failure to Obtain Timely Physician Response for Ongoing Pruritus and Skin Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician supervised and provided consultation or treatment after being contacted regarding a resident with ongoing pruritus and self-inflicted skin injuries. During an interview and observation, the resident reported itching for about three weeks, stated they had requested medication to help, and was observed scratching both arms, which showed deep scratches on the upper and lower arms. The resident’s care plan documented multiple episodes of self-inflicted scratches to the hands and forearm over several weeks, with interventions directing staff to report abnormalities, failure to heal, and signs and symptoms of infection or maceration to the physician. Record review showed that on 3/27/2026 a verbal order was received to restart scheduled Triamcinolone cream to the right arm and left shin daily for 14 days. A skin/wound note dated 4/5/2026 documented that the resident continued to have pruritus to all extremities, with one open area on the left hand and no signs of infection, and that a message was left for the provider questioning the need for systemic medication (cetirizine) to ease the pruritic issue and assist with sleep. A communication note dated 4/11/2026 documented a call to update the physician that there were no changes to the areas on the arms and legs and that the resident continued to scratch and areas remained inflamed, with staff “waiting on updated orders,” but no physician response or new orders were documented. In interviews, an RN and the DON confirmed there had been a delay in physician response despite multiple calls and faxes and that the physician had not yet responded to the request for treatment for this resident’s ongoing scratching and skin issues.
Failure to Complete Required Total Program of Care Reviews
Penalty
Summary
Surveyors identified that physicians failed to complete required total program of care reviews for two residents. One resident with multiple complex diagnoses, including dementia, anxiety, osteoporosis, cachexia, GERD, adult failure to thrive, sacral pressure ulcer, malnutrition, depression, bipolar disorder, and dysphagia, had physician/provider regulatory visit progress notes over a one-year period that did not document a total review of care. At each visit, the physician documented that the resident was taking Vitamin B-12 1000 mcg daily and Diflucan 100 mg daily, even though these medications were not present in the current physician orders. Additionally, nursing progress notes documented the development and treatment of MASD on specific dates, but the physician’s regulatory visit note during that same period did not reflect that the resident was being treated for MASD. Nursing progress notes for the same resident also documented a stage 2 pressure ulcer on the coccyx and bilateral blanchable erythema on the heels, but the corresponding physician/provider regulatory visit note did not document the presence of these wounds or the care needed to treat them. The DON confirmed that the physician had not documented a total review of care for this resident and reported difficulty getting certain providers to complete such reviews. For another resident admitted in January 2025, review of physician/provider notes from admission through the survey date showed no provider visit notes that met the definition of a total program of care review, including a review of all current medications, treatments, and all aspects of the resident’s comprehensive plan of care.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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