Gill Odd Fellows Home Of Vermont
Inspection history, citations, penalties and survey trends for this long-term care facility in Ludlow, Vermont.
- Location
- 8 Gill Terrace, Ludlow, Vermont 05149
- CMS Provider Number
- 475052
- Inspections on file
- 19
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Gill Odd Fellows Home Of Vermont during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow professional food service safety standards, including improper storage and labeling of dry and frozen food items and failure to use required hair restraints. Open and undated items, such as baking mix, tortilla strips, fish sticks, and pie crusts, were stored in dry storage and the freezer, some exposed to air and lacking use-by or open dates. A dietary staff member was observed preparing and plating food without a hair restraint, and both that staff member and the Dietary Manager reported that staff with hair considered short enough were not required to wear hair coverings, despite a facility policy mandating hair restraints for dietary staff.
Surveyors found that the facility did not have a functional system for residents to file anonymous grievances. The posted grievance procedure instructed residents to speak with the grievance officer/Social Service Director or the DON and did not explain how to file anonymously. No blank grievance forms or grievance drop box were available in common areas. The Social Worker reported that residents must request grievance forms from staff, that forms are stored in the social work office, and that completed forms are returned to the Social Worker, the DON, or other staff, with no drop box in place. Although the admission agreement stated that anonymous grievances could be placed in a mailbox near the front lobby door, residents did not have independent access to grievance forms, effectively preventing anonymous grievance submission.
Surveyors found repeat infection control failures during medication administration, including an RN preparing and administering crushed medications in pudding without removing gloves or performing hand hygiene, while placing gloved fingers inside medication cups when giving medications to a resident. In a separate observation, a nurse’s personal drink with a lid and straw was found on a medication cart. The DON confirmed that these practices violate the facility’s hand hygiene policy and prohibition on staff drinks on medication carts due to contamination concerns.
A resident with progressive MS experienced difficulty self-propelling a wheelchair due to a dragging foot and lack of leg rests, despite staff awareness of the problem. An LNA reported the issue to nursing staff, and an OTR acknowledged the resident’s feet were dragging, provided leg rests, and educated staff on their use, noting the resident could self-propel effectively when leg rests were in place. However, the resident’s care plan for wheelchair mobility, last revised weeks earlier, was not updated to include the use of leg rests even after these issues and interventions were identified.
Surveyors identified that the facility’s medication error rate exceeded 5% when an RN failed to administer two prescribed laxative medications during observed med passes, despite documenting them as given on the MAR. In 31 observed medication opportunities, 2 doses (docusate sodium and Miralax powder) ordered for two residents were not actually administered, even though the RN stated all medications had been given. Time-stamp reports produced by the DON showed these medications as administered at the same time as other drugs, conflicting with surveyor observations and resulting in a calculated error rate of 6.45%.
Surveyors observed a medication cart in a hallway between resident rooms left unlocked and unattended while residents were self-propelling nearby. The cart contained OTC medications, syringes, topical agents, injectables, prescribed resident-specific medications, and narcotics in a separately locked compartment. An RN later returned to the cart and confirmed it had been left unlocked and acknowledged it should have been secured. The DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty, demonstrating a failure to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
A resident with dementia and intact cognition reported being physically assaulted by another resident using a walking stick. The incident was documented by staff, but the social worker and DON did not notify the administrator, state agency, or law enforcement as required. No evidence was found of proper investigation, monitoring, or required notifications following the allegation.
A resident with dementia and depression reported being struck multiple times by another resident with a walking stick. Despite the resident's request for police involvement and assurances of increased monitoring, there was no documentation of a thorough investigation, identification of the alleged perpetrator, or evidence of follow-up actions by staff, including the SW and DON.
A resident fell from a wheelchair, resulting in a fractured clavicle, but the LTC facility failed to follow its fall protocol. The necessary assessments, notifications, and documentation were not completed until four days later, when old bruising prompted further investigation. The documentation added later inaccurately reflected the actions taken and the resident's status.
A resident fell from a wheelchair, and the facility failed to ensure nursing staff had the necessary competencies to provide safe care. Despite prior fall education, an LPN did not document or assess the fall, and an LNA involved had not received recent fall education. Bruising was not documented until days later, and a clavicle fracture was discovered five days post-fall, highlighting deficiencies in staff competencies and procedures.
Food Storage and Hair Restraint Failures in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in food storage and labeling practices in the facility kitchen. During an initial tour of the kitchen dry storage area, they observed a 5-ounce box of cornbread muffin mix with an expiration date of 11/5/25 and a 5-ounce bag of tortilla strips that had been opened on 1/7/26 but had no expiration date on the packaging. In the freezer, they found a bag of 24 frozen fish sticks in an open bag exposed to air with no date on the package, and a bag containing three frozen pie crusts that was opened without any expiration or opened date. A staff member confirmed that these items were either undated, open to air, and/or expired. Surveyors also observed failures to follow the facility’s own food safety policy regarding hair restraints. One staff member was seen cooking, assembling, and plating food in the kitchen without a hair restraint. In an interview, this staff member stated that kitchen staff did not need a hair restraint if their hair was of a certain length but was unable to specify the permitted length. The Dietary Manager similarly stated that staff with hair considered short enough did not need to wear a hat or hair net while preparing or assembling food and acknowledged there was no specific hair length standard used by the facility. This practice conflicted with the facility’s written Food Safety policy, which requires dietary staff to wear hair restraints to prevent hair from contacting food.
Failure to Provide a Functional System for Anonymous Resident Grievances
Penalty
Summary
The facility failed to provide a system that enables residents to file anonymous grievances, despite a posted grievance procedure and language in the admission agreement stating that anonymous grievances could be placed in a mailbox near the front lobby door. During observation, surveyors noted that the grievance posting outside the dining room in the lobby did not include information on how to file an anonymous grievance and only directed residents to speak with the grievance officer/Social Service Director or the DON, listing their phone numbers. No blank grievance forms or grievance drop box were observed in resident-accessible areas. In an interview, the Social Worker confirmed that residents file grievances directly with the Social Worker or the DON, stated he did not know how a resident could file a grievance anonymously because residents must request a form from staff and return it to staff, and acknowledged that blank grievance forms are kept in the social work office without independent resident access and that there is no grievance drop box. Although the admission agreement referenced anonymous grievance submission via a mailbox near the front lobby door, there were no grievance forms available to residents without requesting them from staff, and the actual practice required residents to submit grievances through staff, preventing anonymous filing. No specific residents, medical histories, or clinical conditions were described in the report.
Repeat Infection Control Failures During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to medication administration practices and staff personal items on medication carts. During a medication pass observation, an RN donned gloves and poured medications into individual 30 cc cups, accessed the nurse’s station refrigerator twice to obtain pudding for crushed medications, and continued preparing medications without removing gloves or performing hand hygiene. The RN then crushed pills, mixed them with pudding, and carried the cups with his gloved fingers inside the medication cups to administer the medications to Resident #41, without removing gloves or performing hand hygiene before or during this process. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene Policy, which requires handwashing before and after resident contact, including during medication administration. In a separate observation, surveyors noted a large cup with a lid and straw on a medication cart during medication administration. When questioned, the nurse acknowledged the drink was hers and stated she believed it was acceptable because it had a lid. In an interview, the DON confirmed that failing to perform proper hand hygiene before or during medication preparation and placing fingers, gloved or ungloved, inside medication cups increases the risk of contamination, and also confirmed that staff drinks are not allowed on medication carts because of infection control concerns, regardless of whether the cup has a lid. The report notes this is a repeat deficiency, with similar violations cited during the previous three re-certification surveys.
Failure to Revise Care Plan for Resident Wheelchair Mobility Needs
Penalty
Summary
The facility failed to revise the care plan to address a documented decline in mobility for a resident with progressive multiple sclerosis (MS). The resident was observed attempting to self-propel a wheelchair while dragging the right foot, which inhibited movement, and the wheelchair had no leg rests installed at that time. The existing care plan intervention for wheelchair mobility, last revised on 1/12/25, did not include the use of wheelchair leg rests to improve the resident’s ability to self-propel. A licensed nursing assistant (LNA) reported awareness that the resident sometimes had difficulty self-propelling because the resident’s feet became tangled, and stated this concern had been reported to a nurse. An occupational therapist (OTR) also stated she was aware of the resident’s feet dragging and had provided leg rests for the wheelchair and educated staff to use them, noting the resident had sufficient upper body strength to self-propel when leg rests were in place. The OTR could not confirm that this intervention had been incorporated into the care plan. A subsequent observation showed the wheelchair with leg rests attached, but review of the care plan confirmed it still had not been revised to include the use of leg rests.
Medication Error Rate Exceeded 5% Due to Omitted Laxative Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in a calculated error rate of 6.45% during surveyor observations. Out of 31 medication administration opportunities, 29 medications were observed to be given and 2 were omitted, affecting 2 of 6 sampled residents. During a medication pass observation, an RN administered medications to Resident #16, stated that all medications had been given, and the MAR later showed docusate sodium (a stool softener) as administered at the same time as the other medications, although surveyors did not observe this medication being given. In a separate observation, the same process occurred with Resident #14, where the RN confirmed all medications were administered, and the MAR documented Miralax powder (a laxative solution) as given at the same time as other medications, but surveyors did not observe the Miralax being administered. Per interview, the DON produced time-stamp reports indicating that both the docusate sodium for Resident #16 and the Miralax for Resident #14 were documented as administered concurrently with their other prescribed medications, which conflicted with surveyor observations that these medications were not actually given.
Unlocked and Unattended Medication Cart in Resident Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when a medication cart located in the long hallway between rooms [ROOM NUMBER]-119 was observed unlocked and unattended. At approximately 11:44 AM, the cart was found without any nurse or staff member in sight, while residents were seen self-propelling in the same hallway toward the dining room. The unattended cart contained over-the-counter medications, syringes, topical medications, injectables, prescribed resident-specific medications, and narcotics stored in a separate locked compartment, as later confirmed by an RN. At 11:56 AM, the RN was observed walking from the nurse’s station toward the cart and, during an interview at 11:57 AM, acknowledged that the cart had been left unlocked while unattended and confirmed it should have been locked. In a subsequent interview, the DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty. These observations and interviews established that the facility failed to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse as required by regulation. A resident with a history of dementia, depression, and insomnia, but with intact cognition and judgment, reported being struck multiple times by another resident using a walking stick. The resident expressed distress over not being informed about the incident's consequences and stated a desire for police involvement. Documentation in the progress notes indicated the resident's complaint but did not identify the alleged perpetrator or document any monitoring of the involved residents. The social worker followed up with the resident but did not notify the physician, family, state agency, or law enforcement about the allegation. Interviews with facility staff revealed that the social worker did not report the abuse allegation to the administrator or appropriate authorities. The DON, after interviewing the alleged perpetrator, determined the abuse was unlikely and did not report the incident to the State Survey Agency, despite acknowledging that all abuse allegations are required to be reported. There was no evidence of required notifications or investigations being conducted or documented as per regulatory requirements.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for a resident with a history of dementia, depression, and insomnia, who was assessed as having intact cognition and judgment. The resident reported being struck multiple times by another resident using a walking stick, expressing distress over not being informed about the incident or its consequences, and requesting police involvement. There was no documentation that the police were contacted or that the resident was communicated with by management regarding the incident. Progress notes indicated that the nurse did not witness any physical aggression and found no injuries, but stated that both residents would be monitored closely. However, there was no documentation of the identity of the alleged perpetrator or evidence of increased monitoring for either resident. The social worker confirmed knowledge of the alleged perpetrator's identity but did not document it or contribute to a formal investigation. The DON acknowledged that an investigation was required but confirmed there was no written record of interviews or evidence that the abuse allegations were thoroughly investigated.
Failure to Follow Fall Protocols Leads to Undocumented Injury
Penalty
Summary
The facility failed to provide services that meet professional standards of quality following a fall incident involving a resident. The incident occurred when a Licensed Nurse's Aide was pushing the resident in a wheelchair, resulting in the resident falling out of the wheelchair. Despite the fall meeting the facility's definition of a fall, the necessary actions outlined in the facility's 'Managing of a Fall Policy and Procedure' were not followed. This includes a comprehensive assessment, notification of the physician, monitoring, reassessment, and proper documentation. The Director of Nursing (DON) confirmed that there was no documentation of any evaluations, vital signs, neurological checks, or assessments conducted on the resident following the fall. Additionally, there was no record of the fall in the resident's medical record until two days later, when an 'Incident Order' was initiated. Even then, the necessary assessments and documentation were not completed. The Assistant Director of Nursing later added documentation to the resident's medical record, but it inaccurately reflected the actions taken and the resident's status. Four days after the fall, a nurse performing a skin check documented old bruising on the resident's right shoulder and forehead, which was consistent with the fall. An X-ray revealed a right clavicle fracture. The facility's failure to ensure appropriate assessment, notification, and documentation occurred until four days later, when the bruising prompted diagnostic testing, highlights the deficiency in adhering to professional standards of care.
Deficiency in Staff Competency and Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff possessed and implemented the appropriate competencies and skills to provide nursing and related services to assure resident safety. This deficiency was highlighted by an incident involving a resident who fell from a wheelchair. Despite the fall meeting the facility's definition of a fall, the Director of Nursing (DON) was not informed of the incident as a fall, and there was a lack of proper documentation and assessment by the nursing staff involved. The Licensed Practical Nurse (LPN) who reported the incident via voicemail had attended a Fall Procedure education session nine days prior but failed to document the fall or conduct an assessment as required. Additionally, the Licensed Nurse's Aide (LNA) who was involved in the incident had not received any fall education since 2023. The Assistant Director of Nursing (ADON) confirmed that the education provided included instructions for documentation and assessment, which were not followed. The ADON also added a note to the resident's medical record two days after the fall, despite no immediate assessment being documented. Furthermore, there was a delay in documenting and reporting bruising observed on the resident after the fall. The bruising was not documented until three days later, and there was inconsistency in the documentation by LNAs. The DON and ADON were unaware that LNAs could document skin observations, leading to further confusion and lack of proper reporting. Ultimately, a mobile X-ray revealed a right clavicle fracture five days after the fall, indicating the severity of the incident and the deficiency in staff competencies and procedures.
Latest citations in Vermont
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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