Premier Rehab And Healthcare At Burlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Vermont.
- Location
- 300 Pearl Street, Burlington, Vermont 05401
- CMS Provider Number
- 475014
- Inspections on file
- 35
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Premier Rehab And Healthcare At Burlington during CMS and state inspections, most recent first.
A resident with Osteogenesis Imperfecta and Osteoporosis, whose care plan required transfers with a Hoyer lift and two staff, was manually lifted from a wheelchair to a bed by an LNA who acted alone and did not use the mechanical lift despite the resident’s request. After the transfer, the resident reported a popping sensation and pain in the upper back and right shoulder, and an LPN assessment found limited range of motion with grimacing on movement. Hospital evaluation confirmed a fractured scapula. Facility leadership and the DON acknowledged that the LNA knowingly failed to follow the resident’s individualized transfer care plan and the facility’s safe handling policy, leading to the resident’s injury.
A resident recovering from hip surgery did not receive wound vac care and monitoring according to facility policy, as there was no care plan, incomplete physician orders, and a lack of staff competency. The wound vac was removed due to supply issues, and dressing changes were not performed as ordered, leading to infection and hospitalization for additional surgeries.
A resident with a wound vac following hip surgery did not receive proper care due to staff lacking training and competency in wound vac management. The wound vac was not used as required, and there was no care plan or physician orders for over three weeks. This led to the resident developing an infection that required hospitalization and further surgery. Review confirmed that none of the nurses involved had received wound vac education or competency checks, and facility leadership was unaware of required training documentation.
The facility did not have a certified food service director, as the Kitchen Manager was new and not yet certified, and the Registered Dietician was not working full-time at the facility, instead splitting her hours between two locations. This staffing deficiency was confirmed through staff interviews and timecard reviews.
The facility did not ensure that substantial snacks or meal alternatives were available to residents outside of scheduled meal times, particularly for a resident returning late from dialysis who often missed dinner and could not access adequate food options. Staff interviews and observations confirmed that kitchenettes were inconsistently stocked, the kitchen closed early, and there was confusion about staff access to food after hours. Cognitively intact residents also reported that snacks were only available if the kitchenettes were stocked, which was not always the case.
Surveyors found that food was improperly stored in the kitchen and unit kitchenettes, including boxes placed directly on the freezer floor, undated and unlabeled food items, and the presence of expired and moldy food. Facility staff, including the KM and DON, confirmed that these practices did not follow established policies for food labeling and storage.
Surveyors found that medical equipment and supply carts were contaminated with construction dust, and a mattress and pillows with compromised protective coverings were prepared for new resident use after cleaning. Staff confirmed these items could not be properly disinfected. Additional deficiencies included missing sharps containers with used needles left in a medication cart, improper storage of resident-specific ice packs in a food freezer, and undated wound and PICC line dressings for a resident post-surgery. These issues reflect failures in infection prevention and control practices.
A resident requiring hemodialysis did not receive care and services consistent with professional standards, as the Hemodialysis Communication Record was not consistently or completely filled out by facility staff or the dialysis center on multiple occasions. Required pre- and post-dialysis assessments were also not completed, and staff interviews confirmed lapses in documentation and assessment responsibilities.
A medication treatment cart was found unlocked on a unit while a resident was present in the hallway. An LPN confirmed the cart should have been locked, as required by facility policy, which mandates all drugs and biologicals be stored in locked compartments.
Surveyors found that construction dust and debris were present on medical equipment and carts, including code and treatment carts and Hoyer lifts, on one unit. Staff confirmed the dust was from ongoing construction activities and that cleaning was insufficient. Additionally, a room prepared for a new resident contained a mattress with brown stains, a worn protective lining, and pillows with holes, all of which staff acknowledged were not suitable for use but remained in place after terminal cleaning.
A resident with multiple medical conditions and no cognitive impairment alleged that staff members yelled at, pushed, and physically mistreated them. During the investigation, the facility did not remove the accused staff from the premises but reassigned them to other units, contrary to facility policy requiring protection of residents from further harm.
Two residents who required interpreter services did not have baseline care plans addressing their communication needs within 48 hours of admission. Staff were unable to communicate directly with these residents, leading to unmet needs and misinterpretation of requests. Facility leadership confirmed that appropriate care plans were not in place.
Two residents were not protected from physical abuse by other residents, as evidenced by one resident being struck in the face during a verbal altercation and another being punched in the chest while standing in a doorway. These incidents were confirmed by facility leadership and documented in progress notes.
A resident reported being hit with a wet towel by a staff member, but the facility did not report the abuse allegation to the state agency or document an investigation, as required by policy. Facility leadership was aware of the allegation but chose not to report it, citing the resident's hallucinations.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet needs for residents. A resident with a leg amputation missed activities due to late transfers, while another with a fracture waited two hours for medication. Widespread concerns about long call light response times were reported, with some residents waiting over seven hours. Residents with Parkinson's disease experienced delays in medication administration, exacerbating symptoms. These issues highlight systemic staffing deficiencies affecting resident care and safety.
The facility failed to maintain the dignity and respect of several residents, as evidenced by delayed responses to call bells, refusal to assist with bathroom needs, and staff not honoring residents' preferences for personal care. Residents reported feeling disrespected and not treated as if they were in their own home, with some staff displaying rude behavior and ignoring their requests.
The facility failed to support residents' rights to voice grievances without fear of reprisal. During a Resident Council meeting, several cognitively intact residents expressed discomfort in reporting concerns about being treated without dignity and respect due to fear of repercussions. They reported experiencing rude or rough behavior from staff and feared being yelled at or ignored if they reported such issues, despite knowing the grievance process.
Three residents experienced significant delays in receiving assistance with toileting, leading to discomfort and incontinence. One resident with a leg fracture was left on a bedpan for 45 minutes, while another with lumbar issues waited over an hour during meal times. A third resident with spinal stenosis reported long wait times, resulting in incontinence. These incidents highlight a failure to adhere to care plans for timely toileting assistance.
A resident with Parkinson's disease expressed a strong preference for outdoor activities, which was documented in their care plan. However, due to insufficient staff and weather concerns, the resident was only able to go outside once in 33 days, leading to feelings of being trapped. An Activity Aide acknowledged the issue but noted a lack of staff to ensure the resident's needs were met.
A facility failed to enforce its smoking policy and provide adequate supervision for a resident with multiple health conditions, who was found to be smoking unsupervised and keeping smoking supplies in their room, contrary to facility policy. The Unit Manager confirmed the non-compliance, noting that many residents on the floor have dementia and are ambulatory.
A facility failed to document the medical rationale for extending a PRN order of Ativan beyond 14 days for a resident. The medication was prescribed for 90 days without the necessary physician documentation or evaluation, as confirmed by the Unit Manager.
The facility failed to provide residents with drink options that accommodate their preferences, specifically the availability of ginger ale. A resident expressed frustration over the absence of ginger ale, and six active resident council members voiced concerns about its removal. Despite the facility's policy to provide drinks consistent with resident needs and preferences, an LNA confirmed that ginger ale has not been available for about six months, and the drink cart did not include any soda products. The Assistant Activities Director and the Assistant Kitchen Manager also confirmed the unavailability of ginger ale and any alternative soda or carbonated drinks for residents.
The facility failed to provide sufficient dietary staff, resulting in unsatisfactory meal service for residents. Observations and interviews revealed that meals were often cold and served late due to a shortage of staff, with only one dietary staff member available instead of the required 3-4. This led to meals being served by tray service without insulation, causing faster cooling and frequent delays.
The facility failed to provide meals that were palatable, attractive, and at an appetizing temperature. Residents reported meals being served late, cold, and unappetizing, with some relying on family for food. The kitchen was short-staffed, leading to delays and temperature issues, and food temperatures were not consistently documented. The deficiency was linked to inadequate dietary staffing.
The facility failed to offer residents appealing meal options that met their preferences and dietary needs. Multiple residents reported not being given a choice of meals, receiving food that did not align with their preferences or dietary restrictions, and experiencing poor food quality. Staff interviews revealed a lack of awareness and implementation of a process to ask residents their meal preferences, contributing to the deficiency.
The facility did not follow its policy for screening abuse for an LNA. The LNA's background check showed a misdemeanor charge for disturbing the peace with fighting before being hired, but there was no evidence that the facility or corporate HR reviewed this charge to determine employment eligibility. This was confirmed by the Market Operations Advisor.
A resident admitted for sub-acute rehabilitation after a cerebrovascular accident received Apixaban, an anticoagulant, despite hospital instructions to withhold it until after a follow-up CT scan. The facility's medication reconciliation process failed, as the admitting nurse did not clarify the conflicting orders with the physician. The DON acknowledged discrepancies in discharge information, and the admitting physician was unaware of the hold order due to reliance on nursing staff for accurate communication.
A resident experiencing numbness and pain on the left side of their body did not receive a necessary x-ray, which was ordered by a physician to address issues affecting their rehabilitation. The x-ray was not obtained due to a failure in the process to alert nursing staff to enter the order.
The facility did not involve residents and their representatives in developing baseline care plans or provide them with summaries. A resident admitted for rehabilitation after a craniotomy experienced a fall, and two other residents admitted for post-acute care and rehabilitation were not included in care planning. Interviews confirmed the lack of involvement and documentation, contrary to facility policy.
A resident's port-a-cath was neglected in an LTC facility, leading to an infection and delayed chemotherapy. The port was not identified or cared for upon admission, and staff failed to document or monitor it. Despite awareness by some staff, no care was provided, resulting in the resident's hospitalization and emotional distress.
A resident's implanted port was not identified or cared for during their stay at an LTC facility, leading to an infection and removal of the port. The resident, undergoing rehabilitation after surgery and chemotherapy for ovarian cancer, had their chemotherapy delayed due to the infection. Staff were aware of the port but did not perform necessary care, such as dressing changes or monitoring. The facility's admission assessment failed to identify the port, and there was no documentation of port care throughout the resident's stay.
Injury from Failure to Follow Mechanical Lift Transfer Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to an individualized transfer care plan for a resident with significant bone fragility. The resident had diagnoses of Osteogenesis Imperfecta and Osteoporosis, conditions that make bones weak and easily fractured. The resident’s care plan specified that transfers were to be performed using a Hoyer lift with two staff members, in accordance with the facility’s Safe Resident Handling/Transfers policy, which requires staff to follow each resident’s individual plan of care. Despite these requirements, an LNA independently performed a manual transfer of the resident from a wheelchair to a bed, lifting the resident under the arms instead of using the mechanical lift and a second staff member. During the transfer, the resident told the LNA to use the mechanical lift, but the LNA continued the manual transfer. After being placed in bed, the resident felt a pop and experienced discomfort, which was reported to the LNA. The resident later reported pain in the upper back and right shoulder area, and the LNA informed the LPN that the resident needed pain medication, initially stating the pain followed assistance with removing a sweater. Upon assessment, the LPN noted limited range of motion and grimacing with movement, and the resident reported that the LNA had lifted them into bed. The LNA confirmed to facility leadership that she had transferred the resident without the Hoyer lift and was aware of, but did not follow, the care plan. Hospital evaluation documented a fractured scapula, and both the Administrator and DON confirmed that the LNA failed to comply with the resident’s care plan and facility policy, resulting in the resident’s injury.
Failure to Provide Wound Vac Care and Monitoring per Policy
Penalty
Summary
A resident admitted for rehabilitation following a left hip replacement was identified as high risk for post-operative infection and required the use of a wound vacuum (wound vac) for surgical site management. Despite this, the facility failed to develop a care plan or obtain physician orders for the wound vac upon the resident's return from the hospital, and there was no evidence of monitoring the wound vac in accordance with facility policy. The wound vac was not included in the resident's care plan or monitored as required, and physician orders lacked necessary details such as pressure settings. The wound vac was only documented as administered for three days, and when the device became full and supplies were unavailable, it was removed and replaced with wet-to-dry dressings without appropriate orders or frequency of dressing changes. Staff interviews and record reviews revealed that nursing staff were unfamiliar with the wound vac type and lacked training or competencies to provide appropriate care. The facility did not ensure that staff were educated or competent in wound vac management, as confirmed by the review of employee education files for all licensed nursing staff who cared for the resident. Additionally, after the wound vac was removed due to lack of supplies, the resident did not receive the ordered frequency of dressing changes, and the care plan was not updated to reflect the new wound care needs. As a result of these failures, the resident developed an infection at the surgical site, which required hospitalization and two subsequent surgical interventions, including a hip revision. The lack of timely care planning, physician orders, monitoring, and staff competency directly contributed to the resident's adverse outcome. The deficiencies persisted until the care plan and physician orders were finally updated more than three weeks after the initial placement of the wound vac.
Lack of Staff Competency and Education for Wound Vac Care
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies and did not receive necessary education to care for a resident with a wound vacuum (wound vac) following a hip replacement. The resident, who was cognitively intact, required the wound vac due to drainage at the surgical site. However, there was a period when the wound vac was not in use because it became full and staff were unsure how to manage it, leading to its discontinuation. The resident did not have a care plan, physician orders, or evidence of monitoring for the wound vac for 22 days after its placement. Review of staff education files revealed that none of the three licensed nurses who cared for the resident had received wound vac training or competency assessments. The Director of Nursing confirmed that no education or competencies were provided for wound vacs, and the Nurse Educator was unfamiliar with the facility's own education and competency documentation referenced in the facility assessment. As a result of these deficiencies, the resident developed an infection at the surgical site, requiring hospitalization and two additional surgical interventions.
Lack of Qualified Food Service Director and Full-Time Dietician
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, specifically lacking a qualified food service director and a full-time qualified dietician. The Kitchen Manager, who was new to the position, did not possess certification as a dietary manager or food service manager at the time of the survey. Additionally, the Registered Dietician (RD) was not working full-time at the facility, as confirmed by both the Administrator and the RD herself; the RD worked 25 hours in the previous week and was present at the facility three times a week, splitting her full-time hours between two facilities. These findings were based on staff interviews and review of timecard records.
Failure to Provide Substantial Snacks and Meal Alternatives Outside Scheduled Meal Times
Penalty
Summary
The facility failed to provide substantial snacks or meal alternatives for residents who required food outside of scheduled meal times, particularly when there was more than 14 hours between the evening meal and breakfast. Record reviews and interviews revealed that a resident with complex medical conditions, including end stage renal disease, diabetes, and chronic heart failure, often returned from dialysis appointments late in the evening and did not consistently receive dinner or substantial snacks. Documentation of meal intake was inconsistent, and staff sometimes marked the resident as 'not available' for dinner, even though the resident returned later and required food. Observations and staff interviews confirmed that kitchenettes on the units were not consistently stocked with substantial snacks or meal alternatives, such as sandwiches or salads, after the kitchen closed in the evening. The kitchen manager and nursing staff acknowledged that after the kitchen closed, only limited snack items like pudding, crackers, and chips were available, which did not constitute a meal. There was also confusion among staff regarding their ability to access the kitchen after hours to provide food for residents, and the process for restocking snacks was not reliably followed. Additional interviews with cognitively intact residents indicated that snacks were only available if the kitchenettes happened to be stocked, which was not always the case. Observations confirmed that essential snack items and meal alternatives were missing from the units, and the kitchen manager stated that the kitchen was responsible for stocking these items but did not keep track of inventory. As a result, residents who needed food outside of traditional meal times, especially those returning late from medical appointments, did not have access to suitable and nourishing alternatives.
Food Storage and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage and handling practices. During a kitchen tour, boxes of food were found stacked directly on the floor of the walk-in freezer, obstructing access to other food items. The Kitchen Manager acknowledged that boxes should be placed on crates and not directly on the freezer floor. Despite being informed of this issue, a follow-up observation the next day revealed that the problem persisted, with boxes still on the freezer floor. The Kitchen Manager confirmed that the freezer had been organized after the initial observation but reiterated that boxes should not be on the floor. Further deficiencies were identified in all four unit kitchenettes. Observations included microwaves with visible smears, cabinets with crumbs and open, undated food items, and refrigerators containing undated or expired food, moldy bread, and containers with unknown contents. Freezers also contained undated and unlabeled food items. Interviews with the Unit Manager and DON confirmed that facility policy requires all food to be labeled and dated, and that the observed conditions did not meet these standards. The Kitchen Manager also confirmed that all food in the kitchenettes should be labeled with the resident's name and relevant dates.
Infection Control Lapses and Environmental Contamination Identified
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices on the second floor of the facility. Observations revealed that essential medical equipment and supply carts, including the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts, were covered in white/grey powder and dust, later confirmed to be construction debris. Interviews with nursing and administrative staff acknowledged the presence of dust and debris on these items, as well as on the kitchenette hood, and confirmed that cleaning had not been adequately performed. The CDC notes that environmental disturbances, such as construction dust, can release airborne infections, increasing the risk of healthcare-associated infections. Further deficiencies were observed in the handling and maintenance of resident care equipment. A mattress and pillows in a recently vacated room were found to be stained, worn, and with compromised protective coverings, yet were made up and prepared for a new resident after terminal cleaning. Housekeeping and nursing staff confirmed the compromised condition of the mattress and pillows, and administrative staff acknowledged that such items could not be properly disinfected and should not remain in use. Additionally, an out-of-service medication cart was found to be missing a sharps container, with used needles and lancets left inside, and dust-like debris was noted on other equipment and surfaces. Other infection control lapses included the improper storage of resident-specific ice packs in a kitchenette freezer used for food, as confirmed by nursing and administrative staff, and the failure to label wound and PICC line dressings with the date of last change for a resident who had recently undergone surgery. These findings collectively demonstrate a lack of adherence to established infection control protocols and equipment maintenance policies, as confirmed by staff interviews and facility policy review.
Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident requiring hemodialysis. According to facility policy, staff are required to conduct ongoing assessments of the resident's condition and monitor for complications before and after dialysis treatments, as well as maintain ongoing communication and documentation with the dialysis center. Review of the medical record for a resident with end stage renal disease and multiple comorbidities revealed that the Hemodialysis Communication Record was not consistently or completely filled out by either facility staff or the dialysis center on 23 occasions since a specified date. Additionally, on at least one occasion, the required pre- and post-dialysis assessments, including checks for bruit, thrill, vital signs, last meal, diet, and general condition, were not completed by facility staff. Interviews with nursing staff and the DON confirmed that the Hemodialysis Communication Record was not being fully completed as required, and that both facility and dialysis center staff were responsible for documenting their respective portions. The DON also confirmed that nursing staff were not consistently assessing the resident's condition before departure to dialysis and upon return, nor ensuring that the dialysis center completed its documentation. The Unit Manager was identified as responsible for ensuring the records were complete and for contacting the dialysis center when documentation was missing.
Medication Cart Left Unlocked in Resident Area
Penalty
Summary
A medication treatment cart on the second floor was observed to be unlocked during a period of observation from 10:54 AM to 11:04 AM, while a resident was present and walking in the hallway. An interview with a nurse at 11:04 AM confirmed that the cart should have been locked, in accordance with the facility's Medication Storage policy, which requires all drugs and biologicals to be stored in locked compartments. Review of the policy, last updated in September, reiterated this requirement. The unlocked cart constituted a failure to safely store medications as required.
Failure to Maintain Cleanliness and Equipment Integrity During Construction
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment on one of its units, specifically the Second Floor, due to the presence of construction dust and debris on essential medical equipment and carts. White and grey powder-like substances, identified as construction dust, were found on the code cart, wound care/treatment cart, precaution supply carts, and Hoyer lifts. Multiple staff, including an LPN, the DON, the Infection Preventionist, and the Regional Nurse Consultant, confirmed the presence of dust and debris on these items. Additionally, the kitchenette hood was found to have a buildup of debris and had not been cleaned. The dust was attributed to ongoing construction activities, such as sanding and wall preparation for wallpaper installation. Further deficiencies were identified in the maintenance and readiness of resident room equipment. After a resident was discharged, a mattress with brown discoloration, a worn and chipped protective lining, and two pillows with holes in their protective coverings were found in a room that had been terminally cleaned and prepared for a new resident. Staff interviews confirmed that the mattress and pillows were compromised and not suitable for resident use, as they could not be properly cleaned or disinfected. Facility policy requires that equipment in disrepair be reported and removed from use, but this was not followed in this instance, as the compromised items remained in the room ready for the next resident.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to implement effective measures to prevent further potential abuse during the investigation of an abuse allegation involving a resident who was cognitively intact and independent with activities of daily living. The resident, who had diagnoses including COPD, anxiety disorder, major depressive disorder, and Wernicke's encephalopathy, reported that a staff member yelled at them, pushed them causing a fall, and later bounced them on the bed. The resident also indicated that another staff member had engaged in similar behavior. Documentation showed that the alleged incident occurred late in the evening, and the resident was monitored following the accusation. Despite the facility's policy requiring protection of residents from further harm during investigations, records and interviews confirmed that the accused staff members were not removed from the facility but were instead reassigned to other units. Schedule reviews indicated that both staff members continued to work in the facility during the investigation period. The administrator confirmed that the accused staff were not removed from the facility while the investigation was ongoing.
Failure to Develop Baseline Care Plans for Non-English Speaking Residents
Penalty
Summary
The facility failed to create and implement a baseline care plan addressing communication needs for two residents who did not speak English and required interpreter services. Upon admission, both residents' Minimum Data Set (MDS) assessments indicated a preferred language other than English and a need for interpreter assistance to communicate with healthcare staff. Despite this, neither resident had a baseline care plan for communication or interventions for interpreter services within 48 hours of admission, as required. For one resident, a care plan was eventually created ten days after admission, but it still lacked interventions for interpreter services. The other resident did not have any care plan related to communication or interpreter services as of the date of the survey. Interviews with facility staff, including a licensed nurse and facility leadership, confirmed that interpreter services were not available and that staff were unable to communicate directly with the residents. In one instance, staff misinterpreted a resident's attempt to communicate and administered pain medication when the resident was actually trying to indicate they were cold. The administrator and DON acknowledged that baseline care plans should have been in place to address these residents' communication needs but were unable to provide evidence that such plans existed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, one resident was involved in a verbal altercation with another resident, which escalated when the second resident hit the first resident on the side of the face after being confronted about touching personal belongings. In the second incident, another resident was standing in a doorway when a different resident approached and punched them in the left side of the chest; a subsequent skin assessment found no bruising. These events were confirmed through record review and interviews with facility leadership, and the facility's abuse policy defines such actions as abuse resulting in physical harm, pain, or mental anguish.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state licensing agency as required. According to the record review, there was no evidence that a report was submitted after a resident alleged being hit with a wet towel by a staff member. Additionally, there was no documentation of an investigation into the allegation in the resident's medical record. The facility's policy requires immediate reporting and investigation of all alleged violations to the appropriate authorities, including the state agency and adult protective services. Interviews with facility staff revealed that the incident was communicated internally through the EHR and discussed among the hospice nurse, Assistant DON, and former DON. The Administrator and DON were aware of the allegation, but the leadership team decided not to report it to the state agency, citing their belief that the resident was experiencing hallucinations. This decision was made despite the facility's policy, which mandates reporting all allegations of abuse regardless of perceived credibility.
Staffing Deficiencies and Delayed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. This deficiency was observed in the care of multiple residents, including one resident with a right leg below-knee amputation who required assistance from two staff members for transfers. The resident reported missing activities due to delays in being transferred out of bed, which affected their ability to engage in meaningful daily routines and manage mood symptoms related to anxiety and depression. Another resident with a fracture of the right tibia and fibula experienced a significant delay in receiving a muscle relaxant medication, waiting approximately two hours after requesting it, which was confirmed by the unit manager as an excessive wait time. The report also highlights widespread concerns about insufficient staffing leading to long wait times for care and excessive call light response times. Residents and their family members reported wait times of up to 45 minutes or more, with call bell history revealing wait times in excess of seven hours for some residents. Specific instances included a resident with Parkinson's disease who did not receive their medications on time, leading to increased symptoms such as tremors and difficulty speaking. Another resident with spinal stenosis and myelopathy reported long wait times for toileting assistance, resulting in episodes of incontinence and distress. Additionally, the facility's failure to administer medications in a timely manner was noted for residents with Parkinson's disease, who experienced delays in receiving their prescribed medications. This was contrary to the facility's policy, which requires medications to be administered within a two-hour window. The unit manager acknowledged the importance of timely medication administration for managing Parkinson's symptoms. Overall, the report indicates a systemic issue with staffing levels and response times, impacting the quality of care and safety of residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of several residents, as evidenced by multiple incidents. Resident #88 reported that their call bell often went unanswered for over an hour, leading to incontinence episodes. The call bell log confirmed delays in response times, with several instances exceeding 30 minutes and some over an hour. Despite having a care plan to address incontinence, the resident's needs were not met promptly, compromising their dignity and comfort. Similarly, Resident #3 was observed waiting for assistance to use the bathroom while their assigned LNA was on break. The LNA present refused to assist, leaving the resident to wait and eventually call out for help, which was only addressed after the Unit Manager intervened. During a Resident Council meeting, several residents expressed concerns about not being treated with dignity and respect. Residents reported instances where staff did not knock before entering rooms, ignored their preferences for personal care, and sometimes displayed rude behavior. One resident mentioned being rushed during care and not being allowed to participate in their own hygiene routine, while another was told to manage independently despite needing assistance. These accounts highlight a pattern of staff failing to honor residents' rights to self-determination and respectful treatment, as outlined in their care plans.
Failure to Support Resident Grievance Reporting Without Fear of Reprisal
Penalty
Summary
The facility failed to establish a grievance reporting system that adequately supports residents' rights to voice grievances without fear of discrimination or reprisal. This deficiency was identified during a Resident Council meeting attended by six residents, all of whom were cognitively intact as indicated by their BIMS scores. The residents expressed that while they were aware of the grievance process and found it effective for issues like missing personal property, they did not feel comfortable reporting concerns about being treated without dignity and respect due to fear of repercussions. The residents reported that they experienced rude, disrespectful, or rough behavior from staff and feared that reporting such behavior would result in being yelled at or ignored. This sentiment was consistently confirmed by all six residents during the conversation with the survey team. The facility's policy, which states that residents have the right to voice grievances without fear of discrimination or reprisal, was not effectively implemented, leading to a situation where residents felt unable to report their concerns about staff treatment.
Failure to Provide Timely Assistance with Toileting
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, specifically in the areas of transferring and toileting. Resident #145, who was admitted with a fracture of the right tibia and fibula, required assistance with toileting as per their care plan. However, the resident reported being left on a bedpan for 45 minutes despite using the call bell, causing significant discomfort and distress. This incident highlights a failure to adhere to the care plan's specified interventions for toileting assistance. Resident #18, with a history of lumbar spondylopathy and morbid obesity, also experienced delays in receiving assistance with toileting. The resident reported waiting an hour or longer for help, particularly during meal times, which resulted in discomfort and cold meals. Similarly, Resident #73, who has spinal stenosis and requires assistance from two staff members for toileting, reported long wait times for assistance, leading to episodes of incontinence. The resident's family member corroborated these delays, noting wait times of 1-2 hours for call bell responses. These incidents collectively indicate a systemic issue in providing timely assistance for residents' toileting needs, as outlined in their care plans.
Failure to Provide Adequate Outdoor Activities for Resident
Penalty
Summary
The facility failed to provide activities that support the physical, mental, and psychosocial well-being of a resident diagnosed with Parkinson's disease. The resident, who has a cognitive assessment score indicating intact cognitive function, expressed a strong preference for engaging in favorite activities and going outside. The resident's care plan, created in October 2023, emphasized the importance of engaging in meaningful daily routines and included an intervention for going outside when the weather permits. However, the resident reported being unable to go outside daily due to insufficient staff for supervision and being told it was too cold, despite expressing that going outside was very important. During the recertification survey, the resident was not observed outside, and activity logs showed the resident only went outside once in 33 days. An Advanced Practice Registered Nurse note from August 2024 indicated the resident felt trapped and unable to get assistance to go outside. An Activity Aide acknowledged the importance of the resident going outside but was unsure if there were enough staff to facilitate this. The deficiency was identified as the facility's failure to ensure the resident's preferences and care plan interventions were met, impacting the resident's well-being.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to smoking for a resident. The resident, who has diagnoses including osteomyelitis, peripheral vascular disease, and chronic kidney disease, was admitted and readmitted to the facility. Despite the care plan stating that the resident may not smoke per the smoking evaluation and policy, the resident has been signing out and leaving the property to smoke without staff accompaniment. The resident admitted to going out to smoke three times on a particular day without signing out of the building. The facility's smoking policy requires that smoking supplies be labeled and maintained by staff in a suitable cabinet at the nursing station. However, the resident's cigarettes and lighter were kept in their room, contrary to the policy. The Unit Manager confirmed this and noted that approximately 15 residents on the floor have dementia and are ambulatory, which could pose additional risks. This oversight in policy enforcement and supervision led to the deficiency identified by the surveyors.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper evaluation and documentation for a resident receiving PRN (as needed) psychotropic medication. Specifically, a PRN order for Ativan (Lorazepam) 0.5 mg was prescribed to be administered every 4 hours as needed for restlessness/agitation over a 90-day period. This order was initiated without the required physician documentation providing a medical rationale for extending the PRN order beyond the standard 14-day period. An interview with the Unit Manager confirmed the absence of a physician note or documented evaluation justifying the extended use of this medication for more than 14 days.
Facility Fails to Provide Preferred Beverage Options
Penalty
Summary
The facility failed to provide residents with drink options that accommodate their preferences, specifically the availability of ginger ale. Resident #40 expressed frustration over the absence of ginger ale as a beverage option. Additionally, six active resident council members voiced concerns about the removal of ginger ale from the available drink options. The facility's policy, titled FNS304 Person-Centered Choice, effective 5/1/23, states that drinks should be provided consistent with resident needs and preferences. However, a Licensed Nursing Assistant (LNA) confirmed that ginger ale has not been available for about six months, and the drink cart observed did not include ginger ale or any soda products. The Assistant Activities Director and the Assistant Kitchen Manager also confirmed the unavailability of ginger ale and any alternative soda or carbonated drinks for residents.
Insufficient Dietary Staff Leads to Meal Service Deficiencies
Penalty
Summary
The facility failed to ensure sufficient support personnel to effectively carry out the functions of the food and nutrition services, impacting all residents. Observations and interviews with multiple residents revealed complaints about unsatisfactory food quality, with meals being cold when they should be hot and served later than the posted mealtimes. During a dinner service observation, meals were served by tray service without insulated plates, leading to faster cooling. A review of dinner delivery logs from 5/21/24 to 6/26/24 showed that meals were served late 76% of the time, with only 12 out of 52 instances being on time. Interviews with the Unit Manager, DON, and Kitchen Account Manager confirmed awareness of the issues, attributing them to a shortage of dietary staff. The Kitchen Account Manager noted that the kitchen has been short-staffed since April, with only one dietary staff member available instead of the required 3-4. This staffing shortage has led to delays in meal service and contributed to the food being served cold, as meals are delivered by tray service due to insufficient staff to serve from each unit's meal service line.
Deficiency in Meal Service Quality and Timeliness
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at an appetizing temperature. Multiple residents reported that meals were often served late, cold, and unappetizing. Observations confirmed that residents were served meals at inconsistent times, with some waiting significantly longer than others. Complaints were made about the lack of meal choices and the poor quality of food, with some residents relying on family to bring in meals due to dissatisfaction with the facility's offerings. The kitchen staff was found to be short-staffed, which contributed to the delays and temperature issues with the meals. The facility's Director of Nursing and Administrator were aware of the complaints regarding food quality, temperature, and timeliness. The kitchen was operating with insufficient staff, leading to the use of tray service without insulated plate covers, which caused meals to become cold more quickly. The kitchen logs revealed that food temperatures were not consistently documented, with 20 out of 90 meals lacking temperature records. The Kitchen Account Manager confirmed that the staffing shortage had been ongoing since April, affecting the ability to serve meals on time and at the correct temperature. The deficiency was attributed to the lack of adequate dietary staff, which hindered the facility's ability to provide meals that met the required standards for palatability and temperature.
Failure to Provide Appealing Meal Options
Penalty
Summary
The facility failed to provide residents with appealing meal options that accommodated their preferences and dietary needs, as evidenced by multiple observations and interviews. Residents and their representatives reported not being offered a choice of meals, with some residents receiving meals that did not align with their expressed preferences or dietary restrictions. For instance, Resident #11, who had a pork allergy, was served a ham and cheese sandwich instead of the BBQ chicken listed on their meal ticket. Other residents expressed dissatisfaction with the quality and temperature of the food, noting that meals were often served cold and late, and that they were not given the opportunity to choose alternative options. The facility's policy, effective 5/1/23, stated that residents should be offered a choice of nourishing, palatable, well-balanced food and beverage options that meet their daily nutritional needs. However, observations and interviews revealed that this policy was not being implemented. A test tray requested by the surveyor showed that the alternative meal option, BBQ chicken, was not being served, and staff interviews indicated a lack of awareness and implementation of a process to ask residents their meal preferences. The Dietitian confirmed that residents were not offered the second choice on the menu prior to meals, and the Director of Nursing acknowledged that staff should be asking residents about their meal options daily. The deficiency was further highlighted by the dissatisfaction expressed by residents and their representatives, who reported that the food quality had declined over the past few months. Some residents relied on family members to bring in meals or snacks due to the unappealing and inadequate food options provided by the facility. The lack of a structured process to ensure residents were offered alternative, appealing meal options contributed to the deficiency, as staff did not consistently inquire about or accommodate residents' meal preferences.
Failure to Review Background Check for LNA
Penalty
Summary
The facility failed to adhere to its policy regarding the screening for abuse for a Licensed Nursing Assistant (LNA). According to the facility's policy titled HR205 Background Investigations, any applicant with a criminal conviction should be interviewed by Human Resources to assess the relevance of the conviction to the position and determine eligibility for employment. However, the facility did not follow this procedure for LNA #1, a contracted employee, whose background check revealed a misdemeanor charge for disturbing the peace with fighting prior to their hire. There was no evidence that this charge was reviewed by the facility or corporate HR team to determine the employee's eligibility for employment. This oversight was confirmed during an interview with the Market Operations Advisor.
Failure to Prevent Significant Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of anticoagulation medication. The resident, who was admitted for sub-acute rehabilitation following a cerebrovascular accident with petechiae hemorrhaging, had discrepancies in the start date for their anticoagulation medication, Apixaban. The hospital's transition of care report indicated that the medication should not be started until after a follow-up CT scan was performed and evaluated by a neurologist. However, the facility's medication administration record showed that the resident received Apixaban on the day of admission and the following day, without evidence of order clarification with the admitting physician. The Director of Nursing (DON) acknowledged that the transition of care report contained conflicting information regarding the start date for the resident's Apixaban. The facility's policy requires medication reconciliation to be performed by the admitting nurse, reviewed by a second nurse, and by the physician before administering any medication. Despite this policy, there was no evidence that the orders were clarified with the admitting physician or the sending facility. The DON stated that discrepancies in discharge and admission orders are common, and nursing staff are expected to review all discharge information and reconcile medications accordingly. The admitting physician, who is also the medical director, stated that they were not aware of the orders to withhold Apixaban until after the CT scan review. The physician relies on nursing staff to accurately communicate medication orders over the phone, as they do not have access to the transition of care report outside the facility. The physician confirmed that they would not have ordered Apixaban if they had been aware of the information in the transition of care report. This lack of communication and failure to clarify medication orders led to the significant medication error.
Failure to Obtain Ordered X-ray for Resident
Penalty
Summary
The facility failed to provide necessary radiology services for a resident who was experiencing numbness and pain on the left side of their body, which was affecting their rehabilitation. The resident reported that a provider had ordered an x-ray a couple of weeks prior, but it had not been conducted. A physician's note from 6/18/24 indicated that an x-ray was ordered for the resident's left ankle due to pain and numbness, but the medical record showed no evidence that the x-ray was obtained. The Market Clinical Lead confirmed that the x-ray was never obtained and acknowledged that the physician did not follow the process to alert nursing staff to enter the order for the x-ray.
Failure to Involve Residents and Representatives in Care Planning
Penalty
Summary
The facility failed to include residents and their representatives in the development of baseline care plans and did not provide them with a summary of these plans for three residents. Resident #1 was admitted for rehabilitation following a craniotomy due to a subdural hematoma and experienced an unwitnessed fall resulting in a hospital stay. There was no evidence that Resident #1 or their representative participated in the care plan development or received a summary. Similarly, Resident #2, admitted for post-acute care after a lumbar fracture, and Resident #3, admitted for rehabilitation after a subdural hematoma, were not involved in their care plan development, nor were they provided with a summary. Interviews with the residents' representatives confirmed that they were not invited to participate in the care planning process and did not receive copies of the baseline care plans. The facility's policy requires that residents and their representatives be given a summary of the baseline care plan and be invited to care planning conferences. However, the Social Service Specialist and Director confirmed that it was not part of the facility's process to provide these summaries unless requested, and there was no documentation of invitations to the conferences for the residents and their representatives.
Neglect of Port Care Leads to Infection and Chemotherapy Delay
Penalty
Summary
The facility failed to protect a resident from neglect by not providing necessary care for a port-a-cath, leading to an infection. The resident, who was admitted for sub-acute rehabilitation following chemotherapy and surgery for ovarian cancer, had a port that was not identified or cared for during her stay. The port became infected, resulting in its removal and a delay in the resident's chemotherapy treatment, causing her emotional distress. Upon admission, the facility did not identify the resident's port, and there were no physician orders or care plans in place for its maintenance. Despite multiple opportunities for staff to observe and assess the port during skin checks and personal care, the port was neglected. Interviews with staff revealed that some were aware of the port but assumed it was being managed by oncology, while others did not document or monitor the port site. The lack of documentation and monitoring persisted throughout the resident's stay, with no evidence of care provided to the port. The facility's investigation confirmed that the port was not documented in the resident's medical records, and staff failed to obtain necessary care orders or develop a care plan. This oversight resulted in the resident's port becoming infected, requiring hospitalization and disrupting her chemotherapy schedule.
Removal Plan
- Completed a house wide audit of skin to ensure all ports were identified and no residents were identified to have ports.
- Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port, completed.
- The DON or designee will audit all new admissions for ports and audits will be reviewed at monthly QAPI meetings.
Failure to Provide Port Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident's implanted port, which led to an infection and subsequent removal of the port. The resident, who was admitted for sub-acute rehabilitation following abdominal surgery and chemotherapy for ovarian cancer, had a port that was not identified or cared for during their stay. The facility staff did not conduct comprehensive skin assessments, obtain or implement orders for port care, or include port care in the resident's care plan. As a result, the resident's port became infected, delaying their chemotherapy treatment. Interviews and record reviews revealed that the staff were aware of the resident's port but did not perform necessary care, such as dressing changes or monitoring the port site. The resident's family representative reported that the port site appeared red, inflamed, and black, with a moldy bandage, when the resident was admitted to the hospital for chemotherapy. The hospital staff confirmed the infection and removed the port, noting that the dressing was not intended for long-term use and should have been removed upon admission to the facility. The facility's initial admission assessment failed to identify the port, and there was no documentation of port care throughout the resident's stay. The Director of Nursing and Market Clinical Lead confirmed that no staff had reported the lack of care orders or care plan for the port, and the facility's investigation highlighted the absence of comprehensive skin assessments and care planning for the port.
Removal Plan
- Admission assessment should have included removing the protective dressing over the port site and identify the port on admission
- The facility should have initiated orders for care of the port
- The facility should have a care plan for care of the port
- Completed a house wide audit of skin to ensure all ports were identified and no residents were identified to have ports
- Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port
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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