Vermont Veterans' Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 325 North Street, Bennington, Vermont 05201
- CMS Provider Number
- 475032
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Vermont Veterans' Home during CMS and state inspections, most recent first.
A resident with nicotine dependence and respiratory failure, receiving continuous O2 via nasal cannula, was assessed as an unsupervised smoker allowed to keep cigarettes but required to request a lighter. Despite increasing agitation and confusion, the resident went to the smoking room with O2 in use, where another resident lit their cigarette, igniting the O2 tubing. Staff later observed soot on the resident’s nose and burned tubing, and the resident sustained a painful facial burn with redness and skin loss. The resident’s smoking status and O2-related hazards were not added to the care plan until after the injury, and required no-O2 smoking-room signage was not posted until after the incident, contrary to facility smoking policy.
Surveyors found multiple food storage and temperature control deficiencies, including opened and unlabeled sausages, smart dogs, hot dog buns, and hamburger buns in the kitchen freezer and storage areas, as well as expired instant grits and cheese queso in dry storage. Kitchen staff confirmed the items were expired or should have been discarded. Review of freezer temperature logs showed repeated elevated temperatures in two wing freezers, and the Food Service Coordinator acknowledged the temperatures were elevated but did not submit required work orders as outlined in the facility’s dietary food storage policy.
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Cardinal memory care unit. In the 500 hall bathing room, the tub had chipped paint on the seat and basin, one shower stall had damaged tiles and debris, and the toilet backrest showed cracked padding and rusted framing. On both the 500 and 600 halls, surveyors observed stained and damaged ceiling tiles, including outside a resident room. Several rooms lacked proper room number signs, with the numbers instead written on the walls in magic marker. These conditions were confirmed during a tour with the Administrator, DON, and QA Nurse.
Surveyors found multiple instances where medication and treatment carts were left unlocked and unattended in resident-accessible corridors. On one unit, a medication cart and a treatment cart containing various medications, insulins, syringes, and prescription topical products were observed unlocked with a resident ambulating nearby, and the assigned RN confirmed they were not secured. On another occasion on the same unit, the medication cart was again found unlocked, which the RN Unit Manager acknowledged was contrary to expectations. On a different unit, a medication cart was observed unlocked and unattended with a resident sitting next to it, and the assigned LPN confirmed it should have been locked. The facility’s policy requires all medication compartments and carts to be locked when not in use and not left unattended if open.
A resident with nicotine dependence and respiratory failure was admitted, and although a smoking assessment documented that the resident could smoke independently with a lighter secured by nursing, the baseline care plan did not address smoking status or concurrent O2 use. Nursing notes showed the resident frequently went to smoke and required repeated reminders about O2. The omission in the care plan preceded an incident in which the resident, wearing O2 in the smoking room, had a cigarette lit by another resident; after a few puffs, the cigarette ignited, burning the O2 tubing and causing a painful superficial facial burn, including loss of skin on the nose. The ADON later confirmed that the baseline care plan lacked smoking-related interventions until after the incident, despite facility policy requiring such issues to be care planned and communicated to staff.
Surveyors found that an LPN repeatedly failed to follow required hand hygiene practices during medication administration and glucose management for two residents. The LPN did not perform hand hygiene before and after glove use while preparing and administering oral medications, eye drops, and insulin, and while using and cleaning a glucometer and disposing of used testing supplies. In an interview, the LPN acknowledged that hand hygiene is required before and after glove use, direct resident contact, medication handling, room entry, and handling contaminated equipment, and facility policy specifies that alcohol-based hand sanitizer must be used in these situations and that gloves do not replace hand hygiene.
The facility did not provide adequate supervision to prevent altercations between residents with known behavioral risks, resulting in multiple incidents of physical aggression. Additionally, a resident repeatedly sustained injuries from a bathroom fixture after staff failed to report the hazard for maintenance, despite the resident's requests and facility policy requiring such action.
Two residents with PTSD and trauma histories were not properly assessed or care planned for trauma-informed, culturally competent care. Behavioral health assessments were incomplete, lacking documentation of trauma history, triggers, and individualized interventions. Social Services staff confirmed that trauma-specific needs and care plans were not developed, resulting in a failure to address and mitigate potential triggers for these residents.
A resident with dysphagia and no natural teeth was identified as needing permanent dentures and was seen by a dentist, who instructed the facility to contact the VA for service approval. The facility did not follow up with the VA, resulting in the resident's ongoing difficulty chewing and lack of progress toward obtaining permanent dentures.
A facility failed to report an alleged abuse incident involving an LNA and a resident to the State Licensing Agency. The resident's significant other witnessed the LNA abruptly dropping the resident's wheelchair, which startled the resident. Despite an internal investigation, the facility did not report the incident, considering it a customer service issue rather than abuse.
Failure to Prevent Oxygen-Related Smoking Injury
Penalty
Summary
The facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and did not provide adequate supervision. The resident, recently admitted to the LTC unit from residential care with diagnoses including nicotine dependence and respiratory failure, had a smoking assessment completed that identified them as an unsupervised smoker who could keep cigarettes but had to request a lighter. Nursing progress notes documented that on the night prior to the incident the resident experienced increasing agitation and confusion and was receiving 4 liters of continuous oxygen via nasal cannula. At approximately 6:20 a.m., nursing staff observed black soot on the resident’s nose and burned oxygen tubing under their nose. When questioned, the resident stated that another resident had lit their cigarette and it had caught on fire. The resident sustained a painful facial burn measuring 0.67 cm in width, 1.53 cm in length, and 0.58 cm in area, with redness and loss of skin. Review of the care plan showed that the facility had not care planned the resident’s smoking status or the hazard associated with their oxygen use until the day after the burn occurred. The facility’s smoking policy, revised previously, stated that oxygen use is prohibited in smoking areas, and the DON confirmed that the resident went to the smoking room with oxygen on and was burned when the cigarette was lit, and that a sign prohibiting oxygen in the smoking room was not posted on the door until after the injury. This deficiency was cited as a repeat violation from the prior re-certification survey.
Improper Food Storage, Labeling, and Freezer Temperature Management
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices in the facility’s kitchen and dry storage areas. During an observation of the kitchen freezer, surveyors found an opened pack of three sausages and an opened package of smart dogs that were not dated or labeled. In the dry storage area, they observed a 10-pack of instant grits and a 13.7-ounce bag of cheese queso that were past their expiration dates. A kitchen staff member confirmed that the items were expired and that the sausages and smart dogs were opened and unlabeled. On a subsequent observation of the kitchen, surveyors again found the same opened and undated sausages and smart dogs still in the freezer, along with one open and undated package of hot dog buns and two packages of hamburger buns with no date or initials. Another kitchen staff member confirmed these items should have been discarded. Surveyors also identified a deficiency related to freezer temperature monitoring and follow-up. Review of the facility’s freezer temperature logs showed that on multiple dates, the C wing and North wing freezers were recorded at elevated temperatures of 10°F and 5°F. The facility’s Dietary-Food Storage policy required that all refrigerators and freezers meet national sanitation foundation standards, follow recommended temperatures, and that elevated temperatures be immediately brought to the attention of the Dietary Manager or designee and environmental services. In an interview, the Food Service Coordinator acknowledged that these recorded freezer temperatures were elevated and stated that the process was to notify maintenance and submit a work order, but confirmed that she did not submit work orders after these elevated temperatures were documented.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, specifically the Cardinal memory care unit. During observation in the 500 hall bathing room, surveyors noted the tub had chipped paint on both the seat and the tub itself, one of the two shower stalls contained damaged tiles and debris, and the toilet backrest had cracks in the padding and rust on the framing. On both the 500 and 600 halls of the Cardinal memory care unit, there were stained and damaged ceiling tiles, including outside of one resident room. Additionally, room number signs were missing outside several rooms, and the room numbers had been written directly on the walls with a magic marker. These environmental issues were observed and confirmed during a tour and interview with the Administrator, DON, and QA Nurse.
Unlocked Medication and Treatment Carts Left Unattended in Resident Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep drugs and biologicals stored in locked compartments as required by facility policy and professional standards. On the [NAME] Unit, a medication cart and a treatment cart were observed unlocked in the hallway with no staff present, while a resident was ambulating near the medication cart. The RN assigned to the cart confirmed both carts were unlocked. The medication cart contained medications including inhalers, topical patches, syringes, topical medications, insulins, prescribed resident-specific medications, and narcotics in a separate locked compartment. The treatment cart contained wound cleansers, prescription topical creams/pastes, and prescription topical powders. On a subsequent observation on the same unit, the medication cart was again found unlocked, and the RN Unit Manager confirmed it should not have been unlocked. On the North Village Unit, surveyors observed another medication cart unlocked and unattended in the corridor, with a resident sitting next to it. The LPN assigned to that cart confirmed it was not locked as required. The RN Unit Manager and the facility’s written policy on Medication Labeling and Storage both state that compartments containing medications and biologicals must be locked when not in use and that carts used to transport such items are not to be left unattended if open or otherwise available to others.
Failure to Include Smoking and Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's smoking needs, including the resident's use of oxygen, despite documented nicotine dependence and respiratory failure. The resident was admitted with these diagnoses, and a smoking assessment indicated that the resident was capable of holding their own cigarette and smoking unsupervised, with the requirement that nursing secure the lighter and make it available as needed. Nursing progress notes documented that the resident went to smoke multiple times and had to be repeatedly reminded to wear oxygen. However, the baseline care plan in effect from the resident's prior residential care unit admission did not address the resident's smoking status or oxygen use until a later date. The deficiency culminated in an incident in which the resident, while on oxygen, went to the smoking room and had another resident light a cigarette. After taking two puffs, the cigarette caught fire in the resident's face, burning the oxygen tubing and leaving black soot on the resident's nose. The resident sustained a painful superficial burn to the face, including loss of skin from the tip of the nose, with specific measurements documented in the nursing notes. During an interview, the ADON confirmed that the residential care unit care plan served as the baseline care plan on admission and was unable to provide documentation that the baseline care plan addressed the resident's smoking needs until the day after the burn incident, contrary to the facility's smoking policy requiring smoking-related privileges, restrictions, and concerns to be noted in the care plan and communicated to staff.
Failure to Follow Hand Hygiene Protocol During Medication and Glucose Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration for two of nine sampled residents. During an observation of medication administration, an LPN had nine missed opportunities to perform required hand hygiene, failing to use hand sanitizer or soap and water before and after glove use while preparing and administering oral medications to Resident #1. The same LPN also did not cleanse hands before and after glove use when preparing eye drops and glucose testing for Resident #89, instilling eye drops, testing blood glucose with a glucometer, cleaning the glucometer, disposing of used testing supplies, preparing an insulin injection, administering the insulin injection, and upon completion of the injection. In an interview, the LPN acknowledged that hand hygiene should be performed before and after putting on gloves, direct resident contact, preparing or handling medications, visiting a resident’s room, and after handling contaminated equipment such as a glucometer. The facility’s Hand Hygiene Policy states that gloves do not replace hand hygiene and that an alcohol-based hand sanitizer with at least 62% alcohol must be used before preparing or handling medications, before and after direct resident contact, and after glove removal. These observations, interviews, and record reviews demonstrated that the facility did not ensure staff adherence to its own hand hygiene policy and infection control standards during medication preparation and administration and during the use and cleaning of a glucometer for Resident #1 and Resident #89.
Failure to Prevent Resident Altercations and Address Environmental Hazards
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and did not maintain an environment free from accident hazards for several residents. In one incident, two residents with known histories of behavioral issues and prior altercations were left unsupervised on a porch, resulting in a physical altercation. Both residents had care plans indicating risks for aggression and wandering, yet there was no evidence that staff were supervising them at the time of the incident. Facility leadership confirmed that these residents were left together without supervision despite their documented behavioral histories. Another deficiency involved a resident with a history of entering other residents' rooms and being difficult to redirect. This resident's care plan lacked interventions to address their wandering or to provide supervision. As a result, altercations occurred between this resident and another, including an incident where one resident physically assaulted the other in response to repeated room entries. These events were confirmed by facility leadership and documented in progress and incident notes. Additionally, a resident with mobility challenges and a need for physical assistance during transfers repeatedly sustained knee injuries due to a poorly placed toilet paper holder in their bathroom. Despite multiple requests to staff to have the fixture moved, no maintenance request was entered as required by facility policy. The resident expressed frustration and distress over the lack of response, and the Director of Environmental Services confirmed that no action had been taken to address the hazard, even though staff had the means and responsibility to do so.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with a history of trauma, including PTSD. For one resident, the medical record documented a diagnosis of PTSD, a history of military combat, and specific triggers such as startle responses and flashbacks. Despite this, the Behavioral Health Clinical Assessment was incomplete, lacking documentation of current mental health issues, trauma history, symptoms, triggers, identified needs, and a recommended plan of care. The resident's care plan did not address PTSD or include interventions to mitigate triggers, and the Social Services staff confirmed that the resident was not care planned for trauma-related needs. Another resident with diagnoses of PTSD, anxiety, and depression was also not fully assessed for trauma-related triggers. The Behavioral Health Clinical Assessment identified a history of trauma but did not specify the type or provide further information. There was no evidence in the resident's record or care plan regarding identification of triggers or strategies to avoid re-traumatization. Interviews with Social Services staff and the Director of Social Services revealed a lack of awareness and use of trauma assessment tools, and it was confirmed that trauma-specific triggers and care planning had not been completed for this resident.
Failure to Provide Routine Dental Services for Resident Needing Dentures
Penalty
Summary
A resident admitted with dysphagia and edentulism was assessed as having chewing difficulties and was using temporary dentures, with a need for permanent dentures identified upon admission. The resident was seen by a dentist, who noted the need for new dentures and indicated that the Veterans Administration (VA) would be contacted to determine service approval and whether the dentist could proceed with care. However, there is no documentation that the facility followed up with the VA as instructed by the dentist. The resident later reported not knowing when the next dental appointment would be and expressed concern about the lack of follow-up regarding the need for new dentures. The Unit Manager confirmed that the process to contact the VA was not completed and could not ensure that the resident's dental needs were being addressed. The resident continued to experience nutritional risk and chewing difficulties due to being edentulous with only temporary dentures.
Failure to Report Alleged Abuse to State Licensing Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Licensing Agency as required. A resident's significant other placed a camera in the resident's room during a period of restricted visitation due to COVID. On a specific date, the significant other witnessed a licensed nursing assistant (LNA) allegedly abusing the resident by abruptly dropping the resident's wheelchair into a reclined position, which startled the resident. The significant other reported this incident to the facility nearly a year later, believing the LNA had been dismissed. However, upon seeing the LNA still employed, the significant other raised the issue again. The Deputy Administrator confirmed that the LNA was placed on leave and an investigation was conducted by the Human Resource Department, but the incident was not reported to the State Licensing Agency. The facility Administrator stated that the initial report was considered a customer service or resident rights issue rather than an abuse allegation, and the second report was not submitted because the previous investigation found the claim unsubstantiated. This oversight resulted in a failure to comply with mandatory reporting requirements for suspected abuse.
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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