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