Barre Gardens Nursing and Rehab, LLC

Inspectors wroteBased on observation and interview, the facility failed to ensure that food items were stored in accordance with professional standards, that the kitchen was kept neat and orderly, and that food service equipment were clean or dry. This is a repeat deficiency for this facility, with the violation cited during the previous three recertification surveys, dated 6/25/25, 5/9/24, and 4/26/23, and partial survey dated 11/13/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow, maintain, implement their legionella water management plan and implement the use of personal protective equipment when required. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 11/13/25.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident was treated with dignity for 1 of 27 sampled residents (Resident #41). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 11/13/25.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to keep nails trimmed for 1 of 27 residents (Resident #39).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were properly stored for 2 out of 27 residents (Resident #70 and Resident #71). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 6/25/25 and partial survey dated 11/13/25.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and homelike environment for residents who use the common areas by failing to maintain clean air vents for three out of three common areas.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Medical Director fulfilled his/her responsibility to coordinate medical care with facility providers and assist the facility with the development and implementation of resident care policies. This deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview, record review of the facility's Quality Assurance and Performance Improvement Program (QAPI), and facility policy review, the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of infection control, environment, and Medical Director. As a result, GAS (group A strep) spread through the facility and 12 residents developed symptoms of GAS. 2 of 3 sampled residents with symptoms of GAS were hospitalized with sepsis due to cellulitis (Residents #1 and #2). This citation is at the immediate jeopardy level as these failures put all residents at risk for serious harm and/or death.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.71 and following accepted national standards. This has the potential to impact all residents.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure that areas used for bathing/showering, resident rooms, and a resident gathering area were clean, safe, and homelike. This deficient practice has the potential to affect all residents residing in the facility. This is a repeat deficiency for this facility, with the violation cited during the previous two recertification surveys, dated 6/25/25 and 5/9/24, and partial survey dated 4/17/25.

Inspectors wroteBased on observation and interview, the facility failed to ensure that all food was stored safely and to ensure that sanitary conditions for safe food handling were maintained. This has the potential to impact all residents. This is a repeat deficiency for this facility, with violations cited during the previous three recertification surveys, dated 4/26/23, 5/9/24, and 6/25/25.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures to ensure when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure physician visits occurred every 30 days for the first 90 days after admission, and at least once every 60 thereafter for 12 of 25 residents (Resident # 1, 2, 3, 6, 7, 8, 11, 12, 13, 15, 16, and 17).

Inspectors wroteBased on record review and interview it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of her/his quality of life, recognizing each resident's individuality for 1 resident in a sample of 9 residents. (Resident #4).

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure that 1 resident in the applicable sample (Resident #6) received proper foot care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to address the residents' dementia care needs for 1 of 1 residents (Resident #10).

Inspectors wroteBased on observation and interview, the facility failed to ensure only authorized personnel had access to the medication storage rooms. This is a repeat deficiency for this facility, with the violation cited during the previous recertification surveys, dated 6/25/25.

Inspectors wroteBased on review of employee training records and interview, the facility failed to provide evidence of the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the LNAs (Licensed Nursing Assistants) for 1 (LNA #1) of 3 LNAs sampled.

Inspectors wroteBased upon interview and record review, the facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional is employed full-time, or designate a person to serve as the director of food and nutrition services who meets the minimum qualifications.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24.

Inspectors wrote2. Per observations made during the survey, Resident #23 was observed in her/his room in bed without a fitted sheet on 6/25/2025 at 9:25 AM and at 2:40 PM. Throughout the survey, Resident #23 was observed without sheets properly fitted to her/his bed. Per interview with Resident #23 on 06/25/2025 at 09:25 AM, Resident #23 reported that she/he never has the right size fitted sheet and that it happens all the time and that the nursing assistants can never find bariatric sized bed sheets for his/her bed. Per interview with a Licensed Nursing Assistant (LNA) on 6/25/2025 at 9:34 AM, she reported they run out of towels and clean laundry about twice a week and they don't have enough bariatric sheets. Per interview with another Licensed Nursing Assistant (LNA) on 6/25/2025 at 10:00 AM, she reported that they run out of clean linens and that it delays resident care. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise resident care plans for 2 residents related to falls (Residents #34 and #1) and for 2 residents related to pressure ulcers (Residents #39 and #9), of a sample of 23 residents. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to resident altercations and falls for 2 of the 9 sampled residents (Residents #1 and #34) by failing to provide adequate supervision and create and implement effective, timely interventions that would reduce the likelihood of future accidents related to supervision. As a result, Resident #1 suffered a fall that resulted in pain, a large hematoma above his/her left eye, and a fracture of the left hip, which required surgery.

Inspectors wroteBased on interview and observation, the facility failed to safely store locked medications for 2 of 2 units.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from unnecessary psychotropic medications for one of five sampled residents (Resident #17) as evidenced by administration of prn (as needed) psychotropic medications without a discontinued date.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan by failing to notify the provider of specific symptoms for 1 of 23 Residents (Resident #23). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24.

Inspectors wroteBased on interview and employee files, the facility failed to ensure annual performance evaluations were completed for 3 of 3 Licensed Nursing Assistants (LNAs) in the applicable sample (LNA #1, #2, and #3).

Inspectors wroteBased on interview and record review, the facility failed to follow their processes for documenting high value personal property for one of three resident (Resident #1).

Inspectors wroteBased on interview and record review, the facility failed to assist a resident to schedule a follow-up appointment with a provider specializing in the treatment of hearing impairment for one of three residents in the sample (Resident #1).

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received funds and jurisdiction of those funds within thirty days for one resident (Resident #1) out of three sampled residents.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to protect and promote the rights of 1 of 3 sampled residents (Resident #1) by failing to treat the Resident with respect and dignity in a manner and in an environment that promotes the maintenance or enhancement of their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility, by locking all doors to the facility 24 hours a day, 7 days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This has the potential to affect all residents of the facility and all visitors, including family, legal representatives and advocates. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, and record review, the facility failed to ensure that food served to Residents is palatable, attractive, and at an appetizing temperature.

Inspectors wroteBased on resident interview and record review, the facility failed to ensure that residents were served a nourishing snack at bedtime when the time between dinner and breakfast the following morning is more than 14 hours. The facility also failed to ensure that the Resident Council agrees to this amount of time between dinner and breakfast the following morning.

Inspectors wrotePer observation, staff interview, and record review, the facility failed to ensure that it stores and prepares food in accordance with professional standards for food service safety.

Inspectors wroteBased on interview and record review, the facility Governing Body failed to ensure that facility policies were accessible to all staff members operating the facility and providing care to the facility's residents. This has the potential to affect all residents in the facility.

Inspectors wroteBased on interview and review of the facility assessment the facility failed to ensure that the required individuals including a representative of the governing body and the medical director were involved in the development of the facility assessment. This has the potential to affect all residents.

Inspectors wroteBased on interview and review of facility policies, the facility failed to ensure that the Medical Director fulfilled his/her responsibility to coordinate medical care with facility providers and assist the facility with the development and implementation of resident care policies. This deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as evidenced by the improper use of PPE (personal protective equipment) for 1 resident on precautions (Resident #24) and the failure to implement infection prevention practices related to blood glucose monitoring.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for the residents on 1 of 2 units (Unit 1).

Inspectors wroteBased on staff interview and record review, the facility failed to revise the comprehensive care plan as the resident's plan of care changes for 2 of 27 sampled residents (Resident #23 and #62) related to catheter use and pain management for Resident #23 and activity preference for Resident #62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of engaging activities both in and out of resident rooms for 4 of 24 sampled residents (Residents #82, #3, #73, and #23).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that physicians and other providers (as delegated to per regulation) review the Residents' total program of care, including medications and treatments, at each visit as required for 6 of 24 sampled residents (Residents #2, #78, #23, #19, #47, #53).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure residents are seen by a physician personally, face-to-face, for regulatory visits for 1 of 24 sampled residents (Resident #23), and failed to ensure that regulatory visits were conducted every 30 days for the first 90 days after admission for 1 of 24 sampled residents (Resident #31). The facility also did not have a system in place to track required regulatory visits for any resident.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that the attending physician documents in the Resident medical record any rationale against, or actions taken as a result of, irregularities identified by the Pharmacist during the monthly medication regimen review for 4 of 5 sampled Residents (Residents #2, #71, #23, and #19).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that Residents taking psychotropic medications receive gradual dose reductions, unless contraindicated, for 3 of 5 sampled Residents (Residents #2, #25, #19).

Inspectors wroteBased on interview and record review, the facility failed to ensure that records are complete, accurately documented, readily accessible, and systematically organized related to physician notes for 2 of 27 sampled residents (Residents #23 and #31).

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide reasonable accommodation of resident needs for 1 of 24 residents in a standard survey sample (Resident #53).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan that addressed anticoagulant use for 1 of 4 sampled residents reviewed for anticoagulant use (Resident #23).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents with Peripheral IVs receive treatment and care in accordance with professional standards of practice for the only resident in the facility with a Peripheral IV (Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 24 applicable residents (Resident #23) remained free from unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 24 sampled resident (Resident #23) are free from significant medication errors.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that binding arbitration agreements provide for the selection of a neutral arbitrator and a location convenient to both parties for 2 of 3 sampled Residents (Residents #67 and 41).