Vermont Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and CNA 2) did not shave the beard of one of five sampled residents (Resident 1), without Resident 1's Responsible Party's (RP) consent. This deficient practice resulted in Resident 1, who had his beard for many years, beard being completely removed without approval from Resident 1's RP. This deficient practice had the potential for Resident 1 and/or Resident 1's RP to feel disrespect and undignified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 did not prepare medication for two of two sampled residents (Resident 4 and 5) on one tray with intentions of administering them by giving the medications to the residents sequentially (doing things in a set order, one after the other). This deficient practice resulted in LVN 1 attempting to administer Resident 4 and Resident 5's medications literally together had the potential for Resident 4 and 5 to receive the incorrect medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) stored Oxycodone (a Schedule 11 [a drug that has as high risk for abuse and severe physical or psychological dependence) used to treat moderate to severe pain and has a high risk for abuse and dependence) in a secured double locker drawer. This deficient practice had the potential to result in loss, theft, misuse or diversion (the illegal transfer, distribution, or use of a legally prescribed controlled substance for a purpose other than what the prescriber intended) of Resident 5's Oxycodone medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled thermostats (an automatic device used to control and regulate temperature) were powered on and in working condition. This deficient practice resulted in the inability to regulate the facility's temperatures in certain areas of the facility and had the potential for residents' room temperatures to uncontrolled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure medications were administered in a timely manner (within one hour before or one hour after scheduled time of administration) for 18 of 30 Station A residents on 4/21/2026 in Station A of the facility, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.2. Ensure one of six sampled residents (Resident 128's) medications were administered in a timely manner (within one hour before or one hour after scheduled time of administration) on 4/21/2026 in Station A of the facility, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in four of four inspected medication carts (Subacute Medication Cart 1, Station C Medication Cart 3, Station A Medication Cart 1 and Station A-C split Medication Cart 4 and one of two inspected medication rooms (Station A Medication Room Refrigerator) as per manufacturer specifications and facility's policy and procedure (P&P) titled, Medication Storage and Labeling, dated 2024, Medication Labeling, dated 2024, and Medication Storage Temperature Policy, dated 2024, by failing to:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and observe infection control measures for five of 30 sampled residents. The facility failed to:a. Ensure padded side rails that were wrapped with porous (having minute spaces or holes through which liquid or air may pass) foams were disinfected properly for Resident 4 and Resident 37. b. Ensure Resident 39's peripheral intravenous catheter (PIV- small flexible tube inserted into a peripheral vein-usually in the hand or arm to deliver fluids or medications) was discontinued when it was no longer needed and intravenous antibiotic (medication to treat an infection is delivered directly into the bloodstream through a vein) was completed. c. Ensure Certified Nursing Assistant (CNA) 7 practiced hand hygiene before entering Resident 148's room and before donning a pair of gloves. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 10's) Seroquel ([generic name - quetiapine], a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) was prescribed and administered in accordance with an appropriate clinical indication and diagnosis. This deficient practice had the potential to expose Resident 10 to unnecessary medication and to significant adverse consequences (unwanted, uncomfortable, or dangerous drug effects) resulting from the prolonged use of Seroquel for mental health condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the oral and dental status on the Minimum Data Set (MDS) for one of five sampled residents (Resident 26). This failure had the potential to result in Resident 26 not receiving necessary oral care and treatment.

Inspectors wroteBased on interview and record review, facility documentation, and staff interview, the facility failed to ensure timely follow-up and coordination of a require Preadmission Screening and Resident Review (PASRR) Level II evaluation for one of four sampled residents (Resident 14) identified through PASRR Level I screening as needing further evaluation for Serious Mental Illness (SMI). This deficient practice placing the Resident 14 at risk for unmet mental health needs and noncompliance with federal PASRR requirements of competition of level II by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement comprehensive processing center care plan for Resident 14 identified through PASSR level 1 screening as requiring level II evaluation for residents 14. This deficient practice placed the residents at risk for unmet needs and lack of appropriate coordination of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 37) received safe and adequate assistance with activities of daily living by failing to provide the required two person assistance during incontinent care. This failure had the potential to result in injury, accidents, compromised safety, and inadequate personal care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 184) received oral hygiene care who was dependent on staff for oral care. This deficient practice had the potential to place Resident 184 at risk for diseases of the mouth, gums, and teeth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for two of four sampled residents (Resident 163 and 188). The facility failed to:1. Ensure Certified Nursing Assistant (CNA) 2 was informed of Resident 163's (who was assessed as high risk for fall and had a history of fall) of interventions for fall prevention.2. Ensure Resident 163's bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was functioning and operational when Resident 163 was found on the floor on 4/21/2026. These failures resulted in Resident 163 scooting himself on the floor unnoticed and unassisted by the staff near the doorway of resident's room which can put the resident at risk for serious bodily injury.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper urinary catheter care by maintaining the Foley catheter drainage bag below the bladder level during care for one of two sampled residents (Resident 37). This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) and indwelling catheter-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate hydration for one of three sampled residents (Resident 13), who was visually impaired (unable to see) and required assistance with fluid intake. This deficient practice resulted in Resident 13 becoming dehydrated placing the resident at risk for worsening urinary tract infection (UTI - an infection in the bladder/urinary tract), electrolyte imbalance (when the levels the blood become too high or too low), and potential hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 3) who are receiving enteral feeding (delivers liquid nutrition through a flexible tube that goes directly into the stomach or small intestine). The facility failed to:1. Ensure the tube feeding formula (liquid, specialized nutrition delivered directly to the stomach or small intestine to support health when eating by mouth is not possible or sufficient) was not administered more than 24 hours to Resident 3. This failure had the potential to cause Resident 3 to have intolerance to the tube feeding formula leading to diarrhea (loose stool), nausea, vomiting and inadequate nutrition.

Inspectors wroteBased on observation, interview and record, review, the facility failed to ensure one of one sampled residents (Resident 8) received appropriate monitoring and labeling of an intravenous (IV- giving medicine, fluids, or nutrition directly into a person's vein using a small tube, allowing it to enter the bloodstream instantly) site who was on IV antibiotic (a medicine that fights infections caused by harmful bacteria) therapy. This failure had the potential to result in IV infiltration( when the IV catheter slips out of the vein, causing fluids or medication to leak into surrounding tissue), leading to pain, tissue injury, and increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's order and nasal cannula (NC-plastic tube to deliver supplemental oxygen) was dated according to the facility policy and procedure (P&P) for one of one sampled resident (Resident 150). This failure had the potential to result in residents receiving too much oxygen, delayed identification of tubing replacement, and increased the risk of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one of three sampled residents (Resident 44) with a physician order for fluid restriction ( a physician ordered limit on the total amount of liquids resident can consume in 24 hours to prevent fluid buildup in the body) received care and services consistent with the physician order and consistently monitor, implement, or enforce the prescribed fluid restriction. resulting in the resident receiving fluid amounts that exceeded the ordered limit. These failures resulted in Resident 44 receiving fluid amounts that exceeded the physician ordered limit, and placed Resident 44 at risk for adverse health outcomes and demonstrated a lack of adherence to Resident 44's individualized plan of care and physician orders.

Inspectors wroteBased on interview and record review, the facility failed to act on recommendations from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from 1/29/2026, 2/27/2026 and 3/29/2026 regarding clarifying Resident 10's diagnosis to support the use of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought), affecting one of five residents sampled for review of unnecessary medications (Resident 10). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 40) was free from unnecessary drugs. The facility failed to:1. Monitor Resident 40 for side effects (secondary effects of a medication that may be beneficial or harmful) and adverse reactions (undesirable, harmful effects) associated with opioid (class of drugs used to reduce moderate to severe pain and can affect brain areas controlling emotion and breathing) use. Resident 40 was receiving Oxycodone (strong, addictive opioid medication used to manage severe and ongoing pain) 15 milligrams (mg- unit of measurement) by mouth every six hours and 7.5 mg (half tablet) at bedtime, and Morphine Sulfate (prescription-only potent narcotic pain reliever) 15 mg by mouth every 12 hours, both of which are potent opioid medications used to manage severe and ongoing pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of six sampled residents (Residents 128 and 159) by failing to:1. Ensure Resident 128's Keppra ([generic name - levetiracetam] a medication used to treat seizures {a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness}) was administered within one hour before or after its scheduled time of administration, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error for one out of six sampled residents (Resident 128) during medication administration, by failing to administer Resident 128's Keppra ([generic name - levetiracetam] a medication used to treat seizures) within one hour before or after its scheduled time of administration, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024. This deficient practice failed to ensure Resident 128's Keppra was administered in accordance with physician's orders or professional standards of practice and had the potential to result in seizures and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to practice standard hygienic practices in the kitchen when two staff members failed to wear beard restraints (coverings designed to cover facial hair including beards, mustaches, and goatees in the food service) during food preparation. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 136 of 166 medically compromised residents receiving meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical weight records were complete and accurate, and failed to identify and verify the weight loss documented in the medical record for one of six sampled residents (Resident 4) reviewed for nutritional status. This failure placed the resident at risk for not receiving timely clinical evaluation and intervention.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 1), who was a Regional Center client (a person with a developmental disability receiving care in a state-sponsored facility), with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression [persistent feeling of sadness] to elevated periods of emotional highs), unspecified psychosis (mental health condition characterized by a loss of contact with reality), anxiety disorder (intense and persistent worry that is difficult to control and interferes with daily life) and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The facility failed to: 1. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure one of five sampled residents, Resident 1 was provided with a dignity bag (a bag covering Foley catheter [soft, thin, and [NAME] tube that helps a person go to the bathroom when they can't do it on their own] ) for the Foley catheter while seated in wheelchair in the hallway. This failure has the potential to compromise the resident's dignity. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (total paralysis of the arm, leg, and trunk the left side of the body following a stroke), difficulty in walking, anemia (a condition where the body does not have enough healthy red blood cells). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Interdisciplinary Team (IDT-a team composed of members from different departments working collaboratively to set goals and make decisions that ensure residents receive optimal care) initiated a care conference for one of two sampled residents (Resident 2) following an alleged resident-to-resident altercation (an incident involving two residents fighting or mistreating each other). This failure had the potential to delay addressing Resident 2's care needs, resulting in a delay in necessary interventions.

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Diabetic Management and Insulin Administration, which indicated the facility will ensure safe, timely, and effective monitoring of blood sugar (BS) and administration of insulin in accordance with physician orders and regulatory standards, for one of 3 sampled residents (Resident 1), who was diagnosed with diabetes mellitus type 2 ([DM], a disorder characterized by difficulty in BS control and poor wound healing). The facility failed to:1. Ensure Resident 1's primary care provider (PCP) was aware Resident 1 did not have orders for monitoring BS levels, and insulin coverage. 2. Ensure Resident 1 had orders for BS monitoring and insulin coverage as indicated. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who resided at the facility and was transferred to a General Acute Care Hospital (GACH) 2 on 6/23/2025 for evaluation and treatment and was readmitted to the facility on [DATE] after Resident 1 was treated and stabilized at the GACH 1. This deficient practice resulted in Resident 1 remaining at GACH 1 for 3 days after Resident 1 was deemed appropriate to go back to the facility on 7/28/2025.

Inspectors wroteBased on interview and record review the facility failed to assist one of three residents (Resident 2) to shower at least twice a week. This deficient practice had the potential to result in poor hygiene for Resident 2 which can lead to poor self-image and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication was not left on one of three resident's (Resident 1) bedside table. This deficient practice had the potential to result in visitors, residents, and staff unauthorized access and use of Resident 1's medication and could result in a medication error.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan interventions for one of one resident (Resident 1) by failing to ensure visual checks were done and documented to prevent falls. This deficient practice resulted in Resident 1 having an unwitnessed fall that resulted in a bilateral (both sides) inferior pubic ramus (bony structure that forms part of the pelvis [bones between the lower stomach and upper thighs that connect the spine to the leg]) and right superior ramus (branch of the pelvic bone that make up part of the pelvis) fracture that required hospitalization at the General Acute Care Hospital (GACH).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident, who had a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs), did not fall and sustain an injury during transfer from bed to a shower chair for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) and Restorative Nursing Assistant (RNA) 1 used a mechanical lift (a device used to safely move and transfer individuals who have limited mobility, especially those who cannot bear weight independently) to transfer Resident 2 from a bed to a shower chair as recommended by the Physical Therapy (PT) department. 2. Develop a care plan for Resident 2's mode of transfer between surfaces with an intervention to prevent the resident's injury. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the physician for one of three sampled residents (Resident 1) was notified when Resident 1 had scant bleeding to her tracheostomy stoma (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) site, and complaints of pain, following the change of the tracheostomy tube. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's change of condition (COC) and the inability of the physician to give instructions for Resident 1's care. This deficient practice placed Resident 1 at risk for continued bleeding and pain.

Inspectors wroteBased on interview and record review, the facility failed to complete a change of condition (CIC/COC- noticeable shift or alteration in a patient's physical, mental, or functional stated, requiring attention and potentially promoting further medical evaluation or intervention) evaluation for three out of five residents when Resident 2, Resident 3, and Resident 5 were exposed to Coronavirus disease ([COVID 19] an infectious disease caused by the SARS-SoV-2 virus). This failure has the potential to result in missing identification of potential symptoms or complications, risking the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear proper personal protective equipment ([PPE] specialized clothing and equipment like gloves, gown, masks, and eye protection, used to create a barrier between healthcare workers and potential sources of infection) prior to entering the rooms of three out of five sampled residents (Resident 6, Resident 7 and Resident 8), which were designated as Novel Respiratory Precaution room. a. Housekeeping (HK) 1, Certified Nurse Aid (CNA) 1 entered Resident 6 and Resident 7's room without proper PPE. b. one Charge Nurse (CN) 1 entered Resident 8's room without proper PPE. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident did not develop a deep tissue skin injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right lateral (side) foot and the right buttock for one of four reviewed residents (Resident 154). The facility failed to: 1. Ensure Resident 154 was turned and repositioned every two hours per physician order and a care plan titled, Risk for Skin breakdown dated 1/27/25 2. Ensure Resident 154 skin assessment was done during shower days and/or bed bath (a wash that you give to someone who cannot leave their bed). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to ensure morning medication administrations were done on time in the subacute unit (SAU, a nursing unit that provides a level of medical care that is less intensive than acute care but more specialized than typical skilled nursing care) for seven (7) of 26 residents on 3/12/25 and 4 of 25 SAU residents on 3/13/25. 2. Failed to ensure medications were checked for accuracy upon delivery receipt and before administration. As a result, the Zosyn (piperacillin sodium and tazobactam sodium, an antibiotic combination that treat certain infections) intravenous (IV, into the vein) medications for 2 of 2 sampled residents (Residents 22 and 44) were not administered in accordance with the physician orders. The facility pharmacy failed to communicate the changes in physician's order with the facility and the prescriber. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two of three reviewed residents were free of significant medication errors as evident by: 1. The facility administered intravenous (into the vein) antibiotic (medication to treat infection) not in accordance with physician's order for two (2) of 2 sampled (Resident 22 received 30 of 36 doses in total and Resident 44 received 19 of 22 doses). These deficient practices had the potentials of worsening residents' health conditions. 2. Failing to administer Resident 361's Liothyronine (a medication used to treat hypothyroidism {when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs}). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Change of Condition (COC) and notify physician for two of three residents (Resident 48 and Resident 362) when Resident 48 verbalized he wanted to die, and when Resident 362 missed a scheduled thyroid (a small gland in your neck) medication. This failure resulted in the lack of necessary care and treatment and had the potential to result in Resident 48 harming himself and Resident 362 developing hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to five of 11 reviewed residents (Resident 62, 109, 112, 40, and 121) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Resident 62 with passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both arms in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE]. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure there was sufficient Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) staff to provide treatment to five of 11 reviewed residents (Resident 62, 109, 112, 40, and 121) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). This failure had the potential for Resident 62, 109, 11, 40, and 121 and other residents with physician orders for RNA to experience a decline in range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Two medication errors out of 32 total opportunities contributed to an overall medication error rate of 6.25 % for two residents (Resident 134, and 22) observed during medication administration (MedPass). This deficient practice of medication administration error rate of 6.25 percent (%) exceeded the five (5) percent (%) threshold and had the potential of adversely affecting residents' health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intravenous (IV, into the vein) antibiotic (medicines that fight bacterial infections) medications had labels in accordance with the physician orders for two (2) of 2 sampled residents (Residents 22 and 44). This failure had the potential of medication error.

Inspectors wroteBased on observation, and interview the facility failed to ensure the ice machine had an air gap for back flow (the unwanted reverse flow of contaminated water) prevention. This failure had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on observation, interview, and record review, the facility did not provide accurate documentation for five of 11 reviewed residents (Resident 62, 40, 112, 133, and 109) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Ensure Resident 62's Documentation Survey Report (record of nursing assistant tasks) from 3/2024 to 3/2025 (one year) included a task for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to perform active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to the right leg in accordance with the physician's order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by: 1. Failing to maintain an appropriate and recommended temperature of one of three linen dryers. 2. Failing to perform hand hygiene between residents. 3. Failed to handle clean linens in a safe and sanitary manner in the laundry room. 4. Failing to clean two of two cloth gait belts (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) used with Resident 134, 143, and 16 in accordance with the manufacturer's recommendations for disinfecting wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laundry washers were maintained in operational condition for 160 of 160 residents by failing to ensure the washer temperature gauges were functioning properly. This failure had the potential to affect the resident's health and place the residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the failed to ensure a preadmission screening resident review (PASARR) level II was completed for one of two sampled residents (Resident 22). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 22.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one of three sampled residents (Resident 48). This failure had the potential to place Resident 48 at risk for a delay of care and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four reviewed residents (Resident 218) had a Interdisciplinary Team (a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated patient care) meeting scheduled within 72 hours after Resident 218 was admitted to the facility on [DATE] to discuss Resident 218's plan of care. This failure resulted in Resident 218 not aware of his plan of care and not being involved and unable to participate his plan of his care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 154) who was dependent with activities of daily living ([ADL's]- activities such as bathing, dressing and toileting a person performs daily) received the necessary care and services to maintain good grooming, and personal hygiene. These deficient practices resulted in Resident 154 to experience pressure injury (is damage to the skin and underlying tissues caused by prolonged pressure, friction, or moisture, often leading to open sores or wounds) and had the potential to delay wound healing.

Inspectors wroteBased on interview and record review, the facility failed to assist resident who receive proper assistive devices to maintain hearing abilities for one of three sample residents (Resident 20). This failure resulted in a delay in services and Resident 20 not being able to hear adequately during a conversation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of two sampled residents, Residents 22 intravenous catheter (IV - a flexible tube that's inserted into vein to deliver fluids or medications) was rotated when Resident 22's IV site was not changed for nine days. This deficient practice had the potential to cause an infection at the insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who were receiving hemodialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatments was provided with an emergency dialysis kit at bedside, in order to respond to a potential medical complication for one of two sampled residents (Resident 5). This deficient practice had the potential to cause a delay in treatment in case of an emergency.

Inspectors wroteBased interview, and record review the facility failed to ensure staffing information was accurate and current on 1/13/25,2/12/25, 3/9/25 and 3/10/25. This deficient practice had the potential to affect the care of all the residents in the facility and for resident needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 78) was provided necessary behavioral health care and services for the treatment of the residents emotional and mental condition by ensuring: 1. Resident 78 who verbalized feelings of wanting to die was assessed, monitored, and provided interventions to address Resident 78's feelings of wanting to die. 2. Physician, psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders), psychiatrist nurse practitioner, and interdisciplinary team ([IDT]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological [mental and emotional) needs) were notified when Resident 48 verbalized wanting to die. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 112) is free of unnecessary psychotropic medicine(any drug that affects brain activities associated with mental processes and behavior) by failing to: 1. Ensure Resident 112 had a gradual dose reduction(GDR-tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) assessment by the facility or documentation by the physician the dose reduction was not recommended. Resident 112 was on Zoloft(medicine that treat depression) since 11/2/2023. 2. Ensure Resident 112 was seen and evaluated by a psychiatrist when Resident 112 was placed on Zoloft on 11/3/2023 and diagnosed with depression on 1/15/2024. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure Resident 10 was provided with lower dentures. This deficient practice had the potential to result in weight loss because of inability to effectively chew foods for Resident 10.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of activities of daily living care provided for dependent residents, increase and prevent the decrease in range of motion and mobility, pharmacy services, procedures and pharmacist records, free of medication error rates five percent or more, and labeling and storage of drugs and biologicals.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) on one of four sampled residents ( Resident 91) by failing to monitor and address antibiotic use for Resident 91. This failure had the potential to put Resident 91 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a functional call light ( device or button that the residents can press to signal staff for assistance) for one of four sampled residents (Resident 139) by failing to follow facility's policy and procedure regarding call light system. This failure had the potential to result in a delay in meeting Resident 139's needs for assistance which could lead to falls and accidents if assistance is not provided in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who was a high risk for falls and injuries, did not fall and sustain injury for one of three sampled residents (Resident 4). The facility failed to: 1. Ensure staff implemented the fall risk prevention program for Resident 4, which included landing pads (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the residents are falling from the bed), bed in low position, bed and chair alarm (devices that are attached to a resident's bed/wheelchair and sound an alarm when the resident gets up). 2. Ensure Resident 4 had landing pads, and bed alarm in place, and had the bed in the lowest position to prevent from falls per care plan titled, Resident is High Risk For Injury/Accidents And Repeat Falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate picture of the resident ' s status on the Minimum Data Set (MDS- a resident assessment tool) related to fall on one of three sampled residents (Resident 4) to reflect Resident 1 ' s fall on 1/4/2024. This failure had the potential to negatively affect Resident 4 ' s plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures on one of three sampled residents (Resident 1) by failing to ensure a visitor was wearing personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to entering Resident 1 ' s room who was on droplet precautions( a set of infection control measures used to prevent the spread of respiratory illnesses through droplets that are generated by a resident who is coughing, sneezing or talking). This failure had a potential to place residents and staff members at risk for the spread of infectious diseases.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were complete, legible, organized, and were readily available for one of three sampled residents (Resident 1) according to the facility ' s policy and procedure (P&P) titled Health Information Record Manual - Chapter III Legal Health Record. This deficient practice had the potential to cause miscommunication and confusion amongst the health care team due to illegible and/or missing documentation of Resident 1 ' s records which could result in Resident 1 to incur medication errors, a delay in care, and inability for Resident 1 to live at her highest practicable level.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled residents (Resident 3) had tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) care that included changing the tracheostomy tie (a device made of cloth and Velcro used to help stabilize and keep the tracheal cannula secure and in place) and applying a tracheostomy dressing (a covering that protects the area around a tracheostomy and absorbs secretions from the tracheostomy site) after showering. This failure resulted in Resident 3 ' s tracheostomy tie and tracheostomy dressing becoming wet after showering on 9/13/2024 and had the potential for Resident 3 to develop skin breakdown or infection due to a wet tracheostomy tie and tracheostomy dressing.

Inspectors wroteBased on interview, and record review, the facility failed to notify the responsible party of change of condition, when it was discovered that a resident was noted to have a skin tear on her left forearm for one out of three sampled residents, Resident 1. This deficient practice had violated the resident ' s responsible party right to be informed of the care services provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to re-admit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) due to unresponsiveness for evaluation and treatment and not allowed readmission when the GACH wanted to transfer Resident 1 back to the facility. This deficient practice resulted in Resident 1 remaining at the GACH for 16 days after being cleared by the GACH to return to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Standard Precautions (ESP), precautions utilized to prevent the spread of multidrug resistant organisms ([MDROs]- Bacteria that resist treatment with more than one antibiotic [medication that treat bacterial infections]) for three of three sampled residents ( Resident 1, 3, and 4) , who had a gastrostomy tube (Gtube- tube inserted in belly that allows to administration of nutrition and medication) and tracheostomy (surgical opening in the neck where a tube is placed to allow for air to enter lungs). The facility failed to 1) Ensure LVN 1 and LVN 2 had the proper understanding of ESP. 2) Ensure proper signage on the door of residents requiring ESP. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure free from abuse by facility staff, for one of three sampled residents (Resident 1), as evidenced by: 1. Certified Nursing Assistant (CNA) slapped Resident 1's left forearm. 2. Registered Nurse Supervisor (RNS) did not separate Resident 1 from CNA 3 after the incident. These deficient practices had the potential to subject Resident 1 for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document, for one of three sampled resident's (Resident 1), records accurately and completely when Resident 1 had a change of condition. This failure has the potential to result in an inaccurate depiction of care and services rendered for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1), right to be free from physical abuse by Resident 2. Facility failed to: 1. Separate Resident 1 and Resident 2 when CNA 1 witnessed Resident 2 hit Resident 1 on the face on 4/13/2024. 2. Separate Resident 1 and Resident 2 when Resident Representative ([RR] for Resident 1 (resident ' s legal guardian acting on behalf of the resident with the written consent of the resident, or a surrogate) reported the allegation of physical abuse to Registered Nurse (RN) 1 on 4/15/2024. These deficient practices placed Resident 1 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which was considered their home.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse were reported to the state agency (Department of Public Health (DPH) or the police department within two hours of the occurrence of incident and no later than 24 hours for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse from Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 had training on preventing all forms of abuse, and procedures for reporting incidents of abuse. This deficient practice had a potential to place the residents at risk for elder abuse, neglect and exploitation or misappropriation of resident property and inappropriate dementia management.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident, who had a history of urinary tract infection (UTI an infection in the urinary system) and had an indwelling (inserted and left in place) urinary catheter (a flexible tube inserted into the urinary bladder [organ that holds urine to empty the urine and collect it in a drainage bag) in place, did not develop a sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) due to UTI for one of 25 sampled residents (Resident 39). The facility failed to: 1. [...]

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure Dietary Aide (DA) 1 had the appropriate training on how to operate the dishwasher machine. This deficient practice had the potential to result in unsanitized dishes that could lead to foodborne illness (infectious organisms or their toxins are the most common causes of food poisoning with symptoms that may include cramping, nausea, vomiting (throwing up) or diarrhea (loose stool) including death) of 152 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain infection control measures by: 1. Failing to practice hand hygiene (a way of cleaning hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) during provision of care to Resident 98. 2. Failing to ensure dirty linen was not laying on the landing pad (floor mats designed to provide a cushioned and reduce the likelihood of injury to fall risk resident.) on the floor of Resident 98. 3. Failing to monitor washer and dryer temperature. These failures had the potential to spread transmissible diseases to residents, staff members and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: A. Failing to place the call light within reach for Resident 109 and 55. This deficient practice resulted in Resident 109 and 55 not being able to call facility staff for help when needed and felt helpless. B. Failing provide shower/bed bath to Resident 99 when Resident 99 was observed wearing dirty hospital gown with food crumbs resting on neck folds and chest for two days. C.Failing to provide privacy to Resident 99 during a bed bath, when Certified Nursing Assistant (CNA) 1 left Resident 99 half-naked and did not cover the resident while CNA 1 was getting some clothing from Resident 99's closet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living ( activities related to personal care including bathing,showering,dressing dressing, getting in and out of bed or a chair, walking, using the toilet, and eating ) to two of 13 sampled residents ( Resident 47 and 99) when: A.Resident 47 fingernails were not trimmed, cut short and cleaned. This deficient practice in Resident 47 feeling embarrassed and had the potential to cause injury and infection. B. Resident 99 where not provided shower or bath and was observed wearing dirty hospital gown with food crumbs for two consecutive days. This deficient practice had the potential for unpleasant body odor, which can affect Resident 99's self esteem, and social interactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the emergency kit ([E-kit], a small quantity of medications kit that can be dispensed when pharmacy services are not available) of C1 was replaced in the medication storage room after E-Kit was opened on 3/6/2024. This deficient practice had the potential for medication dispensing errors, theft, or diversion and placed residents at risk for not receiving medication due to unavailability in E-kit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to 2 errors observed out of 34 total opportunities (error rate of 5.88 %). The medication errors were as follows: 1. Resident 6 and Resident 253 did not receive metformin (medication to lower blood sugar level) with meals as ordered by the physician. This failure had the potential to result in Resident 6 and 253 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure refrigerator temperature readings were in a correct range of 36 to 46 degrees Fahrenheit (°F- unit of temperature) maintain proper temperature of their medication refrigerator. This deficient practice had the potential for harm to residents due to potential undetected temperature excursions, the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 30) had a completed acknowledgement of advance directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes). This failure had the potential for inadvertently missed health care wishes and decision of the resident during changes in condition or emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 62) was free of physical restraint ( any manual method , physical or mechanical device, equipment or material that is attached or adjacent to resident's body, cannot be removed easily by resident and restricts the freedom of movement) by : 1. Failing to ensure the positioning wedges were not placed under the bed sheet and on both sides of Resident 62's lower body. This failure had the potential to result into unnecessary restraint and placed Resident 62 at risk for physical or psychosocial harm .

Inspectors wroteBased on interview and record review the facility failed to ensure the licensed nurses completed one of 25 sampled residents (Resident 39) Change of Condition ([COC] a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form to alert the resident's physician and interdisciplinary (IDT-a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) team of Resident 39's significant change in condition and the need to alter the resident's medical treatment significantly in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status revised 2/2014. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and follow through with the Preadmission Screening and Resident Review ([PASARR ]- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) Level I and Level II evaluation for one of three sampled residents (Resident 109) to determine the facility's ability to provide the special need of the resident. This deficient practice placed Resident 109 at risk of not receiving necessary care and services needed.

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure one of 31 sampled residents (Resident 137) received Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) services to maintain or improve her ability to carry out her activities of daily living daily five times a week as ordered by Resident 137 physician. This deficient practice had the potential to result in Resident 137 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decrease mobility.

Inspectors wroteDuring observation, interview, and record review the facility failed to provide personal care and implement fall precaution intervention (bed alarm [device applied on the surface of the bed that beeps when resident tries to get up]) for one of six sampled resident (Resident 17) who was assessed as high risk for fall when Resident 17 tried to get out of bed unassisted. These failures resulted in Resident 17 falling out of bed and sustained a hematoma (collection or pooling of blood and usually caused by a broken blood vessel that was damaged by an injury) on the right side of Resident 17 forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective pain management on one of six sampled residents (Resident 6) by failing to: 1. Ensure Resident 6's pain level was assessed before administering pain medication. 2. Ensure appropriate pain medication was provided according to pain assessment. These failures placed Resident 6 at risk for inadequate pain relief and delay of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 109) was free from unnecessary medication (the use of medications when there is no valid medical indication or when multiple drug products are being used for a condition that could be more appropriately treated with a single drug or non-drug approaches). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on necessary dental services for one of five sampled residents (Resident 61). This deficient practice had the potential to cause a delay in dental treatment and place Resident 61 at risk for pain, infection, and degraded self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident, who was a high risk for falls, did not fall and sustained a rib fracture (broken) for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the registered nurse supervisor (RNS) 3 correctly assessed and completed Resident 1's Fall Risk Assessment to reflect the resident's cognitive (the process of thinking, learning, and reasoning), functional mobility (ability of a person to move around in their environment, in order to participate in the activities of daily living) status, medications, and current diagnoses to indicate Resident 1's correct score for falls. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to initiate a care plan for fall risk for one of three sampled residents ( Resident 1. This deficient practice placed Resident 1 at risk of not having goals and planning interventions to meet their needs and had the potential to negatively affect the residents ' well-being.

Inspectors wroteBased on interview and record review, the facility failed to re-admit one of two sampled residents (Resident 1), when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of uncontrolled behavior, and the GACH cleared Resident 1 to return to the facility on 9/29/2023. This deficient practice resulted in the inappropriate and potentially unsafe discharge of Resident 1 to Resident 1's Responsible Party's (RP) home without giving Resident 1 and/or Resident 1's RP timely notice of transfer. This deficient practice had the potential for Resident 1's care needs to go unmet.

Inspectors wrotenterview, and record review, the facility failed to: A. Prevent Resident 2 from being slap on his right thigh by Resident 1 who had a history of striking out. B. Follow Resident 1 ' s care plan (CP) that Resident 1 will have no further episode of aggression that will harm staff and other residents. This deficient practice resulted in Resident 2 physically harmed and placed other 128 residents of the facility at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve Resident 1 ' s ability to communicate with facility staff by failing to provide language line (a service provided by a vendor who offers accurate and reliable telephone on-line interpretation services) for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a negative impact on Residents 1's quality of life and self- esteem and unable to communicate her needs to staff.