Crescent Manor Care Ctrs
Inspection history, citations, penalties and survey trends for this long-term care facility in Bennington, Vermont.
- Location
- 312 Crescent Blvd, Bennington, Vermont 05201
- CMS Provider Number
- 475033
- Inspections on file
- 23
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Crescent Manor Care Ctrs during CMS and state inspections, most recent first.
The facility did not have a clear process or policy in place to allow residents to file grievances anonymously. Two residents and the Social Worker confirmed that the grievance forms required a signature and that there was no documented or communicated option for submitting grievances without revealing the resident's identity.
Surveyors found that food items, including condiments, baking mixes, bread, hot dog rolls, and fish sticks, were stored without expiration dates, and original packaging had been discarded. Kitchen equipment such as a can opener and meat slicer were observed to be unclean with visible residues. Additional issues included unlabeled food containers and snacks in unit kitchenettes, with staff confirming the lack of proper labeling and storage practices.
Surveyors found that a sharps container in the memory care unit's shower room was overfilled and could not close, with uncovered disposable razors left unsecured on top. Additionally, the dining/activity room had a baseboard radiator with missing covers, exposing sharp fins. An LPN and the Unit Manager confirmed these issues during interviews.
Surveyors found expired and undated medications and medical supplies in all medication and treatment rooms inspected. Expired IV tubing kits, sterile water, injectable medications, auto injectors, blood collection sets, needleless connectors, foley care wipes, skin protectant ointments, and a catheter kit were confirmed by the Unit Manager, Nursing Manager, and an LPN. Items without expiration dates, such as glucose tablets and Vitamin B-Complex, were also present and acknowledged as needing removal.
Staff did not consistently or correctly wear required face masks during a COVID-19 outbreak, with multiple instances of masks being worn incorrectly or not at all on two units. Interviews confirmed that universal masking was required, but staff failed to adhere to this protocol, resulting in a repeat deficiency.
Surveyors found that multiple residents did not have accessible call lights while in bed, with call bells often out of reach, hidden, or removed entirely. Some residents were unable to locate or use their call bells, despite care plans requiring accessibility. In one case, a resident with dementia had their call light removed due to behavioral issues, but no alternate communication method was provided. Staff interviews confirmed awareness of the requirement for call lights to be within reach, yet deficiencies persisted.
A resident with a critical sodium level was not promptly reported to the provider as required by facility policy. Nursing staff became aware of the abnormal lab value but did not immediately notify the provider or DON. The resident was only sent to the emergency department after a Nurse Practitioner was informed of the result, and staff interviews confirmed the delay in notification.
A resident with limited mobility and moderate cognitive impairment, who was care planned to use wheelchair leg rests at all times, was observed without them attached. Staff interviews confirmed the resident could not self-propel and that facility policy required footrests for such residents, but the intervention was not implemented, resulting in a fall.
A resident with multiple sclerosis and moderate cognitive impairment, who required staff assistance and used a wheelchair, suffered a fall and injuries when staff failed to use required leg rests during transport. The DON confirmed that staff had not been educated on the facility's practice of using leg rests for non-self-propelling residents, contributing to the incident.
A resident with dementia and cognitive impairment was physically struck on the forehead by another cognitively impaired resident, as witnessed by an LNA. The incident was confirmed by facility investigation, and the DON acknowledged the failure to ensure the resident's right to be free from physical abuse.
A resident with a stage 2 pressure ulcer experienced worsening of their condition due to the facility's failure to obtain a recommended Flexi Seal system to manage fecal contamination. Despite multiple recommendations from the wound care team and physician orders, the device was not secured, leading to the ulcer progressing to stage four and becoming infected. The resident required hospitalization and surgical debridement as a result.
The facility failed to provide effective skin and wound care for several residents, with deficiencies in documentation and management. A resident's care plan required weekly documentation of skin injuries, but inconsistencies were found in the records. Another resident's fungal rash was not addressed in the care plan, causing pain during care. A third resident lacked weekly skin evaluations, and a fourth had no completed evaluations despite having multiple lesions. Additionally, a resident expressed concerns about staff's knowledge of using a wound vac, which was observed unattached to suction for hours. The facility lacked a system for accurate skin assessments and wound evaluations.
The facility failed to implement an effective infection prevention and control program, as staff did not wear required PPE while assisting residents on precautions. Observations showed LNAs assisting residents with MRSA, ESBL, and open areas without gowns, despite being on contact and enhanced barrier precautions. The Infection Preventionist confirmed the need for gowns and gloves during personal care.
The facility failed to ensure that licensed nurses had the necessary competencies to care for residents with wound vacs. Two residents with wound vacs were affected, and a review showed that none of the direct care staff had documented competencies for using the device. The Nurse Educator acknowledged the absence of a competency checklist for wound vac use, despite some staff receiving informal instruction.
The facility did not conduct annual performance evaluations for LNAs who have been employed for over a year. This was confirmed through a review of employee files and an interview with the Administrator.
A resident with a history of falls reported an unwitnessed fall to an LNA, who informed a nurse. The nurse instructed the LNA to notify the RN responsible for the resident, but the RN was not informed, resulting in no assessment for injuries. Five days later, a bruise was found on the resident's head, confirming the lack of immediate assessment.
Failure to Provide Anonymous Grievance Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, as required by regulation. Observations revealed that the grievance policy and procedure posted in the lobby only displayed the first page, which included the grievance officer's contact information but did not provide instructions for filing grievances anonymously. The grievance forms and the facility's written policy required a resident's signature, and there was no indication on the forms or policy that anonymous grievances were permitted. Interviews with three residents confirmed that they were unaware of any process to file grievances without revealing their identity, and they reported using the facility-provided form and submitting it to the Social Worker. The Social Worker, identified as the Grievance Official, stated that while envelopes were available for anonymous grievances, the posted policy and procedure did not include this option, and she was unable to locate any documentation of an anonymous grievance process in the facility's policies. She acknowledged the difficulty in handling anonymous grievances and confirmed that providing an option for anonymous grievance submission is a requirement.
Deficient Food Storage, Labeling, and Equipment Cleanliness
Penalty
Summary
Surveyors identified multiple failures in food storage, labeling, and equipment cleanliness within the facility's food service operations. During a tour of the kitchen's dry storage area, boxes of condiments and various baking mixes were found without expiration dates, as the original packaging had been discarded. Bread racks in the storage area also lacked expiration dates. The Food Service Manager (FSM) confirmed the absence of expiration dates and was unable to provide this information. In the kitchen, a commercial can opener and meat slicer were observed to be unclean, with visible residues and substances present. The FSM acknowledged that these items had not been properly cleaned after use. Further observations revealed additional deficiencies in food labeling and storage. In the freezer, packages of hot dog rolls and a box of fish sticks were found without expiration dates, which was confirmed by both the FSM and the dietician. In a unit kitchenette refrigerator freezer, a cup containing a pink substance was found unlabeled and covered with a paper towel, with the Activities Director confirming it did not belong to any resident and should be discarded. Another unit kitchenette contained containers of food and a loaf of bread without preparation or expiration dates, as well as bins of individual-sized condiments and snacks lacking expiration dates. An LPN confirmed these findings during the inspection.
Unsafe and Unclean Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents on the licensed memory care unit. During an initial tour, a sharps container in the shower room was found to be full and unable to close properly, with a bundle of disposable razors—three of which had no covers—left unsecured on top of the container. An LPN confirmed that the sharps container should have been removed and that razors should not have been left exposed. Additionally, in the dining/activity room, the baseboard radiator had three areas where the covers were missing, exposing sharp fins. The Unit Manager confirmed the exposed areas, and the Maintenance Director noted that the radiator covers frequently get bumped off.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
The facility failed to ensure that medications and biologicals were removed from storage areas once their expiration dates had passed, as required by facility policy and professional standards. During observations and interviews, expired items were found in all three medication and treatment rooms inspected. In the west wing medication room, the Unit Manager confirmed the presence of expired IV tubing kits, sterile water for injection, Piperacillin and Tazobactam for injection, Epinephrine auto injectors, a blood collection set, and needleless connectors. Additionally, a bottle of glucose tablets was found without an expiration date, and the Unit Manager acknowledged that undated items should be discarded. In the north wing medication room, an LPN confirmed that a bottle of Vitamin B-Complex lacked an expiration date and should be thrown out. In the medication treatment room near the south/west nursing station, the Nursing Manager identified expired foley care wipes, skin protectant ointments, and a catheter kit. These findings demonstrate that the facility did not consistently remove expired or undated medications and supplies from storage, contrary to its own policy and accepted professional principles.
Repeat Failure to Ensure Proper PPE Use During COVID-19 Outbreak
Penalty
Summary
Staff failed to consistently and correctly wear required personal protective equipment (PPE), specifically face masks, during an active COVID-19 outbreak in the facility. Observations on two separate units revealed multiple instances where staff, including licensed nursing assistants and registered nurses, were either not wearing masks at all, wearing masks under their chins, or wearing masks below their noses. These observations occurred both at the nurse's station and in the memory care unit. Interviews with staff and the Infection Preventionist confirmed that universal masking was required at the time due to the outbreak, but staff were not adhering to this protocol. The deficiency was further substantiated by staff interviews, where it was acknowledged that masks were required and that staff were not following the correct procedures. The Infection Preventionist confirmed multiple observations of improper mask use, which did not provide adequate protection against infection for residents or staff. This issue was noted as a repeat deficiency, having been cited in previous recertification surveys.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that a working call system was accessible to residents in their beds or other sleeping accommodations in five out of six rooms where residents were care planned for call bell use. Observations revealed that call bells were often out of reach, such as being hung on walls, hidden behind curtains, or placed on the floor under beds. Interviews with residents confirmed that some were unable to locate or access their call bells when needed, despite care plans specifying that call lights should be within reach and residents encouraged to use them. Staff interviews corroborated that call bells were not always accessible, and that staff were aware of the expectation to keep call lights within reach. In one case, a resident with dementia and behavioral issues had their call light removed due to repeated disconnection and aggressive behavior when staff attempted to restore it. The care plan and Kardex for this resident indicated that staff should anticipate needs because the resident could not use the call bell appropriately, but no alternate means of communication was provided after the call light was removed. The resident's medical history included dementia, wandering, delusional and adjustment disorders, depression, and anxiety, and the care plan noted risks related to communication and self-care deficits. Additional observations included a resident whose call light was found on the floor and another whose bed placement made the call light inaccessible. Staff confirmed these situations during interviews. The Staff Development Coordinator stated that staff are educated to ensure call lights are within reach and to respond promptly, and confirmed that call light cords should not be pinned up or removed. Despite these policies, the deficiency persisted across multiple rooms and residents.
Failure to Promptly Notify Provider of Critical Lab Result
Penalty
Summary
The facility failed to promptly notify the provider of a critical laboratory result for one resident. According to facility policy, staff are required to immediately inform the ordering practitioner of laboratory results that fall outside the clinical reference range. In this case, a progress note documented that the resident had a critical sodium level of 161, but there was no evidence that the provider was notified immediately after nursing staff became aware of this result. Interviews with both an LPN and the Director of Nursing confirmed that the provider was not made aware of the critical lab value at the appropriate time. The delay in notification was further substantiated by a Nurse Practitioner note, which identified the resident's severe hypernatremia and documented that the resident was sent to the emergency department only after the Nurse Practitioner became aware of the critical lab value. The LPN confirmed during interview that both the provider and DON were not immediately informed, and acknowledged that critical lab values should be reported to the provider right away, as per facility policy.
Failure to Implement Wheelchair Leg Rest Care Plan Intervention
Penalty
Summary
The facility failed to implement care plan interventions for a resident with multiple sclerosis, dementia, anxiety disorder, and major depressive disorder, who had moderate cognitive impairment and limited physical mobility. The resident's care plan required extensive assistance from one staff member for locomotion using a standard wheelchair with bilateral footrests as needed. After a fall incident in which the resident's foot became caught under the wheelchair while being pushed, the care plan was revised to ensure leg rests were always attached when the resident was in the wheelchair. Despite this revision, observation revealed that the resident was seated in the wheelchair without leg rests attached. Interviews with the resident, an LPN, and the DON confirmed that the resident was not self-propelling and that facility policy required footrests for residents unable to self-propel. The staff failed to follow the care plan and facility policy, resulting in the resident being without the required leg rests at the time of observation and at the time of the fall.
Failure to Provide Wheelchair Leg Rests and Supervision Leads to Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with multiple sclerosis, dementia, and moderate cognitive impairment remained as free from accidents as possible. The resident, who was dependent on staff for activities of daily living and used a wheelchair, had a care plan indicating the need for extensive assistance and the use of bilateral footrests as needed. Despite this, the resident was being transported by a Licensed Nursing Assistant (LNA) without the required leg rests in place. During transport, the resident's foot became caught under the wheelchair, resulting in a fall that caused abrasions and swelling to the left knee and right hand. Interviews and record reviews confirmed that the facility's practice was to use leg rests for residents who do not self-propel, but there was no evidence that staff had been educated on this requirement. The Director of Nursing (DON) acknowledged that the resident required assistance and did not self-propel, and could not provide documentation of staff education regarding the use of wheelchair leg rests. The failure to implement and educate staff on appropriate interventions and assistive devices directly contributed to the resident's fall and subsequent injuries.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. According to the report, both residents involved had diagnoses of dementia and cognitive impairment, with BIMS scores indicating they were unable to answer questions to determine their cognitive functional level. Despite these impairments, regulations clarify that cognitive impairment does not preclude a resident from engaging in deliberate actions. On the date of the incident, a Licensed Nursing Assistant (LNA) witnessed one resident standing over another resident's bed. When questioned, the first resident turned and struck the second resident on the forehead with a closed fist. The resident who was struck was unable to communicate their needs. The incident was immediately witnessed and reported by the LNA, and the facility's investigation confirmed the occurrence of physical abuse. The Director of Nursing (DON) acknowledged that the facility did not ensure the resident's right to be free from physical abuse, as required by regulation. The report specifically notes that the abuse was verified and that the facility failed in its responsibility to protect the resident from harm.
Failure to Obtain Fecal Management System Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services to Resident #87, leading to the worsening of a pressure ulcer. Initially admitted with a stage 2 pressure ulcer, the resident's condition deteriorated due to inadequate management of fecal contamination. Despite recommendations from the wound care team and physician orders for a Flexi Seal system to manage fecal contamination, the facility did not obtain the device, resulting in the ulcer progressing to stage four and becoming infected. Resident #87, who was cognitively intact and frequently incontinent of urine, was admitted with an existing stage 2 pressure ulcer. The wound care team identified moisture-associated skin damage and recommended a Flexi Seal system to prevent stool contamination. However, the facility did not secure the device, and the resident's condition worsened, with the ulcer becoming unstageable and infected, necessitating hospitalization and surgical debridement. Throughout the period from early August to mid-September, multiple progress notes from nurse practitioners and physicians highlighted the need for the Flexi Seal system, yet it remained unavailable. The resident's condition continued to decline, with increased necrosis, malodor, and infection, ultimately leading to a hospital admission for surgical intervention. The Director of Nursing confirmed the facility's failure to obtain the recommended fecal management system, contributing to the resident's deteriorating condition.
Deficiencies in Skin and Wound Care Documentation and Management
Penalty
Summary
The facility failed to provide safe and effective skin and wound care for several residents, as evidenced by the lack of regular and accurate documentation of weekly skin checks and non-pressure ulcer wound evaluations. Resident #25's care plan indicated a need for weekly treatment documentation of skin injuries, yet there were inconsistencies in the documentation of skin evaluations and wound assessments. Observations revealed compromised skin on Resident #25's thigh and bottom, with visible open spots, contradicting the medical record that lacked recent wound assessments. Resident #30's care plan did not address a fungal rash in the groin area, despite observations of a red rash causing pain during incontinence care. The care plan and skin evaluations failed to document this condition, even though a physician had ordered treatment for the rash. Similarly, Resident #34 did not have weekly skin evaluations, and there was no documentation of multiple bruises and scabs observed on the resident's body. Resident #51, admitted after hip surgery, also lacked completed weekly skin evaluations, despite having multiple open lesions documented in a nurse practitioner's note. The facility lacked a system to ensure accurate weekly skin assessments and wound evaluations, with no written procedures for staff to follow. Interviews with the Director of Nursing and other staff confirmed the absence of comprehensive skin assessments and documentation. Additionally, Resident #291 expressed concerns about staff's knowledge of using a wound vac, and observations showed the device was not properly attached to suction for several hours. The facility did not have a standard of practice for using the wound vac, and staff had not completed competencies for its use, leading to inadequate wound care for the resident.
Failure to Implement Infection Control Protocols
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for residents on precautions. Observations revealed that a Licensed Nursing Assistant (LNA) assisted two residents, one with a diagnosis of MRSA and the other with ESBL, without wearing the required gown. This was confirmed by a Licensed Practical Nurse who acknowledged that the LNA should have been wearing a gown while providing personal care to these residents. Additionally, another observation noted that two LNAs assisted a resident with diabetes and neuropathy, who was on Enhanced Barrier Precautions due to open areas on the lower left extremity, without wearing gowns. The Infection Preventionist confirmed that the residents were on precautions and that the LNAs should have been wearing gowns and gloves during personal care activities. These actions demonstrate a failure to adhere to the infection control protocols designed to prevent the transmission of communicable diseases.
Lack of Competency in Wound Vac Use
Penalty
Summary
The facility failed to ensure that all licensed nurses possessed the necessary competencies and skill sets to care for residents' needs as identified through assessments and care plans. Specifically, two residents with wound vacs, which are devices that promote wound healing using suction, were affected. A review of records revealed that none of the direct care staff responsible for these residents had documented competencies for using a wound vac. During an interview, the facility's Nurse Educator admitted that the facility had not developed a competency checklist for wound vac use, although some staff nurses had been shown how to change the dressing and use the required materials.
Failure to Conduct Annual LNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Licensed Nursing Assistants (LNAs) received annual performance evaluations. This deficiency was identified through a review of employee files for LNAs who have been employed at the facility for over a year. It was found that no performance evaluations had been completed for these LNAs within the past year. During an interview, the Administrator confirmed that the annual performance evaluations for the LNAs had not been conducted.
Failure to Assess Resident After Reported Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed for injuries and complications after reporting an unwitnessed fall, which is a deficiency in meeting professional standards of quality care. The resident, who had a history of falling at home, informed a licensed nursing assistant (LNA) about the fall. The LNA reported the incident to a nurse, who then instructed the LNA to inform the registered nurse (RN) responsible for the resident's care. However, the RN was not made aware of the fall and, as a result, did not assess the resident for any injuries or complications on the day of the incident. Five days later, a nursing progress note documented a large bruise of unknown origin on the back of the resident's head. The facility's incident report and witness statements confirmed that the resident had reported the fall, but no assessment was conducted. The Director of Nursing (DON) confirmed during an interview that the resident should have been assessed immediately following the fall, as per the facility's policy, but this did not occur.
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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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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