Elderwood At Burlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Vermont.
- Location
- 98 Starr Farm Rd., Burlington, Vermont 05408
- CMS Provider Number
- 475030
- Inspections on file
- 42
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Elderwood At Burlington during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
A resident with ESRD, anemia in CKD, CHF, pulmonary edema, and a central catheter required off-site hemodialysis, but the facility failed to ensure dialysis care consistent with its policy and professional standards. The resident’s care plan called for monitoring vital signs and pulse oximetry, yet two dialysis communication forms in the dialysis binder lacked key information such as patient identifier, weights, amount of fluid removed, and dialysis center recommendations, which the nurse supervisor acknowledged should be documented. Additionally, an observation found no emergency clamps in the resident’s room, and the unit manager confirmed they should have been present and that the care plan should specify the resident’s central line.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with cellulitis, MRSA, and leg pain was prescribed linezolid 600 mg BID for five days by a telehealth provider, but the medication was never obtained or administered. Record review and a subsequent provider note showed that the ordered linezolid could not be found as given, and interviews with the IP nurse and UM confirmed the order was not transcribed into the system. The IP nurse indicated that either the telehealth provider or the nurse who initiated the telehealth call typically enters such orders and acknowledged there was no specific policy for nurses entering orders, resulting in the resident not receiving the prescribed antibiotic.
Surveyors found that one unit kitchenette contained expired dairy products and unlabeled frozen baked goods, in violation of the facility’s food storage policy. During inspection of the kitchenette refrigerator, a can of whipped topping and two large bottles of milk were discovered past their expiration dates, and the freezer contained multiple packs of donuts without any labels or dates. The Kitchen Manager confirmed the items were expired or unlabeled and that he did not know the origin of the donuts, contrary to the written policy requiring checks for spoilage and labeling with name and date for partially used food items.
A resident with a history of MRSA and a PEG tube had an active order for barrier precautions and an Enhanced Barrier Precautions (EBP) sign posted, but an LPN entered the room and administered medications via PEG tube without donning PPE, contrary to facility policy requiring gown and glove use for high-contact care of MDRO-colonized or at-risk residents. The LPN later acknowledged not wearing PPE and being unsure it was required for tube feeding, while the Infection Preventionist confirmed PPE should be used for EBP residents with PEG tubes. This was cited as a repeat deficiency from prior surveys.
A resident’s record lacked required documentation showing they were educated about, offered, and either received or declined influenza and pneumococcal vaccines. The EMR listed the flu status only as historical without supporting details and did not show any pneumococcal vaccination information. The Infection Preventionist could not produce a consent/declination form and confirmed that documentation of vaccine education, offer, and acceptance or refusal was not available, contrary to facility policies requiring such records.
Surveyors found that a resident’s EMR lacked required documentation showing they had been educated about, offered, and either received or declined the COVID-19 vaccine. The EMR immunization report listed a historical COVID-19 vaccination date, but there was no supporting record of the immunization, consent, or declination. The Infection Preventionist could not provide the facility’s consent/declination form or any other documentation confirming that COVID-19 vaccination education and consent procedures, as required by facility policy, had been completed for this resident.
An LPN was found to have misappropriated multiple controlled pain medications for ten residents by falsifying controlled drug logbooks and related documentation. A nurse first noticed a drastic change in a resident’s PRN medication count and altered documentation during a shift-to-shift controlled count, prompting review of logbooks and MARs. The review revealed overwritten and out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of medications without corresponding MAR entries for several controlled drugs, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine. Handwriting comparisons linked the irregular entries to the LPN, who did not hold an active nursing license, and facility leadership confirmed that medications were removed but believed not to have been administered to the intended residents.
An LPN’s multistate compact license, which had allowed practice in the survey state, expired and was not renewed for that state, leaving the nurse with only a single-state North Carolina license that was not valid where care was being provided. Despite this, the LPN continued to work 11 shifts, including 6 shifts administering medications as an LPN Team Leader, a role requiring a current state LPN license. The Administrator acknowledged awareness of the licensing issue, cited a vacant HR position and an outdated license-tracking spreadsheet, and the former DON reported that review of the personnel file had revealed the expired state license.
An LPN with an expired state nursing license was assigned to pass medications and was later found, through audits of controlled medication logbooks and MARs, to have falsified sign-outs, forged staff signatures, altered dates, and removed controlled pain medications (including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine) without corresponding MAR documentation for ten residents on two units. The issue came to light after a nurse reported that a resident had not received a PRN medication for several months, and subsequent review and staff interviews confirmed that the LPN failed to follow facility policies for controlled substance counts, medication administration, and documentation.
The facility did not send written transfer notices to residents or their representatives when three residents were transferred to outside facilities, nor were copies of these notices sent to the LTC Ombudsman as required. Interviews confirmed that the process for providing these notifications was not followed.
A resident with cognitive impairment and multiple medical conditions was prescribed PRN Lorazepam for itching and anxiety without a required 14-day stop date. The medication was administered multiple times, and the DON confirmed the omission of the stop date in the order.
A resident with multiple chronic conditions and cognitive impairment was given Lisinopril by a nurse despite a systolic blood pressure below the ordered threshold. The medication was administered when the resident's blood pressure was 89/54 mmHg, contrary to the physician's order to hold the medication if systolic blood pressure was under 100 mmHg. The resident subsequently experienced further hypotension and was transferred to the emergency department. There was no documentation of IV normal saline administration prior to transfer, as ordered.
A resident reported allegations of staff misconduct and possible abuse to a State Surveyor, who notified facility leadership and Adult Protective Services. The facility did not report the allegations to the State Survey Agency or document an investigation until a week later, after Adult Protective Services intervened. Interviews confirmed the lack of timely reporting and investigation documentation.
After a resident reported allegations of employee misconduct and possible abuse involving a roommate and a nurse aide, the facility did not document an investigation or implement protective measures. Staff allegedly involved continued to work and had contact with the resident and the alleged victim until Adult Protective Services began an investigation several days later.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. Multiple residents reported long waits for assistance with ADLs, such as toileting and transferring, and some experienced falls due to lack of timely help. Staff interviews confirmed the facility's staffing shortages, with supervisory staff often covering shifts. A review of schedules showed numerous unfilled shifts, highlighting the facility's inability to meet residents' needs.
Several residents in the LTC facility experienced significant delays in receiving assistance with ADLs due to staffing shortages. A resident with mobility impairments waited over an hour for incontinence care, while another resident experienced a fall after attempting to use the bathroom independently due to delayed staff response. Additionally, residents reported missed showers and long waits for transfers, with LNAs confirming insufficient staffing to meet care needs.
The facility failed to monitor adverse effects of psychotropic medications for three residents. A resident with Alzheimer's was lethargic and sleepy due to multiple psychotropic drugs, with no evidence of monitoring or provider notification. Another resident on RisperiDONE and a third on Lorazepam and Zoloft also lacked documented monitoring. The facility's policy requires such monitoring, but it was not followed.
A facility failed to ensure accurate review of a resident's care plan during required visits. The resident, with Alzheimer's and behavioral issues, had discrepancies in physician notes regarding prescribed medications. Despite Seroquel being discontinued, it was still listed in notes. The DON confirmed the inaccuracies, indicating a failure to review the resident's care plan as required.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Repeat Failure to Remove and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and managed in accordance with professional standards, specifically related to removal and disposal of expired medications on all three units. The facility’s “Medication Administration Methods” policy dated 1/25/24 states that medication expiration dates are to be checked prior to administration. However, during observation and interview on 3/24/26, surveyors found seven cases containing 69 packs of nystatin oral suspension 500,000 units/5 ml in the [NAME] medication room that had expired in 2025, and a nurse confirmed these were expired. On the [NAME] Unit medication/treatment cart, surveyors observed Benzonatate 100 mg tablets with an expiration date of 10/31/25 and Aspirin 325 mg with an expiration date of 1/26, which a nurse also confirmed were expired. In another [NAME] medication room, surveyors identified Ipratropium bromide and albuterol sulfate inhalation solution 0.5 mg/3 mg that had expired in 12/25, again confirmed as expired by a nurse. This deficiency is a repeat violation, having been cited during the previous two recertification surveys dated 4/2/25 and 1/11/24, and reflects the facility’s failure to properly store or dispose of expired medications as required by its own policy and professional standards.
Failure to Ensure Complete Dialysis Communication and Emergency Equipment for Hemodialysis Resident
Penalty
Summary
The facility failed to provide dialysis-related care and monitoring consistent with its own policy and professional standards for a resident receiving off-site hemodialysis. The resident was admitted with end stage renal disease, anemia in chronic kidney disease, chronic diastolic heart failure, and pulmonary edema, and had a central catheter in place. The facility’s policy required that vital signs, including weights, be performed as ordered by the provider for residents receiving off-site dialysis. The resident’s care plan included a focus on hemodialysis related to end stage renal disease with an intervention to monitor vital signs as needed, and a separate focus on respiratory status related to CHF, fluid overload, and shortness of breath with an intervention to monitor vital signs and pulse oximetry as needed or ordered. However, review of the dialysis communication binder showed that two dialysis center communication record forms were missing key information, including the patient identifier, the resident’s weight, the amount of fluid removed, and the dialysis center’s recommendations. The nurse supervisor reported that the dialysis communication binder is sent to the dialysis center and acknowledged that it is not always completed, confirming that it should contain the patient identifier, recommendations from dialysis, pre- and post-treatment vital signs, weights, the amount of fluid removed, and the date of treatment. In addition, during observation of the resident’s room, no clamps were found, despite the unit manager confirming that clamps should be present in the room for emergency use. The unit manager was initially unable to locate the clamps in the medication room and later found them in the clean utility room, confirming they were not in the resident’s room as required. The unit manager also confirmed that the resident has a central line rather than a shunt per the treatment plan and that the care plan should indicate the presence of a central line.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Transcribe and Administer Ordered Antibiotic from Telehealth Provider
Penalty
Summary
The facility failed to follow a provider’s medication order for a resident with cellulitis of the left lower limb, MRSA infection, and left leg pain. On 2/19/26, a telehealth provider ordered linezolid 600 mg BID for five days to treat MRSA, but a subsequent provider progress note on 2/24/26 documented that the medication, although prescribed, did not appear to have been obtained or administered. During interviews, the infection preventionist nurse shared a text exchange with the provider questioning whether the resident had received linezolid as ordered and stated that either the telehealth provider or the nurse who called could enter such orders. She also confirmed there was no specific facility policy governing nurses entering orders. In a joint interview, the infection preventionist nurse and the unit manager confirmed that the telehealth order for linezolid was never transcribed and the medication was not given to the resident as ordered. The deficiency centers on the facility’s failure to ensure that services met professional standards of quality by not transcribing and administering a prescribed antibiotic ordered via telehealth for a resident with documented MRSA and cellulitis, as confirmed by record review and staff interviews.
Expired and Unlabeled Food Items Found in Unit Kitchenette
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards for food service safety in one kitchenette on a named unit. During observation of kitchenette #1’s refrigerator, they found a can of Redi-whip with an expiration date of 3/16/26 and two 32-ounce bottles of milk with an expiration date of 3/19/26 still stored in the refrigerator on 3/23/26. In the same kitchenette’s freezer, surveyors observed three packs of two donuts each that had no label or date. In an interview, the Kitchen Manager confirmed that the items in the refrigerator were expired and acknowledged that the donut packs had no label or date and that he did not know what they were from. Per review of the facility’s “Dietary, Food and Supply Orders-Storage” policy, last revised 10/26/18, kitchen personnel are to remove food and non-food items from storage as needed per meal, check all items for spoilage before use, and label partially used food items with name and date and cover them before returning them to storage. The presence of expired dairy products in the refrigerator and unlabeled, undated donuts in the freezer demonstrated noncompliance with these established storage and labeling procedures.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during medication administration via PEG tube for one resident. On 3/25/26 at approximately 8:45 AM, an LPN administered medications via PEG tube to Resident #14, who had an Enhanced Barrier Precautions (EBP) sign posted outside the room. Record review showed an order for this resident stating, “Precautions: Maintain barrier precautions r/t hx of MRSA, PEG tube use.” Despite this, the LPN did not don any PPE before entering the room to perform the PEG tube medication administration. The facility’s policy on Transmission Based Precaution Levels, last revised 6/6/24, states that Enhanced Barrier Precautions involve gown and glove use during high-contact resident activities for residents known to be colonized or infected with an MDRO or at increased risk of MDRO acquisition. During interview, the LPN confirmed she did not put on PPE prior to entering the room and stated she was unsure if PPE was required for tube feeding, acknowledging that tube feeding was listed on the EBP sign. In a separate interview, the Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube. This is a repeat deficiency, with similar violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.
Failure to Document Influenza and Pneumococcal Vaccination Status for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s documentation of influenza and pneumococcal vaccinations for one resident. Record review on 03/25/2026 showed that Resident #124 was admitted on an unspecified date, and the EMR contained no documentation that the resident or their representative had been educated about, offered, and had either received or declined influenza and pneumococcal vaccines. An Immunizations Report from the EMR listed the resident’s influenza status as historical but did not include supporting documentation of the immunization, nor did it indicate whether the resident had received a pneumococcal vaccination. During interviews on 03/25/2026, the Infection Preventionist was unable to provide a Vaccination Review: Consent/Declination SNF Resident Form for this resident and confirmed that documentation of offering, educating, and either receiving or declining the influenza and pneumococcal vaccinations was not available. This lack of documentation was inconsistent with the facility’s written policies, which require education, completion of consent/declination forms, and placement of immunization documentation or reasons for non-immunization in the resident’s record.
Failure to Document COVID-19 Vaccination Education and Status for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for COVID-19 vaccination education, offering, and documentation for one of six sampled residents. Record review on 03/25/2026 showed that Resident #124, admitted on an unspecified date, had no documentation in the EMR indicating that the resident or representative had been educated about, offered, received, or declined the COVID-19 vaccine. An Immunizations Report from the EMR listed the resident’s COVID-19 vaccination status as “historical” with a date of 12/5/24, but there was no supporting documentation of the immunization itself. During interviews on 03/25/2026, the Infection Preventionist was unable to produce the facility’s Vaccination Review: Consent/Declination SNF Resident Form for this resident and confirmed that documentation of offering education and obtaining consent or declination for COVID-19 vaccination was not available, despite the facility’s written policy requiring written affirmation for declinations, provision of vaccination fact sheets, and informed consent (written or verbal) for all individuals being vaccinated. This lack of documentation for Resident #124’s COVID-19 vaccination education, offer, consent/declination, and administration status constituted the cited deficiency.
Misappropriation and Falsified Documentation of Controlled Medications by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to ensure accurate, non-fraudulent documentation of controlled drug administration. A concern was first raised when a nurse, during a change-of-shift controlled drug count, noticed that the count for a resident’s PRN medication had drastically changed since her prior shift, and that her own documentation had been altered. Subsequent review of controlled medication logbooks and MARs for multiple residents revealed overwritten entries, out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding MAR documentation. These irregularities involved six different controlled pain medications, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine, and affected ten residents across two units. Interviews and handwriting comparisons identified an LPN as the individual responsible for the irregular logbook entries. The Administrator confirmed that the LPN’s handwriting matched the questionable entries and that the LPN was involved in ten incidents of removing medications believed not to have been administered to the prescribed residents. The DON and other nursing staff reported that the controlled medication counts themselves were correct, but the signatures and dates in the logbooks did not match staff who had actually worked the shifts, and the sequence of dates was inconsistent with proper administration. The LPN was described as visibly shaky when asked to provide a handwriting sample and did not clearly deny involvement when questioned. It was also confirmed that this LPN did not hold an active state nursing license, and the facility acknowledged a failure to protect residents from this LPN’s misappropriation of medications.
Unlicensed LPN Worked Multiple Shifts and Administered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by a nurse holding an active state license as required for the position. Review of credentials for an LPN under investigation for misappropriation of medications showed that the nurse’s multistate compact license, which had permitted practice in the survey state, had expired on a specified date. A nursys.com search confirmed that the LPN then only held an active single-state license in North Carolina, which was not valid for practice in the survey state. Despite this, the LPN continued to be scheduled and worked 11 shifts after the compact license expiration, including 6 shifts in which medications were administered in the role of an LPN Team Leader, a position whose job description requires a current state LPN license in good standing for the state of employment and includes administering medications and treatments as an essential function. Interviews and record review further showed that the Administrator was aware that the LPN’s license status had changed and stated that the LPN had selected the wrong option during renewal, resulting in a single-state license rather than a multistate compact license that included the survey state. The Administrator also reported that the Human Resources position was vacant and that the spreadsheet used to track staff license expiration dates had not been updated. The former DON stated that during a review of the LPN’s personnel file, it was identified that the LPN’s state nursing license needed for the position had expired, and that the Administrator had taken on the task of researching the expired license. Despite the facility’s stated expectation that staff must have an active license in the state to work, the LPN continued to work multiple shifts without a valid license for that state.
Unlicensed LPN and Falsified Controlled Medication Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff administering medications maintained current licensure and followed required procedures for controlled substances. A concern was raised when an oncoming medication nurse reported that a resident had not received a PRN medication for three months, which the nurse confirmed with the resident. In response, the facility reviewed all controlled medication logbooks and medication administration records and identified irregularities involving one LPN on two units and affecting ten residents. The irregularities included falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding documentation on the medication administration records. During the facility’s investigation, it was discovered that the LPN suspected of these irregularities had been working with an expired state nursing license, despite being assigned to medication administration duties. Interviews with the Administrator and the former DON confirmed that the LPN did not hold a current state license required for the position and that the LPN had fraudulently removed controlled medications, including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine, without following facility policies for administration and documentation. Facility policies required that a licensed nurse administer medications in compliance with state and federal laws, that controlled substances be counted and verified at shift change, and that documentation corrections be made properly by the original author, but these procedures were not followed by the LPN.
Failure to Provide Required Transfer Notifications and Ombudsman Notices
Penalty
Summary
The facility failed to provide required written documentation and notifications regarding resident transfers to outside facilities. Specifically, for one resident who was transferred for geriatric psychiatric care, there was no written notice sent to the resident or their representative. Additionally, for two other residents who were transferred to the hospital, there was no record of written transfer information being sent to their family representatives. Review of the facility's policy indicated that such notifications should be sent following any emergency discharge or planned transfer, but this was not done in these cases. Furthermore, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman for any of the three residents involved. The transfer forms had a designated section for documenting that a copy was sent to the Ombudsman, but this section was left blank for all three cases. Interviews with the Ombudsman and the DON confirmed that the required notifications were not sent, and the process for doing so was not being followed at the time of the incidents.
Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications by prescribing an as-needed Lorazepam order for a resident with vascular dementia, chronic kidney disease, and COPD, who was cognitively impaired with a BIMS score of 9. The physician's order for Lorazepam 0.5 mg every 6 hours as needed for itching and anxiety did not include a required 14-day stop date. The resident received Lorazepam eight times over a period of approximately three weeks. The DON confirmed during interview that the order lacked the appropriate stop date documentation.
Significant Medication Error: Lisinopril Administered Despite Low Blood Pressure
Penalty
Summary
A significant medication error occurred when a resident with a history of Type II Diabetes, Alzheimer's Disease, schizoaffective disorder, and anxiety, who was cognitively impaired with a BIMS score of 4, was administered Lisinopril despite a documented systolic blood pressure of 89/54 mmHg. The physician's order clearly stated that Lisinopril should be held if the systolic blood pressure was under 100 mmHg and the provider should be notified. The medication was administered by a licensed nurse during the morning medication pass, contrary to the order and facility policy. Following the administration, the resident experienced hypotension with blood pressure readings dropping as low as 77/45 mmHg. The resident was found on the floor by a CNA, assessed for injury, and subsequently transferred to the emergency department as ordered by an advanced practice nurse. There was no documentation that normal saline was administered via IV prior to the transfer, as ordered. The Director of Nursing confirmed the medication error and the lack of IV administration before hospital transfer.
Failure to Timely Report Alleged Abuse and Initiate Investigation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime as required by section 1150B of the Act. A resident reported allegations of employee misconduct and possible abuse involving their roommate and a Licensed Nursing Assistant to a State Surveyor, who then informed both the facility's former Administrator and Assistant Director of Nursing, as well as Adult Protective Services, on the same day. Despite this, the facility did not report the allegations to the required State Survey Agency until seven days later, when Adult Protective Services arrived to investigate. Interviews with the current Administrator, Director of Nursing, and Assistant Director of Nursing confirmed that there was no documentation of an investigation or timely reporting to the State Survey Agency prior to the involvement of Adult Protective Services. No additional evidence of timely reporting or investigation was provided by the facility.
Failure to Implement Immediate Protective Measures After Abuse Allegation
Penalty
Summary
The facility failed to take immediate action after being notified of allegations of employee misconduct and possible abuse involving a resident and their roommate by a Licensed Nurse's Aide. The State Surveyor reported these allegations to the former Administrator and Assistant Director of Nursing on the same day they were made, and also notified Adult Protective Services. Despite this notification, there was no documentation of an investigation being conducted by the facility prior to the arrival of Adult Protective Services seven days later. During this period, the staff members allegedly involved in the incident continued to work and had contact with both the resident who made the allegation and the alleged victim. The current administrative staff confirmed that no protective measures were implemented following the initial report of the allegations.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents reported delays in receiving assistance with activities of daily living (ADLs), such as toileting and transferring, which are critical for their well-being. For instance, one resident with cerebral palsy and schizoaffective disorder was left in soiled conditions for over an hour, despite having a care plan that required prompt incontinent care. Another resident, who is always incontinent, reported waiting for hours for assistance, with multiple staff members acknowledging the delay but failing to provide the necessary care. The deficiency extended to other areas of care, including meal assistance and fall prevention. A resident with a history of falls and moderate cognitive impairment attempted to use the bathroom independently after waiting for staff assistance, resulting in a fall. Additionally, residents expressed dissatisfaction with the frequency of showers and the timeliness of call bell responses, indicating a systemic issue with staffing levels. Interviews with staff confirmed that the facility was understaffed, with licensed nursing assistants (LNAs) and unit managers frequently covering shifts outside their usual roles. The facility's staffing challenges were further highlighted by a review of schedules, which revealed numerous unfilled shifts and reassignments. The Director of Nursing and other supervisory staff often had to step in to cover for absent nurses, indicating a persistent shortage of direct care staff. This shortage impacted the facility's ability to provide timely and adequate care, as evidenced by the unmet needs of residents across various units. The report underscores the facility's failure to maintain adequate staffing levels to ensure the health and safety of its residents.
Inadequate Assistance with ADLs Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to significant delays in care. Resident #7, who is cognitively intact but has mobility impairments, reported soiling themselves and waiting over an hour for assistance, with their call light going unanswered for extended periods. Similarly, Resident #10, who requires assistance for incontinence care, experienced delays in receiving care, with multiple staff members acknowledging the need but failing to provide timely assistance. These incidents highlight a pattern of inadequate response to residents' needs, particularly in toileting and incontinence care. Resident #1, who is dependent on staff for eating and prefers to dine in a common area, was consistently left to eat in bed, contrary to their care plan and the wishes of their representative. Resident #8, with moderate cognitive impairment, experienced a fall after attempting to use the bathroom independently due to delayed staff response to their call light. This lack of timely assistance not only contravenes the care plans but also poses safety risks to residents. The facility's staffing issues are further underscored by Resident #4 and Resident #5, who reported long waits for assistance with transfers due to insufficient staff. A confidential resident interview and a Power of Attorney for another resident also highlighted missed showers and inadequate care due to staffing shortages. Interviews with LNAs confirmed the facility's staffing challenges, with insufficient personnel to meet the needs of residents requiring two-person assistance for ADLs, exacerbating delays and compromising care quality.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to monitor three residents for adverse side effects related to psychotropic medications. Resident #9, diagnosed with Alzheimer's and dementia with behavioral disturbances, was prescribed multiple psychotropic medications, including Haloperidol, Lorazepam, and Zyprexa, which have significant side effects such as drowsiness. There was no documented evidence of monitoring for adverse effects prior to medication administration. Observations revealed that Resident #9 was lethargic and often sleepy, with no evidence that providers were notified or that symptoms were addressed. Despite recommendations for medication adjustments, Resident #9 was restarted on antipsychotic medications without documented evidence of following the recommendations. Resident #5 was prescribed RisperiDONE for agitation and behaviors, but there was no documentation of monitoring for side effects or adverse reactions since the medication was started. Similarly, Resident #10 was prescribed Lorazepam and Zoloft, with no documented evidence of monitoring for adverse effects or an interdisciplinary team meeting. The facility's policy requires monitoring for efficacy and adverse consequences of psychotropic drugs, but interviews with the Director of Nursing confirmed the lack of documented monitoring for these residents.
Failure to Accurately Review Resident's Care Plan During Visits
Penalty
Summary
The facility failed to ensure that physicians and other providers reviewed the total program of care, including medications and treatment plans, for a resident during required visits. Specifically, for one resident with Alzheimer's disease and behavioral issues, the physician notes from multiple visits inaccurately reflected the medications the resident was actually prescribed. For instance, a physician note dated June 4, 2024, mentioned that the resident was on Seroquel, Haldol, and Ativan, despite Seroquel having been discontinued on May 23, 2024. Similarly, subsequent notes on July 20, 2024, and August 5, 2024, continued to list medications that did not match the resident's actual orders at the time. The discrepancies in the physician notes were confirmed by the Director of Nursing during an interview on August 14, 2024. The Director acknowledged that the provider visits did not accurately review the resident's total program of care, as required by regulations. This oversight resulted in a failure to ensure that the resident's care plan was appropriately reviewed and updated during regulatory visits, potentially impacting the resident's treatment and care.
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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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