Pine Heights At Brattleboro Center For Nursing & R
Inspection history, citations, penalties and survey trends for this long-term care facility in Brattleboro, Vermont.
- Location
- 187 Oak Grove Avenue, Brattleboro, Vermont 05301
- CMS Provider Number
- 475023
- Inspections on file
- 15
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pine Heights At Brattleboro Center For Nursing & R during CMS and state inspections, most recent first.
Surveyors observed a frozen turkey stored on the floor, an open bag of frozen fish left on a shelf, and clean dishes being put away while still wet. The Dietary Manager confirmed these practices did not meet professional food service safety standards.
The facility did not complete annual evaluations for two of three LNAs who had worked at the facility for over a year. Record review found no documentation of evaluations to determine appropriate education or training, and both the Administrator and DON confirmed that annual evaluations are not conducted for staff.
Surveyors found expired medications on two medication carts, including Isopto Atropine Solution 1% and Glutose 15. LPNs confirmed the presence of expired drugs and indicated that the night shift was responsible for checking for outdated medications.
A resident was not included in the development or review of their care plan and reported being unaware of care plan meetings. Documentation from a care conference did not indicate that the resident or their representative was invited, and facility leadership confirmed that invitations are limited to annual or significant change meetings.
A resident receiving IV antibiotics via a PICC line experienced resistance during medication administration due to a kinked and potentially migrated catheter. The facility failed to document the external catheter length at admission and during weekly assessments, as required by policy, resulting in a lack of evidence regarding the line's position and safety.
An LPN handled an indwelling catheter bag for a resident on enhanced barrier precautions without wearing required PPE, including gloves and a gown, as outlined in facility policy. The LPN admitted to not using PPE and was uncertain about glove availability in the resident's room. The Infection Preventionist confirmed that gloves should be worn during such care to comply with infection control protocols.
The facility failed to meet food service safety requirements. A fan above the clean dish drying area was covered in dust and circulated air over clean flatware, creating an unsanitary condition. Additionally, moldy bread was found in the 2nd floor kitchenette, and the facility lacked a process for monitoring and dating bread to prevent use beyond expiration.
A resident with dysphagia and cognitive impairment was left without meal assistance for 25 minutes, during which another resident took their drink without staff intervention. When finally attended to, the resident declined the meal, which had been left uncovered, and was not offered an alternative or reheating. The DON confirmed the resident's dependency on staff for meal assistance and acknowledged the deficiency.
A resident, dependent on staff for transfers, was found on the floor after sliding from their wheelchair due to inadequate supervision. The care plan required assistance to bed and hourly repositioning, but staff failed to perform safety checks and walking rounds, leading to the incident.
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, several residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
During a kitchen tour with the Dietary Manager (DM), surveyors observed a frozen turkey in a cardboard box stored on the floor and an open bag of frozen fish left on a shelf. The DM confirmed that the turkey had been left over from the previous Thanksgiving and had not yet been discarded, and acknowledged that the bag of fish should not have been left open. Later, clean dishes were seen being put away and placed on food carts while still wet, which the DM also confirmed was not proper procedure. These actions demonstrate failures in storing, preparing, and handling food and dishware according to professional food service safety standards. No specific residents or their medical histories were mentioned as being directly involved or affected in the report.
Failure to Complete Annual Evaluations for LNAs
Penalty
Summary
The facility failed to complete annual evaluations for two out of three Licensed Nursing Assistants (LNAs) who had been employed for over a year. Record review showed no documentation of annual evaluations for these LNAs, which would indicate what education or training was appropriate for each individual. During interviews, both the Administrator and the Director of Nursing confirmed that annual evaluations are not conducted for any staff, including LNAs.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that medications were not stored in accordance with accepted professional principles on two of four medication carts. On the Third Floor Unit, a bottle of Isopto Atropine Solution 1% was found to be expired since 4/2025. The LPN assigned to this cart confirmed the medication was expired and stated that the night shift was responsible for checking for outdated medications. On the Fourth Floor Unit, a tube of Glutose 15 was found to be expired since 6/2025, and the LPN assigned to this cart also confirmed the expired medication, again noting that the night shift was responsible for checking for outdated medications. These findings indicate that expired medications were present on medication carts and that the process for checking for outdated medications was not effectively implemented, as confirmed by staff interviews.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was involved in the care planning process, as required. During an interview, the resident stated that they were not included in the development or review of their care plan and were unaware of when their care plan was reviewed or revised. Review of documentation from a care conference showed that the section indicating whether the resident or their responsible party was invited to the meeting was left blank. Additionally, the facility administrator confirmed that residents and their responsible parties are only invited to comprehensive care plan meetings conducted annually or when there is a significant change, rather than for all care plan reviews or revisions.
Failure to Follow PICC Line Assessment and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice regarding the care and maintenance of a peripherally inserted central catheter (PICC) line for a resident with acute osteomyelitis and a chronic foot ulcer who was receiving intravenous antibiotics. During an observation, an LPN encountered resistance while attempting to administer an antibiotic through the resident's PICC line. The line was found to be excessively long and coiled, causing it to kink under the dressing and impede fluid flow. Upon uncoiling, the line measured 42 cm at the indicator, suggesting possible migration of the catheter. Record review revealed that there was no documentation of the external catheter length at the insertion site upon admission or during subsequent weekly assessments, as required by facility policy. The Assistant Director of Nursing confirmed that the line should have been measured at admission and weekly thereafter, but no such measurements were documented in the medical record. This lack of assessment and documentation meant there was no evidence to determine whether the line had migrated or if it was safe to use.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Licensed Practical Nurse (LPN) was observed handling an indwelling catheter bag for a resident on enhanced barrier precautions without wearing any personal protective equipment (PPE), specifically gloves or a gown, as required by facility policy. The LPN picked up the catheter bag from the floor without donning PPE, despite the facility's urinary catheterization policy defining enhanced barrier precautions as the use of both gown and gloves during such care. The Infection Preventionist confirmed that gloves should be worn when handling indwelling catheter bags, and the LPN acknowledged that PPE should have been used but stated she did not have gloves in her pocket and was unsure if gloves were available in the resident's bathroom. The Centers for Disease Control and Prevention guidance was referenced regarding the importance of enhanced barrier precautions to reduce the transfer of multi-drug resistant organisms.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to meet food service safety requirements as observed during a survey. On two separate occasions, a fan located above the clean dish drying area in the kitchen was found to have a significant accumulation of dark gray dust-like material on its blades and outer surface. This fan was circulating air directly over a tray of clean flatware, creating an unsanitary condition. The facility's Dietary Manager confirmed the unsanitary condition and noted that maintenance had been notified about the need for cleaning, but it had not been completed. Additionally, a bag of white bread slices with visible green mold was found in the facility's 2nd floor kitchenette. The Dietary Manager confirmed the presence of mold and acknowledged that the facility lacked a process for monitoring and dating bread to ensure it was not used beyond its expiration date.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care, specifically in maintaining good nutrition for a resident identified as having dysphagia, cognitive impairment, and a risk for weight loss and malnutrition. The resident's care plan required continual supervision and assistance during meals. However, during a meal observation, the resident was left unattended for 25 minutes without any cueing or assistance from staff, despite being seated with a meal and drink in front of them. During this time, another resident took the drink from the resident without any staff intervention. When a Licensed Nursing Assistant (LNA) finally attended to the resident, the meal had been sitting uncovered for 25 minutes, and the resident declined the food when offered. The LNA did not inquire about the resident's refusal, offer an alternative meal, or reheat the food. The Director of Nursing confirmed the resident's dependency on staff for meal assistance and acknowledged the lack of appropriate care during the observed meal, which contributed to the deficiency in providing necessary ADL support.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent a fall for a resident who was totally dependent on two staff members with a mechanical lift for transfers. The resident was found on the floor of their room at 1:45 AM, having apparently slid out of their wheelchair. The care plan for the resident indicated that they required assistance to bed by 11 PM, intentional rounding every hour for repositioning, and monitoring of positioning while in the room. However, the resident was not assisted to bed or reevaluated until they were found on the floor. The facility's internal investigation revealed that a staff member had brought the resident to their room after the evening meal, but the Licensed Nursing Assistant (LNA) assigned to the resident's care had falsely documented performing safety checks. Additionally, the evening and night shift staff failed to conduct walking rounds at the change of shift as expected. These lapses in supervision and adherence to the care plan contributed to the resident's fall.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, five residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The facility's Grievance/Concern Policy stated that forms should be available on nursing units and in the front lobby, but there was no evidence of such availability. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
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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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