Deficiencies (last 3 years)
Deficiencies (over 3 years)
28 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
536% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision that allowed a resident to elope from the facility.
Complaint Details
The complaint investigation found that Resident #45 eloped on 4/7/25, was found offsite with injuries, and that the facility's supervision and safety measures were inadequate to prevent the elopement.
Findings
The facility failed to provide adequate supervision to prevent Resident #45, an elopement risk, from leaving the facility through a window that was not alarmed. The resident was found offsite with injuries after eloping, and staff failed to redirect the resident when exiting through an alarmed door later.
Deficiencies (1)
Failure to provide adequate supervision to prevent a resident from eloping from the facility.
Report Facts
Residents affected: 1
Date of elopement: Apr 7, 2025
Date resident found: Apr 17, 2025
Distance: 200
Date of Wander Guard initiation: Mar 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Part of the search team that found Resident #45 and confirmed EMS presence | |
| Director of Nursing | Provided information about last staff sighting of Resident #45 and confirmed Wander Guard details |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 6, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory requirements and ensure resident safety and care standards.
Findings
The facility was found deficient in multiple areas including failure to determine clinical appropriateness for residents to self-administer medications, inadequate supervision leading to resident elopement, improper medication storage, unpalatable and cold food served to residents, and failure to perform adequate hand hygiene during wound care.
Deficiencies (5)
Failed to determine clinical appropriateness for residents to self-administer medications for Resident #43, with medications left unattended including a pill that cannot be crushed.
Failed to provide adequate supervision to prevent elopement of Resident #45, who exited through a window and was found injured off campus.
Failed to ensure medications were properly stored during medication pass for Resident #43, with medications left unattended at bedside.
Failed to provide palatable and appealing food; multiple residents reported food being cold, unappetizing, and lacking variety.
Failed to perform adequate hand hygiene during dressing change for Resident #67; Physician's Assistant did not sanitize hands after glove removal.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 10
Residents affected: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #1 | Confirmed medications were left unattended at Resident #43's bedside | |
| Licensed Practical Nurse #1 | Part of search team for Resident #45 after elopement | |
| Director of Nursing | Director of Nursing | Confirmed details about Resident #45's elopement and security system failures |
| Physician's Assistant | Physician's Assistant | Failed to perform hand hygiene after wound care on Resident #67 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 8, 2025
Visit Reason
The inspection was conducted due to complaints and regulatory concerns regarding the facility's failure to notify family of changes in condition, failure to update care plans for pressure injuries, failure to provide appropriate pressure ulcer care, and failure to ensure physician oversight of resident care.
Complaint Details
The visit was complaint-related due to allegations of failure to notify family of changes in condition, inadequate care planning and treatment of pressure injuries, and lack of physician oversight. The complaint was substantiated with findings of repeated deficiencies and immediate jeopardy related to pressure injury care resulting in resident death.
Findings
The facility failed to notify Resident #1's power of attorney of a new pressure ulcer, failed to update care plans for pressure injuries for multiple residents, and failed to provide appropriate treatment and prevention for pressure injuries. Resident #1 developed an unstageable pressure injury that led to infection, hospitalization, and death. The facility also failed to ensure physician and medical director oversight of resident care related to skin and pressure injury management. Licensed nurses lacked competency assessments for skin and wound care.
Deficiencies (6)
Failure to notify Resident #1's power of attorney of a new pressure ulcer identified on 3/14/25.
Failure to revise care plans for 3 residents related to skin, wounds, and pressure injury prevention and treatment.
Failure to provide appropriate pressure ulcer care and prevent new ulcers, resulting in Resident #1 developing an unstageable pressure injury with necrosis, hospitalization, and death.
Failure to ensure physicians and other providers review residents' total program of care including skin and pressure injury risk at each required visit for 3 residents.
Failure to ensure licensed nurses have competencies for skin and wound assessment.
Failure of Medical Director to assist with implementation of resident care policies and coordination of medical care related to skin and pressure injury, contributing to Resident #1's death.
Report Facts
Residents sampled: 7
Residents affected by care plan deficiencies: 3
Residents affected by pressure ulcer care deficiencies: 3
Licensed nurses lacking skin/wound competencies: 4
Dates of key events: Mar 14, 2025
Dates of key events: May 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of notification to family, failure to update care plans, and lack of staff to complete timely skin assessments | |
| Advanced Practice Registered Nurse (APRN) | Identified pressure injuries, wrote orders, but failed to ensure communication and care plan updates | |
| Physician / Medical Director | Failed to address pressure injuries during visits and was unaware of resident skin issues |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as a routine standard survey to assess compliance with regulatory requirements related to resident rights, care planning, trauma-informed care, and supervision.
Findings
The facility failed to promote resident self-determination for one resident by restricting bed mobility until physical therapy assessment, failed to develop and implement comprehensive care plans for palliative care for two residents, and failed to provide trauma-informed care for seven residents. Additionally, supervision interventions such as 15-minute checks were not properly communicated or documented for one resident.
Deficiencies (3)
Failed to provide resident choices specific to aspects of their life important to them, resulting in a resident being confined to bed for two days until physical therapy assessment.
Failed to develop and implement comprehensive care plans for palliative care for two residents and failed to implement care plan interventions related to supervision for one resident.
Failed to provide trauma-informed and culturally competent care for seven residents who are trauma survivors, including incomplete trauma assessments and lack of care plan interventions.
Report Facts
Residents sampled: 20
Residents affected by deficiency F 0561: 1
Residents affected by deficiency F 0656: 3
Residents affected by deficiency F 0699: 7
Dates of medication regimen reviews: 4
Dates with incomplete 15-minute check documentation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed resident admission date and policy on bed transfer pending PT assessment |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed residents #27 and #35 were not care planned for palliative care and was unaware Resident #363 was on 15-minute checks |
| Nurse Practitioner | Nurse Practitioner | Confirmed residents #27 and #35 were not care planned for palliative care |
| Unit Manager | Unit Manager | Identified Resident #363 as being on 15-minute checks and discussed past trauma |
| Social Worker | Social Worker | Confirmed Resident #363 had experienced trauma and care did not include trauma or triggers |
| Social Service Director | Social Service Director | Confirmed several residents lacked trauma informed care assessments and lack of assessment tools |
| Licensed Nurse Assistant | Licensed Nurse Assistant | Confirmed unawareness that Resident #363 was on 15-minute checks |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Feb 6, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for Premier Rehab and Healthcare at Berlin.
Findings
The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, failure to provide resident choices, medication administration errors, inadequate care planning for palliative care, insufficient staffing, improper infection control practices, failure to provide dental services, and failure to maintain sanitary food storage and kitchen conditions.
Deficiencies (16)
Failed to determine clinical appropriateness for residents to self-administer medications, with medications left unattended at bedside.
Failed to provide resident choices specific to aspects of their life important to them, including delays in physical therapy assessment.
Failed to notify physician of symptoms requiring as needed medication whose prescription had expired.
Failed to develop and implement comprehensive care plans for palliative care and supervision interventions.
Failed to provide necessary assistance for activities of daily living related to grooming and personal hygiene.
Failed to provide ongoing activities program to support residents' interests and well-being, with no group activities during survey.
Failed to ensure proper treatment and assistive devices to maintain hearing abilities for a resident.
Failed to provide culturally competent, trauma-informed care for trauma survivor residents.
Failed to provide sufficient nursing staff to meet residents' needs and maintain safety.
Failed to ensure medications were properly stored and secured, with medications left unattended on resident's lap.
Medication error rate was 43%, including late administration, failure to follow administration recommendations, and omission of PRN medication.
Failed to provide or obtain routine and emergency dental services for residents with dental needs.
Failed to store, handle, and serve food in accordance with professional standards, including expired spices and unsanitary kitchen conditions.
Failed to ensure safe and sanitary storage, handling, and consumption of foods brought by residents, including discarding unlabeled food without resident notification.
Failed to conduct and document a facility-wide assessment to determine necessary resources for competent resident care.
Failed to maintain facility-wide infection prevention and control program, including improper mask use, inadequate PPE use, failure to change and date oxygen tubing, and improper cleaning of reusable equipment.
Report Facts
Medication administration opportunities observed: 30
Medication errors observed: 13
Medication error rate: 43
Late medications: 3400
Late medication report pages: 384
Facility census: 66
Residents affected by infection control issues: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Left medications at resident's bedside that should not have been left unattended | |
| Director of Nursing | Confirmed multiple deficiencies including medication errors and staffing issues | |
| Unit Manager | Discussed resident trauma and infection control masking issues | |
| Social Worker | Confirmed lack of trauma-informed care assessments | |
| Licensed Practical Nurse | Confirmed outdated oxygen tubing and infection control practices | |
| Licensed Nursing Assistant | Observed with improper mask use and improper glove use | |
| Nurse Practitioner | Observed using reusable stethoscope without proper cleaning between residents | |
| Dietary Manager | Confirmed expired spices in kitchen | |
| District Manager | Confirmed food discarded from unit refrigerator without resident notification |
Inspection Report
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with licensing requirements and management responsibilities, specifically focusing on the facility's failure to maintain a current license and to appoint a properly licensed administrator.
Findings
The facility failed to hold a current license from the State Agency to operate as a nursing home and did not notify the State Agency of changes in administration. Additionally, the facility operated without a licensed administrator after the previous administrator resigned, with the Director of Nursing acting as interim administrator without holding the required license.
Deficiencies (2)
Facility failed to hold a current license from the State Agency to operate as a nursing home.
Facility failed to appoint an administrator licensed by the state to be responsible for managing the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acted as interim administrator without holding a Nursing Home Administrator License. |
| Chief Nursing Officer | Chief Nursing Officer | Provided interview information regarding administrative changes. |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 19, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with resident rights, safety, cleanliness, care planning, and infection control standards during a routine regulatory survey.
Findings
The facility failed to provide dignity and respect to residents, maintain a safe and clean environment, ensure proper notification of bed hold policies, implement complete care plans for residents with infections and medication errors, and provide appropriate catheter care and infection control measures.
Deficiencies (6)
Failure to provide dignity and respect for residents, including improper wheelchair transfers and lack of toileting assistance.
Failure to maintain a safe, clean, comfortable, and homelike environment, including mold presence, unfinished repairs, and poor housekeeping.
Failure to notify resident or representative in writing of bed hold policy upon hospital transfer.
Failure to develop and implement complete care plans addressing catheter care, urinary tract infection, and antibiotic therapy.
Failure to revise care plan after significant medication error involving administration of ear drops into eyes.
Failure to provide appropriate catheter care and infection control measures for resident with suprapubic catheter.
Report Facts
Residents sampled: 23
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Aide (LNA) | Confirmed pulling resident backwards in wheelchair causing catheter bag to drag on floor | |
| Nurse Practitioner (NP) | Confirmed staff did not bring resident to bathroom due to pending bone density testing | |
| Licensed Nursing Assistant (LNA) | Observed transferring residents with inadequate coverage and leaving resident in shower chair | |
| Regional Environmental Services Director | Confirmed mold presence and dampness in gym and other areas | |
| Market Operations Advisor | Confirmed lack of deep cleaning and housekeeping staffing issues | |
| Clinical Market Advisor | Could not locate bed hold notification and confirmed care plan deficiencies | |
| Clinical Market Lead (Registered Nurse) | Unable to provide evidence of monitoring after medication error | |
| Director of Nursing (DON) | Confirmed expectation to update care plan after medication error but no revisions made | |
| Market Clinical Advisor (MCA) | Confirmed catheter bag dragging on floor represented infection control risk |
Inspection Report
Routine
Deficiencies: 13
Date: Aug 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, environment, care planning, staffing, food and nutrition services, and infection control at Premier Rehab and Healthcare at Berlin.
Findings
The facility was found deficient in multiple areas including failure to provide dignity and respect to residents, inadequate assessment and care planning for medication self-administration, poor environmental cleanliness and maintenance, failure to implement care plans for catheter care and urinary tract infections, medication errors, insufficient nursing staff, lack of annual performance evaluations for nurse aides, improper medication storage, inadequate dental services, failure to provide scheduled and alternative food items, and ineffective pest control measures.
Deficiencies (13)
Failed to provide dignity and respect for 4 of 23 sampled residents, including improper wheelchair transfers and lack of toileting assistance.
Failed to assess a resident for ability to self-administer medications and failed to document orders or care plans for self-administration.
Failed to provide a safe, clean, comfortable, and homelike environment, including mold presence, unfinished repairs, and poor housekeeping.
Failed to implement care plan interventions related to catheter care and monitoring for urinary tract infection and antibiotic therapy.
Failed to revise care plan after significant medication error involving administration of ear drops into eyes causing pain and requiring medical attention.
Failed to ensure physicians signed and dated admission orders for 4 of 6 sampled residents.
Failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed responses and inadequate care.
Failed to provide annual performance evaluations for 3 Licensed Nursing Assistants.
Failed to ensure medications were properly stored; resident self-administered medications without physician orders or lockbox.
Failed to employ a qualified dietitian full-time or designate a qualified director of food and nutrition services with required certification.
Failed to follow posted dinner menu and notify residents of menu changes; residents did not receive scheduled food items.
Failed to provide residents with appealing meal options and alternatives based on preferences; staff shortages limited meal choice communication.
Failed to maintain effective pest control; open window without screen adjacent to food preparation areas.
Report Facts
Residents sampled: 23
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 13
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #103 | N/A | Named in dignity and respect, catheter care, and infection control deficiencies |
| Resident #18 | N/A | Named in medication self-administration and medication storage deficiencies |
| Resident #16 | N/A | Named in medication error and care plan revision deficiencies |
| Resident #25 | N/A | Named in dental services and food service deficiencies |
| Resident #6 | N/A | Named in dignity and respect and food service deficiencies |
| Resident #4 | N/A | Named in environmental and food service deficiencies |
| Resident #39 | N/A | Named in food service deficiencies |
| Resident #7 | N/A | Named in food service deficiencies |
| Resident #46 | N/A | Named in staffing and food service deficiencies |
| Resident #33 | N/A | Named in food service deficiencies |
| Resident #20 | N/A | Named in food service deficiencies |
| Resident #47 | N/A | Named in food service deficiencies |
| Licensed Nursing Assistant | LNA | Named in dignity and respect and staffing deficiencies |
| Licensed Nursing Assistant #1 | LNA | Named in staffing deficiencies |
| Licensed Nursing Assistant #2 | LNA | Named in staffing deficiencies |
| Nurse Practitioner | NP | Named in dignity and respect and medication error deficiencies |
| Clinical Market Lead | RN | Named in medication self-administration and care plan deficiencies |
| Market Clinical Advisor | MCA | Named in catheter care and physician order deficiencies |
| Director of Nursing | DON | Named in staffing and care plan deficiencies |
| Dietary Manager | Dietary Manager | Named in food service and pest control deficiencies |
| Dietitian | Dietitian | Named in food service deficiencies |
| District Manager | District Manager | Named in food service deficiencies |
| Scheduler | Scheduler | Named in staffing deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 1, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to protect residents from sexual abuse, failure to timely report suspected abuse, failure to investigate alleged violations, inadequate supervision to prevent accidents, failure to provide trauma-informed care, and incomplete medical records.
Complaint Details
The complaint investigation focused on allegations of sexual abuse by Resident #28 toward Residents #31 and #38, failure to report and investigate the abuse timely, inadequate supervision, failure to provide trauma-informed care, and incomplete medical and dental records. The facility failed to protect residents, report abuse within 2 hours, investigate allegations, and maintain proper documentation.
Findings
The facility failed to protect residents from sexual abuse by another resident, failed to timely report and investigate abuse allegations, did not provide adequate supervision to prevent accidents, failed to identify residents' trauma history and triggers, and did not maintain complete and accurate medical and dental records for several residents.
Deficiencies (6)
Failed to protect residents from sexual abuse by a resident for 2 applicable residents (Resident #31 and #38).
Failed to timely report suspected abuse and report investigation results to proper authorities for 2 residents (Resident #31 and #38).
Failed to initiate and investigate an investigation of an alleged violation of sexual abuse for 2 residents (Resident #31 and #38).
Failed to ensure the environment was free of accident hazards and provide adequate supervision to prevent accidents for 1 resident (Resident #11).
Failed to identify a resident's past history of trauma and/or triggers which may cause re-traumatization for 3 residents (Residents #22, #31, and #28).
Failed to ensure records are complete, accurately documented, readily accessible, and systematically organized related to dental records and medication reviews for 3 of 5 sampled residents (Residents #16, #32, and #31).
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 3
Sampled residents: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #1 | Licensed Nurse | Witnessed Resident #28 masturbating in another resident's room and reported the event |
| Licensed Nurse #2 | Licensed Nurse | Received report from Licensed Nurse #1 about sexual abuse incident and took statement |
| Administrator | Administrator | Acknowledged failure to investigate and report sexual abuse incident and confirmed lack of documentation |
| Director of Nursing | Director of Nursing | Confirmed no further interviews or investigations were conducted regarding sexual abuse incident |
| Corporate Clinical Specialist | Corporate Clinical Specialist | Confirmed failure to follow care plan intervention for providing secured lids on coffee cups |
| Social Service Specialist | Social Service Specialist | Confirmed limited trauma screening and lack of social worker after August 2023 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 1, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide appropriate mental health services, pharmaceutical services, medication management, laboratory services, timely x-ray services, and COVID-19 vaccination implementation at Premier Rehab and Healthcare at Berlin.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to failure to provide adequate mental health services, pharmaceutical services, medication management, laboratory testing, timely EKG services, and COVID-19 vaccination implementation, resulting in harm to residents.
Findings
The facility failed to provide adequate mental health services, pharmaceutical services including proper medication management for residents with psychiatric diagnoses, timely laboratory testing for urinary tract infections, timely approved EKG services, and failed to implement their COVID-19 vaccination policy effectively, resulting in actual harm to residents and delayed or missed care.
Deficiencies (6)
Failed to provide mental health services and individualized care for a resident with depression and anxiety, including failure to provide psychiatric consultation and medication adjustment.
Failed to provide pharmaceutical services to meet the needs of a resident with schizophrenia, including failure to collaborate with pharmacist and manage Clozapine medication per REMS requirements.
Failed to ensure residents are free from significant medication errors related to abrupt discontinuation of Clozapine and delayed initiation of alternative antipsychotic medication.
Failed to provide timely, quality laboratory services/tests to meet residents' needs, resulting in delayed diagnosis and treatment of urinary tract infections and sepsis.
Failed to provide timely, approved EKG services for a resident at risk for cardiac complications, resulting in delayed diagnosis and treatment of atrial fibrillation with rapid ventricular response and NSTEMI Type II.
Failed to implement COVID-19 vaccination policy effectively, including delays in vaccine ordering, administration, education, consent, and failure to resume vaccination promptly after a pause, resulting in minimal harm.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication administration gap: 7
Pyridium administrations: 19
COVID-19 vaccine doses ordered: 20
Residents vaccinated on 11/26/23: 13
Residents infected in December 2023 COVID outbreak: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Nurse Practitioner (NP) | Involved in medication management and acknowledged inability to order Clozapine refill and EKG |
| Medical Director | Medical Director | Unable to prescribe Clozapine, unaware of COVID-19 vaccination policy, involved in medication decisions |
| Clinical Market Advisor | Clinical Market Advisor | Confirmed failure to provide psych services and lack of Clozapine policies |
| Psychiatric Advanced Practice Registered Nurse | Psychiatric APRN | Requested psych referral, UA, and EKG; confirmed behavioral symptoms related to medical issues |
| Consulting Pharmacist | Consulting Pharmacist | Confirmed Clozapine REMS requirements and cardiac side effects of Risperidone |
| Director of Nursing | Director of Nursing | Confirmed failure to obtain UA and follow-up with provider |
| Infection Preventionist | Infection Preventionist (IP) | Reported COVID-19 vaccination delays and reactions |
| Nurse Practitioner | Nurse Practitioner (NP) | Directed pause in COVID-19 vaccination program |
| Market Clinical Lead | Market Clinical Lead | Confirmed lack of policies and monitoring related to Clozapine and medication errors |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and medication use at Premier Rehab and Healthcare at Berlin.
Findings
The facility failed to ensure residents had reasonable access to call lights for 5 residents on A Wing, and failed to prevent unnecessary use of psychotropic medications for one resident, resulting in minimal harm or potential for harm.
Deficiencies (2)
Failed to provide access to call lights for 5 residents on A Wing, preventing them from making their needs known.
Failed to prevent use of unnecessary psychotropic medications for one resident, resulting in excessive sedation and transfer to emergency department.
Report Facts
Residents affected: 5
Residents affected: 1
Medication dosage: 10
Medication administration dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed medication administration and sedation issues for Resident #1 | |
| Director of Nursing | Confirmed medication administration and sedation issues for Resident #1 |
Inspection Report
Deficiencies: 2
Date: Oct 17, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality and licensing requirements for staff at Premier Rehab and Healthcare at Berlin.
Findings
The facility failed to follow physicians' orders for blood sugar monitoring for one resident and employed a nurse who was not licensed to practice in the state. Both deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failed to follow physicians' orders for blood sugar checks for Resident #1.
Employed a nurse who was not licensed to practice nursing in the state.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nurse Educator | Named in finding for being unlicensed to practice nursing in the state. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by a Registered Nurse.
Complaint Details
The complaint was substantiated based on staff interviews, record review, and witness statements confirming physical abuse by a Registered Nurse on 08/14/23. The facility reported the incident to The Agency, Adult Protective Services, local police, and the Board of Nursing. The RN was suspended and terminated.
Findings
The facility failed to ensure one of two applicable residents was free from abuse. A Registered Nurse physically abused Resident #2 on 08/14/23 by holding the resident's arms down in a wheelchair, resulting in bruising consistent with fingerprints. The facility took corrective actions including suspension and termination of the RN, reporting to authorities, and staff education.
Deficiencies (1)
Failure to protect Resident #2 from physical abuse by a Registered Nurse.
Report Facts
Residents affected: 1
Date of abuse incident: Aug 14, 2023
Date of survey completed: Oct 9, 2023
Date of RN termination: Aug 25, 2023
Date of QAPI discussion: Sep 21, 2023
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
The inspection was conducted following complaints and allegations regarding the treatment of residents during personal care, specifically concerns about respect, dignity, and causing pain or discomfort.
Complaint Details
The visit was complaint-related, triggered by reports of rough handling and causing pain during personal care. Resident #1 reported painful handling of their right arm. Resident #2 had new bruising and was reported crying out during care. Resident #3 confirmed increased crying out and discomfort during care. The Administrator and Market Clinical Lead confirmed a pattern of undignified handling.
Findings
The facility failed to ensure residents were treated with respect and dignity during personal care, resulting in pain or discomfort for 3 sampled residents. Interviews and record reviews revealed incidents of rough handling, increased crying out during care, and a pattern of undignified handling confirmed by facility leadership.
Deficiencies (1)
Failure to honor residents' right to be treated with respect and dignity during personal care, causing pain or discomfort to residents.
Report Facts
Residents affected: 3
Inspection Report
Routine
Deficiencies: 2
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, focusing on treatment documentation, wound care, and assistance with activities of daily living.
Findings
The facility failed to maintain accurate documentation of treatments for two residents with pressure ulcers, resulting in missed wound care and lack of provider notification. Additionally, the facility failed to provide weekly showers and timely incontinence care for one resident, leading to prolonged periods without hygiene assistance.
Deficiencies (2)
Failure to document completion of dressing changes and application of prescribed treatments for pressure ulcers in two residents.
Failure to provide weekly showers and timely incontinence care for one resident, resulting in prolonged periods without hygiene assistance.
Report Facts
Days without shower: 34
Wound measurements: 9.3
Wound measurements: 11.7
Dates of missed treatments: 3
Dates of missed dressing changes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Interviewed regarding documentation gaps and treatment compliance for Residents #1 and #2. | |
| Licensed Nursing Assistant | Interviewed about challenges in providing showers and assistance to Resident #3. | |
| Center Executive Director | Interviewed confirming Resident #3's shower refusals and lack of alternate shower offers. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jul 27, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to obtain accurate physician orders, develop baseline care plans, provide appropriate pressure ulcer care, ensure physician oversight, and prevent significant medication errors for residents.
Complaint Details
The investigation was complaint-driven based on concerns about inaccurate admission orders, inadequate care planning, pressure ulcer care deficiencies, lack of physician oversight, and medication errors affecting Residents #1, #2, and #3.
Findings
The facility failed to obtain accurate admission orders for residents, develop and implement baseline care plans within 48 hours, provide timely and appropriate pressure ulcer care, ensure physician progress notes and orders were signed and dated timely, and prevent significant medication errors including incorrect medication dosing and delayed administration.
Deficiencies (6)
Failure to obtain accurate physician orders for residents' immediate care on admission.
Failure to develop and implement baseline care plans within 48 hours of admission addressing residents' immediate needs.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to ensure physician reviewed care, wrote, signed, and dated progress notes and orders at each required visit.
Failure to ensure residents are free from significant medication errors including incorrect dosing and delayed administration.
Failure of the medical director to fulfill responsibilities related to coordinating medical care and ensuring accurate admission orders.
Report Facts
Residents affected: 3
Days delayed for baseline care plan: 7
Days delayed for wound treatment: 3
Days delayed for physician progress note entry: 29
Days delayed for physician progress note entry: 10
Days without budesonide orders: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1's Attending Physician | Attending Physician/Medical Director | Confirmed lack of review and reconciliation of admission orders and wound care; unaware of medication omissions; acknowledged systemic issues. |
| Market Clinical Lead | Confirmed policy violations, order transcription errors, and lack of baseline care plans and wound monitoring. | |
| Registered Nurse (RN) | Admission Orders Nurse | Admitted not using hospital MAR for medication reconciliation and not reviewing wound care notes. |
| Nurse Practitioner (NP) | Wound Care Certified Nurse Practitioner | Incorrectly reentered morphine orders leading to medication errors. |
| Hospital Registered Nurse (RN) | Reported worsening wounds and inadequate care at the facility. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to include a resident's representative in care planning, failure to notify resident representatives of incidents and changes in condition, failure to timely report suspected abuse or neglect, and failure to respond appropriately to alleged violations.
Complaint Details
The investigation was complaint-driven, focusing on allegations of failure to include resident representatives in care planning, failure to notify representatives of incidents and condition changes, failure to timely report abuse allegations, and failure to prevent further abuse during investigation. The Director of Nursing was terminated due to failure to report an incident within required timeframes.
Findings
The facility failed to ensure inclusion of a resident's representative in care planning, timely notification of resident representatives about incidents and changes in condition, timely reporting of alleged abuse within 2 hours, and prevention of further potential abuse during an ongoing investigation. The Director of Nursing was terminated due to failure to report an incident timely.
Deficiencies (4)
Failed to ensure that Resident #3's representative was included in the care planning process.
Failed to immediately notify resident representatives after incidents involving Resident #2 and Resident #3.
Failed to timely report suspected abuse or neglect within 2 hours for Residents #1 and #2.
Failed to prevent further potential abuse by sending Resident #1 with EMS staff who made threatening statements during transfer.
Report Facts
Residents sampled: 6
Incident date: Jun 6, 2023
Incident date: Jul 14, 2023
Incident date: Jun 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to failure to report incidents timely and was terminated as a result. |
| Senior Administrator | Senior Administrator | Provided written statements regarding incident investigations and stand-down meetings. |
| Market Nurse Consultant | Market Nurse Consultant | Confirmed findings and interview statements regarding notification failures and DON termination. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 9, 2023
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to include a resident representative in care planning meetings and failure to address discharge goals and complete discharge plans in a timely manner for sampled residents.
Complaint Details
The complaint investigation revealed substantiated issues related to care planning and discharge planning deficiencies affecting Residents #1, #2, and #3.
Findings
The facility failed to routinely include a resident representative in care planning meetings for 1 of 3 sampled residents and failed to address discharge goals and complete discharge plans timely for 3 of 3 sampled residents. Interviews and record reviews confirmed these deficiencies, and facility policies were not followed.
Deficiencies (2)
Failed to routinely include a resident representative to participate in care planning meetings for 1 of 3 sampled residents.
Failed to address discharge goals in the plan of care and complete a discharge plan in a timely manner for 3 of 3 sampled residents.
Report Facts
Residents sampled: 3
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Substitute Director of Nursing | Substitute Director of Nursing | Confirmed no discharge care plans for Residents #1, #2, and #3 during interview on 2/9/23 |
| Social Service Specialist | Social Service Specialist | Stated that Resident #1's information was sent to admitting nursing facility on 1/16/23 |
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