Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
248% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 3
Dec 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident safety, environment cleanliness, equipment maintenance, and response to alleged abuse incidents.
Findings
The facility was found to have construction debris and dust on equipment and resident areas, compromised mattresses and pillows in resident rooms, and failed to adequately protect a resident during an abuse investigation. Several staff interviews confirmed these issues, and policies regarding equipment maintenance and abuse prevention were reviewed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide a safe, clean, comfortable, and homelike environment due to construction debris and dust on equipment and resident areas on the Second Floor. | Level of Harm - Minimal harm or potential for actual harm |
| Use of compromised mattresses and pillows with stains, discoloration, and holes that were not properly removed from use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to put effective measures in place to ensure further potential abuse does not occur during investigation of an alleged abuse incident involving a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: Few
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed presence of construction dust on equipment and need for cleaning | |
| Infection Preventionist | Confirmed debris presence and equipment cleaning requirements | |
| Regional Nurse Consultant | Acknowledged need for cleaning of equipment due to construction dust | |
| Assistant Administrator | Described debris as construction particles and dust from sanding and wall preparation | |
| Housekeeping Manager | Confirmed mattress cover should be removed if compromised and expressed concern about mattress condition | |
| Administrator | Confirmed mattress was compromised and not appropriate for resident use; confirmed LNA staff were not removed during abuse investigation | |
| Licensed Practical Nurse (LPN) | Confirmed dusty equipment and compromised mattress condition | |
| Housekeeping Staff | Confirmed terminal cleaning of room but uncertainty about mattress safety |
Inspection Report
Routine
Deficiencies: 11
Dec 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, infection control, medication management, staffing competencies, food and nutrition services, and environmental safety at Premier Rehab and Healthcare at Burlington.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean environment due to construction dust and debris; use of compromised resident equipment such as mattresses; inadequate response to an abuse allegation; failure to provide appropriate wound vac care and staff competency; incomplete dialysis care documentation; unsafe medication storage; insufficient qualified dietary staff; inadequate meal/snack availability and documentation; improper food storage and labeling; and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Actual harm: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide a safe, clean, comfortable environment due to construction dust and debris on equipment and supplies on the Second Floor. | Level of Harm - Minimal harm or potential for actual harm |
| Use of compromised mattress and pillows with stains and holes, not appropriate for resident use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to an allegation of abuse involving a resident and staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate wound vac care, including lack of care plan, physician orders, monitoring, and staff competency, resulting in infection and hospitalization. | Level of Harm - Actual harm |
| Failure to provide safe and appropriate dialysis care and documentation for a resident requiring dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nursing staff had competencies and education to care for residents with wound vacs. | Level of Harm - Actual harm |
| Failure to safely store locked medications; medication cart found unlocked with resident access. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to employ sufficient qualified dietary staff; food service director and dietician not full-time or certified. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide substantial snacks at bedtime and failure to document meal intake for residents, especially those returning late from dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure, store, and label food in a safe and sanitary manner; moldy bread, unlabeled and expired food items found in kitchenettes and refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control measures; construction dust on equipment, compromised mattress use, sharps improperly disposed, unlabeled wound dressings, and ice packs stored improperly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dates with incomplete dialysis communication log: 23
Hours worked by Registered Dietician: 25
Days wound vac care plan delayed: 22
Dates with missing or no dinner documentation: 6
Inspection report pages: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #14 | Resident | Subject of wound vac care deficiencies and infection. |
| Resident #73 | Resident | Subject of abuse allegation investigation. |
| Resident #106 | Resident | Subject of dialysis care and meal/snack deficiencies. |
| Director of Nursing | Director of Nursing | Confirmed dust on equipment, wound vac care deficiencies, dialysis documentation issues, and lack of wound vac staff education. |
| Administrator | Administrator | Confirmed mattress condition and abuse investigation handling. |
| Housekeeping Manager | Housekeeping Manager | Confirmed mattress removal policy and cleaning issues. |
| Unit Manager | Unit Manager | Confirmed sharps disposal issue and snack availability. |
| Kitchen Manager | Kitchen Manager | Reported on food storage, snack availability, and kitchen staffing. |
| Registered Dietician | Registered Dietician | Works part-time at facility, confirmed staffing hours. |
| Licensed Practical Nurse | Licensed Practical Nurse | Confirmed dust on equipment and mattress condition. |
| Nurse Educator | Nurse Educator | Confirmed no wound vac education provided to staff. |
Inspection Report
Deficiencies: 1
Dec 12, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the creation and implementation of baseline care plans for residents' communication needs.
Findings
The facility failed to create and implement baseline care plans related to communication for 2 of 3 sampled residents who required interpreter services. Care plans were not in place within 48 hours of admission, and no interventions for interpreter services were documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to create and implement a baseline care plan for communication needs within 48 hours of admission for residents requiring interpreter services. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse | Interviewed nurse who worked with Resident #1 and explained communication barriers due to lack of interpreter services. | |
| Administrator | Interviewed regarding baseline care plan requirements and inability to provide evidence of compliance. | |
| Director of Nursing | Interviewed regarding baseline care plan requirements and inability to provide evidence of compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 20, 2025
Visit Reason
The inspection was conducted due to allegations of physical abuse involving residents and failure to timely report suspected abuse to the state licensing agency.
Findings
The facility failed to protect residents from physical abuse in two incidents involving Resident #1 and Resident #3. Additionally, the facility failed to timely report an allegation of abuse involving Resident #5 to the state licensing agency and did not conduct an investigation.
Complaint Details
The complaint investigation substantiated physical abuse incidents involving Resident #1 and Resident #3. The facility failed to report an allegation of abuse involving Resident #5 to the state licensing agency and did not investigate the allegation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from physical abuse involving Resident #1 and Resident #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and conduct an investigation for Resident #5. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 4
Residents sampled: 5
Inspection Report
Routine
Deficiencies: 5
Dec 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, care assistance, staffing adequacy, medication administration, and psychotropic medication use at Premier Rehab and Healthcare at Burlington.
Findings
The facility failed to maintain residents' dignity and respect, provide timely assistance with activities of daily living including toileting and transferring, ensure adequate staffing to meet resident needs, administer Parkinson's medications on time, and properly evaluate extended use of PRN psychotropic medications. Excessive call light response times and delayed medication administration were documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to honor residents' rights to dignity and respect, including timely response to call lights and assistance requests. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide proper assistance with activities of daily living including toileting and transferring for residents unable to perform these independently. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to meet resident needs and ensure safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer Parkinson's medications within the prescribed time frames, resulting in delayed symptom control. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate evaluation and physician documentation for extended PRN psychotropic medication orders beyond 14 days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 29
Residents affected: 8
Residents affected: 3
Residents affected: 13
Call bell wait times: 466
Call bell wait times: 316
Call bell wait times: 131
Call bell wait times: 126
Call bell wait times: 103
Call bell wait times: 90
Call bell wait times: 97
Call bell wait times: 81
Call bell wait times: 75
Call bell wait times: 70
Call bell wait times: 69
Call bell wait times: 68
Call bell wait times: 66
Call bell wait times: 62
Call bell wait times: 58
Call bell wait times: 56
Call bell wait times: 55
Call bell wait times: 52
Call bell wait times: 51
Call bell wait times: 49
Call bell wait times: 48
Call bell wait times: 47
Call bell wait times: 45
Call bell wait times: 44
Call bell wait times: 43
Call bell wait times: 42
Call bell wait times: 41
Call bell wait times: 40
Call bell wait times: 38
Call bell wait times: 36
Call bell wait times: 35
Call bell wait times: 32
Call bell wait times: 25
Medication delay: 120
PRN medication order duration: 90
Sample size for psychotropic medication evaluation: 7
Residents affected by psychotropic medication evaluation deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed LNA responsibility for Resident #3 care and acknowledged 2-hour medication wait for Resident #145 | |
| Licensed Nursing Assistant | Explained not providing toileting care while passing meal trays | |
| Market Clinical Advisor | Confirmed excessive call light wait times |
Inspection Report
Annual Inspection
Deficiencies: 9
Dec 4, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, dignity, staffing, medication administration, safety, and food services at Premier Rehab and Healthcare at Burlington.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity and respect, inadequate grievance reporting system, insufficient assistance with activities of daily living, failure to provide meaningful activities, unsafe environment related to smoking policies, insufficient nursing staff leading to long call light response times, untimely medication administration, inappropriate extended PRN medication orders, and failure to accommodate resident drink preferences.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Level of Harm - Potential for minimal harm: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to honor residents' rights to dignity and respect, including delayed response to call lights and disrespectful staff behavior affecting 8 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish a grievance reporting system that supports residents' right to voice grievances without fear of reprisal for 6 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide proper assistance with activities of daily living, including toileting and transferring, resulting in residents being left on bedpans or commodes for extended periods and distress for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide activities that support physical, mental, and psychosocial well-being for 1 resident, including lack of outdoor access despite resident preference. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident environments were free from accident hazards related to smoking, including unsecured cigarettes and lighters for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to meet resident needs, resulting in long call light wait times up to several hours for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer Parkinson's medications within the prescribed time frame, resulting in delayed or early doses for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure PRN psychotropic medication orders were appropriately evaluated and documented beyond 14 days for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide residents with drink options that accommodate preferences, specifically the removal of ginger ale and lack of soda alternatives. | Level of Harm - Potential for minimal harm |
Report Facts
Residents in sample: 29
Residents affected: 8
Residents affected: 6
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 13
Residents affected: 7
Call light wait times: 466
Medication administration delays: 8
Medication administration delays: 7
PRN medication order duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed LNA responsibility for Resident #3 care and acknowledged medication wait time concerns | |
| Licensed Nursing Assistant | Reported not providing toileting care while passing meal trays | |
| Activity Aide | Aware of Resident #21's need to go outside but unsure if staffing allows | |
| Assistant Activities Director | Confirmed residents ask about ginger ale availability | |
| Assistant Kitchen Manager | Confirmed ginger ale and soda alternatives are not offered | |
| Market Clinical Advisor | Confirmed excessive call light wait times |
Inspection Report
Deficiencies: 6
Jul 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to abuse prevention, medication administration, radiology services, food and nutrition services, and resident meal accommodations at Premier Rehab and Healthcare at Burlington.
Findings
The facility was found deficient in multiple areas including failure to properly screen employee background checks for abuse prevention, medication errors related to anticoagulation orders, failure to obtain ordered x-rays, insufficient staffing in food and nutrition services leading to late and cold meals, and failure to provide residents with appealing meal options and alternatives consistent with their preferences and allergies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure screening for abuse was completed according to facility policy for one Licensed Nursing Assistant. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents are free from significant medication errors related to anticoagulation medication administration without proper order clarification. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely, approved x-ray services as ordered for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide sufficient support personnel to safely and effectively carry out food and nutrition service functions, resulting in late and cold meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food and drink served to residents is palatable, attractive, and at a safe and appetizing temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide residents appealing meal options and alternatives consistent with their allergies, intolerances, and preferences. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Many
Dinner delivery times: 52
Dinner served late: 40
Dinner served on time: 12
Meals with undocumented temperature: 20
Dietary staff required: 3
Dietary staff present: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication reconciliation and food service complaints |
| Marker Operations Advisor | Marker Operations Advisor | Confirmed failure to review background check for LNA #1 |
| Admitting Physician | Admitting Physician and Medical Director | Provided statements regarding medication order clarification and transition of care |
| Kitchen Account Manager | Kitchen Account Manager | Provided statements regarding staffing shortages and meal service delays |
| Licensed Practical Nurse | Licensed Practical Nurse | Reported lack of process for asking residents meal preferences |
| Dietitian | Dietitian | Explained residents are not offered second choice on menu prior to meal service |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 12, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to include residents and their representatives in developing baseline care plans and to provide baseline care plan summaries for residents.
Findings
The facility failed to include Residents #1, #2, and #3 and their representatives in developing baseline care plans and did not provide baseline care plan summaries to them after admission or readmission. Interviews and record reviews confirmed no evidence of resident or representative participation or receipt of care plans.
Complaint Details
The complaint investigation found substantiated issues that the facility did not involve residents or their representatives in baseline care planning and did not provide care plan summaries as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to include the resident and their representative in developing a baseline care plan and failure to provide a baseline care plan summary for 3 of 3 residents sampled. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 29, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to protect a resident's right to be free from neglect, specifically related to the care of a port (port-a-cath) for Resident #1, which resulted in infection and delayed chemotherapy treatment.
Findings
The facility failed to identify and provide appropriate care for Resident #1's port, including comprehensive skin assessments, obtaining physician orders, and care planning. As a result, the port became infected, requiring removal and delaying chemotherapy. Multiple staff were aware of the port but did not provide care or monitor the site. The facility implemented corrective actions prior to the investigation.
Complaint Details
The complaint investigation revealed that Resident #1's port was not identified on admission, no physician orders or care plans were established for port care, and staff neglected to monitor or provide care for the port during the entire stay. The port became infected, requiring removal and delaying chemotherapy. The facility conducted an investigation and implemented corrective actions.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect Resident #1 from neglect by not providing necessary care to avoid physical harm and emotional distress related to port care, resulting in infection and delayed chemotherapy. | Level of Harm - Actual harm |
| Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals related to port care. | Level of Harm - Actual harm |
Report Facts
Days port care neglected: 38
Date of inspection: May 29, 2024
Date of chemotherapy appointment: May 10, 2024
Port site photo size: 1.5
Gauze photo size: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Performed Resident #1 admission nursing assessment but did not identify port or dressing on admission. |
| RN #1 | Registered Nurse, Lead Skin Nurse | Did not recall seeing gauze dressing or port on admission skin assessment. |
| RN #2 | Registered Nurse | Completed weekly skin assessments but was unaware of Resident #1's port. |
| LPN #4 | Licensed Practical Nurse | Aware of Resident #1's port under dressing but did not remove dressing to monitor port. |
| LPN #2 | Licensed Practical Nurse | Aware of dressing on Resident #1's port but did not provide care. |
| LPN #3 | Licensed Practical Nurse | Aware of port under dressing but did not remove dressing to monitor port. |
| LNA #1 | Licensed Nursing Assistant | Provided showers to Resident #1 and aware of dressing on chest. |
| LNA #2 | Licensed Nursing Assistant | Provided showers and aware of dressing on Resident #1's chest. |
| DON | Director of Nursing | Confirmed lack of knowledge about Resident #1's port and lack of care orders or care plan. |
| Market Clinical Lead | Market Clinical Lead | Confirmed facility's failure to monitor port site or obtain care orders. |
| HRN #1 | Hospital Outpatient Chemotherapy Registered Nurse | Confirmed accuracy of hospital nursing notes describing port infection. |
| HRN #2 | Hospital Outpatient Chemotherapy Registered Nurse | Confirmed port infection and that dressing was not intended for extended use; explained expectations for facility care. |
| Unit Manager | Unit Manager | Confirmed staff did not inform him/her about Resident #1's port. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 13, 2023
Visit Reason
The inspection was conducted due to multiple resident-to-resident abuse incidents reported at the facility, including physical and sexual abuse allegations involving several residents.
Findings
The facility failed to protect residents from physical and sexual abuse by other residents, substantiated by multiple incidents involving residents #1, #3, and #5. Additionally, the facility failed to timely report suspected abuse to law enforcement as required by policy and regulation for 7 of 7 sampled abuse allegations.
Complaint Details
The complaint investigation substantiated multiple resident-to-resident abuse incidents involving physical and sexual abuse. The facility's investigations confirmed the events occurred and resulted in harm. The facility also failed to report these incidents to law enforcement within required timeframes, including one incident involving serious bodily injury that required reporting within two hours.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from physical abuse by other residents, resulting in actual harm to several residents. | Level of Harm - Actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for multiple abuse allegations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Sampled abuse allegations: 7
Incident dates: 6
Inspection Report
Deficiencies: 1
Sep 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing activities that support the physical, mental, and psychosocial well-being of residents, specifically focusing on Resident #63's activity needs and participation.
Findings
The facility failed to provide adequate activities to meet the needs of Resident #63, who has hemiplegia and communicates nonverbally. Despite care plan goals and interventions, Resident #63 was not observed participating in activities such as listening to music, and interventions to address refusal of activities were not implemented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide activities that support the physical, mental, and psychosocial well-being of Resident #63. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 20
Residents affected: 1
Participation record period: 3
Activity refusals: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Explained Resident #63 has a pattern of refusing activities | |
| Activities Assistant | Checked in with Resident #63 frequently but visits were not substantial for socialization; unable to confirm music setup | |
| Director of Nursing | Confirmed Resident #63's care plan did not include interventions to address refusal of activities | |
| Market Clinical Advisor | Confirmed interventions are not being implemented to meet Resident #63's activity needs |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 14, 2023
Visit Reason
The inspection was conducted to investigate complaints related to residents' rights to receive written notice before room changes, protection from abuse, and pharmaceutical services adequacy.
Findings
The facility failed to provide written notice to residents before room changes, failed to protect a resident from verbal abuse by a staff nurse, and failed to provide the correct pharmaceutical services for a resident's medication needs.
Complaint Details
The complaint investigation found substantiated issues including failure to provide written notice of room changes to residents, verbal abuse of Resident #4 by a Registered Nurse on 10/18/22, and failure to provide the correct calcium medication tablets to Resident #3 from 2/11/2023 through 2/14/2023.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure each resident's right to receive written notice before a room change. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from verbal abuse by a Registered Nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services to meet the needs of a resident due to missing medication tablets. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication administration dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | RN verbally abused Resident #4 on 10/18/22 and was suspended and terminated | |
| Social Services Director (SSD) | Informed Resident #1 of room change on 8/23/2022 | |
| Director of Nursing | Confirmed no written notice of room transfer for Resident #1 | |
| Licensed Practical Nurse (LPN) | Administered incorrect calcium tablets to Resident #3 and reported missing medication | |
| Central supply employee | Confirmed no 600 mg calcium tablets in facility and no prior notification of missing tablets | |
| Social Worker (SW) | Confirmed no written notice was given to Resident #2 for room change |
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