Deficiencies (last 3 years)
Deficiencies (over 3 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
286% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, pain management, and call system accessibility at the Center for Living & Rehabilitation.
Findings
The facility was found deficient in treating a resident with dignity and respect, providing adequate pain management, and ensuring access to a working call bell system. Specifically, a resident was addressed inappropriately by staff, experienced unmanaged pain without timely intervention, and lacked access to the call bell in their room.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure that a resident was treated with dignity and respect, as staff addressed the resident by an inappropriate nickname. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide adequate pain management for a resident, including not offering non-pharmacological interventions and delaying pain relief despite high pain levels. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure that a resident had access to a working call bell in their room, resulting in the resident being unable to summon assistance independently. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 4
Residents affected: 1
Pain level: 9
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to addressing resident with inappropriate nickname and pain management |
| Director of Nursing | Director of Nursing | Confirmed that high pain levels should be addressed timely and nonpharmacological approaches should be implemented |
| Administrator | Administrator | Stated it is not appropriate to address residents with terms of endearment and confirmed pain management expectations |
| Licensed Nursing Assistant #1 | Licensed Nursing Assistant | Involved in observation related to resident's pain and transfer |
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 16, 2025
Visit Reason
The inspection was conducted due to allegations of physical and verbal abuse between two residents, Resident #1 and Resident #2, following two resident-to-resident altercations on 8/7/25 and 9/17/25.
Findings
The facility failed to protect residents from abuse and did not implement effective interventions or update care plans to prevent recurrence of altercations between Resident #1 and Resident #2. Resident #1 sustained blunt trauma to the nose with bleeding and expressed feeling unsafe. The facility relied on informal redirection rather than documented interventions, resulting in actual physical and psychosocial harm.
Complaint Details
The complaint investigation substantiated that Resident #1 and Resident #2 were involved in physical altercations on 8/7/25 and 9/17/25. Resident #1 was injured and expressed feeling unsafe. The facility did not update care plans or implement effective interventions to prevent further incidents.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from physical and verbal abuse by another resident, resulting in actual harm. | Level of Harm - Actual harm |
| Failed to develop and revise comprehensive care plans within 7 days of significant changes related to resident-to-resident altercations. | Level of Harm - Actual harm |
Report Facts
BIMS score: 15
BIMS score: 15
Incident dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Witnessed the 9/17/25 altercation and reported observations |
| Nurse Practitioner | Nurse Practitioner | Witnessed the 9/17/25 altercation and provided assessment |
| Director of Nursing | Director of Nursing | Confirmed lack of specific care plan interventions to separate residents |
| LNA #1 | Licensed Nursing Assistant | Interviewed regarding awareness of resident conflicts |
| Unit Manager | Unit Manager | Interviewed about facility strategy to keep residents separated |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident safety and prevent accidents.
Findings
The facility failed to ensure that one of three residents in the sample was free from accidents and hazards, resulting in a skin tear sustained by Resident #1 during an unsupervised transfer that was supposed to require two staff members.
Complaint Details
The complaint investigation found that Resident #1 was care planned for 2-person assist transfers but was transferred independently by a staff member, leading to a skin tear. The Director of Nursing confirmed the incident during an interview.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in a skin tear to Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that a staff member had transferred Resident #1 independently despite care plan requiring 2-person assist. | |
| Licensed Nursing Assistant (LNA) | Assigned to Resident #1's care and stated she transferred the Resident out of bed for dinner but did not transfer the Resident back to bed. |
Inspection Report
Deficiencies: 1
Jun 30, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to pressure ulcer prevention and treatment in the facility.
Findings
The facility failed to ensure that a resident did not develop an avoidable pressure ulcer. Specifically, Resident #1 developed a right heel pressure ulcer while in the facility, and protective interventions were not implemented until after the ulcer was identified.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Wound dimensions: 7
Wound dimensions: 5
Wound dimensions: 0.1
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that the right heel wound developed in the facility and that no protective interventions were documented prior to 6/2/2025 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Apr 30, 2025
Visit Reason
The inspection was conducted to investigate complaints related to residents' rights regarding advanced directives, fall prevention and supervision, nutritional care, medication regimen reviews, medication storage and labeling, and infection prevention and control practices.
Findings
The facility failed to ensure residents' power of attorney were assisted with advanced directives consistent with their wishes, failed to provide adequate supervision and timely interventions to prevent falls for sampled residents, failed to administer nutritional supplements and appetite stimulants as ordered, failed to maintain complete medication regimen reviews, failed to properly store and label medications including expired drugs, and failed to implement proper infection prevention and control measures during resident care and medication administration.
Complaint Details
The visit was complaint-related, investigating issues including residents' rights to advanced directives, fall prevention, nutritional care, medication regimen reviews, medication storage, and infection control. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure Residents' power of attorney was assisted with developing advanced directives consistent with their wishes for 1 of 40 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing home area was free from accident hazards and provided adequate supervision to prevent accidents for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nutritional supplements and appetite stimulants as ordered for 1 resident with nutritional problems. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain drug regimen reviews for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were stored in accordance with professional principles; expired medications found and medications left unsupervised. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control program; breaches in PPE use and hand hygiene observed during resident care and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Medication doses missed: 5
Weight loss (pounds): 6.9
Weight loss (%): 4.3
Medication regimen review missing months: 3
Expired medication counts: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed confirming deficiencies related to advanced directives, fall prevention, nutritional care, and medication regimen reviews |
| Unit Manager | Unit Manager | Confirmed findings of expired medications and medication cart issues |
| Infection Preventionist | Infection Preventionist | Interviewed confirming breaches in infection control practices |
| Nurse | Observed leaving medications unsupervised on medication cart and improper medication handling without hand hygiene | |
| LPN | Confirmed pill cutter needed cleaning and presence of medication debris |
Inspection Report
Routine
Deficiencies: 1
Feb 12, 2025
Visit Reason
The inspection was conducted to assess the facility's maintenance services and ensure residents have a safe, clean, comfortable, and homelike environment.
Findings
The facility failed to provide necessary maintenance services for 4 of 6 resident units, including issues with communal shower rooms such as open holes in shower walls, missing tiles, leaking showerheads, standing water not draining, and a non-functional toilet. These issues had existed for months but were not documented or addressed through the facility's maintenance tracking system.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment due to unresolved maintenance issues in communal shower rooms including open holes, missing tiles, leaking showerheads, standing water, and a non-functional toilet. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding maintenance issues and use of the TELS maintenance tracking system. |
Inspection Report
Deficiencies: 1
Feb 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care related to treatment and prevention of complications for residents, specifically focusing on skin integrity and wound care for Resident #1.
Findings
The facility failed to ensure appropriate treatment and care for Resident #1, who developed a large, infected right plantar foot wound after the footboard on the bed caused skin issues that were not promptly addressed. The wound deteriorated over time, and care plan updates and wound assessments were delayed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in a large blister type wound with open edges on Resident #1's right plantar foot. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Wound size: 5
Wound size: 6
Wound size: 5.5
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse Practitioner | Received phone call about footboard causing skin issues and conducted wound assessment | |
| Director of Nursing | Confirmed resident risk, care plan details, and delays in wound assessment and intervention | |
| [Staff LPN] | First staff to document skin issue on resident's right foot on 1/9/25 |
Inspection Report
Deficiencies: 7
Nov 20, 2024
Visit Reason
The inspection was conducted to assess the facility's maintenance services and ensure residents have a safe, clean, comfortable, and homelike environment.
Findings
The facility failed to provide necessary maintenance services, resulting in multiple functional and cosmetic repairs needed in several resident rooms across all nursing units, including broken electrical outlets, unrepaired wall damage, missing baseboard trim, broken furniture, and infection control concerns due to broken tiles and leaking toilets.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Broken double electrical outlet receptacle exposing wiring with cords plugged in. | Level of Harm - Minimal harm or potential for actual harm |
| Walls in multiple rooms had unrepaired holes, scratches, peeling wallpaper, or unpainted spackle. | Level of Harm - Minimal harm or potential for actual harm |
| Missing baseboard trim in bathrooms exposing peeling paint and broken sheet rock. | Level of Harm - Minimal harm or potential for actual harm |
| Broken drawer in a wardrobe. | Level of Harm - Minimal harm or potential for actual harm |
| Broken cover over fluorescent light placed against the wall with scratches and missing paint on wall. | Level of Harm - Minimal harm or potential for actual harm |
| Bathroom had two broken tiles with missing pieces creating infection control concern. | Level of Harm - Minimal harm or potential for actual harm |
| Signs of leaking at the base of the toilet presenting as black liquid on the floor. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 27, 2024
Visit Reason
The inspection was conducted based on complaints alleging undignified treatment of a resident, failure to implement employee background checks, failure to timely report and respond to abuse allegations, and issues related to COVID-19 vaccination documentation and administration.
Findings
The facility was found to have substantiated undignified treatment of a resident by staff, failure to complete required annual criminal background checks for staff, failure to timely report and investigate abuse allegations, failure to prevent further potential abuse after allegations, and failure to properly document and administer COVID-19 vaccinations to residents.
Complaint Details
The complaint investigation included allegations of undignified treatment of Resident #87 by a Licensed Nursing Assistant, failure to conduct annual criminal background checks on staff, failure to timely report and investigate verbal abuse allegations involving Resident #101, failure to prevent further potential abuse after the allegation, and failure to properly document and administer COVID-19 vaccinations to residents #100 and #6. The undignified treatment allegation was substantiated. The facility failed to timely report the abuse allegation and failed to remove the alleged perpetrator, allowing continued contact with the resident. The COVID-19 vaccination documentation and administration deficiencies were confirmed by staff interviews and record reviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure all residents were treated with respect and dignity by staff, substantiated undignified treatment of Resident #87 by a Licensed Nursing Assistant. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement policies for screening employees by not completing required annual criminal background checks for 4 of 5 sampled staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for Resident #101. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to alleged violations by not preventing further potential abuse after an allegation for Resident #101. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure documentation of education regarding COVID-19 vaccination benefits and side effects for Resident #100 and failed to ensure Resident #6 received the COVID-19 vaccine or documented consent/refusal. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 29
Staff sampled: 5
Staff without annual background checks: 4
Residents sampled for abuse allegations: 2
Residents sampled for COVID-19 vaccination: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant (LNA) | Named in undignified treatment finding involving Resident #87 | |
| Human Resource Staff | Interviewed regarding lack of annual background checks | |
| Administrator | Interviewed regarding undignified treatment and abuse allegations | |
| Licensed Practical Nurse (LPN) | Witnessed verbal abuse incident involving Resident #101 | |
| LPN Supervisor | Interviewed regarding abuse allegation reporting | |
| Unit Manager (UM) | Interviewed regarding abuse allegation investigation and response | |
| Director of Nursing (DON) | Interviewed regarding abuse allegation reporting and investigation | |
| Infection Preventionist | Interviewed regarding COVID-19 vaccination documentation and administration |
Inspection Report
Annual Inspection
Deficiencies: 11
Mar 27, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the facility's care and services.
Findings
The facility was found deficient in multiple areas including failure to notify a physician of significant weight loss, incomplete criminal background checks for staff, inadequate implementation and revision of care plans related to fall prevention, insufficient assistance with activities of daily living, failure to assist with audiology appointments, inadequate environmental safety measures to prevent falls, failure to maintain residents' nutritional status, lack of trauma-informed care planning, failure to implement gradual dose reductions for psychotropic medications, and administration of anticoagulant medication to a resident with a brain bleed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to notify the resident's physician of significant weight loss for Resident #100. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete required annual criminal background checks for 4 of 5 sampled staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a resident's individualized comprehensive care plan related to fall prevention for Resident #266. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise care plans regarding prevention of future falls for Resident #62 and failed to ensure interdisciplinary team review for Resident #79. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide proper assistance with activities of daily living for Resident #100. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist Resident #71 in making audiology appointments and rescheduling missed appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure an environment free of accident hazards and adequate supervision to prevent falls for Residents #62 and #266. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents maintain acceptable nutritional status and obtain weights as care planned for Resident #100. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create an individualized person-centered trauma informed care plan for Resident #30. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions for psychotropic medications, failed to document specific diagnoses for psychotropic medications, and failed to accurately monitor behaviors and medication side effects for Residents #13, #100, and #30. | Level of Harm - Minimal harm or potential for actual harm |
| Administered anticoagulant medication to Resident #266 despite a diagnosed brain bleed, contrary to physician recommendations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 29
Staff sampled: 5
Weight loss: 20.6
Weight loss percentage: 16.3
Falls: 7
Brain bleed size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed nursing staff should have contacted physician about Resident #100's weight loss and confirmed nails should have been cut | |
| Human Resource Staff | Explained lack of system for annual background checks and plan to implement in June | |
| Director of Nursing | DON | Confirmed failures in fall prevention care plan revisions, inaccurate fall risk evaluations, failure to evaluate effectiveness of interventions, and medication administration error for Resident #266 |
| Scheduler | Responsible for rescheduling audiology appointments and confirmed Resident #71's appointment was not rescheduled | |
| Resident #100's Physician | Physician | Confirmed not notified of Resident #100's significant weight loss and confirmed missing trauma informed care interventions |
| Resident #13's Physician | Physician | Confirmed no gradual dose reduction attempt for psychotropic medications in past year |
| Unit Manager | Observed Resident #30 crying and explained typical behavior; demonstrated lack of documentation system for medication side effects and behaviors | |
| Administrator | Confirmed inability to provide evidence of documentation of medication side effects or behaviors for Residents #30, #13, and #100 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 25, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident care, including refusal of care, failure to follow and revise care plans, and failure to provide necessary behavioral health services for residents.
Findings
The facility failed to ensure that a resident was treated with dignity and respect related to refusal of care, failed to follow and revise care plans for a resident involved in a resident-to-resident altercation, and failed to assess and provide necessary mental health services for two residents. Staff continued to provide care despite resident resistance, care plans were not updated or followed, and required psychiatric services were not initiated.
Complaint Details
The visit was complaint-related, investigating issues including refusal of care, failure to follow care plans, and failure to provide behavioral health services. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to honor the resident's right to be treated with respect and dignity and to retain and use personal possessions, specifically related to refusal of care for Resident #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop the complete care plan within 7 days of the comprehensive assessment; and failed to prepare, review, and revise by a team of health professionals for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident receives necessary behavioral health care and services, specifically failure to assess and provide mental health services for Residents #1 and #2. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Date of survey completed: Sep 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident care issues and care plan deficiencies |
| Licensed Nurse Assistant | Licensed Nurse Assistant (LNA) | Interviewed regarding Resident #3's refusal of care and combative behavior |
| Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding Resident #1's supervision during altercation |
| Social Worker | Social Worker | Interviewed regarding psychiatric services for Resident #1 |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #1's supervision and behavior |
Inspection Report
Annual Inspection
Deficiencies: 8
Mar 2, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and quality of care at the Center for Living & Rehabilitation.
Findings
The facility was found deficient in multiple areas including confidentiality of medical records, failure to revise care plans for residents, improper medication administration, inadequate pressure ulcer care, inconsistent feeding tube management, incomplete binding arbitration agreement disclosures, and failure to notify residents and families about COVID-19 cases and mitigation efforts.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Potential for minimal harm: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to keep residents' personal and medical records private and confidential; electronic records left visible to the public. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans for residents with changing conditions and failed to conduct or notify residents/families of care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide medication (Buprenorphine) according to accepted clinical standards; resident not educated on proper sublingual administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers; wound care orders not followed and heels not properly offloaded. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure feeding tube administration consistent with physician orders, resulting in elevated blood sugar requiring additional insulin. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure binding arbitration agreement was explained in a manner residents or representatives understood; agreement lacked required disclosures about rescission rights and conditions of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Binding arbitration agreements did not provide for selection of a neutral arbitrator or a venue convenient for both parties. | Level of Harm - Potential for minimal harm |
| Failed to inform all residents, representatives, and families about confirmed COVID-19 infections and mitigation actions as required by facility policy. | Level of Harm - Potential for minimal harm |
Report Facts
Deficiencies cited: 8
Medication doses: 34
Medication doses: 10
Feeding volume: 1680
Blood glucose levels: 538
Blood glucose levels: 269
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 13, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to allow unrestricted visitation based on resident choices and failure to provide newly admitted residents with oral and written information about their rights and responsibilities.
Findings
The facility failed to ensure residents' rights to receive visitors in their rooms, restricting visits to common areas only without individualized consideration. Additionally, the facility did not provide oral explanations or obtain written acknowledgements of residents' rights and responsibilities for newly admitted residents.
Complaint Details
The complaint investigation found that the facility barred families from entering resident rooms and required visits to occur only in common areas, which was not based on individualized resident situations. The facility also failed to provide oral explanations and obtain written acknowledgements of residents' rights and responsibilities upon admission for the residents reviewed.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor residents' right to receive visitors of their choosing at the time of their choosing by restricting in-room visits and requiring visits in common areas only. | Level of Harm - Potential for minimal harm |
| Failed to provide newly admitted residents with oral information regarding their rights and responsibilities and failed to obtain written acknowledgement of receipt for 3 of 3 residents reviewed. | Level of Harm - Potential for minimal harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding visitation policy and admission packet procedures. |
| Director of Ancillary Services | Director of Ancillary Services | Interviewed regarding responsibility for providing admission packets and oral explanations. |
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