Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Senior Care Center - Brunswick during CMS and state inspections, most recent first.
Surveyors found that the dumpster area was not maintained in a sanitary condition, with garbage and litter on the ground, unsecured and damaged dumpster lids, and debris including used nitrile gloves and boxes scattered around. The Dietary Kitchen Manager confirmed the unsanitary conditions and was unaware of staff responsibilities regarding dumpster maintenance.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines for care delivery.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within acceptable limits as observed by surveyors.
Expired medications and biologicals were found on a medication cart and in two medication storage areas, including expired Allergy Relief, aspirin, and COVID-19 antigen rapid tests. Staff interviews revealed inconsistent checks for expired medications, with some LPNs and the central supply manager acknowledging lapses in their responsibilities. The DON and ADON confirmed that all nurses were expected to remove expired medications, but the deficiency occurred due to lack of consistent adherence to these procedures.
Two residents or their representatives did not receive timely refunds of their trust fund balances after discharge or death, as required by facility policy. Account statements and interviews confirmed that credit balances remained unpaid beyond the 30-day period, and the Administrator acknowledged the delay was due to staff not issuing refunds promptly.
A resident reported that his bed linens had not been changed for a month, which was confirmed by his tracking method and multiple observations. CNAs acknowledged that linens were not changed as often as required due to workload, and both the ADON and DON confirmed that the linens had not been changed as needed.
Four residents did not have appropriate care plan interventions developed or implemented for elopement risk, smoking, or dietary needs. Two residents with cognitive impairment and behavioral issues were not provided with timely elopement risk care plans despite documented incidents and high-risk assessments. Another resident, allowed to smoke under supervision, lacked a required smoking assessment and care plan. A resident with a mechanical soft diet order was served inappropriate food, resulting in a choking incident, despite the correct diet being documented in the care plan.
A resident with a history of coronary angioplasty and moderate cognitive impairment did not receive daily wound care as ordered by the physician. Staff changed the resident's right-hand dressing less frequently than prescribed, with one bandage remaining in place for several days. The LPN responsible was unaware of the daily order, and the Wound Care Nurse was on vacation, leading to a lapse in following the physician's instructions.
The facility did not complete required elopement and smoking risk assessments for two residents. One resident with dementia and a history of wandering was able to exit the building on multiple occasions without an elopement assessment or care plan being completed after the first incident. Another resident, identified as a smoker, did not have a smoking risk assessment or care plan in place prior to being observed smoking, despite being 'grandfathered in' for tobacco use. Staff interviews confirmed awareness of both residents' behaviors, but necessary assessments and documentation were not completed in a timely manner.
A resident with hemiplegia and dysphagia was served a hamburger patty instead of the required ground meat mechanical soft diet, leading to a choking incident. The error occurred when the resident received a meal tray intended for their roommate, and staff confirmed the meal did not meet the prescribed dietary needs.
Surveyors observed that personal care items such as bed pans, bath basins, and urinals were not bagged or labeled in several shared bathrooms, contrary to facility policy. Interviews with a CNA, ADON, and DON confirmed that these items should be cleaned, bagged, and labeled to prevent cross-contamination, but this was not consistently done.
Two shared rooms were found without privacy curtains, as required by facility policy to ensure visual privacy during care. Multiple observations confirmed the ongoing absence of curtains, and both a CNA and the DON acknowledged that all shared rooms should have privacy curtains for each bed.
A resident who was dependent on staff for mobility and required two-person assistance was being transferred from a chair to a bed using a Hoyer lift when the lift pad strap broke, causing a fall. Only one CNA was present during the transfer, and the wrong lift pad was used, resulting in the resident sustaining a skin tear and a right arm fracture.
The facility did not maintain adequate nursing staff to meet residents' needs for ADL assistance, as evidenced by multiple residents not receiving scheduled showers and staff reporting frequent short-staffing. Interviews with residents, CNAs, LPNs, and administrative staff confirmed that staffing shortages led to missed care, with some staff working alone and unable to provide required services.
Three residents with significant medical needs did not receive scheduled showers as required, with documentation and interviews confirming missed care. Staff and the DHS attributed the deficiency to ongoing CNA shortages, resulting in residents not being assisted with activities of daily living as scheduled.
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. A resident was sexually abused by another resident with a history of inappropriate behavior, and a CNA physically and verbally abused another resident. The facility's abuse prevention and reporting protocols were not effectively implemented, leading to an Immediate Jeopardy situation.
The facility failed to thoroughly investigate allegations of potential sexual abuse between two residents, lacking interviews with the victim, staff, or other residents. Documentation was insufficient, with only two sheets of paper, and no evidence of assessments, notifications, or psychiatric evaluations. Staff interviews revealed a lack of awareness and documentation, leading to an Immediate Jeopardy situation.
The facility failed to create care plans for three residents, leading to deficiencies in addressing abuse and elopement. A resident with severe cognitive impairment was sexually abused without a care plan in place. Another resident experienced verbal and physical abuse from a CNA, yet no care plan was developed. Additionally, a resident at moderate risk for elopement was found outside the facility without a care plan addressing safety precautions. The Administrator was unaware of these omissions, highlighting a lack of communication and oversight.
The facility administration failed to oversee an abuse prevention program, leading to a resident being sexually abused by another resident with a known history of aggressive behavior. The administration did not investigate or prevent further abuse, and care plans for affected residents were not developed. Staff interviews revealed a lack of awareness and communication regarding these issues.
An LPN administered her personal melatonin to two residents without a physician's order, resulting in lethargy. The facility's policies on medication administration and abuse prohibition were not followed, as the LPN did not verify the correct medication or have a physician's order. Staff observed the LPN with melatonin on the medication cart and witnessed her administering it to residents, despite the lack of documentation in the residents' eMAR.
The facility failed to prevent cross-contamination of linens and resident equipment, with clean and dirty linen carts placed side by side and a standup lift used without cleaning. Staff were unaware of proper infection control practices despite recent training, and no related policy was provided during the survey.
A resident in the Memory Care Unit was found with unauthorized medication in their room, which belonged to another resident. The facility's policy requires that no residents in this unit self-administer medications, and staff confirmed that no such assessments had been made. The medication was discovered during an observation, and both the LPN and Administrator acknowledged the oversight, emphasizing the need for regular monitoring of residents' rooms for medications.
A facility failed to report an abuse incident involving a CNA and a resident to the State Agency within the required timeframe. The incident, which included physical and verbal abuse, was observed by two CNA students. Although the former DON stated the incident was reported to local law enforcement and the SA the day after it occurred, there is no evidence of notification to the SA until several days later, violating the facility's policy.
The facility failed to develop discharge plans for several residents, despite their participation in discharge planning. Residents with conditions such as cerebral palsy, dementia, and respiratory failure had no documented discharge care plans in their EMRs. Staff interviews revealed confusion about responsibility for completing these plans, with the administrator stating that nursing staff or a social worker should handle them.
A facility failed to provide a complete discharge summary for a resident discharged with a hip fracture and Stage 2 Pressure Ulcer. The discharge summary lacked a medication list and a post-discharge plan of care. Interviews with staff revealed that the RN Supervisor was unaware of the requirements for medication reconciliation and discharge summary completion. The MDS Coordinator confirmed the form was available in the EMR but not completed, and the Administrator stated that the nursing staff or social worker should have completed these tasks.
A resident with cerebral palsy and functional quadriplegia did not receive necessary passive range of motion (PROM) treatment for stiffness in the right hand, despite being referred to occupational therapy. The facility lacked a structured restorative program, and communication failures among staff led to the resident's decline not being addressed in meetings, resulting in a deficiency.
The facility failed to properly store respiratory equipment for two residents, leading to potential risks of respiratory complications. An AutoPap mask and a container of distilled water were not stored or labeled correctly, and nebulizer and Trilogy masks were left on a bedside dresser. Staff interviews revealed a lack of clarity and compliance with storage policies.
A resident was administered PRN Ativan beyond the 14-day limit without a stop date or documented rationale. Facility staff, including the DON and RN Supervisor, were unaware of the regulatory requirements for PRN psychotropic medications. Despite pharmacy recommendations, the necessary documentation and orders were not updated, leading to non-compliance with facility policy and regulations.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to maintain the dumpster area in a sanitary condition. During an initial tour, garbage and litter were found on the ground around the dumpsters, and three out of four dumpster lids were not secured and remained open. One dumpster lid was damaged, preventing it from closing properly and allowing trash to be exposed. Additional debris, including used nitrile exam gloves, boxes, and other litter, was found both around and behind the dumpsters. Interviews with the Dietary Kitchen Manager (DKM) confirmed the unsanitary conditions, including the unsecured lids and the presence of debris and litter. The DKM acknowledged that the lids should always be closed and that trash should not be left on the ground or behind the dumpsters. The DKM also stated he was unaware that maintaining the dumpster area was the kitchen staff's responsibility and was not previously aware of the condition of the dumpsters. Subsequent observation revealed no improvement in the dumpster area's condition.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices.
Expired Medications Found in Multiple Storage Areas
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were discarded prior to their expiration dates, as required by both professional standards and the facility's own policy. During observations, expired medications were found on one of nine medication carts (Harbor Side) and in two of six medication storage areas (Central Supply and Ocean Breeze). Specifically, a bottle of Allergy Relief with an expiration date of January 2025 was found on a medication cart, two bottles of aspirin with a June 2025 expiration date were found in central supply, and two boxes of COVID-19 antigen rapid tests with a use-by date of April 2025 were found in a medication room. Staff interviews revealed that nurses and aides did not consistently check for expired medications, especially when working outside their usual assignments or after returning from days off. Some staff acknowledged that checking for expired medications was their responsibility but admitted to oversights. Further interviews indicated that the central supply manager was responsible for auditing and rotating stock in the supply closet, but was unsure if expired items were returned to her area by nursing staff. The Director of Nursing and Assistant Director of Nursing confirmed that all nurses were expected to dispose of expired medications immediately and that the pharmacy conducted monthly checks. However, the presence of expired medications in multiple locations demonstrated that these procedures were not consistently followed, leading to the deficiency.
Failure to Timely Refund Resident Trust Fund Balances After Discharge or Death
Penalty
Summary
The facility failed to ensure that residents or their representatives received a final refund of trust fund balances within 30 days of discharge or expiration, as required by facility policy. Specifically, two out of three resident accounts reviewed showed that the refunds were not issued in a timely manner. One resident, who had expired, had a credit balance of $25.01 that was not refunded to the representative within the required timeframe. Another resident, who was discharged, had a credit balance of $57.66 that was also not refunded promptly. Interviews with the residents' representatives confirmed that they had not received the funds and had experienced delays and difficulties in obtaining the refunds. The deficiency was further substantiated by interviews with the facility Administrator, who acknowledged that the financial services staff responsible for issuing refunds had been terminated due to failure to return funds to residents or their representatives in a timely manner. The Administrator confirmed the outstanding balances owed to both residents' representatives and indicated that the issue was known to facility leadership. The review of facility policy and resident account statements supported the finding that the required refunds were not processed within the specified 30-day period.
Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified in one resident room on the 200 hall where clean bed linens were not provided for an extended period. The resident in the affected room reported that his sheets had not been changed in a month and demonstrated to the surveyor that he had placed his initials on the underside of the sheet to track changes. Observations over three consecutive days confirmed the presence of the resident's initials, indicating the sheets had not been changed during that time. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that bed linens were not being changed as often as required, stating that linens should be changed on bath days or as needed, but that workload prevented them from completing this task. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that CNAs were responsible for changing linens and agreed that the resident's sheets had not been changed as required, with the DON stating that the situation was unacceptable.
Failure to Develop and Implement Comprehensive Care Plans for Elopement, Smoking, and Diet Orders
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for four residents, resulting in deficiencies related to elopement risk, smoking, and dietary orders. For one resident with dementia and a history of behavioral disturbances, there were multiple documented incidents of attempted elopement, including leaving the facility grounds and packing belongings to go home. Despite these behaviors and a high-risk elopement assessment, an elopement risk care plan was not developed until after a significant incident occurred. Another resident with severe cognitive impairment was identified as high risk for elopement through an assessment, but no corresponding care plan was created to address this risk. A third resident, who was cognitively intact and identified as a tobacco user, was allowed to participate in supervised smoking breaks without a completed "Smoking Observation Form" or a care plan related to smoking. The required assessment and care plan were only completed after the deficiency was identified. Staff interviews confirmed that the resident was "grandfathered in" for smoking privileges, but the necessary documentation and planning were not in place prior to the surveyor's review. For a fourth resident with hemiplegia, dysphagia, and a physician-ordered mechanical soft diet, the care plan specified the correct diet, but staff failed to follow it, resulting in the resident being served a hamburger, which is not considered mechanical soft. This led to a choking incident. Staff interviews confirmed that the resident's dietary needs were documented in multiple locations, including the care plan, but the prescribed diet was not adhered to during meal service.
Failure to Follow Physician's Order for Daily Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for wound care treatment for one resident with a history of coronary angioplasty and moderate cognitive impairment. The physician's order specified that the resident's right-hand skin tear should be cleaned with wound cleaner, patted dry, and covered with calcium alginate and a dry dressing once daily. However, observations over several days revealed that the resident's bandage had not been changed daily as ordered, with one bandage remaining in place for multiple days. The resident reported that their dressing was changed every six days, and staff interviews confirmed that the dressing change schedule did not align with the physician's daily order. Further investigation revealed that the LPN responsible for the dressing change was unaware of the specific daily order and believed the dressing should be changed on Mondays, Wednesdays, and Fridays or as needed. The Wound Care Nurse, who typically managed these treatments, was on vacation, and the responsibility had shifted to unit nurses. The Direct Health Service confirmed that nurses are expected to follow physician orders for treatments in the absence of the Wound Care Nurse. The failure to administer wound care as prescribed resulted in noncompliance with the facility's medication administration policy and the physician's written orders.
Failure to Complete Elopement and Smoking Risk Assessments
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, specifically in the areas of elopement and smoking risk assessment. One resident with diagnoses including dementia, diabetes, and major depressive disorder exhibited repeated wandering and exit-seeking behaviors, including packing belongings and attempting to leave the facility. On two separate occasions, the resident was able to exit or attempt to exit the building, once following EMS out the front doors and another time through a propped-open smoking door. Despite these incidents and the resident's history of wandering, an elopement risk assessment was not completed after the first occurrence, and interventions were not implemented until after the second incident. Staff interviews confirmed that the resident regularly attempted to leave the building and that staff were aware of her behaviors. The LPN and housekeeper both described the resident's repeated efforts to exit, with the housekeeper discovering the resident outside the facility property during one incident. The administrator acknowledged that an elopement assessment and care plan should have been completed after the initial event but were not, and the nurse consultant confirmed that assessments should occur after such attempts or significant changes. In a separate case, another resident with a history of tobacco use and multiple medical conditions, including nicotine dependence, was identified as a smoker. However, the required smoking risk assessment and care plan were not completed until after the resident was observed smoking in the designated area. Staff interviews revealed that the resident was 'grandfathered in' to smoke at the facility, but the necessary documentation and assessment were missing from the electronic health record until after the deficiency was identified. The MDS coordinator confirmed that the assessment and care plan should have been in place but were not completed until after the oversight was discovered.
Failure to Provide Properly Prepared Mechanical Soft Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction was not provided with food prepared in accordance with their prescribed mechanical soft diet. The resident's medical records, care plan, and physician orders all indicated the need for a mechanically altered, therapeutic diet, specifically requiring ground meats. Despite these documented requirements, the resident was mistakenly served a hamburger patty, which does not meet the criteria for a mechanical soft diet, resulting in a choking incident. Staff interviews confirmed that the error occurred when the resident received their roommate's meal tray, which did not match the resident's dietary needs. The Registered Dietician clarified that mechanical soft meats are considered ground meats and that a hamburger patty is not appropriate for this diet. The Dietary Manager also confirmed the dietary error and observed the incorrect tray delivery. The incident highlights a failure in ensuring that food provided matched the resident's individualized dietary requirements as documented in their care plan and physician orders.
Improper Storage of Personal Care Items in Shared Bathrooms
Penalty
Summary
Staff failed to properly store resident personal care items in three of twelve shared bathrooms on the 200 Hall, as observed during multiple surveyor visits. Specifically, bed pans, bath basins, and urinals were found not bagged or labeled in bathrooms shared between rooms 216 and 218, 215 and 217, and 205 and 207. These observations were made on several occasions, indicating a pattern of non-compliance with the facility's policy on standard precautions, which requires that such items be handled in a manner that prevents contamination and cross-contamination. Interviews with a CNA, the ADON, and the DON confirmed that the expectation is for all urinals and bath basins to be cleaned, bagged, and labeled with the resident's name and room number. The DON acknowledged the presence of unbagged and unlabeled items in the shared bathrooms, confirming the failure to follow established infection prevention and control procedures as outlined in the facility's policy.
Failure to Provide Privacy Curtains in Shared Resident Rooms
Penalty
Summary
The facility failed to provide adequate visual privacy for residents in two shared rooms, specifically rooms 217 A and 218 B, as privacy curtains were missing in both locations. This deficiency was identified through multiple observations over several days, during which surveyors noted the continued absence of privacy curtains. Review of the facility's policy confirmed that full visual privacy during routine care and treatments is required by means of privacy curtains and closed doors. Interviews with a CNA and the DON confirmed that all shared rooms should have privacy curtains for each bed, and both acknowledged the lack of curtains in the identified rooms.
Resident Fall Due to Improper Hoyer Lift Transfer and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia, muscle weakness, and Alzheimer's disease, who was dependent on staff for all self-care and mobility and required two-person assistance for activities of daily living, was being transferred from a chair to a bed using a Hoyer lift. During the transfer, the lift pad strap broke, causing the resident to fall. The resident sustained a skin tear to the left lower arm and was subsequently found to have a nondisplaced transverse fracture of the mid-shaft of the right ulna after evaluation at the emergency department. Record review and staff interviews revealed that the transfer was not performed according to the resident's care requirements. The resident required two-person assistance, but at the time of the incident, only one CNA was present in the room during the transfer. The other CNA had left the room after helping attach the lift pad to the Hoyer lift, leaving the first CNA to complete the transfer alone. Additionally, the administrator confirmed that the wrong lift pad was used, and the seams of the pad broke during the transfer, directly leading to the resident's fall. Documentation from staff statements and the facility's investigation confirmed that the improper use of equipment and lack of adequate staff supervision during the transfer resulted in the accident. The incident was reported by multiple staff members, and the sequence of events was corroborated by written and verbal statements, as well as the facility's internal investigation records.
Insufficient Staffing Resulting in Missed ADL Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically in assisting with activities of daily living (ADLs) such as scheduled showers. Multiple residents with intact cognition reported not receiving showers as scheduled, with some only receiving a few showers over several weeks due to lack of staff. Staff interviews confirmed that the facility was frequently short-staffed, with CNAs sometimes working alone and unable to provide showers or get residents up for therapy as required. The facility assessment indicated a required minimum of 3.48 hours per resident day (HPRD) of total nurse staffing, including specific requirements for RN and CNA hours, but these standards were not consistently met. Further interviews with nursing and administrative staff corroborated the ongoing staffing shortages, with reports of residents missing scheduled showers and therapy sessions due to insufficient staff coverage. The Director of Health Services and other staff acknowledged complaints from residents and families regarding missed showers and confirmed that staffing levels were inadequate. The facility had to close a wing due to lack of staff, and staff members, including the DHS, were required to perform direct care duties to compensate for shortages. These findings demonstrate a pattern of insufficient staffing that affected the delivery of essential care services to all residents.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers to three residents who required assistance with activities of daily living. One resident, admitted with multiple diagnoses including paroxysmal atrial fibrillation, COPD, Parkinsonism, and muscle weakness, reported receiving only three showers during a 20-day stay, while records showed four showers in that period. Another resident with a history of cerebral infarction, hemiplegia, and osteoarthritis stated that he last received a shower five days prior to the interview, despite being scheduled for showers three times a week. A third resident, with chronic respiratory failure, COPD, and a traumatic amputation, also reported not receiving scheduled showers, attributing the missed care to staff shortages. Staff interviews confirmed that the facility was consistently short-staffed, making it difficult to provide showers as scheduled. Certified Nursing Assistants reported being unable to give showers when they were the only CNA on the floor or when there were not enough staff members. The Director of Health Services acknowledged the staffing issues and confirmed that residents were not receiving showers as scheduled, and that complaints had been received from both residents and families regarding this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. One resident, identified as R84, was sexually abused by another resident, R41, who had a history of inappropriate sexual behavior. Despite this history, R41 was not adequately monitored or managed, leading to an incident where R41 was found rubbing R84's genitals, legs, and feet. The staff intervened and moved R84 to another room, but the incident was not properly documented or reported to the necessary authorities, including psychiatric services, for further evaluation and intervention. Another incident involved a Certified Nursing Assistant (CNA) identified as AA, who physically and verbally abused a resident, R14. The CNA was witnessed hitting R14 on the arm and using inappropriate language to get the resident out of bed. Despite being witnessed by other staff members, the incident was not immediately reported to the Director of Nursing or law enforcement, and the CNA received only a written reprimand. This lack of immediate and appropriate response highlights a failure in the facility's abuse prevention and reporting protocols. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the delayed response to these incidents and the lack of proper documentation and follow-up. Interviews with staff revealed a lack of awareness and training on monitoring and reporting abuse, contributing to the ongoing risk to residents. The facility's failure to address these deficiencies promptly resulted in an Immediate Jeopardy situation, indicating a serious threat to resident safety.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of potential sexual abuse involving two residents, R84 and R41. The investigation lacked interviews with the victim, other staff, or residents who might have witnessed or been affected by the incident. The facility's policy on abuse prohibition mandates immediate reporting and investigation of such allegations, but there was no evidence of compliance with these procedures. The incident involved R41, who had a history of inappropriate sexual behavior, being observed in a compromising situation with R84, who had severe cognitive impairment. The documentation related to the incident was insufficient, consisting of only two sheets of paper, one of which was an undated, unsigned handwritten statement. There was no documented assessment of the residents involved at the time of the incident, nor were the physician or local police notified. Additionally, there was no evidence of psychiatric evaluations or written statements from witnesses. The facility's failure to follow its own procedures for investigating abuse allegations was evident in the lack of comprehensive documentation and follow-up actions. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness and documentation regarding the incident. The new Administrator, who had only been in the position for two weeks, was unable to locate any additional documents related to the incident. The Licensed Practical Nurse on duty at the time of the incident could not recall specific details or whether a statement was made. The Social Services worker was not informed to monitor the residents for any negative effects from the incident. This lack of thorough investigation and documentation highlights the facility's noncompliance with regulatory requirements, resulting in an Immediate Jeopardy situation.
Failure to Develop Care Plans for Abuse and Elopement
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to a deficiency in meeting the residents' needs. Resident R84, who had severe cognitive impairment and a history of unspecified dementia and psychosis, was sexually abused by another resident, R41. Despite the incident being documented, no care plan or interventions were put in place to address the abuse. The Social Services staff reported not being informed to develop a care plan for abuse or to monitor the resident for any negative effects from the incident. Resident R14, who had diagnoses including dementia and kidney failure, experienced verbal and physical abuse from a Certified Nursing Assistant. The abuse involved the CNA using profanity and hitting the resident. However, no care plan was created to address the abuse, and the Social Services staff indicated that the resident was not considered a target for abuse, which contributed to the lack of a care plan. Resident R115, with severe dementia and anxiety disorder, was assessed for moderate risk of wandering and elopement. Despite being placed in a secure unit, the resident eloped from the facility. The facility's records showed no care plan addressing elopement and safety precautions. The RN Supervisor found the resident outside the facility, and the Administrator was unaware of the missing care plans for both abuse and elopement, indicating a lack of communication and oversight in care planning.
Failure to Oversee Abuse Prevention Program
Penalty
Summary
The facility administration failed to effectively oversee an abuse prevention program, resulting in a situation where residents were not adequately protected from abuse. Specifically, the administration did not monitor, supervise, or address the sexually aggressive behavior of a resident with a known history of such behavior, leading to the sexual abuse of another resident. This incident caused psychosocial trauma to the victim. Additionally, the facility did not protect another resident from verbal abuse by staff. The administration also failed to investigate, correct, and prevent allegations of abuse between residents. A thorough investigation was not completed for a reportable incident involving sexual abuse, and there was no evidence that the previous administrator took necessary actions such as contacting medical professionals or updating care plans. This lack of action left the facility unable to address and mitigate the risks associated with resident-to-resident abuse. Furthermore, the facility did not develop and implement person-centered comprehensive care plans related to abuse for the affected residents. One resident did not have a care plan addressing the abuse they suffered, and another resident's care plan did not address identified elopement risks. Interviews with staff revealed a lack of awareness and communication regarding the need for these care plans, indicating a breakdown in the facility's processes for ensuring resident safety and care.
Unauthorized Administration of Melatonin to Residents
Penalty
Summary
The facility failed to ensure that two residents, R136 and R302, were given medication only with a physician's order. This deficiency was identified when an LPN administered her personal melatonin to these residents, resulting in them becoming lethargic. The facility's policies on medication administration and abuse prohibition were not adhered to, as the LPN did not verify the correct medication or have a physician's order before administering the melatonin. Resident R136, who had severe cognitive impairment and a history of dementia, major depressive disorder, and other conditions, did not have a physician's order for melatonin in their January 2024 records. Similarly, Resident R302, with moderate cognitive impairment and a history of dementia and other conditions, also lacked a physician's order for melatonin. Despite this, the LPN was witnessed administering melatonin to these residents, which was not documented in their electronic Medication Administration Records (eMAR). The incident was reported by staff who observed the LPN with melatonin on the medication cart and witnessed her administering it to residents. The LPN admitted to having melatonin on her cart, claiming it was for personal use, but denied using it on residents. However, staff interviews and video surveillance provided evidence that the LPN was administering melatonin without orders, leading to the residents' lethargy.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to adhere to infection control standard practices, leading to potential cross-contamination of linens and resident equipment. Observations on Hall OB revealed that a dirty linen cart and a clean linen cart were positioned side by side, and a CNA was seen transferring items between the two carts. Similar issues were noted on Turtle Dove Hall, where a clean linen cart was placed between trash barrels containing dirty items, and a bath shower bed was positioned next to a dirty linen barrel. Staff members, including a CNA and a housekeeping tech, were unaware of the need to separate clean and dirty items, despite having received training on infection control. Additionally, a standup lift on Turtle Cove Hall was observed with a buildup of a dark greyish substance, and it was used to transfer a resident without being cleaned. The Director of Nursing confirmed the issues with the lift and the positioning of the linen carts and trash barrels, acknowledging the risk of cross-contamination. The facility's Administrator also expressed concern over these findings, noting that infection control training had been provided to staff shortly before the surveyor's observations. However, no policy related to these concerns was provided during the survey.
Unauthorized Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident in the Memory Care Unit did not have unsecured unauthorized medications stored at the bedside. This deficiency was identified during an observation where a prescription bottle of Nyamyc, an antifungal powder, was found on the sink counter in the bathroom of a resident's room. The medication was labeled for another resident, indicating a lapse in medication management and security. The resident in question had a diagnosis of dementia with moderate cognitive impairment and was assessed for wandering behaviors, which further underscores the importance of secure medication storage. Licensed Practical Nurse (LPN) LLL confirmed that no residents in the Memory Care Unit had been assessed to self-administer medications, and acknowledged that the medication should not have been in the resident's room. The Director of Nursing (DON) and the facility Administrator both confirmed that nurses are expected to conduct rounds to monitor for medications in residents' rooms. The presence of the medication in the resident's room was unexplained, and it was acknowledged that the medication should not have been left out, highlighting a failure in the facility's medication management procedures.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) in a timely manner, as required by their policy. The policy mandates that the Abuse Coordinator or designee must notify the State Survey Agency immediately, but not longer than two hours after an allegation is made if it involves abuse or results in serious bodily injury. In this case, the incident involved a Certified Nursing Assistant (CNA) who was physically and verbally abusive to a resident. The incident was observed by two CNA students and involved the CNA hitting the resident on the arm and using profanity. The incident occurred on June 7, 2023, but was not reported to the SA until June 13, 2023, which is beyond the required reporting timeframe. The former Director of Nursing (DON) confirmed that the incident was reported to local law enforcement and the SA on June 8, 2023, but there is no evidence to support that the SA was notified before June 13, 2023. The Administrator also confirmed the late reporting of the incident. This delay in reporting is a violation of the facility's policy and the regulatory requirement to report such incidents promptly to the appropriate authorities.
Failure to Develop Discharge Plans for Residents
Penalty
Summary
The facility failed to develop a discharge plan of care for seven residents, as identified through record reviews, staff interviews, and facility policies. The facility's Discharge Planning Policy and Nursing Care Planning policy were not adhered to, resulting in the absence of documented discharge plans for residents R78, R81, R84, R98, R115, R104, and R454. These residents had participated in discharge planning and were expected to remain in the facility, yet no formal discharge care plans were documented in their Electronic Medical Records (EMR). The residents involved had various medical conditions, including cerebral palsy, dementia, respiratory failure, and hypertension, among others. Despite their participation in discharge planning, the facility did not document any discharge plans or care plans for these residents. For instance, R78, who has cerebral palsy and functional quadriplegia, was expected to remain in the facility, but no discharge plan was documented. Similarly, R454 was expected to discharge to a community facility, but the discharge care plan and summary were not completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of discharge care plans. Social Services staff acknowledged the omission of discharge care plans for the residents and expressed uncertainty about who was responsible for completing the discharge summary. The facility administrator indicated that the discharge summary and care plan should be completed by nursing staff or a social worker, but this was not done for the residents in question.
Incomplete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to provide a completed discharge summary with a recapitulation of the resident's stay for a discharged resident, identified as R454. The resident was admitted with a hip fracture and a Stage 2 Pressure Ulcer and was discharged on 10/13/2023. The discharge summary indicated that the resident was to be discharged home with medications, home health services, and follow-up appointments with healthcare providers. However, there was no evidence that a medication list was provided to the resident at discharge, nor was there a post-discharge plan of care developed. Interviews with facility staff, including the Financial Counselor, RN Supervisor, and MDS Coordinator, confirmed the omission of a complete discharge summary in the resident's records. The RN Supervisor, who discharged the resident, was unaware of the requirement to reconcile medications with the resident or family and did not complete the necessary discharge summary. The MDS Coordinator noted that the discharge form was accessible in the EMR system but was not completed. The facility Administrator confirmed that the nursing staff or social worker should have completed the discharge summary and post-discharge plan of care, with all medications signed off by the discharge nurse with the family.
Failure to Provide PROM Treatment for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate passive range of motion (PROM) treatment for a resident with limited range of motion in the right upper extremity, specifically the right hand. The resident, who was admitted with diagnoses including cerebral palsy and functional quadriplegia, was referred to skilled occupational therapy due to increased stiffness in the right hand. An occupational therapist evaluated the resident and recommended a wrist hand splint and PROM/AAROM exercises to address the stiffness. However, the facility did not ensure that these therapeutic interventions were consistently implemented, as the resident did not receive the necessary PROM treatment. Interviews with facility staff revealed a lack of a structured restorative program and inadequate communication regarding the resident's therapy needs. A CNA assigned to restorative services reported that her duties were primarily focused on ambulation and weighing residents, with limited involvement in providing range of motion exercises. The Director of Nursing expected that range of motion exercises would be performed during resident baths and positioning, but this was not consistently done. The OT Director was unaware of the closure of the restorative program and confirmed that therapeutic interventions could have prevented further contractures. The resident's decline in hand function was not addressed in the facility's morning meetings, indicating a breakdown in communication and follow-up care.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents receiving respiratory treatment. For one resident, the AutoPap mask was observed lying on the bedside dresser without being stored in a plastic bag as required by the facility's policy. Additionally, a container of distilled water used with the AutoPap machine was not labeled with an open date. Interviews with staff revealed a lack of clarity regarding responsibility for maintaining respiratory supplies, with a CNA indicating that nurses were responsible for the equipment. Another resident's nebulizer and Trilogy masks were also found not properly stored while not in use. The resident had a history of chronic respiratory failure and was non-compliant with using the Trilogy machine. Observations confirmed that the masks were left on the bedside dresser without being placed in a plastic bag. Interviews with staff, including a CNA and an LPN, revealed that the staff were aware of the storage requirements but failed to ensure compliance. The LPN admitted to not noticing the improper storage and acknowledged the potential risk of microbial contamination. The Director of Nursing confirmed that the expectation was for supplies to be properly stored and labeled, and that all nurses were responsible for ensuring compliance with these regulations. The failure to adhere to the facility's policies on storing respiratory equipment had the potential to increase the risk of respiratory complications for the residents involved.
Failure to Comply with PRN Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN psychotropic medications, specifically Ativan, for a resident identified as R111. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and a psychotic disorder, was readmitted to the facility from the hospital with a PRN order for Ativan. The order did not include a stop date, and the medication was administered multiple times beyond the 14-day limit without documented rationale or reassessment by a provider. Interviews with facility staff, including the LPN, DON, ADON, and RN Supervisor, revealed a lack of awareness and understanding of the regulations requiring PRN psychotropic medications to have a stop date and be reassessed for continued use. The DON and ADON admitted they were unaware of the need for a stop date or reassessment, and the RN Supervisor, who was new to the facility, was uncertain about the requirements. The pharmacy consultant had provided recommendations to address the PRN Ativan usage, but these were not acted upon, and the necessary documentation and orders were not updated in the resident's medical record. The deficiency was further compounded by communication lapses within the facility. The RN Supervisor received a signed recommendation from the physician to continue the PRN Ativan for 180 days but failed to document this in the progress notes or update the order with a stop date. The recommendation was placed on a clipboard in the DON's office and was not followed up due to the RN Supervisor's schedule and responsibilities. This oversight resulted in the continued administration of Ativan without proper documentation or justification, violating the facility's policy and regulatory requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brunswick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sears Manor Nursing Home | 0.7 mi | ★★★★★ | 0 | 0 |
| Gracemore Nursing And Rehab | 0.7 mi | ★★★★★ | 5 | 0 |
| Heritage Oaks | 5.9 mi | ★★★★★ | 1 | 0 |
| Marsh's Edge | 6.9 mi | ★★★★★ | 0 | 0 |
| Bayview Nursing Home | 30.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.