Augusta Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Maine.
- Location
- 188 Eastern Ave, Augusta, Maine 04330
- CMS Provider Number
- 205077
- Inspections on file
- 24
- Latest survey
- November 20, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Augusta Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
The facility failed to maintain a clean and safe environment in two units. Observations included rusty and dusty ceiling vents, dirty toilets and bathroom floors, stained caulking, and a resident's wheelchair with broken armrests. These issues were confirmed by the Administrator and Maintenance Director.
The facility failed to maintain kitchen cleanliness and proper food storage. Surveyors observed rust and dirt on the grease trap, a dusty baseboard heater register with food splatter, and a heavily soiled floor. Additionally, foods in the reach-in freezer and walk-in refrigerator were found unsealed, unlabeled, and undated. These issues were confirmed with the Head Cook.
The facility failed to provide timely incontinence care during meal service, causing distress to two residents. Despite a documented policy suggesting staff should not interrupt meal tray distribution for resident assistance, the facility's administration denied such a policy existed. A CNA confirmed that the practice was to complete meal tray distribution before attending to residents' needs, leading to delays in care.
A resident experienced a fall resulting in facial injuries and was found face down with a puddle of blood. After being transported to the hospital and returning with a negative CT scan but a nasal fracture, the facility failed to initiate neurological assessments. The DNS confirmed the oversight, and the PAC stated that assessments should have been conducted upon the resident's return.
A resident with COPD and CHF was not provided respiratory care according to physician orders. The resident's oxygen therapy was set at 3Lpm, exceeding the prescribed 1-2Lpm to maintain O2 saturation between 90-92%. The RN increased the flow rate after a nebulizer treatment when the resident's O2 sat was 85-86% but did not re-check it. The portable oxygen tank was also found empty. The facility lacked standing oxygen orders, and the physician was notified of the resident's condition.
The facility failed to date open medications and dispose of expired medications according to manufacturer specifications. On the [NAME] unit, a Trelegy Ellipta inhaler for a resident lacked an opened date, and on the Penobscot unit, a Fluticasone Salmeterol inhaler had an opened date on the box but not on the device. Surveyors confirmed these deficiencies with CNAs and an LPN.
A facility failed to maintain accurate clinical records for a resident who experienced a fall. A nurse's report indicated the resident fell forward and sustained a nosebleed, while the physician's notes described the fall as unwitnessed with no trauma. The Director of Nursing confirmed the discrepancies, and the nurse could not recall if neurological monitoring was started.
A resident with decreased fine motor coordination spilled hot chocolate on their lap, causing burns, after being served with a regular coffee cup instead of a recommended covered mug. Despite an OT evaluation recommending a spillproof cup, the resident was observed using an uncovered cup during a meal service.
Two residents experienced disrespectful interactions with CNAs, with one resident reporting deliberate actions to upset them and another overheard being spoken to impatiently. These incidents were not addressed by staff until brought to attention by surveyors.
The facility failed to maintain a sanitary and comfortable environment, with issues such as broken floor tiles, dirty caulking, and uncleanable surfaces observed across three units and a nurse's station. These deficiencies were confirmed by facility staff during a tour.
The facility failed to conduct PASRR Level II evaluations for two residents with mental health diagnoses whose stays extended beyond 30 days. Both residents were initially admitted under short-term convalescence criteria, but their stays transitioned to long-term without the necessary PASRR Level II evaluations being conducted, as confirmed by facility staff.
Two residents did not receive the necessary restorative services to maintain or improve their ambulation and active range of motion (AROM) as outlined in their care plans. One resident reported not receiving required exercises and ambulation assistance, leading to weakness, while another resident stated they no longer received walking assistance, affecting their ability to walk. Documentation confirmed the lack of provided services over the previous 30 days.
The facility failed to provide proper respiratory care for five residents, including unclean CPAP masks, lack of orders for oxygen tubing changes, and incorrect oxygen flow rates. A resident's CPAP mask was found on the floor and not cleaned, while another resident used an oxygen concentrator without proper maintenance. The facility lacked an oxygen policy, leading to inconsistent care.
The facility's kitchen was found to be unsanitary, with a soiled ceiling vent, food disposal unit, and dish machine, as well as a food mixer with dried particles. A kitchen worker lacked facial hair protection, and wet stacking of glasses was observed. These issues were confirmed by the Food Service Director.
A facility failed to provide a resident and their representative with a written notice for a hospital transfer, and also did not notify the Ombudsman. The transfer occurred without the required documentation, and the Director of Social Services, responsible for notifying the Ombudsman, was out sick. The Administrator confirmed the lack of notifications during an interview.
A facility failed to provide a written bed hold notice to a resident or their representative after a hospital transfer. The clinical record lacked evidence of the notice, and the Administrator confirmed its absence during an interview.
A facility failed to follow physician orders for sliding scale insulin administration for a resident. The resident's order specified to hold insulin if blood sugar was less than 150. Despite a documented blood sugar of 109, insulin was administered, as confirmed by a surveyor and the Regional Director of Clinical Operations.
The facility failed to provide adequate nutrition and hydration for two residents. One resident, with severe dementia and dysphagia, was not assisted with meals as required, and fluids were left unattended, risking aspiration. Another resident, also with dementia, was not regularly offered fluids, and beverages were not readily available, leading to insufficient hydration. Staff interviews confirmed these deficiencies in care.
The facility failed to follow physician's orders for a resident with Congestive Heart Failure, as there was no evidence of weekly weigh-ins on three specific dates. This was confirmed in an interview with the Administrator.
The facility failed to transport soiled linens in a sanitary manner on the [NAME] unit. A CNA was observed carrying unbagged soiled bed linens against her body in the corridor, which was confirmed by the CNA and the Director of Nursing. The facility's policy requires soiled linens to be placed directly into a soiled linen hamper or a plain plastic bag.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of its units, as observed during an environmental tour. In the [NAME] Unit, three hallway ceiling vents near resident rooms were found to be rusty and dusty. In one resident room, the toilet surface and area behind the seat were dirty with dried liquid residue, and the bathroom exhaust vent was dusty. The caulking around the bathroom door frame was dirty and stained, and a urine collection cup was found on the floor by the toilet. Another resident room had a dirty bathroom floor, a yellow/brown stain on a ceiling tile near the vent, and dirty caulking at the base of the room and bathroom door trim. A third resident room also had a dirty bathroom floor and stained caulking around the toilet base and door trim, with a dusty bathroom exhaust vent. In the Kennebec Unit, a resident's wheelchair had cracked and broken armrests, and the caulking around the toilet base was dirty and stained. The bathroom exhaust vent was also dusty. These findings were confirmed by the Administrator and the Maintenance Director during an interview with a surveyor.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour conducted by two surveyors. The grease trap had rust on its lid and base, and the caulking around the base was dirty and stained with a black substance. The baseboard heater register, located between the grease trap and a sink, was dusty and dirty, with dried liquid residue and food splatter. Additionally, the floor under the sink across from the steam table was heavily soiled with food debris and dried liquid residue. The facility also failed to ensure that foods were properly sealed, labeled, and dated. In the reach-in freezer, a box of cinnamon donuts and a box of waffles were found unsealed and open to the air. In the walk-in refrigerator, a metal tray containing custard-type pies was uncovered, unlabeled, and undated, and six cakes were also found unlabeled. These findings were confirmed in an interview with the Head Cook.
Failure to Provide Timely Incontinence Care During Meal Service
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by staff not responding promptly to requests for incontinence care during meal service. Two residents expressed concerns about having to wait for assistance, which caused anxiety and discomfort. One resident reported being told to wait to use a urinal, leading to distress about potentially wetting themselves. This situation was exacerbated by the perception of insufficient staffing, which residents believed contributed to the delays in receiving care. A review of the clinical records revealed a Health Status Note indicating that a policy was in place to not interrupt meal tray distribution for resident assistance, which was communicated to one of the residents multiple times. However, during an interview with the facility's Administrator and Regional Directors, it was clarified that no such policy existed. A Certified Nursing Assistant confirmed that while they were not explicitly told not to assist residents, the practice was to complete meal tray distribution before attending to residents' needs. This discrepancy between documented policy and actual practice contributed to the deficiency in resident care.
Failure to Conduct Neurological Assessments After Resident's Fall
Penalty
Summary
The facility failed to complete neurological assessments for a resident who experienced a fall with a major injury. The resident was found face down on the floor with facial injuries and a puddle of blood under their face. Emergency Medical Services (EMS) were called, and the resident was transported to the hospital where a CT scan was performed, revealing no immediate head bleed but a nasal fracture. The resident returned to the facility later that morning. Upon review, it was found that neurological assessments were not initiated upon the resident's return from the emergency room. During an interview, the Director of Nursing Services (DNS) confirmed that the assessments were not conducted. The Physician Assistant - Certified (PAC) stated that even with a negative CT scan, neurological assessments should have been completed if the resident returned to the facility within two days. This expectation was confirmed by the DNS during the interview with the surveyor.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care according to physician orders for a resident with chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). The resident had an active physician order for oxygen therapy at 1-2 liters per minute (Lpm) to maintain oxygen saturation (O2 sat) between 90-92%. However, during an observation, the resident was found with the oxygen flow rate set to 3Lpm, and the portable oxygen tank was empty. The registered nurse (RN) had increased the oxygen flow rate from 2Lpm to 3Lpm after administering a nebulizer treatment when the resident's O2 sat was measured at 85-86%, intending to re-check the O2 sat but got busy and did not follow up. The Regional Director of Clinical Operations (RDCO) and the Director of Nursing Services (DNS) confirmed that the facility did not have standing oxygen orders, and the physician was in the building, suggesting the RN may have intended to discuss the adjustment with the physician. The Assistant Director of Nursing Services (ADNS) and the RN later confirmed the findings and noted that the resident's oxygen saturation improved to 89%, which was usually the resident's baseline. The physician had been notified of the situation.
Failure to Properly Label and Dispose of Medications
Penalty
Summary
The facility failed to adequately date open medications and properly dispose of expired medications according to manufacturer specifications. During an observation on the [NAME] unit, a Trelegy Ellipta Inhalation Aerosol device for a resident was found without a date indicating when it was opened, despite the manufacturer's instructions to discard it 6 weeks after opening or when the counter reads '0'. Similarly, on the Penobscot unit, a Fluticasone Salmeterol inhalation device for another resident was observed with an opened date on the box but not on the device itself. The manufacturer's packaging instructed to discard the inhaler 1 month after opening the foil pouch or when the counter reads '0'. In both cases, surveyors confirmed the lack of proper labeling with the Certified Nurse Med Techs and an LPN, indicating a failure to ensure use and disposal according to manufacturer specifications.
Discrepancy in Fall Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a clinical record contained complete and accurate information for a resident reviewed for falls. On 9/29/24, a fall report completed by a registered nurse indicated that the resident fell forward towards the wall while transferring themselves, resulting in a nosebleed. The report noted that the physician, referred to as Third Eye, was notified shortly after the incident. However, the physician's documentation in the resident's progress notes described the fall differently, stating it was unwitnessed, with the resident found on their buttocks and no head strike or trauma reported. During an interview, the Director of Nursing Services confirmed the discrepancies between the nurse's fall report and the physician's documentation. Additionally, the nurse could not recall if neurological monitoring was initiated following the incident.
Failure to Provide Adaptive Equipment for Hot Liquids
Penalty
Summary
The facility failed to provide the proper adaptive equipment to a resident during a meal service, leading to an incident involving hot liquid spillage. On November 6, 2024, a resident spilled hot chocolate on their lap, resulting in burns that developed into blisters on both thighs. The resident had been evaluated by Occupational Therapy on November 12, 2024, with a recommendation to use a covered mug for hot liquids due to decreased fine motor coordination. However, on November 20, 2024, the resident was observed using a regular coffee cup without a cover during breakfast, despite the previous recommendation. This oversight was noted by a surveyor, who then informed the facility's Administrator and Regional Director of Clinical Operations, leading to the resident being provided with a cup with a cover.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of its residents, as evidenced by the interactions between staff and two residents. Resident #43 reported that a specific CNA, identified as CNA #4, was consistently rude and disrespectful. The resident described instances where CNA #4 would deliberately perform actions to upset them, such as opening window shades and turning on the roommate's television despite requests for quiet. This behavior was known to other staff members, yet it was not addressed until the surveyor's investigation. The acting Director of Nursing confirmed that Resident #43 had been vocal about these negative interactions, but no action had been taken prior to the survey. In another incident, Resident #33 was spoken to in a frustrated tone by CNA #3, who expressed impatience with the resident's requests. The CNA was overheard by the surveyor telling the resident to be patient and accusing them of being unfair. The resident, who was not feeling well, had requested reassurance and ginger ale, which was not promptly provided. The Social Worker who later attended to Resident #33 did not address the inappropriate interaction with the CNA. These incidents highlight a failure to uphold the residents' rights to dignity and respectful communication.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across three units and a nurse's station. During a facility tour, surveyors observed several deficiencies, including a nurse's station with ripped duct tape around the countertop, creating an uncleanable surface. In the Penobscot Unit, multiple resident rooms had broken or cracked floor tiles, dirty caulking around toilets, and a buildup of dirt at door entrances. Additionally, the utility room entrance floor had broken tiles, and one room had dried gray liquid residue spatter on the floor. In the [NAME] Unit, a resident's wheelchair had a ripped armrest, and the bathroom floor in one room was dirty. The Kennebec Unit had similar issues, with dirty bathroom floors and caulking, a hole in the wall near an outlet, and dried gray liquid residue spatter on room entrance doors. These findings were confirmed by the Administrator, Maintenance Director, Regional Housekeeping Manager, and other staff members during the tour.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that two residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred for a PASRR Level II evaluation. Resident #31 was admitted with diagnoses including Panic Disorder, Major Depressive Disorder with Severe Psychotic Symptoms, and Nightmare Disorder. Initially, a PASRR Level I determination indicated no further evaluation was needed due to a short-term convalescence admission. However, when Resident #31's stay transitioned to long-term, there was no evidence that the PASRR Level I was forwarded to the State Mental Health Authority for a Level II evaluation. Similarly, Resident #35 was admitted with Bipolar Disorder and Suicidal Ideations. The PASRR Level I determination also stated no further evaluation was required for a short-term stay. Despite the change to a long-term stay, the facility did not forward the PASRR Level I for a Level II evaluation. Interviews with the Director of Social Services and the Regional Director of Clinical Operations confirmed that neither resident received the necessary PASRR II evaluation after their stays exceeded 30 days.
Failure to Provide Restorative Services for Ambulation and AROM
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the residents' highest level of ambulation and active range of motion (AROM) for two residents. Resident #43 reported that they were not receiving the required exercises and ambulation assistance, which was making them weaker. The care plan for Resident #43 included ambulation with a two-wheeled walker and assistance, as well as participation in a daily exercise program to promote strength and activity tolerance. However, documentation revealed that Resident #43 did not receive the ambulation services as directed over the previous 30 days. Similarly, Resident #21 expressed that they were no longer receiving assistance with walking, which had affected their ability to walk. The care plan for Resident #21 included a daily walking program with a two-wheeled walker and participation in a daily exercise program with a therapy band to promote strength. However, the review of documentation indicated that Resident #21 did not receive the ambulation or range of motion services as outlined in their care plan. The surveyor confirmed these deficiencies during a review with the Regional Director of Clinical Operations.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for five residents. Observations revealed that Resident #43's CPAP nasal mask was repeatedly found on the floor and not cleaned by staff, despite physician orders requiring daily cleaning. The resident expressed concerns about congestion due to the unclean mask. Documentation inaccurately reflected the mask as either refused or worn, without proper cleaning. Additionally, Resident #23 was using an oxygen concentrator without orders for changing oxygen tubing or cleaning the concentrator filters, which was confirmed by the Regional Director of Clinical Operations (RDCO). Further deficiencies were noted with Resident #10, who had no evidence of care for their oxygen tubing and humidifier bottle, and Resident #19, who was observed using oxygen at a higher flow rate than prescribed. Resident #160's oxygen tubing was not dated or changed weekly, and there were no treatments for the care of their CPAP machine, despite being in the facility for nine days. The RDCO confirmed the absence of an oxygen policy, stating that respiratory equipment care was supposed to occur on Fridays, but this was not documented or followed.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour. The ceiling vent in the dish room was heavily soiled with dust, and the food disposal unit had dried food particles and liquid residue. Additionally, there was a significant buildup of chemical residue on top of the dish machine. The large standing food mixer was found with dried food particles on its bowl, protective cage, and base. Furthermore, a male kitchen worker was observed without facial hair protection over his mustache, and 20 clear tumblers were wet stacked on a tray after washing. These findings were confirmed by the Food Service Director during an interview.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a review of the clinical records, which showed that the resident was transferred to the hospital on February 22, 2024, without evidence of a written transfer/discharge notice being given. Additionally, the facility did not notify the Ombudsman of the transfer/discharge, as the Director of Social Services, who was responsible for this task, was out sick. During an interview, the Administrator confirmed the absence of the required notifications.
Failure to Provide Bed Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident and/or the resident's representative following a transfer to an acute care hospital. This deficiency was identified during a review of the clinical records for a resident who was transferred to the hospital on February 22, 2024. The clinical record did not contain evidence that a written bed hold notice was given to the resident or their representative. During an interview on May 30, 2024, the Administrator confirmed the absence of documentation for the bed hold notice.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for sliding scale insulin administration for a resident. The resident's clinical record included a physician order to administer Humalog 12 units of insulin, with instructions to hold the dose if the resident was not eating or if their blood sugar was less than 150. On October 22, 2023, the resident's morning blood sugar was documented as 109, yet the treatment administration record indicated that insulin was administered in the abdomen. This discrepancy was confirmed during a review of the resident's documentation by a surveyor and the Regional Director of Clinical Operations on May 30, 2024.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure proper nutrition and hydration for two residents, leading to deficiencies in their care. Resident #11, diagnosed with severe dementia and unspecified convulsions, was observed receiving meals that did not comply with the prescribed mechanical soft diet for dysphagia. The resident was left unsupervised with meals, contrary to the care plan that required extensive assistance and monitoring to prevent aspiration. Despite the care plan's instructions, Resident #11 was not assisted adequately during meals, and fluids were left unattended, posing a risk of aspiration. Resident #18, also diagnosed with dementia, was observed without access to fluids for extended periods. The resident's care plan included an order to encourage fluid intake, yet fluids were not made readily available between meals. Staff interviews revealed that Resident #18 was not regularly offered fluids, and the resident's inability to use the call bell system due to dementia further exacerbated the issue. The lack of consistent fluid availability and encouragement contributed to the failure to maintain sufficient hydration for Resident #18.
Failure to Follow Physician's Orders for Weekly Weighing
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with Congestive Heart Failure. The Physician Order Summary sheet indicated that the resident was to be weighed weekly. However, there was no evidence in the resident's clinical record to indicate that the resident was weighed on three specific dates. This finding was confirmed in an interview with the Administrator.
Improper Handling of Soiled Linens
Penalty
Summary
The facility failed to transport soiled linens in a sanitary manner on the [NAME] unit. A surveyor observed a Certified Nursing Assistant (CNA) carrying unbagged bed linens against her body in the corridor. During an interview, the CNA confirmed that the bed linens were soiled and acknowledged holding them close to her body. The facility's Handling Soiled Linen Policy & Procedure, dated 1/2020, instructs staff to place soiled linen directly into a soiled linen hamper or a plain plastic bag. This finding was confirmed in an interview with the Director of Nursing.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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