Breakwater Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockland, Maine.
- Location
- 100 Commons Drive, Rockland, Maine 04841
- CMS Provider Number
- 205124
- Inspections on file
- 23
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Breakwater Commons during CMS and state inspections, most recent first.
Surveyors observed that multiple rooms housing residents with Foley catheters lacked required signage and accessible PPE for Enhanced Barrier Precautions, as outlined by CDC guidance. Staff interviews revealed confusion about infection control protocols and a lack of awareness regarding which residents required contact precautions, resulting in a failure to follow established infection control policies.
A resident with a Foley catheter experienced pain and lack of urine flow, leading an LPN to change the catheter after an unsuccessful flush. The LPN did not verify the existence of a provider order for the as-needed catheter change, and nurse practitioners confirmed they were not notified or consulted prior to the intervention.
A resident with an indwelling urinary catheter did not have complete or accurate clinical records, including missing intake and output documentation on several scheduled dates, a delayed and improperly entered nursing progress note about catheter care, and a lack of documented provider order for a catheter insertion. These lapses were confirmed by facility staff and resulted in incomplete records.
The facility did not properly implement its QAPI program to ensure accurate and complete intake and output (I & O) documentation, resulting in ongoing incomplete records for residents requiring I & O tracking. This deficiency was confirmed by surveyors through record review and staff interview.
The facility did not provide required education on urinary catheter care and infection prevention to both its own and agency nursing staff after an incident. Despite preparing educational materials, no training or competency checks were conducted before the survey, and agency staff did not receive orientation or relevant education from the facility. Interviews confirmed that staff lacked training and understanding of key infection prevention practices.
The facility failed to provide residents and/or their representatives with written information about their rights to accept or refuse treatment and formulate an advance directive. This affected 11 out of 13 residents reviewed, as confirmed by the Quality Improvement Specialist.
The facility failed to conduct timely interdisciplinary team (IDT) meetings and document resident participation or invitations after Minimum Data Set (MDS) assessments for several residents. This deficiency affected residents with various medical conditions, including Parkinson's Disease and Chronic Respiratory Failure. Interviews with staff confirmed the lack of timely meetings and documentation, highlighting a systemic issue in the care planning process.
The facility failed to administer insulin timely relative to meal delivery for a diabetic resident, did not obtain necessary physician orders for side rail use for two residents at risk of falls, and lacked physician orders for medications kept at the bedside for two residents. These deficiencies were confirmed by facility staff during interviews.
The facility failed to maintain a sanitary environment for residents requiring respiratory care, with multiple instances of improper storage and maintenance of oxygen and nebulizer equipment. A resident's oxygen tubing was found on the floor, another's nebulizer equipment was unlabeled, and others had discrepancies in their treatment records. These issues were confirmed by the DON, indicating non-compliance with facility policies.
The facility failed to properly label and store medications, including an undated Tuberculin vial and unrefrigerated Acidophilus, leading to deficiencies in medication management. Expired medications were also found on medication carts, which were addressed by staff upon discovery.
The facility failed to properly label and date food items in storage areas and did not maintain a sanitary environment during meal service. Unlabeled and undated food items were found in various storage areas, and a Dietary Aide was observed handling food without proper hand hygiene. The aide had not received training on hand hygiene or safe food handling practices.
The facility did not ensure that CNAs completed the required 12 hours of annual in-service education training. A review of records for five CNAs, employed for over a year, showed they did not meet the 2024 training requirements. The Administrator confirmed these findings during an interview with surveyors.
The facility failed to maintain a sanitary environment on the East and South units, with observations of improperly stored commode buckets and bed pans in bathrooms. The Director of Nursing confirmed the improper storage during discussions with surveyors.
The facility failed to develop comprehensive care plans for residents with specific medical needs, including those with cardiac pacemakers, hospice care, respiratory needs, and psychotropic drug use. These deficiencies were confirmed through staff interviews and record reviews.
The facility did not complete an annual performance evaluation for a CNA employed for over a year. The CNA, hired in early 2021, lacked a 2024 evaluation, as confirmed by the President of Clinical Services and Quality Improvement.
The facility failed to provide evidence of required members' attendance at 3 out of 4 QAPI meetings. The Administrator could only produce an attendance sheet for one meeting, and the previous DON was assumed to be taking attendance. The Medical Director was absent from one meeting, and infection preventionists were not included in any meetings, leading to a deficiency in the QAPI program.
A facility failed to adhere to its Infection Control Program during the administration of subcutaneous insulin to a resident. A registered nurse did not perform hand hygiene or don gloves before administering Novolog Insulin, contrary to the facility's policy. The nurse acknowledged the oversight, and the incident was discussed with the President of Quality Improvement and Nursing Services.
A facility failed to follow its Immunization Policy for a resident, as there was no evidence that the resident's PCV 20 and Influenza immunizations were current, offered, or administered. The policy requires documentation of vaccine information receipt and understanding, as well as proof of vaccination, contraindication, or refusal. This deficiency was confirmed during an interview with the Quality Improvement Specialist.
The facility did not follow its Immunization Policy for a resident, as there was no documentation in the clinical record of the COVID vaccine being current, offered, or administered. The policy requires that residents receive the Vaccine Information Statement (VIS) and that their records reflect vaccination status, medical contraindications, or refusals. This deficiency was confirmed in an interview with the Quality Improvement Specialist.
A facility failed to notify a resident's representative of a significant decline in the resident's condition, resulting in the representative not being present at the time of death. Despite documented observations of the resident's difficulty swallowing and lethargy, there was no record of family notification until after the resident's passing. This deficiency was discussed with the facility's President of Quality Improvement and Nursing Services.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who began receiving hospice services. The assessment, required to ensure coordinated care, was completed 76 days late, as identified during a review and interview with the President of Quality Improvement and Nursing Services.
Two residents were not treated with dignity and respect in a facility. One resident, with severe cognitive impairment, was left on a bedpan for over an hour due to staff communication failure. Another resident was verbally abused by a CNA, who was overheard using derogatory language. The incidents involved agency staff and highlighted deficiencies in resident care.
The facility failed to adhere to professional standards for food service safety by delivering meals in an unsanitary manner. A CNA was seen carrying an uncovered plate of pot pie and dessert to a resident's room. The dietary aide confirmed that meals were typically delivered this way. When questioned, a CNA placed a cover over the next meal tray, and another CNA asked if all items should be covered, to which the surveyor confirmed they should be.
A facility failed to implement a baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including Diabetes Mellitus and chronic kidney disease. The care plan lacked necessary goals and interventions for diabetes and nutrition, despite active medication orders. The DON confirmed these omissions during a surveyor interview.
The facility failed to maintain a comfortable environment in the Memory Care unit, where a resident receiving hospice care was found in a very cold room due to the air conditioning being set to 68°F. This was a result of some CNAs turning on the AC at night to prevent residents from wandering. The issue was known to the DON and addressed in a meeting, but it was unclear if the practice had stopped.
The facility failed to update care plans and monitor residents for side effects of psychotropic medications. A resident with dementia was not monitored for medication side effects, and another resident's care plan lacked fall prevention measures. Additionally, a resident requiring incontinence care did not receive it as per the care plan. These deficiencies were confirmed by the DON during a survey.
The facility failed to implement its grievance policy, resulting in a 30-day delay in responding to a grievance filed on behalf of a resident. The grievance policies provided to the complainant were inconsistent, with one stating a 15-day response time and another indicating a reasonable time frame without specification. Interviews revealed that the responsibility for handling grievances had shifted from the Social Worker to the DON, who believed a 30-day response was reasonable, leading to the deficiency finding.
A resident with dementia and high fall risk was found on the floor with a head laceration after being left unattended in a Broda chair. The injury required hospital evaluation, but the facility failed to report it to the state as required.
A resident, who is a high fall risk and not cognitively intact, was found on the floor with a head laceration after being left unattended in a Broda chair. The resident required hospital transfer for evaluation and treatment. The facility did not investigate the injury, as confirmed by the Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with neurogenic bladder, who was not cognitively intact and dependent on staff for all ADLs. The care plan required frequent incontinence checks and changes, but records showed care was provided less frequently than needed. The DON confirmed the resident should have been toileted or changed more often than documented.
The facility failed to ensure a call bell was accessible to a visually impaired resident with left-sided hemiplegia and cognitive deficits. Despite staff awareness of the issue and the resident's attempts to keep the call bell within reach by wrapping the cord around their neck, no effective alternative solution was provided.
The facility failed to notify the State Agency after two falls that resulted in head injuries for two residents. One resident, who is not cognitively intact, was found on the floor with a brain bleed and was admitted to the emergency room. Another resident, who is nonverbal and dependent on all ADLs, fell from a lift during a transfer and sustained a head injury. The DNS confirmed that these incidents were not reported as she did not believe they were reportable.
The facility failed to thoroughly investigate two falls with head injuries involving two residents. Both residents' clinical records lacked evidence of incident reports, and staff interviews revealed inconsistencies and a lack of proper documentation. The DNS admitted that the facility did not thoroughly investigate the incidents.
The facility failed to update care plans for three residents, leading to deficiencies in fall management and psychotropic medication use. One resident experienced a brain bleed after a fall, another fell from a lift, and a third exhibited unsafe behavior with the call bell. Staff interviews confirmed that care plans were not updated to reflect the residents' current needs.
A resident exhibited symptoms of a hemorrhagic stroke, including left-sided weakness, slurred speech, and facial drooping, but the physician was not notified until approximately 9:00 a.m., despite symptoms being noted between 7:30 a.m. and 8:00 a.m. The resident was sent to the emergency department at 10:21 a.m., and the clinical record lacked timely documentation of notification to the physician and resident representative.
Failure to Implement Infection Control Precautions for Residents with Indwelling Catheters
Penalty
Summary
Surveyors found that the facility failed to implement and maintain an effective infection prevention and control program for residents with indwelling Foley catheters. Observations revealed that multiple resident rooms lacked required signage indicating the type of precautions and necessary PPE, as recommended by CDC guidance for Enhanced Barrier Precautions. In several cases, there was no PPE available outside the resident rooms, and signage was either missing, improperly placed, or not visible at the entrance. These deficiencies were confirmed by the Quality Improvement Specialist during the survey. Additionally, interviews with staff, including the Director of Nursing and Infection Preventionist, revealed a lack of awareness regarding the location of reference materials and the current status of residents on transmission-based precautions. Record review showed that residents with indwelling catheters, including those with active infections such as urinary tract infections caused by multidrug-resistant organisms, were not placed on appropriate contact precautions as required by facility policy and CDC guidelines. Staff interviews indicated that frontline caregivers were not informed about residents' precaution status, and there was confusion among leadership regarding the implementation of infection control protocols. These findings were based on direct observation, record review, and staff interviews, demonstrating a failure to follow established infection control policies for residents at risk of transmitting infectious diseases.
Foley Catheter Changed Without Provider Order
Penalty
Summary
A deficiency occurred when a resident with a history of benign prostatic hyperplasia, urinary retention, urinary tract infection, and an indwelling Foley catheter experienced pain and lack of urine flow from the catheter. Nursing documentation indicated that the nurse attempted to flush the catheter without relief and subsequently changed the Foley catheter, noting the resident's pain was relieved and urine output was restored. However, there was no evidence in the clinical record of a provider order authorizing this as-needed catheter change. Interviews with nurse practitioners confirmed they were not aware of the catheter change at the time and had not provided an order for it. The LPN involved stated she used a PRN order to change the catheter but did not verify the existence of such an order prior to the intervention.
Incomplete and Inaccurate Clinical Record Documentation for Catheterized Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident with an indwelling urinary catheter were complete and accurate. Specifically, there were multiple instances where intake and output (I&O) documentation was missing from the Treatment Administration Records (TAR) on several scheduled dates, despite active physician orders requiring I&O to be recorded twice daily. The Regional Quality Improvement Specialist confirmed that I&O should be documented on the TAR by nursing staff, including information provided by CNAs, as the provider reviews the TAR for urinary output. Additionally, a nursing progress note regarding the resident's catheter care was entered several days after the event occurred, without being marked as a late entry. The note described the removal and reinsertion of a catheter due to the resident's complaint of urinary discomfort and lack of urine drainage, but was not documented until five days later. Furthermore, there was no evidence of a provider order for the catheter insertion on the date it was performed, although the nurse stated a verbal order had been received but not entered. These documentation lapses resulted in incomplete and inaccurate clinical records for the resident.
Failure to Implement QAPI for Accurate I & O Documentation
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, specifically regarding the documentation of intake and output (I & O) for residents. During a revisit survey, surveyors found that I & O documentation remained incomplete and inaccurate, despite previous corrective actions outlined in the POC. This deficiency was confirmed through record review and interview with the Regional Quality Improvement Specialist, indicating that the required processes for accurate I & O tracking and documentation were not consistently followed.
Failure to Implement and Maintain Effective Staff Training on Urinary Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff, specifically in the areas of urinary catheter care and infection prevention, following a facility-reported incident. Despite the facility's 5-day follow-up indicating that licensed staff would be educated on Foley catheter policies and procedures, interviews with staff and management revealed that no education had been provided prior to the survey. Educational materials were prepared and scheduled for future training, but staff, including those directly involved in the incident, confirmed they had not received any education or competency checks related to urinary catheter care. The Director of Nursing Services and the Educator both acknowledged that while resources were gathered, no directive was given to begin education, and the planned training had not been implemented. Additionally, the facility did not provide orientation or education on urinary catheter care and infection prevention to agency nursing staff, relying solely on competencies provided by the staffing agency. Review of agency staff records showed a lack of evidence for education on urinary catheter care. Interviews with agency LPNs confirmed they had not received any training from the facility on catheter care, transmission-based precautions, or enhanced barrier precautions. One LPN demonstrated a lack of understanding of enhanced barrier precautions, indicating gaps in knowledge and training among both facility and agency staff.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment, formulate an advance directive, or appoint a surrogate. This deficiency was identified for 11 out of 13 residents reviewed for advance directives. The facility's policy, dated 10/18, mandates that upon admission, residents should be informed and provided with information about advance directives. However, the review of the electronic medical records for these residents showed a lack of evidence that such information was offered or reviewed with them or their representatives. During an interview, the Quality Improvement Specialist confirmed that the residents and/or their representatives were not provided with the necessary written information concerning their rights to formulate an advance directive. This oversight affected multiple residents, including those identified as Resident #13, #79, #16, #84, #17, #83, #86, #54, #85, #37, and #33, indicating a systemic issue in the facility's admission process regarding advance directives.
Failure to Conduct Timely IDT Meetings and Document Resident Participation
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT) meeting, which included the participation of the resident and their representative, after each Minimum Data Set (MDS) 3.0 assessment for 10 of 26 residents. The facility's policy requires that a comprehensive person-centered care plan be developed within seven days after the completion of the comprehensive assessment. However, the records for several residents, including those with diagnoses such as Parkinson's Disease and Chronic Respiratory Failure, lacked evidence of timely IDT meetings or invitations to residents and their representatives. For instance, Resident #73, who is cognitively intact, was not invited to their IDT meeting, and Resident #79's record lacked evidence of an IDT meeting within seven days of their quarterly MDS assessment. Similarly, Resident #90 was unsure if an IDT meeting occurred, and the facility failed to document attendance or meeting details. Other residents, such as Resident #28 and Resident #51, also experienced delays in IDT meetings or lacked documentation of their participation or invitation. The facility's failure to hold timely IDT meetings and document resident participation or invitations was confirmed through interviews with staff, including the President of Quality Improvement and Nursing Services and the Social Worker. This deficiency affected residents with various medical conditions, including dementia and post-operative recovery, and highlighted a systemic issue in the facility's care planning process.
Deficiencies in Insulin Administration, Falls Management, and Medication Orders
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, particularly in the areas of nutrition and falls management. For one resident with diabetes, the facility did not administer rapid-acting insulin in a timely manner relative to meal delivery. The resident received insulin at 7:20 a.m., but did not receive their breakfast until 8:45 a.m., which is 1 hour and 25 minutes later. This delay in meal delivery after insulin administration was acknowledged by the Registered Nurse, who was unable to verify the exact time of insulin administration due to not recording it. In the area of falls management, the facility did not obtain necessary physician orders for the use of side rails for two residents at risk of falls. One resident with hemiplegia and dementia was observed with side rails in use, but their clinical record lacked evidence of a physician's order for the side rails, informed consent, and quarterly screenings. Similarly, another resident with dementia and a history of falls was observed with side rails, but their record also lacked a physician's order and informed consent for side rail use. Additionally, the facility failed to obtain physician orders for medications kept at the bedside for two residents. One resident had Flonase and Ocu Soft Lid Scrub at their bedside without a physician's order or a self-administration screen. Another resident had an Albuterol inhaler at their bedside, which they used as needed, but there was no physician order to keep the medication at the bedside or evidence of self-administration documentation. These findings were confirmed by facility staff during interviews.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for residents requiring respiratory care, as observed in multiple instances involving oxygen and nebulizer equipment. Resident #54's oxygen nasal cannula tubing was found on the floor with a date label indicating it had not been changed according to the physician's order. Similarly, Resident #70's nebulizer equipment was improperly stored and unlabeled. Resident #17's oxygen and nebulizer tubing were not changed or stored as per the care plan, with discrepancies noted in the treatment administration records. These observations were confirmed during a tour with the Director of Nursing. Resident #13's nebulizer equipment was stored without a barrier, risking cross-contamination, as confirmed by the Director of Nursing. Resident #42's oxygen tubing and antimicrobial bag were not changed weekly as required, with the tubing found on the floor and later improperly stored. The Director of Nursing acknowledged these findings during an interview. These deficiencies highlight a pattern of non-compliance with the facility's policies on respiratory care equipment maintenance and storage, potentially increasing the risk of infection transmission among residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to deficiencies in medication management. During an observation of the South unit nurse treatment cart, a vial of Tuberculin Purified Protein Derivative was found opened and undated, contrary to the manufacturer's instructions which required it to be stored between 36-46 degrees Fahrenheit and discarded after 30 days once opened. The Registered Nurse confirmed the vial was not labeled or stored correctly and disposed of it immediately. Further observations revealed additional issues with medication storage. On the South unit medication cart, an opened bottle of Acidophilus w/Pectin, which required refrigeration after opening, was improperly stored. Additionally, expired medications, including Famotidine 10mg and Loratadine 10mg, were found on the cart. The Certified Medication Technician removed these items upon discovery. Similarly, on another unit, an opened bottle of Acidophilus probiotic was found unrefrigerated, contrary to the manufacturer's instructions. These findings were discussed with the President of Quality Improvement and Nursing Services.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in various storage areas, including the stand-up freezer, dry storage room, and walk-in refrigerator. During a kitchen tour, surveyors observed several unlabeled and undated food items, such as a bag with an unknown brown crumbly substance, a bag of chocolate icing, and multiple bags of freezer-burned bananas. Additionally, the walk-in refrigerator contained undated and unlabeled items, including crumbled bacon, various vegetables, pork chops, a sandwich, and other unidentifiable substances. The Dietary Manager confirmed these findings during the survey. Furthermore, the facility did not maintain a sanitary environment during a dining observation. A Dietary Aide was observed handling food and utensils without proper hand hygiene, including drinking chocolate milk, discarding the cup, and then donning gloves without sanitizing hands. The Dietary Aide admitted to not receiving education on hand hygiene since starting employment. The facility's records showed that while the aide received the Infection Control/Exposure Control Plan, there was no evidence of training on hand hygiene or safe food handling practices. These findings were reviewed with the Quality Improvement Specialist and the Dietary Manager.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training. A review of employee education records for five randomly selected CNAs, all employed for more than one year, revealed that none had completed the necessary continuing education for the year 2024. The CNAs in question were hired between 1994 and 2021, and their records lacked evidence of compliance with the training requirements. During an interview, the Administrator confirmed these findings in the presence of four surveyors.
Improper Storage of Hygiene Equipment in Facility Bathrooms
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East and South units over a three-day survey period. On the East Unit, multiple observations revealed that shared bathrooms in several rooms had commode buckets and wash basins improperly stored on the floor. These observations were confirmed during a discussion between the surveyor and the Director of Nursing. On the South Unit, similar issues were noted, with uncovered bed pans improperly stored on shelves and shower shelves, sometimes containing briefs. The Director of Nursing confirmed during an interview with surveyors that the bed pans were not stored properly.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing specific medical needs. Resident #86 and Resident #83, both with cardiac pacemakers, lacked care plans addressing their cardiac conditions. Despite being followed by cardiology, Resident #86's medical record did not include a care plan for the pacemaker, a deficiency confirmed by the President of Quality Improvement and Nursing Services. Similarly, Resident #83's medical record also lacked a care plan for the pacemaker, as confirmed by the same official and the Quality Improvement Specialists. Additionally, Resident #243, who was admitted to hospice services, did not have a care plan for hospice or end-of-life care, a deficiency noted after the resident's passing. Residents #54 and #16, both receiving oxygen therapy for respiratory conditions, also lacked care plans for their oxygen usage. Furthermore, Resident #71, who was assessed for psychotropic drug use, did not have a comprehensive care plan addressing this area. These deficiencies were confirmed through interviews with various facility staff, including the Director of Nursing and the President of Quality Improvement and Nursing Services.
Failure to Conduct Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to conduct an annual performance evaluation for a Certified Nursing Assistant (CNA) who had been employed for more than one year. Specifically, CNA #4, who was hired on February 8, 2021, did not have a performance evaluation completed for the year 2024. This deficiency was confirmed during an interview with the President of Clinical Services and Quality Improvement, who acknowledged the absence of the required evaluation documentation for CNA #4.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to demonstrate compliance with the Quality Assurance and Performance Improvement (QAPI) requirements by not providing evidence of the required members' attendance at 3 out of 4 quarterly meetings. The Administrator, during an interview, could only provide an attendance sheet for one meeting, indicating a lack of documentation for the others. It was revealed that the previous Director of Nursing was responsible for preparing presentations and was assumed to be taking attendance, but this was not verified. Additionally, the Medical Director was absent from the third quarter meeting, and the infection preventionists were not included in any of the four quarterly meetings reviewed. This lack of documentation and attendance by key members led to the deficiency in the facility's QAPI program.
Infection Control Breach During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective Infection Control Program during the administration of subcutaneous injected medication for a resident. The facility's policy on Injectable Medication Administration, revised in January 2018, requires that hands be washed before putting on examination gloves and upon removal for the administration of injectable medications. During an observation, a registered nurse prepared Novolog Insulin for subcutaneous injection and entered the resident's room without performing hand hygiene or donning gloves. The nurse then cleansed the resident's right lower abdomen with an alcohol prep and administered the insulin. The nurse confirmed that he should have performed hand hygiene and donned gloves prior to the medication administration. This incident was discussed with the President of Quality Improvement and Nursing Services.
Failure to Implement Immunization Policy for Resident
Penalty
Summary
The facility failed to implement its Immunization Policy for a resident whose immunization records were reviewed. According to the policy, before offering vaccines such as Influenza, Pneumococcal, or COVID, each resident or their legal representative should receive a Vaccine Information Statement (VIS) from the CDC, and the resident's clinical record should document the receipt and understanding of this material. Additionally, the policy requires documentation of whether the resident received the vaccine, if it was contraindicated, or if the resident refused it. The policy also specifies that residents should be offered the Influenza vaccine annually between October 1 and March 31, and the Pneumococcal and COVID vaccines upon admission unless contraindicated or previously administered. In the case of the resident in question, the clinical record indicated that the resident was admitted to the facility, but there was no evidence that the resident's PCV 20 and Influenza immunizations were current, offered, or administered as per the facility's policy. This deficiency was confirmed during an interview with the Quality Improvement Specialist, highlighting a lapse in following the established immunization procedures for the resident.
Failure to Implement Immunization Policy for Resident
Penalty
Summary
The facility failed to adhere to its Immunization Policy for a resident whose immunization records were reviewed. According to the policy, before offering vaccines such as Influenza, Pneumococcal, or COVID, each resident or their legal representative must receive the appropriate Vaccine Information Statement (VIS) from the CDC, and the resident's clinical record should document the receipt and understanding of this material. Additionally, the record should show proof of vaccination, medical contraindication, or refusal. However, for one resident, there was no evidence in the clinical record that the COVID vaccine was current, offered, or administered as per the facility's policy. The deficiency was confirmed during an interview with the Quality Improvement Specialist, where it was noted that the resident's clinical record lacked documentation of the COVID immunization status. This oversight indicates a failure to implement the facility's policy regarding the offering and documentation of vaccines, which is crucial for maintaining the health and safety of residents in the facility.
Failure to Notify Family of Resident's Decline
Penalty
Summary
The facility failed to notify a medical provider and the resident's representative of a significant change in the medical condition of a resident who was under hospice care. The resident, identified as Resident #243, experienced a decline in their ability to swallow, which was documented in nursing notes over several days. Despite these observations, there was no documentation indicating that the resident's representative was informed of the resident's transition from a declining state to an active dying phase. This lack of communication resulted in the resident's representative expressing anger for not being given the opportunity to be present at the time of the resident's death. The nursing notes detailed the resident's condition, including difficulty swallowing and lethargy, and the administration of PRN morphine. Although the doctor was notified of the resident's dietary changes, there was no record of notifying the family about the significant decline. The resident ultimately passed away without family present, and the family was only informed postmortem. This deficiency was discussed with the President of Quality Improvement and Nursing Services, highlighting the lack of documentation and communication regarding the resident's decline.
Failure to Timely Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within the required 14-day period following a resident's enrollment in hospice care. According to the Resident Assessment Instrument (RAI) Manual, a SCSA is necessary when a terminally ill resident begins receiving hospice services to ensure a coordinated care plan between the hospice and the nursing home. In this case, a resident was admitted to hospice on June 19, 2024, but the SCSA was not completed until September 17, 2024, which was 76 days later than required. This oversight was identified during a record review and interview with the President of Quality Improvement and Nursing Services.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. In the first incident, a resident with severe cognitive impairment and dependent on staff for toileting was left on a bedpan for approximately one and a half hours. The resident's family member discovered the situation and reported it. The facility's internal investigation revealed that the staff failed to communicate effectively about the resident being placed on a bedpan, leading to the oversight. In the second incident, a licensed nurse overheard a CNA verbally abusing another resident by calling them derogatory names and accusing them of making up reasons to use the call light. The resident, who had multiple medical conditions including spinal stenosis and diabetes, did not recall the incident when interviewed. The CNA involved was employed by a travel staffing agency, and the facility was informed of the allegations.
Unsanitary Meal Delivery Observed
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety by delivering meals in an unsanitary manner. During the noon meal service on the East unit, a CNA was observed carrying a tray with an uncovered plate of pot pie and an uncovered dessert down a hallway to a resident's room. Upon returning to the serving line, the CNA mentioned that the resident wanted a salad instead. When questioned by the surveyor, the dietary aide confirmed that meals were always delivered on trays in this manner. Several CNAs were present at the serving line, and when asked if they knew the correct way to deliver trays, one CNA placed a cover over the next meal tray's plate. The CNA who had delivered the uncovered tray inquired if all items were supposed to be covered, to which the surveyor confirmed that food items should indeed be covered. The surveyor discussed the observation with the Administrator, who acknowledged the concerns regarding the delivery of uncovered meals down the hallways.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy mandates that a baseline care plan should be created based on the admission assessment, physician orders, and resident preferences to ensure a smooth transition of care. This care plan should include initial goals, physician orders, dietary orders, therapy services, social service needs, and PASRR recommendations. However, the care plan for the resident in question, who was admitted with multiple diagnoses including Diabetes Mellitus and chronic kidney disease, lacked goals and interventions specifically related to diabetes and nutrition. During a complaint investigation, it was found that the resident's active orders included medications for managing Type II Diabetes Mellitus and chronic kidney disease. Despite these orders, the baseline care plan did not reflect necessary goals and interventions for managing these conditions. The Director of Nursing confirmed the omission during an interview with surveyors, acknowledging that the care plan did not adequately address the resident's needs in the areas of diabetes and nutrition.
Failure to Maintain Comfortable Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents in the Memory Care unit, as evidenced by the complaint investigation. A resident, who was admitted with diagnoses including dementia, anxiety, depression, and was receiving hospice services, was found to be in a room that was very cold. The Memory Care Unit Manager observed that the air conditioning was set to 68°F, which was too cold for the resident. This issue was not isolated, as multiple rooms were found to have their air conditioning set to the same temperature. Further investigation revealed that some CNAs on the overnight shift were intentionally turning on the air conditioning to keep residents in bed and prevent wandering. This practice was confirmed by a staff member who reported that it had been happening multiple times, including as recently as a few days before the survey. The Director of Nursing was aware of the situation and had addressed it in a CNA meeting, but it was unclear if the practice had ceased.
Deficiencies in Care Plan Updates and Monitoring
Penalty
Summary
The facility failed to update and include necessary goals and interventions in the comprehensive care plans for several residents, leading to deficiencies in monitoring and care. Specifically, Resident #1, who has multiple diagnoses including dementia and is receiving hospice care, was prescribed several psychotropic medications. However, there was no documented evidence that the resident was being monitored for potential side effects of these medications, as required by the facility's Psychoactive Medication Use Policy. This lack of monitoring was confirmed by the Director of Nursing during an interview with surveyors. Similarly, Resident #2, also receiving hospice care, was not monitored for side effects of psychotropic medication use, and their care plan lacked goals and interventions related to fall prevention measures, such as the use of a fall mat and bed positioning. Additionally, Resident #3, who requires total assistance for incontinence care, was not receiving care as per the care plan, and there was no evidence of monitoring for side effects of psychotropic medications. These deficiencies were confirmed by the Director of Nursing upon review of the clinical records during the survey.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to establish and implement its grievance policy, as evidenced by the handling of a grievance filed on behalf of a resident. The complaint was received by the Department of Licensing, indicating that a grievance was filed on 7/25/24, but no response was received for 30 days. The complainant was provided with two different grievance policies, one stating a response would be received in 15 days and the other indicating a response would be given in a reasonable amount of time, without specifying what that time frame was. The facility's grievance policy dated 10/18 states that grievances should be resolved promptly, with a reasonable time frame agreed upon with involved parties. However, the Resident Admission Packet indicated a response should be given within 15 days. Interviews with facility staff revealed inconsistencies in the grievance process. The Social Worker, who was previously the Grievance Officer, stated that grievances should be responded to within 15 days, while the Director of Nursing (DON), who took over the responsibility, believed 30 days was a reasonable time frame. The DON confirmed receiving the grievance on 7/25/24 but did not file it until the following day due to needing additional information. This discrepancy in policy implementation and communication led to the delay in addressing the grievance, resulting in a deficiency finding during the complaint investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency after a resident, who was a high fall risk, was found on the floor with a head laceration. The incident occurred when the resident, who has dementia, anxiety, depression, and is receiving hospice services, was left unattended in a Broda chair. The resident was discovered face down on the floor with a laceration to the outer eye, requiring transfer to an acute care hospital for evaluation and treatment. The facility's Administrator confirmed during an interview that the injury was not reported to the state, as required.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to investigate an injury of unknown origin involving a resident who was found on the floor with a head laceration. The incident occurred when the resident, who is a high fall risk and not cognitively intact due to dementia, was left unattended in a Broda chair. The resident was discovered face down on the floor with a laceration to the head and right hand, necessitating transfer to an acute care hospital for evaluation and treatment. Despite the severity of the incident, the facility did not conduct an investigation into how the injury occurred, as confirmed by the Administrator during an interview with surveyors.
Incomplete Clinical Records for Incontinent Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for incontinent care. The resident, who was not cognitively intact and dependent on staff for all Activities of Daily Living (ADL), was admitted with a diagnosis of neurogenic bladder. The care plan indicated that the resident required total assistance for incontinence care, with checks and changes to be made at specific times throughout the day. However, the ADL Verification Worksheet showed that the resident received incontinent care less frequently than required, with records indicating care was provided only one to three times on various days in July. During a review of the clinical record, the Director of Nursing confirmed that the resident should have been toileted or changed at each meal time, first thing in the morning, before bed, and as needed, which was not reflected in the documentation.
Inaccessible Call Bell for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible to a resident with severe visual impairment and left-sided hemiplegia. The resident, who had a history of stroke and cognitive deficits, was observed unable to locate the call bell, which was affixed to the right-side rail behind the elevated mattress and out of reach. Despite the resident's attempts to keep the call bell accessible by wrapping the cord around their neck, staff repeatedly removed it for safety reasons but did not provide an effective alternative solution. Interviews with various staff members, including LPNs, CNAs, and the Facility Nurse Practitioner, confirmed that the resident frequently wrapped the call bell cord around their neck to ensure it was within reach. Staff were aware of the safety risks but had not found a suitable alternative that worked with the current call system. The Division for the Blind had been contacted for assistance, but the resident's daughter canceled the services, and no recommendations were implemented. The Unit Manager and Director of Nursing acknowledged the issue and confirmed that the call bell was not accessible when the resident was sitting up in bed. Despite being aware of the resident's needs and the potential safety hazards, the facility had not made adequate accommodations to ensure the call bell was within the resident's reach at all times. The Social Worker suggested that hand bells might be a viable alternative, but no action had been taken to implement this solution.
Failure to Report Falls Resulting in Head Injuries
Penalty
Summary
The facility failed to notify the State Agency after two falls that resulted in head injuries for two residents. Resident 1, who has a history of falls and requires substantial assistance with Activities of Daily Living (ADLs), was found on the floor in their room after an unwitnessed fall. The resident, who is not cognitively intact, was covered in blood and had a brain bleed, leading to their admission to the emergency room and subsequent transfer to Maine Health. Despite the severity of the incident, the facility did not report the event to the State Agency as required. Similarly, Resident 2, who is nonverbal, dependent on all ADLs, and receiving hospice care for end-of-life, fell from a lift during a transfer. The resident sustained a head injury with visible bleeding. The Director of Nursing (DNS) confirmed during an interview that the facility did not report this incident either, as she did not believe it was reportable. Both incidents highlight a failure in the facility's protocol for reporting significant injuries to the appropriate authorities.
Failure to Investigate Falls with Head Injuries
Penalty
Summary
The facility failed to thoroughly investigate two falls with head injuries involving two residents. Resident 1, who has a history of falls and requires substantial assistance with ADLs, was found on the floor with a head injury and subsequently admitted to the hospital with a brain bleed. The clinical record for Resident 1 lacked evidence of an incident report for this fall. Similarly, Resident 2, who is dependent for all ADLs and has Alzheimer’s disease, fell from a Hoyer lift during a transfer, resulting in a head injury. The clinical record for Resident 2 also lacked evidence of an incident report for this fall. Interviews with staff revealed inconsistencies in the accounts of the incidents and a lack of proper documentation. The Director of Nursing (DNS) was unable to provide written documentation of the investigations and admitted that the facility did not thoroughly investigate the incidents. The Unit Manager, who was new to the role, indicated that it was her responsibility to ensure incident reports were completed but was unaware of the proper procedures. The facility's failure to document and thoroughly investigate these incidents is a clear deficiency in their handling of resident falls and injuries.
Failure to Update Care Plans for Falls and Psychotropic Medication Use
Penalty
Summary
The facility failed to update and implement care plans for three residents, leading to deficiencies in fall management and psychotropic medication use. Resident 1, who had diagnoses including dementia, left-sided hemiplegia, and seizure disorder, experienced an unwitnessed fall resulting in a brain bleed. Despite new physician orders for various medications, Resident 1's care plan was not updated to reflect goals and interventions for the brain bleed, hemiparesis, vision, and chronic kidney disease. This lack of updates was confirmed by the Unit Manager and Director of Nursing (DNS) during interviews. Resident 2, diagnosed with Alzheimer's disease and depression, and receiving hospice care, fell from a lift during a transfer, resulting in a head injury. The care plan for Resident 2, which was last reviewed in March 2024, did not include updated goals and interventions following the fall, nor did it reflect the resident's current transfer and communication status. Interviews with staff confirmed that Resident 2 was nonverbal, dependent on a Hoyer lift for transfers, and unable to use a call bell, yet the care plan was not appropriately updated. Resident 3, with diagnoses including blindness and a history of stroke, had orders for psychotropic medications but continued to exhibit unsafe behavior with the call bell. Despite multiple incidents where Resident 3 wrapped the call bell cord around their neck, the care plan was not updated to address these behaviors and the use of psychotropic medications. Staff interviews revealed that this behavior was known to management, yet the care plan did not reflect the necessary interventions to ensure Resident 3's safety. The Unit Manager confirmed that care plans were not updated within the required timeframe to reflect the residents' current needs.
Failure to Notify Physician and Resident Representative of Significant Change
Penalty
Summary
The facility failed to notify the physician and the resident representative of significant changes in a resident's condition in a timely manner. The clinical record review and interviews revealed that the resident exhibited symptoms of a hemorrhagic stroke, including left-sided weakness, slurred speech, facial drooping, and confusion. These symptoms were first noted between 7:30 a.m. and 8:00 a.m., but the physician was not notified until approximately 9:00 a.m. The resident was eventually sent to the emergency department at 10:21 a.m., but the delay in notification and action was significant. Additionally, the clinical record lacked documentation that the physician and resident representative were notified of the significant change in the resident's condition in a timely manner. Interviews with staff members, including a registered nurse and a certified nurse aide, indicated that there were multiple observations of the resident's deteriorating condition. Despite these observations and concerns expressed by the CNA, the symptoms were initially attributed to low blood sugar, and the appropriate medical response was delayed. The emergency medical services documentation confirmed that the call for transfer to the emergency department was made at 10:21 a.m., with EMS arriving at 10:29 a.m. The surveyor discussed these findings with the facility, highlighting the failure to notify the physician and resident representative promptly.
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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