Brentwood Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Yarmouth, Maine.
- Location
- 370 Portland Street, Yarmouth, Maine 04096
- CMS Provider Number
- 205079
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Brentwood Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
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The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents.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.
A resident was admitted with a pressure-related skin issue on the left buttock, documented on the nursing admission evaluation and in early skilled notes as a pressure ulcer. Despite this, numerous subsequent daily skilled notes and a skin check documented the skin as intact or without issues. Later documentation identified the wound as a stage 3 pressure ulcer with full-thickness skin loss. The DON confirmed that the ulcer was present on admission, was never thoroughly assessed, was not reported to a physician, and was not appropriately cared for.
A resident was admitted with a documented pressure-related skin issue on the left buttock, and subsequent skilled notes confirmed the presence of a pressure ulcer requiring pressure ulcer care and rehab services. However, there is no indication that the physician was notified, that specific physician orders were obtained, or that an individualized interdisciplinary care plan was implemented for this existing pressure ulcer as required by facility policy. Later, a CNA reported concerns about a wound on the buttocks to the Wound Care Nurse, who stated this was the first time he became aware of the issue, and a new in-house–acquired Stage 3 pressure ulcer on the left sacrum was documented.
A resident had a physician’s order for JP (Jackson Pratt) drain monitoring every shift for prophylaxis, but the Treatment Administration Record for one month showed multiple missing entries where this monitoring was not documented as completed on evening and night shifts. Record review identified specific shifts with no documentation of the ordered JP drain checks, and the DON confirmed these omissions during an interview with surveyors.
The facility experienced repeat deficiencies when QAPI/QAA processes failed to prevent ongoing problems in wound care and clinical documentation. Previously cited issues with pressure ulcer management and incomplete or inaccurate wound care records recurred, including a resident admitted with a pressure ulcer without any MD orders for wound treatment and another resident whose record lacked complete and accurate wound care information. These findings showed that earlier corrective efforts did not resolve the underlying quality of care and record-keeping problems.
A resident was admitted with a documented pressure-related skin issue on the left buttock, identified on the NSG admission/readmission evaluation completed the day of admission. Despite this documented condition, the clinical record lacked a baseline care plan within 48 hours that included the instructions necessary to properly care for the skin issue. The DON confirmed to surveyors that there was no baseline care plan addressing this pressure-related problem.
Two residents requiring wound care did not have care plans developed to address their wounds, including the absence of documented goals and interventions. One had a chronic abscess with new antibiotic orders and wound packing, while the other had wounds on both feet, including an unstageable pressure ulcer. These deficiencies were confirmed by record review and staff interviews.
Two residents did not have documented physician orders for wound care interventions. One resident with a chronic thigh abscess returned from the ER with wound care instructions, but no wound care orders or documentation were present for nearly two weeks. Another resident with a malfunctioning NPWT device had their wound packed with VASHE-soaked gauze based on a reported verbal order, but no such order was documented in the medical record.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care, as the TAR lacked documentation of wound vac dressing changes and wound care on multiple occasions, despite physician orders specifying required care.
Two residents experienced deficiencies in medication administration and documentation. One RN delayed administering Miralax against physician orders, while another left medication unattended with a resident and documented a pain scale without asking the resident. These actions violated the facility's medication pass policy.
The facility failed to maintain accurate records for controlled substances, as staff did not consistently sign the Shift Count pages at shift changes. This issue was observed across multiple units, with instances of staff either failing to sign or pre-signing the narcotic books, contrary to facility policy. The deficiency was confirmed by staff and discussed with the DON.
Expired medications were found on the Sebago unit medication cart, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates. These were confirmed and removed by a nurse. Additionally, an unlocked and unattended medication cart was observed on the Eagle unit, with residents nearby. A surveyor intervened to alert a nurse about the unsecured cart. Both issues were discussed with the DON.
The facility's kitchen was found to be unsanitary, with undated and unlabeled meat, stained ceiling tiles, and dirty equipment, including an ice machine, food slicer, and mixer. These issues were confirmed by staff and the Administrator.
The facility was found to have several maintenance and cleanliness issues, including dust and debris on laundry dryers, a broken closet door hinge, a protruding cable outlet, stained ceilings, a red liquid stain on an air handling unit, and dead bugs on light covers. These deficiencies were confirmed by the facility's Administrator and other staff during a survey.
A facility failed to limit a PRN order for Lorazepam to 14 days, as required by regulations. A resident had a PRN order for Lorazepam 0.5 mg for anxiety, prescribed for 3 months without a 14-day limit or supporting documentation for the extended duration. This deficiency was identified during a surveyor's review and discussed with the Administrator.
A facility failed to accurately document the removal of a Lidocaine patch for a resident. A physician's order required the patch to be applied daily and removed nightly. However, a surveyor observed a nurse applying a new patch without removing the old one, which should have been removed the previous evening. This was confirmed by the nurse and discussed with the DON and Regional Director of Clinical Operations.
A registered nurse on the Eagle unit failed to perform hand hygiene between administering medications to multiple residents. The nurse handled medications for three residents consecutively without sanitizing her hands, citing the absence of hand sanitizer on the medication cart when questioned by a surveyor.
The facility failed to conduct annual performance evaluations for CNAs as required. Two CNAs, one hired in 2021 and another in 2009, did not receive their annual evaluations. The employee file for the CNA hired in 2021 showed an annual review signed only by the Division Head, with no employee signature, and lacked any annual review since hire. Both CNAs confirmed they had not received an annual review since being hired. This was confirmed with the Regional Director of Operations.
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 Accurately Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess, coordinate care with a physician, and document a resident’s pressure-related wound. A nursing admission/readmission evaluation completed on the day of admission in November 2025 identified a skin issue on the resident’s left buttock that was described as pressure related. Daily Skilled Note/Evaluation entries on 11/30/25 and 12/7/25 documented that the resident’s skin was not intact and that there was a pressure ulcer on the left buttock. However, multiple subsequent Daily Skilled Note/Evaluation entries dated between 12/2/25 and 1/1/25 stated that the resident’s skin was intact, and a skin check note on 1/5/26 at 11:02 a.m. documented that no skin issues were identified. On 1/5/25 at 2:06 p.m., a skin issue note documented that the resident had a stage 3 pressure ulcer/injury with full thickness skin loss. In an interview on 1/6/26, the Director of Nursing Services confirmed, in the presence of two surveyors, that the pressure ulcer had been present upon admission, was never thoroughly assessed, was not reported to a physician, and was not cared for appropriately.
Failure to Notify Physician and Care Plan for Existing Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician, obtain physician orders, and implement a care plan for a resident admitted with a pressure-related skin issue. On admission in November 2025, the Nursing Admission/Readmission Evaluation documented that the resident had a pressure-related skin issue on the left buttock. Subsequent Daily Skilled Notes/Evaluations dated 11/30/25 and 12/7/25 indicated that the resident was receiving daily skilled care for pressure ulcer care and rehab services, and that the skin was not intact with a pressure ulcer on the left buttock. Despite this, there is no documentation in the report that a physician was notified, that specific physician orders were obtained for this existing pressure ulcer, or that an individualized care plan addressing this pressure ulcer was implemented upon admission as required by facility policy. On 1/5/26, a wound care nursing note documented a new skin issue on the left sacrum, identified as a Stage 3 pressure ulcer with full-thickness skin loss that was acquired in-house. During an interview on 1/6/25, the Wound Care Nurse stated that a CNA first brought concerns about a wound on the resident’s buttocks to his attention on 1/5/26, and that this was the first time he had heard of this wound. The facility’s Pressure Injury Prevention Management Program policy requires that, based on the resident evaluation process, an individualized comprehensive care plan be implemented by the interdisciplinary team, including a preventive care plan upon admission and a care plan for any actual pressure injury identified on admission/readmission. The Director of Nursing Services confirmed the above information during an interview, supporting the finding that the facility did not follow its policy to ensure appropriate physician notification, orders, and care planning for the resident’s pressure ulcer present on admission.
Incomplete Documentation of JP Drain Monitoring in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with a physician’s order to monitor a Jackson Pratt (JP) drain every shift starting on 11/22/25. Review of the resident’s clinical record confirmed the standing order to monitor the JP drain each shift for prophylaxis. However, review of the Treatment Administration Record (TAR) for December showed missing documentation of the ordered JP drain monitoring on the 3 p.m. to 11 p.m. shift for 12/30/25, and on the 11 p.m. to 7 a.m. shifts for 12/1/25, 12/3/25, 12/10/25, 12/14/25, 12/15/25, 12/16/25, and 12/22/25. These gaps in the TAR indicate that the required monitoring was not documented as completed on multiple shifts. In an interview on 1/6/25 at 1:48 p.m. with the Director of Nursing Services and two surveyors present, the missing documentation findings were confirmed. The incomplete TAR entries for the JP drain monitoring demonstrate that the facility did not ensure the resident’s clinical record was complete and accurate in accordance with accepted professional standards, as required for safeguarding and maintaining resident-identifiable medical records.
Repeat Deficiencies in Wound Care Management and Clinical Record Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective quality assurance and performance improvement (QAPI/QAA) oversight of wound care and clinical record accuracy, resulting in repeat deficiencies. During a prior recertification survey, deficiencies were cited for quality of care related to wound care for two of three residents reviewed, and for incomplete and inaccurate clinical records for two of three residents reviewed for wound care. Despite having a written plan and a stated completion date, the facility’s quality assurance committee did not ensure that these issues were effectively corrected, as the same areas of noncompliance were identified again during a subsequent complaint survey. During the complaint survey, a resident was found to have had a pressure ulcer upon admission, with no physician orders for care and treatment of the wound documented in the clinical record, demonstrating a continued failure in quality of care for pressure ulcers. In addition, another resident’s clinical record lacked complete and accurate information related to wound care, showing that the facility did not maintain accurate, identifiable clinical records as previously cited. At the exit interview, the Administrator and DNS acknowledged that the facility’s prior plan of correction for these areas had not been effective, and that deficient practices persisted beyond the anticipated date of compliance.
Failure to Develop Baseline Care Plan for Resident With Pressure-Related Skin Issue
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included necessary instructions for wound care for one resident. The resident was admitted in November 2025, and the Nursing Admission/Readmission Evaluation completed on the day of admission documented a pressure-related skin issue on the left buttock. Despite this identified pressure-related skin issue, review of the resident’s medical record showed no evidence of a baseline care plan addressing this condition or providing the instructions needed to properly care for it. On 1/6/25 at 2:15 p.m., the Director of Nursing Services confirmed to surveyors that the above information was accurate. This deficiency centers on the absence of a required baseline care plan for a newly admitted resident with a documented pressure-related skin issue, as confirmed through record review and interview with facility leadership.
Failure to Develop Care Plans for Residents Requiring Wound Care
Penalty
Summary
The facility failed to develop and implement care plans for two residents who required wound care. One resident had a chronic abscess on the right lateral thigh, returned from the emergency room with new antibiotic orders for cellulitis, and required wound packing to remain in place for 48-72 hours. Despite these needs, there was no evidence of a care plan addressing the wound, including goals and interventions, as of the date reviewed. Another resident had a wound on the left foot and an unstageable pressure ulcer on the right foot, both requiring wound care, but similarly lacked a documented care plan with goals and interventions. These findings were confirmed through record review and interviews with the Director of Nursing and the Director of Clinical Operations.
Failure to Obtain and Document Physician Orders for Wound Care
Penalty
Summary
The facility failed to obtain and document physician orders for wound care for two residents with significant wounds. For one resident with a chronic right lateral thigh abscess, the clinical record showed that after returning from the emergency room with instructions for wound packing and antibiotics, there was no evidence of wound care orders or documentation of wound care provided from the date of return until nearly two weeks later. Nursing staff acknowledged having the ER discharge summary but were unable to locate it in the medical record, and could not provide documentation of wound care orders or provider instructions during this period, except for a single wound assessment. For another resident requiring negative pressure wound therapy (NPWT), a malfunction in the wound vac led to the wound being packed with VASHE-soaked gauze. Although nursing staff reported obtaining a verbal order from the provider for this alternative dressing, there was no documentation of such an order in the resident's medical record. These lapses resulted in the absence of required provider orders for wound care interventions as specified in the residents' care plans and clinical needs.
Incomplete Documentation of Wound Care in Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents who were receiving wound care. For one resident, the Treatment Administration Record (TAR) did not show evidence that wound vac dressings were changed as ordered on specific dates, despite physician orders specifying the frequency and timing of these changes. For another resident, the TAR lacked documentation that wound care for both the right heel and left foot was completed on several dates, even though there were clear orders for daily wound care and dressing changes. These deficiencies were identified through review of medical records and confirmed in discussion with the Director of Nursing and the Director of Clinical Operations.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of quality in medication administration for two residents. In the first instance, a registered nurse (RN) did not administer Miralax to a resident as per the physician's order, which specified that the medication should be given in the morning. The RN decided to delay the administration until the afternoon without the resident having refused the medication at the scheduled time. This deviation from the prescribed schedule was not based on the resident's immediate needs or preferences at the time of administration. In the second instance, another RN left a medication cup with a resident without observing the resident take the medication, which is against the facility's policy. Additionally, the RN documented a pain scale for the resident without first asking the resident about their pain level. The RN later corrected the documentation after realizing the error. These actions demonstrate a failure to follow the facility's medication pass policy and proper documentation procedures, potentially compromising the quality of care provided to the residents.
Failure to Maintain Accurate Controlled Substances Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, as evidenced by the lack of signatures from authorized personnel on the Shift Count pages of the Controlled Substances Book. This deficiency was observed across multiple units, including the Sebago Unit, Eagle Unit, Short Hall, Kitchen Hall, and Passport Unit, during the period from September 25, 2024, to December 3, 2024. The facility's policy requires that two licensed clinicians conduct a physical inventory of controlled medications at each shift change and document it on an audit record. However, the surveyor found that on several occasions, the licensed nursing staff either coming on duty or going off duty failed to sign the Shift Count page, indicating that the controlled substances count was not properly documented. Specific instances of non-compliance were noted, such as RN #2 and RN #1 failing to sign the shift count book upon accepting the narcotic keys, and LPN #1 pre-signing the nurse going off duty before the end of her shift. These actions were confirmed by the respective staff members during the surveyor's review. The Director of Nursing was informed of these concerns, highlighting a systemic issue in the facility's process for managing controlled substances, which could potentially lead to discrepancies in drug reconciliation.
Expired and Unsecured Medications Found in Facility
Penalty
Summary
The facility failed to remove expired medications from the supply available for use on the Sebago unit medication cart. During an observation, a registered nurse confirmed the presence of expired medications, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates of July, November, and October 2024, respectively. These expired medications were subsequently removed by the nurse. Additionally, on the Eagle unit, a medication cart was found unlocked and unattended in the hallway for approximately two minutes, with residents nearby. A surveyor intervened to alert a registered nurse about the unsecured cart. Both incidents were discussed with the Director of Nursing.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. On December 2, 2024, a surveyor noted two trays of meat in the walk-in refrigerator that were undated and unlabeled, along with seventeen ceiling tiles that were stained or dirty. A staff member, who has been with the facility for several years, confirmed that the ceiling had not been addressed during her tenure. On December 4, 2024, further observations revealed a moderate level of dirt on the inside lid of an ice machine in the Passport Unit kitchen, a small amount of dried debris on a food slicer, and a moderate amount of dried dirt and debris on a large mixer. These findings were confirmed with the Administrator.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several maintenance and cleanliness issues observed during a survey. On December 4, 2024, a surveyor noted a significant accumulation of dust and debris on top of all dryers in the laundry area, which was confirmed by the Director of Maintenance. Further environmental rounds with the Administrator, Director of Maintenance, and Director of Housekeeping revealed additional deficiencies: a closet door hinge in need of repair, a cable outlet protruding from the wall, stained ceilings in the Cafe Sun Room and entry, a red liquid stain on the air handling unit near the Nurses Station, four stained ceiling tiles in the Eagle Unit Dining Room, and dead bugs on light covers in the Sebago Unit hallway. These observations were confirmed with the Administrator.
Non-compliance with PRN Psychotropic Medication Order Limits
Penalty
Summary
The facility failed to ensure compliance with the regulation that limits as needed (PRN) psychotropic medication orders to 14 days. During a review of a resident's physician orders, a surveyor identified an order for Lorazepam, a psychotropic medication, prescribed at 0.5 mg by mouth every 24 hours as needed for anxiety. This order, dated November 18, 2024, was set for a duration of 3 months without a 14-day limit or stop date. Additionally, there was no provider documentation justifying the extension of the PRN order beyond the 14-day limit. This deficiency was noted during a surveyor's review on December 3, 2024, and discussed with the facility's Administrator.
Failure to Remove and Document Lidocaine Patch
Penalty
Summary
The facility failed to ensure accurate documentation of the Medication Administration Record (MAR) for a resident receiving a Lidocaine patch. A physician's order dated December 1, 2024, instructed nursing staff to apply a 5% Lidocaine patch to the affected area once daily for pain and to remove it nightly. However, on the morning of December 3, 2024, a surveyor observed a registered nurse administering a new Lidocaine patch to the resident's lower back without having removed the old patch from the previous day. The nurse confirmed that the old patch should have been removed the previous evening, indicating a lapse in following the physician's order and proper documentation in the MAR. This issue was discussed with the Director of Nursing and the Regional Director of Clinical Operations.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation on the Eagle unit, a registered nurse failed to perform proper hand hygiene between administering medications to multiple residents. The nurse prepared and administered medications to three residents consecutively without sanitizing her hands between each administration. This lapse in protocol was noted when the nurse discarded used medicine and drink cups and continued to handle medications for the next resident without using hand sanitizer. Upon intervention by the surveyor, the nurse acknowledged the oversight and mentioned the absence of hand sanitizer on the medication cart.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) at least every 12 months, as required. Specifically, two CNAs with employment durations exceeding one year did not receive their annual evaluations. CNA #1, hired on February 17, 2021, had an employee file that showed an annual review filled out and signed only by the Division Head, with no evidence of the employee's signature, and lacked any annual review since the date of hire. CNA #1 confirmed during a phone interview that they had not received an annual review since being hired. Similarly, CNA #2, hired on July 13, 2009, had no evidence of an annual review in their employee file since their date of hire. CNA #2 also confirmed in an interview that they had not received an annual review since being hired. This information was confirmed with the Regional Director of Operations.
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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