Cedar Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Skowhegan, Maine.
- Location
- 23 Cedar Ridge Drive, Skowhegan, Maine 04976
- CMS Provider Number
- 205060
- Inspections on file
- 19
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Ridge Center during CMS and state inspections, most recent first.
Multiple residents experienced significant delays in receiving assistance with ADLs, including toileting and changing, due to insufficient nursing staff. Residents reported waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions. Staff confirmed frequent short staffing, with some shifts covered by only one CNA and a nurse, leading to incomplete care and missed tasks such as baths and repositioning. Staffing schedules showed that minimum staffing requirements were not met for the majority of days reviewed.
A resident who transitioned from Medicare to private pay was not provided with consistent discharge planning or assistance with alternative placement, despite being assessed as appropriate for a lower level of care. The facility did not document an active discharge plan for several months, failed to communicate effectively with the POA, and staff threatened to contact APS when the POA attempted to arrange a transfer. Leadership acknowledged a lack of proactive discharge planning and indicated the resident would remain until funds were depleted, without evidence of equal access to services regardless of payor source.
The facility failed to develop and implement care plans for PTSD for three residents diagnosed with the condition. A resident admitted with PTSD lacked a documented care plan with goals, interventions, and triggers. Similarly, two other residents with PTSD diagnoses did not have care plans addressing their condition. The Market Clinical Advisor confirmed the absence of necessary components in the care plans for these residents.
The facility failed to maintain respiratory equipment in a sanitary manner, with observations of oxygen machines, nasal cannulas, and tubing improperly stored on the floor, on a wheelchair, and on a light fixture. An LPN and RN confirmed these items should be bagged and stored properly when not in use. Additionally, a resident was found sleeping on top of an unbagged nasal cannula, which should have been stored in a plastic bag.
The facility failed to maintain accurate records for controlled drugs and did not ensure proper documentation of shift counts across four units. Additionally, a resident requiring IV antibiotics did not receive the medication for three days due to supply issues, and the facility lacked an effective emergency pharmacy plan.
The facility failed to maintain a clean and sanitary kitchen, with food crumbs and debris found on various surfaces, and improperly stored food items in the refrigerator, freezer, and dry storage room. Additionally, the emergency food supply was stored alongside unsecured chemicals, posing a contamination risk. These issues were observed and reviewed with facility staff.
The facility failed to clearly communicate the terms of binding arbitration agreements to residents or their representatives. Several residents, including those who were cognitively intact, were unaware they had signed such agreements and did not receive education on their implications. The Admissions Director confirmed that arbitration agreements were embedded in admission documents and not thoroughly explained, with signatures applied automatically. Additionally, not all residents' records were checked for advanced directives before signing.
The facility failed to implement Enhanced Barrier Precautions for two residents with multi-drug resistant organisms, as required by their care plans. Signage indicating the need for precautions was missing, and staff were unaware of the necessary PPE. The Director of Nursing confirmed the signs had been removed, and the Senior Administrator cited guidance allowing discretion in precautions, leading to a deficiency in infection control practices.
The facility failed to provide sufficient staffing, particularly on weekends, leading to delayed assistance for residents with ADLs. A resident experienced incontinence after waiting 30 minutes for help, while another with PTSD was left in distress in the bathroom. A family member found a resident unattended with the call light on, and another resident was left wet all night due to a leaking catheter. These incidents highlight the facility's inability to meet residents' needs due to inadequate staffing.
The facility failed to maintain resident dignity by not serving all residents at the same table simultaneously during meal service. Observations and staff interviews revealed that meals were organized by room number, leading to staggered service times at tables. Despite resident concerns and discussions about changing the meal delivery order, no changes had been implemented.
A facility failed to update a care plan for a resident diagnosed with PTSD. Despite the diagnosis being made, the care plan lacked goals, interventions, or triggers for PTSD. This oversight was confirmed by the Market Clinical Advisor during an interview.
A facility failed to monitor a resident for behaviors and side effects of psychotropic medications, despite having active orders for anxiety and depression treatment. The resident's clinical record lacked documentation of necessary monitoring, which was confirmed by the Market Clinical Advisor during a review.
The facility did not properly label and dispose of insulin pens in the Scotch Pine House unit. An RN found an Aspart Insulin Flex Pen with an incorrect date and an undated Insulin Glargine-yfgn Solution Pen, both of which should have been discarded after 28 days according to manufacturer instructions.
A facility failed to notify a resident and their representative before changing the resident's room. A complaint was received, and during an interview, the resident and their family member confirmed they were not informed prior to the move. The clinical record lacked evidence of notification, and this was confirmed by the Market Clinical Advisor.
The facility failed to provide 8 residents with written information about their rights to accept or refuse treatment and to formulate an advance directive, as required by policy. The deficiency was confirmed by the Market Clinical Advisor, who noted the absence of documentation in the residents' medical records.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted with a Deep Tissue Injury. The care plan lacked necessary goals and interventions for wound management, as required by facility policy. This deficiency was confirmed by the interim DON during a review.
A facility failed to maintain complete and accurate clinical records for a resident with a Deep Tissue Injury on the coccyx. The resident's Wound Evaluations indicated treatments that lacked corresponding provider orders, contrary to facility policy. Interviews with staff confirmed the absence of required orders, highlighting a deficiency in record-keeping and adherence to wound management protocols.
A resident received excessive doses of Ativan within 7 hours, contrary to the expected practice of administering it every 8 hours. The facility failed to document behavioral symptoms or non-pharmacological interventions before administering the medication and did not monitor for adverse effects. The resident's representative noted the resident appeared sedated and incoherent.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician and the resident's representative immediately, as required by their Falls Management Policy. The fall was reported to the nurse late, and the representative only learned of the incident the next day from a CNA. The resident was in pain and was later found to have a fractured leg after being transported to the hospital.
A facility failed to implement a baseline care plan within 48 hours for a resident with multiple health conditions, including cardiovascular accident, hemiparesis, and neurogenic bladder. The care plan addressing immediate needs such as anticoagulant and antianxiety medication use, as well as other health concerns, was delayed by eight days. This deficiency was confirmed by the interim DON.
A resident experienced a fall due to the facility's failure to follow the care plan requiring a two-person assist transfer. A CNA attempted the transfer alone, resulting in the resident losing balance and falling. Additionally, the care plan inaccurately reflected the resident's advanced directive as Full Code, despite hospital records indicating a DNR status. The interim DON confirmed these deficiencies.
A facility failed to update a resident's care plan to reflect their current COVID-19 status and necessary precautions. Although the resident's medical record and room signage indicated confirmed infection and required PPE, the care plan was not revised accordingly. The DON confirmed this oversight during an interview.
The facility failed to provide a sanitary environment for respiratory care for two residents. A resident's nebulizer equipment was improperly stored and unlabeled, with no record of recent maintenance. Another resident's oxygen tubing was overdue for replacement, and the concentrator filter was dusty, contrary to facility policy. These issues were confirmed by staff.
A facility failed to accurately document the maintenance of oxygen equipment for a resident. Observations revealed outdated oxygen tubing and a dusty concentrator filter, despite records indicating recent maintenance. A nurse confirmed the tubing should be changed weekly, highlighting a discrepancy in documentation.
A facility failed to adhere to infection control protocols when two CNAs entered a resident's room under contact and airborne precautions without wearing the required PPE. Despite clear signage and available PPE, the CNAs mistakenly believed the resident was off precautions. This oversight was confirmed by an RN and discussed with the DON and Administrator.
A resident's bed rail was found broken and stuck in the up position, with the issue reported multiple times to nursing staff without resolution. Maintenance staff confirmed the malfunction but had no work order to address it. The deficiency was discussed with the Administrator.
A resident's dignity was compromised when their uncovered urine-filled Foley catheter bag was visible to passersby in the hallway and dining area. The resident expressed embarrassment and a desire for the bag to be covered. A surveyor observed this on one day, and a nurse confirmed the visibility of the bag.
A facility failed to assess and document a resident's ability to self-administer medication, as required by policy. The resident, with mild to moderately impaired cognition, was observed with eczema cream on their bedside table, despite an active order stating they may not self-administer medications. Interviews with staff confirmed the resident was given cream for self-administration without the necessary order, leading to a deficiency finding.
The facility failed to update and implement care plans for three residents, leading to deficiencies in monitoring their medical needs. A resident on Venlafaxine lacked side effect monitoring, another on Tacrolimus had no care plan goals for the medication, and a third with multiple diagnoses had no interventions for Furosemide use. These issues were confirmed by staff and discussed with the DON.
A facility failed to review and revise a care plan by the interdisciplinary team (IDT) for a resident after each assessment. The facility's policy requires a comprehensive care plan to be developed and reviewed by the IDT, including the resident and/or their representative, after each MDS assessment. However, the clinical record showed no care plan meeting was held following a quarterly MDS assessment, with the last documented IDT meeting occurring months earlier. This was confirmed by a Social Worker during an interview.
A facility failed to monitor and document behaviors for a resident on antipsychotic and antianxiety medications. The facility's policy requires behavior monitoring, but records lacked evidence of such monitoring. The DON stated that CNAs document behaviors and inform the charge nurse, but there was no regular documentation in the MAR/TAR, relying instead on staff trust.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, staffing schedule reviews, and direct observations. Residents reported excessive wait times for assistance with activities of daily living (ADLs), including toileting, changing, and ambulation. Several residents described waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions for extended periods. Staff confirmed that they were frequently short-staffed, with some shifts having only one CNA and a nurse covering the entire unit, leading to delays and incomplete care such as missed baths and repositioning. Staffing schedules reviewed showed that minimum staffing requirements were not met for 23 out of 31 days reviewed. Specific incidents included a resident being left on a bedpan for several hours overnight, ultimately having to remove it themselves, which resulted in a spill that was discovered by the nurse. Other residents reported being told by staff to limit their use of call bells due to short staffing, and some residents experienced a decline in mobility because staff were unable to assist with walking. Staff interviews corroborated these accounts, stating that care was not being provided in a timely manner and that residents were sometimes left in soiled beds. The deficiency was discussed with the Director of Nursing and the Administrator.
Failure to Ensure Equal Access and Discharge Planning Regardless of Payment Source
Penalty
Summary
The facility failed to ensure equal access to services and assistance with alternative placement for a resident whose payor source changed from Medicare Part A to private pay. The resident was admitted for skilled nursing services and, after Medicare coverage ended, continued to reside at the facility as a private pay resident. Assessments indicated that the resident no longer met the medical eligibility for nursing home level of care and was appropriate for a lower level of care, such as assisted living. Despite this, there was no active discharge plan documented in the clinical record for several months, and the facility did not provide evidence of consistent discharge planning or assistance with alternative placement. Documentation showed that the resident and their POA were informed about the need to move to a lower level of care, and a bed was available at an assisted living facility, but the resident refused to move. The resident's cognitive status declined over time, as indicated by BIMS scores, but the facility continued to allow the resident to remain without a documented discharge plan. The POA reported that the facility staff threatened to contact Adult Protective Services (APS) if attempts were made to move the resident, and staff confirmed that APS was contacted due to concerns about the resident's mental health and threats of self-harm during discussions about transfer. Interviews with facility leadership revealed a lack of communication with the POA regarding discharge planning and an absence of proactive steps to prepare for the resident's discharge, despite the resident being assessed as appropriate for a lower level of care months earlier. The facility indicated that if the resident's funds were depleted, they would be considered "days awaiting placement" pending Mainecare, and would need to accept an available assisted living facility within a certain distance. However, there was no evidence that the facility had actively assisted with alternative placement or ensured equal access to services regardless of payment source.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans addressing Post-Traumatic Stress Disorder (PTSD) for three residents diagnosed with PTSD. Resident #1, admitted with a diagnosis of PTSD, lacked a documented care plan that included goals, interventions, and triggers related to PTSD. Similarly, Resident #5, also diagnosed with PTSD, did not have a care plan addressing their condition. Resident #51's medical record indicated a diagnosis of PTSD, yet there was no evidence of a care plan for PTSD. During an interview, the Market Clinical Advisor confirmed that the current care plans for these residents did not include necessary components to address PTSD.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner, as observed over three days of the survey. On the Blue Spruce Unit, a portable oxygen machine, nasal cannula, and tubing were found on the floor next to the exit door, which was confirmed by both an LPN and an RN as inappropriate storage. Additionally, oxygen tubing and a nasal cannula were observed hanging on a wheelchair handle instead of being stored in a bag, as confirmed by the same LPN and RN. These items had not been used by a resident for 2 to 3 days, yet were not stored properly. Further observations revealed that Resident #474's nasal cannula tubing was draped over a light fixture above the bed, with the prongs in direct contact with the fixture. In another instance, Resident #31's nasal cannula was found unbagged at the head of the bed, with the oxygen concentrator's storage bag empty and dated from a previous day. During a follow-up, the nasal cannula was found tucked between the resident's sheets, and the resident was observed sleeping on top of it. An RN confirmed that nasal cannulas should be stored in a plastic bag when not in use, and that tubing and bags are changed weekly.
Deficiencies in Controlled Substance Documentation and IV Antibiotic Availability
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs and did not ensure that two authorized individuals signed the Shift Count page at the change of each shift. This deficiency was observed across four units: Hickory, Elm, Blue Spruce, and Scotch Pine. The review of the Controlled Substance Books and Shift Counts revealed multiple instances where the required signatures were missing, indicating that the controlled substances count was not properly documented on several dates. This lack of documentation was confirmed during an interview with the Director of Nursing. Additionally, the facility failed to provide adequate pharmaceutical services to meet the needs of a resident requiring intravenous antibiotics. The resident, who was admitted with acute osteomyelitis and other serious conditions, did not receive the prescribed IV antibiotic Aztreonam for three days due to the pharmacy's supply issues. The facility's Market Clinical Advisor was unaware of local pharmacies that could handle emergency orders, and the contracted emergency pharmacy did not provide IV medications. This resulted in the resident missing seven doses of the prescribed medication.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. Various issues were noted, including food crumbs and debris on surfaces such as the metal storage cart, double-door oven, stovetop burner plates, and metal food prep table. Additionally, the air conditioner unit and oscillating fans were covered in dust and debris, and the floors throughout the kitchen were littered with food crumbs and debris. The reach-in refrigerator contained unlabeled and undated sliced fruit, and the walk-in refrigerator had several items, including a container of beef-flavored base and a metal bowl of iceberg lettuce, that were either undated, unlabeled, or uncovered. The walk-in freezer and dry storage room also contained improperly stored food items, such as an open bag of potato wedges and a plastic bag of flour-like substance, both unlabeled and undated. Furthermore, the facility's emergency food supply was improperly stored in the Central Supply Room, alongside unsecured chemicals such as Ecolab Grease Strip Plus and Oasis Multi-Quat Sanitizer. This storage arrangement posed a risk of contamination, as the emergency food supply was placed on open shelving next to and directly across from shelves containing these chemicals. These findings were reviewed with the facility's Dietary Aide, Food Services Account Manager, Dietary District Manager, Administrator, and interim Director of Nursing Services.
Failure to Communicate Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives. This deficiency was identified for four out of five residents reviewed for arbitration agreements. During interviews, residents and their representatives expressed that they were unaware of signing arbitration agreements and did not receive any education on what these agreements entailed. For instance, Resident #35, who was cognitively intact, stated that their child signed the admission paperwork, and they were not informed about the arbitration agreement. Similarly, Resident #46 and Resident #57, both cognitively intact, were unaware of having signed such agreements and expressed that they would not have signed if they understood the implications. In the case of Resident #331, who had moderate cognitive impairment, the spouse believed they had signed the admission paperwork but did not recall any explanation of arbitration agreements. The resident's medical record indicated a BIMS score of 8, suggesting moderate cognitive impairment, yet the arbitration agreement was embedded within the admission document and signed by the resident. The spouse confirmed that Resident #331 was not cognitively intact at the time of signing and could not comprehend the agreement. The facility's Admissions Director confirmed that arbitration agreements were included within the admission agreements, which were completed on a tablet. However, the Director admitted to not explaining the arbitration agreements thoroughly, including the residents' right to revoke the agreement within 30 days. The process involved sending the admission agreement via email, where the signature was automatically applied throughout the document. The Director also acknowledged that not all residents' records were checked for advanced directives before signing, indicating a lack of due diligence in ensuring residents or their representatives understood the agreements they were entering into.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and staff awareness regarding Enhanced Barrier Precautions for two residents on the Elm House unit. Resident #327, who was admitted with a colonization of Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CRE), did not have the required signage indicating the need for Enhanced Barrier Precautions. A Registered Nurse initially stated that no special precautions were necessary, and a Certified Nursing Assistant (CNA) was unaware of the need for specific personal protective equipment (PPE) when caring for the resident. Similarly, Resident #331, who required Enhanced Barrier Precautions due to colonization with Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), and Extended Spectrum Beta-Lactamase (ESBL), also lacked appropriate signage. Interviews with the resident's spouse and two CNAs revealed that staff were not informed about the necessary precautions. The clinical records for both residents clearly indicated the need for Enhanced Barrier Precautions, which were not being followed as per the facility's policy. The facility's policy, revised in December 2024, required Enhanced Barrier Precautions for residents with multi-drug resistant organisms, yet these were not implemented effectively. The Director of Nursing acknowledged that the signs had been removed after being posted, and the Senior Administrator mentioned guidance from the Maine CDC allowing discretion in the use of Enhanced Barrier Precautions. However, the lack of consistent implementation and staff awareness led to the deficiency in infection control practices.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was confirmed by the facility's Administrator during an interview with a surveyor, where it was acknowledged that the facility did not have enough staff to meet resident needs on weekends. The Payroll Based Journal staffing report indicated low weekend staffing during the fourth quarter of 2024. This staffing shortage affected residents' ability to receive timely assistance with Activities of Daily Living (ADLs). Multiple residents and a family member reported incidents of delayed response to call bells and inadequate assistance. One resident had to wait 30 minutes after using the call bell, resulting in incontinence due to the lack of staff. Another resident, who requires a sit-to-stand lift for transfers, experienced extended wait times due to insufficient staff available to assist. A family member reported that a resident was left unattended with the call light on, and another resident with PTSD expressed distress over being left in the bathroom for 20 minutes. Additionally, a resident was left wet all night due to a leaking catheter, as no staff responded to the call bell. These incidents highlight the facility's failure to provide adequate staffing to meet the residents' needs effectively.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service by not serving all residents seated at the same table simultaneously. During a dining observation, it was noted that residents at a table were served at different times, with one resident receiving their meal significantly later than others at the same table. This practice was inconsistent with the facility's stated procedure of serving complete tables before moving on to other tables or room service. The issue was highlighted in Resident Council Meeting Minutes, where concerns were raised about the order of meal service. Staff interviews confirmed that meals are typically organized by room number, which affects the order of service in the dining room. Despite discussions about changing the meal delivery order to align with dining room seating, no changes had been implemented. The Director of Nursing acknowledged the issue had been brought to the Quality Assurance and Performance Improvement meeting, but no performance improvement process was in place at the time of the surveyor's exit.
Failure to Update Care Plan for PTSD
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident was admitted to the facility on December 23, 2021, and was diagnosed with PTSD on April 14, 2023. However, the clinical record review revealed that the care plan did not include goals, interventions, or triggers related to PTSD. This deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the care plan had not been updated to address the resident's PTSD needs.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to demonstrate evidence of behavior monitoring and monitoring for side effects of psychotropic medications for a resident diagnosed with anxiety and depression. The facility's policy on medication management requires evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, including adverse consequences of medications. However, the clinical record of the resident lacked evidence of a provider order or monitoring for behaviors and side effects related to the use of psychotropic medications. The resident was admitted with diagnoses of anxiety and depression and had active physician orders for several psychotropic medications, including Clonazepam, Mirtazapine, Escitalopram Oxalate, and Hydroxyzine HCl. Despite these orders, there was no documentation of behavior monitoring or monitoring for side effects in the resident's clinical record. This deficiency was confirmed during an interview with the Market Clinical Advisor, who reviewed the resident's entire clinical record and acknowledged the lack of necessary monitoring documentation.
Improper Labeling and Disposal of Insulin Pens
Penalty
Summary
The facility failed to comply with proper labeling and disposal protocols for biologicals in the Scotch Pine House unit. During an observation of the treatment cart with a Registered Nurse (RN), it was found that an opened Aspart Insulin Flex Pen was dated incorrectly, and an opened Insulin Glargine-yfgn Solution Pen was undated. Both insulin pens had manufacturer instructions indicating they should be discarded after 28 days of first use. The RN confirmed that the insulin pens were either expired or undated, indicating a lapse in adherence to manufacturer specifications for medication storage and disposal.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to appropriately notify a resident and their representative in a timely manner before changing the resident's room. A complaint was received by the Division of Licensing and Certification regarding a room change that occurred without proper notification. During an interview, a resident and their family member confirmed that they had not received any notification prior to the room change. A review of the resident's clinical record showed that the resident was moved from the Elm Unit to the Hickory Unit, but there was no evidence of any notification about the room change. This information was confirmed during an interview with the Market Clinical Advisor.
Failure to Provide Information on Advance Directives
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 and to formulate an advance directive. This deficiency was identified for 8 out of 16 residents reviewed for advanced directives. The facility's policy on Health Care Decision Making, revised on 1/8/24, mandates that residents be informed and provided with written information about their rights concerning medical treatment and advance directives. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the electronic medical records of the affected residents. The deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the residents' medical records lacked evidence of advance directives or documentation that the residents or their representatives had been offered assistance to formulate an advance directive. This oversight affected residents who were admitted on various dates, and there was no evidence that the facility approached these residents or their representatives to discuss or provide information about advance directives, as required by the facility's policy.
Failure to Implement Baseline Care Plan for Resident with Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a Deep Tissue Injury. According to the facility's policy, a baseline person-centered care plan must be created within 48 hours of admission, including necessary healthcare information such as initial goals, physician orders, and interventions. However, upon review, it was found that the care plan for the resident, who was admitted with a Deep Tissue Injury on the coccyx, did not include goals and interventions for wound management. This deficiency was confirmed by the interim Director of Nursing during a review of the resident's care plan.
Incomplete Clinical Records for Wound Treatment
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident with a wound. The resident was admitted with a diagnosis of Deep Tissue Injury on the coccyx. Upon review of the resident's Wound Evaluation dated 12/11/24, it was noted that the wound was present on admission, and the treatment included cleansing with soap and water, with no dressing applied. A subsequent Wound Evaluation on 12/18/24 indicated that the wound was deteriorating, and the treatment included a generic wound cleanser and a primary dressing of zinc oxide covered with optifoam. However, the clinical record for the resident lacked evidence of a provider order for the treatments indicated in the Wound Evaluations dated 12/11/24 and 12/18/24. Interviews with the RN and PA-C revealed that it was expected for a provider order to match the treatments listed in the resident's Wound Evaluation assessment. The interim DON confirmed that the resident's clinical record did not contain a provider order for the treatments documented, indicating a failure to adhere to the facility's policy on Skin Integrity and Wound Management.
Excessive Ativan Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering excessive doses of Ativan within a short period and not monitoring for psychotropic medication side effects. A resident, who was admitted with a history of cardiovascular accident, depression, and anxiety, was prescribed Ativan to be taken three times daily as needed. However, the resident received 3 mg of Ativan within 7 hours, with doses administered at 8:00 p.m., 10:27 p.m., and 3:00 a.m. the following day. The medical record lacked evidence of behavioral symptoms justifying the PRN doses and did not document any non-pharmacological interventions attempted before administering the medication. Additionally, there was no documentation of monitoring for potential adverse consequences of Ativan use. The resident's representative expressed concerns about the resident's condition, noting that the resident appeared sedated and incoherent. The facility's Interim Director of Nursing and the PharMerica pharmacist both indicated that the expectation for administering medication three times daily is every 8 hours, which was not followed in this case.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to adhere to its Falls Management Policy and Procedure by not notifying a resident's physician and representative immediately after an unwitnessed fall. The policy requires that the physician and the resident's representative be informed of any fall, along with the physical findings and extent of injuries. In this case, a resident experienced a fall out of bed, which was not reported to the physician or the resident's representative until the following day. The resident's representative discovered the fall from a Certified Nurses Aide (CNA) and requested immediate hospital transport, where it was confirmed that the resident had a fractured leg. The Director of Nursing (DON) confirmed that the fall occurred in the late afternoon or early evening, but the CNA did not inform the nurse until later that night. Consequently, the physician and the resident's Power of Attorney (POA) were not notified until the next day. The resident was in visible pain, and upon hospital evaluation, a fracture was diagnosed. The medical record lacked evidence of timely notification to the physician and the resident's representative, highlighting a breach in the facility's protocol for managing falls.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident diagnosed with a cardiovascular accident with left side hemiparesis, requiring anticoagulant treatment, dysarthria with modified diet texture, thrombocytopenia, depression, anxiety with ordered antianxiety medications, and neurogenic bladder with an indwelling supra-pubic catheter. Upon review of the resident's clinical record, it was found that there was no evidence of a baseline care plan addressing the immediate health and safety needs related to the use of anticoagulant and antianxiety medications. Additionally, care plans for activities of daily living, impaired swallowing, cognitive loss, chronic pain, indwelling supra-pubic catheter, and risk of falls were not initiated until eight days after admission. This deficiency was confirmed during an interview with the interim Director of Nursing.
Failure to Follow Care Plan and Inaccurate Advanced Directive
Penalty
Summary
The facility failed to ensure that a care plan was followed for a resident requiring a two-person assist transfer, resulting in a fall. The incident occurred when a CNA attempted to transfer the resident to a commode with only one staff member assisting, contrary to the care plan's requirement for two-person assistance. During the transfer, the resident lost balance and fell, despite the CNA's attempt to catch them. This incident was confirmed by the interim Director of Nursing, who acknowledged that the care plan was not adhered to, leading to the resident's fall. Additionally, the facility did not maintain an accurate care plan regarding the resident's advanced directive code status. The resident's medical records from the hospital indicated a Do Not Resuscitate (DNR) status, which was also reflected in the hospital discharge summary and treatment directives. However, the care plan initiated by the facility inaccurately listed the resident's code status as Full Code. This discrepancy was confirmed by the interim Director of Nursing, highlighting a failure to ensure the care plan accurately reflected the resident's advanced directives.
Failure to Update Care Plan for COVID-19 Precautions
Penalty
Summary
The facility failed to revise the care plan to reflect a resident's current status concerning infection prevention and control. Specifically, the care plan for a resident diagnosed with COVID-19 was not updated to include the necessary precautions and status changes. The resident's electronic medical record indicated a confirmed COVID-19 infection with specific isolation precautions and personal protective equipment (PPE) requirements, including gloves, gown, N95 respirator, and eye protection. Despite these requirements being observed on signage and a PPE cart outside the resident's room, the care plan lacked evidence of being updated to reflect these changes. The Director of Nursing confirmed the care plan's deficiency in an interview.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, specifically concerning the use of nebulizers and oxygen equipment for two residents. For Resident #4, the nebulizer tubing and mouthpiece were found unlabeled and stored improperly on a bedside table without a treatment bag. The resident's medical record did not document a recent nebulizer treatment or any provider's order to change the nebulizer tubing, indicating a lack of adherence to the facility's policy requiring daily replacement and proper storage of nebulizer equipment. For Resident #6, the oxygen nasal cannula tubing was observed with a date indicating it had not been changed since 8/25/24, and the oxygen concentrator filter was coated with a thick layer of dust. This was confirmed by both a surveyor and an RN, who acknowledged that the tubing should have been changed weekly, and the filter cleaned regularly. The Director of Nursing confirmed these observations, highlighting a failure to follow the facility's procedures for maintaining respiratory equipment.
Inaccurate Documentation of Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to accurately document the Treatment Administration Record (TAR) for a resident using oxygen. On two separate occasions, a surveyor observed the resident using oxygen via nasal cannula with tubing dated from a previous week and a concentrator filter coated with dust. Despite nursing documentation indicating that the oxygen tubing was changed and the filter cleaned on a more recent date, the observations contradicted this record. A registered nurse confirmed that the tubing should be changed weekly, specifically on Sunday nights. This discrepancy was discussed with the Director of Nursing.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident observed during a survey. On the morning of September 3, 2024, two surveyors noted that a resident was under contact and airborne precautions, requiring the use of an N95 mask, gown, face shield, and gloves when entering the room. Despite clear signage and the availability of personal protective equipment (PPE) on a cart outside the resident's door, two Certified Nursing Assistants (CNAs) entered the room without donning the required PPE. Upon exiting, the CNAs admitted to not using the necessary protective gear, mistakenly believing the resident was no longer under precautions. The Registered Nurse confirmed the oversight, stating that the resident was to remain on precautions until September 4, 2024. This incident was discussed with the Director of Nursing and the Administrator later that day.
Failure to Maintain Resident's Bed in Safe Condition
Penalty
Summary
The facility failed to maintain a resident's bed in good repair and safe operating condition, as evidenced by a broken bed rail that was stuck in the up position. This issue was observed during a survey, where the resident's representative demonstrated the malfunctioning right side rail, which could not be lowered. The representative reported having informed the nursing staff multiple times over the past few weeks, but no action had been taken to address the issue. The left side rail was functioning properly, indicating the problem was isolated to the right side. Further interviews revealed that a CNA/Medication Tech was aware of the issue when the resident returned from a hospital evaluation following a fall. The ambulance crew and the CNA were unable to operate the right side rail. Maintenance personnel attempted to fix the rail but were unsuccessful and confirmed they had no work order for the repair. The deficiency was discussed with the facility's Administrator, highlighting a lack of communication and follow-up on maintenance requests.
Resident Dignity Compromised by Visible Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by allowing an uncovered urine-filled Foley catheter bag to be visible to passersby. On May 7, 2024, at 9:20 a.m., a surveyor observed the catheter bag hanging on the side of the bed, visible from the hallway and dining room. The resident expressed a desire for the bag to be covered, indicating embarrassment if it were seen by others. At 9:30 a.m., a Registered Nurse confirmed the visibility of the catheter bag to those passing by in the hallway and dining area. The issue was discussed with the Administrator on May 8, 2024, at 8:15 a.m.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to complete a Self-Administration of Medication Assessment for a resident reviewed for medication administration. The facility's policy requires an evaluation for safe and clinically appropriate capability for self-administration of medications, along with a physician or advanced practice provider order and care planning for self-administration and medication self-storage. However, the resident in question, who has mild to moderately impaired cognition, was observed with a plastic jar of A&D ointment on their bedside table, which they indicated was their eczema cream. The resident's care plan lacked evidence of their ability to self-administer medications, and their electronic medical record had an active order stating that the resident may not administer their own medications. During interviews, a CNA indicated that the resident self-administers their eczema cream, and an RN confirmed that the resident was given Triamcinolone Acetonide External Cream for self-administration without an order for self-administration in the clinical record. This discrepancy between the facility's policy and the actual practice observed by surveyors led to the identification of a deficiency in the facility's medication administration process.
Deficiencies in Care Plan Implementation and Monitoring
Penalty
Summary
The facility failed to update and implement comprehensive care plans for three residents, leading to deficiencies in monitoring and addressing their medical needs. Resident #1, who was prescribed Venlafaxine for depression, had no evidence of side effect monitoring in their clinical record, despite the care plan indicating a need for such monitoring. This oversight was confirmed by two registered nurses during a survey. Resident #4, who had a recent liver transplant and was on Tacrolimus to prevent organ rejection, lacked goals and interventions related to this medication in their care plan, which was initiated in 2021. Resident #6, with multiple diagnoses including congestive heart failure, dementia, and anxiety, had a care plan that did not include goals and interventions for the use of Furosemide, a diuretic prescribed for heart failure. Additionally, there was no evidence of monitoring for behaviors and side effects related to their psychiatric conditions and medications. These deficiencies were confirmed by a registered nurse and discussed with the Director of Nursing during the survey.
Failure to Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) for one of the sampled residents, Resident #6, after each assessment. According to the facility's policy on Person-Centered Care Plan, a comprehensive, individualized care plan should be developed and reviewed by the IDT, including the resident and/or their representative, after each Minimum Data Set (MDS) assessment. However, the clinical record for Resident #6 showed that a care plan meeting was not held following the quarterly MDS assessment dated January 23, 2024. The last documented IDT meeting for this resident was on October 23, 2023. This deficiency was confirmed during an interview with the Social Worker, who acknowledged that an IDT meeting should have been conducted within seven days of the MDS assessment.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of antipsychotic and antianxiety medications for a resident. The facility's policy on psychotropic medication use requires staff to monitor and document the resident's behavior using a behavioral monitoring chart or assessment record. However, a review of the resident's care plan and clinical records revealed a lack of evidence that the resident was being monitored for behaviors or side effects associated with the medications prescribed for anxiety and delusions. During an interview, the Director of Nursing (DON) indicated that behavior monitoring was documented by exception, with Certified Nursing Assistants (CNAs) responsible for documenting behaviors and informing the charge nurse, who should then include it in a progress note. The DON admitted that there was no regular documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) by nurses, relying instead on trust in the staff. This lack of documentation raises concerns about how the effectiveness of the medications is assessed and whether a Gradual Dose Reduction is justified.
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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