Coastal Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Yarmouth, Maine.
- Location
- 20 West Main Street, Yarmouth, Maine 04096
- CMS Provider Number
- 205157
- Inspections on file
- 21
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Coastal Manor during CMS and state inspections, most recent first.
The facility staff failed to ensure that three residents had access to their call bell devices. One resident's device was hanging on the wall out of reach, another's was found on the floor, and the third's was pulled out of the wall and wrapped around the bed. The Infection Preventionist and surveyor confirmed these deficiencies, while other residents had access to their call devices.
The facility did not follow the printed menu for three days, affecting all residents. Residents expressed dissatisfaction with meal variety, noting repetitive weekly meals and lack of menu access. The cook admitted to not following the 4-week cycle menu, citing instructions from the manager and supply issues. The dietitian was unaware of these deviations, as her assessments were based on the published menus.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as stained ceiling tiles, dirty curtains, non-functional sinks, torn wallpaper, exposed heating elements, and equipment deficiencies. Additionally, the second floor had gouged ceiling tiles and an uncleanable handrail.
A facility failed to accurately code the MDS 3.0 for a resident with PTSD. Despite the resident's documented history of PTSD and related symptoms, the MDS inaccurately indicated no PTSD diagnosis. The surveyor found no information on potential PTSD triggers in the clinical record, and this issue was discussed with the Administrative Assistant.
A facility failed to create a care plan for a resident with PTSD, despite the resident's history of nightmares and trauma from an abusive relationship. The care plan lacked interventions to address PTSD symptoms, and the DON confirmed the absence of guidance for staff on avoiding re-traumatization.
The facility failed to provide trauma-informed care for two residents with PTSD, as trauma assessments were not conducted for non-veteran residents. One resident had a history of PTSD from an abusive relationship, while another exhibited distress likely stemming from childhood trauma. The facility lacked a trauma-informed care policy.
The facility failed to serve food at an appetizing temperature, as reported by residents and observed by surveyors. Residents complained about cold meals, lack of variety, and unappealing presentation. Food trays often sat in hallways before being distributed by CNAs, leading to cold meals. A food committee was formed to address these issues, and the DON acknowledged the problem.
The facility failed to notify a resident's physician and representative after unwitnessed falls, as required by their policy. One resident experienced two falls in one day without proper notification, and another resident had two separate falls with incomplete notifications. These issues were discussed with the RN Consultant.
The facility failed to conduct complete neurological assessments following unwitnessed falls for several residents, as required by their Head Injury Protocol. A resident had two unwitnessed falls on the same day, but a new assessment was not initiated after the second fall. Other residents also experienced unwitnessed falls with incomplete or missing assessments. The RN consultant confirmed these deficiencies.
The facility did not review and update its facility-wide assessment at least annually to determine necessary resources for competent resident care. The last review was in October 2022, with no evidence of further updates by October 2023. The DON confirmed this lapse.
The facility failed to ensure that the Administrator attended the required quarterly QAPI meetings. The QAPI council, as per the facility's plan, must include the Administrator and meet quarterly. Attendance sheets showed the Administrator missed five consecutive meetings, a finding confirmed by the DON.
Failure to Provide Access to Call Bell Devices
Penalty
Summary
The facility staff failed to provide access to resident call bell devices for three out of thirty-five residents. During observations and interviews, it was noted that Resident #2 did not have a call device within reach, as it was hanging on the wall approximately five feet from the bed. This was corrected by a CNA who moved it to the resident's bed covers. Resident #3 was unable to locate their call bell, which was found with the cord behind them and the button on the floor between their chair and bed. Resident #4 was observed in bed without a call bell nearby, and a search revealed the device was pulled out of the wall and on the floor wrapped around the bed. The Infection Preventionist and surveyor confirmed that these three residents did not have access to a call bell, while the remaining residents did have access and knew where their call devices were located.
Failure to Follow Printed Menus and Provide Meal Variety
Penalty
Summary
The facility failed to adhere to the printed menu for three consecutive days during the survey, violating regulations S483.60(c)(2) and S483.60(c)(3), which require menus to be prepared in advance and followed. Observations and interviews with residents revealed dissatisfaction with the lack of variety and predictability in meals, as residents reported receiving the same meals weekly without access to a menu. The food committee meeting notes corroborated these complaints, indicating a desire for more variety and alternative choices beyond the usual egg salad or peanut butter and jelly. Interviews with the facility cook and the Director of Nursing highlighted a disconnect between the printed menu and the meals served. The cook admitted to not following the 4-week cycle menu, instead preparing meals based on instructions from the manager, who was on vacation. The cook also mentioned frequent deviations from the printed menu due to supply issues, such as the unavailability of chicken. The dietitian was unaware of these deviations, as her nutritional assessments were based on the published menus, which she assumed were being followed.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment across two units. On the first floor, the Upper Dining Room, hallway connecting the Upper and Lower Dining Rooms, living room, and resident hallway at the North end all had stained ceiling tiles. Specific resident rooms had issues such as dirty curtains with brown stains, non-functional sinks, stained ceiling tiles, torn wallpaper, and exposed heating elements. Equipment deficiencies included a sit-to-stand device with missing non-slip grips. On the second floor, the resident hallway had ceiling tiles with deep gouges and a handrail with bare and rough wood, creating an uncleanable surface.
Inaccurate MDS Coding for PTSD Diagnosis
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) 3.0 for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted to the facility, had a documented history of PTSD, as noted in the provider's admission progress note. This note detailed the resident's ongoing issues with nightmares and fear of leaving home, attributed to PTSD from a past abusive relationship. However, both the Admission MDS and the most recent Quarterly MDS inaccurately indicated that the resident did not have PTSD under the Active Diagnosis Section. The surveyor could not find any information in the clinical record regarding potential PTSD triggers that might cause re-traumatization for the resident. This discrepancy was discussed with the Administrative Assistant.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted to the facility, has a history of nightmares and PTSD stemming from an abusive relationship and a traumatic divorce. The admission progress note highlighted the resident's ongoing issues with nightmares and fear of leaving home. However, a review of the resident's care plan revealed that it did not include any interventions or strategies to address the PTSD diagnosis. During an interview with the Director of Nursing, it was confirmed that there was no evidence of a care plan addressing potential triggers for the resident's PTSD symptoms or guidance for staff on how to avoid re-traumatization.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address the trauma history of two residents diagnosed with PTSD, leading to a deficiency in providing trauma-informed care. Resident #9's clinical record indicated a history of PTSD due to an abusive relationship and ongoing nightmares. Despite this, the Licensed Social Worker confirmed that trauma assessments were not conducted for residents other than veterans, which was discussed with the Director of Nursing. Similarly, Resident #31 exhibited distress and behavioral symptoms that interfered with care and social interactions. A hospice medical social worker noted that these behaviors likely stemmed from childhood trauma rather than dementia. However, the facility did not screen Resident #31 for trauma upon admission, as the facility's practice was to only screen veterans for trauma history. Additionally, the facility was unable to provide a trauma-informed care policy when requested by the surveyor.
Deficiency in Food Temperature and Variety
Penalty
Summary
The facility failed to serve food at an appetizing temperature to residents on both floors, as observed and reported by surveyors. Multiple residents expressed dissatisfaction with the temperature and variety of the food. One resident in the dining room mentioned that the food was not hot enough and seemed repetitive. Another resident, interviewed in bed, stated that breakfast was cold. A third resident showed a piece of cold French toast and complained about the lack of variety and unpredictability of meals. A resident who requested to speak with a surveyor noted that food trays often sat in the hallway for extended periods before being distributed by CNAs, leading to cold meals. This resident also mentioned the formation of a food committee to address these issues. The surveyor's observations during a lunch meal tray pass confirmed that trays were being distributed by CNAs, with no licensed staff assisting, despite a nurse's claim that they sometimes help. A CNA reported that by the time all trays were delivered and assistance was provided to those needing help, the food was no longer warm. The Director of Nursing acknowledged that food was an issue being addressed. A family member of a resident also confirmed the food temperature was not warm and noted poor variety. The food committee meeting notes highlighted concerns about cold food, melted ice cream, lack of variety, and unappealing presentation.
Failure to Notify Physician and Representative After Unwitnessed Falls
Penalty
Summary
The facility failed to notify a resident's physician and/or representative immediately following significant changes in the resident's medical condition, specifically after unwitnessed falls. According to the facility's policy, any unwitnessed fall should be treated under the Head Injury Protocol, which includes notifying the resident's physician and contact person. However, in the case of one resident, there were two unwitnessed falls on the same day, and there was no evidence that the physician or the resident's representative was notified after the second fall. This was confirmed when the resident's relative called the nurse for an update and inquired why they had not been informed. Another resident experienced unwitnessed falls on two separate occasions. In the first incident, the resident's legal guardian was notified, but there was no evidence that the physician was informed. In the second incident, the resident fell while attempting to use the bathroom, and although the nurse assessed the resident and found vital signs stable, there was no documentation of the legal guardian being notified. These lapses in communication were discussed with the RN Consultant during an interview.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to adequately assess and monitor residents following unwitnessed falls, as per their established protocols. The facility's policy requires that any unwitnessed fall, regardless of whether the resident is alert and oriented, be treated under the Head Injury Protocol. This protocol mandates a series of neurological assessments at specified intervals. However, the facility did not adhere to these protocols for several residents. Resident #1 experienced two unwitnessed falls on the same day. After the first fall, a neurological assessment was initiated, but it was not restarted after the second fall, as required. The resident later requested Tylenol for a headache, indicating a potential oversight in monitoring. The RN in charge acknowledged the failure to initiate a new neurological assessment after the second fall. Other residents also experienced similar deficiencies in care. Resident #3 had multiple unwitnessed falls over several months, with incomplete neurological assessments documented for each incident. Resident #4 had unwitnessed falls with missing incident reports and incomplete assessments. Resident #5 also had an unwitnessed fall with no evidence of a neurological assessment being completed. The RN consultant confirmed that the assessments were not completed as required for these residents.
Failure to Annually Review and Update Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment at least annually to determine the necessary resources for competent resident care during day-to-day operations. The Director of Nursing provided the surveyor with the facility assessment last reviewed in October 2022. However, there was no evidence of any further review or update by October 2023. This was confirmed during an interview with the Director of Nursing, who acknowledged that the review and revision of the facility assessment had not been completed since October 2022.
Administrator's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Administrator attended the required quarterly Quality Performance Improvement Committee meetings. According to the Coastal Manor Quality Assurance and Professional Improvement (QAPI) Plan, the QAPI council must include the Administrator and meet quarterly. A review of the attendance sheets revealed that the Administrator did not attend any of the five quarterly meetings held on 6/2/23, 9/18/23, 12/18/23, 1/29/24, and 3/18/24. This finding was confirmed during an interview with the Director of Nursing on 4/10/24.
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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