Dexter Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Dexter, Maine.
- Location
- 64 Park Street, Dexter, Maine 04930
- CMS Provider Number
- 205115
- Inspections on file
- 22
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Dexter Health Care during CMS and state inspections, most recent first.
A resident who returned from surgery with a drain in place had the drain removed by nursing staff one day after arrival, despite orders for it to remain until a follow-up visit. Documentation did not include a written or verbal order from the medical provider authorizing the removal, and this omission was confirmed by the DON.
A CNA failed to wear a gown while providing care to a resident on Enhanced Barrier Precautions (EBP) due to open wounds and an ileostomy, despite facility policy and posted signage requiring gown and glove use for high-contact care activities.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
A resident exhibiting exit-seeking and agitated behavior was placed in their room by an RN, who then held the door shut, preventing the resident from leaving. Multiple staff witnessed the incident, which involved the resident kicking and yelling to get out. This action violated facility policy prohibiting seclusion.
A deficiency was identified when an RN physically restrained a resident by holding their arms and hands down to prevent movement during an altercation, contrary to facility policy. Staff statements confirmed the RN used body contact to limit the resident's actions after the resident attempted to leave, became agitated, and tried to strike staff.
After staff reported concerns about an RN's escalating and potentially abusive behavior toward a resident, including physical and verbal actions, the DON did not immediately remove the RN from resident care or promptly initiate a thorough investigation. The RN continued to provide care to the resident throughout the weekend, and written statements detailing the incident were not collected until two days later.
Staff failed to promptly notify the State Agency about an alleged abuse incident involving a resident and an RN, where the RN escalated the resident's behavior, resulting in physical altercations and concerning staff conduct. The DON received multiple reports and concerns from CNAs about the RN's actions, but the facility delayed both the investigation and required notification.
A resident with dementia who was at risk for elopement became agitated and attempted to leave the facility. Staff failed to follow the care plan interventions, including using a calm approach and providing diversions, and the section for the resident's preferences was left blank. Instead, an RN escalated the situation by yelling and mimicking the resident, resulting in increased agitation and disruption.
A resident's clinical record was incomplete and inaccurate following a hospital transfer for behavioral evaluation. The record lacked documentation of resident representative notification, charge nurse notes on behaviors as required by the TAR, and information on the resident's return from the hospital. Staff interviews confirmed that required documentation was not entered into the clinical record.
A resident was hospitalized after receiving another resident's medications due to a failure to confirm identity during medication administration. The error involved an Adult Education CNA-M instructor and student who, without proper login credentials, administered medications including Gabapentin, Hydroxyzine, and Metoprolol, leading to adverse effects such as nausea and syncope. The facility's policy to confirm resident identity was not followed.
The facility failed to follow physician orders for medications and treatments for several residents, resulting in missed doses and improper care. One resident did not receive an antibiotic for five days due to authorization delays, while another missed doses of Macrobid due to record errors. A resident with a rash did not receive daily treatment as ordered, and another received incorrect Protonix dosing due to a system error. Additionally, a resident's unwitnessed fall was not properly assessed, and no care orders were found for a resident with an ileostomy.
The facility failed to adhere to infection prevention protocols during pressure ulcer dressing changes for two residents. An LPN and CNAs did not wear protective gowns as required by Enhanced Barrier Precautions (EBPs) for a resident with a Stage IV pressure ulcer and an indwelling urinary catheter. Another LPN also neglected to wear a gown during a dressing change for a resident with a pressure ulcer, and there was no EBP sign outside the resident's room.
A resident's preference for regular showers was not honored, as documented evidence showed missed showers in August and September, and no showers recorded in October after a system transition. Despite being scheduled for weekly showers, the resident only received one per week, with staff claiming the resident did not need additional showers. The DON confirmed missing and incomplete documentation, indicating a failure to support the resident's choice.
A facility failed to implement a care plan intervention for a resident requiring weekly weighing as part of their nutrition care plan. The care plan, established in July 2023, was not followed as weights were not documented for specific weeks in October 2024. This deficiency was confirmed by a surveyor and the RAI Coordinator during a review.
A facility failed to follow a physician's order for a pressure ulcer dressing change. An LPN mistakenly applied a dressing to the wrong toe of a resident's right foot, despite the order specifying the third toe. The error was identified by a surveyor, and the LPN corrected it by applying the dressing to the correct toe.
A facility failed to ensure timely physician review and signature of a resident's medication and treatment orders. The resident's block orders, last signed on July 11, required review by September 19. Despite a physician visit on September 9, the orders remained unsigned, resulting in a 41-day delay confirmed by a surveyor and the DON.
The facility did not maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. On two weekend shifts, there was no evidence of an RN present for the required hours, as confirmed by a review of staffing schedules and interviews.
A facility failed to obtain a physician-ordered renewal for a PRN Lorazepam prescription when transitioning to a new electronic charting system. The medication was entered without a stop date, making it available for administration beyond the intended period. This oversight was confirmed during a review, as the medication remained available without a renewal order.
The facility failed to label thawed health shake supplements with a thaw date and did not remove expired coleslaw from the refrigerator. Additionally, the kitchen's exhaust fan and window casings were heavily dust-covered and remained uncleaned over several days.
The facility failed to maintain accurate clinical records for three residents due to errors during the transfer of physician orders to a new electronic charting system. These errors included incorrect medication dosages, missing discontinuation orders, and significant discrepancies in weight records, complicating accurate resident assessments.
The facility failed to maintain a sanitary and well-maintained environment, as observed during environmental tours. Issues included faded and chipped furniture, dirty and damaged wheelchairs, a flickering bathroom light, and chipped surfaces, all contributing to unsanitary conditions.
Incomplete Clinical Record for Surgical Drain Removal
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident who returned from surgery with a surgical drain in place. Upon review, it was found that there was a physician's order for daily dressing changes and for the drain output to be recorded every 12 hours, with instructions for the drain to remain in place until the resident's follow-up clinic visit in approximately one week. However, documentation showed that the drain was removed at the facility just one day after the resident's return, following a phone call to the surgical center nurse, but without any written or verbal order from the medical provider or surgical team authorizing the removal. The clinical record lacked evidence of such an order, and this was confirmed during interviews with the charge nurses and the Director of Nursing.
Failure to Follow Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when staff failed to implement required infection control practices for a resident with open wounds and an ileostomy who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gowns and gloves when providing high-contact care to residents on EBP, including those with chronic wounds or indwelling catheters. During an observation, a Certified Nursing Assistant (CNA) entered the resident's room to empty a catheter bag without donning a gown, despite a sign posted outside the room indicating EBP precautions were in place. The CNA acknowledged forgetting the need to wear a gown for this resident, and the surveyor confirmed the lapse at the time of the observation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Resident Subjected to Involuntary Seclusion by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) involuntarily secluded a resident by placing the resident in their room and holding the door shut, preventing the resident from leaving. The incident was witnessed by multiple staff members, who provided written and verbal statements confirming that the RN held the door closed while the resident, who was exhibiting exit-seeking behavior and escalating agitation, attempted to get out by kicking and yelling. The facility's policy, revised in March 2025, explicitly prohibits seclusion, defined as placing a resident alone in a room, and this action was in direct violation of that policy. The resident involved was described as being angry, yelling, and attempting to leave the facility, with staff unsuccessfully attempting to redirect the behavior prior to the seclusion. Staff accounts consistently indicated that the RN moved the resident to their room and physically held the door closed for a period of time, during which the resident was observed kicking the door from inside. The duration of the seclusion was not precisely determined, but staff confirmed the resident was confined against their will. The incident was reported to the Division of Licensing and Certification, and the RN was placed on leave pending investigation.
Use of Physical Restraint by RN on Resident
Penalty
Summary
A deficiency occurred when a Registered Nurse (RN) used physical restraint on a resident by holding the resident's arms and hands down to limit voluntary movement. The incident took place after the resident attempted to leave the facility, banged on a door, and threw a cup of coffee at the RN. Multiple staff statements and interviews confirmed that the RN held the resident's arms down from behind the wheelchair, and at one point, placed her arms around the resident's upper chest while wheeling the resident away from the door. The RN and the resident were engaged in a verbal altercation, and the RN was observed to be frustrated during the incident. The facility's policy, revised in March 2025, defines physical restraints as any manual method or device that restricts freedom of movement and cannot be easily removed by the individual. The RN's actions were documented in a Performance Correction Notice and corroborated by written statements and interviews from Certified Nursing Assistants (CNAs) who witnessed the event. The resident was actively resisting and attempting to hit staff, leading the RN to physically restrain the resident, which was not in accordance with the facility's restraint policy.
Failure to Protect Resident After Staff Reported Alleged Abuse by RN
Penalty
Summary
Staff reported concerns regarding the behavior of a Registered Nurse (RN) towards a resident who was agitated. On the day of the incident, multiple staff members notified the Director of Nursing (DON) via text messages that the RN was engaging in escalating behavior with the resident, including flapping her arms at the resident and verbally provoking the resident to hit her. Written statements later indicated that the RN physically put her hands on the resident, placed the resident in their room, closed the door, and held it shut. Despite these reports, the DON's initial response was to instruct the RN to complete an incident report and follow up with Work Health, without immediately removing the RN from resident care or initiating a thorough investigation at that time. The RN continued to provide care to the resident throughout the weekend following the incident, as confirmed by timecard records and staff interviews. The DON did not begin collecting written statements from involved staff until two days after the incident, delaying the facility's investigation. The resident was sent to the hospital following the incident, and upon return, care was reassigned, but the RN insisted on continuing to care for the resident. The facility failed to protect the resident after being notified of staff concerns about the RN's behavior, allowing the RN to remain in direct care of the resident despite allegations of abuse.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Agency (Division of Licensing and Certification) in a timely manner regarding an allegation of abuse involving a resident and a registered nurse. On the date of the incident, staff reported to the Director of Nursing (DON) that a resident was agitated and that a registered nurse escalated the situation, resulting in the resident biting the nurse. Additional information was reported to the DON, including that the nurse placed the resident in their room, closed the door, and held it shut for several seconds up to one minute during the resident's escalating behaviors. Text messages from certified nursing assistants to the DON expressed concerns about the nurse's behavior, including the nurse flapping her arms at the resident and encouraging the resident to hit her. Despite these reports and concerns, the facility did not initiate an investigation or notify the State Agency until two days after the incident occurred.
Failure to Implement Comprehensive Care Plan for Agitated Resident with Dementia
Penalty
Summary
The facility failed to fully develop and implement a comprehensive care plan for a resident with dementia who was identified as an elopement risk and exhibited agitated behaviors. The care plan included interventions such as offering pleasant diversions and approaching the resident in a calm manner, but the section for the resident's preferences was left blank. On the day of the incident, staff observed a Registered Nurse (RN) yelling at the resident and mimicking their behavior, rather than using the calm approach specified in the care plan. Multiple staff statements indicated that the RN's actions escalated the resident's agitation, leading to a disruptive situation where both the RN and the resident were yelling at each other. Interviews with staff revealed that the resident, who has dementia, was triggered and became increasingly agitated when their desire to go outside was not accommodated. Staff noted that the situation could have been defused by taking the resident outside, but this was not done due to a busy period. The care plan's interventions to distract and calm the resident were not effectively implemented, and the lack of documented resident preferences further limited the staff's ability to address the resident's needs appropriately during the incident.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced an incident resulting in hospital transfer for evaluation of increased behaviors. The clinical record did not contain documentation of notification or attempted notification of the resident's representative regarding the hospital transfer. Additionally, there was no documentation from the charge nurse in the nurses/progress notes about the resident's behaviors, as was required by the Treatment Administration Record (TAR). Although the TAR indicated that behaviors were monitored, there was no corresponding narrative documentation in the clinical record. Further review revealed that the clinical record lacked information indicating when the resident returned to the facility after the hospital transfer. Interviews with staff confirmed that the LPN had called and left a message for the resident's representative but did not document this action in the clinical record. The RN acknowledged documenting on the TAR but failed to update the clinical record with details of the behaviors or the resident's return from the hospital. These omissions resulted in incomplete and inaccurate clinical records for the resident involved in the incident.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, leading to the resident being transported to an acute care emergency department and later admitted to the hospital. The incident occurred when a Certified Nursing Assistant-Medication Aide (CNA-M) allowed an Adult Education CNA-M instructor and a student to pass medications without confirming the resident's identity. As a result, the resident received a combination of medications intended for another resident, including Gabapentin, Hydroxyzine, Metoprolol, and others, which led to adverse effects such as nausea and syncope episodes. The error was identified when the resident, who had received the wrong medications, reported feeling unwell and exhibited symptoms such as nausea and a syncope episode. The nursing staff documented the incident, noting that the resident's blood pressure and pulse were affected by the medications, particularly the combination of Gabapentin and Hydroxyzine, which can be sedating, and Metoprolol, which can significantly lower blood pressure and pulse. The resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with the facility staff revealed that the Adult Education CNA-M instructor and the student did not have their own login for the computer system and relied on the CNA-M to log in for them. They failed to confirm the resident's identity before administering the medications, leading to the error. The facility's policy on administering oral medications clearly states the need to confirm the identity of the resident, which was not followed in this instance. The resident remained hospitalized for treatment following the incident.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications and treatments were followed for several residents. One resident was sent to the Emergency Department due to respiratory concerns and returned with an order for Levaquin to treat pneumonia. However, the resident did not receive the antibiotic until five days after the physician ordered it due to a delay in obtaining prior authorization and a lack of follow-up with the physician. Another resident had a written order to change the duration of Macrobid treatment from 14 days to 5 days, but missed three doses due to a failure to update the Medication Administration Record (MAR) and administer the medication as ordered. A resident with a rash on their stomach had orders for daily cleaning and application of cream, but the treatment was not performed daily as required. The Treatment Administration Record (TAR) incorrectly listed the treatment as 'as needed,' resulting in missed treatments. Additionally, another resident had an order for Protonix to be administered twice a day, but due to an error during the transfer of orders to a new electronic system, the medication was only given once a day for several weeks without a physician's order to change the frequency. Further deficiencies included a resident who experienced an unwitnessed fall and did not receive the required neurological assessments, as well as a resident with an ileostomy for which no active care orders were found. These lapses in following physician orders and ensuring proper documentation and administration of medications and treatments highlight significant deficiencies in the facility's care processes.
Infection Control Lapses in Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during pressure ulcer dressing changes for two residents. Resident #17, diagnosed with multiple sclerosis and a chronic Stage IV pressure ulcer, was observed during a dressing change where the attending LPN and CNAs did not adhere to Enhanced Barrier Precautions (EBPs) by failing to wear protective gowns. Despite being aware of the EBP sign on the resident's room entrance, the staff did not comply with the necessary precautions, which are crucial for residents with wounds or indwelling medical devices. Similarly, for Resident #11, who had a physician's order for a daily pressure ulcer dressing change, the attending LPN did not follow the facility's EBP and wound care policies by only wearing gloves and not a gown during the procedure. The absence of an EBP sign outside Resident #11's room further indicates a lapse in the facility's adherence to infection control protocols. These observations highlight the facility's failure to implement and follow established infection prevention measures, particularly for residents at increased risk of MDRO acquisition.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing preferences, specifically for a resident identified as R3. During an interview, a resident representative expressed concerns that R3 was not receiving scheduled showers, with staff indicating that R3 did not need a shower because they had already been washed. R3 reportedly enjoys showers but was only receiving one per week. A review of R3's electronic clinical record showed that R3 was scheduled to receive a shower on Saturdays during the day shift. However, documentation revealed that R3 missed five showers in August and September, and there was no evidence of any showers being provided in October after the facility transitioned to a new electronic charting system. The Director of Nursing confirmed the missing and incomplete documentation regarding R3's showers, indicating that the resident's preferences were not being honored.
Failure to Implement Weekly Weighing for Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident reviewed for nutrition. The care plan for the resident included an intervention added on July 13, 2023, under the care area of Nutrition, which required the resident to be weighed every week. However, during a review on October 30, 2024, it was found that the resident's weights were not documented weekly in the electronic system for the periods from September 29, 2024, to October 5, 2024, and from October 13, 2024, to October 19, 2024. This lack of documentation was confirmed during a review by a surveyor and the Resident Assessment Instrument (RAI) Coordinator.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to follow a physician's order for a pressure ulcer dressing change for a resident. On October 29, 2024, a surveyor observed an LPN perform a dressing change on the resident's right foot. The physician's order specified that the dressing should be changed daily on the resident's Stage II pressure ulcer located on the right third toe. However, the LPN mistakenly applied the dressing to the second toe instead of the third. Upon being informed by the surveyor, the LPN confirmed the error and corrected it by applying the dressing to the correct toe.
Physician's Delay in Signing Orders
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. The resident's clinical record showed block orders signed by the physician on July 11, 2024. These orders required review and the physician's signature by September 19, 2024, including a 10-day grace period. Although the physician visited on September 9, 2024, they did not sign the block orders. As of October 30, 2024, the orders were 41 days overdue, as confirmed by a surveyor during an interview with the Director of Nursing.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of daily staffing schedules and interviews conducted by a surveyor on 10/31/24. Specifically, on two weekend shifts, 10/13/24 and 10/20/24, there was no evidence of an RN being present in the building for the required 8 consecutive hours.
Failure to Renew PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure a physician-ordered renewal for a PRN psychotropic medication before transitioning to a new electronic charting system (PCC). This oversight involved a resident who had a previous order for Lorazepam, an anti-anxiety medication, to be administered as needed at bedtime until a specified date. However, when the facility switched to the new system, the medication order was entered without a renewal from a physician and lacked a stop date, making it available for administration beyond the intended 14-day period. During the review, it was confirmed that there was no renewal order for the PRN Lorazepam, yet the medication remained available for use.
Deficiencies in Food Labeling and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly label thawed health shake supplements with a thaw date, as observed by a surveyor in the walk-in refrigerator. The storage and handling instructions on the carton specified that the supplements should be used within 14 days after thawing, but the absence of a thaw date made it impossible to determine their usability. This issue was confirmed with the Dietary Manager, who acknowledged the lack of labeling. Additionally, the facility did not remove expired food items from the walk-in refrigerator. A surveyor found individual serving cups of coleslaw that were past their use-by date, yet still available for use. This was confirmed with the Dietary Manager, who acknowledged the presence of expired coleslaw. Furthermore, the kitchen's cleanliness was compromised by a heavily dust-covered exhaust fan and window casings in the dishwashing room, which remained uncleaned over multiple days of observation.
Inaccurate Clinical Records and Data Entry Errors
Penalty
Summary
The facility failed to ensure that clinical records contained complete and accurate information for three residents during a review. For one resident, an order for Protonix was incorrectly entered into the new electronic charting system (PCC) as once a day instead of twice a day during the transfer of physician orders. Another resident's record lacked evidence of a discontinued order for Trazodone, which was omitted during the same transfer process. Additionally, this resident's weight records showed inconsistencies, with significant discrepancies noted in the recorded weights over several months, making it difficult for the dietician to assess the resident's nutritional status accurately. For a third resident, multiple data entry errors were identified in the transfer of orders from the old electronic charting system (ECS) to PCC. These errors included missing dosage information for Calcium Carbonate, incorrect dosage for artificial tears, an active order for Lorazepam that should have been stopped, and a duplicate entry for Miconazole powder. The Director of Nursing confirmed these errors during the review, and there was no order found to renew the Lorazepam as needed.
Facility Fails to Maintain Sanitary and Well-Maintained Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building and resident equipment in good repair and in a sanitary condition. During environmental tours, it was observed that several pieces of furniture in residents' rooms were in disrepair, with issues such as faded veneer, chipped wood, and missing handles. Additionally, some residents' wheelchairs were found to be dirty, with missing foam pieces and cracked armrests, creating uncleanable surfaces. A bathroom ceiling light was flickering, and a bedside table surface was chipped, further contributing to the unsanitary conditions.
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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