Eastside Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 516 Mt Hope Avenue, Bangor, Maine 04401
- CMS Provider Number
- 205106
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eastside Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors and facility leadership observed standing water in two basement areas, one beneath the kitchen and another below resident rooms. The Maintenance Director explained that the water originated from leaks at the loading dock and windows, as well as landscaping that directed runoff toward the building.
Surveyors and the Food Service Director confirmed that food was not stored, prepared, or served according to professional standards, as food debris was found on kitchen floors, utensils were partially buried in debris, and various food items were stored directly on the floor in both dry and cold storage areas.
A resident with dysphagia and a physician order for a minced and moist diet was given a roll, which is not permitted under IDDSI Level 5 guidelines. After attempting to eat the roll, the resident experienced vomiting and difficulty swallowing, resulting in another ED visit. Facility staff confirmed the dietary order was not followed.
Surveyors found that garbage and refuse were not properly disposed of, with trash bags left on the ground next to dumpsters, a dumpster lid with broken hinges, and uncovered trash barrels containing debris and frozen items near the loading dock. These conditions were confirmed by the Regional Director of Clinical Operations.
Surveyors found that slings used for resident transport were improperly stored on the floor and on wall hooks where they touched the floor and a lint-filled garbage can. Additionally, there was a buildup of lint behind the dryer and the laundry room floor was covered with dirt and debris, all of which were confirmed by the Regional Director of Clinical Operations.
A resident experienced severe pain due to constipation after the facility failed to monitor bowel movements and initiate the Bowel Regime protocol. Despite receiving scheduled Miralax and Senna plus, the resident did not have a bowel movement for 16 shifts, leading to significant distress. The facility's policy required CNAs to document bowel movements and Licensed Nurses to review alerts, but this was not done. The issue was only addressed after a medical provider was called, who ordered a suppository and x-ray, confirming constipation.
The facility did not maintain adequate staffing levels on weekends during the fourth quarter of 2024, as indicated by a PBJ report. The Administrator confirmed the issue, attributing responsibility for the PBJ data to Human Resources, who did not provide evidence to refute the low staffing findings.
The facility failed to provide written information on advance directives to four residents, as confirmed by the Administrator. Clinical records lacked evidence of offering advance directives or obtaining Power of Attorney paperwork, indicating a systemic issue in ensuring residents' rights to make informed care decisions.
The facility was found deficient in maintaining a safe and sanitary environment, with issues such as a torn vinyl door covering, broken wood trim, broken blind slats, chipped paint, and cracked wheelchair arms. These deficiencies were observed during a survey, highlighting inadequate housekeeping and maintenance services.
A resident with mental health diagnoses was not referred for a PASRR Level II evaluation after a 30-day exemption expired. The resident's record lacked evidence of re-evaluation for 8 months, which was confirmed by the DON.
A resident did not receive a scheduled dose of the antibiotic Meropenem for an ESBL infection, despite the medication being available in the facility's emergency supply. Additionally, the facility failed to administer Normal Saline Flushes as ordered, with no documentation of these treatments in the resident's EMAR.
The facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. This notice is essential for informing residents about their potential financial responsibility for services not covered by Medicare. The oversight was confirmed by the facility's Administrator.
A facility failed to develop a care plan for a resident's Atrophic Vaginitis, a condition requiring daily treatment as per physician orders. Despite documentation of the condition in physician progress notes and the resident experiencing symptoms, the care plan lacked any related problem, goal, or interventions. The DON confirmed the absence of this information during a surveyor interview.
A facility failed to follow physician orders for a resident requiring a low sodium diet and assistance to get out of bed for meals. The resident received a regular diet with salt packets and was not assisted out of bed for meals until 11 days after the order was given. Interviews and record reviews confirmed these discrepancies.
The facility failed to ensure a safe environment by having baseboard heaters with exposed heating elements in five rooms and the B-Unit dining room. One room also had a torn mattress bumper, creating an uncleanable surface. These hazards were observed and discussed with the DON.
A facility failed to follow a Physician Assistant's order for a neurological follow-up for a resident with post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. The Administrator confirmed the absence of evidence that the order was followed.
Standing Water Observed in Basement Areas Due to Leaks
Penalty
Summary
Surveyors observed and confirmed the presence of standing water in two separate basement areas of the facility during an environmental tour. One area of standing water was located in a basement storage room beneath the kitchen, which the Maintenance Director attributed to water leaking in from the loading dock and traveling through the wall. Another area of standing water was found in the basement space below resident rooms, which the Maintenance Director stated was due to leaking windows and landscaping that directed snow melt and runoff water toward the building. These conditions were directly observed and confirmed by surveyors and the Regional Director of Clinical Operations during the survey. No specific residents or staff were identified as being directly affected at the time of the deficiency, and no additional medical history or resident conditions were mentioned in the report.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen sanitation during a tour of the facility's kitchen and food storage areas. Food debris was found on the floor under kitchen surfaces and shelves in the meal preparation area, not related to the current meal service. Behind the stove, a large pile of food debris was present against the wall, with cooking utensils partially buried in it. In the dry food storage area, loose fries and a biscuit were found on the floor. The walk-in freezer contained food debris, including a fish filet and loose fries on the floor, and an open box of green beans stored directly on the floor, along with boxes of hamburger patties, chicken breasts, and creamer stacked and stored on the floor. In the walk-in refrigerator, a large mesh bag of onions was also stored on the floor. These observations were confirmed by both the surveyor and the Food Service Director, indicating that food was not stored, prepared, or served in accordance with professional standards for food service safety.
Failure to Provide Physician-Ordered Minced and Moist Diet
Penalty
Summary
A resident with a history of dysphagia and recent emergency room visits for increased cough, congestion, and concerns for aspiration pneumonia was placed on a physician-ordered minced and moist diet with thin liquids. The order, based on the IDDSI Level 5 guidelines, specifically excluded regular, dry bread, sandwiches, or toast. Despite this, the resident was provided a roll for lunch while on the modified diet. Following the consumption attempt, the resident was unable to swallow secretions and vomited upon swallowing food or drink, which led to another emergency department visit. Interviews with facility staff, including the Rehab Director and Director of Nursing, confirmed that the dietary order was not followed and that bread is not permitted on the minced and moist diet per IDDSI standards.
Improper Disposal of Garbage and Refuse Observed
Penalty
Summary
Surveyors observed several deficiencies in the disposal of garbage and refuse at the facility. On the survey day, multiple bags of trash were found stored on the ground next to the facility dumpsters, rather than inside them. The hinges on the lid of one dumpster were broken, preventing the lid from covering the refuse. Additionally, in the outside area by the loading dock, a used food container was seen frozen in the snow on top of a snow-covered cooler, and a round trash barrel without a lid was found containing trash and debris, with a milk crate frozen in place and ice accumulating over the edges of the barrel. These findings were confirmed during an interview with the Regional Director of Clinical Operations.
Infection Control Deficiency in Laundry Room Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices in the laundry room. Specifically, there was a buildup of lint behind the dryer, and the floor was covered with dirt and debris. Slings used for resident transport were found piled on the floor between a door and a wall, and additional slings were hanging on wall hooks near the dryer in such a way that parts of the slings were touching the floor and the inside of a lint-filled garbage can. These observations were confirmed during a tour and interview with the Regional Director of Clinical Operations, who acknowledged the improper storage of slings on the floor and on hooks where they touched the floor.
Failure to Monitor and Initiate Bowel Regime Protocol
Penalty
Summary
The facility failed to monitor a resident's bowel movements and initiate the Bowel Regime protocol, resulting in significant discomfort for the resident. The resident, identified as R46, did not have a bowel movement for 16 shifts, leading to severe pain and distress. The facility's policy required Certified Nursing Assistants (CNAs) to document bowel movements accurately and for Licensed Nurses to review clinical alerts daily to identify residents needing bowel regime interventions. However, this protocol was not followed for R46, who was already receiving scheduled Miralax and Senna plus but did not receive additional PRN bowel regime medications until the situation escalated. On the day of the incident, a surveyor observed R46 in significant pain, crying out for help due to constipation. Despite the resident's visible distress, the facility staff did not initiate the bowel protocol until a medical provider was called, who then ordered a suppository and an abdominal x-ray. The x-ray confirmed a non-obstructive bowel gas pattern with fecal residue, correlating with clinical constipation. Interviews with staff revealed that the CNAs and nurses did not document or act on the lack of bowel movements, and the Director of Nursing confirmed the protocol was not initiated as required. The medical provider noted that R46 had a history of constipation and minimal oral intake, which contributed to the issue. Despite this, there were no nursing complaints or actions taken from the last medical review until the incident. The failure to follow the bowel regime protocol and the lack of communication between nursing staff and medical providers led to the resident's prolonged discomfort and pain.
Insufficient Weekend Staffing in Q4 2024
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents during weekends in the fourth quarter of 2024. A Payroll Based Journal (PBJ) report indicated that the facility triggered for low weekend staffing during this period. During an interview, the Administrator acknowledged the issue and stated that Human Resources was responsible for the PBJ data. However, Human Resources did not provide any additional information to dispute the PBJ report findings, which confirmed low weekend staffing levels.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information to formulate an advance directive or appoint a surrogate. This deficiency was identified for four out of seven residents reviewed for advance directives. Specifically, the clinical records of these residents lacked evidence that the facility had provided or obtained the necessary documentation regarding the right to formulate an advance directive or appoint a surrogate. The residents involved were admitted to the facility between January and February 2025, with one resident having been admitted as early as 2020. During interviews with surveyors, the facility's Administrator confirmed the absence of evidence in the clinical records regarding the offering of advance directives or obtaining Power of Attorney paperwork, if applicable. This lack of documentation was consistent across the reviewed records, indicating a systemic issue in the facility's process for ensuring residents' rights to make informed decisions about their care and treatment preferences.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. On the first day of the survey, a torn vinyl covering on the inside of a bathroom door was noted, which was later removed by the Interim Maintenance Director. On the second day, an environmental tour revealed additional issues: broken wood trim behind a bed, broken blind slats in two rooms, chipped paint in a bathroom, and cracked, uncleanable wheelchair arms for a resident. These observations indicate a lack of adequate housekeeping and maintenance services necessary to keep the building and resident equipment in good repair and sanitary condition.
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred for a Pre-Admission Screening & Resident Review (PASRR) Level II evaluation after the expiration of a Convalescence Categorical exemption. The resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder, had a PASRR Level I evaluation dated 5/10/24, which granted a 30-day exemption. However, the resident's clinical record did not show evidence of a PASRR Level II re-evaluation after the exemption period ended on 6/11/24, leaving an 8-month gap without the necessary assessment. This deficiency was confirmed during an interview with the Director of Nursing Services, who acknowledged the oversight.
Failure to Administer IV Antibiotics and Saline Flushes as Ordered
Penalty
Summary
The facility failed to follow hospital discharge orders for a resident who required intravenous administration of the antibiotic Meropenem for the treatment of bilateral pyelonephritis with an ESBL infection. Despite having an emergency supply of the medication available, the resident did not receive the scheduled dose at 9:00 p.m. on the day of admission. Interviews with the Administrator, DON, and Infection Preventionist confirmed the availability of the medication in the emergency kit, yet there was no documentation in the clinical record or EMAR indicating that the resident received the required dose. Additionally, the facility did not adhere to physician orders for administering Normal Saline Flushes before and after each medication administration. The resident's EMAR lacked evidence of the Normal Saline Flush being completed as ordered from the date of admission to several days thereafter. This was confirmed during a review of the EMAR with a registered nurse, indicating a failure to provide the necessary intravenous care as prescribed.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. Resident #24's Medicare Part A services ended on December 20, 2024, and Resident #36's services ended on December 26, 2024. However, there was no evidence that either resident received the required SNFABN, which would have informed them of their potential financial responsibility for continued skilled services not covered by Medicare. This oversight was confirmed by the facility's Administrator during an interview with the surveyor on February 25, 2025.
Failure to Develop Care Plan for Atrophic Vaginitis
Penalty
Summary
The facility failed to develop a care plan for a resident's current medical problem of Atrophic Vaginitis, which required physician-ordered treatment. The resident's clinical record, reviewed on January 2, 2025, indicated that Atrophic Vaginitis was identified as a current problem in physician progress notes dated October 1, 2024, and December 5, 2024. The condition required daily treatment with creams and a gel, and the resident experienced vulva pain and vulvovaginal irritation. Despite this, the care plan lacked any problem, goal, or interventions related to the Atrophic Vaginitis. The Director of Nursing confirmed the absence of this information in the care plan during an interview with the surveyor.
Failure to Follow Physician Orders for Diet and Mobility Assistance
Penalty
Summary
The facility failed to follow physician orders for a resident who required a low sodium diet and assistance to get out of bed for meals. On 4/8/24, the resident's cardiologist ordered a low sodium diet, but the resident continued to receive a regular diet with salt packets on their meal trays from 4/15/24 to 4/22/24. Additionally, the same cardiologist ordered the resident to be assisted out of bed and into a chair for meals starting on 4/8/24. However, this order was not followed until 4/19/24, as indicated by the resident's Treatment Administration Record (TAR). Interviews with the resident and the Food Service Supervisor confirmed these discrepancies, and the Director of Nursing acknowledged the oversight during a discussion with the surveyor on 4/22/24.
Exposed Heating Elements in Baseboard Heaters
Penalty
Summary
The facility failed to ensure that the resident's environment was free from accident hazards related to baseboard heaters in disrepair with heating elements exposed. During observations on 4/22/24 between 11:30 a.m. and 11:50 a.m., it was noted that five rooms had baseboard heaters with missing connectors, exposing heating elements. Additionally, one room had a baseboard heater with an end cap off and a mattress bumper torn, creating an uncleanable surface. The B-Unit dining room also had baseboard connectors missing, exposing heating elements. These findings were discussed with the Director of Nursing at 12:45 p.m. on the same day.
Failure to Follow Physician Assistant's Order for Neurological Follow-Up
Penalty
Summary
The facility failed to follow a Physician Assistant's order for a resident. The resident had an order dated 3/14/24 for a neurological follow-up due to post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. Upon review of the clinical record on 4/9/24, there was no evidence that an appointment with neurology had been made. The Administrator confirmed the absence of evidence that this order was followed during an interview with the surveyor on the same day.
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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