Edgewood Rehab & Living Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Maine.
- Location
- 221 Fairbanks Rd, Farmington, Maine 04938
- CMS Provider Number
- 205131
- Inspections on file
- 14
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Edgewood Rehab & Living Ctr during CMS and state inspections, most recent first.
The facility was found to have multiple deficiencies in maintaining a sanitary and comfortable environment. Issues included debris in laundry room lights, untreated surfaces, soiled fans, chipped toilet seats, and missing floor tiles. Several resident rooms had peeling laminate, soiled wheelchairs, and damaged walls and heaters, creating uncleanable surfaces. These findings were confirmed by the Administrator and Maintenance Director.
The facility failed to monitor and maintain appropriate storage temperatures for medications and biologicals, as required by policy and USP guidelines. Logs from August to October showed missing temperature readings and temperatures out of range, confirmed by the DON.
The facility's kitchen was found to be unsanitary, with issues such as a soiled fan, chipped paint on a food mixer, and dirty ceiling vents. Additionally, there were lapses in monitoring and documenting refrigerator/freezer temperatures, dishwasher cycles, and sanitizer levels, as confirmed by the Food Service Director.
The facility failed to maintain sanitary garbage storage areas over three days. Observations included missing or open doors on dumpsters, exposed trash, and scattered plastic and paper waste around the dumpsters. Trash was also stored in an open top cart outside the laundry room exit. The Administrator confirmed these findings during interviews.
The facility's Quality Assurance Committee failed to implement an effective Plan of Correction for deficiencies identified in a previous survey. Persistent issues included inadequate housekeeping, failure to develop timely care plans, lack of resident monitoring post-fall, improper medication storage, unsanitary kitchen conditions, and failure to offer vaccines to residents. These deficiencies were noted during a revisit survey, indicating that corrective actions were not successfully executed.
The facility failed to implement its pneumococcal immunization policy for three residents, as their records lacked evidence of receiving the PCV 20 vaccine or related documentation. This deficiency was confirmed during an interview with the Infection Preventionist and DON, highlighting a lapse in following established vaccination protocols.
The facility did not offer updated COVID-19 vaccine doses to five residents, despite their policy requiring it. The residents' clinical records showed no evidence of being offered the updated 2023-2024 vaccinations, even though some had been diagnosed with COVID-19. This was confirmed during an interview with the DON and the Infection Preventionist.
The facility failed to conduct post-fall neurological assessments and appropriate fall assessments for three residents with cognitive impairments who experienced unwitnessed falls. Additionally, the facility did not follow physician orders for a resident who was supposed to wear a knee brace when out of bed. The absence of required documentation and adherence to physician orders was confirmed by staff interviews and record reviews.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident with a history of stroke, dementia, and atrial fibrillation. The resident was on multiple medications, but no care plan was in place to ensure safe and effective care. This was confirmed by the DON.
A survey found that a Soiled Utility room in an LTC facility was unlocked, with cabinets containing hazardous chemicals also unlocked. CNAs confirmed that the key was kept above the door and that the room and cabinets should have been locked. The MSDS for these chemicals indicated they should be kept out of reach of children, highlighting a failure to maintain a safe environment.
The facility did not post daily nurse staffing information, missing details on the total number and actual hours worked by RNs, LPNs, and unlicensed staff responsible for resident care. This was observed on two survey days and confirmed with the DON.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in several areas, as observed during an Environmental Tour. The laundry room had debris in the ceiling lights and an untreated wooden stand under the washing machine's chemicals, creating an uncleanable surface. The large dining room's standing floor fan was heavily soiled with dust and dirt. The bathroom near the nurses' station had a chipped toilet seat and a heavily soiled floor. In the whirlpool room, floor tiles were missing along the wall edge, and a ceiling tile had a large brown stain. In several resident rooms, various issues were noted, including peeling laminate on a bed footboard, soiled floor fans, and broken surface protectors on door jambs. Some resident wheelchairs were soiled or had damaged armrests. Walls in certain rooms were marred, chipped, and gouged, creating uncleanable surfaces. Additionally, baseboard heaters had chipped or missing paint, and some entrance doors were chipped or gouged. These findings were confirmed by the Administrator and the Maintenance Director during the tour.
Medication Storage Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored at appropriate temperatures, as required by their policy and the United States Pharmacopeia (USP) guidelines. During an observation of the medication storage room, a refrigerator containing insulin, influenza vaccinations, and Tuberculin Purified Protein was found. The Registered Nurse (RN) stated that refrigerator temperatures are checked twice daily, but the facility's Medication Refrigerator log showed otherwise. The logs from August 2024 to October 2024 lacked evidence of temperatures being monitored twice daily and showed that temperatures were not maintained within the required range. Specifically, in August 2024, temperature readings were missing for 16 out of 31 days, and temperatures were out of range for 11 days. In September 2024, temperature readings were missing for 17 out of 30 days, and temperatures were out of range for 11 days. In October 2024, temperature readings were missing for 5 out of 15 days, and temperatures were out of range for 2 days. These findings were confirmed with the Director of Nursing, indicating a systemic issue in monitoring and maintaining the appropriate storage conditions for medications and biologicals.
Kitchen Sanitation and Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour. The surveyor noted several issues, including a heavily soiled standing floor fan, a food mixer with chipped paint, and dirty ceiling vents and fans. Additionally, the kitchen office had a ceiling light missing its lens and lacked bulb protectors, while some ceiling tiles were stained. The reach-in freezer had an open bag of french fries, and the walk-in cooler door threshold was rusty and broken. These observations were confirmed by the Administrator during an interview. The facility also failed to monitor and document the temperatures of the walk-in freezer and refrigerator, as well as the dishwasher wash and rinse cycle temperatures and chemical sanitizer levels. The review of logs for July, August, September, and October 2024 revealed missing entries for refrigerator/freezer temperatures, sink/bucket sanitizer levels, and daily high-temperature ware wash checklists. These lapses in monitoring and documentation were confirmed by the Food Service Director during an interview.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain garbage storage areas in a sanitary condition, which was observed over three consecutive days. On the first day, a surveyor noted that the large trash dumpster had a missing or open left side slide door and an open top left front door, exposing trash. Additionally, a small dumpster had its front right top open, and there was plastic and paper trash scattered on the ground around the dumpsters. Trash was also stored in an open top cart outside the laundry room exit. The Administrator confirmed these findings during an interview. On the second day, the surveyor observed the left side door missing and the right side door of the large trash dumpster fully open, again exposing trash. Plastic and paper trash were still present on the ground around the dumpster. The Administrator confirmed these observations in a subsequent interview. On the third day, the surveyor found the left side door of the large trash dumpster missing and fully open, with trash exposed. The ground around the dumpster continued to have plastic and paper trash scattered. Trash was also observed in an open top cart outside the laundry room exit. The Administrator confirmed these findings during an interview.
Quality Assurance Failures in Implementing Plan of Correction
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for deficiencies identified during the annual Long Term Care Recertification Survey. During a revisit survey, several issues were found to persist, indicating that the corrective measures were not successfully implemented. Specifically, the facility did not maintain adequate housekeeping and maintenance services, as evidenced by the failure to keep the interior sanitary, orderly, and comfortable. Additionally, the facility did not develop and implement baseline care plans within 48 hours for new admissions, which are necessary to provide essential healthcare information. Further deficiencies included the failure to monitor residents after a fall, despite staff education on the Neurological Assessment and Fall Policies. The facility also did not ensure proper storage and temperature monitoring of medications and biologics, as required by pharmacy policies. The kitchen was not maintained in a clean and sanitary manner, and the facility failed to identify residents who were not offered the vaccine. Moreover, the Infection Preventionist did not ensure that residents were educated about, offered, and administered the updated COVID-19 vaccines for 2024-2025.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for three out of five residents whose immunization records were reviewed. The policy required that each resident, or their legal representative, receive educational material about the benefits and potential side effects of the vaccines, with documentation of receipt and understanding. Additionally, the policy mandated that each resident be offered a pneumococcal vaccine upon admission unless contraindicated or previously immunized. However, the clinical records for Residents #18, #19, and #28 lacked evidence that the PCV 20 vaccine was current, offered, or administered as per the facility's policy. The deficiency was confirmed during an interview with the Infection Preventionist and the Director of Nursing. The surveyor found that the facility did not adhere to its own immunization procedures, as the required documentation and vaccine administration were not evident in the residents' records. This oversight indicates a failure to follow established protocols for ensuring residents receive necessary vaccinations, potentially impacting their health and safety.
Failure to Offer Updated COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer updated COVID-19 vaccine doses to five residents, as required by their policy. The policy, revised on 5/7/24, mandates that the facility educate residents and staff on vaccines and offer updated vaccines to all residents. However, during an interview with the Director of Nursing and the Infection Preventionist, it was confirmed that the updated 2023-2024 COVID-19 vaccinations were not offered to the residents reviewed. Resident #7, who was diagnosed with COVID-19 on 9/5/24, had their last documented COVID-19 vaccination on 12/21/23. Resident #15's last documented vaccination was on 12/20/22, and Resident #18, diagnosed with COVID-19 on 9/9/24, had their last vaccination on 10/20/22. Resident #19's last vaccination was on 7/8/22, and Resident #28, also diagnosed with COVID-19 on 9/9/24, had their last vaccination on 9/20/23. In all these cases, the clinical records lacked evidence of offering the updated COVID-19 vaccination, indicating a failure to comply with the facility's vaccination policy.
Failure to Conduct Post-Fall Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to complete post-fall neurological assessments and appropriate fall assessments for three residents who experienced falls. Resident #17, with severe cognitive impairment, had four unwitnessed falls, yet the facility did not continue monitoring for further injuries or neurological changes as required by their policy. The Director of Nursing and Quality Improvement Specialist confirmed the absence of post-fall observation tools and daily nursing notes for three days following each fall. Similarly, Resident #3, with moderate cognitive impairment, experienced an unwitnessed fall, and the facility did not document the incident in the nurse's notes for the subsequent three shifts as per policy. Resident #333, with severe cognitive impairment, also experienced an unwitnessed fall, and the facility failed to monitor for further injuries or neurological changes. Additionally, the facility did not follow physician orders for Resident #18, who was supposed to wear a knee brace on the left knee when out of bed. Despite a physician's order dated 9/24/24, the resident was observed without the knee brace while in a wheelchair. Interviews with a CNA and the resident confirmed that the knee brace was never provided. The Quality Improvement Specialist verified that the facility was not adhering to the physician's order for the knee brace, indicating a failure to provide appropriate treatment and care according to orders.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was newly admitted. The resident, who was admitted on July 12, 2024, had a medical history of an acute ischemic stroke with mild left upper extremity weakness, difficulty swallowing, mixed Alzheimer's and vascular dementia with agitation, and was newly anticoagulated for atrial fibrillation. The resident was prescribed an anticoagulant, antidepressant, beta blocker, and an opioid. As of October 17, 2024, there was no evidence of a baseline care plan that included the necessary instructions to provide safe and effective care for the resident. This information was confirmed with the Director of Nursing on October 17, 2024.
Unlocked Storage of Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that doors were locked where potentially dangerous chemicals were stored, as observed during a survey. On the Long-Term Care unit, the Soiled Utility room was found unlocked, containing cabinets with unlocked padlocks. These cabinets housed various cleaning and disinfectant products, including Eco lab Rapid Multi Surface Disinfectant cleaner, 3M Glass cleaner, Simplex scour power and instant chlorine bleach, WD-40, True Clean Emerald Optically Enhanced floor cleaner, and Apollos Power Clean Industrial Grade cleaner & detergent. The Material Safety Data Sheets for these products indicated that they should be kept out of reach of children and required specific first aid measures in case of exposure. During an interview, two Certified Nursing Assistants confirmed that the key to the Soiled Utility room was kept above the door and that the door should have been locked. They also stated that the padlocks on the cabinets inside the room were supposed to be locked. This oversight was discussed with the Administrator, highlighting a lapse in maintaining a safe environment free from accident hazards, as required by regulations.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff responsible for direct resident care. This deficiency was observed on two out of three survey days. On October 15 and 16, 2024, a surveyor noted that the nurse staffing information posted at the main entrance lacked the required details for Registered Nurses, Licensed Practical Nurses, and unlicensed nursing staff. This issue was confirmed with the Director of Nursing on October 16, 2024, at 9:26 a.m.
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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