Hibbard Skilled Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover Foxcroft, Maine.
- Location
- 1037 West Main Street, Dover Foxcroft, Maine 04426
- CMS Provider Number
- 205004
- Inspections on file
- 28
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Hibbard Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s clinical record was found to be incomplete and inaccurate when staff documented pacemaker monitor checks on the TAR using a code indicating “drug not available,” which was inappropriate for this treatment and acknowledged as incorrect by the RN. In addition, a surveillance UA dip ordered to verify resolution of a UTI was signed off as completed, but no UA result was documented in the record or attached to the physician order, and the RN reported he performed the test but did not chart or file the machine-generated results.
A resident with dementia, visual loss, and a history of falls was not provided with hip protectors as required by their care plan and physician orders. Staff interviews revealed a lack of awareness and follow-through regarding this intervention, and it was confirmed during the survey that the resident was not wearing hip protectors, despite being at high risk for falls.
A resident with chronic leg ulcers was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy, despite ongoing wound care orders and a care plan indicating EBP should be followed. Staff interviews revealed confusion about the resident's precaution status, and no EBP signage was posted outside the room.
A resident's clinical record and care plan contained inaccurate information regarding the location of a venous ulcer for several months. Although treatment and physician notes consistently referenced the right lower leg, nursing documentation and the care plan incorrectly identified the left lower leg as the site of the wound. The error persisted through multiple care plan revisions and was confirmed by nursing staff during a record review.
The facility did not provide or document adequate assistance and follow-up for several residents and their representatives regarding the completion of advanced directives, including cases involving cognitively impaired individuals and those whose families were involved in decision-making. Staff interviews confirmed the lack of documentation and follow-up in the clinical records.
The facility did not ensure that two residents received required PASRR-related services or referrals after changes in mental health status or diagnosis. One resident did not receive or have documented specialized services as recommended in their PASRR Level II, while another was not referred for a new PASRR Level II after new suicidal behaviors and a new schizophrenia diagnosis. Staff interviews and record reviews confirmed these deficiencies.
A resident with recent surgical wounds and pressure ulcers received wound care from an RN without documented physician orders for the right arm surgical incision and left heel pressure ulcer. Review of the clinical record confirmed the absence of necessary orders, and the RN acknowledged the oversight during a surveyor review.
Two residents with PTSD did not receive timely trauma-informed assessments, individualized care planning, or appropriate behavioral health referrals, despite documented episodes of suicidal ideation and psychiatric symptoms. Facility staff did not complete required trauma assessments or make necessary referrals to counseling or external providers, resulting in unmet mental health needs.
The facility did not consistently monitor and record temperatures in the walk-in refrigerator and freezer as required by policy, with multiple missing entries over two months. The Dietary Manager confirmed the lapses in temperature logging, citing challenges with staff compliance.
The facility failed to assess and document the clinical appropriateness of self-administration of medications for two residents. In both cases, medications were kept at bedside and self-administered without required IDT assessments, physician orders, or care plan documentation, as confirmed by staff interviews and record reviews.
A resident with multiple complex medical conditions, including recent surgery, wounds, and use of anticoagulants, was admitted without a baseline care plan developed and implemented within 48 hours. The care plan did not address the resident's immediate needs such as cardiac issues, pain, wound care, diabetes, or therapy services, despite active physician orders and observed bleeding from a surgical site.
A resident with ALS on hospice care, who actively smokes and declined smoking cessation, did not have a Safe Smoking Evaluation completed as required by facility policy. The absence of this evaluation was confirmed by both the resident and the Skilled Nursing Manager.
A resident with a Foley catheter and urinary retention showed signs of a possible UTI, including a foul-smelling, sediment-filled catheter bag and a change in mental status. Although nursing staff documented the need for a urinalysis to rule out infection, there was no evidence that a physician was notified or that the urinalysis was completed.
Two residents with significant pain needs did not receive appropriate pain management due to failures in monitoring medication interactions and ensuring timely access to prescribed pain medications. One resident experienced unmanaged pain and severe drug interaction warnings were not addressed, while another resident went extended periods without pain medication due to stock issues, resulting in distress and inability to tolerate necessary care.
Surveyors found expired, unlabeled, and improperly stored medications on a treatment cart, including open and undated normal saline, expired wound dressing and arthritis relief cream, unrefrigerated insulin vials, and an opened package of lidocaine jelly in an unsealed bag. An LPN confirmed these items were available for use and could not verify how long the insulin had been unrefrigerated.
Surveyors observed that a resident's wound dressing change was performed in a room where soiled linens were left unbagged on the floor, and a pillow with a blood-stained pillowcase was used to support the resident's leg. The RN stepped on the soiled gown while washing hands and did not bring adequate supplies, and staff failed to remove the soiled linens throughout the observation, resulting in a breakdown of infection control practices.
Two residents were not offered the updated PCV20 vaccine as required by facility policy and CDC recommendations. Documentation showed that both had received earlier pneumococcal vaccines, but there was no evidence that PCV20 was offered, administered, or refused. The Administrative Coordinator believed prior vaccination with PCV13 was sufficient, leading to the omission.
The facility did not thoroughly investigate injuries of unknown origin for two residents, including a case involving multiple fractures after a hospital stay and another involving a large hematoma following an unwitnessed fall. Required interviews and documentation were missing, and there was insufficient evidence that the incidents were properly assessed or investigated as potential abuse or neglect.
Surveyors identified incomplete and inaccurate clinical documentation for five residents, including missing provider assessments after resident altercations, care plans not updated for behavioral issues, discrepancies in psychotropic medication diagnoses, and inconsistent documentation of physician orders and treatments such as I&O, weights, wound care, and insulin administration. Staff interviews confirmed these documentation lapses.
A resident with functional quadriplegia sustained a second-degree burn after accidentally spilling hot coffee on their thigh. Despite this incident, the care plan was not updated to address the new safety risk related to the resident independently handling hot beverages, as confirmed by the DON.
A facility failed to update the care plan for a resident with chronic constipation and dementia. Despite having multiple physician orders for bowel management, the resident was transferred to acute care for constipation and fecal impaction. Upon return, the care plan was not updated to reflect new orders, including discontinuing Ducosate and adding Miralax. The administrator confirmed the care plan did not address the resident's constipation issues.
A resident experienced a skin tear incident, but the facility failed to document the event accurately and timely as required by their policy. The incident occurred when the resident attempted to stand from a wheelchair and hit their leg, causing a skin tear. The clinical record lacked an Accident/Incident report, and a late entry was made weeks later, which was not documented correctly.
The facility failed to prevent COVID-19 transmission by allowing fans and air conditioners to blow air from infected residents towards their uninfected roommates. Staff recognized the need for closed doors but overlooked the direction of airflow within rooms.
The facility failed to maintain a clean and well-repaired environment, with surveyors noting chipped furniture, soiled fans, and torn chairs. Uncleanable surfaces and persistent odors were observed, indicating inadequate housekeeping and maintenance services.
The facility failed to follow physician orders for medications and treatments for several residents. A resident did not receive Prazosin for 25 days due to pharmacy issues, while another missed multiple doses of various medications due to unavailability and prescription renewal problems. Additionally, a resident's Eliquis was held and restarted incorrectly, another received unnecessary insulin, and daily weight checks were not completed for a resident. These issues were confirmed by staff and surveyors.
A facility failed to accurately code the MDS 3.0 for a resident, resulting in a deficiency. The resident had a Level II PASRR and PTSD, but these were not correctly reflected in the admission and annual MDS assessments. The error was confirmed during a review and interview with the MDS Coordinator, who acknowledged the inaccurate entry of information into the resident's clinical record.
A facility failed to create a care plan for a resident with PTSD, as identified during a survey. The resident's records confirmed the PTSD diagnosis and a past trauma assessment, but no care plan was found to address potential triggers or interventions for re-traumatization. This deficiency was confirmed during an interview with a surveyor.
A facility failed to follow physician orders for a resident's positioning needs, as a wedge pillow prescribed to maintain proper positioning and prevent shoulder issues was not in use. The resident reported difficulty maintaining position and reaching items without the pillow, which had been missing for some time. Observations confirmed the absence of the required support equipment, despite clinical records and care plans indicating its necessity.
A facility failed to maintain an oxygen concentrator per manufacturer's directions for a resident using oxygen. The concentrator was observed missing the cabinet filter compartment, which is necessary for proper operation. This issue persisted over several days, indicating non-compliance with the maintenance schedule.
A facility failed to complete a physician-ordered urinalysis for a resident. The order was placed due to suspected infection symptoms, but there was no evidence of urine collection until a later date. The LTC Manager confirmed the oversight during an interview.
The facility failed to accurately document weights for two residents reviewed for weight loss concerns. One resident's record showed a 51% weight loss over 30 days with fluctuating weights, while another resident's record indicated significant weight loss despite high meal consumption. The LTC Manager confirmed inaccuracies in the recorded weights.
A facility failed to inform a resident's representative about two new Stage II pressure ulcers. A nurse's note documented the ulcers, but there was no evidence that the resident's son was notified. The Administrator confirmed the lack of notification.
Incomplete and Inaccurate Documentation of Pacemaker Monitoring and Urinalysis Results
Penalty
Summary
The deficiency involves incomplete and inaccurate clinical records for a resident related to pacemaker monitoring and urinalysis documentation. On review of the February Treatment Administration Record (TAR), the order to check that the resident’s pacemaker monitor was plugged in once per evening shift was documented on two dates with staff initials and a code of “2,” indicating “drug not available,” which was not appropriate for this type of treatment. During interview, the RN who documented these entries acknowledged that both entries were incorrect and could not explain why the “drug not available” code was used for the pacemaker monitor check, and the surveyor confirmed this inaccurate documentation. Additionally, the TAR contained an order for a surveillance urinalysis (UA) dip with instructions to follow up with a culture if positive to ensure a urinary tract infection was resolved. The TAR showed staff initials indicating the UA dip was performed on one date, but the clinical record and the corresponding physician order lacked any evidence of the UA dip result. In an interview, the Skilled Unit Manager reported that the RN who performed the treatment stated he completed the UA dip but did not chart the result because nothing appeared in the system for him to document after signing off the treatment, nor did he print and file the machine-generated results with the physician order. The surveyor confirmed the absence of documentation for the UA dip result in the record.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive care plan for fall prevention. The resident, who has diagnoses including dementia, visual loss, and a history of falls, was identified as high risk for falls due to factors such as poor balance, unsteady gait, blindness, and dementia. The care plan and physician orders specified that the resident should have hip protectors in place at all times unless being laundered. However, during the survey, it was observed that the resident was not wearing hip protectors as required. Interviews with staff revealed a lack of awareness and follow-through regarding the use of hip protectors for this resident. A CNA stated she was only aware of fall mats and a low bed as interventions, and upon inspection, confirmed the absence of hip protectors. An RN acknowledged that the resident was supposed to have hip protectors but had not had them since transferring to the current unit several months prior. The LTC manager also confirmed the resident should have had hip protectors in place but was unsure why they were not being used.
Failure to Follow Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to maintain its Infection Control Program by not following its own Enhanced Barrier Precautions (EBP) policy for a resident with chronic wounds. According to the facility's policy, EBPs are required for residents with wounds, and these precautions should remain in place for the duration of the wound or the resident's stay. The policy also requires staff training and the posting of signage outside the resident's room indicating the type of precautions and required PPE. During the survey, it was observed that there was no EBP sign posted outside the room of a resident with chronic right leg ulcers, and a Certified Nursing Assistant confirmed that the resident was not on any type of precautions, despite the care plan indicating the need to follow EBP. Further review of the resident's medical records showed ongoing physician orders for wound care and documentation of wound treatments provided by a Registered Nurse. Interviews with staff revealed confusion regarding the resident's EBP status, with the nurse stating that the resident was previously on EBP but was removed when the wounds improved, and the Infection Preventionist indicating that EBP was not needed if the wound was not draining. These actions and inactions resulted in the facility not adhering to its own infection control policy for residents with wounds, as required.
Inaccurate Documentation of Venous Ulcer Location in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained accurate and complete information regarding the location of a venous ulcer over a seven-month period. Documentation provided to the surveyor indicated that the resident had a chronic ulcer being treated on the right lower extremity, and physician progress notes consistently referenced treatment for right lower leg wounds. However, a progress note written by a registered nurse on 10/3/25 incorrectly documented treatment on the left lower leg and noted a new abrasion on that leg. The care plan also inaccurately identified the left lower leg as the site of the venous wound, despite ongoing treatment and documentation indicating the wound was on the right lower leg. Further review of the care plan revealed that the focus on the left lower leg had been in place since 10/2/24 and was revised multiple times, but continued to reference the incorrect extremity. The goals and interventions under this focus were also updated without correcting the error. During the record review, the registered nurse confirmed that the resident had never had a venous wound on the left leg and acknowledged the documentation error in both the care plan and the progress note. The surveyor verified that the clinical record and care plan did not accurately reflect the correct location of the venous wound.
Failure to Assist and Document Follow-Up on Advanced Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received appropriate assistance and follow-up regarding the completion of advanced directives, as required by facility policy. For five out of seven residents reviewed, documentation was lacking to show that staff offered or followed up on assistance to complete advanced directives or to ensure that residents' wishes regarding the right to accept or refuse medical or surgical treatment were addressed. In several cases, residents indicated they did not have an advanced directive and either planned to look into it or had a family member working on it, but there was no evidence in the medical record of further follow-up or documentation of outcomes. One resident with cognitive impairment and a listed representative declined to have an advanced directive, but there was no documentation that the representative was followed up with regarding the resident's rights. In other cases, residents or their families stated they would provide or were working on the necessary documents, but the clinical records did not reflect any follow-up or confirmation of completion. Interviews with facility staff, including the Social Services Director and Licensed Social Worker, confirmed the absence of documented notes or evidence of follow-up actions related to advanced directives for these residents.
Failure to Coordinate PASRR Services and Referrals After Mental Health Changes
Penalty
Summary
The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for two residents. For one resident, the PASRR Level II evaluation recommended specialized services including individual therapy, neuropsychiatric evaluation, rehabilitative therapies, and supportive counseling. However, the clinical record did not show evidence that these services were offered, provided, refused, or addressed in the resident's assessments or care planning. Interviews with facility staff confirmed the absence of appointments, referrals, or documentation related to these specialized services. For another resident, the clinical record indicated a history of suicidal talk and behaviors, a new diagnosis of schizophrenia, and recent incidents of suicidal ideation. Despite these changes, there was no evidence that the facility referred the resident for a new PASRR Level II determination as required after a significant change in mental health status or diagnosis. The PASRR assessment was not updated to reflect the resident's current condition, and required services such as psychiatric evaluation and individual therapy were not documented as provided or addressed in the care plan.
Wound Care Provided Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders for the treatment of a surgical wound and a pressure ulcer for a resident who was recently admitted with multiple complex wounds, including surgical incisions and pressure ulcers. During an observation of dressing changes, a registered nurse performed wound care on the resident's right arm surgical incision and left heel pressure ulcer without documented physician orders for these treatments. A review of the clinical record and Treatment Administration Record confirmed the absence of orders for these specific wound care treatments. The nurse acknowledged the lack of orders and was unable to locate any active orders for the required wound care.
Failure to Provide Trauma-Informed Care and Timely Behavioral Health Referrals for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD), as evidenced by multiple missed opportunities to assess, refer, and address the mental health needs of two residents. One resident had a documented history of suicidal ideation, hallucinations, and an active diagnosis of PTSD, yet there was no evidence of timely referrals for behavioral health services, counseling, or follow-up with external providers such as Acadia or the VA. Despite repeated episodes of suicidal speech and behavior, as well as recommendations for mental health counseling, the facility did not initiate appropriate referrals or interventions from admission through several months of the resident's stay. Clinical documentation revealed that the resident experienced severe psychiatric symptoms, including visual hallucinations and multiple expressions of suicidal intent, but the facility's response was limited to medication administration and basic medical workup. There was no documentation that the resident's PTSD was addressed during these episodes, nor that a trauma-informed assessment was completed. The Pre-admission Screening and Resident Review (PASRR) also indicated a need for individual therapy, but no evidence was found that the facility made the required referrals until several months later. A second resident with an active PTSD diagnosis also did not receive a trauma-informed care plan that identified or addressed their specific triggers. The social services staff confirmed that trauma assessments were not completed based on the resident's current diagnosis, and the care plan lacked individualized interventions related to PTSD. The facility's own policy required in-depth assessment and care planning to minimize re-traumatization, but these steps were not followed for either resident.
Failure to Monitor and Record Food Storage Temperatures
Penalty
Summary
The facility failed to consistently monitor and record temperatures in the walk-in refrigerator and freezer as required by its own food storage policy, which mandates that temperatures be checked and logged twice daily to ensure food safety. Specifically, temperature logs for January and February 2025 showed missing entries for both the refrigerator and freezer on multiple dates and times, with no evidence that temperatures were taken or recorded as required. The Dietary Manager confirmed these omissions during a review of the logs, stating that there were difficulties ensuring compliance with the logging process by the cook responsible at the time. These findings were also acknowledged during an interview with the Administrator.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for two residents to self-administer medications and keep medications at bedside. For one resident, a medication technician stated there was an order for self-administration, but the care plan did not reflect this, and there was no documented assessment or care plan intervention for self-administration. The resident's clinical record lacked evidence of a self-administration assessment, a physician order for self-administration, and documentation in the care plan. The Long Term Care Unit Manager confirmed these findings during a review of the resident's record. For another resident, a bottle of eye drops was observed at bedside, but the clinical record did not contain an order for self-administration, an IDT assessment, or care plan documentation for self-administration. The medication administration record also lacked evidence of administration of the eye drops. The resident reported self-administering the drops, and an LPN confirmed that the record lacked the required order and assessment for self-administration. These findings were discussed with facility staff and confirmed through interviews and record review.
Failure to Develop and Implement Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with multiple complex medical conditions. The facility's policy requires a baseline care plan to be created within 48 hours to address immediate health and safety needs, including initial goals, physician and dietary orders, therapy and social services, and any relevant recommendations. However, for one resident recently admitted with diagnoses such as coronary artery disease, chest pain, COPD, diabetes, neuropathy, acute and chronic pain, peripheral artery disease, recent lower extremity bypass surgery, surgical incisions, arterial wound, and stage 2 pressure ulcers, the baseline care plan did not include goals or interventions for these conditions. Observation revealed the resident had active bleeding through a dressing on the left lower extremity and reported being on two anticoagulants. Review of the clinical record showed multiple active physician orders for pain management, COPD, chest pain, DVT prophylaxis, blood glucose monitoring, and wound care. Despite these needs, the baseline care plan lacked evidence of interventions for the resident's cardiac issues, anticoagulant use, COPD, diabetes, pain, wound care, nutrition, or therapy services. These concerns were confirmed during an interview with the Director of Nursing.
Failure to Complete Safe Smoking Evaluation for Resident Who Smokes
Penalty
Summary
The facility failed to complete a Safe Smoking Evaluation for a resident who actively smokes cigarettes. According to the facility's Smoking Policy, each resident's smoking status must be evaluated upon admission, including an assessment of their ability to smoke safely with or without supervision, documented through a completed Safe Smoking Evaluation. A review of the resident's clinical record showed no evidence that this evaluation was performed, despite the resident having a diagnosis of Amyotrophic Lateral Sclerosis (ALS), being on hospice for palliative care, and declining smoking cessation. The resident confirmed during an interview that they continue to smoke when able, and the Skilled Nursing Manager acknowledged that the required evaluation had not been completed.
Failure to Notify Physician of Suspected UTI in Catheterized Resident
Penalty
Summary
The facility failed to notify the physician of a suspected urinary tract infection (UTI) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including benign prostatic hyperplasia, urinary retention, obstructive uropathy, and a Foley catheter, exhibited signs suggestive of a UTI, such as a catheter bag full of sediment and a foul odor. A nursing progress note documented the need to rule out a UTI and recommended a urinalysis, but there was no evidence in the clinical record that the physician was notified or that a urinalysis was performed. Additionally, the resident's representative reported being informed by staff about plans to check for a UTI due to a change in mental status, but received no follow-up information.
Failure to Implement and Monitor Safe Pain Management Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with significant pain needs. For one resident with chronic pain related to end-stage liver failure, the care plan identified the need for pain management, and the resident was prescribed both oxycodone and a buprenorphine transdermal patch. Multiple severe drug interaction warnings were triggered in the electronic medical record regarding the concurrent use of these medications, but there was no evidence that these warnings were reviewed or discussed with the provider. The resident continued to report increased pain and even exhibited suicidal behaviors due to unmanaged pain, yet the facility did not monitor or revise the pain management interventions as necessary. Another resident, recently admitted with acute and chronic pain following lower extremity bypass surgery and with multiple wounds, had orders for both scheduled and PRN oxycodone. The resident reported not receiving pain medication for extended periods, including a 12-hour gap, due to the medication not being available in the facility. The resident expressed distress and was unable to tolerate dressing changes due to inadequate pain control. Documentation confirmed gaps in pain medication administration, and staff interviews revealed confusion about medication availability and stock management. In both cases, the facility did not ensure that pain management interventions were implemented, monitored, or revised as needed. There was a lack of communication regarding medication interactions and failures in ensuring timely access to prescribed pain medications, resulting in unmanaged pain for both residents.
Expired and Improperly Stored Medications Found on Treatment Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and removal of expired or improperly stored medications from a treatment cart. Specifically, the cart contained an open, unlabeled, and undated bottle of normal saline irrigation fluid; an open, unlabeled tube of hydrophilic wound dressing with an expiration date of 3/31/25; two sealed multi-use vials of insulin (glargine and lispro) labeled for refrigeration but found unrefrigerated, with the LPN unable to determine how long they had been out; a tube of arthritis relief cream expired as of 1/2025; a tube of triamcinolone acetonide labeled to be discarded after 11/28/24; and an opened package of lidocaine jelly in an unsealed zip lock bag dated 4/4/25. These items were available for use on the cart at the time of the surveyor's review, and the LPN confirmed their presence and status.
Failure to Maintain Infection Control During Wound Care and Linen Handling
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices during a wound dressing change and in the handling of soiled linens. During the dressing change for Resident #333, a soiled gown and an open trash bag containing soiled linen were found unbagged and lying on the floor under the sink. The registered nurse performing the dressing change stepped on the soiled gown while washing her hands and then proceeded with the dressing change without addressing the contamination. Additionally, a pillow with a dried blood-stained pillowcase, which the resident reported using for sleep, was used to support the resident's leg during the procedure. The pillowcase was only changed after the surveyor intervened. Throughout the observation, multiple staff members entered and exited the room but did not remove the soiled linens from under the sink. The registered nurse admitted to not bringing adequate supplies for the dressing change, as the resident was previously able to support their own leg. These actions and inactions resulted in a failure to provide a sanitary environment and to prevent the potential development and transmission of infection, as required by the facility's infection prevention and control program.
Failure to Offer Updated Pneumococcal Vaccination per Policy and CDC Guidelines
Penalty
Summary
The facility failed to offer the updated Pneumococcal Conjugate Vaccine (PCV20) to two residents, despite both the facility's policy and current CDC recommendations requiring assessment and offering of the vaccine. According to the facility's policy, residents are to be assessed for pneumococcal vaccination status upon or prior to admission, and the appropriate vaccine series should be offered within thirty days unless contraindicated or already completed. Documentation review revealed that one resident had previously received PCV13 in 2016 and PPSV23 in 2018, while another had received PCV13 in 2018 and refused PPSV23 in 2022. In both cases, there was no evidence in the clinical records that PCV20 was offered, administered, or refused. During an interview, the Administrative Coordinator stated that PCV20 was not offered to these residents because she believed that receipt of PCV13 meant the residents were up to date with pneumococcal vaccinations. This belief was contrary to both CDC recommendations and the facility's own policy, which require consideration of PCV20 administration based on the timing and type of previous pneumococcal vaccines. The surveyor confirmed that the required vaccine was not offered as indicated by policy and CDC guidelines.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents, as required by its own policies and federal regulations. In the first case, a resident returned from an acute care hospital and was noted to have a swollen, warm left knee, with subsequent imaging revealing a femoral fracture. The resident later also complained of wrist pain, which was found to be an acute angulated right distal radial fracture. Although the facility's 5-day investigation follow-up indicated that interviews were conducted with staff, the resident, and a family member, there was no written documentation to support that these interviews took place. Additionally, the clinical record lacked evidence that the injury was noted in the emergency department, and the facility was unable to determine whether the injuries occurred in the facility or during the hospital stay. In the second case, another resident sustained a large hematoma near the left eye, with no known history of a fall at the time of the incident. The facility's report later noted that the resident had an unwitnessed fall prior to the bruise being noticed, but the bruise was not observed during the initial assessment following the fall. The resident also exhibited increasing confusion and an unsteady gait. The facility's follow-up documentation did not provide evidence of a thorough investigation into the injury of unknown origin. The LTC Unit Manager confirmed that comprehensive investigations were not conducted for these incidents and acknowledged a lack of familiarity with the required follow-up procedures.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents, as evidenced by multiple deficiencies in documentation and care planning. For five residents, there were missing or inaccurate entries in the medical records, including lack of provider assessments, incomplete care plans, and discrepancies in medication documentation. In one instance, after a reported altercation between two residents, the clinical record lacked evidence that both residents were assessed by a provider, and the care plans were not updated to reflect new or ongoing behavioral issues. Additionally, documentation for one resident was found to be a direct copy and paste from another resident's note, further indicating incomplete and inaccurate record-keeping. Another resident's clinical record showed inconsistencies regarding the diagnosis and use of psychotropic medication. The record indicated a new diagnosis of schizophrenia without evidence of an evaluation to confirm this diagnosis, and the provider was unable to explain the origin of the diagnosis. Furthermore, the social services documentation inaccurately stated that the resident was not receiving psychotropic medications, despite evidence to the contrary, and the PASRR contained incorrect information about the resident's medical condition. Additional deficiencies were found in the documentation of physician orders and treatment administration. For one resident with a Foley catheter, intake and output measurements and weekly weights were not consistently recorded as ordered. Another recently admitted resident with wounds and diabetes had missing documentation for wound care treatments and insulin administration, with no evidence that treatments were given, held, or refused on several occasions. These findings were confirmed through record reviews and staff interviews, highlighting incomplete and inaccurate clinical documentation for multiple residents.
Failure to Update Care Plan After Resident Burn Incident
Penalty
Summary
The facility failed to update and revise a resident's care plan to address a new safety concern after the resident, who is a functional quadriplegic, accidentally spilled hot coffee on their right lateral thigh, resulting in a second-degree burn. The resident had previously been able to handle their own coffee cup independently. Despite this incident, a review of the resident's current care plan showed that it did not address the new potential safety risk associated with the resident independently handling hot beverages. The Director of Nursing Services confirmed in an interview that the care plan had not been updated to reflect this safety issue.
Failure to Update Care Plan for Constipation Management
Penalty
Summary
The facility failed to update the care plan for a resident with a history of dementia and chronic constipation. The resident had multiple physician orders for bowel management, including a high fiber diet and various laxatives. Despite these measures, the resident was transferred to acute care for evaluation and treatment of constipation and fecal impaction. Upon returning to the facility, the resident's care plan was not updated to reflect the new orders, which included discontinuing Ducosate and adding Miralax. On review, it was found that the current care plan did not address the resident's constipation or potential for fecal impaction. The facility's administrator confirmed that the care plan had not been updated to reflect the resident's increasing problem with constipation. This oversight indicates a failure to adequately manage and document the resident's bowel management needs, leading to a deficiency in care planning.
Incomplete Documentation of Skin Tear Incident
Penalty
Summary
The facility failed to ensure that a clinical record contained complete and accurate information for a resident who experienced a skin tear incident. The facility's policy on Accidents & Incidents required that all incidents be promptly documented and reported, including details such as the date, time, nature of the injury, and any corrective actions taken. However, in the case of the resident with a skin tear, there was no evidence of an Accident/Incident report being completed at the time of the incident. The clinical record only included a nurse's note indicating that the resident's representative was notified of the skin tear, but lacked comprehensive documentation of the incident. Further investigation revealed that the LTC Unit Manager was unable to find any documentation of the incident in the computer system, and there was no record of the wound or the dressing applied. A late entry incident charting was completed several weeks after the incident, but it was not documented timely or correctly. Interviews with staff indicated that the skin tear occurred when the resident attempted to stand up from a wheelchair and hit their leg on the wheelchair frame. The lack of timely and accurate documentation of the incident and the wound care provided constitutes a deficiency in maintaining complete and accurate medical records in accordance with professional standards.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of COVID-19 among residents. During a survey, it was observed that three residents who tested positive for COVID-19 were in rooms with fans or air conditioners blowing air towards their roommates, who were negative for the virus. Specifically, one resident's room had an air conditioner blowing towards the roommate, while two other rooms had fans blowing air towards their respective roommates. The staff, including the Administrator, acknowledged that the doors should remain closed and fans should not blow towards the hallway. However, they did not consider the direction of airflow within the rooms, which could potentially facilitate the spread of the virus to roommates who were not infected. This oversight in infection control measures contributed to the deficiency identified by the surveyors.
Inadequate Housekeeping and Maintenance in LTC Facility
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an environment that was not in good repair or sanitary condition. During environmental tours, surveyors observed several deficiencies, including chipped and missing veneer on bedside tables and dresser drawers, which created uncleanable surfaces. Additionally, fans in multiple rooms were soiled with dust, and fall safety floor mats had soiled and cracked covers. The cove base on the floor was detached from the wall, and room divider curtains were soiled. In the locked unit, torn cloth chairs were found around tables and in hallways, and some chairs had wet spots or dried soiled areas. Specific rooms had small holes in walls, chipped headboards, and soiled bed rails. Baseboard register covers were unsecured, and a bathroom had a persistent urine odor with bulging drywall. Other issues included a soiled chair cover, a soiled arm of a blue chair, and a bent window screen. These observations indicate a lack of proper maintenance and cleaning, compromising the residents' right to a safe, clean, and comfortable environment.
Failure to Follow Physician Orders for Medications and Treatments
Penalty
Summary
The facility failed to ensure that physician orders for medications and treatments were followed for several residents. Resident #39 did not receive Prazosin for 25 days due to the facility's inability to obtain the correct dose from the pharmacy. Resident #22 missed multiple doses of various medications, including Cranberry capsules, Mirabegron, Calcium with Vitamin D3, Memantine, and Tramadol, due to unavailability and prescription renewal issues. Resident #77 also missed a dose of Trazodone because it was not available. The Long Term Care Manager acknowledged ongoing issues with medication availability. Resident #55's Eliquis was held one dose too early and restarted one dose too late, contrary to physician orders. Resident #49 received insulin when it was not needed, as the blood sugar level was below the threshold for administration. Additionally, Resident #50's daily weight checks were not completed as ordered on several occasions, with no evidence of refusal by the resident. These deficiencies were confirmed through interviews with facility staff and surveyors.
Inaccurate MDS Coding for PASRR and PTSD
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) 3.0 for a resident, leading to a deficiency in the assessment process. The resident, who had a state Level II Preadmission Screening and Resident Review (PASRR) and a diagnosis of Post Traumatic Stress Disorder (PTSD), was inaccurately coded in both the admission and annual MDS assessments. The clinical record review revealed that the resident's PASRR Level II, dated 5/2/23, indicated the need for Level II services and documented the PTSD diagnosis. However, the MDS assessments were incorrectly coded to reflect that the resident did not have a Level II PASRR or PTSD. This error was confirmed during an interview with the MDS Coordinator, who acknowledged the inaccurate entry of information into the resident's clinical record, affecting both the admission and annual MDS assessments.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), as identified during a survey. The resident's clinical record included a Level II PASRR and physician progress notes confirming the PTSD diagnosis and a trauma assessment completed a year prior, indicating a past traumatic experience. However, upon review, the Long Term Care (LTC) Manager was unable to locate a care plan addressing potential PTSD triggers or interventions for staff to follow if the resident displayed signs of re-traumatization. This deficiency was confirmed during an interview with a surveyor.
Failure to Follow Physician Orders for Positioning Equipment
Penalty
Summary
The facility failed to adhere to physician orders for a resident's positioning and mobility needs. A resident, identified as R50, was observed on multiple occasions without the prescribed wedge pillow, which was necessary to maintain proper positioning and prevent the resident from lying on their right side due to a shoulder condition. The resident expressed difficulty in maintaining position and reaching items during meals without the wedge pillow, which had been missing for some time. The clinical records confirmed a doctor's order for daily use of the wedge pillow, and the Plan of Care Summary specified the need for positioning support to prevent the resident from lying on the right side. Despite these directives, the wedge pillow was not in use during the surveyor's observations, and the Skilled Nursing Facility Manager confirmed the absence of the required support equipment.
Oxygen Concentrator Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that an oxygen concentrator was operated and maintained according to the manufacturer's directions for a resident using oxygen. The deficiency was identified when a surveyor observed the oxygen concentrator in the resident's room missing the cabinet filter compartment, which is essential for proper operation as per the manufacturer's manual. The manual explicitly states that the concentrator should not be operated without the filter installed. This issue was observed on multiple occasions over several days, indicating a lack of adherence to the prescribed maintenance schedule, which included cleaning the filter and changing the tubing weekly.
Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis was completed for a resident. The physician had ordered a urinalysis on June 17, 2024, suspecting an infection due to the symptoms the resident was experiencing. The order was entered into the computer system to be completed the following day, June 18, 2024. However, the clinical record did not show any evidence that the urine was collected for testing until a subsequent order was received and collected on July 7, 2024. During an interview on July 11, 2024, the Long Term Care Manager confirmed that there was no evidence of the urine being collected and tested on the initially ordered date. This oversight resulted in a delay in the diagnostic process for the resident's suspected infection.
Inaccurate Documentation of Resident Weights
Penalty
Summary
The facility failed to accurately document resident weights for two residents who were reviewed for weight loss concerns. For one resident, the clinical record showed a significant weight loss of 51% over 30 days, with weights fluctuating between 148.4 pounds and 216 pounds over a two-month period. The Registered Dietician noted the difficulty in assessing trends due to these discrepancies. During an interview, the Long Term Care Manager confirmed that several of the weights were inaccurate and acknowledged that a re-weigh should have been conducted. For the second resident, the clinical record indicated a significant weight loss in April, with a 13.7% decrease over 30 days and 14.8% over 90 days. The Registered Dietician questioned the accuracy of the weight, as the resident was consuming 75-100% of meals on average. The Long Term Care Manager noted that the weights did not seem correct, particularly the weight recorded in April, and suggested that the resident probably did not experience such a significant weight loss.
Failure to Notify Resident's Representative of New Pressure Ulcers
Penalty
Summary
The facility failed to inform a resident's representative about the development of two new Stage II pressure ulcers. On October 18, 2023, a nurse's note documented the presence of two new open skin areas on a resident: one on the right buttocks/leg crease and another on the upper back side of the right leg. However, there was no evidence in the clinical record that the resident's representative, specifically the son, was notified of these new pressure ulcer areas. This was confirmed during an interview with the Administrator on July 10, 2024, who acknowledged that the son was never informed of the new pressure ulcers.
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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