Ledgewood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Windham, Maine.
- Location
- 200 Route 115, Windham, Maine 04062
- CMS Provider Number
- 205137
- Inspections on file
- 14
- Latest survey
- April 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ledgewood Manor during CMS and state inspections, most recent first.
A nurse failed to follow professional standards by pre-drawing doses of morphine and lorazepam and instructing a resident's family to administer these controlled medications themselves, rather than administering them as ordered. This occurred for a resident with dementia on hospice care, after the nurse stated she was too busy to provide the PRN medications as frequently as requested.
The facility did not provide two residents with written information about their right to formulate an advance directive upon admission, and for another resident, failed to document the preferred code status in provider orders. The Business Office Manager confirmed these omissions and stated that offering or assisting with advance directives was not routine practice.
Baseline care plans were not completed or implemented within 48 hours of admission for several residents, with some plans initiated days late and one missing entirely from the EMR. Staff confirmed that these care plans should have been completed and available within the required timeframe.
Surveyors found that chemicals and over-the-counter medications were left unsecured in multiple areas, including unlocked cupboards and closets with keys left in the locks. A resident with severe cognitive impairment was observed wandering in and out of these accessible areas, where hazardous cleaning agents and medications were not properly secured.
The facility did not ensure that staff authorized to administer medications signed the Shift Count page to verify completion of controlled substance counts at shift changes. This resulted in missing signatures for multiple shifts on both units, as required by facility policy. The issue was confirmed by the DON and Administrator.
Surveyors identified multiple sanitation and maintenance issues in the kitchen, including uncleanable surfaces, improper plumbing lacking required air gaps, and inconsistent monitoring and documentation of dish machine temperatures and sanitizer strengths. The Food Service Director confirmed the lack of alternative methods for checking dishwashing temperatures and acknowledged lapses in record-keeping.
A resident receiving Fluoxetine and Trazodone did not have a comprehensive care plan in place to address psychotropic drug use and nutrition, despite assessment findings indicating the need for such planning. This lack of care planning was confirmed through record review and interview with the DON.
A resident with chronic respiratory failure and an active order for nebulizer treatments was found with a nebulizer machine and tubing that had not been changed weekly as required and was left exposed on a shelf. Staff were unaware of the resident's need for respiratory care, and the equipment was not maintained in accordance with facility policy, resulting in a failure to provide a sanitary environment for respiratory care.
The facility did not complete the required Significant Change in Status Assessment (SCSA) within 14 days for three residents after they began receiving hospice care, as mandated by the RAI Manual. This omission was confirmed by the DON during the survey.
A resident reported feeling uncomfortable due to a comment made by a male CNA about their genitalia. The DON was informed by APS but did not report the incident to the State Agency within the required 24-hour timeframe, relying on incorrect information from APS. The CNA denied the allegation, was reassigned, and later left the facility without disciplinary action.
Controlled Medication Administration Delegated to Family
Penalty
Summary
A facility failed to ensure professional standards of quality were met in the administration of controlled medications for a resident with dementia who was receiving hospice care. The resident had active physician orders for morphine sulfate and lorazepam to be administered as needed for pain and anxiety. According to the facility-reported incident and interviews, a registered nurse informed the resident's family that she did not have time to administer the PRN medications as frequently as requested. The nurse then pre-drew doses of morphine and lorazepam into syringes and provided them to the family, instructing them to administer the medications themselves at a later time. The nurse admitted during an interview that she was aware she was not supposed to leave medications at the bedside for family administration. The incident was reported after the family informed staff about the nurse's actions. The facility's documentation and interviews confirm that the nurse delegated the administration of controlled substances to the resident's family, which is not in accordance with professional standards of medication administration.
Failure to Provide Advance Directive Information and Document Code Status
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an advance directive to two residents upon admission. For both residents, a review of their electronic medical records showed no evidence that either the residents or their representatives were offered or provided with written information about advance directives. The Business Office Manager confirmed that the facility's admission process did not include documentation of whether residents were offered the opportunity to create an advance directive or if they declined, and it was not routine practice to offer or assist with formulating advance directives. Additionally, for another resident, the provider orders in the electronic medical record did not specify the resident's preferred code status, such as whether to resuscitate or not. The Business Office Manager reviewed the record and confirmed that there was no provider order indicating the resident's code status. These findings were confirmed during interviews with the Business Office Manager.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and implement baseline care plans within 48 hours of admission for five out of sixteen sampled residents, as required. For each of these residents, the baseline care plan was either initiated several days after admission or was not present in the electronic medical record (EMR) at all. Specifically, one resident admitted in September 2024 had a care plan initiated nearly two weeks later, while another admitted in December 2024 had their care plan started several days post-admission. Three residents admitted in February 2025 also experienced delays, with one resident's care plan missing entirely from the EMR at the time of surveyor review. Interviews with facility staff, including a charge nurse and the Director of Nursing, confirmed that baseline care plans were not completed or available as required within the 48-hour timeframe.
Unsecured Chemicals and Medications in Resident-Accessible Areas
Penalty
Summary
Surveyors observed multiple instances where chemicals and over-the-counter medications were not securely stored in the facility. On one occasion, a storage room door was propped open and cupboards containing the facility's supply of over-the-counter medications were unlocked. In two separate whirlpool rooms, doors were propped open and closets containing bottles of G2-2100 surface cleaner and Simoniz hospital disinfecting deodorant were found unlocked, with keys left in the locks. Additionally, a bottle of G2-2100 was found unsecured on a shelf next to a sink. These chemicals, according to their Safety Data Sheets, are classified as eye irritants and contain hazardous ingredients such as propane, n-butane, and ethyl alcohol. During these observations, a resident with a diagnosis of dementia and a BIMS score of 0, indicating severe cognitive impairment, was seen wandering in and out of accessible areas. The unsecured storage of hazardous chemicals and medications in areas accessible to residents, including those with severe cognitive impairment, constituted a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Document Controlled Substance Shift Counts
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. According to the facility's Controlled Drug Policy and Procedure, controlled substances are required to be counted every shift by the nurse or med tech reporting on duty with the nurse or med tech reporting off duty, and both must sign the narcotic records to verify the count. However, a review of the Controlled Substance Books and Shift Counts revealed that on multiple days, staff authorized to administer medications did not sign the Shift Count page to indicate that the controlled substances count was completed. This deficiency was observed on both units reviewed, with missing staff signatures for verification and completion of the controlled medication count on several specific dates. The findings were confirmed with the DON and the Administrator.
Sanitation and Maintenance Deficiencies in Kitchen and Dishwashing Procedures
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility's kitchen during an inspection. The kitchen countertop near the food preparation sink had several gouged areas, making the surface uncleanable. Two floor fans in the dish room had chipped paint, and the ceiling vent in the dishwashing room was covered in dust and debris. The dishwashing room's floor was soiled with missing tiles, and the ceiling and walls were stained with chipped, loose paint, all of which created uncleanable surfaces. Additionally, the kitchen ice machine and food preparation sink were not plumbed according to code requirements, lacking the necessary air gaps to prevent contamination between wastewater and potable water. This direct connection violated both state and federal regulations regarding plumbing and food safety. The Food Service Director (FSD) confirmed that the dishwashing machine's final rinse temperature gauge was not always accurate and that there was no alternative method for checking the final rinse temperature while the machine was in use. Record reviews revealed that dish machine temperatures were sometimes recorded below the recommended range and, on several occasions, were not recorded at all. The facility also lacked evidence that sanitizer bucket strengths were consistently monitored and documented as required. These lapses were confirmed by the FSD, who stated that the facility began using disposable items once the dishwasher was taken out of service. The findings were discussed with the Administrator and the Director of Nursing.
Failure to Develop Comprehensive Care Plan for Psychotropic Drug Use and Nutrition
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing both psychotropic drug use and nutrition for one resident. Record review showed that the resident had been receiving Fluoxetine 40 mg daily since October 2024 and Trazodone 100 mg at bedtime since May 2024. The resident's most recent MDS assessment indicated that care planning was needed for psychotropic drug use and nutrition. However, as of late February 2025, there was no evidence in the medical record of a care plan covering these areas. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Maintain Sanitary Respiratory Equipment for Resident with Active Nebulizer Order
Penalty
Summary
Surveyors observed a nebulizer machine with a face mask and tubing dated 10/27 placed exposed on a shelf next to a resident's bed. The treatment nurse stated that nebulizer tubing is changed weekly and other items are washed nightly, but was unaware of any current residents using a nebulizer and did not know why the equipment was present. Upon review, the resident had an active provider order for DuoNeb Solution to be administered via nebulizer every four hours as needed for chronic respiratory failure with hypoxia and panlobular emphysema. The Director of Nursing confirmed the active order and the facility's policy requiring weekly change of small volume nebulizers. The equipment had not been changed according to policy and was not stored in a sanitary manner, leading to a failure to provide a sanitary environment for respiratory care.
Failure to Complete SCSA After Hospice Enrollment
Penalty
Summary
The facility failed to conduct a comprehensive Minimum Data Set (MDS) 3.0 Significant Change in Status Assessment (SCSA) within 14 calendar days after three residents experienced a significant change in condition, specifically the initiation of hospice services. According to the Resident Assessment Instrument (RAI) Manual, an SCSA is required when a terminally ill resident enrolls in a hospice program or changes hospice providers while remaining in the facility, to ensure a coordinated plan of care. Documentation in the clinical records showed that each of the three residents was admitted to hospice care at different times, but no SCSA was completed for any of them. This was confirmed during an interview with the DON, who acknowledged the assessments were not performed as required.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident sexual abuse to the State Agency within the required 24-hour timeframe. The incident involved a resident who reported feeling uncomfortable due to a comment made by a male Certified Nursing Assistant (CNA) regarding the resident's genitalia. The resident, who was at Maine Medical Center for a Urinary Tract Infection, could not recall the CNA's name but identified him as being from a different country. The facility's policy mandates that such incidents be reported promptly to the State Licensing/Certification Agency, but this was not done. The Director of Nursing (DON) was informed of the incident by Adult Protective Services (APS) staff and subsequently interviewed the resident, who initially denied but later confirmed the incident. The CNA denied making the inappropriate comment and agreed to cooperate with the investigation. Despite the facility's policy and regulatory requirements, the DON did not report the incident to the State Agency, relying on incorrect information from APS that they would handle the reporting. The CNA was reassigned away from the resident and later left the facility, but no disciplinary action was taken against him.
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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