Mainegeneral Rehab & Long Term Care - Gray Birch
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Maine.
- Location
- 37 Gray Birch Drive, Augusta, Maine 04330
- CMS Provider Number
- 205054
- Inspections on file
- 15
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Mainegeneral Rehab & Long Term Care - Gray Birch during CMS and state inspections, most recent first.
The facility breached confidentiality by displaying residents' personal and medical information on monitors visible to others. Monitors showed names, therapy schedules, weighing devices, shower days, and meal times. Additionally, a resident with developmental disorder was interviewed for depression in a public hallway, compromising privacy.
The facility failed to develop comprehensive care plans for two residents, one with obstructive sleep apnea (OSA) and congestive heart failure (CHF), and another with post-traumatic stress disorder (PTSD). The care plan for the resident with OSA and CHF did not include necessary elements like oxygen use and weight monitoring. Similarly, the resident with PTSD lacked a care plan addressing their condition, including triggers and interventions. These deficiencies were confirmed by the DON during a surveyor's review.
The facility failed to maintain a sanitary environment for respiratory care, with improper storage and maintenance of oxygen equipment for several residents. Observations included oxygen tubing stored improperly and soiled concentrator filters. Additionally, incorrect oxygen flow settings and an empty portable oxygen tank were noted, leading to inadequate respiratory care.
A facility failed to ensure proper monitoring of a dialysis catheter site for a resident. The resident, admitted with a right chest dialysis catheter, lacked physician orders for monitoring the catheter dressing and daily documentation of such monitoring. The unit manager confirmed the absence of an order and instructions for emergencies related to the catheter site during surveyor interviews.
The facility failed to maintain resident dignity during meal service, as observed by surveyors. A resident was left watching others eat for extended periods during both lunch and breakfast, while staff served other tables. This delay in serving meals was confirmed by the Administrator, who acknowledged the lack of dignity in the meal service process.
A facility failed to notify the State mental health authority for PASRR re-evaluation after a resident was diagnosed with PTSD, Major depressive disorder, and Generalized anxiety disorder upon admission. Despite these diagnoses, the facility did not update the PASRR evaluation, and the resident began experiencing PTSD symptoms and was prescribed medication for anxiety and depression. The DON confirmed the oversight during an audit.
A facility failed to update the care plan for a resident with diabetes who uses a continuous glucose monitoring device. The resident's care plan, last revised months prior, lacked mention of the device and necessary safety instructions, despite physician orders specifying its use. This oversight was confirmed by the DON.
The facility failed to follow physician's orders for wound care and insulin administration for two residents. An LPN used faucet water instead of Vashe solution and applied clobetasol incorrectly for a resident with venous insufficiency. Another resident received incorrect insulin dosage, and there was no documentation of provider notification for high blood sugar levels.
The facility failed to maintain sanitary conditions and proper food storage practices, as observed during a survey. The kitchen floors were heavily soiled, and containers used for food preparation were improperly stored. The air gap for the kitchen sink violated plumbing codes, and the walk-in refrigerator and freezer contained open and undated food items. Dented cans were also found in dry storage. These issues were confirmed with the Food Service Director, indicating a potential risk to all residents.
An LPN failed to maintain proper infection control during a resident's wound care by using the same gloves for multiple tasks without hand hygiene, touching contaminated surfaces, and accessing personal items under her gown. This compromised the sterile environment necessary to prevent disease transmission.
The facility failed to offer pneumococcal vaccinations to two residents as per CDC guidelines. Despite the Infection Preventionist's assertion that the Medical Provider follows CDC recommendations, the necessary vaccination protocol was not followed for these residents.
The facility failed to accurately code the MDS 3.0 for two residents. One resident's discharge was incorrectly recorded as to a short-term hospital instead of the community. Another resident's PASARR indicated a need for Level II services, but the MDS was inaccurately coded to show otherwise. These errors were confirmed by the MDS coordinator.
A resident with a history of falls and cognitive intactness fell from bed and reported that a nurse used profanity and did not assess or provide care. The facility's policy requires RN assessment after falls, but no evidence of such assessment or provider notification was found. The resident's catheter was not reinserted until five hours later by another RN. A CNA confirmed the nurse's refusal to provide care, and the DON acknowledged the nurse's failure to complete necessary actions.
The facility failed to maintain complete and accurate clinical records for two residents. A resident with a history of falls did not receive a required post-fall assessment by an RN, and another resident did not have a provider's order for a respiratory panel or a referral to geriatrics despite cognitive concerns. Documentation of behaviors was also lacking.
Confidentiality Breach in Resident Information Display
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information by displaying sensitive details on monitors visible to other residents and visitors. During the survey, it was observed that monitors located near the nurse's stations on the Birch and Pine Units displayed residents' first names, initials of last names, room numbers, and bed locations. Additionally, these monitors showed the times residents were scheduled for various therapies, the type of device used for weighing, shower days, participation in walking programs, and meal times corresponding with group activities. This information was confirmed by the Director of Nursing during an interview. Furthermore, the facility did not protect the privacy of a resident with developmental disorder and severe intellectual disabilities. A surveyor observed the MDS Coordinator conducting a depression interview with the resident in a public hallway, compromising the resident's privacy. This was confirmed in an interview with the MDS Coordinator, who acknowledged that the interview was conducted in a public space.
Deficiencies in Care Planning for Residents with OSA, CHF, and PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the physical needs of a resident with obstructive sleep apnea (OSA) and congestive heart failure (CHF). The resident was admitted with these diagnoses, which required the use of 2 liters of oxygen at night and daily weight monitoring. However, the care plan did not include these critical elements, as confirmed by the Director of Nursing during a surveyor's review. Additionally, the facility did not ensure a care plan was developed for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's clinical record indicated a diagnosis of PTSD, with documented issues such as trauma, abuse, and nightmares. Despite this, there was no evidence of a care plan addressing PTSD, including problem areas, triggers, or interventions. The Director of Nursing acknowledged that the resident was missed during an audit of residents with PTSD.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by multiple observations of improper storage and maintenance of oxygen equipment for several residents. For instance, Resident #9's oxygen nasal cannula tubing was repeatedly observed stored improperly over the oxygen concentrator handle and wheelchair. Similarly, Resident #221's oxygen tubing was found wrapped and stored under the handle of the oxygen concentrator, and Resident #60's tubing was observed lying across the bed instead of being stored in the provided bags. These practices were contrary to the facility's policy, which requires proper storage of oxygen equipment to prevent contamination. Additionally, the facility did not adhere to its policy regarding the cleaning of oxygen concentrator filters. Resident #15's oxygen concentrator filter was heavily soiled, and the oxygen flow was set incorrectly, deviating from the prescribed 2 liters per minute during sleep. Furthermore, Resident #49 was connected to an empty portable oxygen tank, resulting in an oxygen saturation level of 88%, below the care plan's requirement of maintaining 92% or greater. These deficiencies were confirmed through observations and interviews with the Director of Nursing, indicating a failure to implement appropriate respiratory care as directed.
Failure to Monitor Dialysis Catheter Site
Penalty
Summary
The facility failed to ensure that the clinical record contained necessary information to meet professional standards of practice for monitoring a dialysis catheter site for a resident requiring dialysis services. The resident, who was admitted to the facility with a right chest dialysis catheter, had no physician orders for monitoring the catheter dressing or documentation of daily monitoring. During interviews, the Pines Unit Manager acknowledged the absence of an order for monitoring the catheter dressing and was unable to find instructions for handling emergencies related to the dialysis catheter site. This deficiency was identified during a surveyor's review of the resident's clinical record and subsequent interviews with the unit manager.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service, as observed by surveyors. During a lunch meal observation, a resident was left watching two other residents eat while staff served other tables, resulting in a delay of 14 minutes before the resident was served. A similar incident occurred during breakfast the following day, where the same resident was again left watching others eat for 10 minutes before being served. These observations were confirmed in an interview with the Administrator, who acknowledged that the residents were not served with dignity when meals were not provided to all residents at a table simultaneously.
Failure to Notify State Mental Health Authority for PASRR Re-evaluation
Penalty
Summary
The facility failed to notify the State mental health authority for Pre-Admission Screening and Resident Review (PASRR) after a resident was newly diagnosed with mental health conditions. The resident, identified as R56, was admitted with a PASRR evaluation from the hospital indicating no mental health diagnosis and no need for a PASRR level II. However, on the date of admission, the resident's clinical record included diagnoses of Post-traumatic stress disorder (PTSD), Major depressive disorder, and Generalized anxiety disorder. Despite these diagnoses, the facility did not send the updated information to the State mental health authority for re-evaluation. The resident began experiencing symptoms related to PTSD, including nightmares, and was prescribed medication for anxiety and depression in the months following admission. During an interview, the Director of Nursing confirmed that the facility had not sent the necessary information for re-evaluation and acknowledged that the resident was missed during an audit of residents with PTSD.
Failure to Update Diabetes Care Plan for Resident with Glucose Monitoring Device
Penalty
Summary
The facility failed to update the care plan for a resident with diabetes who uses a continuous glucose monitoring device. On August 5, 2024, an observation was made of the resident with a continuous glucose monitoring device attached to the back of their right arm. The physician's orders, dated January 22, 2024, specified the use of a FreeStyle Libre 2 Sensor kit to be changed every fourteen days, with instructions to check finger stick readings if they were below 70 or above 350, or if the patient exhibited symptoms of hypoglycemia. However, the resident's care plan for diabetes management, last revised on April 19, 2023, did not include any mention of the glucose monitoring device or related safety instructions and interventions. This deficiency was confirmed during an interview with the Director of Nursing on August 7, 2024.
Failure to Follow Physician's Orders for Wound Care and Insulin Administration
Penalty
Summary
The facility failed to adhere to physician's orders for wound management for a resident with venous insufficiency. During an observation, an LPN was seen using faucet water instead of the prescribed Vashe solution to cleanse the resident's legs. Additionally, the LPN applied clobetasol directly to the open wounds rather than to the legs as directed by the physician's orders. The LPN confirmed the deviation from the prescribed wound care protocol during an interview. In another instance, the facility did not follow physician's orders for insulin administration for a resident. The resident's blood sugar level was recorded at 330, but they were administered 10 units of insulin instead of the prescribed 8 units. Furthermore, there was a lack of documentation indicating that the medical provider was notified of several high blood sugar readings in July, which exceeded the threshold for provider notification. These findings were confirmed during an interview with the Nurse Manager.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey conducted over two days. On the first day, the kitchen floors were found to be heavily soiled with crumbs, grease, fruit, and other debris. A container of measuring cups used for food preparation was observed with the lid ajar and covered in crumbs, with visible food debris inside the cups. Additionally, a large bin containing oats was left partially open to the environment. The air gap for the left kitchen sink was less than the required one inch, violating the Maine State Plumbing Code. The walk-in refrigerator floor was also heavily soiled with food debris, including shredded chicken. In the dry food storage area, several cans were found with dents, compromising their integrity, and in the walk-in freezer, boxes of breaded chicken breasts and pork sausage patties were open and undated, exposing them to the environment. On the second day, similar issues persisted. The dry food storage area still contained dented cans of diced beets, and the walk-in refrigerator floor remained soiled with plastic tape, food debris, and a potato. The kitchen's air gaps for both the left sink and the steamer were still less than one inch. These observations were confirmed with the Food Service Director at the time of each inspection, indicating a failure to maintain sanitary conditions and proper food storage practices, which could potentially affect all residents in the facility.
Infection Control Deficiency in Wound Management
Penalty
Summary
The facility failed to maintain an effective Infection Control Program during wound management for a resident. During an observation, two surveyors noted that an LPN did not adhere to proper infection control protocols while performing a bilateral leg dressing change for the resident. The LPN was observed using the same pair of gloves for multiple tasks without performing hand hygiene in between. This included touching potentially contaminated surfaces, such as the curtain and personal belongings, and then proceeding to handle wound care materials and apply ointment directly to the resident's wounds. The LPN also failed to maintain a sterile environment by repeatedly reaching under her gown to access personal items, such as a marker and Q-tips, and using them without changing gloves or washing hands. Additionally, the LPN placed scissors into a basin containing the resident's personal belongings multiple times during the procedure. These actions were confirmed by the LPN during an interview, acknowledging the failure to provide an environment that prevents the development and transmission of disease and infection during the dressing change.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. Specifically, two residents, identified as R54 and R66, were not reviewed, offered, or administered the Prevnar 20 vaccine as recommended by the CDC. R54 and R66 were both admitted to the facility, but the necessary vaccination protocol was not followed for either resident. During an interview with a surveyor, the Infection Preventionist confirmed that the Medical Provider is responsible for following CDC vaccination recommendations, yet the required actions were not taken for these residents. This oversight was identified during a surveyor's review of records and interviews, highlighting a deficiency in the facility's vaccination procedures.
Inaccurate MDS Coding for Discharge and PASARR
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) 3.0 for two residents. For one resident, the clinical record indicated a discharge to the community, but the discharge MDS inaccurately stated the resident was discharged to a short-term general hospital. This discrepancy was confirmed by the MDS coordinator during an interview. For another resident, the Pre Admission Screening And Resident Review (PASARR) indicated a qualification for Level II services, but the Annual MDS was incorrectly coded to show that the resident did not have a Level II PASARR. This error was also confirmed by the MDS coordinator during an interview with a surveyor.
Failure to Provide Care and Assessment After Resident Fall
Penalty
Summary
The facility failed to provide an environment free of abuse and neglect for a resident who experienced a fall from bed. The resident, who was cognitively intact and had a history of paraplegia, neurogenic bladder, neuromuscular deficiency, and falls, reported that after the fall, a nurse used profanity and did not enter the room to assess or provide care. The facility's policy requires a registered nurse to assess residents after a fall, but there was no evidence that the nurse completed an assessment or notified a provider following the incident. Additionally, the resident's clinical record indicated an order to reinsert a catheter if dislodged, but this was not done until approximately five hours later by another nurse. A certified nursing assistant corroborated the resident's account, stating that the nurse swore at the resident and refused to provide care. The Director of Nursing confirmed that the nurse failed to complete the necessary assessment, notify the provider, or provide care after the resident's fall.
Incomplete Clinical Records and Missing Provider Orders
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For Resident #1, who was admitted with diagnoses including paraplegia and a history of falls, the facility did not complete a required post-fall assessment. An incident report indicated that the resident fell out of bed and was found on the floor by a CNA. Although the report noted that an assessment was done with no injuries, the clinical record lacked evidence of a complete assessment by an RN, as required by the facility's fall prevention policy. The Director of Nursing confirmed that the RN failed to perform the necessary assessment. For Resident #5, admitted for skilled services with diagnoses including anxiety and depression, the facility did not obtain a provider's order for a respiratory panel, nor did it document a referral to geriatrics despite concerns about cognitive dysfunction. The resident's clinical record showed a lack of documentation regarding behaviors and a missing order for a respiratory panel that was conducted without provider authorization. A Nurse Practitioner confirmed the absence of a geriatrics referral, and an RN confirmed the lack of documentation for the resident's behaviors.
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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