Marshwood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 33 Roger Street, Lewiston, Maine 04240
- CMS Provider Number
- 205072
- Inspections on file
- 19
- Latest survey
- December 19, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marshwood Center during CMS and state inspections, most recent first.
The facility failed to provide four residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. Clinical records lacked evidence of offering or assisting with advance directives, with one resident not receiving paperwork due to being on leave.
The facility failed to maintain a sanitary and comfortable environment across all units and the activity room. Observations included missing hooks and disrepair of privacy curtains, cracked heating unit grills, soiled bathroom floors, dirty caulking, and dirty ceilings. Linen closets contained trash and debris, and rooms had strong odors and visible dirt. These findings were confirmed by the Maintenance Director, DON, and Administrator.
The facility failed to secure chemicals, including Bleach Germicidal Wipes and an unlabeled bleach/water spray bottle, in unlocked shower rooms accessible to residents with dementia and other compromising conditions. This was confirmed by an LPN, the DON, and the Administrator.
The facility did not ensure sufficient direct care staff were scheduled to meet resident needs, particularly on weekends. A review of staffing reports revealed excessively low weekend staffing during a specific quarter, and facility personnel confirmed the shortfall. This deficiency potentially affects all residents needing assistance with ADLs.
The facility failed to ensure that 8 out of 25 licensed staff members, including LPNs and RNs, had current BLS certification as required by their job descriptions. This deficiency was identified through interviews and record reviews, and discussed with the DON.
The facility's kitchen was found to be unsanitary, with food and trash on the floor, leaking sinks, and equipment covered in residue. Additionally, the ice machine was not plumbed according to code, risking contamination. These issues were confirmed by the Food Service Director and other management staff.
The facility failed to meet the needs of two residents: one was unable to obtain Ginger Ale unless deemed medically necessary, and another, with a recent amputation, struggled with an inadequately sized bed, leading to a fall. Staff were unaware of these issues, indicating communication and assessment gaps.
A facility failed to refer a resident with Major Depressive Disorder and Suicidal Ideations for a PASRR Level II evaluation after their stay extended beyond 30 days. Initially, a PASRR Level I determination indicated no further evaluation was needed due to a 30-day waiver. However, the resident's stay became long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority for further assessment, as confirmed by the Licensed Social Worker.
A resident's eyeglasses were lost, and the facility failed to document the loss or assist in obtaining a replacement, despite the resident's cognitive intactness and reliance on glasses for watching TV. Interviews confirmed the oversight, and the facility did not follow its policy on personal property management.
The facility failed to maintain or improve ROM and mobility for two residents after discharge from therapies. One resident's restorative program was not documented or followed, leading to falls and a return to therapy. Another resident reported decreased strength due to lack of daily exercises. CNAs were unable to perform restorative tasks due to staffing issues, and the facility lacked a restorative nursing program.
The facility failed to maintain a sanitary environment for respiratory care, as two residents' respiratory equipment was improperly stored. Observations revealed that a resident's nebulizer tubing was on the bedside table, and another resident's oxygen tubing was under the oxygen concentrator handle, contrary to facility procedures. This was confirmed by the DON.
The facility did not have an Infection Preventionist present at two of the four quarterly QAA meetings. The absence was due to the departure of the Infection Preventionist in mid-October, and the position remained vacant until a new hire was finalized recently. This was confirmed by the Administrator and the Marketing Clinical Advisor.
The facility did not post daily nurse staffing information, including the resident census, for three survey days and failed to maintain these records for 18 months. The absence of the resident census was confirmed by the Scheduler/Payroll/HR personnel, who was unaware of the record-keeping requirement. This was corroborated by the RN Market Clinical Advisor.
The facility failed to maintain a sanitary and comfortable environment in three units. Observations included chipped and missing paint on wall heaters and door frames, rust creating uncleanable surfaces, marred walls, and dirty areas in resident rooms and bathrooms. These issues were confirmed by the DON during the survey.
The facility failed to ensure a safe environment for residents, with observations of a loose toilet, sharp splintered wood on doors, and a broken baseboard heater exposing sharp metal. These hazards were identified during a survey and discussed with the DON.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for four residents during a review of their clinical records. Specifically, the records for these residents lacked evidence that the facility had provided or obtained the necessary documentation concerning these rights. For one resident, the social worker confirmed that the clinical records did not include evidence of offering or assisting with an advance directive. Another resident did not receive the advance directive paperwork because they were out on leave, and the task was not completed. The absence of documentation for these residents indicates a failure to comply with the requirement to inform and document residents' rights to make decisions about their medical care.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across all seven units and the activity room. During an environmental tour conducted by two surveyors, accompanied by the Maintenance Director, the Director of Nursing, and the Administrator, numerous deficiencies were observed. These included missing hooks and disrepair of privacy curtains, cracked and broken heating unit grills, heavily soiled bathroom floors, dirty caulking around toilets, and dirty ceilings with holes. Additionally, there were issues with linen closets containing trash and debris, and various rooms had strong odors, fruit flies, and visible dirt and dust. Specific observations included a cracked plastic grill on a room heating unit, missing ceiling tiles, and a sit-to-stand patient lift with food and debris. The activity room doors had chipped paint and black marks, while the dining room window was fogged, and a table fan was dusty. The storage room and shower room also had issues with debris and black substances in the grout. These findings were confirmed in an interview with the Maintenance Director, the Director of Nursing, and the Administrator.
Improper Storage of Chemicals in Resident Areas
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards due to improper storage of chemicals. On two separate days of the survey, surveyors observed unsecured containers of Bleach Germicidal Wipes in unlocked shower rooms. These chemicals were accessible to residents, including those who were confused, compromised, and could move around the unit, even in wheelchairs. The presence of these unsecured chemicals was confirmed by both an LPN and the Director of Nursing, who acknowledged the potential risk posed to residents. Additionally, a surveyor found an unlabeled spray bottle marked as containing bleach and water, with an unknown bleach-to-water ratio, in a shower room. The Administrator confirmed that the bottle was not labeled appropriately and should have been secured behind a locked door. The unit housed residents with dementia and other compromising conditions, further emphasizing the risk of having unsecured and improperly labeled chemicals accessible to them.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed excessively low weekend staffing during the fourth quarter of 2024. On December 19, 2024, both the Director of Nursing and the Scheduler/Payroll/Human Resource personnel confirmed that the facility did not have enough staff to meet resident needs on weekends. This staffing shortfall has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Deficiency in Staff BLS Certification
Penalty
Summary
The facility failed to ensure that 8 out of 25 licensed staff members had current certification in Healthcare Basic Life Support (BLS) as required by the facility's job descriptions for Registered Nurses and Licensed Practical Nurses. This deficiency was identified through interviews and record reviews conducted by a surveyor. The surveyor found that the documentation provided by the facility did not include current BLS/CPR certification for these 8 staff members, which included both LPNs and RNs. The issue was discussed with the Director of Nursing during the survey process.
Kitchen Sanitation and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour conducted by two surveyors. The tour revealed several issues, including food and trash scattered on the floor and under equipment, a leaking dish room spray sink, and chipped paint on the food mixer. Additionally, five ceiling tiles above a food preparation area had dried liquid spatter, and a broken ceiling tile was found near the walk-in freezer. The food disposal unit, blender, and convection oven were all covered with dried food particles and residue. In the dry storage room, a 50-pound bag of sugar was left open and unsecured, and a large box of sandwich buns in the walk-in freezer had significant ice build-up. Furthermore, the facility failed to ensure that the kitchen ice machine was plumbed according to code requirements, which is necessary to prevent food contamination. This was a direct violation of the State of Maine Rules Chapter 226 and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d), which mandate that plumbing must be designed, installed, and maintained to prevent contamination of the water supply, food, and food utensils. These findings were confirmed in an interview with the Food Service Director, the Director of Operations, and the District Manager.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the beverage preferences of a resident, as evidenced by the restriction on Ginger Ale availability. During a resident council meeting, a resident expressed dissatisfaction with not being able to obtain Ginger Ale unless deemed medically necessary by a nurse. Staff members confirmed that they were instructed to only provide Ginger Ale to residents who were sick. However, the Food Service Director stated that residents could have Ginger Ale if their diet allowed it, indicating a communication breakdown between the kitchen staff and the nursing staff. Additionally, the facility did not adequately address the bed size needs of a resident with a recent right below-the-knee amputation. The resident, who is 6 feet 2 inches tall, reported falling out of bed while reaching for the call bell and expressed difficulty moving in the bed due to its size. Despite the resident's complaints and a documented fall, staff members, including the RN and Director of Nursing, were unaware of any issues with the bed size. The initial bed assessment upon admission did not note any problems, suggesting a lack of follow-up on the resident's changing needs.
Failure to Initiate PASRR Level II Evaluation for Long-Term Resident
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred for a Pre-Admission Screening & Resident Review Level II (PASRR) evaluation. The resident was admitted with a diagnosis of Major Depressive Disorder and Suicidal Ideations. Initially, a PASRR Level I determination letter indicated that no further evaluation was required due to a 30-day Time Limited Waiver. However, the resident's stay transitioned from short-term to long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority to assess the need for a Level II evaluation. This oversight was confirmed during an interview with the Licensed Social Worker, who acknowledged that the resident had been in the facility for more than 30 days without the necessary PASRR Level II evaluation being initiated.
Failure to Assist Resident in Obtaining Replacement Eyeglasses
Penalty
Summary
The facility failed to assist a resident in obtaining new eyeglasses after the original pair was lost, as per the facility's policy on personal property. The policy requires personnel to identify and record a patient's belongings upon admission and document any loss or breakage of personal items. However, the facility did not complete an inventory sheet or incident report for the missing glasses of a resident who was cognitively intact and relied on glasses to watch television. Interviews with the resident and staff confirmed that the glasses had been missing for several months, and no action was taken to replace them. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitive intactness, reported the loss of glasses, which were necessary for watching television. Despite the resident's report and the facility's policy, the staff did not document the loss or assist in obtaining a replacement. Interviews with the CNA and the Registered Nurse Manager revealed that the inventory sheet and incident report were not completed, and the Director of Nursing confirmed the oversight. This inaction led to the resident being unable to see the television clearly, impacting their quality of life.
Failure to Maintain Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to maintain or improve the range of motion (ROM) and mobility for two residents following their discharge from physical and occupational therapies. For one resident, a restorative nursing program was recommended to maintain physical abilities achieved during therapy, which included ambulation with a walker and a home exercise program. However, this program was not included in the resident's care plan, and there was no documentation to show that the program was followed. This resident experienced falls and was referred back to physical therapy, indicating a decline in their physical abilities. Another resident reported not being able to walk or perform exercises daily since ending therapy, leading to a perceived decline in strength. The restorative plan for this resident was also not included in their care plan, and there was no documentation of the program being followed. Interviews with CNAs revealed that they were unable to perform restorative tasks due to staffing issues, and a unit manager confirmed that the facility lacked a restorative nursing program. The facility's assessment indicated that it should provide mobility and fall prevention care, but this was not being implemented effectively.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by observations and interviews. The facility's procedure for oxygen nasal cannula, revised on 8/7/23, requires that cannulas be dated and stored in a treatment bag when not in use. However, observations on 12/16/24 and 12/17/24 revealed that Resident 98's nebulizer tubing was stored on the bedside table, and Resident 405's oxygen tubing was stored under the oxygen concentrator handle. These storage practices were confirmed by the Director of Nursing during an interview on 12/17/24.
Infection Preventionist Absence at QAA Meetings
Penalty
Summary
The facility failed to ensure that an Infection Preventionist attended two of the four quarterly Quality Assessment and Assurance (QAA) meetings, specifically those held on July 25 and October 31, 2024. A review of the QAA meeting attendance sheets confirmed the absence of the Infection Preventionist at these meetings. During an interview on December 18, 2024, the Administrator acknowledged the absence, stating that the Infection Preventionist left the facility in mid-October and had not been replaced until recently. This was corroborated by the Marketing Clinical Advisor later that day.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the resident census per shift, for three out of four survey days. Specifically, on 12/16/24, 12/17/24, and 12/18/24, a surveyor observed that the nurse staffing information posted at the main entrance did not include the resident census. Additionally, the facility did not maintain records of the posted daily nurse staffing data for a minimum of 18 months as required. During an interview on 12/18/24, the Scheduler/Payroll/HR personnel confirmed the absence of the resident census on the posted nurse staffing information and admitted to being unaware of the requirement to keep these records for at least 18 months. This was further confirmed by the Registered Nurse Market Clinical Advisor.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in three of its six units, as observed during a survey. On the Gilber Unit, several resident rooms were found with chipped or missing paint on wall heater units, which also had rust, creating uncleanable surfaces. The walls in these rooms and bathrooms were marred and marked, and one room had a privacy curtain with large dirty and stained areas. These findings were confirmed by the Director of Nursing during the survey. In the [NAME] Unit and [NAME] Unit, similar issues were observed. Multiple resident rooms had entrance and bathroom door frames with chipped or missing paint. The dining room heater also had chipped or missing paint, creating an uncleanable surface. Additionally, one room had a dirty floor around the base of the toilet. These deficiencies were discussed with the Director of Nursing by the surveyor, highlighting the facility's failure to provide adequate housekeeping and maintenance services.
Environmental Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment for residents, as observed during a survey on the [NAME] Unit. In one resident room, the bathroom toilet was found to be loose and not secured to the floor, posing a potential hazard. Additionally, the bathroom door had chipped, gouged, and splintered wood, which was sharp and could cause injury. In another resident room, a baseboard heater was broken apart, exposing sharp metal edges. Furthermore, the entrance door to this room also had chipped, gouged, and splintered wood, creating another sharp hazard. These deficiencies were discussed with the Director of Nursing during the survey.
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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