Mercy Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle Lake, Maine.
- Location
- 3402 Aroostook Road, Eagle Lake, Maine 04739
- CMS Provider Number
- 205129
- Inspections on file
- 13
- Latest survey
- August 1, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mercy Home during CMS and state inspections, most recent first.
The facility failed to notify physicians of head injuries for three residents who experienced falls. Despite incidents resulting in bruising and head injuries, clinical records lacked evidence of immediate physician notification. Interviews confirmed that providers were not informed, contrary to expectations for such notifications.
The facility failed to offer and document influenza and pneumococcal vaccinations for several residents as per CDC recommendations. Despite signed consents, records lacked evidence of offering, receiving, or refusing the vaccines. Interviews confirmed the deficiency in following vaccination protocols.
A resident admitted after hip surgery did not have a baseline care plan developed within 48 hours, failing to address therapy services, oxygen use, and medication monitoring for pain, depression/anxiety, and a blood thinner. This deficiency was confirmed by a surveyor during an interview with the DON.
A facility failed to develop a care plan for falls for a resident after two comprehensive assessments indicated the need for such a plan. The resident's care plan lacked documentation addressing falls, including problem identification, interventions, and goals. This deficiency was confirmed by the DON during an interview.
A facility failed to provide individualized activities for a resident with communication difficulties, as outlined in their care plan. The resident's care plan aimed to address social isolation by engaging them in one-on-one activities with staff three times weekly. However, records showed no evidence of these activities being offered, received, or refused during July. The Activities Coordinator confirmed the absence of structured activities for the resident.
The facility failed to complete fall assessments per policy for two residents, omitting required Glasgow Coma Scale scores and neglecting to address pain and range of motion. Additionally, a resident received medication against a physician's order to hold it if blood pressure was below a certain threshold. These deficiencies were confirmed through interviews with facility staff.
A resident known to be exit-seeking managed to elope from the facility due to inadequate supervision. After dinner, the resident wandered and attempted to exit to the patio, bypassing staff redirection efforts. An alarm was triggered, but it took time for staff to identify the source. The resident was eventually found outside after being out of camera sight for several minutes.
A resident's tube feeding was not administered according to facility policy, as an LPN used a syringe plunger instead of gravity for feeding and mixed medications with the formula. Additionally, bacitracin was applied around the feeding tube area without a physician's order. The DON confirmed these practices were against policy.
Expired medications were found in a medication cart and supply cabinet during a survey. A bottle of Calcium 600 mg + D 5 mcg with an expiration date of June 2024 was found in the medication cart. In the supply cabinet, three bottles of Calcium 600 mg + D 5 mcg, one bottle of Melatonin 1 mg, and four bottles of Vitamin B-12 100 mcg were found with expiration dates ranging from October 2023 to June 2024. These findings were confirmed with a CNA-M.
The facility failed to maintain professional standards for food service safety, including not monitoring food temperatures, improper hair restraint by staff, unsanitary dish storage, and unclean kitchen floors. These issues were observed over several days and confirmed with the Dietary Manager.
The facility failed to document medical records accurately for two residents. One resident's records lacked evidence of pulse checks before administering Metoprolol Tartrate and showed Tramadol was given without prior acetaminophen, against orders. Another resident's records did not document ROM exercises as part of a restorative program, despite the resident's report of reduced ROM in their left elbow and shoulder.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. An LPN was observed providing care without wearing a gown, as required by the facility's policy. Additionally, the LPN did not follow proper hand hygiene protocols, failing to change gloves at appropriate times and not using hand sanitizer or washing hands between glove changes. This was confirmed during an interview with the LPN, who admitted to not adhering to the correct procedures.
A CNA in a long-term care facility was reported for physical and verbal abuse towards residents. The CNA was rough and rude while washing a resident's hair, causing distress, and verbally abused another resident in the dining room. The incidents were corroborated by witness statements and led to the CNA's termination.
A resident with dementia eloped from the facility through an unsecured loading dock door, which was not alarmed. The resident, who had a history of wandering, was found outside with minor injuries after a neighbor alerted the facility. Staff were unaware of the resident's absence until notified by the neighbor, highlighting a lack of adequate supervision.
Failure to Notify Physician of Head Injuries
Penalty
Summary
The facility failed to immediately notify the resident's physician of accidents involving head injuries for three out of four sampled residents. Resident #24 experienced multiple falls, including one observed by a surveyor, where the resident hit their head, resulting in bruising. Despite these incidents, there was no evidence in the clinical records or fall reports that the physician was notified immediately. This pattern of non-notification was consistent across other incidents involving Resident #24, where falls resulted in head injuries, yet the physician was not informed. Similarly, Resident #22's incident report indicated a fall with a head injury, but there was no documentation of physician notification. Resident #11 also experienced a fall with a head injury, resulting in a large bruise, and again, the clinical record lacked evidence of immediate physician notification. Interviews with the nursing staff and the Director of Nursing confirmed that the provider was not notified of these incidents, despite expectations for such notifications in cases of head injuries or significant changes in the resident's condition.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered influenza and pneumococcal vaccinations in accordance with CDC recommendations. Specifically, four out of five residents reviewed for immunizations did not have documented evidence of being offered, receiving, or refusing the recommended vaccinations. Resident #13, #23, and #26 were all recommended to receive the Prevnar 20 vaccine, but their records lacked evidence of being offered or receiving the vaccine. Resident #28 was recommended to receive the Influenza Vaccine, and although consent was signed by the resident's representative, there was no evidence in the records that the vaccine was offered, received, or refused. The facility's policy, revised in February 2024, indicated that physicians would order immunizations following the CDC immunization schedule. However, during interviews with the Administrator and Nursing Supervisor, it was confirmed that the vaccines were not offered according to CDC recommendations. This deficiency highlights a failure in the facility's process to ensure compliance with vaccination protocols, as evidenced by the lack of documentation and follow-through on vaccination offers and administration.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted following a hip injury that required surgery. The care plan did not address the admission orders, which included necessary services for therapy, the use of oxygen, and the monitoring of medications prescribed for pain, depression/anxiety, and a blood thinner. This deficiency was confirmed during an interview with the Director of Nursing by a surveyor.
Failure to Develop Falls Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for falls for a resident after two comprehensive assessments. The clinical record of the resident was reviewed, and it was noted that the admission Minimum Data Set (MDS) and a significant change MDS indicated that the resident should be care planned for falls. However, upon review of the resident's care plan, no care plan addressing falls, including problem identification, interventions, and goals, was found. This deficiency was confirmed during an interview with the Director of Nursing, who also could not locate a care plan for falls for the resident.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to promote the psychosocial well-being of a resident as directed by the care plan. The resident, identified as having difficulty with communication, expressed not participating in activities due to a lack of applicable options. The care plan for this resident identified social isolation as a problem and set a goal for the resident to participate in one-on-one activities with staff at least three times each week. However, the clinical record review showed no evidence that these one-on-one activities were offered, received, or refused three times per week for the month of July. The Activities Coordinator confirmed that there were no structured activities for the resident, and the clinical record lacked documentation of the required one-on-one activities.
Failure to Complete Fall Assessments and Adhere to Medication Orders
Penalty
Summary
The facility failed to complete fall assessments according to its policy for two residents, R24 and R11. The policy required that after a fall, a nurse should assess and document various health indicators, including neurological status using the Glasgow Coma Scale, for three days post-fall. However, for R24, multiple instances were noted where neurological assessments were documented as normal or negative without including a Glasgow Coma Scale score. Additionally, there were occasions where pain and range of motion were not addressed in the documentation. A surveyor observed R24 fall and noted that the resident was moved before a licensed staff member assessed them for injuries, which was against the facility's policy. Similarly, for R11, the documentation of fall assessments also lacked the inclusion of a Glasgow Coma Scale score, despite the resident having a head injury. The documentation repeatedly noted neuro checks as within normal limits or negative without the required scoring. This omission was confirmed during an interview with the facility's Administrator, who acknowledged the missing fall assessment documentation per policy. Additionally, the facility failed to adhere to a physician's order for resident R30, which specified that the medication Amlodipine Besylate should be held if the resident's blood pressure was less than or equal to 140/80. Despite this order, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold. This was confirmed during an interview with the Nurse Supervisor, who acknowledged that the medication was given contrary to the physician's order.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was known to be exit-seeking. On the evening of 7/30/24, after dinner, the resident wandered around the dayroom for 10 minutes before attempting to exit to the patio. Although staff attempted to redirect the resident, these efforts were ineffective, and the resident managed to push through the door to the patio. The resident was outside for less than 30 seconds before being retrieved by an LPN. An alarm went off on the East Wing, but it took time for staff to determine which alarm was triggered. A CNA, who was providing care behind closed doors, heard the alarm and eventually located the resident outside the East Wing door. The facility's investigation noted that the CNA did not initially see the resident outside and had to search room to room before realizing the resident was missing. The resident was found after being out of camera sight for several minutes.
Improper Tube Feeding Administration and Dressing Application
Penalty
Summary
The facility failed to administer tube feedings according to its policy for a resident with a gastrostomy tube (G-tube). The policy outlined specific steps for bolus feedings, including flushing the G-tube with water to ensure patency, using gravity to administer the formula, and not mixing medications with the formula. However, during an observation, a Licensed Practical Nurse (LPN) was seen using a syringe plunger to push the formula into the feeding port, contrary to the policy that requires gravity feeding. Additionally, the LPN mixed medications with the Jevity formula, which was not in accordance with the facility's policy. Furthermore, the LPN applied bacitracin around the feeding tube area before applying a clean gauze dressing, despite the absence of a physician's order for such an application. The Director of Nursing (DON) confirmed that bacitracin should not be used unless ordered, and that medications should not be mixed with the Jevity. These actions were observed during a survey, and the DON acknowledged the discrepancies between the observed practices and the facility's established policies.
Expired Medications Found in Medication Cart and Supply Cabinet
Penalty
Summary
The facility failed to ensure that expired medications were removed from the supply available for use, as observed during a survey on July 29, 2024. During a review of the medication cart and the medication supply cabinet in the charge nurse room, a surveyor, along with a Certified Nursing Aid-Medications (CNA-M), found several expired medications. In the medication cart, a bottle of Calcium 600 mg + D 5 mcg was available for use with an expiration date of June 2024. In the medication supply cabinet, three bottles of Calcium 600 mg + D 5 mcg with expiration dates of June 2024, one bottle of Melatonin 1 mg with an expiration date of April 2024, and four bottles of Vitamin B-12 100 mcg, three with expiration dates of April 2024 and one with an expiration date of October 2023, were available for use. These findings were confirmed by the surveyor with the CNA-M at the time of observation.
Deficiencies in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On multiple occasions, the facility did not monitor food temperatures to prevent foodborne illness, did not ensure that kitchen staff restrained their hair with hair nets, and did not store dishes in a sanitary manner. Specifically, on one day, a kitchen aid was observed with a long ponytail not contained by a hair net. Additionally, serving pans were wet stacked and stored facing upward, allowing them to accumulate debris from the environment. These issues were confirmed with the Dietary Manager (DM) at the time of observation. The facility also failed to maintain cleanliness in the kitchen area. Over the course of four days, the kitchen floor, particularly in the dishwashing area, was consistently found to be unclean and uncleanable due to ongoing repairs. The dry food storage room floor was soiled with dark grey black streaks, and Freezer #4 was heavily soiled with food debris. These conditions were observed and confirmed with the DM, indicating a persistent issue with maintaining sanitary conditions in the food preparation and storage areas.
Deficiencies in Medication Administration and ROM Documentation
Penalty
Summary
The facility failed to maintain complete documentation of medical records for two residents, leading to deficiencies in care. For one resident, the clinical record included physician orders for Metoprolol Tartrate, a blood pressure medication, with specific parameters to hold the medication if the pulse was less than or equal to 55. However, there was no evidence in the clinical record that the pulse was checked prior to each administration of the medication. Additionally, the same resident had an order for Tramadol, an opioid pain medication, to be given as needed if pain was not relieved by acetaminophen. On one occasion, Tramadol was administered without prior administration of acetaminophen, contrary to the physician's orders. For another resident, the facility failed to document the provision of range of motion (ROM) exercises as part of a restorative program intended to reduce the risk of contractures. The resident reported that the facility did not address the reduced ROM in their left elbow and shoulder. The clinical record lacked evidence that the resident was offered, participated in, or refused ROM exercises on several specified days in July. These findings were confirmed by a surveyor during an interview with the Director of Nursing.
Inadequate Infection Control Practices for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically in the application of Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The facility's policy, revised in February 2024, mandates that EBP, including the use of gowns and gloves, should be implemented for residents with indwelling medical devices. However, during an observation, a Licensed Practical Nurse (LPN) was seen providing care to a resident with a feeding tube without wearing a gown, which is a requirement under EBP. The LPN only wore gloves and did not adhere to the facility's policy of wearing a gown before entering the resident's room. Additionally, the LPN failed to follow proper hand hygiene protocols during the care process. The LPN was observed changing the dressing around the resident's feeding tube and performing other tasks without changing gloves at appropriate times or using hand sanitizer or washing hands between glove changes. This lack of adherence to hand hygiene and EBP was confirmed during an interview with the LPN, who admitted to not wearing a gown for the resident's care and not following the correct procedures for glove changes and hand hygiene.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse and two residents from verbal abuse. The incident involved a Certified Nursing Assistant (CNA1) who was reported to have been rough and rude to a resident (R1) while washing their hair. According to a witness, CNA1 became frustrated with R1, threatened not to change or wash them if they continued moving, and was forceful during the process. CNA1 was reported to have yanked R1's hair into a ponytail, causing the resident to cry. R1, who has Huntington's Disease, confirmed that their hair was pulled and described CNA1 as mean. Additionally, CNA1 was involved in a separate incident of verbal abuse towards another resident (R3). During an interaction in the dining room, CNA1 reportedly swore at R3 after the resident accidentally ran over CNA1's toe. CNA1 admitted that the comment might have slipped out impulsively. The facility's internal investigation and witness statements corroborated these incidents of abuse. The facility's records indicate that CNA1 received an employment termination notice due to the reported actions and behaviors. Furthermore, a Registered Nurse (RN) received a written warning for hearing CNA1's inappropriate comment and not taking immediate action. These findings were confirmed by a surveyor during an interview with the facility's Administrator.
Resident Elopement Due to Unsecured Exit
Penalty
Summary
The facility failed to ensure that doors were locked and/or alarmed to prevent a resident identified as an elopement risk from leaving the building unnoticed. This deficiency resulted in an avoidable elopement incident involving a resident with a diagnosis of neurocognitive disorder with Lewy bodies, a form of dementia. The resident's care plan indicated a history of wandering into unsafe situations and a risk for falls due to poor safety awareness. Despite these known risks, the resident was able to exit the facility through a loading dock door that was not alarmed, leading to an unwitnessed elopement. The incident occurred when a nearby neighbor alerted the facility that the resident was outside near another healthcare building. The resident was found sitting on the side of the road with superficial abrasions to the forehead and nose. Video surveillance footage confirmed that the resident exited the building at approximately 4:52 a.m. and was outside the facility for about 18 minutes before being returned. Interviews with staff revealed that the resident's absence was not noticed until the neighbor's call, indicating a lack of adequate supervision and monitoring at the time of the incident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
