Odd Fellows Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Maine.
- Location
- 85 Caron Lane, Auburn, Maine 04210
- CMS Provider Number
- 205170
- Inspections on file
- 13
- Latest survey
- March 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Odd Fellows Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection control program, as staff did not consistently use or provide PPE, did not implement or document transmission-based precautions during a GI illness outbreak, and did not maintain comprehensive infection surveillance records. The Legionella water management policy was incomplete, and there were additional lapses such as a nurse administering eye drops without gloves and facility cats being allowed on food preparation and dining surfaces without proper cleaning.
The facility did not assign a qualified staff member to serve as a dedicated Infection Preventionist (IP) for at least 24 hours per week. Instead, the DON was performing both her full-time duties and the IP role, despite having completed IP training, and was unaware that both roles could not be held simultaneously.
Surveyors found that the facility did not include necessary goals and interventions in the care plans for residents with COPD, congestive heart failure, cardiac pacemaker, and those requiring pain management. Despite updated care plans and active medication orders, the plans lacked documentation addressing these specific medical needs, as confirmed by nursing leadership.
A resident who required substantial assistance with personal hygiene was repeatedly observed over several days with a pinky ring coated in white dried debris, despite receiving help from CNAs. Assessment and documentation confirmed the resident's dependence on staff for personal hygiene, but the issue persisted and was noted by surveyors.
The facility did not ensure that staff maintained current CPR certification as required by its own policy, resulting in multiple shifts where no certified personnel were present. Interviews with the DON and ADON confirmed that only nurses were required to be certified, and staffing records showed repeated gaps in coverage. Four residents were identified as Full Code and could require CPR, while all residents were at risk for choking.
Two residents requiring continuous oxygen therapy were observed using nasal cannulas and tubing that were either discolored, undated, or not changed according to the facility's policy, which requires tubing changes every two weeks. Documentation and staff interviews confirmed that tubing was being changed monthly instead, resulting in a failure to maintain a sanitary environment and adhere to infection control procedures.
Surveyors found that medications were not properly labeled, dated, or disposed of according to manufacturer instructions. An LPN was observed with an opened, unlabeled vial of Tuberculin Purified Protein Derivative in the medication room refrigerator, and two opened bottles of Lumigan eye drops with different expiration dates in the medication cart. Additionally, a medicine cup containing a pill for the facility's house cat and the cat's Phenobarbital tablets were stored with resident medications, contrary to policy.
Surveyors found the kitchen and food service areas to be unsanitary, with dirty floors, walls, and equipment, and observed staff failing to wear required hair and beard coverings or perform proper hand hygiene while serving and preparing food. These deficiencies were confirmed by facility leadership and were not in accordance with facility policy.
Surveyors found that clinical records were incomplete and inaccurate for two residents. An LPN documented daily application and removal of a resident's hearing aids in the MAR, but admitted this was not done unless requested by family, contrary to physician orders. Additionally, ADL documentation for another resident was missing for several days. These issues were confirmed through interviews, observations, and record reviews.
Four residents did not have documentation showing they received, were offered, or refused the pneumococcal vaccine as required by facility policy. The ADON confirmed that assessments and vaccine offers had not occurred due to the absence of a clinic, despite policy requiring timely assessment and offering of the vaccine upon admission.
A review of CNA employee education records showed that several CNAs did not complete the required 12 hours of annual in-service education or the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. The DON confirmed the lack of documentation for these trainings.
A resident's MDS assessments were not accurately coded to reflect their active diagnoses of HTN, hyperlipidemia, and diabetes. Review of the medical record and interview with the DON confirmed that these conditions were omitted from the Active Diagnosis section of the MDS.
A resident with a documented history of PTSD was not assessed for trauma triggers, and their care plan lacked trauma-informed interventions. The facility's staff confirmed that no assessment for PTSD or trauma-informed care was conducted.
Staff did not consistently ensure resident dignity during care, as evidenced by multiple residents being observed with their incontinence briefs exposed or not fully dressed during daily activities such as ambulation and meals. Some staff acknowledged the lapses but did not take immediate action to address them, and at least one resident expressed discomfort with the situation.
Infection Control Program Deficiencies and Lapses in Policy Adherence
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple lapses in infection surveillance, implementation of transmission-based precautions, and adherence to established policies. During a gastrointestinal illness outbreak affecting both residents and staff, staff interviews revealed inconsistent use and availability of personal protective equipment (PPE), lack of transmission-based precaution signage, and failure to consistently isolate symptomatic individuals. Staff reported that gowns were not readily accessible on the units, and that residents with only diarrhea were not always kept in their rooms. Documentation of the outbreak was incomplete, with the infection preventionist unable to provide comprehensive tracking forms, line lists with symptom onset and resolution dates, or evidence of interventions taken. Medical records for affected residents lacked documentation of symptoms, physician or family notification, and implementation of precautions. The facility's Legionella Water Management Program was found to be inadequate, consisting only of a brief policy referencing bi-weekly water temperature checks without a detailed water system flow diagram, control measures, monitoring protocols, or documentation of testing results and corrective actions. When requested, the administrator was unable to provide additional documentation or evidence of a comprehensive water management plan, relying instead on city testing and a single-page policy. Additional infection control deficiencies were observed, including a nurse administering eye drops to a resident without wearing gloves, contrary to facility policy, and repeated observations of facility cats on kitchenette countertops and dining room tables. Staff acknowledged that cats frequently accessed these surfaces, which were not cleaned after each incident, despite the facility's pet policy requiring removal and disinfection when pets violate these boundaries. These lapses in infection control practices and policy adherence had the potential to affect all residents in the facility.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. During an interview, the Director of Nursing (DON) confirmed that she was functioning as both the full-time DON and the IP, despite having completed her IP training. The surveyor determined that the facility did not have a dedicated IP working at least 24 hours per week in that role, as required. The DON stated she was unaware that she could not fulfill both roles simultaneously, which resulted in the absence of a staff member dedicated to infection prevention and control.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
Surveyors observed that the facility failed to develop and implement complete care plans addressing all identified needs for several residents. Specifically, one resident with COPD requiring continuous oxygen and peripheral neuropathy managed with Gabapentin did not have documented goals or interventions for COPD or pain management in their care plan, despite recent updates. Another resident with congestive heart failure, respiratory failure requiring continuous oxygen, and a cardiac pacemaker also lacked care plan goals and interventions for both heart failure and the presence of the pacemaker, even though regular pacemaker checks were ordered. Additionally, a third resident with an active order for Tramadol for pain management did not have any documented goals or interventions related to pain management in their care plan. These deficiencies were confirmed through observations, medical record reviews, and interviews with facility nursing leadership, indicating a failure to update and implement individualized care plans for residents with significant medical needs.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) in the area of personal hygiene for a resident who required substantial to maximal assistance. Over a three-day period, the resident was repeatedly observed with a pinky ring coated in white dried debris, despite being offered and receiving assistance with dressing and personal care. Documentation and assessment records confirmed the resident's need for significant help with personal hygiene, yet the issue with the soiled ring persisted across multiple observations by surveyors. The deficiency was discussed with facility leadership during the survey.
Failure to Maintain CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all staff maintained current certification in cardiopulmonary resuscitation (CPR) for Healthcare Providers, as required by facility policy. During interviews, the DON and ADON stated that only nurses were required to have CPR certification, and a review of employee records confirmed that only two full-time and two per-diem staff members were CPR certified. Staffing records for the month of March revealed multiple shifts, including day, evening, and night shifts, where no staff members present held current CPR certification. The facility's own Cardiopulmonary Policy requires that key clinical staff, including non-licensed personnel, maintain CPR/BLS certification and that each shift have a designated CPR team consisting of at least one nurse, one LPN, and two CNAs, all with current certification. Despite this policy, there were numerous shifts with no certified staff available. At the time of the review, four out of twenty-four residents were identified as Full Code, meaning they could potentially require CPR, and all residents were noted to be at risk for choking.
Failure to Follow Oxygen Tubing Change Policy for Residents on Continuous Oxygen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to its own policy regarding the frequency of oxygen tubing changes for two residents requiring continuous oxygen therapy. Observations revealed that one resident with COPD was using a nasal cannula with discolored prongs and undated tubing, despite a physician order and documentation indicating monthly tubing changes. The facility's policy, however, required oxygen tubing to be changed at least every two weeks. Another resident with congestive heart failure and respiratory failure was observed with an undated nasal cannula on one occasion and tubing dated nearly a month prior on another, also in contradiction to the facility's two-week change policy. Review of the Treatment Administration Records for both residents showed documentation of monthly tubing changes, which did not align with the facility's updated policy. During an interview, the Director of Nursing confirmed that oxygen tubing should be changed every two weeks as per policy, acknowledging the discrepancy between practice and policy. These findings demonstrate a failure to follow established infection control procedures related to respiratory care for residents requiring continuous oxygen supplementation.
Improper Medication Storage, Labeling, and Disposal
Penalty
Summary
Surveyors observed that the facility failed to properly label, date, and dispose of medications in accordance with manufacturer specifications and professional standards. In the medication room, an opened and unlabeled vial of Tuberculin Purified Protein Derivative was found in the refrigerator, despite manufacturer instructions to discard the vial 30 days after opening. On the medication cart, two opened bottles of Lumigan eye drops were present, one with an expiration date of 2024/08 and the other with an expiration date of 2025/02, and an unlabeled medicine cup containing a small white pill was also found. Further investigation revealed that the pill was medication intended for the facility's house cat, and the cat's Phenobarbital tablets were stored in a cabinet in the medication room. The LPN stated that it was the nurse's responsibility to administer the cat's medication, and the pill was left in the cart because the cat could not be located at the time. These findings indicate that expired and unlabeled medications were not removed from use, and non-resident medications were stored alongside resident medications.
Sanitation and Staff Hygiene Deficiencies in Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and hygiene deficiencies in the facility's kitchen over a three-day period. The kitchen floor, walls, and dishwasher were found to be dirty, with food debris and trash present throughout the area, including under equipment and shelving. Additionally, the stand mixer and food processor were also covered with dirt and debris. These findings were confirmed with both the Director of Food Services and the Facility Administrator during the survey. Staff were also observed failing to follow proper hygiene protocols. A Certified Nursing Assistant was seen serving food trays without wearing required hair protection and did not perform hand hygiene after touching her hair and clothing until prompted by the surveyor. Further observations included a kitchen staff member prepping food without beard protection and a dietary aide working in the kitchen without a hair net. Facility policy requires continuous use of hair and beard restraints and handwashing after touching any part of the body or clothing, but these protocols were not followed as observed and confirmed by supervisory staff.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, an LPN documented in the Medication Administration Record (MAR) that bilateral hearing aids were applied each morning and removed at night, as per physician orders, but stated during observation that the hearing aids were not actually put in unless requested by the family, despite daily documentation indicating otherwise for two months. Additionally, review of another resident's Activities of Daily Living (ADL) documentation revealed that Certified Nurses Aides did not complete ADL care documentation for 3 out of 19 days reviewed. These findings were confirmed through interviews, observations, and record reviews, and discussed with facility leadership.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for four out of nine residents whose immunization records were reviewed. Specifically, the medical records for these residents either lacked evidence that the pneumococcal vaccine had been administered, offered, or refused, as required by facility policy. For example, one resident had documentation of receiving the Pneumococcal conjugate vaccine 13 several years prior, but there was no record of subsequent vaccination, offer, or refusal. Another resident, admitted in March 2023, had no documentation of receiving, being offered, or refusing the pneumonia vaccine, and the Assistant Director of Nursing (ADON) confirmed that there was no proof of vaccination and that the resident had not been offered the vaccine. Similar documentation gaps were found for two other residents, including one whose only record of vaccination dated back to 1998. Interviews with the ADON confirmed that the required assessment and offering of the pneumococcal vaccine had not occurred for these residents, with the ADON stating that vaccines had not been offered because a clinic had not been held. The facility's own policies, updated in February 2025, require that all residents be assessed for vaccination status upon admission and be offered the pneumococcal vaccine series within thirty days unless medically contraindicated or already vaccinated. The lack of documentation and failure to offer or assess for the vaccine as outlined in policy led to the identified deficiency.
Failure to Ensure Required CNA Annual Training and Mandatory In-Services
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, as well as mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. A review of employee education records for five CNAs employed for more than one year revealed that none had documentation of completing the required 12 hours of continuing education for the year 2024. Additionally, three of these CNAs lacked evidence of having attended the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. These findings were confirmed during a review of employee files, which showed missing or incomplete in-service attendance records for each CNA. The Director of Nursing verified the absence of documentation for the required trainings. The deficiency was identified through record review and staff interview, with no evidence provided to show that the CNAs had met the annual training requirements.
Inaccurate Coding of Active Diagnoses on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded for one resident. Record review showed that the resident had documented diagnoses of Hypertension, Hyperlipidemia, and Diabetes. However, the resident's Quarterly MDS assessments did not include these diagnoses under the Active Diagnosis section. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS assessments did not accurately reflect the resident's current medical status.
Failure to Assess and Care Plan for PTSD/Trauma-Informed Care
Penalty
Summary
The facility failed to identify and assess a resident's history of Post-Traumatic Stress Disorder (PTSD) to determine potential triggers and methods to prevent re-traumatization. Record review showed that the resident's medical history included a diagnosis of PTSD, as documented in multiple provider progress notes. However, there was no evidence in the medical record that the facility conducted an assessment to identify specific trauma triggers or developed interventions to prevent re-traumatization. Additionally, the resident's care plan did not include trauma-informed approaches or interventions related to their PTSD. During interviews, both the Licensed Social Worker and the Director of Nursing confirmed that the facility does not assess residents for PTSD or trauma-informed care.
Failure to Maintain Resident Dignity During Care Activities
Penalty
Summary
Staff failed to maintain resident dignity and respect during daily care activities, as evidenced by multiple observations. On one occasion, a resident was assisted in ambulating from the dining room to their room with their clothing open, exposing their incontinence brief. The staff member assisting the resident acknowledged the situation but continued to allow the resident to walk with their brief exposed. In another instance, a resident was observed eating breakfast in the dining room while only partially dressed, wearing a [NAME] and a zip-up sweatshirt. When asked, the resident expressed discomfort with not being fully dressed and stated a preference to be dressed daily before meals. Additionally, another resident was seen walking in the dining room with assistance from a CNA, with their clothing open and incontinence brief exposed. The CNA stated that she typically covers residents to prevent exposure but did not do so in this instance, as she was taking the resident to the bathroom. These incidents were observed and discussed with facility leadership, highlighting a pattern of staff not consistently ensuring residents' privacy and dignity during care and daily routines.
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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