Pine Point Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scarborough, Maine.
- Location
- 67 Pine Point Rd, Scarborough, Maine 04074
- CMS Provider Number
- 205070
- Inspections on file
- 21
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pine Point Center during CMS and state inspections, most recent first.
Medication and treatment carts were found unlocked and unattended, with accessible medications and supplies, while expired drugs and lab supplies were present in both medication carts and lab rooms. Staff confirmed the presence of expired items and did not consistently secure medication storage areas, leading to deficiencies in medication management and storage practices.
Surveyors identified unsanitary conditions in the kitchen, including dirty floors, walls, equipment, and vents, as well as improper use of hair restraints by dietary staff. Compromised canned goods were also found available for use, contrary to facility protocol.
Staff failed to follow infection control protocols, including hand hygiene during medication administration and meal tray service, and proper doffing of PPE after transmission-based precautions. An LPN administered medications after touching his face without hand hygiene, two CNAs delivered meal trays after resident care without sanitizing hands, and a therapy assistant wore an isolation gown into a dining area before removing it.
The facility did not ensure that care plans were reviewed and revised by an IDT within 7 days of MDS assessments for three residents. In these cases, there was no documentation of timely IDT meetings, and in one instance, a resident's representative was neither present nor notified. The Social Services Director also confirmed the absence of a process for scheduling IDT meetings or notifying residents and their representatives.
The facility did not properly assess or monitor a surgical wound for a resident, failed to follow physician orders for wound care for another resident, and did not obtain a physician order for a wrist brace used by a resident with hemiparesis. These deficiencies were confirmed by clinical staff and through record review.
The facility did not ensure adequate direct care staffing on weekends, as confirmed by staffing reports and the DON. Residents repeatedly expressed concerns about inconsistent staffing ratios, especially on second shift, and long waits for call light responses, with grievances and meeting minutes documenting these ongoing issues.
Unsecured containers of germicidal wipes and toilet bowl cleaner were found in resident bathrooms on one unit, with a registered nurse confirming these chemicals should not be accessible to residents and removing them after discovery. Safety Data Sheets indicated potential health risks if exposed.
A resident with a diagnosis of PTSD was not assessed for trauma triggers, and the care plan did not include interventions to prevent re-traumatization. The facility's records and care planning failed to address the resident's trauma history or identify specific triggers.
A resident reported that meals were not hot upon arrival, and a test tray during a lunch service confirmed that food was served below recommended temperatures. Only two CNAs were available to serve 20 residents, and interruptions for resident care further delayed meal delivery, resulting in cold food being served.
A resident with protein-calorie malnutrition had a physician order for whole milk and full fat ice cream milkshakes, but there was no documentation on the MAR or TAR for several months indicating that the milkshakes were administered or refused. The unit manager confirmed the lack of documentation during a review with a surveyor.
A resident sustained an injury to the left ankle while being assisted by an unidentified CNA, resulting in pain, bruising, and swelling. The facility's investigation was limited to interviews with the resident, a family member, and an OT student, with no evidence of staff interviews or thorough documentation in the risk management portal, as required by policy.
The facility did not document that advance directive information was offered or reviewed with four residents or their representatives upon admission. Both electronic and paper medical records lacked evidence that the required written information or discussions about advance directives took place.
The facility's Oak Hill Unit bathrooms were found to be unsanitary, with wax and dirt buildup and a strong urine odor. The Housekeeping Manager cited loose floor tiles as a reason for not using cleaning machines, while the Maintenance Supervisor stated that floors should be cleaned regardless, with repairs to follow if necessary. These issues were confirmed by surveyors and the Administrator.
Failure to Secure Medications and Remove Expired Drugs and Lab Supplies
Penalty
Summary
The facility failed to properly secure medications and remove expired drugs and lab supplies from areas accessible for use. On multiple occasions, treatment and medication carts were observed unlocked and unattended on the Short Stay unit, with medications and supplies such as insulin pens, pen needles, lancets, fish oil, and guaifenesin accessible while residents and staff were present. Staff members, including a Certified Nurses Aid and a Registered Nurse, did not address the unsecured carts until prompted by the surveyor. Additionally, expired medications were found in medication carts, and expired lab supplies, including various types of vacutainers and butterfly needles, were available for use in both the Short Stay and Long Term units. These expired items were confirmed by nursing staff and the Director of Nursing during the survey. The observations revealed that expired medications and lab supplies remained in circulation, with staff confirming their presence and availability for use. The facility's process allowed for expired items to accumulate, and staff were not consistently ensuring that medication and treatment carts were locked when unattended. The surveyor's findings were confirmed through interviews with staff, who acknowledged the presence of expired supplies and the lapses in securing medication storage areas.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen. The kitchen floor, walls, dishwasher, and vents were found to be dirty, with food debris, trash, and dust present throughout the area, including under equipment and shelving. Two dietary aides were seen preparing food without proper hair restraints, only applying them after being prompted by surveyors. Additionally, three large cans of peaches with denting along the seal were available for use, despite facility protocol requiring damaged cans to be set aside and not used. These findings were confirmed during the initial kitchen tour and discussed with the Food Service District Manager.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective Infection Control Program as evidenced by multiple observed lapses in hand hygiene and improper use of personal protective equipment (PPE) by staff during medication administration, meal tray service, and while exiting transmission-based precaution areas. On one occasion, an LPN was observed rubbing his eyes and nose multiple times at the nurse's station and again while preparing and administering medications to a resident, all without performing hand hygiene. The LPN acknowledged that he should have performed hand hygiene, especially given his condition that causes frequent eye rubbing. During a lunch meal pass, two CNAs were observed turning and boosting a resident in bed, then exiting the room and immediately handling and delivering meal trays to other residents without performing hand hygiene. Both CNAs confirmed they should have performed hand hygiene after providing care and before handling food trays. Additionally, a Physical Therapy Assistant was seen exiting a unit wearing an isolation gown, walking through common areas, and only removing the gown in the dining room after being reminded, despite having just left a room where transmission-based precautions had been lifted. The staff member admitted to forgetting to remove the gown before leaving the resident's room.
Failure to Timely Review and Revise Care Plans by IDT After MDS Assessments
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT) within 7 days following each Minimum Data Set (MDS) assessment for three residents. For one resident, the medical record showed multiple MDS assessments, including a Significant Change MDS and several Quarterly MDSs, without evidence of IDT meetings being held within the required timeframe; the last documented IDT meeting was several months prior. Another resident's record also lacked evidence of timely IDT meetings after MDS assessments, and although an IDT meeting was held after admission, the resident's family representative was not present, nor was there documentation that the representative was invited or provided a copy of the care plan. For a third resident, the record similarly lacked evidence of an IDT meeting within 7 days of a Quarterly MDS assessment, and the Social Services Director confirmed there was no established process for scheduling IDT meetings or notifying residents and their representatives in advance.
Failure to Assess, Monitor, and Follow Physician Orders for Wound and Positioning Care
Penalty
Summary
The facility failed to provide appropriate assessment, monitoring, and care for residents with wounds and positioning needs. One resident with a surgical wound following a left intertrochanteric femur fracture did not have evidence in the medical record of an initial nursing assessment, ongoing monitoring, or assessments of the surgical site throughout their stay. This lack of documentation and monitoring was confirmed by the Market Clinical Advisor. Another resident with an open wound on the right forearm had a physician order for topical Mupirocin and for the wound to be covered with a bandage, but was observed on two occasions with the wound uncovered. Nursing staff confirmed that the wound should be covered and that the resident does not typically refuse or remove dressings. Additionally, a resident with hemiparesis was observed using a left wrist brace as part of their care plan, but there was no physician order for the brace in the clinical record. The Director of Rehabilitation and Occupational Therapist confirmed that a physician order should be present for the brace.
Failure to Provide Sufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents during weekends in the first quarter of the reporting period. Review of the Payroll Based Journal staffing report indicated that the facility triggered for low weekend staffing, and the DON confirmed that staffing levels were inadequate to meet resident needs on weekends. This deficiency was identified through both record review and direct confirmation by facility leadership. Additional evidence of insufficient staffing was found in Resident Council meeting minutes, which documented ongoing concerns about inconsistent staffing ratios, particularly on the second shift, and long wait times for call light responses. Residents reported that there was often only one aide per unit on the second shift, leading to delays in assistance. Grievances filed by the Resident Council further corroborated these concerns, specifically noting repeated issues with untimely responses to call lights.
Unsecured Chemical Storage in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards due to improper storage of chemicals on Pleasant Hill House. On two separate occasions, unsecured containers of Micro-Kill One Germicidal Alcohol Wipes and a bottle of toilet bowl cleaner were found in resident bathrooms. These chemicals were accessible to residents, and their presence was confirmed by a registered nurse, who acknowledged that such items should not be stored in resident bathrooms and subsequently removed them. The Safety Data Sheets (SDS) for both Micro-Kill One Germicidal Alcohol Wipes and 3M Bathroom Disinfectant Cleaner Ready-to-Use indicate that exposure to these chemicals can result in the need for medical attention if inhaled, ingested, or if they come into contact with skin or eyes. The observations were made during the survey, and the findings were discussed with facility leadership during the exit conference.
Failure to Assess and Care Plan for PTSD Triggers
Penalty
Summary
The facility failed to identify and assess a resident's history of Post-Traumatic Stress Disorder (PTSD) to determine specific triggers that could lead to re-traumatization. Record review showed that the resident, admitted in 2018 and diagnosed with PTSD, did not have an assessment or care plan documentation addressing potential trauma triggers or interventions to prevent re-traumatization. The care plan and assessments lacked evidence of any evaluation or planning related to the resident's trauma history and associated needs.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at an appetizing and palatable temperature for one of two meals observed. During a lunch meal service, only two CNAs were available to serve trays to 20 residents, and their responsibilities were interrupted by the need to assist residents with boosting, turning, and toileting. As a result, the last meal tray was served 31 minutes after the first, and a test tray revealed that the BBQ pulled pork sandwich was at 121.7°F and the seasoned potato wedges were at 85°F, both below recommended serving temperatures. A resident expressed concerns about food not being hot when it arrived, and a CNA confirmed that limited staffing often led to cold food being served.
Incomplete Clinical Record Documentation for Nutrition Orders
Penalty
Summary
The facility failed to ensure that clinical records for a resident with protein-calorie malnutrition were complete and accurately documented. An active physician order was present for the resident to receive 8oz whole milk and full fat ice cream milkshakes three times daily with meals and at bedtime. However, physician progress notes indicated that the order for milkshakes could not be found on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and this issue persisted over multiple months. Review of the resident's MAR and TAR for January, February, and March showed no documentation that the milkshakes were given or refused. The unit manager confirmed the absence of this documentation during a record review with the surveyor.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident sustained an injury to the left ankle while an unidentified CNA was assisting with putting on the resident's shoe. Medical records included a provider note documenting an evaluation and subsequent X-ray, which showed soft tissue swelling but no fracture. However, there was no nursing documentation regarding the occurrence of the injury or any monitoring of the resident's left foot following the incident. The facility's investigation consisted only of interviews with the resident, a family member, and a note from an OT student, who documented the resident's report of pain, bruising, and swelling. The OT student also recorded the resident's account that the injury occurred when an aide twisted the leg while putting on shoes. The investigation lacked evidence of interviews or observations involving staff who worked with the resident at the time of the incident. Additionally, there was no thorough documentation in the risk management portal as required by facility policy, and no evidence that witness statements were collected.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to provide evidence that advance directives were offered, reviewed, or that written information regarding the right to formulate an advance directive was given to residents and/or their representatives. This deficiency was identified for four residents who were admitted between December 2024 and February 2025. For each of these residents, a review of both electronic and paper medical records did not show documentation that the facility had fulfilled its obligation to inform or discuss advance directives with the residents or their representatives. Specifically, the records for these residents lacked any indication that the facility had provided the required information or engaged in the necessary discussions about advance directives at the time of admission. These findings were confirmed during interviews and record reviews, and the absence of documentation was discussed with the Market Clinical Advisor on two separate occasions.
Unsanitary Conditions in Oak Hill Unit Bathrooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Oak Hill Unit, as observed by surveyors. A complaint was received by the Department of Licensing regarding the unclean state and urine-like odor in the bathrooms of this unit. During an interview, the Housekeeping Manager acknowledged issues with loose floor tiles, which prevented the use of a scrubber and buffing machine. A tour confirmed the presence of wax and dirt buildup on the bathroom floors, with bathrooms #2, #3, and #7 having extensive wax buildup and a strong urine odor in one bathroom. The Maintenance Supervisor indicated that the floors had been worked on previously and should be cleaned as needed, with repairs to follow if damage occurred. These findings were confirmed with the Administrator.
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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