Pinnacle Health & Rehab Canton
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Maine.
- Location
- 26 Pleasant St, Canton, Maine 04221
- CMS Provider Number
- 205101
- Inspections on file
- 20
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Pinnacle Health & Rehab Canton during CMS and state inspections, most recent first.
A resident with a documented fall risk experienced an unwitnessed fall when their call bell was not within reach, contrary to care plan interventions requiring staff to ensure accessibility and encourage its use.
A facility failed to maintain a resident's dignity by not grooming them properly over three days, despite their dependency on staff for daily living activities. Additionally, an RN incorrectly identified a medication during a pass, telling a resident that a PreserVision ARDES 2 tablet was TUMS. The DON confirmed these practices were unacceptable.
The facility failed to maintain a sanitary and comfortable environment, as observed during a tour. Issues included dirty floors, stained tiles, and uncleanable surfaces on equipment and wheelchairs. These deficiencies were confirmed by the Maintenance Director and Administrator.
The facility failed to update and implement care plans for residents, leading to deficiencies in care. Two residents had call bells out of reach, contrary to their care plans. Another resident with PTSD lacked an updated trauma-informed care plan, and a resident with dementia had no goals or interventions for behaviors in their care plan.
The facility failed to properly label and remove expired medications from a medication cart and did not maintain appropriate storage temperatures for biologicals in two refrigerators. Insulin pens were found expired or without opened dates, and medications like Ozempic and Trulicity were stored at incorrect temperatures due to ice buildup in the refrigerators.
The facility did not conduct PASRR Level II evaluations for two residents with mental health diagnoses whose stays extended beyond 30 days. Both residents were initially admitted for short-term convalescence, but their stays became long-term without the necessary PASRR Level II referrals. This was confirmed by the Social Service Director and discussed with the DON.
A facility failed to implement a baseline care plan within 48 hours for a resident with COPD. Despite having active medication orders for respiratory issues, the care plan lacked goals and interventions for the resident's condition. This deficiency was confirmed during a record review with a surveyor.
A resident with cerebral palsy had a care plan that was not updated to reflect the discontinuation of a wrist brace. Despite observations and staff interviews confirming the resident had not used a brace for over a year, the care plan still included outdated information. The DON confirmed the care plan was incorrect.
A patient lift in the hallway was found missing a sling bar safety clip, posing a potential accident hazard. The DON confirmed the deficiency during the survey.
A facility failed to provide trauma-informed care for a resident with PTSD, who was cognitively intact and distressed by loud noises. The resident's care plan did not include identification of PTSD triggers, as required by facility policy. The LSW admitted that while new residents had trauma-informed care plans, long-term residents like this one had not been updated.
Surveyors found deficiencies in kitchen safety and temperature monitoring, including improper facial hair protection and missing temperature logs for dish machines and refrigeration units.
The facility failed to properly contain garbage, as observed by surveyors during a kitchen tour. Trash was stored in an open-top cart outside the kitchen, leaving it exposed and potentially attracting pests. The Food Service Director confirmed the practice of keeping trash in the open bin before moving it to a larger trash trailer.
The facility's kitchen walk-in freezer was not maintained in good repair, with a significant ice build-up preventing the left fan from running and causing the right fan to make noise. The Food Service Director confirmed these issues, noting that the freezer had been worked on earlier in the year but continued to malfunction.
Failure to Ensure Call Bell Accessibility for Resident at Risk for Falls
Penalty
Summary
A resident who was identified as being at risk for falls experienced an unwitnessed fall and was found in front of their wheelchair next to their bed. Review of the resident's care plan indicated that staff were required to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. However, documentation from the post-fall assessment confirmed that the call bell was not within the resident's reach at the time of the incident. This failure to follow the care plan intervention contributed to the resident's fall.
Deficiencies in Resident Grooming and Medication Identification
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident #31, who was dependent on staff for all activities of daily living due to a diagnosis of dementia. Over three consecutive survey days, the resident was observed with long facial and chin hair, indicating a lack of grooming. Despite the facility's policy that residents should be shaved daily, interviews with CNAs revealed that if a resident refuses grooming, it should be documented, and the resident should be re-approached. However, the observations and interviews confirmed that Resident #31 was not groomed appropriately, as confirmed by the Director of Nursing. Additionally, the facility failed to correctly identify a medication for a resident, identified as Resident #242, during a medication pass. An RN incorrectly informed the resident that a PreserVision ARDES 2 chewable tablet was TUMS. The RN later admitted to the error, stating that the resident was particular about taking medications. The Director of Nursing confirmed with surveyors that providing incorrect information about medication was unacceptable practice.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unsanitary and uncomfortable environment. During a facility environment tour, several deficiencies were observed. The bathroom across from the nurse's station had a dirty floor and stained tiles. A ceiling tile in the hallway had a large brown stain. A sit-to-stand patient lift had chipped paint and dirt, making it uncleanable. In various resident rooms, there were issues such as dust and debris in bathroom lights, dirty floors around toilets, and soiled wheelchairs with food debris. Additionally, a resident's reclining wheelchair had a torn footrest, creating an uncleanable surface. These findings were confirmed by the Maintenance Director and the Administrator during the tour.
Deficiencies in Care Plan Implementation and Updates
Penalty
Summary
The facility failed to update and implement care plans for several residents, leading to deficiencies in care. Resident #30 was observed in a wheelchair with the call bell out of reach, despite the care plan instructing that the call light should be within reach. Similarly, Resident #8, who requires a hoyer lift for transfers, had the call bell coiled up and out of reach, contrary to the care plan's instructions. These observations were confirmed by CNA #4, indicating a failure to adhere to the care plans designed to prevent falls and ensure prompt assistance. Additionally, the facility did not update the care plan for Resident #9, who was admitted with PTSD, to include trauma-informed care as required. The Licensed Social Worker acknowledged that while new residents had updated care plans, long-term residents like Resident #9 did not. Furthermore, Resident #31, who has dementia and exhibits physical and verbal behaviors, lacked a care plan with goals and interventions for mood and behaviors. This was confirmed during interviews with staff, highlighting a gap in addressing the resident's behavioral needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired medications from the medication cart, as well as maintaining appropriate storage temperatures for biologicals in the medication room refrigerators. During an observation, surveyors found several insulin pens, including Aspart, Basaglar, Lantus, and Lispro, that were either expired or lacked an opened date, contrary to the manufacturer's instructions. The Registered Nurse confirmed the expiration and removed the medications from availability. Additionally, the facility did not maintain the required temperature range for storing medications in two of the three refrigerators observed. The top refrigerator had excessive ice buildup, preventing the freezer door from closing, and contained medications like Ozempic, Trulicity, and Lorazepam, which were stored at incorrect temperatures. Similarly, the bottom refrigerator also had ice buildup and contained insulin pens, COVID-19 vaccines, and an unlabeled vial of Tuberculin, all stored at inappropriate temperatures. The temperature logs for both refrigerators showed that only two days in July had temperatures within the recommended range.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that two residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred for a PASRR Level II evaluation and determination. Resident #10 was admitted with a diagnosis of Schizophrenia and initially received a PASRR Level I determination indicating no further evaluation was needed due to a short-term convalescence admission. However, when Resident #10's stay transitioned to long-term, the facility did not forward the PASRR Level I to the State Mental Health Authority for a Level II evaluation. Similarly, Resident #15, admitted with Schizophrenia and Bipolar Disorder, also had a PASRR Level I determination that did not require further evaluation for a short-term stay. Like Resident #10, Resident #15's stay extended beyond the short-term period, and the facility failed to initiate a PASRR Level II evaluation. These findings were confirmed during interviews with the Social Service Director and discussed with the Director of Nursing.
Failure to Implement Baseline Care Plan for COPD Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted with active orders for medications including Advair, Ipratropium-Albuterol, Prednisone, and ProAir, all related to their COPD diagnosis. Despite these orders, the care plan initiated did not include necessary goals and interventions for the resident's respiratory concerns. This deficiency was confirmed during a review of the resident's clinical record with a surveyor, where it was noted that the care plan lacked evidence of addressing the resident's respiratory diagnoses within the required timeframe.
Failure to Update Care Plan for Discontinued Brace
Penalty
Summary
The facility failed to update the care plan for a resident with cerebral palsy, who was admitted with muscle wasting and atrophy, to reflect the discontinuation of a wrist brace. Observations revealed that the resident had bilateral hand/arm contractures and did not have a hand brace, nor did they want one. The clinical record showed an order for a brace to be worn as needed for positioning, which was discontinued, but the care plan was not updated to reflect this change. Care plan meetings were held on several occasions, yet the care plan still included outdated information about the use of braces and splints. Interviews with facility staff, including an occupational therapist, a certified nursing assistant, and a registered nurse, confirmed that the resident had not used a brace for at least a year, and the care plan was incorrect. The Director of Nursing also confirmed these findings, indicating a lapse in ensuring the care plan accurately reflected the resident's current needs and the discontinuation of the wrist brace.
Patient Lift Safety Deficiency
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to a deficiency related to a patient lift. On July 29, 2024, at 9:35 a.m., two surveyors observed a patient lift in the hallway near a resident room that was missing a sling bar safety clip. This missing safety clip posed a risk as it could potentially allow the sling strap to come off during a lift or transfer. At 10:15 a.m., the Director of Nursing confirmed the absence of the safety clip on the patient lift during the surveyor's observation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, paranoid schizophrenia, anxiety disorder, bipolar disorder, and major depressive disorder, was found to be cognitively intact with a mental status score of 15 out of 15. Despite this, the facility did not identify the resident's PTSD triggers or incorporate them into a care plan, as required by their policy on Trauma Informed Care. During interviews, the resident expressed that loud noises were particularly distressing, yet no staff had inquired about their triggers or how to assist them. The Licensed Social Worker (LSW) acknowledged that the resident's care plan lacked necessary measures for trauma-informed care, admitting that while new residents had these considerations included, long-term residents had not been updated accordingly. This oversight was confirmed during a review of the resident's care plan with a surveyor.
Deficiencies in Kitchen Safety and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to its Refrigeration Policy and Dish Machine Temperature Log procedures during a kitchen tour conducted by surveyors. Observations revealed that a kitchen worker with facial hair was not wearing proper facial hair protection, as it was pulled down below the mouth while working. Additionally, another kitchen worker was observed without any facial hair protection. These observations were confirmed by the Food Service Director during an interview. Furthermore, the facility did not consistently monitor and record temperatures for the dish machine and refrigeration units. The Dish Machine Temperature Log was missing entries for several dates in April 2024, specifically for breakfast on the 5th, 19th, and 24th. Similarly, the Refrigerator/Freezer Temperature Log was missing entries for various times in July 2024, including the 4th, 24th, and 25th. These lapses in documentation were discussed with the Food Service Director by a surveyor.
Improper Garbage Containment
Penalty
Summary
The facility failed to ensure that garbage was properly contained, as observed during a survey. On July 29, 2024, from 9:40 a.m. to 10:10 a.m., two surveyors conducted an initial kitchen tour with the Food Service Director. During this tour, they observed trash being stored in an open-top cart outside the facility next to the kitchen area. This lack of proper containment left the garbage exposed, creating the potential for the harborage and feeding of pests. The Food Service Director confirmed that the trash is kept in the open bin and then wheeled to the large trash trailer later in the day.
Walk-in Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen walk-in freezer in good repair and safe operating condition. During a kitchen tour conducted by two surveyors, it was observed that the walk-in freezer had a significant ice build-up, which prevented the left fan of the freezing unit from running. Additionally, the right fan was making a loud noise as it spun and hit the ice build-up nearby. The Food Service Director confirmed these observations and stated that the freezer had been worked on in February 2024 but had not functioned properly since then. Despite multiple repair attempts, the freezer continued to experience ice build-up issues.
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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