River Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kennebunk, Maine.
- Location
- 3 Brazier Lane, Kennebunk, Maine 04043
- CMS Provider Number
- 205065
- Inspections on file
- 15
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at River Ridge Center during CMS and state inspections, most recent first.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
Surveyors found that the facility did not maintain safe hot water temperatures, with logs and direct observations showing consistently excessive readings across all resident units. Despite repeated documentation of the issue and reports to management, no effective monitoring or corrective actions were implemented, and the Administrator confirmed she had not been overseeing the situation. This failure had the potential to affect all residents.
Surveyors found that expired medications, including Heparin lock flush syringes and a vial of Insulin Lispro prescribed to a discharged resident, were not removed from medication storage areas in two units. Additionally, a vial of PPD was available for use past the recommended 30-day period. These findings were confirmed by the unit nurse manager and Market Clinical Advisor.
Three residents did not consistently receive meals that matched their documented food preferences and dietary restrictions. One resident was repeatedly served pork despite a clear dislike, another was not provided real eggs or alternative preparations as requested, and a third received meals containing multiple disliked foods. Communication breakdowns and incomplete documentation contributed to these failures.
The facility did not ensure its QAPI committee addressed a known safety concern about elevated water temperatures in resident-accessible areas. Although the Safety Committee had previously noted the issue, there was no documentation of follow-up actions or escalation to QAPI, and the Administrator confirmed the committee was not addressing water temperature concerns. Surveyors found water temperatures above 124°F in several areas.
Surveyors identified that staff across three units were not knowledgeable about Enhanced Barrier Precautions (EBP), as multiple staff members could not explain EBP protocols or recall receiving training, despite EBP signage being present on resident room doors. The Infection Preventionist confirmed education was verbal and lacked documentation.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not ensure adequate direct care staffing on multiple weekends, as evidenced by PBJ reports and staffing schedules, resulting in insufficient staff to meet resident needs on several weekend days in two consecutive quarters. This was confirmed by a Market Clinical Advisor during a review of staffing records.
A resident with Type 2 Diabetes Mellitus and a history of insulin use had all insulin discontinued by physician order, but the care plan was not updated to reflect this change. The care plan continued to indicate insulin dependence, and there was no documentation that the resident received education or information about the change in diabetes management.
Surveyors found that after unwitnessed falls, several residents did not have complete or available neurological assessment logs as required by facility policy. In some cases, logs were missing entirely, while in others, documentation was incomplete for the required monitoring period. The facility could not confirm that the assessments were performed or provide the missing records.
A resident experienced a fall from an elevated bed after being left unsupervised by a CNA, resulting in significant injury and subsequent death. The facility did not submit an initial report of the incident to authorities within the required timeframe, only submitting a final report nearly two days later, in violation of its own policy.
A resident who required extensive assistance for ADLs was left unattended in a raised bed, resulting in a fall and injury, despite a care plan intervention to use a low bed. Environmental hazards were also identified, including unsecured storage and electrical rooms and areas with jagged, splintered wood.
The facility failed to ensure proper food storage and labeling, with expired and unlabeled items found in the kitchen. Additionally, food temperatures were not consistently maintained within safe parameters, as documented in the Service Line Checklist. These issues were confirmed during a survey and interview with the Healthcare Services Group District Manager.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific actions or omissions by staff or management that led to the deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Control Hot Water Temperatures Creates Accident Hazard
Penalty
Summary
The facility failed to administer its operations in a manner that ensured the resident environment was free from accident hazards, specifically by not maintaining hot water temperatures at safe levels. Review of hot water temperature logs from late October through mid-July revealed repeated and consistent recordings of excessively high hot water temperatures, with some readings as high as 137 degrees Fahrenheit. Comments on the logs over several months indicated ongoing issues with the hot water system, including notes about faulty equipment, inability to regulate temperatures, and reports made to management. Despite these documented concerns, there was no evidence that a process was in place to monitor or correct the high temperatures, nor that effective interventions were implemented. Observations by surveyors and the Maintenance Supervisor confirmed hot water temperatures above 120 degrees Fahrenheit on all resident units. The Safety Committee meeting minutes acknowledged the unsafe temperatures but did not document any follow-up actions or plans to address the issue. In interviews, the Administrator confirmed awareness of the problem but stated she had not been monitoring the hot water temperatures. The deficiency was found to have the potential to affect all 57 residents in the facility, as excessively hot water temperatures were present throughout all resident areas.
Expired Medications Not Removed from Storage
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from the supply available for use in two of three medication storage rooms reviewed. In the Kennebunk River Unit, two prepackaged syringes of Heparin lock flush with expiration dates of 4/30/25 were found in the emergency intravenous medication and supply stock, and a vial of Insulin Lispro prescribed to a resident who had been discharged on 4/16/25 was still stored in the medication refrigerator. The unit nurse manager confirmed these findings at the time of observation. In the Mousam River Unit, a vial of PPD labeled with an opened date of 6/1/25 remained available for resident use beyond the recommended 30-day period, as confirmed by the Market Clinical Advisor during the observation. These observations indicate that expired and potentially unusable medications were not properly removed from medication storage areas, making them accessible for use.
Failure to Accommodate Resident Food Preferences and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents' food preferences and dietary restrictions were consistently honored, as evidenced by multiple incidents involving three residents. One resident, who had previously communicated a dislike for pork to the dietician, was repeatedly served pork products such as ham and bacon. Despite staff notifying the kitchen and requesting substitutions, the resident continued to receive meals containing pork, and the dietary slip on the food tray did not accurately reflect the resident's preferences. Communication barriers between kitchen staff and dietary management contributed to the ongoing issue, as changes or preferences were not reliably updated on meal tickets. Another resident expressed dissatisfaction with the use of egg substitutes instead of real eggs and reported that requests for eggs prepared differently were ignored. The Food Service Director and Regional Director of Food Services confirmed that only egg substitutes were used due to cost considerations, but stated that special requests could be accommodated if made. However, the resident's requests were not fulfilled, indicating a lack of follow-through on stated accommodations. A third resident, who had documented dislikes for several foods including wheat, tuna, and chicken, was served meals containing these items on multiple occasions. The resident had to request alternative meals, which sometimes still included disliked foods. Review of the resident's food preference form showed that their dislikes were not fully reflected on the meal slips. Staff interviews revealed inconsistent processes for communicating food preferences to the kitchen, with some staff unable to locate the necessary forms or relying on verbal communication, which was not always effective.
Failure to Address Elevated Water Temperatures Through QAPI
Penalty
Summary
The facility failed to ensure that its QAPI committee systematically identified and addressed a known safety concern regarding elevated water temperatures in resident-accessible areas. Although the Safety Committee had previously documented water temperature issues in its February 2025 meeting minutes, there was no documentation of required actions or evidence that the issue was escalated to or addressed by the QAPI committee. During interviews, the Administrator confirmed that the QAPI committee's focus areas did not include water temperature concerns, and was unable to provide any records showing QAPI involvement in addressing the issue. Surveyors measured water temperatures exceeding 124°F in multiple resident areas, confirming the ongoing concern.
Staff Lacked Knowledge of Enhanced Barrier Precautions (EBP)
Penalty
Summary
Surveyors found that the facility failed to ensure staff were educated and knowledgeable about Enhanced Barrier Precautions (EBP) across all three units surveyed. Observations revealed EBP precaution signage on multiple resident room doors, but when staff members, including CNAs and an Environmental Services Worker, were questioned about EBP, they were unable to explain what EBP was, when to use it, or what PPE was required. Several staff members stated they did not recall receiving any training on EBP, despite having worked at the facility for several months to over a year. Interviews with the Infection Preventionist confirmed that staff education on EBP was conducted verbally, but there was no documentation to demonstrate staff understanding or knowledge of EBP protocols. The lack of staff awareness and training was observed in all three units, with staff unable to identify or implement appropriate infection control measures as outlined in the facility's own policy for Enhanced Barrier Precautions.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Insufficient Weekend Staffing Documented by PBJ Reports
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents on weekends during the first and second quarters of 2025. Payroll Based Journal (PBJ) reports and weekend staffing schedules revealed that there were 8 weekend days in the first quarter and 2 weekend days in the second quarter where the number of direct care staff was insufficient. The Center for Medicare & Medicaid Services (CMS) PBJ report indicated that the facility triggered for low weekend staffing during these periods. During an interview and review of the staffing records, the Market Clinical Advisor confirmed that the facility did not ensure enough staff were on duty to meet resident needs on weekends, as reflected in the PBJ reports.
Failure to Update Care Plan After Discontinuation of Insulin
Penalty
Summary
The facility failed to revise the care plan to reflect a resident's current diabetes management status after a significant change in treatment. A resident with a diagnosis of Type 2 Diabetes Mellitus and a history of long-term insulin use was admitted with orders for both long-acting and rapid-acting insulin. On a later date, all insulin orders were discontinued by the physician. Despite a care plan meeting attended by the resident and the discontinuation of insulin, the care plan was not updated to reflect this change, and there was no documentation that the resident received education or information regarding the rationale for stopping insulin. The care plan continued to list the resident as insulin dependent and did not address the new approach to diabetes management.
Incomplete Neurological Assessment Documentation After Unwitnessed Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents who experienced unwitnessed falls. According to the facility's own policies, any resident who sustains an unwitnessed fall or a head injury is to receive neurological assessments at specific intervals for at least 72 hours following the incident. Upon review, surveyors found that for several residents, either the neurological assessment logs were missing entirely or, when present, were incomplete for the required 72-hour period. Progress notes did not provide explanations for the missing or incomplete assessments. Specifically, two residents had no neurological assessment logs available for their unwitnessed falls, while three residents had logs that were incomplete for the required monitoring period. The facility was unable to produce the missing documentation or confirm that the required neurological assessments were performed as per policy. These findings were confirmed during an interview with the Corporate Representative, who acknowledged the absence of the necessary records.
Failure to Timely Report Suspected Neglect and Injury After Resident Fall
Penalty
Summary
The facility failed to report a fall with suspected negligence and significant injury within the required time frame for one resident. According to the facility's own policy, allegations involving neglect or mistreatment that result in serious bodily injury must be reported to state and local authorities within two hours. In this case, a resident fell from an elevated bed after being left unsupervised by a CNA. The incident occurred late in the evening, and the resident subsequently experienced increased pain, prompting an x-ray order for suspected fractures. The resident died the following morning. Despite the serious nature of the incident, the facility did not submit an initial report to the Department of Licensing and Certification as required. Instead, a final report was submitted nearly two days after the fall, and there was no evidence of an initial, timely notification. The deficiency was confirmed through interviews, record reviews, and policy examination, which showed the facility did not adhere to its own reporting requirements following the incident.
Failure to Prevent Accidents and Maintain a Hazard-Free Environment
Penalty
Summary
A resident who was dependent on staff for nearly all activities of daily living, including bed mobility, was left unattended in a raised bed by a CNA who exited the room to retrieve linens. During this time, the resident fell between the bed and the wall, resulting in lower back and left leg pain, and a provider subsequently ordered an x-ray due to suspected fracture. The resident's care plan had identified a risk for falls and included an intervention to utilize a low bed, which was not followed at the time of the incident. Additionally, environmental hazards were observed in two separate unit hallways. One closet in a corridor was found with a missing doorknob and jagged, splintered wooden edges. In another unit, an unlocked storage room containing electrical panels and a locked biohazard cabinet was accessible, as well as an unlocked electrical room with a non-functional keypad lock and jagged, splintered wood beneath the keypad. These conditions were confirmed by the surveyor with facility leadership.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, as observed during a survey. Foods in the dry storage room, walk-in refrigerator, and freezer were not labeled or dated, and some were expired. The dry storage room had dirt, debris, and food particles on the floor, with shelves that had peeling paint. Several food items, including buns, bread, and tortillas, were past their use-by dates. Additionally, opened and unsecured food items were found, such as a box of rice, bags of cereal, and a bucket of icing. In the walk-in refrigerator, containers of egg salad, tuna salad, apple pie filling, and potato salad were not labeled or dated. The walk-in freezer contained uncovered pies and uncovered hamburger patties. The cook was observed preparing food without a hair net, which was only applied after being prompted by the surveyor. The facility also failed to maintain appropriate food temperatures as per the Service Line Checklist. Documentation revealed that for several days, food temperatures were outside the required parameters for Time/Temperature Control for Safety (TCS) foods, or there was a lack of documentation altogether. This issue was confirmed during an interview with the Healthcare Services Group District Manager. The facility's policies on food storage and preparation were not adhered to, leading to these deficiencies in food safety and handling practices.
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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