Rumford Community Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rumford, Maine.
- Location
- 11 John F Kennedy Lane, Rumford, Maine 04276
- CMS Provider Number
- 205099
- Inspections on file
- 22
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rumford Community Home during CMS and state inspections, most recent first.
A resident with dementia and extensive ADL needs was injured during a transfer when staff failed to open the legs of a mechanical lift as required by policy, causing the lift to tip over and the resident to fall. The resident sustained multiple lacerations and a hematoma to the head but remained alert and without pain complaints after the incident. Staff interviews and documentation confirmed the lift was not used according to safety protocols.
Surveyors identified multiple sanitation and food safety deficiencies, including stained ceiling tiles, unclean floors, a dusty fan, and chipped paint in the kitchen. Several food items in storage were found unlabeled, undated, or improperly sealed. The kitchen ice machine was not plumbed with the required air gap, and dish machine temperature logs showed numerous missing entries, indicating inconsistent monitoring. The Food Service Director confirmed these findings, which were not in accordance with facility policy.
The facility did not complete regular inspections or measurements of bed frames, mattresses, and bed rails to identify possible entrapment areas for all beds. Both the Administrator and the Director of Ancillary Services confirmed that these safety checks had not been performed or documented since early last year.
Two residents did not have their bathing preferences accommodated as documented in their care plans and schedules. One resident, with moderate cognitive impairment, was not consistently offered or documented as refusing scheduled showers or bed baths. Another cognitively intact resident, who valued choosing bathing options, reported not being offered showers as scheduled and instead received bed baths, with records lacking evidence of offers or refusals. Staff and DON interviews confirmed these findings.
Surveyors identified multiple deficiencies in facility maintenance and housekeeping, including uncleanable surfaces on a laundry cart, dirty ceiling lights, chipped and damaged doors and heaters, stained bathroom fixtures, and a dirty laundry room. These issues were confirmed by the Administrator and the Director of Ancillary Services during environmental tours.
A resident's oxygen tubing and nasal cannula were repeatedly found improperly stored—on personal belongings, on top of the concentrator, and on the floor—without being bagged. Staff confirmed the equipment was not stored according to sanitary practices, and the facility lacked a written policy for respiratory equipment storage.
A review of CNA education records revealed that five CNAs did not receive the required 12 hours of annual in-service training, including mandatory topics such as Resident Rights, Dementia care, QAPI, and Infection Control. The Administrator confirmed the deficiency during an interview.
A container of Oxivir Tb Wipes, a chemical disinfectant, was found unsecured in an open conference room accessible to confused and vulnerable residents who ambulate or use wheelchairs. The facility administrator confirmed the wipes were left accessible to residents.
A resident with Bipolar Disorder and Major Depressive Disorder was administered Venlafaxine ER 225 mg daily for several months without evidence of a gradual dose reduction (GDR) attempt or documentation of a clinical contraindication, despite a pharmacy recommendation to do so.
The facility did not complete an annual review of its Infection Prevention and Control Program, as several key policies lacked evidence of recent review or revision, and the Administrator confirmed the annual review had not occurred.
The facility did not have a qualified staff member designated as the Infection Preventionist responsible for the infection prevention and control program after the previous IP became the DON. Although a new acting IP and ADON was hired, this individual had not completed the required infection control training, leaving the facility without a qualified IP as required by policy.
A resident did not receive the influenza vaccine as required by facility policy after initially refusing it, and staff failed to follow up in a timely manner, resulting in a delayed administration. The DON acknowledged losing track of the resident's vaccination status.
A resident's COVID-19 vaccination was not administered and documented according to facility policy after initial refusal and planned re-approach by staff, resulting in a lapse in timely immunization and recordkeeping.
Two residents were admitted without timely and complete baseline care plans. One resident with a Foley catheter was not identified for Enhanced Barrier Precautions, and their care plan lacked necessary problems, goals, and interventions. Another resident under hospice care with multiple complex needs did not have goals or interventions documented for key areas such as pain, falls, oxygen use, and nutrition. The DON confirmed these omissions.
The facility did not complete required documentation or monitoring after an unwitnessed fall for a resident, including omitting a fall risk assessment and neurological checks. Additionally, physician orders were not followed for two residents: one received oxygen at an incorrect flow rate, and another experienced a significant delay in ordered lab work.
Resident Injury Due to Improper Mechanical Lift Use During Transfer
Penalty
Summary
A deficiency occurred when staff failed to properly transfer a resident who required total assistance with a mechanical lift due to dementia and extensive ADL self-care deficits. During a transfer from bed to a Broda chair using a mechanical (hoyer) lift, the staff did not open the legs of the lift as required by facility policy, resulting in the lift tipping over sideways while the resident was in the sling. The resident fell to the floor, sustaining a laceration to the bridge of the nose, an 8x7 cm hematoma with a 0.5 cm laceration on the left side of the head, and a 0.5 cm laceration on the back of the head. The resident was alert, able to answer questions, and did not complain of pain or discomfort following the incident. Interviews with staff confirmed that the hoyer lift was operated with the legs in the closed position during the transfer, and the attempt to open the legs while the resident was suspended caused the lift to become unbalanced and fall. Facility policy required that the base legs of the lift be locked in the maximum open position for stability and resident safety during all transfers. Documentation and staff statements consistently indicated that this policy was not followed at the time of the incident, directly leading to the resident's injuries.
Deficiencies in Kitchen Sanitation, Food Labeling, and Dish Machine Monitoring
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen, including three stained ceiling tiles above a food preparation area, trash and food debris on the floor under equipment and around the edges, and a dusty wall-mounted fan with a baseboard heater that had chipped or missing paint, creating an uncleanable surface. Additionally, several food items in the kitchen, walk-in refrigerator, and walk-in freezer were found unlabeled and undated, such as a plastic container of cereal, a large bin of flour, a pie crust wrap, a container of peeled eggs that was not securely sealed, and various packages of meatballs, stuffed shells, chicken patties, and pancakes. The kitchen ice machine was not plumbed in accordance with code requirements, lacking the proper air gap to prevent contamination, which was confirmed to be in violation of state and federal regulations. Review of the Dish Machine Temperature Logs revealed numerous missing entries for breakfast, lunch, and dinner across several months, indicating that dish machine temperatures were not consistently monitored or documented as required by facility policy. The Food Service Director confirmed these findings, acknowledging the lapses in monitoring and documentation. The facility's policies require all food to be covered, labeled, and dated, and for dish machine temperatures to be recorded at each meal to ensure proper sanitization, but these procedures were not followed.
Failure to Perform Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a maintenance program to identify possible areas of entrapment for all 32 beds. During the survey, the Administrator confirmed that documentation of bed gap and side rail gap measurements had not been completed since February 2023. The Director of Ancillary Services also verified that these regular inspections and measurements had not been performed since that time. This lapse in routine safety checks was identified through review of documentation and staff interviews.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to ensure that the bathing preferences of two residents were accommodated as outlined in their care plans and documented preferences. One resident, who was moderately cognitively impaired, was care planned to receive assistance with bathing twice daily and as needed, with instructions to re-approach if care was refused. However, clinical records lacked evidence that this resident was offered or refused a shower or bed bath on multiple scheduled days. Staff interviews confirmed that the resident primarily received bed baths and occasionally refused care, but documentation did not reflect offers or refusals on the specified dates. Another resident, who was cognitively intact and had expressed that choosing bathing options was very important, was scheduled to receive a shower on a specific day each week. Despite this, the resident reported that staff did not offer a shower and instead provided a bed bath, even when the resident wanted a shower. Review of records showed that the resident received a shower on only one documented occasion, with no evidence of being offered or refusing a shower or bed bath on numerous other scheduled days. Staff interviews confirmed the resident's dependence on assistance for bathing and the use of a Hoyer lift for transfers. The DON confirmed that staff are expected to follow the bathing schedule and resident preferences as documented.
Failure to Maintain Clean, Sanitary, and Well-Repaired Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and housekeeping services across both the East and West units, as well as in common areas such as the conference room and laundry room. Specifically, a laundry cart in use had untreated wood, which was confirmed by the Administrator to be an uncleanable surface. During an environmental tour, four ceiling lights in the conference room were found to contain dirt and debris. Numerous resident room entrance doors and baseboard heaters in both units exhibited chipped, gouged, or missing paint, and some heaters were broken or hanging down, all of which created uncleanable surfaces. Additional findings included stained caulking and toilet seats in resident bathrooms, a large spackled area on a wall, and a dirty, stained laundry room floor and ceiling. The Director of Ancillary Services confirmed these findings during the tour. The report does not mention any specific residents by name or medical history, nor does it describe the condition of residents at the time of the deficiency. The focus of the findings is on the physical environment and the failure to maintain cleanable, sanitary, and well-repaired surfaces throughout the facility.
Failure to Maintain Sanitary Storage of Respiratory Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain respiratory equipment in a sanitary manner for a resident requiring oxygen therapy. On multiple occasions, the resident's oxygen concentrator tubing and nasal cannula were found improperly stored: once on top of the resident's bureau among personal belongings, another time on top of the oxygen concentrator, and later lying on the floor next to the bed. In each instance, the equipment was not bagged as required for sanitary storage. The resident reported only using oxygen at night, with the equipment stored during the day in these unsanitary conditions. Interviews with facility staff, including the Administrator and an LPN, confirmed that the oxygen tubing and nasal cannula were not stored in accordance with expected sanitary practices. The Administrator acknowledged that the equipment should be bagged and not left on surfaces or the floor. When asked, the facility was unable to produce a specific policy or procedure regarding the storage of oxygen or respiratory equipment in resident rooms, and the regional clinical director confirmed that while the practice is to use respiratory bags, there was no formal written policy available.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education and training, as evidenced by a review of employee education records for five randomly selected CNAs who had been employed for more than one year. The records showed that none of the five CNAs had completed the mandated training hours for the year, with missing topics including Resident Rights, Dementia care, Quality Assurance and Performance Improvement Program (QAPI), and Infection Control. This deficiency was confirmed by the Administrator during an interview, who acknowledged that the required education and in-service training had not been provided to these staff members in the specified year.
Unsecured Chemical Disinfectant Accessible to Residents
Penalty
Summary
A container of Oxivir Tb Wipes, a disinfectant cleaner with virucidal, bactericidal, fungicidal, and tuberculocidal properties, was observed unsecured in an open conference room. The room was accessible to confused and vulnerable residents who ambulate independently or use wheelchairs. The Safety Data Sheet for the product indicates the need for caution in case of eye contact or ingestion. The facility administrator confirmed that the wipes were left unsecured and accessible to residents during the surveyor's observation. No information was provided regarding any specific incidents of resident exposure or harm at the time of the deficiency.
Lack of Gradual Dose Reduction or Justification for Antidepressant Use
Penalty
Summary
The facility failed to provide evidence of an attempted gradual dose reduction (GDR) or documentation of a clinical contraindication for the continued use of an antidepressant medication in one resident. The resident, who has diagnoses of Bipolar Disorder and Major Depressive Disorder, had been receiving Venlafaxine Extended Release 225 mg daily since June 2024. A pharmacy report in November 2024 recommended considering a GDR or documenting a contraindication, but the clinical record did not show that a GDR was attempted or that a contraindication was documented between November 2024 and February 2025. This finding was confirmed during an interview with the Administrator.
Failure to Conduct Annual Review of Infection Prevention and Control Program
Penalty
Summary
The facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP) as required. During a review of the IPCP policies and procedures, a surveyor observed that several policies, including the Infection Control/Exposure Control Plan Review Policy, Immunizations - Influenza and Pneumococcal Policy, and COVID-19 Vaccine Policy, either lacked dates indicating a recent review or had not been updated since 2018 or 2023. The Administrator confirmed that the IPCP policies and procedures had not been reviewed on an annual basis.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) since the previous IP transitioned to the DON position. Although a new acting IP and ADON was hired in January 2024, this individual had not completed the required infection control training for the IP role as of the time of the survey. The facility's policy requires the IP to have specific qualifications, including professional training, relevant experience or certification, part-time employment at the facility, completion of specialized infection prevention and control training, and active participation in the quality assessment and assurance committee. Interviews with the DON and Administrator confirmed that the facility had not had a designated and qualified IP since December 2022.
Failure to Implement Influenza Vaccination Policy
Penalty
Summary
The facility failed to implement its policy regarding influenza vaccination for one of five residents whose immunization records were reviewed. According to the facility's Infection Prevention & Control Policy, all residents are to be offered influenza immunization each fall, with education provided to the resident or their responsible party. For the resident in question, the clinical record showed no evidence that the influenza vaccine was administered as required. The DON confirmed that consent for the vaccine was obtained from the resident's POA in October, but the resident initially refused, and staff intended to reapproach. However, the DON lost track of the vaccination status, resulting in a delay in administration.
Failure to Timely Administer and Document COVID-19 Vaccination per Policy
Penalty
Summary
The facility failed to follow its Infection Prevention & Control Policy regarding COVID-19 immunization for one resident. According to the policy, all eligible residents should be offered the COVID-19 vaccine and provided with education, with proper documentation of immunization status. For one resident, although consent for the COVID-19 vaccine was obtained from the Power of Attorney in October 2024 and the resident initially refused, staff planned to reapproach the resident but did not follow up in a timely manner. As a result, there was no evidence in the resident's clinical record that the COVID-19 vaccine was administered as directed by facility policy until a later date.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required by policy. For one resident with a Foley catheter, the baseline care plan did not include problems, goals, or interventions related to Enhanced Barrier Precautions (EBP), despite the resident having an active order for Foley care. The resident was not identified as needing EBP, and there was no EBP signage or personal protective equipment (PPE) available at the resident's room. The Director of Nursing confirmed that the resident had been missed for EBP and that the baseline care plan lacked the necessary information. Another resident admitted under hospice care with multiple diagnoses, including heart failure, chronic respiratory failure, and a history of falls, had several active orders for pain management, skin care, fall prevention, oxygen therapy, and diuretic use. The baseline care plan for this resident did not include goals and interventions for hospice care, activities of daily living, pain, anxiety, diuretic use, impaired skin integrity, falls, oxygen use, or nutrition. The Director of Nursing confirmed the absence of these required elements in the care plan.
Failure to Document Post-Fall Monitoring and Follow Physician Orders
Penalty
Summary
The facility failed to document and monitor a resident after an unwitnessed fall. Specifically, after a resident sustained an unwitnessed fall, there was no evidence in the clinical record that a fall risk assessment or a Post Fall Observation Tool was completed, nor were neurological checks initiated as required by facility policy. The Director of Nursing confirmed that the necessary documentation and monitoring were not performed following the incident. Additionally, the facility did not follow physician orders for two residents. One resident had a physician order for continuous oxygen at 2L/min to maintain oxygen saturation above 88%, but was observed receiving oxygen at a flow rate of 2.5L/min, with the concentrator out of reach and adjustments made only by staff. Another resident had a physician order for specific bloodwork to be drawn on a certain date, but the labs were not completed until nearly a month later. These findings were confirmed through record review and staff interviews.
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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