Sandy River Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Maine.
- Location
- 119 Livermore Falls Road, Farmington, Maine 04938
- CMS Provider Number
- 205069
- Inspections on file
- 27
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Sandy River Center during CMS and state inspections, most recent first.
The facility failed to provide sufficient staffing to meet residents' needs, resulting in delayed care and increased falls. Interviews with residents and staff revealed that only two CNAs were available for an entire floor, causing delays in basic care and response to call bells. A CNA and RN confirmed staffing shortages, leading to preventable falls and delayed care. The DON acknowledged that the facility did not staff to acuity levels, and a review showed numerous falls across shifts.
The facility failed to provide written information to several residents or their representatives about their rights to accept or refuse medical treatment and to formulate an advance directive. A review of clinical records for seven residents showed no evidence of this information being provided, and the Market Clinical Advisor confirmed the lack of documentation.
The facility failed to maintain a sanitary and comfortable environment across all units, common areas, and the laundry room. Observations revealed soiled floors, dirty caulking, chipped paint, dust accumulation, and stained ceiling tiles in various units. Additionally, the patio fence door was broken, and the laundry room had a heavy lint build-up. These issues were confirmed by facility staff during interviews.
The facility did not ensure that three residents with mental health diagnoses, whose stays extended beyond 30 days, were referred for PASRR Level II evaluations. Initially admitted for short-term convalescence, these residents continued to reside in the facility without the necessary evaluations being conducted, as confirmed by the Market Clinical Advisor.
The facility failed to update and implement care plans for residents with specific medical needs, leading to deficiencies in their care. A resident with obstructive sleep apnea and COPD had a broken CPAP machine for over a month without an updated care plan. Another resident with COPD and CHF received continuous oxygen therapy without a corresponding care plan. Additionally, a resident with PTSD had no documented efforts to address their triggers. These deficiencies were confirmed by staff and surveyors.
The facility failed to ensure timely review and revision of care plans by the IDT within 7 days after comprehensive assessments for several residents. Additionally, a resident's care plan was not updated to address significant weight loss and nutritional needs, despite a noted weight loss since admission.
The facility failed to provide adequate respiratory care for a resident with severe morbid obesity, COPD, and sleep apnea by not replacing a broken CPAP machine for over a month. Additionally, another resident's oxygen tubing was not changed weekly as required, with inaccurate documentation of care. These deficiencies indicate a failure to adhere to professional standards of practice in respiratory care.
The facility failed to provide adequate snacks for residents outside of scheduled meal times across six units. Observations and interviews revealed limited snack options, such as white bread and a few crackers, with residents and staff confirming the lack of variety and availability. The Food Service Director acknowledged the issue, citing staff absences as a contributing factor.
The facility was found to have multiple deficiencies in kitchen sanitation and food storage. Observations included soiled ceiling vents, lights, and tiles, chipped paint on the hood system, and food equipment with dried particles. Unlabeled and undated food items were found in storage areas, and a cook was observed without facial hair protection. These issues were confirmed by the Food Service Director and the cook.
The facility failed to maintain a sanitary garbage storage area, with trash bags observed in open containers outside the building over four consecutive days. The Administrator and Maintenance Director confirmed these findings during the survey.
The facility failed to maintain complete and accurate clinical records for residents. One resident's ADLs documentation was incomplete over 11 days, lacking records for essential care activities. Another resident's oxygen tubing management was inaccurately documented, with tubing not changed as per active orders. The DON and Market Clinical Advisor confirmed these deficiencies.
The facility did not ensure the Infection Preventionist attended the required quarterly QAPI/QAA meetings, missing 3 out of 4 meetings. The facility's policy mandates the presence of the Infection Preventionist or a designee, but no alternate was designated. The Administrator and DON confirmed the absence, although reports were provided for review.
The facility failed to secure a medication cart, leaving it unlocked and unattended, and did not remove expired medications from storage. Additionally, vaccines were improperly stored in a dormitory-style refrigerator, which poses a risk of freezing. These deficiencies were confirmed by staff during the survey.
The facility failed to ensure a safe environment by not addressing a hazard at the nursing station. A surveyor observed that the laminate wall covering was chipped and missing pieces, creating sharp edges accessible to residents, staff, and visitors. The Market Clinical Advisor confirmed this hazard during an interview.
A facility failed to document monitoring of side effects for psychotropic medications prescribed to a resident with anxiety and depression. The resident was on multiple medications, including Abilify, Buspirone, Trazodone, and Sertraline, but the clinical record lacked evidence of side effect monitoring. This deficiency was confirmed by the DON during a surveyor interview.
A CNA-M failed to sanitize her hands between administering medications to two residents. After discarding a medication cup, she bypassed a hand sanitizer station and began preparing medications for another resident without sanitizing her hands. When questioned, she acknowledged the oversight.
The facility failed to maintain cleanliness and repair in its dining areas and kitchenettes, as observed by surveyors. Refrigerators, microwaves, and dining tables in several units were found soiled with dried liquids and food debris. Additionally, kitchenette cabinet doors had chipped paint, creating uncleanable surfaces. These deficiencies were confirmed with the Administrator.
The facility was found deficient in properly storing, labeling, and dating food items in various unit refrigerators and the kitchen. Observations included unlabeled, expired, or moldy food items accessible to residents, and cleanliness issues in the walk-in freezer. These deficiencies were confirmed by the Food Service Director and the Administrator.
Inadequate Staffing Leads to Delayed Care and Increased Falls
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly those requiring assistance with Activities of Daily Living (ADLs). Interviews with residents revealed that there were only two Certified Nursing Assistants (CNAs) on duty to cover an entire floor during both day and evening shifts, leading to delays in providing basic care such as offering a basin of water or assisting with brushing teeth. One resident reported waiting over two hours to be changed after being incontinent, and another resident mentioned that call bells were not answered in a timely manner, a concern that had been repeatedly raised in resident council meetings. Staff interviews corroborated these issues, with a CNA and a Registered Nurse (RN) both indicating that staffing shortages were a persistent problem, resulting in preventable falls and delayed care. The RN noted that there were many residents requiring two-person assistance, which further strained the limited staff resources. The Director of Nursing confirmed that the facility did not staff to acuity levels and acknowledged that falls occurred on days when staffing was insufficient. A review of the fall report over three months showed a significant number of falls across all shifts, highlighting the impact of inadequate staffing on resident safety.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for seven residents during a review of their clinical records. Specifically, the records for these residents lacked evidence that the facility had provided or attempted to provide this crucial information. The residents involved were admitted to the facility on various dates, but none had documentation indicating they were informed of their rights concerning medical treatment decisions or advance directives. Interviews with the Market Clinical Advisor confirmed the absence of documentation in the clinical records of these residents. The advisor acknowledged that the records did not show that the residents or their representatives were asked about or offered assistance with completing an advance directive. This oversight affected residents who were admitted over a range of dates, indicating a systemic issue in the facility's process for informing residents of their rights upon admission.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across all six units, common areas, a patio, and the laundry room. During a tour, it was observed that the upper level common area had a public bathroom with a dirty floor and caulking around the toilet. In the Mt. [NAME] Unit, multiple resident rooms had soiled floors, dirty caulking around toilets, and chipped or missing paint on cabinet doors. The Mt. Blue Unit's dining room floor was heavily soiled, and several resident rooms had chipped paint, dust accumulation, and stained ceiling tiles. In the Sugarloaf Unit, ceiling tiles in the hallway were stained, and several resident rooms had dirty caulking around toilets and missing towel bars. The Porter Unit had chipped paint on kitchenette cabinets and dusty dining room floors. The Rangeley Unit's shower room had a commode bucket on the floor, and resident rooms had chipped paint and exposed sheetrock. The [NAME] Unit had a resident room with chipped paint and exposed sheetrock in the bathroom. The lower level common area had stained ceiling tiles, and the laundry room had a heavy build-up of lint on and behind the dryers and washers. Additionally, the patio fence door between the Rangeley Unit and the [NAME] Unit was broken and missing two door panels, with a green chair blocking the opening. These findings were confirmed by the Maintenance Director, the Regional Health Care Services Housekeeping Supervisor, and the Administrator during interviews conducted on the same day as the observations.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that three residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred to the appropriate state-designated authority for a PASRR Level II evaluation and determination. Each resident was initially admitted under a short-term convalescence admission, which did not require further PASRR evaluation according to their PASRR Level I determination letters. However, when their stays transitioned from short-term to long-term, the facility did not forward the PASRR Level I to the State Mental Health Authority to assess the need for a PASRR Level II evaluation. Resident #48, diagnosed with Bipolar Disorder, Resident #66, diagnosed with Anxiety, and Resident #68, also diagnosed with Bipolar Disorder, all continued to reside in the facility beyond their short-term stays and were assessed to require Nursing Facility level of care. Despite this change in their stay status, there was no evidence in their clinical records to indicate that the necessary PASRR Level II evaluations were pursued. The Market Clinical Advisor confirmed these findings during an interview.
Deficiencies in Care Plan Updates and Implementations
Penalty
Summary
The facility failed to update and implement care plans for residents with specific medical needs, leading to deficiencies in their care. Resident #28, who has obstructive sleep apnea, morbid obesity, and COPD, had a care plan that was not updated to reflect the broken CPAP machine, which had been out of service for over a month. Despite the resident's request for oxygen as a temporary measure, the care plan did not reflect this change in respiratory care. This oversight was confirmed during an interview with the unit manager and a surveyor. Similarly, Resident #69, diagnosed with COPD and CHF, received continuous oxygen therapy from May to July 2024, yet their care plan lacked any focus, goals, or interventions related to oxygen therapy. This deficiency was confirmed by a surveyor in an interview with the Market Clinical Advisor. Additionally, Resident #26, who has PTSD, depression, and anxiety, had a care plan that did not document any efforts to identify or address PTSD triggers, as confirmed by the Director of Nursing. These failures indicate a lack of proper care plan updates and implementations for residents with specific health needs.
Failure to Timely Review and Revise Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were reviewed and revised by the interdisciplinary team (IDT) within 7 days after each comprehensive assessment. This deficiency was identified for four residents whose IDT meetings were not held within the required timeframe following their Minimum Data Set (MDS) assessments. Specifically, Resident #7's IDT meeting occurred 30 days after the MDS date, while Residents #32, #33, and #65 had their IDT meetings before their MDS dates, indicating a lack of timely review and revision of care plans. Additionally, the facility did not revise a resident's care plan to address significant weight loss and nutritional needs. Resident #42, who was admitted with a dysphagia advanced texture diet, experienced a weight loss of 10.3 lbs. since admission. Despite this, the care plan was not updated to include appropriate nutritional interventions, and there was no evidence of follow-up monthly weight monitoring. The Registered Dietitian and Market Clinical Advisor confirmed that the care plan had not been revised to address the resident's nutritional needs.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident #28, who was admitted with severe morbid obesity, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea requiring a CPAP machine. Despite having active orders for CPAP use and maintenance, the Treatment Administration Record (TAR) showed that these orders were not completed for 24 days. The resident's CPAP machine was reported as broken, and there was a lack of evidence that the facility made adequate attempts to contact the CPAP supplier or follow up on the issue. Interviews revealed that the resident had been without a CPAP machine for over a month, and the facility had not taken necessary actions to replace it or arrange for a sleep study. Additionally, the facility failed to change the oxygen tubing for Resident #69 as per the procedure, which requires replacement every seven days. Observations showed that the tubing had not been changed since 6/18/24, despite active orders indicating weekly changes. The Treatment Administration Record (TAR) inaccurately documented that the tubing was changed on several dates, which was confirmed to be incorrect by a surveyor. These deficiencies highlight the facility's failure to adhere to professional standards of practice in providing respiratory care, as evidenced by the lack of timely equipment replacement and inaccurate documentation of care provided to the residents.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide nourishing snacks to residents who wished to eat at non-traditional times or outside of scheduled meal service times across six units. Observations and interviews revealed that the snack cupboards and refrigerators in the units were inadequately stocked, with limited options such as white bread, Ensure, a few small cracker packages, and minimal other items like small snack oatmeal pies and a small container of tuna salad. Residents reported not being offered snacks and having to rely on minimal options like toast, with no yogurt, puddings, or hydration cups available. Staff interviews confirmed the lack of variety and quantity of snacks and drinks, with reports of having to wait hours for additional supplies from the kitchen. The Food Service Director acknowledged the issue, attributing it to the absence of two staff members responsible for stocking the kitchenettes. The Food Service Director District Manager confirmed that upon his arrival, the units were not properly stocked with enough snacks or a variety of snacks for the residents. The deficiency was observed over two days of the survey, affecting all six units, and no policy or procedure for stocking snacks in the kitchenettes was provided to the surveyor.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during an initial kitchen tour. The surveyor noted several deficiencies, including heavily soiled ceiling vents, lights, and tiles in the dish room, as well as a dirty air vent at the kitchen entrance. The hood system had chipped paint, creating an uncleanable surface, and food equipment such as the slicer and mixer had dried food particles. Additionally, untreated cement blocks were found under the ice machine. In the dry storage room, several food items were unlabeled and undated, and similar issues were found in the reach-in and walk-in refrigerators and freezer. The facility's policies on food storage and environment cleanliness were not adhered to, as confirmed by the Food Service Director. Furthermore, the facility failed to ensure proper labeling and dating of food items in various storage areas, including the dry storage room, reach-in refrigerator, and walk-in refrigerator and freezer. The Activity room refrigerator also contained undated whipped cream canisters, and the temperature log for the refrigerator/freezer was incomplete. Additionally, a cook was observed not wearing facial hair protection, which was confirmed during an interview. These findings indicate a lack of compliance with the facility's policies on food storage, cleanliness, and employee hygiene, as confirmed by the Food Service Director and the cook.
Improper Garbage Storage
Penalty
Summary
The facility failed to maintain a sanitary garbage storage area, which was observed over four consecutive days. On the first day, a surveyor noted trash bags stored in an open container outside the building by a lower level exit. This observation was repeated the following day, and the Administrator confirmed the findings during an interview. On the third day, both the surveyor and the Administrator observed the same issue, with the Administrator again confirming the findings. On the final day, the surveyor and the Maintenance Director observed trash stored in an open container outside the kitchen, with the Maintenance Director confirming the observation.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for residents, as evidenced by the deficiencies found during the survey. For one resident, documentation of activities of daily living (ADLs) was incomplete over an 11-day period, with missing records for bed mobility, eating, bathing, dressing, drinks/snacks, hygiene, toileting, transfers, wheelchair mobility, and walking. The Director of Nursing confirmed the lack of documentation, noting that the resident had not received a shower or tub bath since admission, and multiple shifts were missing records of care provided. Another resident's clinical records were found to be inaccurate regarding the management of oxygen tubing. The resident's active orders required weekly changes of the oxygen tubing, with each component labeled with the date and initials. However, the tubing observed on the resident's wheelchair was dated over a month prior, and the Treatment Administration Record (TAR) did not reflect the required weekly changes. A surveyor confirmed the discrepancy with the Market Clinical Advisor, who acknowledged the need to inform staff to change the tubing again.
Infection Preventionist Absence from QAPI/QAA Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist attended the required quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meetings. A review of the meeting attendance sheets revealed that the Infection Preventionist did not attend any of the four quarterly meetings, specifically on 10/31/23, 1/26/24, and 7/29/24. According to the facility's policy, the QAA Committee must include the Infection Preventionist or a designee, but the facility did not have an alternate designee for this role. The Administrator and Director of Nursing confirmed that the Infection Preventionist was absent from 3 of the 4 meetings in the past year, although they provided copies of reports for review at the meetings.
Medication and Vaccine Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as observed during a survey. On one occasion, a medication cart was left unlocked and unattended in the hallway of the Sugarloaf unit, allowing potential access to medications by residents and unauthorized persons. This incident was confirmed by the Unit Manager upon her return to the cart. Additionally, expired medications were found in the lower level Medication Storage room and on a medication cart in the Rangeley Lake unit. Specifically, expired bottles of Geri Care Senna liquid and Geri Care Aspirin were observed, with expiration dates indicating they should have been removed from use. Furthermore, the facility was found to be improperly storing vaccines in a dormitory-style refrigerator with a freezer, which is against the guidelines provided by the United States Centers for Disease Control and Prevention. This type of refrigerator poses a significant risk of freezing vaccines, which can compromise their efficacy. The Clinical Market Advisor confirmed the use of such a refrigerator for storing pneumococcal vaccines and Purified Protein Derivative (PPD) used for tuberculosis testing, highlighting a failure in adhering to proper vaccine storage protocols.
Accident Hazard Due to Damaged Laminate Wall Covering
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and visitors by not addressing an accident hazard at the nursing station. On August 5, 2024, a surveyor observed that the laminate wall covering at the nursing station was chipped, gouged, and missing pieces along the bottom edge. This condition created sharp edges that posed a risk of injury to anyone passing by. The Market Clinical Advisor confirmed the presence of this hazard during an interview, acknowledging the potential danger it posed.
Lack of Monitoring for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to document the monitoring of side effects for psychotropic medications prescribed to a resident. The resident, who was admitted with diagnoses of anxiety and depression, was on multiple medications including Abilify, Buspirone, Trazodone, and Sertraline. Despite these prescriptions, the clinical record lacked evidence of monitoring for side effects, as confirmed by the Director of Nursing during an interview with surveyors. This oversight was identified during a review of the resident's records, highlighting a deficiency in the facility's medication management practices.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control procedures during a medication pass task. On August 8, 2024, at 8:34 a.m., a surveyor observed a Certified Nursing Assistant Med Technician (CNA-M) administering medications to a resident using a plastic medication cup. After discarding the cup into the trash, the CNA-M bypassed a hand sanitizer station in the resident's room and proceeded to the medication cart without sanitizing her hands. She then began preparing medications for another resident. When questioned by the surveyor, the CNA-M admitted she had not sanitized her hands and acknowledged the necessity of doing so between residents. Later, at 9:53 a.m., the surveyor discussed the observed lack of hand hygiene during the medication pass with the Market Clinical Advisor.
Facility Fails to Maintain Cleanliness in Dining Areas and Kitchenettes
Penalty
Summary
The facility failed to maintain housekeeping and maintenance services necessary to ensure a safe, clean, and homelike environment in its dining areas and kitchenettes. During a survey conducted on 4/29/24, it was observed that the refrigerator shelves and door shelves in several units, including Mount Blue, Sugarloaf, and Rangely Lake, were soiled with dried liquids. Additionally, the kitchenette cabinet doors on one unit had chipped paint, creating an uncleanable surface. Microwaves in multiple units were found with dried food debris, and the kitchenette cabinets in the Mount Blue unit were soiled with food crumbs. Dining room tables in the Rangely Lake and another unit were also observed to be soiled with food debris. These findings were confirmed with the facility's Administrator.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to properly store, label, and date food items in the walk-in refrigerator and unit refrigerators across six units, the first-floor recreation area, and the kitchen. During the survey, numerous food items were found unlabeled, expired, or out of date, which were accessible for resident use. Specific observations included a variety of food items such as cookies, muffins, dips, sauces, ice cream, and sandwiches that were either undated or past their expiration dates. Additionally, some items, like a container of brown rice, were found with visible mold. In the kitchen, the reach-in refrigerator contained undated and expired items, including ham salad and milk. The walk-in freezer was noted to have excessive dirt and debris on the floor, indicating a lack of proper maintenance and cleanliness. These findings were confirmed by the Food Service Director and the Administrator during the survey, highlighting a significant deficiency in the facility's food storage 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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