Springbrook Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westbrook, Maine.
- Location
- 300 Spring St, Westbrook, Maine 04092
- CMS Provider Number
- 205068
- Inspections on file
- 23
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Springbrook Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities who was fully dependent on staff for transfers fell from a mechanical lift during a bed-to-wheelchair transfer when one sling loop was not properly secured to the hanger bar. Two CNAs were present, but the straps were not double-checked before the transfer, and the care plan was not updated to reflect the correct sling size. The resident sustained serious injuries, including fractured ribs, a fractured arm, and a lacerated spleen.
A resident who required full assistance for transfers was observed using a large (green) sling instead of the care-planned medium (purple) sling for mechanical lift transfers. Multiple CNAs relied on the Kardex and sling color coding to select sling size, but the resident was not in the correct sling as specified in the care plan, a fact confirmed by the Regional Administrator.
A resident with multiple comorbidities and full assistance needs had a care plan and Kardex that were not updated to reflect the correct size sling for mechanical lift transfers. Although staff used the appropriate blue (extra large) sling as determined by a transfer evaluation, the documentation continued to specify a green (large) sling, and this discrepancy was confirmed by the DON.
An LPN failed to maintain sterile technique while changing the dressing on a resident's stage 4 pressure ulcer with tunneling by using a piece of silver alginate dressing that had been placed on a non-sterile surface before insertion into the wound, contrary to facility policy and physician's orders.
A CNA-M administered another resident's medications after failing to use two required identifiers, relying instead on room and verbal confirmation. This error resulted in a resident experiencing hypotension and requiring transfer to the ER and subsequent admission to the critical care unit for monitoring and treatment.
The facility failed to maintain a safe, clean, and homelike environment, with deficiencies observed in four units and common areas. Issues included gouged and water-damaged walls, missing laminate, dirt and debris, and stained ceiling tiles. These deficiencies were noted during an environmental tour, highlighting inadequate housekeeping and maintenance services.
The facility failed to update care plans for residents requiring oxygen therapy, leaving them without documented focus, goals, or interventions for their respiratory needs. Additionally, a resident with limited vision and specific ADL requirements was not assisted according to their care plan, resulting in missed meals and lack of toileting support. These deficiencies highlight significant gaps in care planning and implementation.
The facility failed to provide adequate ADL care for two residents, leading to deficiencies in bathing and nutrition. A resident with multiple sclerosis and an amputation received only one shower in June, despite needing weekly assistance. Another resident, requiring help with eating, was observed with uneaten meals while sleeping, with no attempts by staff to assist. These issues were discussed with the facility's management.
A facility failed to manage respiratory care for a resident with COPD, with conflicting oxygen orders and undocumented adjustments. Another resident with a wound on the gluteal folds did not have provider notification or treatment orders. Additionally, a resident who experienced an unwitnessed fall did not receive required neurological assessments, as per facility policy.
A facility failed to ensure staff competency in tracheostomy care for a resident with complex medical needs. A charge nurse, lacking recent training, required coaching during a procedure and relied on others for deep suctioning, despite signing off on the task. The last competency testing was nearly two years prior.
The facility failed to properly store medications, with an unlocked medication cart found unattended and a resident's pills left on an overbed table. A CMT accessed the cart to prepare medication, and a charge nurse confirmed leaving pills unattended for a resident who forgot to take them.
A facility failed to follow a physician's order to refer a resident to a dentist for gingivitis and cleaning. The resident's clinical record showed no evidence of follow-up, and the Marketing Clinical Advisor confirmed that the referral had not been scheduled.
A facility failed to maintain accurate clinical records for a resident's ADL. The resident was observed sleeping through meals without staff cueing and did not eat, yet documentation inaccurately recorded 50% consumption and incorrect levels of assistance. These discrepancies were discussed with the Administrator.
A resident was observed in a common area sitting at a dining table in a wheelchair, naked from the waist down. Two CNAs present did not act to preserve the resident's dignity. An LPN was called to assist in removing the resident to their room. The DON confirmed these findings.
Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift, resulting in a resident falling from the lift sling onto the floor and sustaining significant injuries. During the transfer from bed to wheelchair, two CNAs were involved in applying the sling and operating the lift. One CNA moved the lift while the other guided the resident, but the resident rolled out of the sling and fell. Upon assessment, it was found that one of the sling loops had come off the lift hook, and the nurse on duty observed the loop hanging off the swing bar. The resident suffered a contusion, bleeding from the nose, fractured ribs, a fractured left arm, and a lacerated spleen, requiring hospital admission. The resident involved had multiple medical conditions, including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, and was fully dependent on staff for mobility and transfers. The care plan specified the use of a green full body sling with two staff for all transfers, but the lift-transfer evaluation indicated a blue (extra large) sling was required. The care plan and Kardex had not been updated to reflect this change. During interviews, staff could not confirm how many times the sling loops were checked before the transfer, and one CNA admitted that the straps were not double-checked on the day of the incident. Review of facility policies and manufacturer instructions revealed that staff are required to check that all sling straps are properly connected to the hanger bar before and after elevating the resident, and to lower the resident if any attachments are not secure. Both CNAs involved had completed required training and demonstrated competency in lift use. The lift and sling were found to be in good working order, with no broken parts, and had passed recent maintenance inspections. Despite these measures, the failure to ensure all sling loops were properly secured directly led to the resident's fall and subsequent injuries.
Failure to Follow Care Plan for Mechanical Lift Transfer Sling Size
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required transfers using a mechanical lift. According to the resident's most recent assessment and lift transfer evaluation, the resident was dependent on staff for transfers and required the use of a medium (purple) full body sling with the electric mechanical lift. The care plan and CNA Kardex both specified the use of a medium (purple) sling for all transfers, based on the manufacturer's guide and nursing assessment. Despite these documented requirements, observations on the day of the survey found the resident in a wheelchair with a large (green) sling underneath, which did not match the care plan instructions. Multiple CNAs interviewed confirmed that they determine sling size by the color indicated in the Kardex, but the resident was observed using the incorrect color and size. The Regional Administrator also confirmed during the review that the resident was not in the correct sling as per the plan of care.
Failure to Update Care Plan for Correct Sling Size During Transfers
Penalty
Summary
The facility failed to update a resident's care plan and Kardex to accurately reflect the correct size sling required for mechanical lift transfers. The resident, who had diagnoses including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, was dependent on staff for all transfers. Although a Lift-Transfer Evaluation determined that the resident required a blue (extra large) sling based on weight and height, the care plan and Kardex continued to instruct staff to use a green (large) sling. Staff interviews confirmed that the blue sling was being used in practice, but the documentation had not been revised to match this change. The DON confirmed that the care plan and Kardex were not updated to reflect the current transfer method.
Sterile Technique Breach During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency occurred when an LPN failed to maintain sterile technique during a dressing change for a resident with a stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, the LPN retrieved a piece of silver alginate dressing that had been resting on the non-sterile outer wrapper of the product packaging and inserted it into the tunneling wound using a sterile cotton-tipped applicator. The LPN acknowledged that the outer surface of the packaging was not sterile and that this action could have contaminated the dressing. Physician's orders required daily cleansing with Vashe solution, drying, and application of silver alginate to the wound bed. Facility policy directed that dressings be opened without contaminating and kept within the open packet or placed directly on top of a barrier.
Failure to Properly Identify Resident Leads to Medication Error and Hospitalization
Penalty
Summary
A medication error occurred when a Certified Nurse's Assistant - Medication Aide (CNA-M) administered medications intended for one resident to another resident. The CNA-M retrieved medication cards from a slot labeled for a specific room and bed, prepared the medications, and asked the resident in that room if they were the name on the medication card. The resident confirmed, and the medications were administered. Upon returning to the medication cart, the CNA-M realized the error and immediately notified the nurse. The CNA-M admitted to not verifying the resident's identity using the required two identifiers, such as the identification bracelet and photograph, as outlined in facility policy. The resident who received the incorrect medications was subsequently assessed and initially found to be stable, but was later transferred to the hospital for abnormal vital signs. The medications administered included several antihypertensive agents and other drugs, which led to a hypotensive episode requiring admission to the critical care unit for monitoring and treatment. Facility policy requires the use of at least two resident identifiers before medication administration, and specifically prohibits using room number or physical location as an identifier. The failure to follow these procedures directly resulted in the medication error and the resident's hospitalization.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions across four of its seven units, as well as in the clean utility room and the third-floor common area. During an environmental tour, several deficiencies were observed and confirmed. In the Wayside Unit, resident bathrooms had gouged and water-damaged walls with exposed sheetrock, and dirt and debris were found around the toilet base. The Saccarappa Unit had a resident room with a missing piece from the entrance door and an open area under the window sill. The Mayflower Unit had a resident room with peeling laminate and a chipped area on the entrance door, along with stained ceiling tiles in the common area and dirt and debris in the clean utility room. In the King Unit, multiple resident rooms had gouged walls, chipped or gouged doors, and loose or peeling wall cove base in bathrooms. Additionally, the kitchenette counter was missing laminate in several areas.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents requiring oxygen therapy and other essential care needs. Specifically, four residents receiving oxygen therapy did not have their care plans updated to include a focus, goal, or intervention related to their oxygen or CPAP therapy. This oversight was identified through observations and reviews of electronic medical records, which showed that orders for oxygen therapy were present but not reflected in the care plans. The lack of proper documentation and planning for these residents' respiratory care needs indicates a significant gap in the facility's care planning process. Additionally, the facility did not implement a care plan for a resident requiring assistance with Activities of Daily Living (ADL), nutrition, and incontinence. The resident, who has limited vision and requires specific assistance during meals, was observed sleeping at the dining table with uneaten meals served on regular plates, contrary to the care plan instructions. The certified nursing assistant (CNA) failed to wake the resident or assist with eating, and repeatedly approached the resident from the left side, which is against the care plan's guidance due to the resident's limited vision. This lack of adherence to the care plan resulted in the resident not receiving the necessary support for eating and toileting over an extended period.
Deficiencies in ADL Care for Bathing and Nutrition
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, leading to deficiencies in showering/bathing and nutrition. Resident #18, who has multiple sclerosis and an above-the-knee amputation, required extensive assistance for bathing, including a mechanical lift and two-person assistance. However, documentation revealed that Resident #18 received only one shower in June, despite the care plan indicating a need for weekly showers. There was no documentation of any refusal from the resident, and the issue was only addressed after the resident's family intervened. Resident #53, who requires supervision or touching assistance for eating, was observed sleeping at the dining room table with uneaten meals in front of them on multiple occasions. Despite the care plan indicating the need for assistance with eating, the CNA did not attempt to wake or assist the resident during meal times. The resident's guardian expressed concerns about the resident's eating habits and potential hunger-related behaviors. These observations were discussed with the facility's LPN Manager and Administrator, highlighting a failure to provide necessary nutritional support.
Deficiencies in Respiratory Care, Wound Management, and Fall Assessment
Penalty
Summary
The facility failed to properly manage the respiratory care of a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident had conflicting oxygen orders in their clinical record, with one order for 3 liters per minute and another for 2.5 liters per minute. Despite these orders, the resident's oxygen was set at 4 liters per minute, which was not documented or communicated to the provider. The charge nurse confirmed that the resident had been receiving 4 liters for a couple of months, indicating a lack of proper documentation and communication regarding the resident's oxygen needs. In another instance, the facility did not notify the provider or obtain orders for a resident with a wound on the gluteal folds. The wound was identified as moisture-associated skin damage, but there was no documentation of treatment steps taken by the staff. The charge nurse admitted to leaving a message for the skin care team but had not contacted the provider for an order since the wound assessment. This oversight highlights a failure in the facility's process for managing new wounds. Additionally, the facility did not conduct appropriate neurological assessments for a resident who experienced an unwitnessed fall. The resident was found on the floor after losing balance, but there was no evidence of continued neurological monitoring as required by the facility's policy. The Administrator was unable to provide documentation of neurological checks following the fall, indicating a lapse in adherence to the facility's falls management policy.
Inadequate Competency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for a resident on the Wayside Unit. The deficiency was identified when a surveyor observed a charge nurse performing tracheostomy care for a resident with a tracheostomy, who was dependent on staff for all activities of daily living and had a history of drug-resistant organisms. During the observation, the charge nurse expressed a lack of confidence in performing the procedure and required coaching from the Nurse Practice Educator (NPE) using a check-off sheet. The charge nurse initially did not perform deep suctioning until prompted by the surveyor, despite the resident showing signs of labored breathing and copious secretions. Further investigation revealed that the charge nurse had not received recent training on tracheostomy care, with the last skills fair and competency testing completed nearly two years prior. The charge nurse admitted to relying on other nurses to perform deep suctioning when needed, despite signing off on the treatment administration record as if they had performed the procedure themselves. The facility's assessment indicated that it provides care for respiratory treatments, including tracheostomy care, but the charge nurse's lack of recent training and competency testing contributed to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed by surveyors. On the Saccarappa House Unit, an unlocked and unattended medication cart was found in the hallway, which was later accessed by a Certified Medication Technician to prepare a resident's medication. Additionally, on the Wayside Unit, a resident was found asleep in bed with a cup of pills left unattended on the overbed table. The charge nurse confirmed that the pills were left there, as the resident had forgotten to take them.
Failure to Schedule Dental Referral
Penalty
Summary
The facility failed to follow through with a physician's order for a dental referral for a resident. The resident's clinical record included a physician's order dated March 18, 2023, instructing staff to refer the resident to a dentist for gingivitis and a cleaning. However, the clinical record lacked evidence of any follow-up with the dental referral. During an interview with the surveyor on July 17, 2024, the Marketing Clinical Advisor confirmed that the dental referral for the resident had not been scheduled.
Inaccurate Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident reviewed for Activities of Daily Living (ADL). During observations on two separate meal occasions, the resident was seen sleeping through both meals without any cueing from staff and did not consume any food or fluids. However, the certified nursing aid documentation inaccurately recorded that the resident consumed 50% of the meals. Additionally, the documentation incorrectly stated that the resident was under supervision with encouragement or cueing during one meal and was independent with no help or staff oversight during the other meal. These discrepancies were discussed with the Administrator during an interview.
Resident Dignity Not Maintained in Common Area
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. On April 25, 2024, at 8:20 a.m., a resident was observed in the common area of the Wayside Gardens Unit sitting at the dining table in a wheelchair, naked from the waist down. Two CNAs were present in the dining area serving other residents but did not take any action to address the resident's lack of clothing or preserve the resident's dignity. An LPN, who was nearby passing medications, was called to assist in removing the resident to their room. The Director of Nursing confirmed these findings upon arrival at the unit at 8:30 a.m.
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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