Waterville Center For Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterville, Maine.
- Location
- 7 Highwood St, Waterville, Maine 04901
- CMS Provider Number
- 205120
- Inspections on file
- 24
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Waterville Center For Health And Rehab during CMS and state inspections, most recent first.
Surveyors identified that clinical records for several residents were incomplete or inaccurate, including missing documentation of ROM exercises, bathing, vital signs, and follow-up on physician orders. Staff confirmed that required entries were not made, and legal documents such as POA and Advance Directives were not present in the records despite being referenced in care plans.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A resident admitted with a specialized mental health diagnosis was not screened for PASRR Level I, and no evidence was found that the required documentation was submitted to the state authority prior to admission. This lapse was confirmed by facility leadership during surveyor interviews.
The facility did not ensure that care plans were reviewed and revised by the IDT within the required timeframe after each MDS assessment for several residents. In some cases, IDT meetings were delayed, held before the assessment was completed, or lacked evidence of timely review. Additionally, care plans were not updated to address current diagnoses and care needs, such as chronic pain, atrial fibrillation, genital herpes, and MRSA.
A facility failed to maintain complete and accurate clinical records for a resident with venous stasis ulcers and DVT. The resident's care plan indicated a risk for DVT, but physician orders lacked evidence of monitoring for DVT signs. Daily skilled assessments were incomplete or missing on several dates. The Unit Manager confirmed the lack of documentation and incomplete assessments during an interview.
A resident was found restrained in a wheelchair with a sheet, without a physician's order or proper documentation, leading to an immediate jeopardy situation. Staff interviews revealed confusion and lack of accountability, with some believing the family was responsible. The facility's Restraint Use policy was not followed, as there was no documentation or consent for the restraint.
The facility failed to report a suspected abuse incident involving a resident being restrained in a wheelchair, violating the resident's right to be free from physical restraint. Despite facility policies requiring immediate reporting to authorities, the incident was not reported to law enforcement or the State Survey Agency. Interviews with staff revealed confusion about the incident, with some believing the family was responsible. The failure to report within the required timeframe resulted in immediate jeopardy for all residents.
A facility failed to investigate an incident where a resident was allegedly restrained with a bedsheet, violating their right to be free from physical restraint. Despite awareness of the incident, staff could not recall specific details, and the facility's records lacked documentation of a comprehensive investigation. The resident, who had severe cognitive impairment, was unable to be interviewed, and the failure to investigate placed all residents at risk.
A resident with severe cognitive impairment and multiple diagnoses was found restrained to a wheelchair with a bedsheet, leading to increased anxiety and distress. The incident occurred when the facility was reportedly short-staffed, and the resident, who could independently transfer, experienced a change in condition. Hospice was notified, and new medication orders were issued to manage the resident's anxiety.
The facility failed to provide or obtain written information about the right to accept or refuse treatment and formulate an Advance Directive for eight residents with various medical conditions, including liver transplant and chronic kidney disease. This deficiency was confirmed by the Administrator and Social Worker during an interview.
The facility failed to maintain a sanitary and comfortable environment, with issues such as mildew, fruit flies, and maintenance problems observed in two units. Staff confirmed these findings during facility tours.
The facility failed to maintain a sanitary environment for respiratory care equipment for three residents. A resident's nebulizer and oxygen tubing were not labeled or bagged, and another resident's oxygen concentrator filter was heavily soiled. Additionally, a third resident's oxygen tubing was outdated, and the concentrator was missing a filter. Staff confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to maintain adequate staffing levels, affecting resident care. Interviews and record reviews revealed that residents missed scheduled baths and experienced delays in care due to insufficient staff. Staff reported challenges in managing care, particularly for residents requiring two-person assistance. The facility did not meet minimum staffing ratios on several occasions, as confirmed by the DON and surveyor.
The facility failed to ensure controlled medication counts were conducted and documented at shift changes on two units. The Harbor and Cove units' medication logs lacked evidence of counts by oncoming and outgoing nurses on multiple occasions. These deficiencies were confirmed by CNAs and the Administrator, with the DON acknowledging awareness of the issue due to a previous improvement plan.
The facility failed to properly label, store, and dispose of drugs and biologicals, with expired vaccines found in storage and controlled substances not securely locked. Additionally, there were significant gaps in monitoring medication refrigerator temperatures, contrary to facility policies.
The facility failed to serve meals at appropriate temperatures, with residents reporting lukewarm or cold food that often required reheating. Test trays confirmed that hot foods were served below the required 140 degrees Fahrenheit. Operational inefficiencies, such as delays in serving due to limited staff, contributed to the issue. The Interim Food Service Director acknowledged the inappropriate temperatures.
The facility failed to maintain a clean and sanitary kitchen, with issues such as a soiled fan, improper dishwasher temperatures, and unlabeled food. Staff were observed without hair protection, and documentation for dish machine and refrigerator/freezer temperatures was incomplete. The Administrator confirmed these deficiencies.
The facility failed to ensure residents' well-being due to multiple deficiencies in care and management, affecting all 91 residents. Issues included lack of access to personal funds, failure to provide medical rights information, unsanitary conditions, unnecessary restraints, inadequate staff training, and improper medication management. These failures highlight significant lapses in the facility's operations.
The facility failed to implement proper infection control measures for residents with wounds on enhanced barrier precautions (EBP). Over two days, surveyors observed a lack of necessary signage and PPE, aside from gloves, in the rooms of three residents. This issue was confirmed during a tour with the Memory Care Unit Manager, who acknowledged the oversight.
The facility failed to offer pneumococcal vaccinations to several residents as per their policy and CDC guidelines. Despite the policy requiring assessment and offering of the vaccine within thirty days of admission, records showed that five residents were not reviewed, offered, or received the vaccine. An LPN confirmed these findings during an interview.
The facility's kitchen dish machine was not maintained in safe operating condition, operating at only 110°F instead of the required 150°F. Despite being instructed to wash dishes by hand, staff continued using the malfunctioning machine, which leaked water and required the water to be turned off after each use to prevent flooding. The Director of Facilities Operations and Interim Food Service Director were aware of the issues, but the machine remained in use until the Administrator intervened.
A resident was denied access to personal funds due to incorrect deductions for the cost of care. The facility deducted $1,291.00 instead of the usual $1,251.00 for two months, leaving the resident without the allocated $40.00 per month for personal use. The issue was identified when the resident's guardian attempted to access the funds and found them insufficient. The Nursing and Operations Assistant confirmed the error, which was pending resolution with the Corporate office.
The facility did not complete required Maine background checks for a CNA and an RN before they began working with residents, contrary to its policy on preventing abuse, neglect, and misappropriation of resident funds or property. The CNA's check was completed 48 days after hire, and the RN's check was completed 295 days after hire, as confirmed by the HR Director.
The facility failed to issue written transfer or discharge notices to two residents or their legal representatives for facility-initiated transfers to a hospital. One resident with dementia and other conditions was transferred without notice, and another with multiple diagnoses, including chronic respiratory failure, also did not receive the required notice. The absence of documentation was confirmed by the administrator during a survey review.
The facility failed to issue written bed hold notices to two residents or their legal representatives upon transfer to a hospital. One resident, with dementia and other conditions, was transferred without receiving a notice. Similarly, another resident with multiple diagnoses, including chronic respiratory failure, was also transferred without a written notice. The facility administrator confirmed these omissions during interviews with surveyors.
The facility did not ensure that residents with specialized mental health diagnoses were referred for PASRR evaluation and determination. A resident with bipolar disorder, anxiety disorder, and depression was not re-evaluated for a PASRR Level II determination after their Convalescence Categorical exemption ended, as confirmed by the Administrator.
A facility failed to update and follow physician orders for a resident, leading to the continued administration of an incorrect acetaminophen dosage and lack of physical and occupational therapy. Staff interviews revealed unawareness of the new orders, which were filed without being addressed.
The facility did not complete annual performance evaluations for a CNA hired in 2021, missing evaluations for 2023 and 2024. This was confirmed by the Administrator during a surveyor interview.
A resident with muscle weakness and dysphagia was not provided with necessary adaptive eating equipment, such as a Kennedy cup and built-up utensils, as required by their care plan. Observations over several days showed the absence of these items on the resident's meal trays, and an LPN confirmed the lack of adaptive dishes.
The facility failed to maintain accurate clinical records and proper maintenance of oxygen equipment for three residents. One resident's records lacked evidence of medication administration or refusal, while two residents had inaccurate documentation regarding oxygen tubing changes. Additionally, one resident's oxygen concentrator was heavily soiled, and another's lacked a filter.
The facility did not provide required yearly education on Resident Rights for a CNA hired in 2022. The HR Director confirmed the CNA had not received the necessary training in 2023 and 2024.
The facility failed to ensure a CNA completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. Despite the facility's assessment indicating the necessity of at least 12 hours of in-service training per year, including dementia management and resident abuse prevention, CNA4, hired in 2022, had not received this training in 2023 and 2024, as confirmed by the HR Director.
The facility failed to provide mandatory training on its QAPI program to a CNA hired in 2022. A review of the CNA's education records showed no evidence of the required annual training, which was confirmed by the HR Director during a surveyor interview.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for multiple residents. For several residents, documentation was missing or inaccurate regarding range of motion (ROM) exercises and bathing, with no evidence that these activities were completed or refused on numerous dates. Interviews with facility management confirmed the absence of required documentation in the residents' records. In other cases, clinical records lacked documentation of significant clinical events and follow-up. One resident experienced low blood pressure and dizziness, but the initial low blood pressure reading, the re-check, and physician notification were not documented, despite staff confirming these actions occurred. Another resident had a physician order for a urinalysis due to suspected infection, but the record did not show that the sample was collected, sent, or refused, nor that the provider was notified of the inability to obtain the sample, as required. Additional deficiencies included the absence of required legal documentation, such as Power of Attorney (POA) and Advance Directives, despite care plans and meeting notes indicating their existence. There were also inconsistencies in documenting the timing and assessment of a resident's fall, with vital signs and neurologic checks not accurately recorded in relation to the incident. Facility staff acknowledged these documentation gaps during interviews.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Complete PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred to the appropriate state-designated authority for a Pre-admission Screening & Resident Review (PASRR) evaluation and determination. Record review showed that the resident was admitted from a hospital with a mental health diagnosis, but there was no evidence in the clinical record that a PASRR Level I screening was completed or submitted to the state authority prior to admission. This deficiency was confirmed during an interview with the Social Services Director and the Administrator, who acknowledged the absence of required PASRR documentation in the resident's record.
Failure to Timely Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT), including participation of the resident and/or their representative, within 7 days following each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for several residents, there was either a delay in holding the IDT meeting after the MDS assessment, the meeting was held before the assessment was completed, or there was no evidence that the meeting occurred within the required timeframe. For example, one resident's IDT meeting was held 17 days after the MDS assessment, another's was held 19 days after, and in some cases, the IDT meeting was held prior to the completion of the MDS. Interviews with facility staff confirmed that the scheduling of IDT meetings was based on the Assessment Reference Date (ARD), and not always aligned with the completion of the MDS as required. Additionally, the care plans for some residents were not updated to reflect current diagnoses and care needs. One resident's care plan did not specify the cause or location of chronic pain and failed to address the monitoring and management of atrial fibrillation, a history of genital herpes, and MRSA, despite these being active or relevant diagnoses. The Director of Nursing acknowledged that certain diagnoses had not been included or updated in the care plan, and there was no documentation explaining the omissions.
Incomplete Clinical Records and Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as evidenced by a review of the resident's care plan and physician orders. The resident, who was admitted with diagnoses including venous stasis ulcers and deep vein thrombosis (DVT), had a care plan indicating a history of DVT and a risk of developing another. However, the active physician orders lacked evidence of monitoring for DVT signs and symptoms. Additionally, daily skilled assessments on specific dates were incomplete, missing cardiovascular and skin assessments, and some assessments were not completed at all. During an interview, the Unit Manager confirmed the absence of documentation for DVT monitoring and incomplete skilled assessments, which did not meet the facility's expectations for comprehensive resident monitoring.
Failure to Ensure Resident's Right to Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to remain free from physical restraints, resulting in an immediate jeopardy situation. An anonymous complaint was received alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was revealed that a resident was found in a wheelchair with a sheet double-knotted around their waist, effectively acting as a restraint. This incident occurred without a physician's order, evaluation, assessment, monitoring, or informed consent, and there was no documentation in the clinical record regarding the medical need for such a restraint. Interviews with staff members revealed a lack of clarity and accountability regarding the incident. The Life Enrichment and Pastoral Care staff member and RN1 were unable to recall specific details about the resident or the staff involved. CNA-M2 mentioned that CNA3 was placed on administrative leave due to the incident but returned quickly, with the belief that the family had restrained the resident. The Director of Nursing, who was not present at the time of the incident, provided partial notes and witness statements from CNA6 and CNA7, confirming the use of a sheet as a restraint. The facility's Restraint Use policy requires specific documentation and consent, none of which were present in this case.
Failure to Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. This failure resulted in the facility not protecting a resident from potential harm by not reporting an incident of possible abuse, which involved the violation of the resident's right to be free from physical restraint. The incident was not reported to law enforcement or the State Survey Agency (SA) as required by regulations. The facility's policy on abuse, neglect, and misappropriation of resident funds or property required immediate reporting of such incidents to the Administrator or designee, who would then notify the State Agency within 24 hours. However, this protocol was not followed. The incident involved a resident who was allegedly restrained in a wheelchair, which was reported anonymously to the State of Maine, Division of Licensing and Certification. Interviews with staff members revealed a lack of clarity and communication regarding the incident, with some staff members believing the family had restrained the resident. The Director of Nursing and other key personnel confirmed that the incident was not reported to the appropriate authorities. The facility's failure to report the incident within the required timeframe and to conduct a follow-up investigation within five working days resulted in immediate jeopardy for all residents, as the facility did not ensure the implementation of policies to report suspected crimes against residents.
Failure to Investigate Restraint Incident
Penalty
Summary
The facility failed to fully investigate an incident involving possible abuse and the use of an unnecessary physical restraint on a resident, identified as Resident #99 (R99). The incident was reported through an anonymous complaint alleging that CNAs were tying residents to chairs due to short staffing. Interviews with staff members revealed that there was awareness of the incident, but no one could recall specific details about the resident or the staff involved. The facility's policy required a thorough investigation, including interviews with the resident, accused, and potential witnesses, but this was not completed. The Director of Nursing (DON) provided partial notes and a visitor log, but these documents did not clarify who restrained R99 or when the restraint occurred. The notes indicated that R99 was able to transfer independently from bed to chair, and the visitor log showed only one visitor on the day of the incident. Staff interviews revealed that R99 was last seen in a wheelchair without restraint, but later found restrained with a bedsheet. The facility's records lacked documentation of the incident or a comprehensive investigation. The incident was not fully investigated by the Unit Manager, Director of Clinical and Quality Assurance, or the Interim Director of Nursing at the time. The resident had severe cognitive impairment and was unable to be interviewed. The facility's failure to investigate the incident violated the resident's right to be free from physical restraint, as outlined in S483.12, and placed all residents at risk. Immediate jeopardy was identified, and the facility was notified of this status.
Resident Restrained with Bedsheet Leading to Increased Anxiety
Penalty
Summary
The facility failed to protect and promote a resident's right to be free from physical restraints, as required by S483.12. An anonymous complaint was received by the State of Maine, Division of Licensing and Certification, alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was found that a resident, who was admitted on hospice with severe cognitive impairment and multiple diagnoses including dementia and anxiety disorder, was restrained to a wheelchair using a bedsheet tied in a double knot. The incident report indicated that the resident was found restrained at 6:30 p.m. and was observed resisting the restraint by attempting to stand. The Director of Nursing, who was not present at the time of the incident, provided surveyors with documentation including witness statements and a visitor log. The resident, who was able to independently transfer from bed to chair, experienced a change in condition at the time of the incident, leading to increased anxiety and agitation. Hospice was notified, and new medication orders were given to address the resident's severe anxiety. The use of the physical restraint resulted in increased anxiety and distress for the resident, as confirmed by interviews with facility staff and surveyors.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide or obtain written information concerning the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive for eight residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not adhere to its policy of ensuring that residents or their representatives were informed about their rights regarding medical treatment and Advance Directives. The facility's policy requires the Social Service Department to document whether a resident has an Advance Directive and to provide information about Maine's Advance Directive laws if one is not present. The residents affected by this deficiency had various medical conditions, including recent liver transplant, chronic kidney disease, heart failure, diabetes mellitus, COPD, and others. Despite these significant health issues, there was no evidence in their clinical records that the facility provided the necessary information about their rights to accept or refuse treatment or to formulate an Advance Directive. During an interview, the Administrator and Social Worker confirmed the findings, indicating a systemic issue in the facility's admission process and documentation practices.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in two of its units, the Mountain Top Unit and the Harbor Unit, as observed during three facility tours. On the Mountain Top Unit, issues included a pile of wet towels under an ice machine, stripped flooring, and peeling cabinet laminate, with visible mildew on the wall and floor. Additionally, fruit flies were observed in the Blueberry dining room and in a resident's room, with staff confirming these findings. On the Harbor Unit, a fly was observed in a metal container with a partially covered trifle cake during lunch service. Further observations during an Environmental Tour revealed additional maintenance issues. The shower room had non-skid tape peeling up, a resident's bathroom wall had chipped paint, and a wheelchair armrest was torn. Another resident's room had a dusty ceiling vent. These findings were confirmed by the Administrator and the Director of Facilities Operations during the tour.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment, impacting three residents. For Resident #251, a nebulizer was observed on a bedside table with tubing connected to a mask, neither labeled nor bagged, and an oxygen concentrator with nasal cannula/tubing was found lying on the floor, undated and unbagged. There was no evidence of an active order for oxygen or nebulizer use for this resident. During interviews, both a registered nurse and the unit manager confirmed that the equipment was not properly stored or labeled, which was against the facility's expectations. For Resident #3, the oxygen concentrator's filter was heavily soiled, and the oxygen tubing was dated from several weeks prior, with the nebulizer mask and tubing not stored in a sanitary manner. Similarly, Resident #47's concentrator was missing its filter, and the oxygen tubing was labeled with a date from over a month ago. A registered nurse confirmed these findings, noting that the tubing should be changed weekly, but it had not been updated as required. These observations indicate a failure to adhere to the facility's policy on maintaining clean and properly stored respiratory equipment.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by multiple interviews and record reviews. Certified Nursing Assistant #2 reported difficulties in providing timely care due to understaffing, with a nurse covering two floors and a medication assistant present. A resident expressed that they had missed three consecutive baths in the past month due to staff unavailability, despite their care plan indicating a need for extensive assistance with personal hygiene and scheduled showers twice a week. Another resident mentioned missing shower days when only two aides were available for 28 residents, highlighting the challenge of managing care during meal times. Interviews with staff further revealed delays in care, with residents potentially sitting in incontinence for extended periods before receiving assistance. The Cove Unit, in particular, faced challenges due to the high number of residents requiring two-person assistance, including those needing a Hoyer lift. The facility's staffing schedules confirmed that minimum staffing ratios were not met on several occasions, and the Director of Nursing acknowledged the ongoing efforts to address staffing issues. The surveyor confirmed that the facility was not staffing based on the residents' needs, impacting the quality of care provided.
Failure to Document Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that controlled medication counts were conducted and documented by authorized personnel at the change of shifts on two of the three units observed for medication storage, specifically the Cove and Harbor units. The bound controlled medication book labeled Harbor Log #119 showed no evidence of controlled medication counts being conducted by the oncoming nurse on several occasions, including on 8/17/24 at 18:20 and by the outgoing nurse on 8/17/24 at 5:40 a.m., 8/18/24 at 6:00 a.m., and 8/28/24 at 6:00 a.m. These findings were confirmed by a Certified Nursing Assistant-Medications (CNA-M1) during an interview with a surveyor. Similarly, the bound controlled medication book labeled Cove #21 lacked evidence of controlled medication counts being conducted by the oncoming nurse on multiple dates, including 7/26/24 at 18:00, 7/27/24 at 5:30 a.m., and 9/3/24 at 21:00, among others. Additionally, there was no evidence of counts being conducted by the outgoing nurse on several dates, including 7/5/24 at 5:30 a.m., 7/11/24 at 18:00, and 9/4/24 at 5:30 a.m. These findings were confirmed by another Certified Nursing Assistant-Medications (CNA-M2) and the facility's Administrator during a review with a surveyor. The Director of Nursing acknowledged that controlled medication should be counted during each shift change and was aware of the issue due to a previous performance improvement plan that was not followed through.
Deficiencies in Medication Storage and Temperature Monitoring
Penalty
Summary
The facility failed to comply with proper labeling, storage, and disposal of drugs and biologicals, as well as maintaining appropriate storage temperatures for medications and vaccines. During observations, it was found that expired vaccines and medications were stored alongside unexpired ones, making them available for use. Specifically, expired doses of the Moderna and Pfizer COVID-19 vaccines were found in the vaccination refrigerator on the Cove Unit. Additionally, the facility did not store controlled substances in a permanently affixed and double-locked compartment, as required. In the Cove Medication Room, controlled substances like Lorazepam were found in an unlocked, unaffixed metal box, and similar issues were observed in the Harbor Medication Room. The facility also failed to monitor and record medication refrigerator temperatures consistently. Temperature logs for the Cove and Harbor Units revealed significant gaps in daily temperature monitoring, with some refrigerators only having temperatures recorded on a few days each month. This lack of consistent monitoring could lead to improper storage conditions for medications and vaccines, potentially affecting their efficacy. The facility's policies on storage and expiration dating of medications and biologicals were not adhered to, as evidenced by the observations and record reviews conducted during the survey.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures, resulting in meals being served at unappetizing temperatures. During observations and interviews, residents consistently reported that their meals were often lukewarm or cold, with some stating that the food had to be reheated before it was palatable. Test trays confirmed these complaints, with hot foods such as potato salad, beans, and hamburgers being served at temperatures significantly below the facility's policy of maintaining food at 140 degrees Fahrenheit. The Interim Food Service Director acknowledged that the temperatures were inappropriate and confirmed that the meals would not be palatable at those temperatures. The issue was further compounded by operational inefficiencies, such as delays in serving meals due to limited staff availability and logistical challenges. For instance, food carts were observed sitting in dining areas for extended periods before being served, leading to further cooling of the meals. Residents and family members expressed dissatisfaction with the quality and temperature of the food, and these concerns were documented in Resident Council Meeting Minutes, indicating that the problem was ongoing and had been previously reported without resolution.
Deficiencies in Kitchen Sanitation and Documentation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a kitchen tour and subsequent observations. Specific issues included a heavily soiled wall-mounted fan, food disposals with dried food and liquid residue, a high-temperature dishwasher that failed to reach the required 150°F, dusty and dirty ceiling air vents and tiles, and a standing floor mixer with chipped paint. Additionally, the walk-in freezer contained ice build-up on food items, and several food items were found unlabeled and undated. Staff were also observed not wearing appropriate hair protection, which was confirmed by the Kitchen Supervisor and Interim Food Service Director. The facility's documentation practices were also found lacking, with missing records for dish machine temperatures, kitchen and unit refrigerator/freezer temperatures, and sanitizing testing logs over several months. The surveyor requested these logs multiple times before receiving them, and upon review, found numerous days where monitoring and documentation were not completed. The Administrator confirmed the absence of daily monitoring and documentation for these critical areas, which are essential for ensuring food safety and sanitation standards are met.
Multiple Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility failed to administer its operations in a manner that ensured residents could attain or maintain their highest practicable well-being. This was evidenced by multiple deficiencies cited during a recertification survey. The deficiencies spanned various aspects of resident care and facility management, including resident rights, freedom from abuse, neglect, and exploitation, admission and discharge procedures, resident assessments, quality of life and care, nursing services, pharmacy services, food and nutrition services, administration, infection control, physical environment, and training requirements. These failures affected all 91 residents in the facility, as the administration did not follow the facility assessment to ensure staff education, training, and competencies were completed. Specific incidents included the failure to provide a resident access to personal funds, failure to provide residents or their representatives with written information about their rights to accept or refuse medical treatment, and failure to maintain a sanitary and comfortable environment in certain units. Additionally, the facility did not protect a resident from unnecessary physical restraints, which resulted in immediate jeopardy and potential harm to all residents. The facility also failed to conduct required background checks for new employees and did not report or investigate incidents of possible abuse, including the use of unnecessary restraints. Other deficiencies involved the failure to issue proper transfer or discharge notices, ensure specialized mental health evaluations, update physician orders, maintain a sanitary environment for respiratory equipment, and provide sufficient staffing. The facility also failed to ensure proper medication management, serve food at appropriate temperatures, maintain kitchen cleanliness, and complete necessary staff training. These deficiencies highlight significant lapses in the facility's ability to provide safe and effective care to its residents.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of enhanced barrier precautions (EBP) for residents with wounds. Over two days of observation, surveyors noted the absence of necessary signage and personal protective equipment (PPE) other than gloves in the rooms of three residents who were on EBP due to their wounds. This deficiency was observed consistently across multiple rooms and confirmed during a tour of the Memory Care Unit with the Unit Manager, who acknowledged the absence of required signage and PPE for these residents.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with their policy and CDC recommendations. The policy required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within thirty days unless medically contraindicated or previously vaccinated. However, for five residents reviewed, there was no evidence that they were reviewed, offered, or received the pneumococcal vaccine as per CDC guidelines. Specifically, the immunization records for these residents showed lapses in adherence to the vaccination policy. One resident admitted in December 2023 had no evidence of being reviewed or offered the vaccine. Another resident, admitted in August 2024, had a consent signed for vaccination but had not received it by September 2024. Similar issues were found with three other residents, where records did not show compliance with the vaccination policy. An interview with the LPN Memory Care Unit Manager confirmed these findings.
Dish Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen's high-temperature dish machine in good repair and safe operating condition. During a kitchen tour, it was observed that the dish machine was operating at only 110 degrees Fahrenheit, below the required 150 degrees Fahrenheit for proper cleaning and sanitizing. The Kitchen Supervisor acknowledged the machine's issues, including inaccurate temperature readings and water leakage, which required the water to be turned off after each use to prevent flooding. Despite these problems, the dish machine continued to be used by the kitchen staff. Interviews with the Director of Facilities Operations and the Interim Food Service Director revealed that the dish machine had been serviced two weeks prior, but additional parts were needed for full repair. The Interim Food Service Director had instructed staff to wash dishes by hand in a three-bay pot sink, but was unaware that the dish machine was still in use. The Administrator confirmed the ongoing use of the malfunctioning dish machine and stated it would not be used until fixed. A subsequent work log indicated further issues with the machine, including a non-functioning booster and timer.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide a resident access to personal funds, specifically for Resident #47 (R47). On two occasions, the facility deducted an incorrect amount for the cost of care, leaving R47 without the $40.00 per month allocated for personal use. This discrepancy was noted when R47 reported not receiving the funds for two months and expressed frustration over the situation. The financial statements showed that the facility deducted $1,291.00 instead of the usual $1,251.00 for the cost of care in August and September, without any explanation for the increased charge. The issue was further highlighted when R47's guardian attempted to access the funds for shopping purposes but found insufficient money in the account. The Nursing and Operations Assistant acknowledged awareness of the error when the guardian raised the concern. An email was sent to the Corporate office to address the error, but compensation was delayed pending a response, resulting in R47 not having access to $80.00 of personal funds that were deducted without explanation.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to adhere to its own policy regarding the prevention of abuse, neglect, and misappropriation of resident funds or property by not completing required Maine background checks for new employees before they began working. Specifically, two employees, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), were allowed to work with residents without having their background checks completed. The CNA was hired and started working on June 12, 2023, but their background check was not completed until July 30, 2023, which was 48 days after their hire date. Similarly, the RN was hired on November 6, 2023, but their background check was only completed on September 13, 2024, 295 days after their hire date. This oversight was confirmed during an interview with the Human Resource Director, who acknowledged that the employees were working with residents prior to the completion of their background checks.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to residents or their legal representatives for facility-initiated transfers to an acute care hospital. This deficiency was identified for two residents during a survey. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024, without receiving the required written notice. The clinical record review confirmed the absence of this documentation. Similarly, the second resident, with diagnoses such as Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred on July 22, 2024, also without a written notice being provided. The administrator confirmed the lack of documentation for both cases during the survey review.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their legal representatives upon transfer to an acute care hospital, as required. This deficiency was identified in the cases of two residents. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024. A review of the resident's clinical record showed no evidence that a written bed hold notice was provided. The facility administrator confirmed this omission during an interview with a surveyor on September 11, 2024. Similarly, the second resident, with diagnoses including Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred to a hospital on July 22, 2024. A review of this resident's clinical record also lacked evidence of a written bed hold notice being issued. The administrator confirmed this deficiency during an interview with a surveyor on September 12, 2024.
Failure to Conduct PASRR Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents with specialized mental health diagnoses were referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review (PASRR) evaluation and determination. This deficiency was identified for three residents reviewed for PASRR evaluation. One resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and depression, had a PASRR Level I with a Convalescence Categorical exemption, which is a time-limited 30-day exemption. However, the resident's clinical record lacked evidence of a re-evaluation for a PASRR Level II determination after the convalescent period ended. This was confirmed during an interview with the Administrator.
Failure to Update and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that physician orders were updated and followed for a resident reviewed for unnecessary medications. On September 12, 2024, during a clinical record review, it was found that a new physician order dated September 4, 2024, for the resident included discontinuing acetaminophen 650 mg three times daily, starting acetaminophen 1 g three times daily for chronic pain, and initiating physical and occupational therapy evaluations and treatments for decreased mobility. However, the clinical record lacked evidence that these orders were reviewed or updated by a provider. Interviews with staff revealed a lack of awareness and action regarding the new orders. A registered nurse on the Memory Care Unit was unaware of the updated orders and continued administering the previous dosage of acetaminophen. The unit manager confirmed that the orders were filed without being addressed. This oversight resulted in the facility not following the physician's updated orders for medication and therapy, as confirmed by a surveyor during an interview with the unit manager.
Failure to Conduct Annual Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a Certified Nursing Assistant (CNA) who was hired on July 1, 2021. The deficiency was identified during a performance evaluation review and interview, revealing that the CNA did not receive evaluations for the years 2023 and 2024. This was confirmed by the Administrator during an interview with a surveyor on September 13, 2024.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment and utensils for a resident with specific nutritional needs. The resident, who was admitted with diagnoses including generalized muscle weakness, dysphagia, and protein-calorie malnutrition, had a care plan that required the use of adaptive equipment such as a Kennedy cup, rimmed plate, and built-up utensils during meals. Despite these documented needs, observations over several days revealed that the resident's meal trays consistently lacked the required adaptive equipment. A surveyor noted the absence of these items during multiple meal observations, and an LPN confirmed that the resident had not been using the adaptive dishes as directed by the care plan and dietary communication slip.
Inaccurate Clinical Records and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for three residents. For one resident, the clinical record lacked evidence of administration or refusal of multiple medications on specific dates, including Bupropion, Famotidine, Apixaban, Carvedilol, Timolol Maleate, Sevelamer carbonate, Tramadol, and Insulin Lispro. The Director of Nursing confirmed these findings during a record review with a surveyor. Additionally, the facility did not maintain accurate documentation for two residents using oxygen concentrators. One resident's oxygen concentrator was heavily soiled, and the tubing was dated incorrectly, with the Registered Nurse confirming that the tubing had not been changed as documented. Another resident's oxygen tubing was labeled with an outdated date, and the filter was missing from the concentrator. The Registered Nurse confirmed that the documentation of tubing changes was inaccurate.
Deficiency in Resident Rights Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included training on Resident Rights for one of the Certified Nursing Assistants (CNA) reviewed. CNA4, who was hired on June 27, 2022, had not received the required yearly education on Resident Rights since her hiring date. This deficiency was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Required Yearly Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. A review of the facility's assessment for 2024-2025 indicated that in-service training for new aides must be sufficient to ensure the continuing competence of nurse aides, with a minimum of 12 hours per year, including dementia management and resident abuse prevention training. Additionally, for nurse aides providing services to individuals with cognitive impairments, the training must address the care of the cognitively impaired. CNA4, who was hired on June 27, 2022, had not received the required yearly education for Abuse, Neglect, Exploitation, and Misappropriation of Property since being hired. This was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI). This deficiency was identified during a review of employee files, specifically for a Certified Nursing Assistant (CNA) who was hired on June 27, 2022. The review revealed that the CNA's education records did not contain evidence of receiving the required annual training on the facility's QAPI program. During an interview with a surveyor, the Human Resource Director confirmed that the CNA had not received the necessary in-service training in 2023 and 2024.
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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