Augusta Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Maine.
- Location
- 188 Eastern Ave, Augusta, Maine 04330
- CMS Provider Number
- 205077
- Inspections on file
- 26
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Augusta Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Failure to maintain a clean, safe, and sanitary environment was observed across multiple units and a common area. Findings included a stained hallway ceiling tile, items left on resident room floors, an unbagged bed pan, dirt and dried residue on an oxygen concentrator and overbed table, broken window blinds, a container of wipes on a rollator, and chipped or missing paint on baseboard heating units, all confirmed by the Maintenance Director and Administrator.
Failure to hold timely IDT care plan reviews after MDS assessments. For multiple residents, IDT meetings were not held within the required timeframe after annual, quarterly, or significant change assessments, and one resident’s care plan was not updated to reflect post-hospital left hip incision care after a fall, hip fracture, and surgery. Staff interviews showed the MDS Coordinator and LSW used scheduling practices that did not align with the assessment-based timing expected for care plan review.
Medication storage and refrigerator monitoring were deficient when two residents had topical medications left at bedside areas without physician orders for self-administration. A resident who stated staff applied his/her meds had miconazole powder and an unknown white substance at the sink area, and another resident had Calamine lotion at the bedside without an order. The med room refrigerator, which stored insulin, vaccines, and other refrigerated meds, also had repeated missing AM/PM temperature log entries across several months despite a policy requiring twice-daily checks.
Resident assignment sheets and a monthly weight sheet containing PHI were left unattended on a table in the solarium, an area accessible to residents and visitors. The documents included resident names, room numbers, diagnoses, continence status, ADL assistance needs, transfer needs, fall risk status, and recorded weights. A surveyor observed the records while two residents and one visitor were present, and an HRA confirmed the documents contained sensitive and private information.
The facility failed to follow ordered care for two residents. One resident with Parkinson's disease and dysphagia was observed eating breakfast in bed without staff present despite an order for full meal supervision, while records and staff interviews showed the resident needed supervision at meals. Another resident with a chronic LLE ulcer did not receive the ordered barrier cream to the wound edges during wound care, and the RN acknowledged missing that step.
Missing Adaptive Dining Equipment: A resident with Parkinson's Disease and dysphagia did not receive the adaptive utensils and mug listed in the care plan. Surveyors observed standard utensils instead of the ordered left and right angled spoon and specialized mug at breakfast and lunch, and CNA and FSD interviews confirmed the equipment was not on the tray even though the meal ticket listed it. The DON stated the resident sometimes feeds self and sometimes needs assistance.
Kitchen sanitation and food storage deficiencies were identified during an initial kitchen tour. Surveyors observed two kitchen workers with facial hair not wearing facial hair protection, a wall behind the toaster with chipped and missing paint, food debris and trash throughout the kitchen, and a previously opened package of strips/tenders in the reach-in freezer that was not labeled and dated. The findings were discussed with the Dietary Aide and the Acting Administrator.
Infection Control Lapse During Wound Care and Soiled Linen Handling: An RN performed wound care for a resident with left leg wounds on Contact precautions for shingles, using a towel under the resident’s leg while the open wounds were in direct contact with it. After the dressing change, the RN placed the unbagged soiled towel on a shared sink counter, carried it with bare hands to the soiled utility room, and later cleaned bandage scissors in the sink without first cleaning the sink counter.
A resident's record showed a signed consent form declining the COVID-19 vaccine, yet the resident later received the vaccine and the chart did not include evidence of acceptance for that dose. During interview, the DON and Administrator said they were looking for proof of consent, and the RDCO stated the resident had refused one season's vaccine but consented to the next season's vaccine. The facility did not provide evidence by the end of the survey that the resident consented to the vaccine administered.
The facility failed to maintain a clean and safe environment in two units. Observations included rusty and dusty ceiling vents, dirty toilets and bathroom floors, stained caulking, and a resident's wheelchair with broken armrests. These issues were confirmed by the Administrator and Maintenance Director.
The facility failed to maintain kitchen cleanliness and proper food storage. Surveyors observed rust and dirt on the grease trap, a dusty baseboard heater register with food splatter, and a heavily soiled floor. Additionally, foods in the reach-in freezer and walk-in refrigerator were found unsealed, unlabeled, and undated. These issues were confirmed with the Head Cook.
The facility failed to provide timely incontinence care during meal service, causing distress to two residents. Despite a documented policy suggesting staff should not interrupt meal tray distribution for resident assistance, the facility's administration denied such a policy existed. A CNA confirmed that the practice was to complete meal tray distribution before attending to residents' needs, leading to delays in care.
A resident experienced a fall resulting in facial injuries and was found face down with a puddle of blood. After being transported to the hospital and returning with a negative CT scan but a nasal fracture, the facility failed to initiate neurological assessments. The DNS confirmed the oversight, and the PAC stated that assessments should have been conducted upon the resident's return.
A resident with COPD and CHF was not provided respiratory care according to physician orders. The resident's oxygen therapy was set at 3Lpm, exceeding the prescribed 1-2Lpm to maintain O2 saturation between 90-92%. The RN increased the flow rate after a nebulizer treatment when the resident's O2 sat was 85-86% but did not re-check it. The portable oxygen tank was also found empty. The facility lacked standing oxygen orders, and the physician was notified of the resident's condition.
The facility failed to date open medications and dispose of expired medications according to manufacturer specifications. On the [NAME] unit, a Trelegy Ellipta inhaler for a resident lacked an opened date, and on the Penobscot unit, a Fluticasone Salmeterol inhaler had an opened date on the box but not on the device. Surveyors confirmed these deficiencies with CNAs and an LPN.
A facility failed to maintain accurate clinical records for a resident who experienced a fall. A nurse's report indicated the resident fell forward and sustained a nosebleed, while the physician's notes described the fall as unwitnessed with no trauma. The Director of Nursing confirmed the discrepancies, and the nurse could not recall if neurological monitoring was started.
A resident with decreased fine motor coordination spilled hot chocolate on their lap, causing burns, after being served with a regular coffee cup instead of a recommended covered mug. Despite an OT evaluation recommending a spillproof cup, the resident was observed using an uncovered cup during a meal service.
Two residents experienced disrespectful interactions with CNAs, with one resident reporting deliberate actions to upset them and another overheard being spoken to impatiently. These incidents were not addressed by staff until brought to attention by surveyors.
The facility failed to maintain a sanitary and comfortable environment, with issues such as broken floor tiles, dirty caulking, and uncleanable surfaces observed across three units and a nurse's station. These deficiencies were confirmed by facility staff during a tour.
The facility failed to conduct PASRR Level II evaluations for two residents with mental health diagnoses whose stays extended beyond 30 days. Both residents were initially admitted under short-term convalescence criteria, but their stays transitioned to long-term without the necessary PASRR Level II evaluations being conducted, as confirmed by facility staff.
Two residents did not receive the necessary restorative services to maintain or improve their ambulation and active range of motion (AROM) as outlined in their care plans. One resident reported not receiving required exercises and ambulation assistance, leading to weakness, while another resident stated they no longer received walking assistance, affecting their ability to walk. Documentation confirmed the lack of provided services over the previous 30 days.
The facility failed to provide proper respiratory care for five residents, including unclean CPAP masks, lack of orders for oxygen tubing changes, and incorrect oxygen flow rates. A resident's CPAP mask was found on the floor and not cleaned, while another resident used an oxygen concentrator without proper maintenance. The facility lacked an oxygen policy, leading to inconsistent care.
The facility's kitchen was found to be unsanitary, with a soiled ceiling vent, food disposal unit, and dish machine, as well as a food mixer with dried particles. A kitchen worker lacked facial hair protection, and wet stacking of glasses was observed. These issues were confirmed by the Food Service Director.
A facility failed to provide a resident and their representative with a written notice for a hospital transfer, and also did not notify the Ombudsman. The transfer occurred without the required documentation, and the Director of Social Services, responsible for notifying the Ombudsman, was out sick. The Administrator confirmed the lack of notifications during an interview.
A facility failed to provide a written bed hold notice to a resident or their representative after a hospital transfer. The clinical record lacked evidence of the notice, and the Administrator confirmed its absence during an interview.
A facility failed to follow physician orders for sliding scale insulin administration for a resident. The resident's order specified to hold insulin if blood sugar was less than 150. Despite a documented blood sugar of 109, insulin was administered, as confirmed by a surveyor and the Regional Director of Clinical Operations.
The facility failed to provide adequate nutrition and hydration for two residents. One resident, with severe dementia and dysphagia, was not assisted with meals as required, and fluids were left unattended, risking aspiration. Another resident, also with dementia, was not regularly offered fluids, and beverages were not readily available, leading to insufficient hydration. Staff interviews confirmed these deficiencies in care.
The facility failed to follow physician's orders for a resident with Congestive Heart Failure, as there was no evidence of weekly weigh-ins on three specific dates. This was confirmed in an interview with the Administrator.
The facility failed to transport soiled linens in a sanitary manner on the [NAME] unit. A CNA was observed carrying unbagged soiled bed linens against her body in the corridor, which was confirmed by the CNA and the Director of Nursing. The facility's policy requires soiled linens to be placed directly into a soiled linen hamper or a plain plastic bag.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to adequately maintain maintenance and housekeeping services necessary to keep the facility in good repair and sanitary conditions in 3 of 3 units and a common area. During an environmental tour with the Maintenance Director and the Administrator, a hallway ceiling tile near the main entrance door was observed with a large brown stain. In the Penobscot Unit, a resident room had a full cup of liquid with a straw on the floor next to bed B and an unbagged bed pan on the bathroom floor. Another resident room had a medium size bottle of powder lying on the floor behind the head of bed A, and the oxygen concentrator between the beds had dirt, debris, and dried liquid residue on it. Additional observations showed further maintenance and housekeeping concerns in the Kennebec Unit and the [NAME] unit. In one resident room, the window blind was broken in many places, hanging down, and in disrepair, and the bathroom had a container of purple wipes on a rollator walker with a wipe sticking out. In two resident rooms on the [NAME] unit, the baseboard heating units had chipped and missing paint creating an uncleanable surface, and another resident room had a window blind broken in many places, hanging down, and in disrepair. The Maintenance Director and the Administrator confirmed the observed findings during interview.
Failure to Hold Timely IDT Care Plan Reviews After MDS Assessments
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team, including resident and/or representative participation to the extent possible, after MDS assessments for 5 of 7 residents reviewed. For Resident #3, an MDS quarterly assessment was completed, but the IDT meeting occurred 13 days later and there was no evidence of an IDT meeting within 7 days of a subsequent significant change assessment. Resident #3 had an unwitnessed fall, was hospitalized with a left hip fracture, underwent left hip surgery, and returned to the facility with post-hospital needs documented in the record, including monitoring of the left hip incision and dressing care. The care plan lacked goals and interventions for the left hip incision, and the Administrator confirmed the care plan was not revised to reflect the resident’s current needs. For Resident #6, an annual assessment and a quarterly assessment were completed, but the record lacked evidence of IDT meetings within 7 days of either assessment. For Resident #7, a quarterly assessment was completed and the record lacked evidence of an IDT meeting within 7 days. For Resident #9, a quarterly assessment and a significant change assessment were completed after the resident was admitted to hospice services, but the IDT meeting was not held until later and there was no evidence it occurred within 7 days of either assessment. For Resident #24, an annual assessment and a quarterly assessment were completed, but the IDT meetings were held outside the 7-day timeframe tied to the assessments. During interviews, the MDS Coordinator stated the facility did not schedule IDT meetings based on MDS assessment dates, and the LSW stated she scheduled meetings based on a report and understood LTC residents should be scheduled within 7 days of the review date.
Medication Storage and Refrigerator Monitoring Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because medications were found at residents’ bedside areas without evidence of physician orders for self-administration. During an observation of Resident #64’s room, a 43 g bottle of miconazole topical 2% powder labeled for that resident and a medicine cup containing an unknown white substance were found on the counter next to the shared sink. Resident #64 stated that he/she could not apply the medications independently because he/she was disabled and that staff applied the medications. In another room, a 6 fluid ounce bottle of Calamine lotion labeled for Resident #9 was found on the counter next to the shared sink, and the resident’s clinical record did not contain a physician order allowing self-administration of medications. The facility also lacked consistent monitoring of the medication storage room refrigerator temperatures. The refrigerator contained insulin, vaccinations, and other refrigerated medications, and the facility policy required temperatures to be recorded twice daily and maintained between 36 F and 46 F. Review of the temperature log showed missing AM and PM documentation across multiple months, including August, September, October, and November 2025, with several days lacking recorded temperatures in both the morning and evening.
Confidential Resident Records Left Unattended in Public Area
Penalty
Summary
The facility failed to ensure the confidentiality of protected health information when resident-identifiable assignment sheets and a monthly weight documentation sheet were left unattended in the solarium, an area accessible to residents and visitors. On 2/1/26 at 11:00 a.m., a surveyor observed copies of multiple resident care assignment sheets and a document titled December Monthly Weights left on a table in the solarium while two residents and one visitor were present. The assignment sheets included resident names, room numbers, diagnoses, continence status, required assistance with ADLs, transfer needs including Hoyer use, fall risk status, and other personal care instructions. The monthly weight sheet included resident names and recorded weights. At approximately 11:20 a.m., the Human Resources Assistant confirmed the documents contained sensitive and private protected health information and stated they should not have been left unattended in the solarium.
Failure to Follow Meal Supervision and Wound Care Orders
Penalty
Summary
The facility failed to ensure that Resident #6 received care in accordance with the physician order for full supervision with all meals. Resident #6 was admitted with diagnoses including Parkinson's disease and dysphagia. During an observation, the resident was seen in bed with breakfast set up on the over-the-bed table, including utensils placed with the meal, and no staff were present in the room. The DON later stated there had been concerns about aspiration and overall functional decline, and that staff had been assisting the resident more with feeding recently. The resident's record also included a nutrition evaluation noting holding food in the mouth/cheeks or residual food after meals and needing supervision at all meals, as well as a physician progress note stating the resident requires supervision with meals. A CNA stated the resident feeds self about 50% of the time and staff often set up the meal and leave the room, checking back periodically, while the DON stated she was unaware the full supervision order had been in place since May. The facility also failed to follow the ordered wound treatment for Resident #9, who was admitted with a chronic ulcer of the left leg. The physician order directed cleansing the wound, applying collagen, oil emulsion, barrier cream to the wound edges, ABD pads, and Kerlix. During observation of wound care, the RN cleansed the wound, applied collagen and oil emulsion, then covered and wrapped the leg, but did not apply the barrier cream to the wound edges. When questioned, the RN stated the resident often refuses barrier cream but that she should have offered it and missed that step. A late-entry nursing note documented that the RN inadvertently did not apply the barrier cream during the dressing change and later reapproached the resident, who agreed to the treatment and it was applied.
Missing Adaptive Dining Equipment
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance was not met for Resident #6, who was admitted in May 2023 with diagnoses including Parkinson's Disease and dysphagia. On 2/5/26 at 8:05 a.m., a surveyor observed the resident's breakfast tray set up on the over-the-bed table with a standard spoon resting in the oatmeal and a standard fork next to the entree served on a lip plate. No adaptive utensils or cup were present, despite the care plan listing a lip plate at meals, left and right angled spoons, and a blue insulated mug. Later that day, at 12:53 p.m., a repeat observation of the lunch tray again showed the meal ticket indicating a blue insulated mug and left and right-angled spoon, but no adaptive utensils or specialized mug were on the tray. During interview, CNA #1 stated the kitchen sends specialized eating and drinking utensils on the resident's tray and confirmed they were missing, and also stated the resident feeds himself/herself about 50% of the time and staff set him/her up before leaving to get other trays. The Food Service Director stated specialized equipment is listed on the meal ticket and placed on the tray when sent, while the DON stated the resident sometimes feeds himself/herself and sometimes needs assistance, and that adaptive utensils are not required if staff are feeding him/her.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food storage and staff hygiene practices were followed during an initial kitchen tour. Surveyors observed two male kitchen workers with facial hair, including beards and moustaches, who were not wearing facial hair protection. They also observed chipped and missing paint on the wall behind the toaster, creating an uncleanable surface, and food debris and trash throughout the kitchen, including under equipment and shelving. In addition, a previously opened package of strips/tenders in the reach-in freezer nearest the walk-in refrigerator was not labeled and dated. These findings were discussed with the Dietary Aide and later with the Acting Administrator.
Infection Control Lapse During Wound Care and Soiled Linen Handling
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection during the transport of soiled linens and the disinfection of a soiled surface during a wound dressing change for one resident with left leg wounds who was on Contact precautions for shingles. During observation of the wound care, the RN sanitized her hands, donned PPE, and placed the resident’s leg on a towel on the bed while removing the existing dressing, providing wound care, and applying a new dressing. The resident’s open wounds were in direct contact with the towel during the procedure. After the dressing change, the RN discarded the soiled dressing and removed the soiled towel from under the resident’s leg. She placed the unbagged towel on the counter of the sink shared by the resident and another resident, then placed bandage scissors in the sink basin and washed her hands. She later doffed her PPE, picked up the unbagged soiled towel with bare hands, and carried it across the hall to the soiled utility room. She then returned to the room, sanitized her hands, donned new PPE, and cleaned the scissors in the sink with disinfectant wipes, but did not clean the sink counter before leaving. The RN stated she did not like carrying soiled linens with bare hands but was not supposed to wear gloves in the hall, and the Administrator stated the facility’s procedure was that staff do not wear gloves when transporting soiled linens in the hall.
Missing Documentation of COVID-19 Vaccine Consent
Penalty
Summary
The facility failed to ensure that Resident #24's medical record included documentation showing that the resident or resident representative accepted the COVID-19 vaccine that was administered. Review of the clinical record showed a signed Immunization Consent Form dated 6/6/25 indicating that Resident #24 declined the COVID-19 vaccine, yet the record also showed that the resident received the COVID-19 immunization on 11/5/25. During an interview on 2/5/26, the DON and Administrator stated they were looking for evidence that Resident #24 had consented to receive the vaccine, and the Regional Director of Clinical Operations stated that Resident #24 had refused the 2024-2025 COVID-19 vaccine but consented to receiving the 2025-2026 vaccine. The facility did not provide evidence by the end of the survey that Resident #24 consented to receiving the vaccine administered on 11/5/25.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of its units, as observed during an environmental tour. In the [NAME] Unit, three hallway ceiling vents near resident rooms were found to be rusty and dusty. In one resident room, the toilet surface and area behind the seat were dirty with dried liquid residue, and the bathroom exhaust vent was dusty. The caulking around the bathroom door frame was dirty and stained, and a urine collection cup was found on the floor by the toilet. Another resident room had a dirty bathroom floor, a yellow/brown stain on a ceiling tile near the vent, and dirty caulking at the base of the room and bathroom door trim. A third resident room also had a dirty bathroom floor and stained caulking around the toilet base and door trim, with a dusty bathroom exhaust vent. In the Kennebec Unit, a resident's wheelchair had cracked and broken armrests, and the caulking around the toilet base was dirty and stained. The bathroom exhaust vent was also dusty. These findings were confirmed by the Administrator and the Maintenance Director during an interview with a surveyor.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour conducted by two surveyors. The grease trap had rust on its lid and base, and the caulking around the base was dirty and stained with a black substance. The baseboard heater register, located between the grease trap and a sink, was dusty and dirty, with dried liquid residue and food splatter. Additionally, the floor under the sink across from the steam table was heavily soiled with food debris and dried liquid residue. The facility also failed to ensure that foods were properly sealed, labeled, and dated. In the reach-in freezer, a box of cinnamon donuts and a box of waffles were found unsealed and open to the air. In the walk-in refrigerator, a metal tray containing custard-type pies was uncovered, unlabeled, and undated, and six cakes were also found unlabeled. These findings were confirmed in an interview with the Head Cook.
Failure to Provide Timely Incontinence Care During Meal Service
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by staff not responding promptly to requests for incontinence care during meal service. Two residents expressed concerns about having to wait for assistance, which caused anxiety and discomfort. One resident reported being told to wait to use a urinal, leading to distress about potentially wetting themselves. This situation was exacerbated by the perception of insufficient staffing, which residents believed contributed to the delays in receiving care. A review of the clinical records revealed a Health Status Note indicating that a policy was in place to not interrupt meal tray distribution for resident assistance, which was communicated to one of the residents multiple times. However, during an interview with the facility's Administrator and Regional Directors, it was clarified that no such policy existed. A Certified Nursing Assistant confirmed that while they were not explicitly told not to assist residents, the practice was to complete meal tray distribution before attending to residents' needs. This discrepancy between documented policy and actual practice contributed to the deficiency in resident care.
Failure to Conduct Neurological Assessments After Resident's Fall
Penalty
Summary
The facility failed to complete neurological assessments for a resident who experienced a fall with a major injury. The resident was found face down on the floor with facial injuries and a puddle of blood under their face. Emergency Medical Services (EMS) were called, and the resident was transported to the hospital where a CT scan was performed, revealing no immediate head bleed but a nasal fracture. The resident returned to the facility later that morning. Upon review, it was found that neurological assessments were not initiated upon the resident's return from the emergency room. During an interview, the Director of Nursing Services (DNS) confirmed that the assessments were not conducted. The Physician Assistant - Certified (PAC) stated that even with a negative CT scan, neurological assessments should have been completed if the resident returned to the facility within two days. This expectation was confirmed by the DNS during the interview with the surveyor.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care according to physician orders for a resident with chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). The resident had an active physician order for oxygen therapy at 1-2 liters per minute (Lpm) to maintain oxygen saturation (O2 sat) between 90-92%. However, during an observation, the resident was found with the oxygen flow rate set to 3Lpm, and the portable oxygen tank was empty. The registered nurse (RN) had increased the oxygen flow rate from 2Lpm to 3Lpm after administering a nebulizer treatment when the resident's O2 sat was measured at 85-86%, intending to re-check the O2 sat but got busy and did not follow up. The Regional Director of Clinical Operations (RDCO) and the Director of Nursing Services (DNS) confirmed that the facility did not have standing oxygen orders, and the physician was in the building, suggesting the RN may have intended to discuss the adjustment with the physician. The Assistant Director of Nursing Services (ADNS) and the RN later confirmed the findings and noted that the resident's oxygen saturation improved to 89%, which was usually the resident's baseline. The physician had been notified of the situation.
Failure to Properly Label and Dispose of Medications
Penalty
Summary
The facility failed to adequately date open medications and properly dispose of expired medications according to manufacturer specifications. During an observation on the [NAME] unit, a Trelegy Ellipta Inhalation Aerosol device for a resident was found without a date indicating when it was opened, despite the manufacturer's instructions to discard it 6 weeks after opening or when the counter reads '0'. Similarly, on the Penobscot unit, a Fluticasone Salmeterol inhalation device for another resident was observed with an opened date on the box but not on the device itself. The manufacturer's packaging instructed to discard the inhaler 1 month after opening the foil pouch or when the counter reads '0'. In both cases, surveyors confirmed the lack of proper labeling with the Certified Nurse Med Techs and an LPN, indicating a failure to ensure use and disposal according to manufacturer specifications.
Discrepancy in Fall Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a clinical record contained complete and accurate information for a resident reviewed for falls. On 9/29/24, a fall report completed by a registered nurse indicated that the resident fell forward towards the wall while transferring themselves, resulting in a nosebleed. The report noted that the physician, referred to as Third Eye, was notified shortly after the incident. However, the physician's documentation in the resident's progress notes described the fall differently, stating it was unwitnessed, with the resident found on their buttocks and no head strike or trauma reported. During an interview, the Director of Nursing Services confirmed the discrepancies between the nurse's fall report and the physician's documentation. Additionally, the nurse could not recall if neurological monitoring was initiated following the incident.
Failure to Provide Adaptive Equipment for Hot Liquids
Penalty
Summary
The facility failed to provide the proper adaptive equipment to a resident during a meal service, leading to an incident involving hot liquid spillage. On November 6, 2024, a resident spilled hot chocolate on their lap, resulting in burns that developed into blisters on both thighs. The resident had been evaluated by Occupational Therapy on November 12, 2024, with a recommendation to use a covered mug for hot liquids due to decreased fine motor coordination. However, on November 20, 2024, the resident was observed using a regular coffee cup without a cover during breakfast, despite the previous recommendation. This oversight was noted by a surveyor, who then informed the facility's Administrator and Regional Director of Clinical Operations, leading to the resident being provided with a cup with a cover.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of its residents, as evidenced by the interactions between staff and two residents. Resident #43 reported that a specific CNA, identified as CNA #4, was consistently rude and disrespectful. The resident described instances where CNA #4 would deliberately perform actions to upset them, such as opening window shades and turning on the roommate's television despite requests for quiet. This behavior was known to other staff members, yet it was not addressed until the surveyor's investigation. The acting Director of Nursing confirmed that Resident #43 had been vocal about these negative interactions, but no action had been taken prior to the survey. In another incident, Resident #33 was spoken to in a frustrated tone by CNA #3, who expressed impatience with the resident's requests. The CNA was overheard by the surveyor telling the resident to be patient and accusing them of being unfair. The resident, who was not feeling well, had requested reassurance and ginger ale, which was not promptly provided. The Social Worker who later attended to Resident #33 did not address the inappropriate interaction with the CNA. These incidents highlight a failure to uphold the residents' rights to dignity and respectful communication.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across three units and a nurse's station. During a facility tour, surveyors observed several deficiencies, including a nurse's station with ripped duct tape around the countertop, creating an uncleanable surface. In the Penobscot Unit, multiple resident rooms had broken or cracked floor tiles, dirty caulking around toilets, and a buildup of dirt at door entrances. Additionally, the utility room entrance floor had broken tiles, and one room had dried gray liquid residue spatter on the floor. In the [NAME] Unit, a resident's wheelchair had a ripped armrest, and the bathroom floor in one room was dirty. The Kennebec Unit had similar issues, with dirty bathroom floors and caulking, a hole in the wall near an outlet, and dried gray liquid residue spatter on room entrance doors. These findings were confirmed by the Administrator, Maintenance Director, Regional Housekeeping Manager, and other staff members during the tour.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that two residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred for a PASRR Level II evaluation. Resident #31 was admitted with diagnoses including Panic Disorder, Major Depressive Disorder with Severe Psychotic Symptoms, and Nightmare Disorder. Initially, a PASRR Level I determination indicated no further evaluation was needed due to a short-term convalescence admission. However, when Resident #31's stay transitioned to long-term, there was no evidence that the PASRR Level I was forwarded to the State Mental Health Authority for a Level II evaluation. Similarly, Resident #35 was admitted with Bipolar Disorder and Suicidal Ideations. The PASRR Level I determination also stated no further evaluation was required for a short-term stay. Despite the change to a long-term stay, the facility did not forward the PASRR Level I for a Level II evaluation. Interviews with the Director of Social Services and the Regional Director of Clinical Operations confirmed that neither resident received the necessary PASRR II evaluation after their stays exceeded 30 days.
Failure to Provide Restorative Services for Ambulation and AROM
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the residents' highest level of ambulation and active range of motion (AROM) for two residents. Resident #43 reported that they were not receiving the required exercises and ambulation assistance, which was making them weaker. The care plan for Resident #43 included ambulation with a two-wheeled walker and assistance, as well as participation in a daily exercise program to promote strength and activity tolerance. However, documentation revealed that Resident #43 did not receive the ambulation services as directed over the previous 30 days. Similarly, Resident #21 expressed that they were no longer receiving assistance with walking, which had affected their ability to walk. The care plan for Resident #21 included a daily walking program with a two-wheeled walker and participation in a daily exercise program with a therapy band to promote strength. However, the review of documentation indicated that Resident #21 did not receive the ambulation or range of motion services as outlined in their care plan. The surveyor confirmed these deficiencies during a review with the Regional Director of Clinical Operations.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for five residents. Observations revealed that Resident #43's CPAP nasal mask was repeatedly found on the floor and not cleaned by staff, despite physician orders requiring daily cleaning. The resident expressed concerns about congestion due to the unclean mask. Documentation inaccurately reflected the mask as either refused or worn, without proper cleaning. Additionally, Resident #23 was using an oxygen concentrator without orders for changing oxygen tubing or cleaning the concentrator filters, which was confirmed by the Regional Director of Clinical Operations (RDCO). Further deficiencies were noted with Resident #10, who had no evidence of care for their oxygen tubing and humidifier bottle, and Resident #19, who was observed using oxygen at a higher flow rate than prescribed. Resident #160's oxygen tubing was not dated or changed weekly, and there were no treatments for the care of their CPAP machine, despite being in the facility for nine days. The RDCO confirmed the absence of an oxygen policy, stating that respiratory equipment care was supposed to occur on Fridays, but this was not documented or followed.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour. The ceiling vent in the dish room was heavily soiled with dust, and the food disposal unit had dried food particles and liquid residue. Additionally, there was a significant buildup of chemical residue on top of the dish machine. The large standing food mixer was found with dried food particles on its bowl, protective cage, and base. Furthermore, a male kitchen worker was observed without facial hair protection over his mustache, and 20 clear tumblers were wet stacked on a tray after washing. These findings were confirmed by the Food Service Director during an interview.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a review of the clinical records, which showed that the resident was transferred to the hospital on February 22, 2024, without evidence of a written transfer/discharge notice being given. Additionally, the facility did not notify the Ombudsman of the transfer/discharge, as the Director of Social Services, who was responsible for this task, was out sick. During an interview, the Administrator confirmed the absence of the required notifications.
Failure to Provide Bed Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident and/or the resident's representative following a transfer to an acute care hospital. This deficiency was identified during a review of the clinical records for a resident who was transferred to the hospital on February 22, 2024. The clinical record did not contain evidence that a written bed hold notice was given to the resident or their representative. During an interview on May 30, 2024, the Administrator confirmed the absence of documentation for the bed hold notice.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for sliding scale insulin administration for a resident. The resident's clinical record included a physician order to administer Humalog 12 units of insulin, with instructions to hold the dose if the resident was not eating or if their blood sugar was less than 150. On October 22, 2023, the resident's morning blood sugar was documented as 109, yet the treatment administration record indicated that insulin was administered in the abdomen. This discrepancy was confirmed during a review of the resident's documentation by a surveyor and the Regional Director of Clinical Operations on May 30, 2024.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure proper nutrition and hydration for two residents, leading to deficiencies in their care. Resident #11, diagnosed with severe dementia and unspecified convulsions, was observed receiving meals that did not comply with the prescribed mechanical soft diet for dysphagia. The resident was left unsupervised with meals, contrary to the care plan that required extensive assistance and monitoring to prevent aspiration. Despite the care plan's instructions, Resident #11 was not assisted adequately during meals, and fluids were left unattended, posing a risk of aspiration. Resident #18, also diagnosed with dementia, was observed without access to fluids for extended periods. The resident's care plan included an order to encourage fluid intake, yet fluids were not made readily available between meals. Staff interviews revealed that Resident #18 was not regularly offered fluids, and the resident's inability to use the call bell system due to dementia further exacerbated the issue. The lack of consistent fluid availability and encouragement contributed to the failure to maintain sufficient hydration for Resident #18.
Failure to Follow Physician's Orders for Weekly Weighing
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with Congestive Heart Failure. The Physician Order Summary sheet indicated that the resident was to be weighed weekly. However, there was no evidence in the resident's clinical record to indicate that the resident was weighed on three specific dates. This finding was confirmed in an interview with the Administrator.
Improper Handling of Soiled Linens
Penalty
Summary
The facility failed to transport soiled linens in a sanitary manner on the [NAME] unit. A surveyor observed a Certified Nursing Assistant (CNA) carrying unbagged bed linens against her body in the corridor. During an interview, the CNA confirmed that the bed linens were soiled and acknowledged holding them close to her body. The facility's Handling Soiled Linen Policy & Procedure, dated 1/2020, instructs staff to place soiled linen directly into a soiled linen hamper or a plain plastic bag. This finding was confirmed in an interview with the Director of Nursing.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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