Bangor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 103 Texas Ave, Bangor, Maine 04401
- CMS Provider Number
- 205020
- Inspections on file
- 27
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Bangor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
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.
The facility did not follow its Abuse, Neglect and Exploitation policy by allowing several new employees to begin work without required pre-employment screening and by delaying required reporting of an allegation of resident-to-resident sexual contact. Employee file review showed that multiple CNAs began work without a current Maine background check completed by the facility, with some checks done weeks after hire, and a therapist was hired without documented reference checks. Separately, documentation showed that a wheelchair-bound resident reported being touched in a sexually inappropriate manner by another wheelchair-bound resident, but the DON was not informed until two days after the event, and state agencies were not notified until that time, contrary to the policy’s requirement for timely reporting.
The facility failed to timely report a resident-to-resident sexual altercation to the State Agency as required by its abuse reporting policies. A cognitively impaired, wheelchair-dependent resident was inappropriately sexually touched by another cognitively impaired, wheelchair-dependent male resident. Although the incident was documented in the nurse’s notes, the DON and Social Worker were not informed until two days later, and the State Agency was only notified after the DON became aware, exceeding the policy requirement to notify appropriate agencies immediately and within 24 hours of discovery.
A resident who experienced a fall with major injury and was transferred to the hospital for evaluation and treatment did not receive the required written bed-hold notice at the time of transfer. Review of the clinical record showed no documentation that the resident or representative was given a bed-hold notice for that hospitalization, and a social worker confirmed during interview that, although other bed-hold notices existed in the record, none corresponded to the date of this specific transfer.
A resident with a pressure ulcer did not receive proper monitoring and wound care, leading to the deterioration of the wound and hospitalization. The facility failed to adhere to the treatment plan, with missed dressing changes and inaccurate documentation by staff. The resident's condition worsened, requiring hospital admission for further treatment.
The facility failed to provide and document that Advance Directives were offered or reviewed with residents and their representatives for several residents. Clinical records lacked evidence of written information concerning Advance Directives, and there was a discrepancy in code status documentation for a resident. Interviews with staff confirmed the absence of a process to ensure residents were informed about Advance Directives.
The facility was found deficient in maintaining a safe and clean environment, with issues such as chipped paint, damaged furniture, and uncleanable surfaces in several rooms. Observations included soiled walkers, ripped wheelchair armrests, and unpainted patched walls, indicating inadequate maintenance and housekeeping services.
The facility failed to incorporate PASARR Level II recommendations into the care plans for three residents with serious mental illnesses. These residents required ongoing psychiatric services, socialization activities, and supportive counseling, which were not provided or included in their care plans. The DON was unaware of the specific services needed and had not read the Level II reports, leading to deficiencies in care planning and service provision.
The facility failed to follow up on pharmacist recommendations for four residents, including confirming diagnoses, evaluating medication doses, and updating medication records to include daily limits. The Director of Nursing confirmed that these recommendations were not reviewed or acknowledged by the medical provider, indicating a lapse in the facility's process for addressing pharmacist recommendations.
The facility failed to offer pneumococcal vaccinations to five residents in accordance with CDC guidelines. Despite previous vaccinations, there was no evidence that these residents were reviewed or offered the PCV20 vaccine as recommended. The Infection Preventionist confirmed the oversight during a survey.
The facility failed to follow physician orders for two residents, resulting in unsupervised meals for one and incorrect insulin administration for another. Additionally, a third resident was not monitored for treatment effectiveness after being treated for lice.
The facility failed to maintain an effective Infection Control Program, with staff observed handling medications with bare hands and providing care to residents requiring Enhanced Barrier Precautions without proper PPE. Signage and PPE were not adequately provided, leading to multiple breaches in infection control protocols.
A resident experienced significant vomiting and other health changes, but the facility failed to notify the provider despite an existing order to do so. The resident vomited a large amount of dark brown/black liquid, had hypoactive bowel sounds, and coarse crackles in the lungs. The lack of communication was confirmed by the DON.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted after a fall with fractures. The resident required therapy, pain monitoring, and had conditions including diabetes, anti-coagulant use, and a pressure ulcer. These care areas were not added to the care plan until several days post-admission, as confirmed by the DON and a surveyor.
A facility failed to provide the recommended nutritional services for a resident dependent on renal dialysis. The resident was supposed to follow a renal, carb consistent, low sodium diet, but was mistakenly placed on a House/Regular diet upon returning from a hospital discharge. Interviews confirmed the discrepancy in diet recommendations, and the facility did not adhere to the prescribed dietary management.
A facility failed to maintain sanitary conditions for a resident's oxygen therapy. During an inspection, a surveyor noted that the oxygen concentrator's filter was dusty while the resident was using it. This was confirmed by the Director of Plant Operations and the Healthcare Services Group District Manager.
A facility failed to address the needs of a resident with a history of trauma, leading to potential re-traumatization. The resident, admitted with hospice services and diagnosed with anxiety, hallucinations, delusional disorder, and dementia, reported feeling molested and afraid, possibly triggered by a male caregiver. Surveyors confirmed the lack of interventions to prevent re-traumatization.
A resident missed two doses of prescribed IV Vancomycin due to the facility's failure to ensure timely availability of the medication from the pharmacy. The resident, admitted for a surgical wound infection, left the facility against medical advice to seek treatment elsewhere. The Infection Preventionist acknowledged issues with medication delivery, which were confirmed by a surveyor.
The facility failed to monitor food temperatures adequately, with ground and pureed chicken served below the safe holding temperature. Additionally, improper air gaps on the ice machine's drain line were observed, risking contamination of the water supply.
The facility failed to maintain accurate clinical records for two residents. An LPN documented dressing changes for a resident with a pressure ulcer that were not performed, and there was a discrepancy in the wound's condition. Another resident's oxygen tubing change was inaccurately recorded in the TAR. These issues were confirmed by surveyors.
The facility failed to provide timely incontinence care for four residents, leading to issues such as skin redness, rawness, and heavily saturated briefs. Residents reported significant delays in response to call bells, with one resident waiting over six hours for assistance. These delays were confirmed by a surveyor with the facility's administration.
The facility failed to provide sufficient staffing, resulting in delayed responses to call bells and inadequate incontinence care. Residents reported long wait times for assistance, with one fearing a urinary tract infection due to care delays. A physical therapist noted having to assist residents out of bed due to busy nursing staff.
A resident with Parkinsonism and Dementia experienced significant changes in condition, including disorientation and refusal of medications. Despite these changes, the facility failed to promptly notify the resident's POA, potentially delaying medical decisions. The DON confirmed the delay, as the RN wanted to assess intervention effectiveness first.
The facility failed to ensure contracted nursing staff completed essential trainings in dementia care, resident rights, and abuse prevention before providing care. The Clipboard app used for staffing did not require these trainings, and the facility's Scheduler and DON could not verify their completion.
A facility failed to respect a resident's dignity and self-determination by pressuring them to disclose a private conversation with APS and insisting on nail care against their preferences. The resident was distressed by being questioned about the APS conversation and feared eviction. Despite the resident's refusal, the LSW continued to discuss nail trimming, citing APS concerns.
A resident did not receive necessary dental care despite multiple provider orders over six months. The resident's electronic medical record and paper chart contained instructions for dental referrals, but no appointments were scheduled. Interviews confirmed the resident had not seen a dentist, resulting in multiple broken teeth.
A resident with chipped and broken teeth did not receive timely dental care. Despite a provider order for a dental referral due to a dental infection and instructions for a dental examination, no appointments were scheduled. This resulted in a six-month delay in dental services.
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 Follow Abuse Policy for Staff Screening and Timely Reporting of Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy regarding pre-employment screening for multiple staff. The policy, revised 11/1/25, required that potential employees, contracted staff, students, volunteers, and consultants be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks, with documentation maintained as proof. Review of employee files on 1/6/26 with the Assistant DON showed that one CNA hired on 3/4/24 had no Maine background check completed by the facility prior to hire; the only background check present was from a staffing agency dated more than a year before hire. Two CNAs hired on 10/9/24 had Maine background checks completed 21 days after their hire dates, rather than before they began working. A therapist hired on 10/28/25 had no evidence in the file that references were checked, contrary to the facility’s policy requirements. The facility also failed to implement its Abuse, Neglect and Exploitation policy regarding timely reporting of an allegation of resident-to-resident inappropriate sexual contact. A nurse’s note dated 1/3/26 documented that a resident had been touched in a sexually inappropriate manner by a male resident; both residents involved were wheelchair-bound. Another nurse’s note dated 1/5/26 indicated that the affected resident’s guardian was notified of the incident. In an interview on 1/8/26, the DON confirmed that the incident occurred on 1/3/26, but she was not informed until 1/5/26, at which time she notified the state agencies (Licensing and Certification and Adult Protective Services). The DON acknowledged that the state agencies were not notified in a timely manner, as required by the facility’s abuse, neglect, and exploitation policy.
Failure to Timely Report Resident-to-Resident Sexual Altercation to State Agency
Penalty
Summary
The facility failed to timely notify the State Agency of a resident-to-resident sexual altercation involving a cognitively impaired, wheelchair-dependent resident (R28). Record review showed that on a Saturday afternoon, R28 was inappropriately sexually touched by a cognitively impaired, wheelchair-dependent male resident. Nursing notes documented the incident in the clinical record, but the Director of Nursing (DON) and Social Worker were not notified until the following Monday. Facility policies in the Abuse-Risk Management Folder and the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation procedure require that appropriate agencies, including the State Agency and Adult Protective Agency, be notified immediately and no later than 24 hours after discovery of an allegation of abuse. In an interview, the DON confirmed that the incident occurred on Saturday and acknowledged it should have been reported to Licensing and Certification at that time, but the State Agency was not notified until she became aware of the incident on Monday.
Failure to Provide Required Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident who was transferred to the hospital for medical evaluation and treatment following a fall with major injury. Record review on 1/7/26 showed that the resident was transferred on 2/24/25, but the clinical record contained no evidence that the resident or the resident’s representative received the required written bed-hold notice at the time of transfer. During an interview on 1/8/26 at 9:45 a.m., the Licensed Social Worker reported that she had reviewed the entire record and found several bed-hold notices, but none corresponding to the date of the hospital transfer in question, confirming that the notice was not provided for that hospitalization. This deficiency is based solely on the absence of documentation of a bed-hold notice for the specific transfer date and the Licensed Social Worker’s confirmation during the surveyor interview that no such notice was given for that event.
Inadequate Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring and wound care for a resident with a pressure ulcer, leading to the deterioration of the wound and subsequent hospitalization. The resident, who was cognitively intact, had a physician-ordered treatment plan for a right heel pressure wound, which included specific dressing changes and the use of off-loading boots. However, the facility did not adhere to the treatment plan, as evidenced by the lack of regular dressing changes and inaccurate documentation by the staff. On multiple occasions, the dressing on the resident's wound was not changed as scheduled, and the wound was not properly assessed. A Licensed Practical Nurse (LPN) documented dressing changes that did not occur, and a Registered Nurse (RN) discovered that the dressing had not been changed for several days, leading to the wound developing an odor and blackened tissue. The Family Nurse Practitioner (FNP) had previously identified the wound as unstageable and ordered antibiotics due to infection concerns, but the lack of consistent care and monitoring allowed the wound to worsen. The facility's failure to conduct weekly pressure wound assessments and adhere to the care plan resulted in the resident's condition deteriorating to the point of requiring hospital admission for further treatment. The Director of Nursing confirmed that the required weekly assessments were not completed, and the LPN admitted to not remembering performing or documenting the necessary care. This lack of proper wound care and monitoring highlights significant deficiencies in the facility's adherence to care protocols.
Failure to Provide and Document Advance Directives
Penalty
Summary
The facility failed to provide evidence that Advance Directives were offered or reviewed with residents and/or their representatives for seven out of fourteen residents reviewed. The clinical records for these residents lacked documentation showing that the facility provided written information concerning the right to formulate an Advance Directive. Specific residents, including R19, R16, R17, R11, R18, R37, and R102, were identified as not having this documentation in their records. Interviews with facility staff, including the Administrator and Social Services Interim, confirmed the absence of such documentation and the lack of a process to ensure residents and their representatives were informed about Advance Directives. Additionally, there was a discrepancy in the code status documentation for one resident, R102, where the electronic medical record indicated a 'Do Not Resuscitate' status, but the printed demographic at the nurse's station showed a 'Full Code' status. This inconsistency was confirmed during an interview with a Registered Nurse and further validated by surveyors. The Administrator acknowledged the lack of evidence in the Social Services office or resident records to show that Advance Directives were offered or reviewed, confirming the findings of the surveyors.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by multiple maintenance and housekeeping deficiencies observed during an environmental tour. In several rooms, there were issues such as chipped paint near televisions and bed enablers, damaged nightstand coverings, water-stained ceiling tiles, missing dresser drawer handles, and broken trim on headboards and footboards. Additionally, some rooms had uncleanable surfaces due to torn or cracked vinyl seats on chairs and cracked wheelchair backs. Dust and dirt were visible on the windows both inside and outside, and there were gouged areas on walls under plastic shelves. Further observations revealed heavily soiled walkers with crusted debris stored behind doors, and ripped armrests on wheelchairs, creating uncleanable surfaces. In the horseshoe-shaped hallway, multiple areas on the walls were patched but not painted, contributing to the overall lack of maintenance. These deficiencies indicate a failure to provide adequate maintenance and housekeeping services necessary to keep the facility in good repair and sanitary conditions, compromising the residents' right to a safe and comfortable environment.
Failure to Incorporate PASARR Level II Recommendations
Penalty
Summary
The facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) Level II determination into the assessment, care planning, and transitions of care for three residents. Resident #16 was diagnosed with serious mental illness, specifically depression, which led to functional limitations. The PASARR Level II required ongoing psychiatric services, peer support, and rehabilitative services, including socialization activities and supportive counseling. However, during a review, it was found that these services were not included in the care plan or provided to the resident. The Director of Nurses (DON) was unaware of the specific services required and had not read the Level II report. Similarly, Resident #19, diagnosed with bipolar disorder and anxiety, required ongoing psychiatric services, socialization activities, and family involvement in care. The review revealed that these services were not incorporated into the care plan or provided. The DON acknowledged the lack of psychiatric services due to a long waitlist and had not ensured the inclusion of necessary services in the care plan. Resident #37, diagnosed with depression and anxiety, also required ongoing psychiatric services, individual therapy, and various rehabilitative services. The care plan review showed that these services were not provided or included. The DON had placed the resident on a waitlist for in-person psychiatric services, dismissing a telehealth option. The surveyors confirmed the absence of evidence that the required Level II services were provided or included in the care plan.
Failure to Address Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up on pharmacist recommendations in a timely manner for four residents reviewed for medications. For Resident #11, the pharmacist recommended confirming a diagnosis for Buspar therapy and evaluating the dose of Risperidone, but there was no evidence that these recommendations were reviewed or responded to by the medical provider. Similarly, for Resident #16, the pharmacist suggested reviewing the dosing schedule for Oxybutynin and Gabapentin and evaluating the dose of Sertraline, yet there was no indication that these recommendations were addressed. The Director of Nursing confirmed the lack of responses to these pharmacy recommendations. For Resident #34, the pharmacist recommended updating the Medication Administration Record (MAR) to include a daily limit for Tums, but the orders were not updated. Resident #37 had a similar issue, with the pharmacist recommending a daily limit for Acetaminophen, but the orders remained unchanged. In both cases, the Director of Nursing confirmed that there was no evidence of the recommendations being reviewed or acknowledged by the provider. These findings indicate a failure in the facility's process for addressing pharmacist recommendations, as confirmed by interviews with the Director of Nursing and surveyors.
Failure to Offer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. During a survey, it was found that five residents, identified as R3, R43, R25, R28, and R12, were not reviewed, offered, or received the pneumococcal vaccine as per the guidelines. The Infection Preventionist confirmed that these residents should have been offered the PCV20 vaccine five years after their last pneumococcal vaccine, as per CDC guidance. However, there was no evidence in the immunization records to show that these residents were reviewed or offered the vaccine. Each of the residents had been admitted to the facility at different times, with some having received previous pneumococcal vaccinations years prior. For instance, R3 had received a PPSV23 in 2018 and a Pneumovax Dose 2 in 2006, while R43 had received a PPSV23 in 2011. Despite these previous vaccinations, there was no documentation indicating that these residents were assessed for the need for the PCV20 vaccine. The surveyor confirmed the lack of compliance with CDC recommendations during an interview with the Infection Preventionist.
Failure to Follow Physician Orders and Monitor Treatments
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For one resident, a diet order required constant supervision during meals, but observations revealed that the resident was left unsupervised during breakfast. A CNA confirmed that the resident ate alone, and an RN, new to the facility, was unaware of the supervision requirement. This lack of supervision was confirmed by a surveyor, indicating a failure to follow the prescribed dietary order. Another resident with diabetes had a physician order to hold insulin if their blood sugar was below 100. However, the resident received 44 units of Lantus despite having a blood sugar level of 86, contrary to the physician's instructions. Additionally, a third resident was treated for lice with a medicated shampoo, but there was no evidence of monitoring the treatment's effectiveness for four days post-treatment. The Infection Preventionist confirmed the lack of monitoring, highlighting a failure to follow up on the prescribed treatment plan.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by multiple observations and interviews during the survey. On one occasion, a Certified Nursing Assistant (CNA) was observed handling medications with bare hands while administering them to a resident, which is a breach of infection control protocols. Additionally, a resident with a Foley catheter and a history of Extended-spectrum beta-lactamase (ESBL) was not properly managed under contact precautions. The required personal protective equipment (PPE) was not available outside the resident's room, and staff were observed providing care without wearing the necessary gowns and gloves. Further deficiencies were noted with another resident who had a wound requiring Enhanced Barrier Precautions (EBP). There was no signage or PPE cart outside the room, leading to staff providing care without the necessary protective equipment. Similarly, another resident with a Foley catheter did not have appropriate EBP signage or PPE available, and staff were unaware of the need for PPE until informed later. These lapses indicate a systemic failure in implementing and maintaining infection control measures, as outlined in the facility's policy.
Failure to Notify Provider of Resident's Health Change
Penalty
Summary
The facility failed to notify the provider of a change in status for a resident, identified as Resident #11 (R11), who experienced a significant health event. On October 11, 2024, R11 vomited a large amount of dark brown/black liquid containing undigested food and medication. The resident's bowel sounds were hypoactive, and coarse crackles were heard throughout all lung lobes, although the resident was afebrile with a pulse of 87, blood pressure of 97/66, and oxygen saturation of 95% on room air. Despite these findings, there was no documentation that the provider was informed of this incident, even though there was a physician's order dated August 10, 2024, to notify the provider if vomiting recurred. This lack of communication was confirmed during an interview with the Director of Nurses on December 18, 2024.
Failure to Implement Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted after experiencing a fall that resulted in fractures. The resident required therapy and pain monitoring and had diagnoses including diabetes, use of an anti-coagulant, and a pressure ulcer to the sacrum. These critical care areas were not included in the baseline care plan until more than 48 hours after admission. During an interview, the Director of Nursing confirmed that the nurses are responsible for creating the baseline care plan, and the surveyor verified that the necessary care areas were not added until several days after the resident's admission.
Failure to Provide Recommended Nutritional Services for Dialysis Resident
Penalty
Summary
The facility failed to provide the recommended nutritional services for a resident who was dependent on renal dialysis. The resident was admitted with a care plan indicating a renal diet, which was revised to include a carb consistent, low sodium diet. However, upon returning from a hospital discharge, the resident was mistakenly placed on a House/Regular diet, which is not considered low sodium, contrary to the discharge orders. Interviews with the Kitchen Manager and the Director of Nursing confirmed the discrepancy in diet recommendations, and it was noted that the facility did not adhere to the prescribed dietary management for the resident upon their return from the hospital.
Unsanitary Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide oxygen therapy in a sanitary manner for a resident using oxygen. During an environmental tour, a surveyor observed a resident wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator's filter, located on the back of the machine, was found to be dusty. This observation was confirmed during an interview with the Director of Plant Operations and the Healthcare Services Group District Manager.
Failure to Prevent Re-traumatization in Resident with Trauma History
Penalty
Summary
The facility failed to address the needs of a resident to minimize triggers that may cause re-traumatization. The resident, who was admitted with hospice services, had significant diagnoses including anxiety disorder, hallucinations, delusional disorder, and dementia with behavioral disturbance. On two occasions, the resident reported feeling molested and afraid, suggesting a possible trigger from a male caregiver due to a history of old trauma. Despite these reports, the clinical record lacked evidence of interventions to prevent re-traumatization, as confirmed by surveyors during an interview with the Director of Nursing.
Failure to Provide Timely IV Medication
Penalty
Summary
The facility failed to ensure the availability of physician-ordered medications for a resident, leading to a deficiency in pharmaceutical services. A resident was admitted to the facility after a hospital stay for a surgical wound infection and required Vancomycin HCI in dextrose IV solution to be administered twice daily. However, the Treatment Administration Record indicated that the medication was not available from the pharmacy, resulting in the resident missing the evening dose on the first day and the morning dose on the following day. The resident and their spouse expressed dissatisfaction with the care and the unavailability of the IV medication, deciding to leave the facility against medical advice to seek treatment at the emergency room. The Infection Preventionist acknowledged ongoing issues with timely medication delivery from the pharmacy, noting that while there are pharmacy runs during the week, the facility struggles to obtain IV medications from local sources like Walgreens. This deficiency was confirmed by a surveyor, who verified that the resident missed two doses of the prescribed IV antibiotics due to the unavailability of the correct formulation.
Food Temperature Monitoring and Plumbing Deficiencies
Penalty
Summary
The facility failed to monitor food temperatures adequately, which could lead to foodborne illness. On December 17, 2024, a surveyor observed the Kitchen Manager serving mashed potatoes, pureed green beans, and ground chicken from a steam table. The food was placed on an early plate before the lunch service began. The surveyor noted that the Kitchen Manager checked the holding temperatures of the food after the plate was prepared. The ground chicken was at 133 degrees Fahrenheit, and the pureed chicken was at 126 degrees Fahrenheit, both below the minimum safe holding temperature of 135 degrees Fahrenheit. The Kitchen Manager confirmed that the food was not maintained at a safe temperature. Additionally, the facility did not ensure proper installation of plumbing fixtures to prevent backflow, as required by the Maine State Plumbing Code. On December 17 and 18, 2024, a surveyor observed an improper air gap on the drain line of the ice machine. This finding was confirmed with the Kitchen Manager. The lack of a proper air gap could potentially lead to contamination of the water supply, food, and food utensils, affecting all residents in the facility.
Inaccurate Clinical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to deficiencies in care documentation. For one resident with a pressure ulcer, a Licensed Practical Nurse (LPN) documented dressing changes on specific dates, but the dressing was observed unchanged since an earlier date, and there was a discrepancy in the wound's condition as documented by different healthcare professionals. Additionally, the Treatment Administration Record (TAR) inaccurately reflected that the oxygen tubing for another resident was changed on a date when it was not, as confirmed by the date on the tubing itself. These inaccuracies were confirmed through interviews and observations by surveyors.
Delayed Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care for four residents, as observed during a complaint investigation. Resident 1, who has a history of urinary tract infections and intact cognition, reported that call bells went unanswered for up to 40 minutes, and incontinence checks were not performed on specific nights. Resident 2, with a diagnosis of cerebral infarction and intact cognition, activated the call light for incontinence care, which was delayed by 45 minutes, resulting in skin redness and rawness. Resident 3, with multiple sclerosis and moderate cognitive impairment, requested assistance at 5 a.m. but did not receive care until over six hours later, leading to heavily saturated briefs and bedding. Resident 4 reported waiting an hour and a half for assistance, leading to soiling the bed due to staff not emptying the urinal timely. These incidents highlight a pattern of delayed response to incontinence care needs, which is critical for maintaining skin integrity and preventing infections. The residents involved have varying degrees of cognitive and physical impairments, necessitating prompt and regular care. The surveyor confirmed these findings with the facility's Administrator and Director of Nursing, indicating a systemic issue in responding to residents' needs for incontinence care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, as evidenced by multiple instances of delayed response to call bells and inadequate incontinence care. Interviews with anonymous staff members revealed that the facility was not staffing according to resident acuity, leading to situations where residents were left in soiled conditions. One staff member reported that call bells could go unanswered for about 40 minutes due to staff being busy. This was corroborated by residents who reported long wait times for assistance, with one resident expressing fear of developing a urinary tract infection due to delays in care. Specific incidents included a resident who reported not being checked for incontinence during the night shift on two occasions, and another resident whose call bell went unanswered for 35 minutes, resulting in a 45-minute wait for incontinence care. Additionally, a resident requested assistance at 5 a.m. but was not attended to until after noon, resulting in heavily saturated bedding. Another resident reported waiting an hour and a half for assistance and expressed a desire to refuse medication to prevent incontinence due to the lack of timely care. The facility's physical therapist noted that she often had to assist residents out of bed because the nursing staff was too busy.
Failure to Notify Resident's Representative of Significant Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified immediately of a significant change in the resident's medical condition. The resident, who had diagnoses of Parkinsonism, Dementia, and hallucinations, was found on the floor and exhibited symptoms such as disorientation, lethargy, and refusal of medications. Despite these significant changes, there was no evidence that the resident's Power of Attorney (POA) was informed in a timely manner, which could have delayed medical decision-making. Nursing notes documented several concerning observations, including the resident's dark bloody urine, confusion, difficulty speaking, and a high respiratory rate. The resident was eventually sent for further evaluation and treatment, but the Director of Nursing confirmed that the POA was not notified promptly. The Registered Nurse had delayed contacting the resident's representative to assess the effectiveness of interventions first, which led to the deficiency noted by the surveyor.
Deficiency in Training for Contracted Nursing Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application in critical areas such as dementia care, resident rights, and abuse, neglect, and exploitation training. The deficiency was identified through interviews and record reviews, revealing that contracted professionals were not required to complete these essential trainings before independently providing services to residents. The Clipboard app, which serves as a marketplace for professionals to sign up for shifts, does not mandate these trainings as part of its requirements, as confirmed by the facility's Scheduler and a contracted CNA. During interviews, the Scheduler and the DON were unable to provide evidence that the necessary trainings were completed by contracted staff. The Scheduler admitted to not typically checking for these trainings, and the DON could not verify their completion either. This lack of oversight and verification led to the deficiency, as contracted staff were allowed to provide direct care to residents without the necessary training in dementia care, resident rights, and abuse prevention.
Violation of Resident's Dignity and Self-Determination
Penalty
Summary
The facility failed to uphold a resident's right to dignity and self-determination by attempting to provide nail care against the resident's preferences and by disclosing a private conversation. During an interview, a resident expressed distress after being brought into an office and questioned about a private conversation with Adult Protective Services (APS), fearing eviction if they did not disclose the details. The resident also expressed a preference for their nails to remain at their current length, which was not respected by the Licensed Social Worker (LSW). The LSW continued to discuss nail trimming with the resident despite their refusal, citing concerns raised by an APS representative. This interaction occurred after an activity, where the resident was brought to the office to discuss both the APS visit and nail care, contrary to the resident's expressed wishes.
Failure to Follow Physician Orders for Dental Care
Penalty
Summary
The facility failed to follow physician orders for a resident who required dental care. A provider order was placed in the resident's electronic medical record on December 7, 2023, for a referral to a dentist due to a dental infection. Additional instructions for dental services were given on April 26, 2024, and May 30, 2024, but no appointments were scheduled. Interviews with the resident and staff confirmed that the resident had not been to a dentist, despite needing an appointment for multiple broken teeth. This deficiency persisted over six months, with no referrals or appointments made as ordered by the providers.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had chipped and broken teeth. On June 11, 2024, the resident reported to a surveyor that they had not been to a dentist despite needing an appointment due to a chipped tooth that had worsened into multiple broken teeth. The facility's Scheduler confirmed that no dental appointments were scheduled for the resident. A review of the resident's clinical record on June 12, 2024, revealed a provider order from December 7, 2023, for a dental referral due to a dental infection, which was not completed or scheduled. Additionally, instructions for a dental examination were noted in the resident's paper chart on April 26, 2024, and May 30, 2024. Despite these orders, no referrals or appointments were made, resulting in a six-month delay in dental services for the resident.
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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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