Brentwood Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Yarmouth, Maine.
- Location
- 370 Portland Street, Yarmouth, Maine 04096
- CMS Provider Number
- 205079
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Brentwood Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
Facility Maintenance and Housekeeping Deficiencies: Surveyors observed missing Whirlpool room tiles, frayed and stained carpeting, marred walls, and other maintenance issues across multiple units. Additional findings included a missing hand sanitizer cover, an exposed wall heater, nonworking overbed lights, a hole in a bathroom wall, a stained divider curtain, a urinal and bed pan left on a bathroom floor, a broken night stand hinge, heavy dust on a TV arm, and damaged ceiling tiles in the dining room.
Failure to Hold Required IDT Care Plan Meetings The facility failed to review and revise care plans by an IDT, including resident and/or representative participation to the extent possible, after required MDS assessments for three residents. Records lacked evidence that IDT meetings were held within 7 days of quarterly, annual, and admission MDS completion, and both the Regional Director of Operations and the social worker confirmed the meetings were not done within the required timeframe. One resident also stated he/she had not met with the care team and had concerns to discuss.
Broken floor heaters exposed piping and sharp metal fins in resident areas, including rooms [ROOM NUMBER] and the TV room on the Passport Unit. The condition was observed by surveyors and confirmed with the Maintenance Director and the DCO.
Insufficient weekend staffing was identified after review of the PBJ staffing report showed Excessively Low Weekend Staffing for the quarter. During interview with the Facility Administrator, it was confirmed that the facility did not have enough staff to meet resident needs on the shifts when staffing was short, affecting residents needing ADL assistance.
Incomplete controlled substance shift count documentation was identified across multiple med cart narcotic bound books. On Eagle, Passport, Short Hall, and Kitchen Hall, the oncoming and/or offgoing med pass staff failed to sign the Shift Count page confirming the narcotic count at shift change on numerous occasions, and the RDCO confirmed the findings during interview.
Expired and undated medications were found in several medication carts, a medication room, and the Pixis machine. Observations with an RN, LPN, and CNA-M identified expired tablets, insulin pens without open dates, and other medications kept available for use despite manufacturer instructions for dating and disposal after opening.
Infection control failures were observed involving EBP, PPE, and urinal handling. A resident with an indwelling catheter and another resident with a catheter had no EBP signage posted, an LPN performed trach care for a resident with chronic respiratory failure and a tracheostomy without face protection, and two unlabeled urinals were found hanging in a shower room.
A resident's call bell was not kept within reach on two observed occasions. The resident was seen in bed with the call bell wrapped around the bed rail and later on the floor, and both a CNA and an RN confirmed the call bell was not reachable.
Respiratory care and the oxygen care plan were not followed for a resident with COPD. Staff observed the resident receiving O2 by NC at 1.5 LPM even though the current provider order was for 2 LPM continuously for SOB, and the resident was unsure of the correct setting. The care plan still listed oxygen as PRN at 1-2 L to keep O2 sat at or above 90%, and the RN and Regional Director confirmed the plan had not been updated to match the current order.
The facility failed to complete an annual performance evaluation for a CNA within the required 12-month period. The CNA was hired in December 2023, and the employee file lacked evidence of a 2025 evaluation; the DCO confirmed the missing evaluation during interview.
The facility failed to ensure that one CNA completed the required annual dementia, abuse and neglect, and resident rights training. Review of the CNA’s employee record showed no evidence of the 2025 in-service training, and the missing training was confirmed by the DCO during interview.
A resident was admitted with a pressure-related skin issue on the left buttock, documented on the nursing admission evaluation and in early skilled notes as a pressure ulcer. Despite this, numerous subsequent daily skilled notes and a skin check documented the skin as intact or without issues. Later documentation identified the wound as a stage 3 pressure ulcer with full-thickness skin loss. The DON confirmed that the ulcer was present on admission, was never thoroughly assessed, was not reported to a physician, and was not appropriately cared for.
A resident was admitted with a documented pressure-related skin issue on the left buttock, and subsequent skilled notes confirmed the presence of a pressure ulcer requiring pressure ulcer care and rehab services. However, there is no indication that the physician was notified, that specific physician orders were obtained, or that an individualized interdisciplinary care plan was implemented for this existing pressure ulcer as required by facility policy. Later, a CNA reported concerns about a wound on the buttocks to the Wound Care Nurse, who stated this was the first time he became aware of the issue, and a new in-house–acquired Stage 3 pressure ulcer on the left sacrum was documented.
A resident had a physician’s order for JP (Jackson Pratt) drain monitoring every shift for prophylaxis, but the Treatment Administration Record for one month showed multiple missing entries where this monitoring was not documented as completed on evening and night shifts. Record review identified specific shifts with no documentation of the ordered JP drain checks, and the DON confirmed these omissions during an interview with surveyors.
The facility experienced repeat deficiencies when QAPI/QAA processes failed to prevent ongoing problems in wound care and clinical documentation. Previously cited issues with pressure ulcer management and incomplete or inaccurate wound care records recurred, including a resident admitted with a pressure ulcer without any MD orders for wound treatment and another resident whose record lacked complete and accurate wound care information. These findings showed that earlier corrective efforts did not resolve the underlying quality of care and record-keeping problems.
A resident was admitted with a documented pressure-related skin issue on the left buttock, identified on the NSG admission/readmission evaluation completed the day of admission. Despite this documented condition, the clinical record lacked a baseline care plan within 48 hours that included the instructions necessary to properly care for the skin issue. The DON confirmed to surveyors that there was no baseline care plan addressing this pressure-related problem.
Two residents requiring wound care did not have care plans developed to address their wounds, including the absence of documented goals and interventions. One had a chronic abscess with new antibiotic orders and wound packing, while the other had wounds on both feet, including an unstageable pressure ulcer. These deficiencies were confirmed by record review and staff interviews.
Two residents did not have documented physician orders for wound care interventions. One resident with a chronic thigh abscess returned from the ER with wound care instructions, but no wound care orders or documentation were present for nearly two weeks. Another resident with a malfunctioning NPWT device had their wound packed with VASHE-soaked gauze based on a reported verbal order, but no such order was documented in the medical record.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care, as the TAR lacked documentation of wound vac dressing changes and wound care on multiple occasions, despite physician orders specifying required care.
Two residents experienced deficiencies in medication administration and documentation. One RN delayed administering Miralax against physician orders, while another left medication unattended with a resident and documented a pain scale without asking the resident. These actions violated the facility's medication pass policy.
The facility failed to maintain accurate records for controlled substances, as staff did not consistently sign the Shift Count pages at shift changes. This issue was observed across multiple units, with instances of staff either failing to sign or pre-signing the narcotic books, contrary to facility policy. The deficiency was confirmed by staff and discussed with the DON.
Expired medications were found on the Sebago unit medication cart, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates. These were confirmed and removed by a nurse. Additionally, an unlocked and unattended medication cart was observed on the Eagle unit, with residents nearby. A surveyor intervened to alert a nurse about the unsecured cart. Both issues were discussed with the DON.
The facility's kitchen was found to be unsanitary, with undated and unlabeled meat, stained ceiling tiles, and dirty equipment, including an ice machine, food slicer, and mixer. These issues were confirmed by staff and the Administrator.
The facility was found to have several maintenance and cleanliness issues, including dust and debris on laundry dryers, a broken closet door hinge, a protruding cable outlet, stained ceilings, a red liquid stain on an air handling unit, and dead bugs on light covers. These deficiencies were confirmed by the facility's Administrator and other staff during a survey.
A facility failed to limit a PRN order for Lorazepam to 14 days, as required by regulations. A resident had a PRN order for Lorazepam 0.5 mg for anxiety, prescribed for 3 months without a 14-day limit or supporting documentation for the extended duration. This deficiency was identified during a surveyor's review and discussed with the Administrator.
A facility failed to accurately document the removal of a Lidocaine patch for a resident. A physician's order required the patch to be applied daily and removed nightly. However, a surveyor observed a nurse applying a new patch without removing the old one, which should have been removed the previous evening. This was confirmed by the nurse and discussed with the DON and Regional Director of Clinical Operations.
A registered nurse on the Eagle unit failed to perform hand hygiene between administering medications to multiple residents. The nurse handled medications for three residents consecutively without sanitizing her hands, citing the absence of hand sanitizer on the medication cart when questioned by a surveyor.
The facility failed to conduct annual performance evaluations for CNAs as required. Two CNAs, one hired in 2021 and another in 2009, did not receive their annual evaluations. The employee file for the CNA hired in 2021 showed an annual review signed only by the Division Head, with no employee signature, and lacked any annual review since hire. Both CNAs confirmed they had not received an annual review since being hired. This was confirmed with the Regional Director of Operations.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to adequately maintain the building in good repair and sanitary condition across 4 of 4 units, including Passport, LTC both Long Hall and Short Hall, Eagle, and Sebago. Surveyors observed missing tiles in the Whirlpool room near the Sebago and Eagle units, multiple areas of frayed and dirty carpeting throughout the facility, and marred walls in the Eagle Unit Dining Room. Additional observations included a marred wall in room [ROOM NUMBER]A, a hand sanitizer dispenser missing its cover in room [ROOM NUMBER], and a wall heater in room [ROOM NUMBER]A missing its cover with exposed components and unpainted sheet rock. During later rounds with the Administrator, surveyors confirmed badly worn and stained carpeting in both hallways, a nonworking overbed light and a hole in the bathroom wall in room [ROOM NUMBER]A, a stained divider curtain in room [ROOM NUMBER], a urinal and bed pan left on the bathroom floor behind the toilet in room [ROOM NUMBER], a night stand door that could not be closed because of a broken hinge in room [ROOM NUMBER], heavy dust on a TV arm in room [ROOM NUMBER], a nonworking overbed light in room 105A, and tape on the ceiling in the Common Dining Room with a torn ceiling tile in front of the clock.
Failure to Hold Required IDT Care Plan Meetings
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 required assessments for 3 of 24 residents reviewed. Resident #7 had a Quarterly MDS dated 1/14/26, but the clinical record lacked evidence that an IDT meeting was held within 7 days of completion of that assessment. Resident #66 had a Quarterly MDS dated 12/30/25, and the record also lacked evidence of an IDT meeting within 7 days of completion of the quarterly assessment. Resident #68 stated during interview on 3/2/26 that he/she had not met with the care team and had concerns to bring to them; the record contained an annual MDS dated 2/11/26, quarterly MDSs dated 8/13/25 and 5/13/25, and an admission MDS, but lacked evidence that IDT meetings were held within 7 days of completion of those assessments. The Regional Director of Operations and the social worker confirmed that the meetings were not held within the required timeframe.
Broken Floor Heaters Exposed Piping and Sharp Metal Fins
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to broken floor heaters. On 3/2/26 at 10:15 a.m., floor radiators were observed missing coverings, exposing piping and sharp metal fins in rooms [ROOM NUMBER]. This was confirmed with the Maintenance Director at 10:37 a.m. On 3/3/26 at 7:02 a.m., a broken radiator exposing piping and sharp metal fins was also observed in the TV room on the Passport Unit, and this was observed with the Director of Clinical Operations.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all residents in the facility. Review of the Payroll Based Journal staffing report showed the facility triggered for Excessively Low Weekend Staffing during the fourth quarter 4, covering July 1, 2025 through September 30, 2025. During review of weekend staffing with the Facility Administrator, it was confirmed that the facility did not have enough staff to meet resident needs on the shifts when staffing was short. The deficiency was identified based on record review and interview and was noted to affect all residents needing assistance with ADLs.
Incomplete Controlled Substance Shift Count Documentation
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to allow an accurate reconciliation. Record review showed that controlled substance shift counts were expected at each change of shift, approximately three times per day, but the required documentation was incomplete on multiple medication cart narcotic bound books. On Eagle unit, Passport unit, Short Hall, and Kitchen Hall, the person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty did not sign the Shift Count page confirming the controlled substance count on numerous dates across the reviewed books. The missing signatures were identified in Controlled Substance Book #2 on Eagle unit, Book #8 on Passport unit, Book #5 on Short Hall, and Book #5 on Kitchen Hall. During an interview on 3/3/26 at 8:46 a.m., the Regional Director of Clinical Operations confirmed the findings.
Expired and Undated Medications Found in Multiple Storage Areas
Penalty
Summary
Drugs and biologicals were not consistently labeled, dated, or removed from use when expired in multiple medication storage areas. During observation of the Sebago medication room with an RN, expired Lactaid tablets, Vitamin B6 tablets, and Aspirin 325 mg were found available for use. In the Eagle unit medication cart, expired Naproxen 220 mg tablets were present, along with opened and undated Lantus Solostar pens and an opened and undated Novolog insulin pen, despite manufacturer instructions requiring dating and timely disposal after opening. In the Passport medication cart, an opened and undated Tresiba flex pen was available for use, and in the Kitchen Hall medication cart, an opened bottle of Naproxen Sodium 220 mg tablets with an expired date was observed. A review of the facility's Pixis machine also identified expired medications available for use, including Amiodarone 200 mg tablets, Cefepime 1 gram for injection, fentanyl 25 mcg patches, and Ropinirole 1 mg tablets. These findings were observed by the surveyor with facility staff present, including RNs, an LPN, and a CNA-M, and were discussed with the Regional Director of Clinical Operations.
Infection Control Failures With EBP, PPE Use, and Urinal Storage
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent cross contamination and infection development for residents requiring Enhanced Barrier Precautions (EBP), including residents with indwelling medical devices. On 3/2/26, Resident #7 was observed in his/her room with an indwelling catheter, and there was no evidence of appropriate EBP signage. On 3/2/26, Resident #73 was interviewed and stated he/she had a catheter; the surveyor observed no EBP signage posted in the room at 8:25 a.m. and again at 11:38 a.m. The Infection Preventionist confirmed there was no signage and stated there should be. The facility policy reviewed on 3/2/26 stated EBP applies to residents with indwelling medical devices and requires gown and glove use for certain high-contact care activities. The facility also failed to use correct PPE during tracheostomy care and failed to properly label and store urinal collection devices. On 3/3/26, an LPN performed routine tracheostomy care for Resident #9, who had diagnoses including stroke, persistent vegetative state, chronic respiratory failure with hypoxia, and tracheostomy; the LPN wore a disposable gown and gloves but did not wear face protection during the procedure. The resident’s record showed a December 2025 sputum culture with MDROs including ESBL Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Also on 3/3/26, two unlabeled urinals were observed hanging on the side rail by the toilet in the Passport Unit shower room, and the Director of Clinical Operations confirmed the observation.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not keeping the resident's call bell within reach. Resident #59 was observed on 3/2/26 lying in bed with the call bell wrapped around the bed rail facing outside the bed rail, making it unreachable. During an interview shortly after the observation, CNA #5 confirmed the resident could not reach the call bell. The same resident was again observed on 3/3/26 lying in bed with the call bell on the floor and not within reach. RN #1 later confirmed this finding during an interview with the surveyor.
Respiratory Care and Oxygen Care Plan Not Followed
Penalty
Summary
The facility failed to provide respiratory care as ordered for one resident with COPD and failed to keep the plan of care updated for oxygen therapy. On 3/2/26 at 7:47 a.m., the resident was observed receiving oxygen via nasal cannula with the concentrator set at 1.5 LPM, and the resident stated he/she uses oxygen all the time but was not sure what the LPM should be set at. The medical record showed a current provider order dated 5/10/25 for oxygen at 2 liters per minute continuously every shift for shortness of breath. Review of the oxygen saturation documentation for 3/1/26 stated the resident's oxygen saturation was 94% on room air and that the resident was not utilizing oxygen as ordered. The care plan for COPD, initiated on 3/13/24 with a target date of 5/24/26, instructed nursing staff that oxygen settings were O2 via nasal cannula at 1-2 liters as needed to maintain oxygen saturation at or above 90% and noted the resident had intermittent oxygen therapy related to ineffective gas exchange secondary to COPD. On 3/3/26 at 9:10 a.m., the surveyor and RN observed the resident again receiving oxygen at 1.5 LPM, and the RN reviewed the order and confirmed the resident should have 2 LPM, stating, "I'm gonna bump it up. I believe (he's/she's) always been on 2, even when (he/she) was up front." The Regional Director of Clinical Operations later reviewed the findings and confirmed the care plan was not revised to reflect the current oxygen order.
Missing Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete an annual performance evaluation, at least every 12 months, for 1 of 5 sampled employees, CNA #4. CNA #4 was hired in December 2023, and the employee file lacked evidence of a completed annual performance evaluation for 2025. During an interview on 3/4/26 at 9:12 a.m., the Director of Clinical Operations confirmed that CNA #4 did not have an annual performance evaluation in 2025.
Missing Required Annual CNA Training
Penalty
Summary
The facility failed to monitor and ensure that one CNA attended the mandatory yearly dementia, abuse and neglect, and resident rights training for 2025. A surveyor reviewed CNA #2’s employee file and found that the in-service/attendance record lacked evidence of the required annual training. CNA #2 was hired in February 2021, and the missing training was confirmed during an interview with the Director of Clinical Operations.
Failure to Accurately Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess, coordinate care with a physician, and document a resident’s pressure-related wound. A nursing admission/readmission evaluation completed on the day of admission in November 2025 identified a skin issue on the resident’s left buttock that was described as pressure related. Daily Skilled Note/Evaluation entries on 11/30/25 and 12/7/25 documented that the resident’s skin was not intact and that there was a pressure ulcer on the left buttock. However, multiple subsequent Daily Skilled Note/Evaluation entries dated between 12/2/25 and 1/1/25 stated that the resident’s skin was intact, and a skin check note on 1/5/26 at 11:02 a.m. documented that no skin issues were identified. On 1/5/25 at 2:06 p.m., a skin issue note documented that the resident had a stage 3 pressure ulcer/injury with full thickness skin loss. In an interview on 1/6/26, the Director of Nursing Services confirmed, in the presence of two surveyors, that the pressure ulcer had been present upon admission, was never thoroughly assessed, was not reported to a physician, and was not cared for appropriately.
Failure to Notify Physician and Care Plan for Existing Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician, obtain physician orders, and implement a care plan for a resident admitted with a pressure-related skin issue. On admission in November 2025, the Nursing Admission/Readmission Evaluation documented that the resident had a pressure-related skin issue on the left buttock. Subsequent Daily Skilled Notes/Evaluations dated 11/30/25 and 12/7/25 indicated that the resident was receiving daily skilled care for pressure ulcer care and rehab services, and that the skin was not intact with a pressure ulcer on the left buttock. Despite this, there is no documentation in the report that a physician was notified, that specific physician orders were obtained for this existing pressure ulcer, or that an individualized care plan addressing this pressure ulcer was implemented upon admission as required by facility policy. On 1/5/26, a wound care nursing note documented a new skin issue on the left sacrum, identified as a Stage 3 pressure ulcer with full-thickness skin loss that was acquired in-house. During an interview on 1/6/25, the Wound Care Nurse stated that a CNA first brought concerns about a wound on the resident’s buttocks to his attention on 1/5/26, and that this was the first time he had heard of this wound. The facility’s Pressure Injury Prevention Management Program policy requires that, based on the resident evaluation process, an individualized comprehensive care plan be implemented by the interdisciplinary team, including a preventive care plan upon admission and a care plan for any actual pressure injury identified on admission/readmission. The Director of Nursing Services confirmed the above information during an interview, supporting the finding that the facility did not follow its policy to ensure appropriate physician notification, orders, and care planning for the resident’s pressure ulcer present on admission.
Incomplete Documentation of JP Drain Monitoring in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with a physician’s order to monitor a Jackson Pratt (JP) drain every shift starting on 11/22/25. Review of the resident’s clinical record confirmed the standing order to monitor the JP drain each shift for prophylaxis. However, review of the Treatment Administration Record (TAR) for December showed missing documentation of the ordered JP drain monitoring on the 3 p.m. to 11 p.m. shift for 12/30/25, and on the 11 p.m. to 7 a.m. shifts for 12/1/25, 12/3/25, 12/10/25, 12/14/25, 12/15/25, 12/16/25, and 12/22/25. These gaps in the TAR indicate that the required monitoring was not documented as completed on multiple shifts. In an interview on 1/6/25 at 1:48 p.m. with the Director of Nursing Services and two surveyors present, the missing documentation findings were confirmed. The incomplete TAR entries for the JP drain monitoring demonstrate that the facility did not ensure the resident’s clinical record was complete and accurate in accordance with accepted professional standards, as required for safeguarding and maintaining resident-identifiable medical records.
Repeat Deficiencies in Wound Care Management and Clinical Record Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective quality assurance and performance improvement (QAPI/QAA) oversight of wound care and clinical record accuracy, resulting in repeat deficiencies. During a prior recertification survey, deficiencies were cited for quality of care related to wound care for two of three residents reviewed, and for incomplete and inaccurate clinical records for two of three residents reviewed for wound care. Despite having a written plan and a stated completion date, the facility’s quality assurance committee did not ensure that these issues were effectively corrected, as the same areas of noncompliance were identified again during a subsequent complaint survey. During the complaint survey, a resident was found to have had a pressure ulcer upon admission, with no physician orders for care and treatment of the wound documented in the clinical record, demonstrating a continued failure in quality of care for pressure ulcers. In addition, another resident’s clinical record lacked complete and accurate information related to wound care, showing that the facility did not maintain accurate, identifiable clinical records as previously cited. At the exit interview, the Administrator and DNS acknowledged that the facility’s prior plan of correction for these areas had not been effective, and that deficient practices persisted beyond the anticipated date of compliance.
Failure to Develop Baseline Care Plan for Resident With Pressure-Related Skin Issue
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included necessary instructions for wound care for one resident. The resident was admitted in November 2025, and the Nursing Admission/Readmission Evaluation completed on the day of admission documented a pressure-related skin issue on the left buttock. Despite this identified pressure-related skin issue, review of the resident’s medical record showed no evidence of a baseline care plan addressing this condition or providing the instructions needed to properly care for it. On 1/6/25 at 2:15 p.m., the Director of Nursing Services confirmed to surveyors that the above information was accurate. This deficiency centers on the absence of a required baseline care plan for a newly admitted resident with a documented pressure-related skin issue, as confirmed through record review and interview with facility leadership.
Failure to Develop Care Plans for Residents Requiring Wound Care
Penalty
Summary
The facility failed to develop and implement care plans for two residents who required wound care. One resident had a chronic abscess on the right lateral thigh, returned from the emergency room with new antibiotic orders for cellulitis, and required wound packing to remain in place for 48-72 hours. Despite these needs, there was no evidence of a care plan addressing the wound, including goals and interventions, as of the date reviewed. Another resident had a wound on the left foot and an unstageable pressure ulcer on the right foot, both requiring wound care, but similarly lacked a documented care plan with goals and interventions. These findings were confirmed through record review and interviews with the Director of Nursing and the Director of Clinical Operations.
Failure to Obtain and Document Physician Orders for Wound Care
Penalty
Summary
The facility failed to obtain and document physician orders for wound care for two residents with significant wounds. For one resident with a chronic right lateral thigh abscess, the clinical record showed that after returning from the emergency room with instructions for wound packing and antibiotics, there was no evidence of wound care orders or documentation of wound care provided from the date of return until nearly two weeks later. Nursing staff acknowledged having the ER discharge summary but were unable to locate it in the medical record, and could not provide documentation of wound care orders or provider instructions during this period, except for a single wound assessment. For another resident requiring negative pressure wound therapy (NPWT), a malfunction in the wound vac led to the wound being packed with VASHE-soaked gauze. Although nursing staff reported obtaining a verbal order from the provider for this alternative dressing, there was no documentation of such an order in the resident's medical record. These lapses resulted in the absence of required provider orders for wound care interventions as specified in the residents' care plans and clinical needs.
Incomplete Documentation of Wound Care in Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents who were receiving wound care. For one resident, the Treatment Administration Record (TAR) did not show evidence that wound vac dressings were changed as ordered on specific dates, despite physician orders specifying the frequency and timing of these changes. For another resident, the TAR lacked documentation that wound care for both the right heel and left foot was completed on several dates, even though there were clear orders for daily wound care and dressing changes. These deficiencies were identified through review of medical records and confirmed in discussion with the Director of Nursing and the Director of Clinical Operations.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of quality in medication administration for two residents. In the first instance, a registered nurse (RN) did not administer Miralax to a resident as per the physician's order, which specified that the medication should be given in the morning. The RN decided to delay the administration until the afternoon without the resident having refused the medication at the scheduled time. This deviation from the prescribed schedule was not based on the resident's immediate needs or preferences at the time of administration. In the second instance, another RN left a medication cup with a resident without observing the resident take the medication, which is against the facility's policy. Additionally, the RN documented a pain scale for the resident without first asking the resident about their pain level. The RN later corrected the documentation after realizing the error. These actions demonstrate a failure to follow the facility's medication pass policy and proper documentation procedures, potentially compromising the quality of care provided to the residents.
Failure to Maintain Accurate Controlled Substances Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, as evidenced by the lack of signatures from authorized personnel on the Shift Count pages of the Controlled Substances Book. This deficiency was observed across multiple units, including the Sebago Unit, Eagle Unit, Short Hall, Kitchen Hall, and Passport Unit, during the period from September 25, 2024, to December 3, 2024. The facility's policy requires that two licensed clinicians conduct a physical inventory of controlled medications at each shift change and document it on an audit record. However, the surveyor found that on several occasions, the licensed nursing staff either coming on duty or going off duty failed to sign the Shift Count page, indicating that the controlled substances count was not properly documented. Specific instances of non-compliance were noted, such as RN #2 and RN #1 failing to sign the shift count book upon accepting the narcotic keys, and LPN #1 pre-signing the nurse going off duty before the end of her shift. These actions were confirmed by the respective staff members during the surveyor's review. The Director of Nursing was informed of these concerns, highlighting a systemic issue in the facility's process for managing controlled substances, which could potentially lead to discrepancies in drug reconciliation.
Expired and Unsecured Medications Found in Facility
Penalty
Summary
The facility failed to remove expired medications from the supply available for use on the Sebago unit medication cart. During an observation, a registered nurse confirmed the presence of expired medications, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates of July, November, and October 2024, respectively. These expired medications were subsequently removed by the nurse. Additionally, on the Eagle unit, a medication cart was found unlocked and unattended in the hallway for approximately two minutes, with residents nearby. A surveyor intervened to alert a registered nurse about the unsecured cart. Both incidents were discussed with the Director of Nursing.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. On December 2, 2024, a surveyor noted two trays of meat in the walk-in refrigerator that were undated and unlabeled, along with seventeen ceiling tiles that were stained or dirty. A staff member, who has been with the facility for several years, confirmed that the ceiling had not been addressed during her tenure. On December 4, 2024, further observations revealed a moderate level of dirt on the inside lid of an ice machine in the Passport Unit kitchen, a small amount of dried debris on a food slicer, and a moderate amount of dried dirt and debris on a large mixer. These findings were confirmed with the Administrator.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several maintenance and cleanliness issues observed during a survey. On December 4, 2024, a surveyor noted a significant accumulation of dust and debris on top of all dryers in the laundry area, which was confirmed by the Director of Maintenance. Further environmental rounds with the Administrator, Director of Maintenance, and Director of Housekeeping revealed additional deficiencies: a closet door hinge in need of repair, a cable outlet protruding from the wall, stained ceilings in the Cafe Sun Room and entry, a red liquid stain on the air handling unit near the Nurses Station, four stained ceiling tiles in the Eagle Unit Dining Room, and dead bugs on light covers in the Sebago Unit hallway. These observations were confirmed with the Administrator.
Non-compliance with PRN Psychotropic Medication Order Limits
Penalty
Summary
The facility failed to ensure compliance with the regulation that limits as needed (PRN) psychotropic medication orders to 14 days. During a review of a resident's physician orders, a surveyor identified an order for Lorazepam, a psychotropic medication, prescribed at 0.5 mg by mouth every 24 hours as needed for anxiety. This order, dated November 18, 2024, was set for a duration of 3 months without a 14-day limit or stop date. Additionally, there was no provider documentation justifying the extension of the PRN order beyond the 14-day limit. This deficiency was noted during a surveyor's review on December 3, 2024, and discussed with the facility's Administrator.
Failure to Remove and Document Lidocaine Patch
Penalty
Summary
The facility failed to ensure accurate documentation of the Medication Administration Record (MAR) for a resident receiving a Lidocaine patch. A physician's order dated December 1, 2024, instructed nursing staff to apply a 5% Lidocaine patch to the affected area once daily for pain and to remove it nightly. However, on the morning of December 3, 2024, a surveyor observed a registered nurse administering a new Lidocaine patch to the resident's lower back without having removed the old patch from the previous day. The nurse confirmed that the old patch should have been removed the previous evening, indicating a lapse in following the physician's order and proper documentation in the MAR. This issue was discussed with the Director of Nursing and the Regional Director of Clinical Operations.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation on the Eagle unit, a registered nurse failed to perform proper hand hygiene between administering medications to multiple residents. The nurse prepared and administered medications to three residents consecutively without sanitizing her hands between each administration. This lapse in protocol was noted when the nurse discarded used medicine and drink cups and continued to handle medications for the next resident without using hand sanitizer. Upon intervention by the surveyor, the nurse acknowledged the oversight and mentioned the absence of hand sanitizer on the medication cart.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) at least every 12 months, as required. Specifically, two CNAs with employment durations exceeding one year did not receive their annual evaluations. CNA #1, hired on February 17, 2021, had an employee file that showed an annual review filled out and signed only by the Division Head, with no evidence of the employee's signature, and lacked any annual review since the date of hire. CNA #1 confirmed during a phone interview that they had not received an annual review since being hired. Similarly, CNA #2, hired on July 13, 2009, had no evidence of an annual review in their employee file since their date of hire. CNA #2 also confirmed in an interview that they had not received an annual review since being hired. This information was confirmed with the Regional Director of Operations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
