Caribou Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Caribou, Maine.
- Location
- 10 Bernadette St, Caribou, Maine 04736
- CMS Provider Number
- 205117
- Inspections on file
- 21
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Caribou Rehab And Nursing Center during CMS and state inspections, most recent first.
Three residents experienced avoidable falls with two sustaining major injuries due to staff failing to provide required assistance during bed mobility, improper use of a mechanical lift in a cramped room, and omission of wheelchair footrests during transport. These incidents occurred despite care plans and facility policies outlining necessary safety measures.
Staff failed to secure medication and treatment carts, leaving them unlocked and unattended in areas accessible to residents, including those with cognitive impairment. On multiple occasions, carts containing medications, syringes, and other medical supplies were left without proper locking mechanisms, and a resident was observed approaching and touching an unlocked medication cart while staff were not present.
A review of the facility's water management program revealed it lacked documented control measures, monitoring protocols, and testing procedures to prevent the growth and spread of legionella and other water-borne pathogens. This deficiency was confirmed during an interview with maintenance staff.
A staff member was seen pulling a resident backwards in a wheelchair, causing the resident's feet to drag on the floor, and on another occasion, a staff member stood while assisting a resident to eat. Both incidents were confirmed by facility staff and did not uphold resident dignity during transportation and meal assistance.
A resident was observed keeping and self-applying a medicated antifungal powder at bedside without evidence that the IDTM had assessed and determined clinical appropriateness for self-administration, despite a physician's order and an LPN's evaluation.
A resident's advance directive for DNR/DNI was not accurately reflected in the EHR, which incorrectly listed the code status as full code, while the paper record indicated DNR/DNI. This discrepancy was confirmed during a review by a surveyor and the ADON.
A resident developed a new stage III pressure ulcer on the posterior left foot, but the care plan was not updated to reflect this change or the necessary skin care interventions. Review with the ADON confirmed the care plan did not address the resident's current wound status or treatment needs.
A resident did not receive insulin according to the prescribed sliding scale, with staff administering incorrect doses and failing to notify the physician when blood sugar levels exceeded the ordered threshold. Documentation did not show that the physician was contacted or that appropriate orders were obtained.
Surveyors identified multiple instances of improper food storage and handling, including open and undated food items in the freezer, exposed raw meat, expired milk, undated juice containers, and moldy raspberries in the refrigerator. These deficiencies were confirmed by dietary and nursing staff during the survey.
A resident who previously received PCV13 and PPV23 was not offered the updated PCV20 vaccine as recommended by the CDC. Review of clinical records and staff interviews confirmed the absence of documentation or evidence that the updated pneumococcal vaccine was offered.
A resident with dementia, identified as an elopement risk and wearing a wander guard, exited the facility through an unlocked and non-alarmed door. The wander guard did not activate, and the resident remained outside for over thirty minutes before being found by staff after a visitor reported the incident. Staff interviews and video footage confirmed the failure of both door security and monitoring procedures.
Surveyors found that the facility failed to maintain clean oxygen concentrator filters for several residents over a three-day period. Despite a weekly cleaning task assigned to the Charge Nurse, the filters remained heavily soiled with dust and debris. Interviews with staff, including a RN and the DON, confirmed the issue, highlighting a lapse in maintaining respiratory equipment cleanliness.
Expired medications were found in the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. Observations revealed expired Prochlorperazine, Premarin, Acetaminophen, Hydrocodone, Bisacodyl, saline nose spray, and Loratadine, which were available for use despite being past their expiration dates. These findings were confirmed by RNs during the survey.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over several days, surveyors observed that only gloves were used as PPE, with no signage or documentation of EBP. Interviews revealed that staff were unaware of EBP protocols, and residents reported inadequate protective measures during catheter care.
A facility failed to transmit a resident's quarterly MDS to the State MDS database within the required timeframe. The MDS, completed in mid-May, was due by the end of May but was not submitted until late June, 26 days late. The MDS Coordinator was unaware of the delay until informed by a surveyor.
The facility failed to provide annual Infection Control training for a CNA, as required by their program standards. The CNA's last documented training was in December 2022, and the required training for 2023 was not completed until June 2024. This deficiency was confirmed through employee file reviews and staff interviews.
A resident requiring a two-person assist transfer was improperly transferred by a CNA with the help of a non-family member visitor, resulting in a fracture. The CNA was aware of the transfer requirements but proceeded due to the resident's insistence and the absence of another staff member.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from accident hazards and provided with adequate supervision and assistance devices to prevent accidents, resulting in three avoidable falls, two of which caused major injuries. In one case, a resident with hemiplegia and a history of cerebral infarction required extensive assistance for bed mobility and personal care. During peri-care, a CNA turned away from the resident to dispose of a soiled brief, leaving the resident unattended. The resident, unable to control movement due to hemiplegia, rolled out of bed and sustained a displaced fracture of the right femoral neck and a laceration to the forehead. In another incident, a resident dependent on a mechanical lift (Hoyer) for transfers due to multiple sclerosis was being transferred by two CNAs. The staff failed to open the legs of the Hoyer lift because of space constraints in the resident's room, which was too small to allow proper maneuvering. As a result, the resident slipped out of the sling and fell to the floor, sustaining an abrasion to the upper back. The care plan for this resident specified total dependence on two staff for Hoyer transfers and highlighted the need for adequate space and proper use of equipment. A third resident suffered a fall with major injury during wheelchair transport when a CNA failed to attach footrests to the wheelchair. The resident, who was unable to lift their legs, fell forward from the wheelchair and sustained a nasal bone fracture. Facility policy and posted signage required the use of footrests during all wheelchair transports to prevent injury, but this protocol was not followed, directly leading to the fall.
Unsecured Medication and Treatment Carts Accessible to Residents
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications and medical equipment on multiple occasions. On one occasion, a CNA-M left an unlocked and unattended medication cart in the dining/activity area of a locked Special Care Unit for residents with advanced cognitive impairment. While the CNA-M was administering medications to a resident seated away from the cart, another resident in a wheelchair approached the cart, placed a hand on the lock and a drawer, and then moved away. The CNA-M admitted to not keeping the cart keys with her and confirmed the cart was left unlocked and unattended, a fact also verified by the ADON. On two separate days, a treatment cart containing syringes, lancets, medicated creams, ointments, and powders was observed left unattended and unlocked in a resident hallway. Multiple residents and staff passed by the cart, and the Charge Nurse confirmed the cart did not have a lock. On another occasion, the same type of cart was secured only with a swivel snap hook, not a locking device, and was accessible to residents. The DON acknowledged that the cart required a lock to secure the drawers, and surveyors confirmed the lack of proper security for the treatment cart and its contents.
Deficient Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive water management program aimed at preventing the growth and spread of legionella and other water-borne pathogens. During a review of the facility's Water Management Program policy and related documentation, it was found that the program did not include evidence of specific control measures to prevent the growth of opportunistic waterborne pathogens, nor did it outline how these measures would be monitored. Additionally, there was no documentation of testing protocols for these control measures, including details on monitoring frequency, acceptable control limits, required interventions if limits were exceeded, or criteria for when water testing for legionella should occur. This deficiency was confirmed during an interview with the facility's maintenance staff.
Failure to Maintain Resident Dignity During Transportation and Meal Services
Penalty
Summary
On one occasion, a staff member was observed pulling a resident backwards in their wheelchair in a hallway, resulting in the resident's feet dragging on the floor. This incident was confirmed by the Assistant Director of Nursing. On a separate occasion during lunch service, a staff member was seen standing while assisting a resident to eat, which was confirmed by Activities staff present at the time. These actions did not maintain the dignity and respect of the residents during transportation and meal services.
Failure to Complete IDTM Assessment for Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team meeting (IDTM) group failed to determine if it was clinically appropriate for a resident to self-administer and keep a medicated antifungal powder (Desenex) at bedside. Observation revealed the powder on the resident's nightstand, and the resident reported self-applying the powder as needed. Although there was a physician's order allowing the resident to self-administer the medication and keep it at bedside, and an LPN had evaluated the resident for safe application, there was no evidence that the IDTM had completed the required assessment to determine clinical appropriateness for self-administration, as required by facility policy.
Inaccurate Documentation of Advance Directive in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive regarding cardiopulmonary resuscitation (code status) was accurately documented in the clinical record. Upon review, the resident's electronic health record (EHR) listed the code status as FULL CODE, while the paper health record, specifically the hospital discharge summary, indicated DNR/DNI (do not resuscitate/do not intubate). During a joint review of the records by a surveyor and the Assistant Director of Nursing (ADON), it was confirmed that the EHR should have reflected DNR/DNI, not full code. The discrepancy between the electronic and paper records resulted in the resident's wishes regarding resuscitation not being clearly and accurately documented in the EHR.
Failure to Update Care Plan for New Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident after the discovery of a new stage III pressure ulcer on the posterior of the left foot. Record review showed that the resident's care plan had last been revised for skin alteration on 6/9/25, but there was no evidence that it was updated to address the new pressure ulcer and the associated skin care needs. During an interview, the Assistant Director of Nursing confirmed that the care plan did not reflect the resident's current wound status or the care required for treatment. This deficiency was identified through clinical record review and staff interview, focusing on the lack of timely care plan updates following a significant change in the resident's condition.
Failure to Follow Physician Orders for Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for the administration of sliding scale insulin for one resident. The resident had a physician order specifying the amount of insulin to be administered based on finger stick blood sugar (FSBS) results, with instructions to call the physician if the FSBS exceeded a certain threshold. On one occasion, the resident's FSBS was recorded as 563, but staff administered 15 units of insulin without contacting the physician as required by the order. On another occasion, the resident's FSBS was 288, but only 3 units of insulin were administered instead of the 6 units specified in the order. These discrepancies were confirmed through record review and interview with the Assistant Director of Nursing. The clinical record did not contain evidence that the physician was notified or that a new order was obtained for insulin administration when the FSBS exceeded the ordered range, and the insulin doses given did not always match the sliding scale instructions.
Improper Food Storage and Handling Practices Observed
Penalty
Summary
Surveyors observed multiple instances of improper food storage, preparation, and service that did not meet professional standards for food safety. On two separate days, the walk-in freezer contained several open and exposed food items, including veggie lasagna, pasta with meat sauce showing freezer burn, pizza with partially peeled plastic wrap, raw Philly chicken slices, and various packages of vegetables and meats that were open and undated. Additionally, in the dayroom refrigerator, there was a half gallon of milk past its expiration date, several open and undated containers of juices, and a pint of raspberries that were shriveled and moldy. These conditions were confirmed by the Dietary Supervisor and a CNA during the survey observations. No information about specific residents or their medical conditions was provided in relation to the deficiency.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the updated pneumococcal vaccination (PCV20) to one resident, despite CDC recommendations indicating that a dose should be considered at least five years after the last pneumococcal vaccine. Record review showed that the resident had previously received PCV13 in 2015 and PPV23 in 2017, but there was no documentation that the updated vaccine was offered. During interviews, the Assistant Director of Nursing confirmed that there was no evidence of the PCV20 being offered, and the Director of Nursing/Infection Preventionist stated that the facility follows CDC recommendations for pneumococcal vaccinations.
Failure to Monitor Exit Doors and Alarm Systems Resulting in Resident Elopement
Penalty
Summary
A resident with a diagnosis of dementia, identified as an elopement risk and equipped with a wander guard alert device, was able to exit the facility unnoticed. The resident left through an unlocked and non-alarmed door, and the wander guard did not activate an alarm or lock the door as intended. The resident was outside for approximately thirty-three minutes before being found by staff, after a visitor alerted them to the resident's presence outside in a wheelchair near the gazebo across the employee parking lot. Facility records and video surveillance confirmed that the resident exited through the D Wing door without staff awareness. Interviews with staff, including an LPN and the DON, corroborated that the alarm system failed to function and that the door was not secured. The resident was assessed after being returned to the facility and was found to have no lasting effects from the incident. The deficiency resulted from the lack of monitoring and failure of safety devices intended to prevent elopement for residents at risk.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice by not ensuring that the oxygen concentrator filters for several residents were clean. Over the course of three days, surveyors observed that the oxygen concentrator filters for multiple residents, including Resident #33, Resident #13, Resident #35, Resident #24, and Resident #48, were heavily soiled with dust and debris. These observations were made repeatedly, indicating a persistent issue with the cleanliness of the respiratory equipment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that cleaning the filters on the oxygen concentrators was supposed to be a weekly task assigned to the Charge Nurse. Despite this, the filters remained dusty, as verified by both the surveyor and the Director of Nursing during their observations. This indicates a failure in the facility's process to maintain the respiratory equipment in a clean and safe condition for the residents.
Expired Medications Found in Medication Storage and Cart
Penalty
Summary
The facility failed to ensure that expired medications were removed from the available supply in both the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. During an observation on June 24, 2024, the surveyor found several expired medications in the C-D Wing Medication Storage Room, including Prochlorperazine suppositories, Premarin vaginal cream, Acetaminophen suppositories, and a blister pack of Hydrocodone and Acetaminophen. These medications were available for use despite their expiration dates having passed, with some dating back to February 2024. Further inspection of the B-Wing Medication Storage Room revealed additional expired medications, such as Bisacodyl suppositories, Deep Sea Premium Saline nose spray, Acetaminophen suppositories, Pain Relief Acetaminophen/Aspirin/Diphenhydramine, and Loratadine. The B-Wing Medication Cart also contained a bottle of Loratadine that had expired in December 2023. These findings were confirmed by Registered Nurses present during the observations, indicating a lapse in the facility's medication management protocols.
Inadequate Infection Control for Foley Catheter Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over the course of three days, surveyors observed that there was no personal protective equipment (PPE) other than gloves, nor was there signage notifying of EBP for residents with urinary Foley catheters. This was noted for multiple residents, including Resident #48 and Resident #10. Additionally, there was no documentation available pertaining to the use of EBP, and the Director of Nursing confirmed that the facility did not have a plan in place for the use of EBP for residents with urinary Foley catheters. Interviews with staff and residents further highlighted the deficiency. Resident #48 reported that staff emptied the urinary Foley catheter bag without wearing a protective gown. A registered nurse admitted to not knowing what EBP were and stated that only gloves were worn during urinary Foley catheter care, with sterile equipment used only during insertion. These observations and interviews indicate a lack of adherence to infection control protocols, specifically regarding the use of EBP for residents with urinary Foley catheters.
Delayed Transmission of MDS to State Database
Penalty
Summary
The facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within the required 14 days of completion for a resident. The quarterly MDS for the resident, with a target date of May 16, 2024, was completed on May 17, 2024. This assessment was supposed to be submitted by May 31, 2024, but was not transmitted until June 26, 2024, resulting in a delay of 26 days. During an interview on June 26, 2024, the MDS Coordinator admitted to just submitting the resident's quarterly MDS and expressed uncertainty about why it was not transmitted earlier. The coordinator was unaware of the transmission failure until questioned by the surveyor.
Deficiency in Annual Infection Control Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included annual training on the Infection Control program standards, policies, and procedures for one of the five Certified Nursing Assistants (CNA) reviewed. Specifically, CNA1's employee file and Inservice record showed that the last documented Combined Inservice, which included training on the Infection Control program standards, was completed on December 6, 2022. During an interview with a surveyor, the Clinical Assistant confirmed the absence of evidence that CNA1 completed the required training in December 2023. The Staff Educator later stated that CNA1 completed the Infection Control training on June 25, 2024, but acknowledged that it should have been completed in 2023, which it was not. The surveyor confirmed these findings during the interviews.
Failure to Provide Appropriate Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident who required a two-person assist transfer received the appropriate assistance. On 4/23/24, a CNA transferred a resident with the help of a non-family member visitor instead of another staff member. The resident, who was identified as needing a two-person assist transfer, later complained of pain in the right knee to right ankle area. An X-ray revealed an acute to subacute non-displaced fracture of the lower tibial shaft, complicated by severe osteoporosis. The CNA admitted to the surveyor that he was aware of the resident's transfer requirements but proceeded with the transfer due to the resident's insistence and the absence of his teammate who was at lunch. Interviews with other staff members, including another CNA and an LPN, confirmed that the resident was indeed a two-person assist transfer. The Physical Therapist also noted that the resident had been evaluated as needing a two-person assist transfer at a previous facility. The incident was reported to the Director of Nursing, and the facility's investigation confirmed the deficiency. The resident was subsequently assessed, and an X-ray was ordered, revealing the fracture. The resident's transfer method was changed to a Hoyer lift following the incident.
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.
