Clover Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Maine.
- Location
- 440 Minot Ave, Auburn, Maine 04210
- CMS Provider Number
- 205063
- Inspections on file
- 22
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Clover Health Care during CMS and state inspections, most recent first.
The facility failed to ensure its infection prevention and control program included clearly visible entrance signage alerting visitors to an active coronavirus outbreak. The DON informed surveyors of multiple active coronavirus cases on two units and instructed them to wear masks, but when the survey team entered earlier there was no clearly visible outbreak notice at the entrance. A sign requiring all visitors to wear masks was later shown to surveyors on the top of the reception desk, but it was not readily visible upon entry.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not provide required behavioral health and trauma-informed care training to new and existing staff, despite a significant portion of residents having psychiatric or mood conditions. Staff files lacked documentation of this training, and facility leadership confirmed the lapse was due to staff turnover and issues with the learning platform. The facility's behavioral health policy was also inaccessible during the review.
A resident with MS, muscle weakness, and a Stage III pressure ulcer, who required total assistance by two staff for transfers and repositioning, experienced a fall with injury after a CNA, unfamiliar with the care plan and lacking proper information, attempted to reposition the resident alone and left the bed in a raised position. The CNA did not review the care plan or Kardex and relied on inconsistent verbal instructions, resulting in the resident being left unsafely and subsequently falling.
Surveyors found that hot water temperatures in several resident rooms exceeded 120°F, with no consistent monitoring or documentation by staff. Hazardous cleaning chemicals were left unsecured in a resident's room, and a resident assessed as needing supervision and a protective apron while smoking was observed without these safety measures. Staff interviews confirmed lapses in awareness and adherence to safety protocols.
The facility did not provide or document the provision of written information about the right to formulate an advance directive to multiple residents or their representatives. Record reviews and staff interviews confirmed that neither information nor assistance regarding advance directives was offered, and staff lacked understanding of what advance directives include beyond CPR.
Surveyors found that the facility did not provide adequate housekeeping and maintenance services, resulting in uncleanable surfaces, chipped and missing paint, stained ceiling tiles, and dirty equipment across all units. These deficiencies were confirmed by staff and affected both common areas and resident rooms.
The facility did not ensure that care plans were reviewed and revised by an IDT within 7 days after MDS assessments for several residents. Record reviews and staff interviews confirmed that required IDT meetings were either delayed or not documented, resulting in noncompliance with care planning regulations.
Annual performance evaluations were not completed for five CNAs who were all hired on the same date, with no documentation available to confirm evaluations for the required period. Administration reported that all staff were considered new hires after a change in ownership, but no performance reviews had been conducted as required.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with staff failing to wear required facial hair protection, unclean surfaces and equipment, undated food items, and an improperly installed ice machine lacking an air gap. Additionally, required temperature monitoring and documentation for dishwashing and refrigeration were incomplete or missing for several months, with dish machine rinse temperatures often below the required level for sanitization. The Food Service Director confirmed these findings.
The facility's QA Committee failed to ensure that corrective actions for previously cited deficiencies were effective, resulting in repeat citations for inadequate assessment and monitoring of a resident after an unwitnessed fall, and for not maintaining kitchen cleanliness or proper food labeling and dating.
The facility did not ensure that all staff received required training on the Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by missing documentation for several certified nurse assistants. This training was mandated by facility policy to be included in both orientation and annual education, but records showed it was not completed or documented for the staff reviewed.
The facility did not follow physician orders for urine collection prior to surgery for a resident with complex medical needs, resulting in the cancellation of a scheduled procedure due to incomplete lab paperwork. Additionally, the facility failed to document or perform required neurological and vital sign monitoring after unwitnessed falls for another resident with dementia and mobility issues.
A resident's clinical records were found to be incomplete, with missing documentation for multiple ADL care tasks such as bathing, elimination, oral hygiene, toileting, scheduled toileting programs, and eating across several shifts. These gaps in recordkeeping were identified during a review and confirmed by staff.
Six residents were served their evening meal on trays in the dining room, which was confirmed by the Regional Director of Operations as not being homelike, dignified, or respectful.
A resident with a mental health diagnosis was admitted under a short-term PASRR exemption, but when their stay extended beyond the initial period, the facility did not refer them for the required PASRR Level II evaluation. Review of records confirmed the absence of this referral after the resident's status changed to long-term.
A resident admitted with a history of falls, mobility issues, and muscle weakness required significant assistance with ADLs, but the facility did not develop or implement a baseline care plan with appropriate goals and interventions within 48 hours of admission. Staff interviews and care plan review confirmed the omission.
Two residents did not have complete care plans addressing their specific needs. One resident, assessed as safe to smoke only with supervision, did not have this requirement documented in their care plan. Another resident using a CPAP device lacked a care plan for its use. These deficiencies were confirmed by facility leadership.
Surveyors found that two residents did not receive proper infection control for their respiratory care equipment. A nebulizer mask and tubing were left unbagged on a bedside table, and a CPAP machine lacked documentation of cleaning or maintenance.
A resident with end-stage renal disease and an AV fistula did not receive required monitoring and assessments of the dialysis access site, as well as pre- and post-dialysis evaluations, according to facility policy. Interviews with the resident, an LPN, and the DON confirmed that staff did not routinely check the fistula or perform necessary assessments before or after dialysis treatments, and documentation of these actions was absent from the clinical record.
Food and trash were found on the ground outside the back kitchen door, and a dumpster was left open with trash exposed and additional trash scattered around it. These unsanitary conditions were observed and confirmed by the FSD.
A nurse provided high-contact care to a resident on Enhanced Barrier Precautions (EBP) without wearing the required PPE, including gown, gloves, or face mask, after re-entering the room to assist with positioning the resident's leg during intravenous medication administration.
Surveyors found that medications were improperly stored in a refrigerator with significant ice buildup, and a resident was self-administering Tylenol without a physician's order or completed safety assessment by the IDT, as confirmed by an LPN and the DON.
The facility failed to maintain adequate maintenance and housekeeping services, leading to unsanitary conditions in two units. Surveyors observed heavily soiled sit-to-stand patient lifts and a commode lid on the floor in the [NAME] Unit, along with broken window shades in several resident rooms. These issues were confirmed by an RN and a CNA and discussed with the Administrator.
The facility failed to maintain sufficient staffing levels, impacting resident care. A resident reported needing assistance with ambulation and toileting, but due to staff shortages, they often had to use a bedpan. Staff interviews confirmed that the facility was frequently understaffed, leading to incomplete care tasks such as baths and grooming. The facility did not meet state staffing requirements for 19 out of 53 days reviewed, and the administrator acknowledged the issue.
The facility failed to maintain proper infection control practices, as observed on two units. A CNA was seen carrying soiled linen unbagged, contrary to policy, and another CNA carried clean linen against her body, placing it in a soiled hamper. These actions were confirmed as infection control issues by RN #1 and the Administrator.
A facility maintenance staff member entered a resident's room without knocking or announcing his presence, which was identified as a dignity issue. The staff member acknowledged the oversight, and the facility's Administrator confirmed the breach of protocol.
The facility failed to ensure a safe environment by not addressing a trip hazard in the [NAME] unit. Surveyors observed a missing section of linoleum flooring with edges coming up, creating a potential trip hazard. A CNA confirmed the hazard and noted the presence of ambulatory residents. The Administrator also acknowledged the hazard.
The facility failed to maintain proper food temperatures and assess residents' dietary needs, leading to cold, unpalatable meals. Interviews with residents and staff highlighted consistent issues with food being served cold, requiring reheating by nursing staff. The kitchen supervisor confirmed that food temperatures were not monitored on the units, and regular meals were served without proper dietary assessments.
Failure to Post Clearly Visible Signage for Active Coronavirus Outbreak
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring clearly visible signage at the entrance to alert visitors of an active respiratory (coronavirus) outbreak. On the survey date at 7:45 AM, the DON informed surveyors that there was an active coronavirus outbreak, with thirteen active cases on one unit and one active case on another unit, and instructed the surveyors to wear masks. The surveyors noted that when they entered the facility earlier that morning at 7:00 AM, there was no clearly visible signage at the entrance alerting visitors to the outbreak. When questioned, the DON directed the surveyor to a sign taped to the top of the reception desk stating that all visitors must wear masks, but observation confirmed that this sign was not readily visible upon entry into the facility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective behavioral health training program for both new and existing staff, as required by its own facility assessment and policy. Specifically, a review of six Certified Nursing Assistants' (CNAs) education files revealed no evidence that behavioral health or trauma-informed care training had been provided since February. The facility's resident profile indicates that 35-65% of its population is admitted with psychiatric or mood conditions, necessitating specialized care and interventions. Despite this, staff files for CNAs hired between March and July showed no documentation of required behavioral health training. Interviews with the Interim Director of Nursing, Administrator, and Director of Nursing confirmed the absence of this training, attributing it to the departure of the previous Social Worker and a lapse in the facility's learning platform. Further review found that the facility's behavioral health services policy, which outlines the need for staff to recognize psychological distress, implement and monitor care plan interventions, and follow protocols for mental disorders and trauma, was not accessible due to a transition between policy portals. The policy statement provided lacked an initial or revision date, and there was no evidence that staff were qualified or competent in behavioral health and trauma-informed care as required. The deficiency was identified through record reviews, staff interviews, and examination of facility policies.
Failure to Implement and Communicate Resident Care Plan Leads to Fall with Injury
Penalty
Summary
The facility failed to implement a resident's care plan for a resident with multiple complex medical needs, including Multiple Sclerosis, muscle weakness, and a Stage III pressure ulcer. The resident was dependent on staff for transfers, bed mobility, and personal hygiene, requiring total assistance by two staff members and the use of a mechanical lift. Despite these documented needs, a CNA assigned as a float was not adequately informed about the resident's care requirements and did not review the care plan or Kardex. The CNA relied on verbal instructions from other CNAs and was unaware of the resident's diagnosis or specific care needs. On the day of the incident, the CNA turned the resident alone, left the resident positioned on their side, and exited the room to get a nurse, leaving the bed in a raised position. Upon returning, the resident was found on the floor, having fallen from the bed. Interviews revealed that the CNA had never accessed the care plan or Kardex and believed only nurses had access to these documents. There was inconsistency in the information provided to the CNA by nursing staff, and the CNA did not have a clear understanding of the resident's needs or the proper procedures for safe repositioning and transfer. The administrator acknowledged that staff were not following care plans, which directly contributed to the resident's fall and injury.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision within the facility. On several units, hot water temperatures accessible to residents were found to be above the facility's policy limit of 120 degrees Fahrenheit, with readings as high as 131.1 degrees. Staff interviews revealed that water temperatures were not being regularly monitored or documented, and the Director of Plant Operations had not calibrated his thermometer or maintained consistent records. The last documented temperature checks were from several months prior, and the facility was unaware of the ongoing issue until informed by surveyors. Staff also reported experiencing excessively hot water but did not report it to management. Additionally, a surveyor observed an unsecured container of PDI Sani-Cloth Bleach Germicidal Disposable Wipes left in a resident's room, making hazardous chemicals accessible to residents. The Facility Administrator confirmed that such chemicals should not be available for resident use and removed the item after being notified by the surveyor. The facility also failed to provide required supervision and safety equipment for a resident assessed as needing assistance while smoking. The resident was observed smoking outside without a protective apron and with only intermittent staff supervision, despite assessments indicating the need for both. Interviews with staff confirmed that the resident often smoked alone and that staff were unaware of the requirement for a protective apron during smoking activities.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide or document the provision of written information regarding the right to formulate an advance directive to residents and/or their representatives. Record reviews for 13 out of 14 residents revealed no evidence that such information was offered, reviewed, or provided at the time of admission or thereafter. This deficiency was confirmed through interviews with the Clinical Reimbursement Manager and the Social Services Assistant, both of whom acknowledged the absence of documentation and the lack of discussion or provision of advance directive information. The Social Services Assistant further stated she did not know what an advance directive includes beyond cardiopulmonary resuscitation (CPR). The affected residents were admitted over a span of several years, and both electronic and paper medical records were reviewed for evidence of compliance. In each case, there was no documentation that residents or their representatives were asked to provide a copy of their advance directives, nor were they given information or assistance to formulate one if they did not have it. The deficiency was identified through both record review and staff interviews, with staff confirming the lack of process and understanding regarding advance directives.
Failure to Maintain Sanitary and Homelike Environment Across All Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all four units during two separate facility tours. Specific deficiencies included uncleanable surfaces due to ripped duct tape on laundry carts, chipped and missing paint on floors, heaters, and door frames, as well as missing lens covers on bathroom lights. Additional findings included food debris and dirt on patient lifts, marred and stained walls and doors, and unbagged or dirty equipment such as bedpans and plungers left in resident rooms and bathrooms. Several ceiling tiles were noted to be stained, cracked, or broken, and some furniture and equipment had surfaces that were worn, ripped, or otherwise uncleanable. These observations were confirmed through interviews with facility staff, including the Food Service Director, Administrator, Director of Plant Operations, Assistant Director of Plant Operations, Housekeeping Supervisor, and Regional Director of Operations. The deficiencies were present in both common areas and resident rooms, affecting the overall sanitary and orderly condition of the environment. No specific residents' medical histories or conditions were mentioned in relation to the deficiencies, but the findings were consistent across multiple units and areas within the facility.
Failure to Conduct Timely IDT Care Plan Reviews After MDS Assessments
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT) within 7 days following the completion of each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for five out of seven residents reviewed, there was no evidence that an IDT meeting occurred within the required timeframe after the most recent MDS assessments. The clinical records for these residents showed that the last IDT meetings were held outside the 7-day window or were missing entirely following the assessments. Interviews with facility staff, including the Social Service Assistant and the Area Manager of Clinical Reimbursement, confirmed that the required IDT meetings did not occur within the mandated period after MDS completion. The deficiency was identified through both record review and staff interviews, which substantiated that the care planning process was not conducted in accordance with regulatory requirements for timely interdisciplinary review and revision.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five sampled Certified Nursing Assistants (CNAs) who were all hired on the same date. Documentation confirming the completion of annual performance evaluations for the year following their hire was not available for any of these employees. During an interview, the Administrator and Regional Director of Operations explained that when the previous administration sold the company, all employee records were taken, and all staff were considered new hires as of the same date. Despite this, none of the required performance reviews for the relevant period had been completed at the time of the surveyor's review.
Multiple Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to food safety and sanitation. During a kitchen tour, it was observed that two kitchen staff members with facial hair were not wearing required facial hair protectors. The kitchen environment was found to be unclean, with six ceiling tiles stained, a fan in the dish room covered in dust, seven ceiling vents dusty and two of them rusted, and 16 ceiling tiles around vents with significant dust buildup. The wall above the reach-in freezer and refrigerator was heavily soiled with dust, and the dry storage room floor had chipped or missing paint, with trash and debris present throughout the room and under shelving. Additionally, a package of whipped topping in the reach-in refrigerator was not dated as required by manufacturer instructions, and the ice machine lacked a proper air gap, violating state plumbing code and federal regulations intended to prevent contamination. Further review of facility policies revealed that dish machine temperatures were to be monitored and recorded at each meal, and refrigerator and freezer temperatures were to be logged twice daily. However, documentation for both the dish machine and refrigeration units was incomplete or missing for several months. Specifically, there were numerous days with missing or low rinse temperatures for the dish machine, which were confirmed to be below the required 180 degrees Fahrenheit for effective sanitization. Temperature logs for various refrigerators and freezers, including those in the kitchen and on units, were also missing for multiple days across several months. The Food Service Director confirmed the findings of missing documentation and inadequate temperature monitoring. The lack of proper installation of the ice machine, failure to date food items, and insufficient cleaning and maintenance of kitchen surfaces and equipment contributed to the facility's failure to maintain a clean and sanitary food service environment as required by professional standards and regulatory codes. No widespread outbreak of illness was reported during the period in question.
Repeat Deficiencies in Resident Monitoring and Kitchen Sanitation
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. Specifically, the same deficiencies—F684 and F812—were cited again during a follow-up survey. F684 was cited due to the facility's failure to adequately assess and monitor a resident after an unwitnessed fall. F812 was cited for the facility's failure to maintain the kitchen in a clean and sanitary manner and to ensure that foods were properly labeled and dated. These deficiencies were confirmed through record review and interviews, and the findings were discussed with the Executive Director and interim DON during the exit conference.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to all staff, as required by its own policy. Record reviews showed that five certified nurse assistants did not have evidence of receiving QAPI training, which should have included education on QAPI principles, staff roles, communication with the program, and participation in performance improvement projects. The facility's policy specified that all staff, including contracted staff, must be educated on QAPI during orientation and annually, but this requirement was not met for the employees reviewed. The Administrator and Regional Director of Operations confirmed the lack of documentation for this mandatory training during an interview with the surveyor.
Failure to Follow Physician Orders and Inadequate Post-Fall Monitoring
Penalty
Summary
The facility failed to follow physician orders for urine collection for a resident with multiple complex medical conditions, including Multiple Sclerosis and an indwelling urinary catheter. The Family Nurse Practitioner at a urology center ordered a clean catch urine collection for urinalysis and culture a week prior to a scheduled surgery. Although the specimen was collected and sent to the lab, the accompanying paperwork was not completed by facility staff, resulting in the lab being unable to process the specimen. This failure led to the cancellation of the resident's scheduled surgery, as the preoperative requirements were not met. Additionally, the facility did not adequately assess and monitor another resident after unwitnessed falls. Facility policy required neurological and vital sign monitoring at specific intervals following an unwitnessed fall. However, review of the clinical record for a resident with dementia and mobility difficulties showed no evidence that neurological or vital sign monitoring was completed or documented after two separate unwitnessed falls. Interviews with staff confirmed that the required monitoring was not performed or recorded in the resident's records.
Incomplete Clinical Documentation for ADL Care
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as required by accepted professional standards. Record review revealed multiple instances of missing documentation for activities of daily living (ADL) care, including bathing/showering, elimination (urinary and bowel), oral hygiene, toileting hygiene, scheduled toileting programs, and eating. These omissions occurred across both day and night shifts on various dates. The lack of documentation was identified during a review of the resident's medical record and was confirmed through interview with facility staff.
Failure to Provide Homelike and Dignified Meal Service
Penalty
Summary
During the evening meal on one of the units, six residents were observed eating their dinner in the dining room with their meals served on trays. This method of meal service was noted to be neither homelike nor respectful, failing to promote the residents' dignity. The Regional Director of Operations confirmed during observation and interview that serving meals on trays in this manner did not support a homelike environment or demonstrate dignity and respect for the residents.
Failure to Refer Resident for PASRR Level II Evaluation After Exemption Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a specialized mental health diagnosis, specifically Post-Traumatic Stress Disorder, who was initially admitted under a 30-day convalescence categorical exemption, was properly referred for a PASRR Level II evaluation after their stay extended beyond the expected short-term period. Clinical record review showed that while the initial PASRR Level I was completed and the exemption applied, there was no evidence that the required referral to the State Mental Health Authority was made once the resident's status changed to long-term. This lapse was confirmed during an interview with the Area Manager of Clinical Reimbursement.
Failure to Develop Baseline Care Plan for ADLs Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was recently admitted with repeated falls, difficulty walking, muscle weakness, and a need for assistance with personal care. The admission Minimum Data Set indicated the resident required substantial to maximal assistance with activities of daily living (ADLs). However, review of the care plan initiated on 4/2/25 showed it lacked documented goals and interventions for ADLs. During interviews, a CNA confirmed the resident needed help with toileting and ambulation, and the DON acknowledged that the care plan did not address these needs.
Failure to Develop Comprehensive Care Plans for Smoking and Respiratory Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. One resident, admitted in May 2018, was assessed as safe to smoke with supervision according to a Smoking Safety Screening completed in November 2024; however, the resident's care plan did not include any documentation of the need for supervised smoking. Another resident, admitted in March 2025, had physician orders for the use of a Continuous Positive Airway Pressure (CPAP) device since mid-March 2025, but there was no evidence of a care plan addressing CPAP usage in the medical record. These omissions were confirmed with facility leadership during the survey.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary environment for respiratory care equipment for two residents. For one resident, a nebulizer mask and tubing were repeatedly found unbagged and left on the bedside table, despite an active physician order for nebulizer treatments as needed. The medication administration record indicated the last use of the nebulizer was on 4/23/35, but the equipment remained exposed and improperly stored during multiple surveyor visits. For another resident using a CPAP machine since 3/13/25, there was no documentation in the medical record to show that the CPAP had been cleaned or maintained, and facility staff were unable to provide evidence of any cleaning having occurred.
Failure to Monitor and Assess Dialysis Access Site and Treatments
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident with end-stage renal disease who was dependent on hemodialysis and had an arteriovenous (AV) fistula in the right arm. Facility policy required staff to assess and document the condition of the dialysis access site every shift, including checking for signs of infection, monitoring the color and temperature of the fingers, presence of radial pulse, and assessing for thrill and bruit at the fistula site. Additionally, staff were required to complete pre- and post-dialysis assessments and document these in the resident's record. However, review of the resident's medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed no evidence that these assessments or monitoring were performed or documented. Interviews with the resident, an LPN, and the Director of Nursing confirmed that staff did not routinely check the resident's fistula or perform assessments before or after dialysis treatments. The resident reported that nurses did not check the fistula or monitor him after returning from dialysis. The LPN stated that no assessment or vital signs were taken after dialysis unless required for medication administration. The DON acknowledged that pre- and post-dialysis assessments were not being completed and that the clinical record lacked documentation of required monitoring and assessments for the dialysis access site.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition, as evidenced by food and trash observed on the ground outside the back kitchen door and an open dumpster with trash exposed and additional trash on the ground around it. These conditions were directly observed by a surveyor and confirmed by the Food Service Director during the survey. No information about residents or their medical conditions is included in the report.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program to prevent the spread of infection related to Enhanced Barrier Precautions (EBP) for a resident receiving intravenous medication. A sign posted outside the resident's room indicated that staff were required to wear personal protective equipment (PPE), including a gown, gloves, and face mask/eye protection, when providing care. During an observation, a registered nurse wore PPE while administering intravenous medication but removed her PPE to leave the room and retrieve a clean pillowcase. Upon returning, she did not don new PPE and proceeded to provide high-contact care by placing a pillow under the resident's right thigh and handling the leg with both hands. The nurse confirmed in an interview that she provided this care without wearing the required PPE, despite the resident being on EBP.
Improper Medication Storage and Lack of Self-Administration Assessment
Penalty
Summary
Surveyors observed that drugs and biologicals were not stored in accordance with professional standards. In the medication storage room on the [NAME] Unit, a dormitory-style refrigerator with significant ice buildup was being used to store several medications, despite this type of refrigerator being inappropriate due to temperature fluctuations. This failure to use proper storage equipment for medications was directly observed by the surveyor and the Director of Nursing (DON). Additionally, a resident was found to have a bottle of extra strength Tylenol, 500 mg, on their bedside table and reported self-administering the medication as needed. There was no evidence in the resident's medical record of a completed safety assessment by the interdisciplinary team (IDT) or a physician's order permitting self-administration, as required by the facility's policy. An LPN confirmed the absence of both the order and assessment and subsequently removed the medication from the resident's room.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain adequate maintenance and housekeeping services, resulting in unsanitary conditions in two of its units. During an environmental tour, surveyors observed that sit-to-stand patient lifts in the [NAME] Unit were heavily soiled with food debris and dirt in the foot base area. This was confirmed by a Registered Nurse (RN #1). Additionally, a commode lid was found on the floor leaning against the wall in the [NAME] Unit, and broken window shades were observed in resident rooms #29, #35, #38, and #43. These findings were confirmed by a Certified Nursing Assistant (CNA #1) and discussed with the facility Administrator.
Staffing Deficiency Affects Resident Care
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, as required by state regulations. Interviews with residents and staff revealed that the facility was often staffed below the required state staffing ratios, affecting the quality of care provided. A resident reported that due to insufficient staff, they sometimes could not be assisted to walk or use the bathroom, resulting in the use of a bedpan. Staff members, including RNs, CNAs, and LPNs, confirmed the short staffing issue, noting that it led to delays in answering call bells and incomplete care tasks such as baths, nail care, and teeth brushing. The staffing schedules and daily resident census review indicated that the facility did not meet the minimum staffing requirements for 19 out of 53 days reviewed. Staff interviews highlighted that the shortage was exacerbated by the reliance on agency staff, which affected the continuity and quality of care. The facility's administrator confirmed the findings of insufficient staffing during a phone interview with a surveyor. The deficiency was documented under the State tag ST-T-0222, indicating non-compliance with the State of Maine Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities.
Improper Linen Handling Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by improper linen handling observed on two units during a survey. On the [NAME] Unit, a Certified Nursing Assistant (CNA #4) was seen carrying a small bag of soiled linen with a visibly soiled bundle of unbagged linen on top, which was not in compliance with the facility's policy requiring soiled laundry to be bagged. CNA #4 confirmed the linen was not bagged as required. Additionally, on the same unit, CNA #5 was observed carrying clean linen against her body and placing it in a soiled linen hamper, which was also confirmed as an infection control issue. These observations were discussed with RN #1 and the Administrator, who both acknowledged the infection control concerns.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident when a maintenance staff member entered the resident's room without knocking or announcing his presence. On the specified date and time, a surveyor observed a tall male facility worker, dressed in black jeans and a black shirt, entering the resident's room without following the proper protocol of knocking and requesting permission. The staff member moved a Velcro stop sign aside and entered the room, later exiting with a wheeled bag of tools. During an interview, the maintenance staff member acknowledged that he entered the room without knocking, recognizing it as a dignity issue. The facility's Administrator also confirmed that the staff member should have knocked and announced himself before entering the resident's room.
Trip Hazard Due to Unsecured Linoleum Flooring
Penalty
Summary
The facility failed to maintain a safe environment for residents by not addressing a trip hazard in the [NAME] unit (core 1). During a survey, two surveyors observed a section of linoleum flooring, approximately 2 feet by 1 foot, that was missing, with edges coming up, creating a potential trip hazard. A Certified Nursing Assistant (CNA #6) confirmed the hazard, noting that the desk previously in that area had been removed, and acknowledged the presence of ambulatory residents who could be at risk. The Administrator also confirmed the existence of the trip hazard and the presence of ambulatory residents in the unit.
Deficiency in Food Temperature and Dietary Assessment
Penalty
Summary
The facility failed to ensure that food served from the kitchen was maintained at adequate and proper hot temperatures throughout the meal service, resulting in cold and unpalatable meals for residents. Interviews with residents and staff revealed consistent complaints about the food being cold and mushy, requiring nursing staff to reheat meals before serving them to residents. The kitchen supervisor confirmed that food temperatures were only taken in the kitchen and not monitored on the units during meal service, leading to uncertainty about whether the food was held at appropriate temperatures until served. Additionally, the facility did not adequately assess and identify residents' nutritional needs and diets before meals were distributed from the kitchen. The kitchen supervisor admitted that due to incomplete meal tags and lack of information on new admissions, regular meals were served without consideration of individual dietary plans. This lack of coordination and communication between the kitchen and nursing staff contributed to the deficiency, as evidenced by a test tray that was found to be cold and unpalatable by surveyors.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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