Dexter Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Dexter, Maine.
- Location
- 64 Park Street, Dexter, Maine 04930
- CMS Provider Number
- 205115
- Inspections on file
- 22
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Dexter Health Care during CMS and state inspections, most recent first.
A resident who returned from surgery with a drain in place had the drain removed by nursing staff one day after arrival, despite orders for it to remain until a follow-up visit. Documentation did not include a written or verbal order from the medical provider authorizing the removal, and this omission was confirmed by the DON.
A CNA failed to wear a gown while providing care to a resident on Enhanced Barrier Precautions (EBP) due to open wounds and an ileostomy, despite facility policy and posted signage requiring gown and glove use for high-contact care activities.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
A resident exhibiting exit-seeking and agitated behavior was placed in their room by an RN, who then held the door shut, preventing the resident from leaving. Multiple staff witnessed the incident, which involved the resident kicking and yelling to get out. This action violated facility policy prohibiting seclusion.
A deficiency was identified when an RN physically restrained a resident by holding their arms and hands down to prevent movement during an altercation, contrary to facility policy. Staff statements confirmed the RN used body contact to limit the resident's actions after the resident attempted to leave, became agitated, and tried to strike staff.
After staff reported concerns about an RN's escalating and potentially abusive behavior toward a resident, including physical and verbal actions, the DON did not immediately remove the RN from resident care or promptly initiate a thorough investigation. The RN continued to provide care to the resident throughout the weekend, and written statements detailing the incident were not collected until two days later.
Staff failed to promptly notify the State Agency about an alleged abuse incident involving a resident and an RN, where the RN escalated the resident's behavior, resulting in physical altercations and concerning staff conduct. The DON received multiple reports and concerns from CNAs about the RN's actions, but the facility delayed both the investigation and required notification.
A resident with dementia who was at risk for elopement became agitated and attempted to leave the facility. Staff failed to follow the care plan interventions, including using a calm approach and providing diversions, and the section for the resident's preferences was left blank. Instead, an RN escalated the situation by yelling and mimicking the resident, resulting in increased agitation and disruption.
A resident's clinical record was incomplete and inaccurate following a hospital transfer for behavioral evaluation. The record lacked documentation of resident representative notification, charge nurse notes on behaviors as required by the TAR, and information on the resident's return from the hospital. Staff interviews confirmed that required documentation was not entered into the clinical record.
A resident was hospitalized after receiving another resident's medications due to a failure to confirm identity during medication administration. The error involved an Adult Education CNA-M instructor and student who, without proper login credentials, administered medications including Gabapentin, Hydroxyzine, and Metoprolol, leading to adverse effects such as nausea and syncope. The facility's policy to confirm resident identity was not followed.
The facility failed to follow physician orders for medications and treatments for several residents, resulting in missed doses and improper care. One resident did not receive an antibiotic for five days due to authorization delays, while another missed doses of Macrobid due to record errors. A resident with a rash did not receive daily treatment as ordered, and another received incorrect Protonix dosing due to a system error. Additionally, a resident's unwitnessed fall was not properly assessed, and no care orders were found for a resident with an ileostomy.
The facility failed to adhere to infection prevention protocols during pressure ulcer dressing changes for two residents. An LPN and CNAs did not wear protective gowns as required by Enhanced Barrier Precautions (EBPs) for a resident with a Stage IV pressure ulcer and an indwelling urinary catheter. Another LPN also neglected to wear a gown during a dressing change for a resident with a pressure ulcer, and there was no EBP sign outside the resident's room.
A resident's preference for regular showers was not honored, as documented evidence showed missed showers in August and September, and no showers recorded in October after a system transition. Despite being scheduled for weekly showers, the resident only received one per week, with staff claiming the resident did not need additional showers. The DON confirmed missing and incomplete documentation, indicating a failure to support the resident's choice.
A facility failed to implement a care plan intervention for a resident requiring weekly weighing as part of their nutrition care plan. The care plan, established in July 2023, was not followed as weights were not documented for specific weeks in October 2024. This deficiency was confirmed by a surveyor and the RAI Coordinator during a review.
A facility failed to follow a physician's order for a pressure ulcer dressing change. An LPN mistakenly applied a dressing to the wrong toe of a resident's right foot, despite the order specifying the third toe. The error was identified by a surveyor, and the LPN corrected it by applying the dressing to the correct toe.
A facility failed to ensure timely physician review and signature of a resident's medication and treatment orders. The resident's block orders, last signed on July 11, required review by September 19. Despite a physician visit on September 9, the orders remained unsigned, resulting in a 41-day delay confirmed by a surveyor and the DON.
The facility did not maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. On two weekend shifts, there was no evidence of an RN present for the required hours, as confirmed by a review of staffing schedules and interviews.
A facility failed to obtain a physician-ordered renewal for a PRN Lorazepam prescription when transitioning to a new electronic charting system. The medication was entered without a stop date, making it available for administration beyond the intended period. This oversight was confirmed during a review, as the medication remained available without a renewal order.
The facility failed to label thawed health shake supplements with a thaw date and did not remove expired coleslaw from the refrigerator. Additionally, the kitchen's exhaust fan and window casings were heavily dust-covered and remained uncleaned over several days.
The facility failed to maintain accurate clinical records for three residents due to errors during the transfer of physician orders to a new electronic charting system. These errors included incorrect medication dosages, missing discontinuation orders, and significant discrepancies in weight records, complicating accurate resident assessments.
The facility failed to maintain a sanitary and well-maintained environment, as observed during environmental tours. Issues included faded and chipped furniture, dirty and damaged wheelchairs, a flickering bathroom light, and chipped surfaces, all contributing to unsanitary conditions.
Incomplete Clinical Record for Surgical Drain Removal
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident who returned from surgery with a surgical drain in place. Upon review, it was found that there was a physician's order for daily dressing changes and for the drain output to be recorded every 12 hours, with instructions for the drain to remain in place until the resident's follow-up clinic visit in approximately one week. However, documentation showed that the drain was removed at the facility just one day after the resident's return, following a phone call to the surgical center nurse, but without any written or verbal order from the medical provider or surgical team authorizing the removal. The clinical record lacked evidence of such an order, and this was confirmed during interviews with the charge nurses and the Director of Nursing.
Failure to Follow Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when staff failed to implement required infection control practices for a resident with open wounds and an ileostomy who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gowns and gloves when providing high-contact care to residents on EBP, including those with chronic wounds or indwelling catheters. During an observation, a Certified Nursing Assistant (CNA) entered the resident's room to empty a catheter bag without donning a gown, despite a sign posted outside the room indicating EBP precautions were in place. The CNA acknowledged forgetting the need to wear a gown for this resident, and the surveyor confirmed the lapse at the time of the observation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Resident Subjected to Involuntary Seclusion by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) involuntarily secluded a resident by placing the resident in their room and holding the door shut, preventing the resident from leaving. The incident was witnessed by multiple staff members, who provided written and verbal statements confirming that the RN held the door closed while the resident, who was exhibiting exit-seeking behavior and escalating agitation, attempted to get out by kicking and yelling. The facility's policy, revised in March 2025, explicitly prohibits seclusion, defined as placing a resident alone in a room, and this action was in direct violation of that policy. The resident involved was described as being angry, yelling, and attempting to leave the facility, with staff unsuccessfully attempting to redirect the behavior prior to the seclusion. Staff accounts consistently indicated that the RN moved the resident to their room and physically held the door closed for a period of time, during which the resident was observed kicking the door from inside. The duration of the seclusion was not precisely determined, but staff confirmed the resident was confined against their will. The incident was reported to the Division of Licensing and Certification, and the RN was placed on leave pending investigation.
Use of Physical Restraint by RN on Resident
Penalty
Summary
A deficiency occurred when a Registered Nurse (RN) used physical restraint on a resident by holding the resident's arms and hands down to limit voluntary movement. The incident took place after the resident attempted to leave the facility, banged on a door, and threw a cup of coffee at the RN. Multiple staff statements and interviews confirmed that the RN held the resident's arms down from behind the wheelchair, and at one point, placed her arms around the resident's upper chest while wheeling the resident away from the door. The RN and the resident were engaged in a verbal altercation, and the RN was observed to be frustrated during the incident. The facility's policy, revised in March 2025, defines physical restraints as any manual method or device that restricts freedom of movement and cannot be easily removed by the individual. The RN's actions were documented in a Performance Correction Notice and corroborated by written statements and interviews from Certified Nursing Assistants (CNAs) who witnessed the event. The resident was actively resisting and attempting to hit staff, leading the RN to physically restrain the resident, which was not in accordance with the facility's restraint policy.
Failure to Protect Resident After Staff Reported Alleged Abuse by RN
Penalty
Summary
Staff reported concerns regarding the behavior of a Registered Nurse (RN) towards a resident who was agitated. On the day of the incident, multiple staff members notified the Director of Nursing (DON) via text messages that the RN was engaging in escalating behavior with the resident, including flapping her arms at the resident and verbally provoking the resident to hit her. Written statements later indicated that the RN physically put her hands on the resident, placed the resident in their room, closed the door, and held it shut. Despite these reports, the DON's initial response was to instruct the RN to complete an incident report and follow up with Work Health, without immediately removing the RN from resident care or initiating a thorough investigation at that time. The RN continued to provide care to the resident throughout the weekend following the incident, as confirmed by timecard records and staff interviews. The DON did not begin collecting written statements from involved staff until two days after the incident, delaying the facility's investigation. The resident was sent to the hospital following the incident, and upon return, care was reassigned, but the RN insisted on continuing to care for the resident. The facility failed to protect the resident after being notified of staff concerns about the RN's behavior, allowing the RN to remain in direct care of the resident despite allegations of abuse.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Agency (Division of Licensing and Certification) in a timely manner regarding an allegation of abuse involving a resident and a registered nurse. On the date of the incident, staff reported to the Director of Nursing (DON) that a resident was agitated and that a registered nurse escalated the situation, resulting in the resident biting the nurse. Additional information was reported to the DON, including that the nurse placed the resident in their room, closed the door, and held it shut for several seconds up to one minute during the resident's escalating behaviors. Text messages from certified nursing assistants to the DON expressed concerns about the nurse's behavior, including the nurse flapping her arms at the resident and encouraging the resident to hit her. Despite these reports and concerns, the facility did not initiate an investigation or notify the State Agency until two days after the incident occurred.
Failure to Implement Comprehensive Care Plan for Agitated Resident with Dementia
Penalty
Summary
The facility failed to fully develop and implement a comprehensive care plan for a resident with dementia who was identified as an elopement risk and exhibited agitated behaviors. The care plan included interventions such as offering pleasant diversions and approaching the resident in a calm manner, but the section for the resident's preferences was left blank. On the day of the incident, staff observed a Registered Nurse (RN) yelling at the resident and mimicking their behavior, rather than using the calm approach specified in the care plan. Multiple staff statements indicated that the RN's actions escalated the resident's agitation, leading to a disruptive situation where both the RN and the resident were yelling at each other. Interviews with staff revealed that the resident, who has dementia, was triggered and became increasingly agitated when their desire to go outside was not accommodated. Staff noted that the situation could have been defused by taking the resident outside, but this was not done due to a busy period. The care plan's interventions to distract and calm the resident were not effectively implemented, and the lack of documented resident preferences further limited the staff's ability to address the resident's needs appropriately during the incident.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced an incident resulting in hospital transfer for evaluation of increased behaviors. The clinical record did not contain documentation of notification or attempted notification of the resident's representative regarding the hospital transfer. Additionally, there was no documentation from the charge nurse in the nurses/progress notes about the resident's behaviors, as was required by the Treatment Administration Record (TAR). Although the TAR indicated that behaviors were monitored, there was no corresponding narrative documentation in the clinical record. Further review revealed that the clinical record lacked information indicating when the resident returned to the facility after the hospital transfer. Interviews with staff confirmed that the LPN had called and left a message for the resident's representative but did not document this action in the clinical record. The RN acknowledged documenting on the TAR but failed to update the clinical record with details of the behaviors or the resident's return from the hospital. These omissions resulted in incomplete and inaccurate clinical records for the resident involved in the incident.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, leading to the resident being transported to an acute care emergency department and later admitted to the hospital. The incident occurred when a Certified Nursing Assistant-Medication Aide (CNA-M) allowed an Adult Education CNA-M instructor and a student to pass medications without confirming the resident's identity. As a result, the resident received a combination of medications intended for another resident, including Gabapentin, Hydroxyzine, Metoprolol, and others, which led to adverse effects such as nausea and syncope episodes. The error was identified when the resident, who had received the wrong medications, reported feeling unwell and exhibited symptoms such as nausea and a syncope episode. The nursing staff documented the incident, noting that the resident's blood pressure and pulse were affected by the medications, particularly the combination of Gabapentin and Hydroxyzine, which can be sedating, and Metoprolol, which can significantly lower blood pressure and pulse. The resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with the facility staff revealed that the Adult Education CNA-M instructor and the student did not have their own login for the computer system and relied on the CNA-M to log in for them. They failed to confirm the resident's identity before administering the medications, leading to the error. The facility's policy on administering oral medications clearly states the need to confirm the identity of the resident, which was not followed in this instance. The resident remained hospitalized for treatment following the incident.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications and treatments were followed for several residents. One resident was sent to the Emergency Department due to respiratory concerns and returned with an order for Levaquin to treat pneumonia. However, the resident did not receive the antibiotic until five days after the physician ordered it due to a delay in obtaining prior authorization and a lack of follow-up with the physician. Another resident had a written order to change the duration of Macrobid treatment from 14 days to 5 days, but missed three doses due to a failure to update the Medication Administration Record (MAR) and administer the medication as ordered. A resident with a rash on their stomach had orders for daily cleaning and application of cream, but the treatment was not performed daily as required. The Treatment Administration Record (TAR) incorrectly listed the treatment as 'as needed,' resulting in missed treatments. Additionally, another resident had an order for Protonix to be administered twice a day, but due to an error during the transfer of orders to a new electronic system, the medication was only given once a day for several weeks without a physician's order to change the frequency. Further deficiencies included a resident who experienced an unwitnessed fall and did not receive the required neurological assessments, as well as a resident with an ileostomy for which no active care orders were found. These lapses in following physician orders and ensuring proper documentation and administration of medications and treatments highlight significant deficiencies in the facility's care processes.
Infection Control Lapses in Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during pressure ulcer dressing changes for two residents. Resident #17, diagnosed with multiple sclerosis and a chronic Stage IV pressure ulcer, was observed during a dressing change where the attending LPN and CNAs did not adhere to Enhanced Barrier Precautions (EBPs) by failing to wear protective gowns. Despite being aware of the EBP sign on the resident's room entrance, the staff did not comply with the necessary precautions, which are crucial for residents with wounds or indwelling medical devices. Similarly, for Resident #11, who had a physician's order for a daily pressure ulcer dressing change, the attending LPN did not follow the facility's EBP and wound care policies by only wearing gloves and not a gown during the procedure. The absence of an EBP sign outside Resident #11's room further indicates a lapse in the facility's adherence to infection control protocols. These observations highlight the facility's failure to implement and follow established infection prevention measures, particularly for residents at increased risk of MDRO acquisition.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing preferences, specifically for a resident identified as R3. During an interview, a resident representative expressed concerns that R3 was not receiving scheduled showers, with staff indicating that R3 did not need a shower because they had already been washed. R3 reportedly enjoys showers but was only receiving one per week. A review of R3's electronic clinical record showed that R3 was scheduled to receive a shower on Saturdays during the day shift. However, documentation revealed that R3 missed five showers in August and September, and there was no evidence of any showers being provided in October after the facility transitioned to a new electronic charting system. The Director of Nursing confirmed the missing and incomplete documentation regarding R3's showers, indicating that the resident's preferences were not being honored.
Failure to Implement Weekly Weighing for Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident reviewed for nutrition. The care plan for the resident included an intervention added on July 13, 2023, under the care area of Nutrition, which required the resident to be weighed every week. However, during a review on October 30, 2024, it was found that the resident's weights were not documented weekly in the electronic system for the periods from September 29, 2024, to October 5, 2024, and from October 13, 2024, to October 19, 2024. This lack of documentation was confirmed during a review by a surveyor and the Resident Assessment Instrument (RAI) Coordinator.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to follow a physician's order for a pressure ulcer dressing change for a resident. On October 29, 2024, a surveyor observed an LPN perform a dressing change on the resident's right foot. The physician's order specified that the dressing should be changed daily on the resident's Stage II pressure ulcer located on the right third toe. However, the LPN mistakenly applied the dressing to the second toe instead of the third. Upon being informed by the surveyor, the LPN confirmed the error and corrected it by applying the dressing to the correct toe.
Physician's Delay in Signing Orders
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. The resident's clinical record showed block orders signed by the physician on July 11, 2024. These orders required review and the physician's signature by September 19, 2024, including a 10-day grace period. Although the physician visited on September 9, 2024, they did not sign the block orders. As of October 30, 2024, the orders were 41 days overdue, as confirmed by a surveyor during an interview with the Director of Nursing.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of daily staffing schedules and interviews conducted by a surveyor on 10/31/24. Specifically, on two weekend shifts, 10/13/24 and 10/20/24, there was no evidence of an RN being present in the building for the required 8 consecutive hours.
Failure to Renew PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure a physician-ordered renewal for a PRN psychotropic medication before transitioning to a new electronic charting system (PCC). This oversight involved a resident who had a previous order for Lorazepam, an anti-anxiety medication, to be administered as needed at bedtime until a specified date. However, when the facility switched to the new system, the medication order was entered without a renewal from a physician and lacked a stop date, making it available for administration beyond the intended 14-day period. During the review, it was confirmed that there was no renewal order for the PRN Lorazepam, yet the medication remained available for use.
Deficiencies in Food Labeling and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly label thawed health shake supplements with a thaw date, as observed by a surveyor in the walk-in refrigerator. The storage and handling instructions on the carton specified that the supplements should be used within 14 days after thawing, but the absence of a thaw date made it impossible to determine their usability. This issue was confirmed with the Dietary Manager, who acknowledged the lack of labeling. Additionally, the facility did not remove expired food items from the walk-in refrigerator. A surveyor found individual serving cups of coleslaw that were past their use-by date, yet still available for use. This was confirmed with the Dietary Manager, who acknowledged the presence of expired coleslaw. Furthermore, the kitchen's cleanliness was compromised by a heavily dust-covered exhaust fan and window casings in the dishwashing room, which remained uncleaned over multiple days of observation.
Inaccurate Clinical Records and Data Entry Errors
Penalty
Summary
The facility failed to ensure that clinical records contained complete and accurate information for three residents during a review. For one resident, an order for Protonix was incorrectly entered into the new electronic charting system (PCC) as once a day instead of twice a day during the transfer of physician orders. Another resident's record lacked evidence of a discontinued order for Trazodone, which was omitted during the same transfer process. Additionally, this resident's weight records showed inconsistencies, with significant discrepancies noted in the recorded weights over several months, making it difficult for the dietician to assess the resident's nutritional status accurately. For a third resident, multiple data entry errors were identified in the transfer of orders from the old electronic charting system (ECS) to PCC. These errors included missing dosage information for Calcium Carbonate, incorrect dosage for artificial tears, an active order for Lorazepam that should have been stopped, and a duplicate entry for Miconazole powder. The Director of Nursing confirmed these errors during the review, and there was no order found to renew the Lorazepam as needed.
Facility Fails to Maintain Sanitary and Well-Maintained Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building and resident equipment in good repair and in a sanitary condition. During environmental tours, it was observed that several pieces of furniture in residents' rooms were in disrepair, with issues such as faded veneer, chipped wood, and missing handles. Additionally, some residents' wheelchairs were found to be dirty, with missing foam pieces and cracked armrests, creating uncleanable surfaces. A bathroom ceiling light was flickering, and a bedside table surface was chipped, further contributing to the unsanitary conditions.
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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