Hawthorne House
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Maine.
- Location
- 6 Old County Rd, Freeport, Maine 04032
- CMS Provider Number
- 205098
- Inspections on file
- 20
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hawthorne House during CMS and state inspections, most recent first.
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Surveyors found that the facility did not provide or document required information about advanced directives for the majority of sampled residents. Both electronic and paper records lacked evidence that residents or their representatives were offered or reviewed information on their right to formulate an advanced directive, as confirmed by facility leadership.
Surveyors identified widespread deficiencies in housekeeping and maintenance, including dirty and stained bathroom floors, disrepair of privacy curtains, untreated wooden laundry carts, chipped paint, broken heater parts, and uncleanable surfaces in several resident rooms and common areas. These issues were confirmed by staff interviews and affected the overall cleanliness and comfort of the facility.
Surveyors found unsecured cleaning chemicals, medical and wound care supplies, and a sharp object accessible to residents in multiple units. Environmental hazards included a loose toilet and a headphone cord taped across a walkway with lifting tape, creating a tripping risk. These deficiencies were confirmed through staff interviews and direct observation, indicating a failure to ensure a safe environment and adequate supervision to prevent accidents.
The facility did not have a functioning Antibiotic Stewardship Program, as infection tracking logs were incomplete and lacked essential information such as organism identification, culture results, and antibiotic appropriateness. Key data fields were left blank, and there was no evidence of monitoring infection trends or antibiotic use. Leadership confirmed that infection tracking was not fully implemented, and a recent staff change in the Infection Preventionist role contributed to the deficiency.
A resident with a possible serious mental disorder did not receive a required PASRR Level II face-to-face evaluation after the initial screening indicated it was necessary. Review of records and staff interview confirmed that the assessment was not completed as instructed to determine the need for specialized services.
A resident with suicidal ideation had physician orders for 15-minute checks, but staff failed to consistently document these checks, resulting in numerous missed entries over several days. This deficiency was confirmed by the DON.
The facility did not complete required annual performance evaluations for three CNAs, as there was no evidence of evaluations for the current year for staff hired in various years. This was confirmed through review and interviews with facility leadership.
A medication cart was found to contain an expired punch card of Codeine Sulfate 30mg, which remained available for use. The expired medication was discovered during a medication pass and confirmed by the DON.
Surveyors found unsanitary kitchen conditions, improper food labeling and dating, expired food items in use, and significant gaps in required temperature monitoring and documentation for dish machines and refrigerators/freezers. Staff and administrator interviews confirmed these deficiencies, which were observed across multiple areas and units.
A CNA was observed carrying unbagged soiled linen with bare hands from a resident's room to the soiled linen room, in violation of facility policy requiring contaminated laundry to be bagged and handled with standard precautions. The CNA confirmed the improper handling during the survey.
A resident who had indicated a desire to receive the pneumococcal vaccine did not have documentation in their clinical or immunization records showing that the vaccine was reviewed or administered, as confirmed by the Administrator during a surveyor interview.
A resident who had indicated a desire to receive the COVID-19 vaccine did not have documentation in their immunization records showing that the vaccine was reviewed or administered. This was confirmed by the Administrator during a surveyor interview.
A CNA did not complete the required annual dementia training, as confirmed by a review of employee education records and verification with the Facility Administrator.
A resident with schizophrenia, bipolar disorder, and PTSD did not receive effective treatment and services. The facility failed to complete a comprehensive trauma assessment and did not document trauma triggers. Despite the resident expressing suicidal ideations and experiencing hallucinations, safety measures were inconsistently documented, and the care plan lacked specific interventions for PTSD. Multiple self-harm attempts occurred, yet the care plan was not updated, and the resident's safety plan was missing, leading to repeated hospitalizations.
The facility failed to provide adequate housekeeping and maintenance services in three units. Issues included cracked floor tiles, black substances around toilets, torn adhesive coverings, stained floor tiles, peeling laminate, dirty equipment, and damaged wheelchairs. These deficiencies were confirmed during an environmental tour with the Director of Maintenance and the Maintenance Assistant.
The facility failed to maintain a sanitary environment for respiratory care equipment, including unlabeled and improperly stored oxygen nasal cannulas and nebulizer equipment for six residents. Additionally, one resident's oxygen concentrator was set incorrectly, contrary to the physician's order.
The facility failed to monitor vaccine storage temperatures consistently and did not remove expired medications. The immunization refrigerator on the Kennebec unit had inconsistent temperature logs, and an expired bottle of Milk of Magnesium was found on a medication cart in the [NAME] Short Hall. These issues were confirmed by staff and discussed with the Acting Director of Nursing.
The facility failed to maintain sanitary conditions in food storage and preparation areas. Undated and unlabeled hard-boiled eggs were found in the walk-in refrigerator, and dust and debris were observed on ceiling vents and a rarely used stand mixer.
The facility failed to issue written transfer/discharge notices to two residents or their legal representatives for facility-initiated transfers/discharges to an acute care facility. This deficiency was confirmed by a surveyor during an interview with the Licensed Clinical Social Worker.
The facility failed to issue written transfer/discharge notices to two residents or their legal representatives for facility-initiated transfers/discharges to an acute care facility. The clinical records for both residents lacked evidence of such notices, which was confirmed by the surveyor during an interview with the Licensed Clinical Social Worker.
The facility failed to review and revise the care plan by an IDT that included, to the extent possible, participation of a resident and/or their representative after each assessment. The resident stated they had only participated in one care plan meeting in the past year, and records showed no evidence of their invitation or participation in other meetings. This was confirmed by the Licensed Social Worker.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Document and Provide Advanced Directive Information
Penalty
Summary
The facility failed to ensure that documentation regarding residents' advanced directives was accurate and present in the clinical records for 20 out of 24 sampled residents. Record reviews revealed that both electronic and paper medical records for these residents lacked evidence that the facility had offered, reviewed, or provided written information about the right to formulate an advanced directive to the residents or their representatives. This deficiency was identified through a comprehensive review of multiple residents' records, which consistently showed missing documentation related to advanced directives. The absence of such documentation was noted across a significant number of residents, indicating a widespread issue rather than isolated incidents. The findings were confirmed during interviews with facility leadership, including the Director of Nursing and the Administrator, who acknowledged the lack of proper documentation. No information was provided in the report regarding the specific medical histories or conditions of the affected residents at the time of the deficiency. The focus of the findings was solely on the facility's failure to provide and document the required information about advanced directives as mandated by policy and regulation.
Failure to Maintain Sanitary and Comfortable Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's housekeeping and maintenance services across three of four units and the laundry room during two separate facility tours. Specific findings included dirty and stained floors around the base of toilets in several resident rooms, a pink wash bucket left on the bathroom floor, and privacy curtains in disrepair. Additional issues were noted such as untreated wooden bases on laundry carts, peeling laminate and missing finish on bathroom doors, chipped and missing paint on baseboard heaters, broken heater parts on the floor, rusty sinks, stained transition strips, and dusty wall fans. The walls behind residents' beds were also marred with black marks and chipped paint exposing sheetrock. These conditions were confirmed by interviews with facility staff, including a Registered Nurse, the Administrator, and the Director of Nursing. The observations indicated that the facility failed to maintain a sanitary, orderly, and comfortable environment as required, impacting the safety and comfort of residents in multiple areas of the building.
Unsecured Chemicals, Medical Supplies, and Environmental Hazards Create Accident Risks
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision across several units in the facility. Unsecured cleaning chemicals, including a container of Sani-Cloth Plus Germicidal Disposable Cloth and a spray bottle of Virex TB Ready-To-Use Disinfectant Cleaner, were found accessible to residents in their rooms and common areas. Additionally, wound care and medication supplies, as well as a sharp object (scissors), were left unattended and accessible to residents on the Geriatric Psychiatric Kennebec Unit. A toilet in one resident's room was observed to be loose and not secured to the floor, and a resident was found with a headphone cord taped across the walkway, with the tape lifting and creating a tripping hazard. Oxygen tanks were also not stored securely on one of the days observed. These deficiencies were confirmed through direct observation and interviews with facility staff, including the Unit Manager, Housekeeping Team Lead, Quality Improvement Manager, Registered Nurse, and Administrator. The presence of unsecured chemicals, medical supplies, sharp objects, and environmental hazards such as a loose toilet and tripping hazards demonstrated a failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required. Record reviews showed that the Infection Preventionist's monthly antibiotic log for the period from 1/1/25 through 3/11/25 listed 13 resident infections, but the documentation was incomplete. Several columns intended to capture critical information such as bacteria type, infection site, and other relevant data were left blank. The log also lacked evidence of follow-through on antibiotic use, analysis of infection trends, identification of organisms, detection of infection clusters, and tracking of antibiotic types used. During an interview, the Administrator and DON acknowledged that infection tracking was incomplete, missing information on whether cultures were performed, culture results, organism identification, and appropriateness of antibiotic selection. The facility had a recent change in Infection Preventionist staff, with the previous person leaving abruptly and a new employee starting on the day of the interview, further contributing to the lack of an implemented ASP.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to coordinate and complete the required Pre-Admission Screening and Resident Review (PASRR) Level II evaluation for a resident with a possible serious mental disorder. Record review showed that a PASRR Level I screening, conducted by Maximus, indicated the need for a face-to-face Level II evaluation to determine the necessity for specialized services. However, there was no evidence in the clinical record that the Level II evaluation was completed as instructed. This was confirmed during an interview with the Administrator, who acknowledged the absence of documentation showing that the required assessment had been performed.
Failure to Complete Physician-Ordered 15-Minute Checks for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to follow physician orders for 15-minute checks for a resident who had been placed on this monitoring protocol due to suicidal ideation. The clinical record indicated that the 15-minute checks were to be documented on a paper sheet from 3/27/25 to 4/16/25. However, review of the documentation revealed multiple missing checks on several dates within this period, with the number of missed checks ranging from 7 to 75 on specific days. This information was confirmed with the Director of Nursing.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five sampled certified nursing assistants (CNAs), as required. Specifically, there was no evidence of completed annual performance evaluations for the year 2024 for CNAs who were hired in July 2001, July 2023, and March 1990. This deficiency was identified through performance evaluation reviews and staff interviews, and the absence of documentation was confirmed with the Facility Administrator.
Expired Medication Found in Medication Cart
Penalty
Summary
Surveyors observed that a medication cart on the [NAME] Unit contained a medication punch card of Codeine Sulfate 30mg that had expired in January 2025. This expired medication was still available for use in the cart at the time of observation. The issue was identified during a morning medication pass and brought to the attention of the Certified Nursing Assistant responsible for administering medications from the cart, as well as the Registered Nurse present. The Director of Nursing confirmed the presence of the expired medication in the cart later that morning. The deficiency was related to the facility's failure to ensure that expired medications were removed from the supply available for use, as required by regulations for the storage and labeling of drugs and biologicals.
Deficiencies in Kitchen Sanitation, Food Storage, and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including unsanitary conditions and improper food handling practices. During an initial kitchen tour, observations included a broken ceiling light lens, rusty and dirty dish machine table legs, missing floor tiles exposing untreated cement, and food debris and dirt on the kitchen and dry storage floors. Additionally, a chemical hose was found hanging into a sink, a bus bucket was collecting drain water under a vegetable sink, and a standing floor mixer had dried residue. Dishes and cups were found wet stacked and stained, and several food items in dry storage, the walk-in refrigerator, and the walk-in freezer were not properly labeled or dated. Further deficiencies were noted with expired food items, as a container of thickened orange juice was found on a unit service cart ten days past its best use by date. Staff interviews confirmed the presence and use of these expired and improperly stored items. The facility's policies require proper dating, labeling, and storage of food, as well as regular monitoring and documentation of dish machine and refrigerator/freezer temperatures to ensure food safety, but these procedures were not consistently followed. A review of temperature monitoring logs revealed significant gaps in documentation for both dish machine and refrigerator/freezer temperatures across multiple units and months. No documentation was provided for certain months, and numerous dates were missing for others. The administrator confirmed the lack of monitoring and documentation, as well as the other observed deficiencies in food storage, cleanliness, and equipment maintenance.
Improper Handling of Soiled Linen by CNA
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices regarding the handling of soiled linen. On one unit, a Certified Nursing Assistant (CNA) was observed exiting a resident's room while carrying unbagged soiled linen with bare hands, contrary to the facility's policy which requires all used laundry to be handled as potentially contaminated and bagged or contained at the point of collection. The CNA confirmed handling the soiled linen without gloves or a bag and transporting it to the soiled linen room, where it was placed in a hamper. This incident was observed and discussed with a Registered Nurse/Unit Manager during the survey.
Failure to Administer Pneumococcal Vaccine as Requested
Penalty
Summary
A deficiency was identified when a resident's clinical and immunization records were reviewed and found to lack evidence that a pneumococcal vaccine had been reviewed or administered. The resident had previously indicated on a vaccine consent form a desire to receive the pneumonia vaccine. During an interview, the Administrator confirmed that there was no documentation of the vaccine being reviewed or given to the resident.
Failure to Review and Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to review and/or offer the COVID-19 vaccine to one of five residents reviewed for immunizations. Specifically, the clinical record for this resident included a form indicating that the resident understood the information provided and wished to receive the COVID-19 vaccine. However, the resident's immunization records did not contain evidence that the COVID-19 vaccine was reviewed or administered. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the COVID-19 vaccine had not been reviewed or given to the resident.
Failure to Ensure Mandatory Dementia Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) attended the mandatory yearly dementia training. Review of the CNA's employee in-service and attendance record showed no evidence that the required dementia training was completed for the year 2024. This deficiency was identified during a review of employee files and was confirmed by the Facility Administrator.
Deficiency in Mental Health Care and Safety Measures
Penalty
Summary
The facility failed to provide effective treatment and services for a resident diagnosed with schizophrenia, bipolar disorder, and PTSD. The resident's medical record was incomplete, lacking a comprehensive trauma assessment and documentation of trauma triggers. Despite the resident expressing suicidal ideations and experiencing hallucinations, there was no consistent documentation of safety measures or notifications to the provider. The care plan did not include specific focus, goals, or interventions for PTSD, and safety checks were inadequately documented or not performed. The resident experienced multiple incidents of self-harm attempts, including being found with a pillowcase and sheet around their neck. Despite these serious events, the care plan was not updated with additional safety measures, and the facility failed to locate the resident's safety plan. The lack of documentation and appropriate interventions contributed to the resident's repeated hospitalizations due to safety concerns. Interviews with nursing staff revealed awareness of the resident's triggers, yet this information was not documented in the medical record, further indicating a deficiency in the facility's care and treatment of the resident's mental health needs.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in three of its units: Long Hall, Kennebec, and Somerset. On the Long Hall unit, room [ROOM NUMBER] had seven cracked floor tiles and a black substance around the base of the toilet. The common area had a torn and lifting nonslip adhesive covering on the wheelchair scale. On the Somerset unit, the shared bathroom for rooms [ROOM NUMBERS] had a stained floor tile, peeling laminate on the sink vanity, and an area of patched drywall requiring paint. The base and frame of the sit-to-stand lift were dirty, and a wheelchair had a ripped armrest and torn seat cushion. On the Kennebec unit, the shared bathroom for rooms [ROOM NUMBERS] had a black substance at the base of the toilet. These findings were confirmed during an environmental tour with the Director of Maintenance and the Maintenance Assistant.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection related to oxygen and nebulizer mask/tubing for six residents. Observations revealed that oxygen nasal cannulas and nebulizer equipment were not labeled, dated, or stored properly. Specifically, Resident #2's nasal cannula was found lying across the bed without evidence of weekly changes, Resident #3's nasal cannula was dated 4/14/24 and stored improperly, and Resident #16's nebulizer equipment was not stored in a bag. Additionally, Resident #37's oxygen tank had an unlabeled nasal cannula, and Resident #69's nasal cannula was also unlabeled and improperly stored. Resident #172 was observed wearing an unlabeled nasal cannula with the concentrator set at 1 LPM, contrary to the physician's order of 2 LPM for dyspnea and oxygen saturation below 90%. The Acting DON confirmed these observations and adjusted Resident #172's oxygen to the correct setting as per the physician's order. The facility's Respiratory Therapy policy and procedure, revised in February 2022, mandates that oxygen cannulas and tubing be changed every seven days or as needed, and stored in a plastic bag when not in use. Nebulizer equipment should be rinsed, dried, and stored in a plastic bag marked with the date and resident's name between uses, and discarded every seven days. The facility failed to adhere to these guidelines, as evidenced by the improper storage and lack of documentation for the respiratory equipment of the six residents reviewed. This non-compliance with the facility's own infection control policies contributed to the deficiencies observed during the survey.
Inadequate Monitoring of Vaccine Storage and Expired Medication Found
Penalty
Summary
The facility failed to adequately monitor vaccine storage temperatures and ensure the removal of expired medications. Specifically, the immunization refrigerator on the Kennebec unit was found to contain various vaccines, including Influenza, COVID-19, and Pneumonia vaccines. However, the temperature log attached to the refrigerator showed inconsistent monitoring. For several months, temperatures were either recorded only once a day or not at all, contrary to the facility's policy and CDC guidelines, which require temperature checks twice daily. This lack of consistent monitoring was confirmed by an LPN during the surveyor's observation. Additionally, an expired medication was found on one of the medication carts in the [NAME] Short Hall. An opened bottle of Milk of Magnesium with an expiration date was discovered and subsequently discarded by a CNA-M. This issue was confirmed during an observation and later discussed with the Acting Director of Nursing. These deficiencies highlight lapses in the facility's medication management and vaccine storage protocols.
Failure to Maintain Sanitary Food Storage and Preparation
Penalty
Summary
The facility failed to serve and store food in a sanitary manner on two of three survey days. On 5/6/24 at 9:05 a.m., during an initial kitchen tour with the Director of Food Service, a surveyor observed a bag of hard-boiled eggs in the walk-in refrigerator that were not dated and not labeled. This was confirmed with the Director of Food Service at that time. On 5/8/24 at 10:30 a.m., during a return observation of the kitchen with the Food Service Director, a surveyor observed a light to moderate amount of dust and debris on all ceiling vents. Additionally, a large stand mixer that had not been used in over a month was found with a small amount of dark liquid at the bottom of the bowl and was covered with a light amount of dust and scattered food particles. This was confirmed with the Food Service Manager at that time.
Failure to Issue Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to issue a written transfer/discharge notice to two residents or their legal representatives for facility-initiated transfers/discharges to an acute care facility. Resident 13 was transferred to an acute hospital on two occasions, and the clinical record lacked evidence of a written notice for both instances. Similarly, Resident 31 was transferred to an acute hospital on two occasions, and the clinical record also lacked evidence of a written notice for both instances. These findings were confirmed by a surveyor during an interview with the Licensed Clinical Social Worker.
Failure to Issue Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to issue a written transfer/discharge notice to two residents or their legal representatives for facility-initiated transfers/discharges to an acute care facility. Resident 13 was transferred to an acute hospital on two occasions, 3/24/24 and 7/2/23, and subsequently readmitted, but the clinical record lacked evidence of a written notice. Similarly, Resident 31 was transferred to an acute hospital on 5/25/23 and 9/21/23, and subsequently readmitted, with no written notice documented in the clinical record. These findings were confirmed by the surveyor during an interview with the Licensed Clinical Social Worker on 5/7/24 at 3:26 p.m.
Failure to Include Resident in Care Plan Meetings
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for Resident #37. During an interview, Resident #37 stated he/she had only participated in one care plan meeting in the past year. Review of the IDT care plan meeting notes indicated that meetings occurred on 7/26/23 and 11/1/23, but there was no evidence that Resident #37 was invited or participated. Additionally, the IDT meeting on 2/7/24 noted that Resident #37 did not attend because the resident was in the middle of a dressing change. This was confirmed by the Licensed Social Worker during an interview.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
