Lakewood A Continuing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterville, Maine.
- Location
- 220 Kennedy Memorial Dr, Waterville, Maine 04901
- CMS Provider Number
- 205138
- Inspections on file
- 18
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Lakewood A Continuing Care Center during CMS and state inspections, most recent first.
Surveyors found that care plans for several residents were incomplete or not updated to reflect current physical needs, including fall risk, mobility limitations, and toileting requirements. The plans lacked specific, person-centered interventions and did not accurately address changes in condition following hospitalizations or surgeries, as confirmed by facility staff.
Two residents were not properly assessed or documented for pneumococcal vaccination status as required by CDC guidelines and facility policy. One resident's consent form was incomplete and lacked evidence of vaccine administration or refusal, while another resident's record showed no documentation of being offered the vaccine.
The facility failed to maintain a sanitary and comfortable environment across all units, with issues such as exposed sheetrock, chipped paint, and uncleanable surfaces on equipment and wheelchairs. Multiple resident rooms had unpainted walls and ceilings with holes, and common areas had dirty equipment. The Facilities Director confirmed these findings during an environmental tour.
The facility did not follow physician orders for a resident's oxygen therapy, consistently setting the concentrator at 3 liters instead of the prescribed 4 liters. Additionally, PT recommendations for another resident's ambulation were not implemented due to communication issues and staffing constraints.
The facility failed to maintain a sanitary environment for respiratory care, affecting five residents. Observations revealed unlabeled and improperly stored nebulizer masks and nasal cannula tubing, confirmed by the DON. Additionally, an oxygen concentrator had dusty filters, and a nebulizer machine was found with uncovered tubing.
The facility failed to properly store and secure medications across three units. Inappropriate storage in a dorm-style refrigerator led to temperature fluctuations affecting medications, including a vaccination. Temperature records showed a year-long failure to maintain recommended ranges. Additionally, medication and treatment carts were found unlocked and unattended in various units, with residents and staff nearby.
The facility failed to maintain cleanliness in the kitchen, with dusty fans, vents, and lights observed. Additionally, the kitchen and skilled unit ice machines were not plumbed according to code, risking contamination. These deficiencies were confirmed by the Food Service Director.
The facility failed to notify the State Agency of potential neglect concerns and did not investigate an unwitnessed fall with a major injury. A complaint was received about a CNA not providing adequate care, but the DON and Administrator were unaware of the incident reports. Additionally, the facility could not provide evidence of a completed investigation or a 5-day report for a resident's unwitnessed fall with a fracture.
The facility failed to secure a container of Clorox Healthcare Hydrogen Peroxide disinfectant wipes, which was found open with a wipe sticking out in a resident's bathroom. This was observed on two separate days, and the DON confirmed the wipes were not locked away, posing a potential hazard.
The facility failed to provide sufficient staffing, resulting in delayed call bell responses for residents. A resident reported waiting up to an hour for assistance, leading to incontinent episodes. Interviews with CNAs confirmed staffing issues, and the DON acknowledged the problem. The residents involved were cognitively intact, highlighting the impact on their care.
A resident's call bell was found non-functional despite previous reports of it being fixed. The issue was confirmed by a surveyor, RN, and CNA, with a temporary hand bell provided. The call bell briefly worked when the box was wiggled, indicating a potential battery issue.
A resident with a right-hand splint did not receive scheduled whirlpool baths for several weeks, impacting their self-determination and hygiene. The resident, unable to shave due to the injury, reported that staff were too busy to assist. Records lacked documentation of the baths on scheduled dates, and the issue was discussed with the DON.
A resident with dementia, anxiety, depression, PTSD, and agoraphobia was forcibly dressed and transferred by a CNA, leading to physical and emotional distress. Despite being asked to stop by another CNA, the abusive behavior continued, resulting in the resident experiencing pain and yelling for help. The incident was corroborated by witness statements and led to the dismissal of the CNA involved.
A nurse failed to follow infection control procedures during a medication pass, neglecting to perform hand hygiene before and after glove use. Despite receiving education on the facility's hand hygiene policy, the nurse admitted to forgetting to sanitize and expressed difficulty with glove application after using sanitizer. The Director of Nursing confirmed the nurse's training and expectations for compliance.
The facility did not ensure the Medical Director's attendance at three required quarterly Quality Assurance Committee meetings, as confirmed by attendance sheets and an interview with the Administrator.
Failure to Develop and Revise Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and revise comprehensive care plans that accurately addressed the physical needs of four sampled residents. For one resident with chronic pain and bilateral hand and knee contractures, the care plan did not specify the current fall risk status and included interventions for conditions not present in the resident's clinical record. The care plan was not updated to reflect the resident's actual diagnoses and needs, as confirmed by the DON and MDS Coordinator during review. Another resident with a recent left femur fracture and an indwelling urinary catheter had a care plan that did not reflect current ADL and toileting needs, despite changes in condition following hospitalizations and surgical interventions. Additional residents with recent fractures and mobility limitations had care plans that lacked person-centered details, such as specific assistance requirements, frequency, and interventions tailored to their post-operative and rehabilitative needs. In each case, the care plans were not revised or completed to address the residents' current physical conditions and care requirements, as confirmed by facility staff during surveyor interviews.
Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations, as required by facility policy. Record review and interviews revealed that two residents were not properly assessed or documented for pneumococcal vaccination status within the required timeframe. For one resident, a consent form for the Prevnar20 vaccine was present in the paper chart and signed, but the form was left blank regarding whether the vaccine was accepted or declined, and there was no evidence in the clinical record that the vaccine was offered, administered, or refused. For another resident, the clinical record lacked any documentation indicating that the pneumococcal vaccine was offered, administered, or refused. These findings were confirmed during an interview with the Infection Preventionist.
Deficiencies in 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 across all units, including the Skilled Unit, Long-Term Care Unit, and Memory Care Unit. During an environmental tour, surveyors observed several deficiencies, such as a ceiling in the activity room with exposed sheetrock and floor seams held down with black tape. In the skilled unit common area, sit-to-stand lifts were found with dirt and debris in the foot base areas, and one lift had ripped non-skid tape and chipped paint, creating uncleanable surfaces. Multiple resident rooms had unpainted ceilings and walls with holes, dusty bathroom ceiling vents, and dirty bathroom floors. Additionally, a hallway ceiling tile had a brown stain, and several rooms had large unpainted areas and chipped paint. In the Memory Care Unit, a resident's wheelchair had ripped armrests, and hallway walls had chipped paint and exposed metal corners. A sit-to-stand lift and baseboard heater register also had chipped paint. The Personal Care Room had cabinets with chipped laminate and missing pieces, and a linen warmer was improperly used to store a doll and blanket. In the Long-Term Care Unit, residents' wheelchairs had ripped armrests, creating uncleanable surfaces, and an electric wheelchair had tape on the armrest. The Facilities Director confirmed these findings during an interview with the surveyors.
Failure to Follow Physician Orders and PT Recommendations
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for Resident #3. The resident had a physician order for continuous oxygen therapy at 4 liters per minute via nasal cannula, documented since August 26, 2024. However, observations by surveyors on multiple occasions from November 12 to November 14, 2024, revealed that the oxygen concentrator was consistently set at 3 liters instead of the prescribed 4 liters. The Director of Nursing confirmed that staff were not following the physician's orders, and an LPN admitted to setting the concentrator at 3 liters, stating that the resident did not need 4 liters, despite the physician's directive. Additionally, the facility did not implement the recommendations provided by Physical Therapy for Resident #87's restorative care. The PT note from October 8, 2024, outlined a Functional Maintenance Program for ambulation, which included specific instructions for the resident to be out of bed for meals and to receive consistent verbal cues during walks. However, the resident reported that staff frequently cited insufficient staffing as a reason for not assisting with walks. The Administrator acknowledged a lack of communication, resulting in the failure to follow up on the PT recommendations.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, affecting five residents. Observations revealed that a resident's nebulizer mask was unlabeled and stored on their bedside table, while another resident's nasal cannula tubing was similarly unlabeled and stored on their bedside table. Additionally, a resident's nasal cannula tubing was found unlabeled and stored on a wheelchair in the hallway. The Director of Nursing confirmed these findings. Furthermore, an oxygen concentrator in a resident's bathroom had tubing taped to the floor and filters heavily built up with dust. Another resident's nebulizer machine was found with a mask and oxygen tubing resting uncovered on a chest of drawers, which was also confirmed by the Director of Nursing.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly store medications and biologicals across three units, as observed by surveyors. In the long-term care unit, a dorm-style refrigerator with a freezer compartment was used inappropriately for medication storage, leading to significant temperature fluctuations. The refrigerator showed a 10-degree Fahrenheit difference in temperatures, with ice buildup and pooled water affecting medications, including a Spice Vax vaccination. The temperature records for this refrigerator indicated a year-long failure to maintain the recommended range of 36-46 degrees Fahrenheit, with no follow-up actions taken. Similarly, in the Skilled Nursing unit, influenza vaccinations were stored without documented temperature checks for the past year, confirmed by the Unit Manager. Additionally, the facility failed to secure medication and treatment carts. An unlocked and unattended medication cart was observed in the Skilled Unit hallway for approximately five minutes, with residents and staff nearby. This was brought to the attention of an LPN by a surveyor. Similarly, two treatment carts containing insulin and ointments were found unlocked and unattended in the Long Term Care Unit hallway, with residents nearby. This was confirmed with an LPN. Another incident involved an unlocked and unattended medication cart in the Memory Care Unit nurses station, observed for about three minutes with residents and a Hospice CNA nearby. This was confirmed with a Certified Medication Technician.
Sanitation and Plumbing Deficiencies in Kitchen and Ice Machines
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey conducted by a surveyor and the Food Service Director (FSD). The surveyor noted that the dish room contained two wall-mounted fans that were dusty and dirty. Additionally, there were two ceiling vents over food preparation areas that were also dusty and dirty. Furthermore, five ceiling lights in the kitchen were heavily soiled with dust and debris. These observations indicate a lack of adherence to professional standards for cleanliness in food preparation areas. Moreover, the facility did not ensure that the kitchen ice machine and the skilled unit ice machine were plumbed in accordance with code requirements, specifically regarding the air-gap separation needed to prevent food contamination. The direct connection of wastewater and potable water was in violation of the State of Maine Rules Chapter 226 and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d). This deficiency was confirmed by the FSD during an interview, highlighting a significant oversight in maintaining sanitary conditions and preventing potential contamination in the facility's water supply and food handling processes.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to notify the State Agency after identifying potential neglect concerns and did not investigate an unwitnessed fall resulting in a major injury. In the first incident, a complaint was received by the Division of Licensing and Certification alleging that a CNA did not provide adequate care during a night shift, resulting in residents being soaked with urine. An email from the facility confirmed the complaint, but the Director of Nursing (DON) was unaware of the incident reports due to her recent start at the facility. The Administrator was also not informed of the complaint and confirmed that the State Agency was not notified of the concerns. In the second incident, the facility reported an unwitnessed fall with a fracture involving a resident to the State Agency. However, the facility could not provide evidence of a completed investigation or a 5-day report sent to the State Agency. The DON confirmed the absence of the investigation and report during an interview. These failures were identified during an annual survey, highlighting deficiencies in the facility's reporting and investigation processes.
Improper Storage of Disinfectant Wipes
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During the survey, it was observed that a container of Clorox Healthcare Hydrogen Peroxide disinfectant wipes was left open with a wipe sticking out in the bathroom of a resident's room. This occurred on two separate days of the survey. The Director of Nursing confirmed that the wipes were not secured in a locked cabinet, making them accessible and posing a potential hazard.
Staffing Deficiency Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents on the Long Term Care Unit. This deficiency was identified through interviews and record reviews, revealing that residents experienced significant delays in response times to their call bells. Resident #4 reported waiting between 30 minutes to 1 hour for staff to respond, with records showing waits of 25 minutes to 1 hour and 18 minutes on multiple occasions. Resident #45 also experienced delays, leading to incontinent episodes, with waits ranging from 27 minutes to 1 hour and 26 minutes. Resident #87 reported similar issues, with waits of 25 minutes to 1 hour and 18 minutes. Interviews with Certified Nursing Assistants (CNAs) confirmed the staffing issues, with CNA #1 and CNA #2 acknowledging difficulties in responding to call bells promptly due to limited staff. The Director of Nursing confirmed the information provided by the CNAs. The residents involved were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, which further emphasizes the impact of the staffing deficiency on their care and daily living activities.
Non-Functional Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a call bell was functional for one of the sampled residents. During an interview, the resident reported that their call bell had not been working despite being told it was fixed. When the surveyor tested the call bell, the light above the door did not illuminate, and the call bell screen at the nurse's station did not show an active call. A Certified Nurses Aid confirmed the call bell was not working. The Minimum Data Set project manager provided a hand bell for the resident to use temporarily. RN #3 attempted to fix the call bell, which briefly illuminated when the call bell box was wiggled, suggesting a possible battery issue. The resident mentioned that the call bell had been reported as fixed recently.
Failure to Provide Scheduled Whirlpool Baths
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not adhering to the resident's preferred bathing schedule. Resident #37, who had a splint on his/her right hand, expressed that he/she had not received the scheduled whirlpool baths on Tuesdays for several weeks. The resident, who was unable to shave him/herself due to the injury, also reported that staff were too busy to assist with shaving. Observations confirmed that the resident was unshaven and had not received the whirlpool bath as scheduled. Further review of the resident's Activities of Daily Living records revealed a lack of documentation for whirlpool baths on the scheduled dates, as well as missing records of bathing on several occasions. The issue was discussed with the Director of Nursing, and it was noted that the resident did not receive the whirlpool bath on the day of the survey but was scheduled to have one the following day.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and emotional abuse by staff when a Certified Nursing Assistant (CNA) forcibly dressed and transferred a resident. The incident involved a resident with a medical history of dementia, anxiety, depression, PTSD, and agoraphobia, who requires a gentle and patient approach due to their condition. On the day of the incident, the resident was subjected to forceful handling by CNA #1, who dressed the resident with an abrasive attitude and forced them into a sit/stand position without proper securement, causing the resident to yell for help. Witnesses, including another CNA and an RN, reported that CNA #1 continued to manhandle the resident despite being asked to stop. The resident expressed pain in their back following the incident, which was noted to be reddened. CNA #1 admitted to forcing the resident's arm into a shirt and acknowledged that it was a mistake. The facility's internal investigation and witness statements corroborated the occurrence of abuse, leading to the dismissal of CNA #1.
Infection Control Deficiency During Medication Pass
Penalty
Summary
The facility failed to adhere to its infection control procedures during a medication pass observation on the Memory Lane unit. Registered Nurse (RN) #2 was observed checking a resident's blood sugar with gloved hands and then exiting the room without performing hand hygiene. RN #2 removed her gloves and, without using hand sanitizer, handled a pen and a set of keys, and accessed the medication cart. She then donned a new pair of gloves without sanitizing her hands, prepared insulin, and administered it to the resident. After discarding the gloves, RN #2 again failed to perform hand hygiene before donning another pair of gloves to attend to another resident. During an interview, the Director of Nursing confirmed that RN #2 had received education on the facility's hand hygiene policy, which requires sanitizing hands before and after glove use. Despite this, RN #2 admitted to forgetting to sanitize and expressed difficulty in donning gloves after using sanitizer due to stickiness. The surveyor intervened to ensure compliance with the hand hygiene policy, highlighting the deficiency in infection control practices.
Medical Director's Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the required quarterly Quality Assurance Committee meetings. A review of the attendance sheets for these meetings revealed that the Medical Director was absent from all three meetings held on January 17, April 17, and July 24, 2024. This deficiency was confirmed during an interview with the Administrator on November 14, 2024.
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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