Mainegeneral Rehab & Long Term Care - Glenridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Augusta, Maine.
- Location
- 40 Glenridge Drive, Augusta, Maine 04330
- CMS Provider Number
- 205139
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Mainegeneral Rehab & Long Term Care - Glenridge during CMS and state inspections, most recent first.
The facility failed to maintain accurate controlled substance count records and did not ensure that both authorized medication administrators signed the Bound Book at each shift change. Surveyors found missing oncoming and off-going signatures, incomplete entries without time or count status, and instances where an RN signed the off-duty column before the count was actually completed on multiple med carts and units, including Cove, Gardens, and Valley.
Housekeeping and maintenance services were not adequately provided in a laundry room, a common area, and multiple resident rooms on the Cove Unit. Surveyors observed missing cove base, chipped and missing paint exposing sheetrock, dusty fans and vents, stained caulking, torn fall mats, a broken bathroom light, and unlabeled items on a shared toilet, and the ES Mgr and Maintenance Assistant confirmed the findings.
Kitchen sanitation, labeling, and facial hair protection deficiencies. During a kitchen tour, the air conditioning unit, fans, food disposal units, shelving, ceiling vents, grease trap cover, and service door were observed dirty or damaged with chipped paint. A large container of brown powder and a bag of diced product were not labeled and/or dated, and two kitchen workers with facial hair were not wearing facial hair protection. The FSD confirmed the findings.
The facility failed to provide written information about the right to accept or refuse treatment and to formulate an advance directive for two residents reviewed. The clinical record lacked evidence that the residents' representatives were asked or offered the opportunity to complete an advance directive, and the LSW confirmed this during interview with surveyors.
A resident with an amoxicillin allergy received Augmentin after two antibiotic orders were entered for ear pain, even though the physician note indicated cefdinir should be used instead. Pharmacy later questioned the order because of the allergy, and the LPN did not notify the physician that the resident had already received the dose; the DON later confirmed the physician had not been informed.
Care plans were not developed and implemented to reflect the current needs of two residents. One resident with Alzheimer's disease, suicidal ideations, delusional disorder, mood disorder, and bipolar disorder had an active order for quetiapine, but no care plan for antipsychotic use. Another resident with chronic pain and depression had active orders for sertraline, methadone, and PRN oxycodone, but the care plan lacked goals, interventions, and side effect monitoring for pain management and antidepressant use.
Damaged doors and protective coverings created accident hazards in common areas and on the Cove Unit. A small sitting room door had a broken protector sticking out and sharp, and a wooden double door in the lobby had a gouge with missing wood and sharp edges; an LPN and the Administrator both confirmed the observations.
Unclean and improperly stored oxygen tubing was observed for two residents receiving O2. One resident’s tubing was left unbagged on top of the concentrator, while another resident’s unbagged tubing was connected to a portable tank on a wheelchair with the prongs touching the seat cushion and additional tubing tucked under the blankets. Records lacked evidence that tubing was changed weekly or that the concentrator filter was cleaned, despite facility policy requiring weekly cleaning and storage in plastic bags when not in use.
A resident with otitis media and a documented amoxicillin allergy was prescribed two antibiotics, including Augmentin and cefdinir, on the same order date. Augmentin was administered before the order was clarified, even though the resident’s allergy was in the chart and pharmacy later called to verify the order. Interviews with the unit manager, DON, and LPN confirmed the resident received the medication despite the known allergy.
Improperly Maintained Garbage Dumpster: The facility failed to keep 1 of 2 trash dumpsters in sanitary condition when a small garbage/refuse dumpster was observed with one slide door open and the other missing, exposing garbage and refuse. The same condition was observed again the next day, and a laundry staff member confirmed the findings before the surveyor discussed them with the Administrator.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not provide written transfer/discharge notices or bed hold notices to resident representatives for 4 sampled residents transferred to an acute hospital. Records showed the notices were not sent in writing, and the SS Mgr and an LSW confirmed the facility only sent a packet with the resident and notified the Ombudsman.
The facility failed to provide adequate oral hygiene care for two residents, leading to deficiencies in their daily living activities. One resident was observed with a thick whitish substance on their teeth, indicating a lack of proper care despite their need for assistance. Another resident expressed dissatisfaction with the frequency of oral care and had to remind staff to assist with brushing, highlighting inconsistencies in adhering to care plans.
Surveyors identified sanitation deficiencies in the facility's kitchen, including built-up ice in the walk-in freezer, chipped paint on the grill hood, and dust on the dishwasher exhaust vent. A soiled face cloth was found on a fluid line at the prewash sink, with maintenance unaware of the issue. The Warewash Service Report lacked evidence of a review of the affected areas.
The facility failed to implement effective infection control practices, as staff did not adhere to contact precautions for a resident with ESBL, and there was a lack of proper disinfection practices for equipment contaminated with C. diff. Staff, including the Infection Preventionist, demonstrated inconsistent understanding and application of infection control policies, leading to deficiencies in maintaining a safe environment.
The facility failed to implement its Antibiotic Stewardship Program effectively, lacking protocols and monitoring systems for antibiotic use. The Infection Preventionist did not track culture completions, results, or correct antibiotic usage, nor communicated with medical staff. The facility also failed to track Multi-Drug Resistant Organisms, as confirmed by the DON and Administrator.
A facility failed to refer a resident with bipolar disorder for a PASRR Level II evaluation after their stay exceeded the 30-day Convalescence Categorical exemption. The resident's clinical record lacked evidence of re-evaluation, which was confirmed by the Care Manager Supervisor.
A facility failed to obtain a physician's order with a supporting diagnosis for a resident's indwelling foley catheter and did not specify the catheter and balloon sizes. The resident was unaware of the catheter's purpose, and staff could not provide a medical diagnosis for its use. The resident had multiple diagnoses, including brain cancer and seizures, but records lacked documentation justifying the catheter's necessity.
Incomplete Controlled Substance Shift Count Documentation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs that allowed accurate reconciliation, and it failed to ensure that two authorized medication administrators signed the Shift Count page of the Bound Book to show that controlled substances were counted at each change of shift. During a medication storage observation on the Cove Unit, the Bound Book showed missing signatures for the nurse coming on duty and the nurse going off duty for a controlled substance count documented on the med cart, and another entry on the Long Hall med cart included an undated and untimed notation with the Nurse Going Off Duty signature entered before the count was completed. Similar problems were identified on the Gardens Unit and Valley Unit. On the Gardens Unit Short Hall med cart, the Bound Book contained missing oncoming and off-going signatures for shift counts, multiple entries that lacked the time and/or status of count, and an entry where the Nurse Going Off Duty had already signed and marked the count exact before the count was actually performed. On the Valley Unit medication tech med cart, the Bound Book showed missing signatures and a missing count status for a shift count, and all three Valley Unit shift count books showed that nurses had already signed the Nurse Going Off Duty column before completing the count with the oncoming nurse. The Unit Managers and the DON were informed of these findings during the survey.
Housekeeping and Maintenance Deficiencies in Common Areas and Resident Rooms
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in the laundry room, a common area, and on the Cove Unit. During an observation of the laundry room, the Environmental Services Manager confirmed that many areas around the room were missing cove base on the walls. During an environmental tour of the common area, the bathroom in the main entrance lobby had chipped and missing paint exposing sheetrock above the baseboard heater, and the baseboard heater itself had chipped and missing paint, creating uncleanable surfaces. On the Cove Unit, multiple resident rooms had maintenance and housekeeping issues observed by the surveyor and confirmed by the Maintenance Assistant. Findings included bathroom door frames and walls with chipped and missing paint creating uncleanable surfaces, visibly dusty floor fans and heating units, a dusty bathroom ceiling vent, privacy curtains missing hooks and hanging in disrepair, caulking around toilets that was visibly stained and dirty, fall mats with ripped or torn edges, a bathroom light that was not working, and an unlabeled bed pan and unlabeled graduated cylinder on the back of a toilet shared by two rooms. The Maintenance Assistant confirmed these findings during the tour.
Kitchen sanitation, labeling, and facial hair protection deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner during an initial kitchen tour completed with the Food Service Director. In the dish room, the wall mounted air conditioning unit had heavy dust and dirt on the top air intake grill, the wall fan was dusty and dirty, and food disposal unit #1 had dried food particles and dried liquid residue on it. Food disposal unit #2 near a shelving unit also had dried food particles and dried liquid residue, and it was rusty on the body and legs. The shelving unit next to that disposal unit was dirty and had dried liquid residue on it, and three ceiling vents over food preparation areas were dusty and dirty. Additional observations included a grease trap cover with chipped and missing paint that created an uncleanable surface, a wall fan that was dusty and dirty, and a service entrance/exit door with chipped and missing paint creating an uncleanable surface. The surveyor also observed a large plastic container of a brown powder substance that was not labeled or dated, a large bag of diced product in the walk-in refrigerator that was not labeled, and two kitchen workers with facial hair who were not wearing facial hair protection. The Food Service Director confirmed these findings during interview.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to provide residents or their representatives with written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive for 2 of 10 residents reviewed for advance directives. Resident 72, admitted in 2023, had no evidence in the clinical record that the resident's representative was asked or offered the opportunity to formulate an advance directive. Resident 12, admitted in 2024, also had no evidence in the clinical record that the resident's representative was asked or offered the opportunity to formulate an advance directive. During an interview with 4 surveyors on 3/24/26 at 2:45 p.m., the LSW confirmed that the clinical record did not include evidence that the residents' representatives were asked or offered the opportunity to formulate an advance directive.
Failure to Notify Physician After Allergy-Related Antibiotic Error
Penalty
Summary
The facility failed to notify the physician when Resident #40 received Augmentin despite a known amoxicillin allergy. Resident #40 was admitted with diagnoses including otitis media, and a physician progress note documented that because of the amoxicillin allergy, cefdinir would be used for ear pain. However, physician orders were entered for both Augmentin and cefdinir, and the Medication Administration Record showed that Augmentin was administered during the afternoon medication pass before it was discontinued later that day. A nursing progress note stated that the resident had been seen by the PCP for left ear pain and that two antibiotic orders were placed, with the initial dose of Augmentin given because cefdinir was not available in Pyxis. The note also stated that pharmacy later called to verify the Augmentin order because of the resident’s amoxicillin allergy, and that the resident was not showing signs or symptoms of an allergic reaction. During interview, the LPN stated she did not notify the physician after learning the resident had received Augmentin, and the DON later confirmed that the physician had not been notified of the dose given.
Care Plans Not Developed for Psychotropic Use and Pain Management
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented to reflect the current needs of 2 of 27 residents reviewed for care planning. Facility policy stated that psychopharmacological medication use care plans must be developed or updated as appropriate, including goals of therapy and evaluation of progress toward goals, and the facility assessment identified medication administration and polypharmacy management as part of resident care needs. Resident #9 was admitted in August 2025 with diagnoses including Alzheimer's disease, suicidal ideations, delusional disorders, adjustment disorder with mixed anxiety and depressed mood, unspecified mood disorder, and bipolar disorder. The clinical record showed an active order for quetiapine 25 mg daily for bipolar disorder, but the resident's current care plan was not developed and initiated for the use of an antipsychotic medication. Resident #40 had diagnoses including chronic pain and adjustment disorder with mixed anxiety and depressed mood, with active orders for sertraline 50 mg daily for depression, methadone 2.5 mg daily for chronic pain, oxycodone 5 mg PRN twice daily for chronic pain, and renew narcotics every 30 days. The care plan lacked evidence of goals and interventions for chronic pain and for the antidepressant, including side effect monitoring. The DON and Gardens Unit Manager reviewed Resident #40's care plan and confirmed it had not been developed and implemented for chronic pain or for the antidepressant.
Damaged Doors Created Accident Hazards
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards by allowing damaged doors and protective coverings to remain in place. On the Cove Unit, a small sitting room door had a broken door protector covering that was sticking out and sharp, and an LPN confirmed the finding during observation. In the lobby area leading to the units, the left wooden double door had a gouge with a chunk missing, exposing untreated wood and sharp edges, and the Administrator confirmed this observation. These conditions were identified during surveyor observations and interviews as hazardous and unsafe.
Unclean and Improperly Stored Oxygen Tubing
Penalty
Summary
The facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care. Facility policy stated that nasal cannula tubing should be detached and discarded once per week and that the concentrator particle filter should be removed and cleaned weekly. However, surveyors observed unbagged oxygen tubing connected to a concentrator next to one resident’s bed, and the tubing was stored on top of the concentrator rather than in a plastic drawstring bag when not in use. For another resident, surveyors observed unbagged nasal cannula tubing dated 3/24/26 connected to a portable oxygen tank on the back of a wheelchair, with the prongs in direct contact with the wheelchair seat cushion. Additional oxygen tubing was connected to the resident’s concentrator next to the bed, and the unbagged tubing was tucked under the blankets. The resident’s record showed an order for oxygen at 2 L/min via nasal cannula as needed and an order to change oxygen tubing weekly when in use, but the March 20206 Treatment Administration Record lacked evidence that the tubing was being changed or that the concentrator particle filter was being cleaned. RN #1 stated that oxygen tubing is stored in a plastic bag when not in use and is dated and labeled when changed, but she was not sure how often it was changed. The DON stated that oxygen tubing is changed weekly and stored in plastic bags when not in use.
Medication Error Involving Antibiotic Given Despite Documented Allergy
Penalty
Summary
A resident admitted with diagnoses including otitis media was prescribed and administered an antibiotic to which the resident had a known amoxicillin allergy. A physician progress note documented that the resident had left ear pain, had a fever over the weekend, and that because of the amoxicillin allergy, cefdinir 300 mg twice daily for 10 days would be used for otitis media. However, two antibiotic orders were entered for the same start date: Augmentin 875 mg/125 mg twice daily for 10 days and cefdinir 300 mg twice daily for 10 days. The Medication Administration Record showed that Augmentin was given during the afternoon medication pass and then discontinued later that day, while cefdinir was administered starting that night. A nursing progress note stated that two antibiotic orders were placed, cefdinir was not available in Pyxis, and Augmentin was given as the initial dose before pharmacy called to verify the order because of the resident’s amoxicillin allergy. Interviews with the unit manager, DON, and LPN confirmed that the resident received Augmentin despite the documented allergy and that the order had not been clarified before administration.
Improperly Maintained Garbage Dumpster
Penalty
Summary
The facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters over 2 of 4 days of survey. On 3/23/26 at 8:15 a.m., a surveyor observed the small garbage/refuse dumpster with the left-side slide door open and the right-side slide door missing, exposing garbage and refuse. On 3/24/26 at 8:07 a.m., the surveyor and a laundry staff member again observed the same small garbage/refuse dumpster with the left-side slide door open and the right-side slide door missing, exposing garbage and refuse. The laundry staff member confirmed the findings, and the surveyor discussed the two observations with the Administrator at 8:10 a.m. on 3/24/2026.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that written transfer/discharge notices and bed hold notices were provided to the resident and/or the resident's legal representative for 4 of 4 sampled residents who were transferred or discharged to an acute care facility. Resident #5's clinical record showed transfer to an acute hospital, but there was no evidence that a written transfer/discharge notice or bed hold notice was issued to the resident's representative. Resident #56's record similarly showed transfer to an acute hospital without evidence of a written transfer/discharge notice or bed hold notice being provided to the resident's representative. Resident #86 was transferred to an acute care hospital and later admitted on 2/21/26; although the record contained a Notice of Transfer or Discharge/Bed Hold Policy dated 2/21/26, there was no evidence that the notice was provided in writing to the resident's representative. Resident #17's record also showed transfer to an acute hospital without evidence that the facility issued a written transfer/discharge notice or bed hold notice to the resident's representative. During interviews on 3/25/26, the Social Service Manager confirmed the facility does not send transfer/discharge notices and bed hold notices in writing to resident representatives, and an LSW stated that a packet with the notices goes with the resident and the Ombudsman is notified, but the notices are not sent in writing to the resident representatives.
Deficiency in Oral Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene care for two residents, leading to deficiencies in their daily living activities. Resident #40 was observed multiple times with a thick whitish substance coating their teeth at the gum line, indicating a lack of proper oral care. Despite the resident's moderate cognitive impairment and need for assistance as documented in their care plan, staff did not consistently provide the necessary support. The resident's care plan indicated a requirement for limited to extensive assistance with personal hygiene, yet observations and interviews revealed inconsistencies in the care provided. Similarly, Resident #10, who is also moderately impaired and dependent on staff for oral hygiene, expressed dissatisfaction with the frequency of oral care. The resident reported having to remind staff to assist with brushing their teeth, and documentation showed gaps in oral care being completed after meals. The CNA responsible for Resident #10 acknowledged forgetting to assist with oral hygiene, despite the resident's expressed need and care plan requirements for extensive assistance. These findings highlight a failure to adhere to the care plans and provide necessary assistance for activities of daily living, specifically in the area of oral hygiene.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner during two separate kitchen tours. On the first tour, surveyors observed built-up ice on the fans and ceiling of the walk-in freezer, as well as chipped and peeling paint on the hood frame above the grill. These observations were confirmed with the Food Service Supervisor (FSD) and the Food Service Manager (FSM), who acknowledged that the walk-in freezer had been recently serviced for the ice build-up. During a subsequent tour, surveyors noted a thick layer of dust on the dishwasher hood exhaust vent and a visibly soiled face cloth wrapped around a fluid line at the prewash sink. The FSD mentioned that maintenance was aware of the issue and had ordered a part, but was unsure of how long the condition had persisted. The maintenance staff later removed the face cloth, stating there was no leak, and indicated they had not been notified of any issues. The FSM provided a Warewash Service Report from the servicing company, which lacked evidence of a review of the prewash sink and rinse line, suggesting the face cloth was placed after the service date.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain and implement an effective infection control program, as evidenced by multiple observations and interviews during the survey. On two separate days, staff did not adhere to the required contact precautions for a resident with Extended-Spectrum Beta-Lactamase (ESBL) in the urine. Despite a contact precaution sign and a PPE cart outside the resident's room, housekeeping staff and CNAs were observed entering the room wearing only gloves, contrary to the facility's policy that required both gloves and gowns. The Cove Unit Nurse Manager and the Administrator provided conflicting information about the necessity of wearing gowns, indicating a lack of consistent understanding and implementation of the infection control policy. Additionally, the facility demonstrated a lack of proper disinfection practices for shared medical equipment, particularly concerning Clostridioides difficile (C. diff) contamination. Interviews with various staff members, including CNAs and nurses, revealed a lack of awareness and training on the appropriate disinfectants to use. The Infection Preventionist, who had been in the role for four years, admitted to not providing education on infection control practices and incorrectly identified the use of Super Sani Cloth Germicidal Wipes, which are ineffective against C. diff, as the appropriate disinfectant. This indicates a significant gap in the facility's infection control education and practices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by the lack of antibiotic use protocols and a system to monitor antibiotic use. The facility's policy on infection control, last revised on May 24, mandates tracking and trending of infection control rates and antibiotic use, assessing appropriate and safe use of antibiotics, and ensuring evidence-based practices. However, the Infection Preventionist did not track whether cultures were completed, what the culture results indicated, or if the correct antibiotics were used. Additionally, there was no communication with medical doctors and pharmacists regarding antibiotic usage, and the Infection Preventionist did not cohort residents or track which residents were on precautions and why. Interviews with the Clinical Nursing Supervisor/Infection Preventionist and the Director of Nursing revealed that the facility was not tracking the use of Multi-Drug Resistant Organisms as per the facility's antibiotic stewardship policy. The Infection Preventionist's monthly log for antibiotics lacked evidence of monitoring antibiotic use, infection trends, organism clusters, and types of antibiotics used. The Director of Nursing confirmed the absence of tracking for Multi-Drug Resistant Organisms, and the Administrator Director was informed of these deficiencies during an interview.
Failure to Conduct PASRR Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred for a Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination. The resident, who was readmitted to the facility with a diagnosis of bipolar disorder, had a PASRR Level I assessment indicating a Convalescence Categorical exemption, which is a time-limited 30-day exemption. However, the resident's clinical record did not show evidence of a re-evaluation for a PASRR Level II determination after the convalescent period ended. This deficiency was confirmed by the Care Manager Supervisor during an interview.
Lack of Physician Order and Diagnosis for Foley Catheter
Penalty
Summary
The facility failed to obtain a physician's order with a supporting diagnosis for the use of an indwelling foley catheter for a resident. Additionally, the physician order for the foley catheter did not include the size of the catheter and the size of the catheter balloon. During an interview, the resident expressed unawareness of the reason for having the catheter, stating that they did not have one at home and wished it could be removed. Interviews with the nursing staff revealed uncertainty about the medical diagnosis justifying the catheter's use, with explanations provided that were not supported by a documented medical diagnosis. The resident was admitted with multiple diagnoses, including malignant neoplasm of the brain, unspecified convulsions, and seizure disorder, among others. The admission records indicated catheter care orders but lacked evidence of a diagnosis or provider notes acknowledging the necessity of the indwelling foley catheter. The Administrative Director confirmed the absence of documentation related to the catheter's medical justification, highlighting a deficiency in the facility's documentation and communication processes regarding the resident's care plan.
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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