Odd Fellows Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Maine.
- Location
- 85 Caron Lane, Auburn, Maine 04210
- CMS Provider Number
- 205170
- Inspections on file
- 14
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Odd Fellows Health Care Center during CMS and state inspections, most recent first.
A resident with severe dementia and agitation had a PRN order for Seroquel 25 mg twice daily that was written without a stop date and remained in effect beyond the required 14‑day limit. Record review showed no documented clinical rationale to support continuation of this PRN antipsychotic beyond 14 days or to justify an extended time frame, and the DON confirmed that the order did not meet the 14‑day requirement.
Surveyors found that the facility failed to develop, update, and implement accurate care plans for multiple residents. Two residents were repeatedly transferred by CNAs using manual stand-pivot techniques under the arms, despite existing ADL care plans and CNA assignment sheets requiring use of a mechanical lift, sit-to-stand device, or specified assistive equipment and staffing levels. In addition, a resident receiving hospice/palliative care had no corresponding hospice or palliative care plan or interventions in place, and another resident who was always incontinent of bowel and bladder per the MDS had no care plan addressing incontinence. The DON confirmed that these care plans did not reflect the residents’ current needs.
A resident with cerebral palsy and a documented need for extensive ADL assistance, including an oral care routine, was observed on multiple occasions with a white, thick coating at the gum line and reported not receiving staff help with tooth brushing. Review of CNA records showed no documentation of personal hygiene care, and an LPN stated that after a switch to an online documentation system, personal hygiene items were not added for CNAs to record care or assistance levels, resulting in a lack of documented oral hygiene services.
Surveyors found that the facility failed to remove expired medications and biologicals from active stock in both a medication cart and the medication room. During an observation with an LPN, multiple opened and unopened products, including ibuprofen, aspirin, calcium carbonate, vitamin D, vitamin B complex, multivitamins, a Fleets enema, and bisacodyl suppositories, were noted with past expiration dates yet remained stored as available for use in the cart, medication room, and medication refrigerator. These findings were discussed with the DON.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and did not follow its own policies for food labeling, dating, and dish machine temperature monitoring. During a kitchen tour with the FSD, dust and dirt were observed on metal ductwork above food prep areas, food debris and trash were present on floors under equipment and shelving, and dried food residue was found on the cook stove, a solid floor pad with chipped paint, a food mixer, a food processor and its table, and a dish room food disposal unit, along with a heavily soiled wall-mounted fan. In the reach-in refrigerator, pizza dough and multiple bags of whipped topping were unlabeled and undated, and in the walk-in freezer, large bags of popcorn chicken were also unlabeled and undated, despite policies requiring labeling, dating, and disposal of expired items, and documentation of daily dish machine temperatures.
A resident receiving Duloxetine for alcohol abuse and Trazodone for anxiety-related behaviors had psychoactive medications administered without documented informed consent. Physician orders directed routine and PRN dosing, but the medical record contained no evidence that the resident or representative was informed of the risks and benefits of these treatments or that consent was obtained. The Administrator and DON confirmed the absence of this documentation during surveyor interviews.
Surveyors found that housekeeping and maintenance services were inadequate to maintain sanitary, orderly, and comfortable conditions on two wings, a hallway, and the laundry room. Observations included stained ceiling tiles, chipped and missing paint on baseboard and wall heaters creating uncleanable surfaces, a dining room television stand with missing sealant exposing untreated wood, and a dusty floor fan. In a resident room, surveyors noted dirty, yellow-stained caulking around the toilet base, a dirty glove and soiled towel on the floor under the sink, and a baseboard heater with chipped paint. In the laundry room, the painted cement floor and metal floor drain cover had chipped paint, the drain cover was heavily rusted, and multiple ceiling tiles were stained, all of which were confirmed by the Administrator and Maintenance Director during the tour.
The facility failed to implement and support an effective infection prevention and control program when a resident on contact precautions for ESBL in the urine was cared for by an LPN who entered and exited the room to administer medications without donning required PPE, despite posted instructions and available supplies. Staff interviews revealed misunderstanding of when gowns and gloves were required and lack of familiarity with EBP, with a CNA stating the facility does not use EBP and that PPE is not needed if direct care is not provided. Review of the infection control manual showed no written EBP policies, and the DON acknowledged she had assumed EBP were in place but was unaware they were not included in the manual.
The facility did not ensure that a qualified Infection Preventionist (IP) was in place to oversee the infection prevention and control program. After the previous IP left, another staff member was asked to assume the IP role without having completed the required infection prevention training. Documentation showed that this staff member did not finish the necessary training until several weeks later, and the facility could not provide evidence of required training prior to the staff member taking on IP responsibilities. This lapse had the potential to affect all residents.
The facility failed to maintain and post current daily nurse staffing information. On two separate survey days, the only posted staffing data was more than a month old, and it did not reflect the current day’s breakdown of RNs and LPNs responsible for direct resident care or the shifts covered. The DON confirmed that there was no current staffing posting available at the time of the survey.
The facility failed to maintain an effective infection control program, as staff did not consistently use or provide PPE, did not implement or document transmission-based precautions during a GI illness outbreak, and did not maintain comprehensive infection surveillance records. The Legionella water management policy was incomplete, and there were additional lapses such as a nurse administering eye drops without gloves and facility cats being allowed on food preparation and dining surfaces without proper cleaning.
The facility did not assign a qualified staff member to serve as a dedicated Infection Preventionist (IP) for at least 24 hours per week. Instead, the DON was performing both her full-time duties and the IP role, despite having completed IP training, and was unaware that both roles could not be held simultaneously.
Surveyors found that the facility did not include necessary goals and interventions in the care plans for residents with COPD, congestive heart failure, cardiac pacemaker, and those requiring pain management. Despite updated care plans and active medication orders, the plans lacked documentation addressing these specific medical needs, as confirmed by nursing leadership.
A resident who required substantial assistance with personal hygiene was repeatedly observed over several days with a pinky ring coated in white dried debris, despite receiving help from CNAs. Assessment and documentation confirmed the resident's dependence on staff for personal hygiene, but the issue persisted and was noted by surveyors.
The facility did not ensure that staff maintained current CPR certification as required by its own policy, resulting in multiple shifts where no certified personnel were present. Interviews with the DON and ADON confirmed that only nurses were required to be certified, and staffing records showed repeated gaps in coverage. Four residents were identified as Full Code and could require CPR, while all residents were at risk for choking.
Two residents requiring continuous oxygen therapy were observed using nasal cannulas and tubing that were either discolored, undated, or not changed according to the facility's policy, which requires tubing changes every two weeks. Documentation and staff interviews confirmed that tubing was being changed monthly instead, resulting in a failure to maintain a sanitary environment and adhere to infection control procedures.
Surveyors found that medications were not properly labeled, dated, or disposed of according to manufacturer instructions. An LPN was observed with an opened, unlabeled vial of Tuberculin Purified Protein Derivative in the medication room refrigerator, and two opened bottles of Lumigan eye drops with different expiration dates in the medication cart. Additionally, a medicine cup containing a pill for the facility's house cat and the cat's Phenobarbital tablets were stored with resident medications, contrary to policy.
Surveyors found the kitchen and food service areas to be unsanitary, with dirty floors, walls, and equipment, and observed staff failing to wear required hair and beard coverings or perform proper hand hygiene while serving and preparing food. These deficiencies were confirmed by facility leadership and were not in accordance with facility policy.
Surveyors found that clinical records were incomplete and inaccurate for two residents. An LPN documented daily application and removal of a resident's hearing aids in the MAR, but admitted this was not done unless requested by family, contrary to physician orders. Additionally, ADL documentation for another resident was missing for several days. These issues were confirmed through interviews, observations, and record reviews.
Four residents did not have documentation showing they received, were offered, or refused the pneumococcal vaccine as required by facility policy. The ADON confirmed that assessments and vaccine offers had not occurred due to the absence of a clinic, despite policy requiring timely assessment and offering of the vaccine upon admission.
A review of CNA employee education records showed that several CNAs did not complete the required 12 hours of annual in-service education or the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. The DON confirmed the lack of documentation for these trainings.
A resident's MDS assessments were not accurately coded to reflect their active diagnoses of HTN, hyperlipidemia, and diabetes. Review of the medical record and interview with the DON confirmed that these conditions were omitted from the Active Diagnosis section of the MDS.
A resident with a documented history of PTSD was not assessed for trauma triggers, and their care plan lacked trauma-informed interventions. The facility's staff confirmed that no assessment for PTSD or trauma-informed care was conducted.
Staff did not consistently ensure resident dignity during care, as evidenced by multiple residents being observed with their incontinence briefs exposed or not fully dressed during daily activities such as ambulation and meals. Some staff acknowledged the lapses but did not take immediate action to address them, and at least one resident expressed discomfort with the situation.
Noncompliant PRN Antipsychotic Order Exceeding 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication order complied with the required 14‑day limit. Record review on 2/17/26 showed that Resident #9, who had severe dementia with agitation, had a current physician order dated 1/19/26 for Seroquel 25 mg twice daily PRN for agitation, with no stop date. The medical record did not contain documentation of clinical rationale to support continuation of this PRN antipsychotic medication beyond the 14‑day period or to justify an extended time frame. In an interview on 2/17/26 at 2:20 p.m., the Director of Nursing confirmed that the PRN Seroquel order initiated on 1/19/26 did not meet the required 14‑day limit. This lack of a stop date and absence of documented clinical justification for extending the PRN psychotropic medication order led to the cited deficiency for unnecessary medications for 1 of 5 residents reviewed.
Failure to Develop and Implement Accurate Care Plans for Transfers, Incontinence, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to develop, update, and implement comprehensive care plans that accurately reflected residents’ transfer, incontinence, and hospice/palliative care needs. For one resident, surveyors observed CNAs transferring the resident between a wheelchair and recliner by lifting under the arms and performing a pivot transfer, with one CNA needing to grab the resident’s pants to assist with weight support. The resident’s ADL care plan stated the resident may use a hemi-walker to transfer and may use a stand/pivot lift when weak, and the falls care plan indicated use of a hemi-walker and stand/pivot lift as needed. The current CNA assignment sheet listed the resident as a sit-to-stand transfer, but CNAs reported using 1–2 person stand-pivot transfers, sometimes with a walker and sometimes without a sit-to-stand lift, indicating that the care plan and assignment sheet were not being followed or consistently implemented. Another resident, admitted in January 2026, was repeatedly observed being transferred by CNAs using a manual pivot transfer under the arms from wheelchair to recliner and from bed to wheelchair, despite the ADL care plan requiring a mechanical lift with two staff assistance for transfers and the CNA assignment sheet listing the resident as a two-assist with walker. The facility also failed to develop care plans for specific clinical conditions identified in residents’ assessments. One resident’s quarterly MDS documented that the resident was receiving hospice care, and the medical record showed the resident had started palliative care on 1/16/26, yet as of 2/17/26 there was no evidence of a care plan or interventions addressing palliative care needs; the DON confirmed the care plan did not reflect this resident’s current needs. Another resident’s annual MDS indicated the resident was always incontinent of bowel and bladder, but as of 2/17/26 there was no care plan or interventions addressing bowel and bladder incontinence, and the DON similarly confirmed that the care plan did not reflect the resident’s current needs.
Failure to Provide and Document Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate ADL care in the area of personal hygiene, specifically oral care, for one resident over two days of survey. On two separate observations, the resident’s teeth were noted to have a visible white, thick coating at the gum line. The resident, who has a self-care deficit related to cerebral palsy and is care planned to need extensive assistance with ADLs, including set-up with a basin each morning and assistance as needed, stated that staff do not help with tooth brushing and that the resident performs this independently. The resident’s care plan also included an intervention for an oral care routine to brush teeth. Review of CNA documentation for the month showed no evidence that personal hygiene care was being completed. During an interview, an LPN reported being unable to locate documentation of personal hygiene and explained that the facility had recently transitioned to an online documentation system but failed to add personal hygiene items for CNAs to document the care provided and the level of assistance needed. This concern was subsequently discussed with the Director of Nursing.
Expired Medications and Biologicals Left Available for Use in Medication Cart and Room
Penalty
Summary
Surveyors identified a failure to ensure that medications and biologicals available for use were free of expired products during an observation of one medication cart and the medication storage room with an LPN. On the medication cart, surveyors observed an opened bottle of ibuprofen 200 mg tablets with an expiration date of 12/2025, an opened bottle of calcium carbonate 500 mg tablets with an expiration date of 1/2026, an opened bottle of aspirin 325 mg with an expiration date of 10/2025, and an opened bottle of vitamin D 10 mcg with an expiration date of 12/2025, all still available for use. In the medication storage room, surveyors found one Fleets enema with an expiration date of 8/2024, two bottles of aspirin 325 mg with expiration dates of 4/2025 and 5/2025, one bottle of calcium carbonate 500 mg tablets with an expiration date of 1/2026, one bottle of vitamin D 10 mcg with an expiration date of 11/2024, three bottles of vitamin B complex with expiration dates of 11/2025, and two bottles of multivitamins with expiration dates of 11/2025, all stored as available stock. The medication room refrigerator also contained one opened box of bisacodyl suppositories with an expiration date of 11/2025. These findings were discussed with the DON on the same day. The deficiency centers on the facility’s failure to remove expired medications and biologicals from active stock in both the medication cart and medication room, despite their continued availability for use as observed by surveyors.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Labeling/Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a clean and sanitary condition and to follow its own policies for labeling, dating, and monitoring food and dishwashing temperatures. During a kitchen tour with the Food Service Director, surveyors observed dust and dirt buildup on metal ductwork above food preparation areas, food debris and trash on the kitchen floor including under equipment and shelving, and dried food particles and liquid residue on the cook stove surfaces. The solid floor pad under the stove had chipped and missing paint, creating an uncleanable surface. Additional equipment, including a food mixer, a food processor and the table it sat on, and the dish room food disposal unit, had dried food particles and dried liquid residue. A wall-mounted fan in the dish room was heavily soiled with dust and dirt. Surveyors also found that the facility did not follow its Labeling & Dating Procedure and Temperature Log Policy. In the reach-in refrigerator, there was a large plastic container of pizza dough balls that was unlabeled and undated, and four bags of whipped topping without thaw dates, despite manufacturer directions that the product was good for two weeks after thawing. In the walk-in freezer, two large bags of popcorn chicken were unlabeled and undated. The facility’s policies required all items to be labeled and dated when opened or prepared, with expiration dates and disposal of expired items, and required dish machine temperatures to be reviewed and recorded on each shift. Daily dishwasher temperatures were not monitored or documented as required. The Food Service Director confirmed these findings during the surveyor interview.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consent for psychoactive medications for one resident. The resident was admitted in May 2025 and had physician orders dated 12/16/25 for Duloxetine HCl delayed-release capsules 60 mg once daily related to alcohol abuse, and for Trazodone HCl 50 mg, with instructions to give 0.5 tablet at bedtime and 0.5 tablet every 12 hours as needed for aggressive or "on edge" behavior related to an anxiety disorder. Review of the resident’s medical record showed no evidence that the resident or the resident’s representative had been informed of the risks and benefits of these psychoactive medications and no documentation that consent to treatment with these medications had been obtained. On 2/18/26 at 8:20 a.m., during an interview with a surveyor, the Administrator and the Director of Nursing confirmed that the medical record lacked documentation of informed consent and discussion of risks and benefits for the prescribed psychoactive medications.
Environmental and Housekeeping Deficiencies in Resident Care Areas and Laundry
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment during an environmental tour of the East and [NAME] Wings, an inter-unit hallway, and the laundry room. In the hallway between units, three ceiling tiles had brown stains and the baseboard heating unit had chipped and missing paint, creating uncleanable surfaces. On the [NAME] Wing, the wooden television stand in the dining room had missing surface sealant exposing untreated wood, the large standing floor fan in the corner was dusty and dirty, and in one resident room the caulking around the base of the toilet was yellowish and dirty, with a dirty glove and soiled towel on the floor under the sink and a baseboard heater with chipped and missing paint. On the East Wing, the solarium baseboard heater and the dining room wall heating unit also had chipped and missing paint, creating uncleanable surfaces. In the laundry room, the painted cement floor had chipped and missing paint in many areas, the large metal floor water drain cover had chipped and missing paint and was heavily rusted, and five ceiling tiles had brown stains, all contributing to uncleanable and unsanitary conditions. These conditions were observed by the surveyor during the tour and were confirmed in an interview with the Administrator and the Maintenance Director at the time of the survey.
Failure to Implement Contact Precautions and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to establish and implement written infection prevention and control policies and procedures consistent with nationally recognized guidelines, including Enhanced Barrier Precautions (EBP), and to prevent transmission of communicable diseases. A Contact Precautions sign was posted on the door of a resident’s room instructing staff to perform hand hygiene before entering and exiting, don gloves and gown prior to room entry, discard them before exiting, and use dedicated or disposable equipment with appropriate cleaning and disinfection of reusable equipment. A PPE cart was present outside the room. Despite these posted instructions, an LPN was observed entering the room to administer medication without donning any PPE and exiting the room without wearing a gown or gloves. When questioned, the LPN stated that the sign was for staff providing care and that she was only giving medication, acknowledged not wearing PPE, and described contact precautions as requiring gloves and gowns only when providing personal care for residents with colostomies or Foley catheters. She also stated she was not familiar with EBP. Further interviews showed inconsistent understanding and implementation of infection control practices among staff. A CNA reported having received infection control training, including contact precautions and EBP, but stated the facility does not utilize EBP and only uses contact precautions, and that gowns and gloves are not required if staff are not providing direct care. The resident in the room had a documented history of ESBL in the urine and required extensive assistance with activities of daily living, including personal care. Review of the facility’s Infection Control Manual, last updated in April 2025, showed no written policies or procedures addressing EBP. In an interview, the DON stated she assumed EBP were implemented in the facility and was unaware they were not included in the facility’s infection control manual.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to be responsible for the Infection Prevention and Control Program for the period from 8/8/25 to 8/29/25. During an interview on 2/18/26 at 1:57 p.m., the DON reported that the previous IP left employment on 8/7/25 and that another staff member was asked to assume the IP role starting 8/8/25. Review of training documentation showed that the newly designated IP did not complete the required infection prevention training until 8/29/25, and the facility could not provide any documentation that this individual had completed the required IP training before assuming responsibility for the Infection Prevention and Control Program. On 2/25/26 at 3:00 p.m., the Administrator confirmed these findings. This failure to have a qualified, trained individual in place as the IP during that time frame had the potential to affect all residents in the facility.
Failure to Maintain Current Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post the current daily nurse staffing information as required, including the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care, and the shifts to which those numbers corresponded. On two separate survey days, the only posted nurse staffing information available was dated more than a month earlier. On the first survey day at 8:36 a.m., the surveyor observed that the posted nurse staffing information was for 1/7/26. On the second survey day at 8:10 a.m., the surveyor again observed that the posted nurse staffing information was for 1/7/26. Later that morning, at 10:04 a.m., the DON confirmed to the surveyor that there was no current posting of the staffing.
Infection Control Program Deficiencies and Lapses in Policy Adherence
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple lapses in infection surveillance, implementation of transmission-based precautions, and adherence to established policies. During a gastrointestinal illness outbreak affecting both residents and staff, staff interviews revealed inconsistent use and availability of personal protective equipment (PPE), lack of transmission-based precaution signage, and failure to consistently isolate symptomatic individuals. Staff reported that gowns were not readily accessible on the units, and that residents with only diarrhea were not always kept in their rooms. Documentation of the outbreak was incomplete, with the infection preventionist unable to provide comprehensive tracking forms, line lists with symptom onset and resolution dates, or evidence of interventions taken. Medical records for affected residents lacked documentation of symptoms, physician or family notification, and implementation of precautions. The facility's Legionella Water Management Program was found to be inadequate, consisting only of a brief policy referencing bi-weekly water temperature checks without a detailed water system flow diagram, control measures, monitoring protocols, or documentation of testing results and corrective actions. When requested, the administrator was unable to provide additional documentation or evidence of a comprehensive water management plan, relying instead on city testing and a single-page policy. Additional infection control deficiencies were observed, including a nurse administering eye drops to a resident without wearing gloves, contrary to facility policy, and repeated observations of facility cats on kitchenette countertops and dining room tables. Staff acknowledged that cats frequently accessed these surfaces, which were not cleaned after each incident, despite the facility's pet policy requiring removal and disinfection when pets violate these boundaries. These lapses in infection control practices and policy adherence had the potential to affect all residents in the facility.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. During an interview, the Director of Nursing (DON) confirmed that she was functioning as both the full-time DON and the IP, despite having completed her IP training. The surveyor determined that the facility did not have a dedicated IP working at least 24 hours per week in that role, as required. The DON stated she was unaware that she could not fulfill both roles simultaneously, which resulted in the absence of a staff member dedicated to infection prevention and control.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
Surveyors observed that the facility failed to develop and implement complete care plans addressing all identified needs for several residents. Specifically, one resident with COPD requiring continuous oxygen and peripheral neuropathy managed with Gabapentin did not have documented goals or interventions for COPD or pain management in their care plan, despite recent updates. Another resident with congestive heart failure, respiratory failure requiring continuous oxygen, and a cardiac pacemaker also lacked care plan goals and interventions for both heart failure and the presence of the pacemaker, even though regular pacemaker checks were ordered. Additionally, a third resident with an active order for Tramadol for pain management did not have any documented goals or interventions related to pain management in their care plan. These deficiencies were confirmed through observations, medical record reviews, and interviews with facility nursing leadership, indicating a failure to update and implement individualized care plans for residents with significant medical needs.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) in the area of personal hygiene for a resident who required substantial to maximal assistance. Over a three-day period, the resident was repeatedly observed with a pinky ring coated in white dried debris, despite being offered and receiving assistance with dressing and personal care. Documentation and assessment records confirmed the resident's need for significant help with personal hygiene, yet the issue with the soiled ring persisted across multiple observations by surveyors. The deficiency was discussed with facility leadership during the survey.
Failure to Maintain CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all staff maintained current certification in cardiopulmonary resuscitation (CPR) for Healthcare Providers, as required by facility policy. During interviews, the DON and ADON stated that only nurses were required to have CPR certification, and a review of employee records confirmed that only two full-time and two per-diem staff members were CPR certified. Staffing records for the month of March revealed multiple shifts, including day, evening, and night shifts, where no staff members present held current CPR certification. The facility's own Cardiopulmonary Policy requires that key clinical staff, including non-licensed personnel, maintain CPR/BLS certification and that each shift have a designated CPR team consisting of at least one nurse, one LPN, and two CNAs, all with current certification. Despite this policy, there were numerous shifts with no certified staff available. At the time of the review, four out of twenty-four residents were identified as Full Code, meaning they could potentially require CPR, and all residents were noted to be at risk for choking.
Failure to Follow Oxygen Tubing Change Policy for Residents on Continuous Oxygen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to its own policy regarding the frequency of oxygen tubing changes for two residents requiring continuous oxygen therapy. Observations revealed that one resident with COPD was using a nasal cannula with discolored prongs and undated tubing, despite a physician order and documentation indicating monthly tubing changes. The facility's policy, however, required oxygen tubing to be changed at least every two weeks. Another resident with congestive heart failure and respiratory failure was observed with an undated nasal cannula on one occasion and tubing dated nearly a month prior on another, also in contradiction to the facility's two-week change policy. Review of the Treatment Administration Records for both residents showed documentation of monthly tubing changes, which did not align with the facility's updated policy. During an interview, the Director of Nursing confirmed that oxygen tubing should be changed every two weeks as per policy, acknowledging the discrepancy between practice and policy. These findings demonstrate a failure to follow established infection control procedures related to respiratory care for residents requiring continuous oxygen supplementation.
Improper Medication Storage, Labeling, and Disposal
Penalty
Summary
Surveyors observed that the facility failed to properly label, date, and dispose of medications in accordance with manufacturer specifications and professional standards. In the medication room, an opened and unlabeled vial of Tuberculin Purified Protein Derivative was found in the refrigerator, despite manufacturer instructions to discard the vial 30 days after opening. On the medication cart, two opened bottles of Lumigan eye drops were present, one with an expiration date of 2024/08 and the other with an expiration date of 2025/02, and an unlabeled medicine cup containing a small white pill was also found. Further investigation revealed that the pill was medication intended for the facility's house cat, and the cat's Phenobarbital tablets were stored in a cabinet in the medication room. The LPN stated that it was the nurse's responsibility to administer the cat's medication, and the pill was left in the cart because the cat could not be located at the time. These findings indicate that expired and unlabeled medications were not removed from use, and non-resident medications were stored alongside resident medications.
Sanitation and Staff Hygiene Deficiencies in Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and hygiene deficiencies in the facility's kitchen over a three-day period. The kitchen floor, walls, and dishwasher were found to be dirty, with food debris and trash present throughout the area, including under equipment and shelving. Additionally, the stand mixer and food processor were also covered with dirt and debris. These findings were confirmed with both the Director of Food Services and the Facility Administrator during the survey. Staff were also observed failing to follow proper hygiene protocols. A Certified Nursing Assistant was seen serving food trays without wearing required hair protection and did not perform hand hygiene after touching her hair and clothing until prompted by the surveyor. Further observations included a kitchen staff member prepping food without beard protection and a dietary aide working in the kitchen without a hair net. Facility policy requires continuous use of hair and beard restraints and handwashing after touching any part of the body or clothing, but these protocols were not followed as observed and confirmed by supervisory staff.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, an LPN documented in the Medication Administration Record (MAR) that bilateral hearing aids were applied each morning and removed at night, as per physician orders, but stated during observation that the hearing aids were not actually put in unless requested by the family, despite daily documentation indicating otherwise for two months. Additionally, review of another resident's Activities of Daily Living (ADL) documentation revealed that Certified Nurses Aides did not complete ADL care documentation for 3 out of 19 days reviewed. These findings were confirmed through interviews, observations, and record reviews, and discussed with facility leadership.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for four out of nine residents whose immunization records were reviewed. Specifically, the medical records for these residents either lacked evidence that the pneumococcal vaccine had been administered, offered, or refused, as required by facility policy. For example, one resident had documentation of receiving the Pneumococcal conjugate vaccine 13 several years prior, but there was no record of subsequent vaccination, offer, or refusal. Another resident, admitted in March 2023, had no documentation of receiving, being offered, or refusing the pneumonia vaccine, and the Assistant Director of Nursing (ADON) confirmed that there was no proof of vaccination and that the resident had not been offered the vaccine. Similar documentation gaps were found for two other residents, including one whose only record of vaccination dated back to 1998. Interviews with the ADON confirmed that the required assessment and offering of the pneumococcal vaccine had not occurred for these residents, with the ADON stating that vaccines had not been offered because a clinic had not been held. The facility's own policies, updated in February 2025, require that all residents be assessed for vaccination status upon admission and be offered the pneumococcal vaccine series within thirty days unless medically contraindicated or already vaccinated. The lack of documentation and failure to offer or assess for the vaccine as outlined in policy led to the identified deficiency.
Failure to Ensure Required CNA Annual Training and Mandatory In-Services
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, as well as mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. A review of employee education records for five CNAs employed for more than one year revealed that none had documentation of completing the required 12 hours of continuing education for the year 2024. Additionally, three of these CNAs lacked evidence of having attended the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. These findings were confirmed during a review of employee files, which showed missing or incomplete in-service attendance records for each CNA. The Director of Nursing verified the absence of documentation for the required trainings. The deficiency was identified through record review and staff interview, with no evidence provided to show that the CNAs had met the annual training requirements.
Inaccurate Coding of Active Diagnoses on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded for one resident. Record review showed that the resident had documented diagnoses of Hypertension, Hyperlipidemia, and Diabetes. However, the resident's Quarterly MDS assessments did not include these diagnoses under the Active Diagnosis section. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS assessments did not accurately reflect the resident's current medical status.
Failure to Assess and Care Plan for PTSD/Trauma-Informed Care
Penalty
Summary
The facility failed to identify and assess a resident's history of Post-Traumatic Stress Disorder (PTSD) to determine potential triggers and methods to prevent re-traumatization. Record review showed that the resident's medical history included a diagnosis of PTSD, as documented in multiple provider progress notes. However, there was no evidence in the medical record that the facility conducted an assessment to identify specific trauma triggers or developed interventions to prevent re-traumatization. Additionally, the resident's care plan did not include trauma-informed approaches or interventions related to their PTSD. During interviews, both the Licensed Social Worker and the Director of Nursing confirmed that the facility does not assess residents for PTSD or trauma-informed care.
Failure to Maintain Resident Dignity During Care Activities
Penalty
Summary
Staff failed to maintain resident dignity and respect during daily care activities, as evidenced by multiple observations. On one occasion, a resident was assisted in ambulating from the dining room to their room with their clothing open, exposing their incontinence brief. The staff member assisting the resident acknowledged the situation but continued to allow the resident to walk with their brief exposed. In another instance, a resident was observed eating breakfast in the dining room while only partially dressed, wearing a [NAME] and a zip-up sweatshirt. When asked, the resident expressed discomfort with not being fully dressed and stated a preference to be dressed daily before meals. Additionally, another resident was seen walking in the dining room with assistance from a CNA, with their clothing open and incontinence brief exposed. The CNA stated that she typically covers residents to prevent exposure but did not do so in this instance, as she was taking the resident to the bathroom. These incidents were observed and discussed with facility leadership, highlighting a pattern of staff not consistently ensuring residents' privacy and dignity during care and daily routines.
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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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