Orchard Park Rehab & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Maine.
- Location
- 107 Orchard Street, Farmington, Maine 04938
- CMS Provider Number
- 205168
- Inspections on file
- 19
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Orchard Park Rehab & Living Center during CMS and state inspections, most recent first.
Surveyors identified widespread environmental and housekeeping deficiencies across three units, the therapy room, a common area, and the laundry room. Cooking dishes were stored under a therapy room sink near the drainpipe. Multiple resident rooms had privacy curtains in disrepair, rusty and chipped baseboard heaters, damaged bathroom doors with exposed unsealed wood, and a rusty toilet water line escutcheon. Hallways on two units had numerous chipped and broken floor tiles, and a whirlpool room had damaged walls, ripped and missing linoleum, rusty ceiling components, and a dirty, stained, and cracked whirlpool tub with soiled jets and intake screen. Additional findings included a damaged bathroom ceiling tile around a sprinkler head, cracked floor tiles and chipped paint in a shower room, stained ceiling near a nurse’s station, a broken ramp handrail, and laundry equipment and carts held together with Velcro and duct tape. These conditions were confirmed by the DON, Maintenance Director, and Director of Environmental Services.
Two residents were transferred multiple times to acute care hospitals, including ED visits and an admission for an intestinal blockage, without documented written transfer/discharge notices or bed-hold notices, including cost of care, being provided to their legal representatives. Clinical records and nursing notes confirmed the transfers and hospital admissions, but lacked evidence of the required written notifications. The LSW later acknowledged that there was no documentation of these notices and indicated that one ED transfer was viewed as a scheduled appointment, and thus she believed notices were not required.
A resident was found seated in a wheelchair with a sheet tied around their waist and johnny pants applied backwards, both secured in double knots, to prevent access to their brief. These actions, performed by a CNA without inclusion in the care plan, were determined to be abuse and use of a restraint, violating the resident's rights to dignity and respect.
A resident was found with a sheet tied around their waist and johnny pants applied backwards, both double knotted, restricting their ability to access their brief. A CNA implemented these measures, which were not part of the care plan, to prevent the resident from removing their brief. The CNA had received training on abuse and restraints but did not recognize the actions as inappropriate. The facility determined these actions constituted abuse and the use of a restraint, violating the resident's rights.
A resident was found with a sheet tied around the waist and johnny pants applied backwards, both secured in double knots, restricting movement and access to personal care items. A CNA performed these actions without including them in the care plan, intending to prevent the resident from removing their brief. The facility's policy defines such practices as physical restraint, and the CNA had previously received training on restraint use and resident rights.
The facility did not implement a policy to ensure staff received education on the COVID-19 vaccine, including its benefits and risks. The Infection Preventionist confirmed the absence of such education since the previous year, and the new employee packet lacked COVID-19 information. Interviews with the Maintenance Director, an LPN, and a facility clerk revealed they had not received education on the COVID Spikevax in the past year.
The facility failed to maintain a safe and clean environment, with issues such as broken fixtures, inadequate water temperatures, and non-operational dryers. A resident's room had a persistent urine odor due to a leaking foley bag, and wash basins were improperly stored on the bathroom floor. These deficiencies were confirmed by facility staff.
The facility failed to implement baseline care plans within 48 hours of admission for four residents, as required by policy. A resident with COPD and respiratory failure lacked a care plan addressing respiratory needs, while another with sleep apnea had no interventions for respiratory care. A resident with dementia had no care plan for behavioral needs, and another with multiple chronic conditions had no baseline care plan initiated. These deficiencies were confirmed by staff interviews.
A resident with severe cognitive impairment reported an unwitnessed fall, but the facility failed to complete a fall incident report, post-fall observation tool, or continued monitoring as required by policy. The resident's medical record lacked evidence of necessary documentation and monitoring for further injuries or neurological changes.
The facility failed to secure hazardous chemicals in an unlocked utility room, posing a risk to vulnerable residents. Despite the presence of Safety Data Sheets outlining potential harm, chemicals like disinfectants and hand sanitizers were observed unsecured on multiple survey days. The Acting DON and Infection Preventionist confirmed the unsafe storage, acknowledging the risk to confused and compromised residents.
The facility failed to maintain sanitary conditions and follow provider orders for respiratory care for three residents. A resident's nebulizer was left unbagged, and their oxygen concentrator was set below the prescribed rate. Another resident received oxygen at a lower rate than ordered, and a third resident's CPAP mask was improperly stored. These issues were confirmed by facility staff during observations.
The facility's kitchen was found to be unsanitary, with dusty and dirty hood system filters, wall air conditioning units, and walls. The ceiling grid hangers were rusty and stained, the floor fan was dusty, and the grease trap lid had chipped paint, creating an uncleanable surface. These issues were confirmed by the Food Service Director.
The facility failed to implement its Antibiotic Stewardship Program, as outlined in its policy, which aims to improve antibiotic use and prevent resistance. The Infection Preventionist did not have a system to monitor antibiotic use effectively, and the facility's quarterly reports lacked evidence of a review of antibiotic use. This deficiency could affect all residents receiving antibiotics.
A resident with severe cognitive impairment and a history of fractures fell while using a walker. The facility delayed notifying the medical provider by 20 hours and failed to promptly inform the resident's representative. The incident report and nursing documentation lacked necessary details and notifications.
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living. A resident with severe cognitive impairment was not receiving proper mouth care, resulting in significant tartar buildup. Another resident was observed in dirty clothes, highlighting a failure to maintain personal hygiene and dignity. These issues were confirmed by staff and a Quality Improvement Specialist.
A resident with type 2 Diabetes Mellitus received Novolog insulin doses outside of physician orders, which specified administration only for blood sugar levels above 110. Despite this, nursing staff administered insulin on several occasions when the resident's blood sugar was below 110, contrary to the care plan aimed at preventing diabetes complications. This was confirmed by Quality Improvement Specialists.
The facility's Quality Assurance Committee failed to ensure the effectiveness of corrective actions for previously identified deficiencies. During a follow-up survey, deficiencies F684 and F757 were cited again. F684 involved a failure to document and monitor a resident after an unwitnessed fall, while F757 involved a failure to ensure a resident's drug regimen was free from unnecessary medications. These issues were confirmed with the President of Quality Improvement and Nursing Services and the DON.
An LPN failed to maintain sanitary conditions during a lunch meal on the Cortland Unit by not sanitizing hands between resident contacts. The LPN handled a lunch tray, removed trash with bare hands, and touched a resident and a side table without using hand sanitizer, despite passing a sanitizer station. The DON confirmed the expectation for hand sanitization before and after resident contact.
Environmental and Housekeeping Deficiencies Across Multiple Units and Service Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and comfortable environment across multiple units and service areas. Surveyors observed multiple cooking dishes stored under the therapy room sink next to and below the drainpipe; this was confirmed by a COTA and the DON. During an environmental tour, surveyors, accompanied by the Maintenance Director and Director of Environmental Services, identified resident rooms on Cortland and Northern Spy units with privacy curtains missing hooks, hanging down, and in disrepair. In one Cortland resident room, the bathroom baseboard heater and room baseboard heater had chipped/missing paint and rust, creating uncleanable surfaces; the bathroom door’s protective surface was pulled away on both sides, and the bottom of the door was chipped/gouged with exposed unsealed wood. The same bathroom contained a wash basin on the floor under the sink and a toilet water fill line with a rusty escutcheon. Additional environmental issues were found throughout the facility. On Cortland, the hallway floor had seven chipped/broken tiles, and the whirlpool room had walls with chipped/missing paint and damaged sheetrock, ripped/missing linoleum at the wall corner and sink cabinet, ripped/missing flooring around the floor drain, split seams in the middle of the floor, a rusty ceiling light and ceiling grid, and a whirlpool tub that was dirty, yellow-stained, cracked, with soiled and stained water intake screen and jets. On Northern Spy, one resident room had a bathroom ceiling tile around a sprinkler head that was bubbled and bent, and the hallway floor had 32 chipped/broken tiles. On the [NAME] unit, six cracked/broken floor tiles and a shower room with chipped and missing paint on the walls were observed. In common areas, the ceiling near the nurse’s station had large brown stains, and a ramp handrail going downstairs was broken. In the laundry room, the left clothes dryer had Velcro tape holding the bottom lint door and tape on the door glass, and a three-shelf laundry cart had ripped and hanging duct tape on the bottom shelf. The Maintenance Director and Director of Environmental Services confirmed these findings.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge and bed-hold notices, including cost of care information, to residents and/or their legal representatives when residents were transferred to an acute care hospital. For one resident admitted in January 2024, the clinical record showed that the resident was transported to an acute care hospital on a specified date, but there was no documentation that the resident or the resident’s representative received a written transfer/discharge notice or a written bed-hold notice for that transfer. For another resident admitted in October 2022, the clinical record showed multiple transfers to an acute care hospital on several dates, including an Emergency Department visit followed by an admission for an intestinal blockage. Nursing progress notes documented communication with a gastroenterologist, the decision by the team to send the resident to an alternate ED, and the subsequent hospital admission. Additional record review showed another hospital transfer and admission on a later date. However, the record lacked evidence that the resident’s representative received written transfer/discharge notices and written bed-hold notices for any of these transfers. During an interview, the LSW confirmed there was no evidence of such notices for the identified transfers and stated that one ED transfer was considered a scheduled appointment, and therefore she believed notices were not required.
Resident Restrained with Improper Use of Sheet and Clothing, Violating Dignity and Rights
Penalty
Summary
A deficiency occurred when a certified nurse's assistant (CNA) applied a sheet around a resident's waist and secured it in a double knot while the resident was seated in a wheelchair. Additionally, the CNA put johnny pants on the resident backwards, with the ties positioned in the back and also secured in a double knot. These actions were taken to prevent the resident from accessing and removing their brief, as the CNA could not locate a belt. The CNA confirmed that these interventions were not part of the resident's care plan and acknowledged having received prior training on abuse, neglect, restraints, and resident rights. The facility's internal investigation determined that the CNA's actions constituted abuse and the use of a restraint, as they restricted the resident's ability to access their brief and were not authorized in the care plan. The investigation also found that the resident's rights to dignity and respect were violated by being inappropriately tied with a sheet and having clothing applied in a manner that restrained movement. The CNA did not recognize these actions as inappropriate, despite previous training and orientation on proper care and resident rights.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, as well as wearing johnny pants that had been applied backwards with the ties positioned in the back and also double knotted. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident was known to shred and remove it. The CNA admitted to not being able to locate a belt and therefore used the sheet and johnny pants as alternatives. These interventions were not part of the resident's care plan. The CNA confirmed during an interview that they had received training on abuse, neglect, restraints, and resident rights, but did not recognize their actions as inappropriate or as a form of restraint. The facility's investigation determined that the use of the sheet and backwards johnny pants, both double knotted, constituted a restraint and violated the resident's rights, amounting to abuse. The facility's policy clearly prohibits such actions, defining them as unreasonable confinement and restraint, and requires that residents be free from abuse, neglect, and harm.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A deficiency occurred when a resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, and wearing johnny pants applied backwards with the ties also secured in a double knot. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident had a history of shredding and removing it. The CNA admitted to tying the sheet and securing the clothing in this manner because a belt was not available, and confirmed that these interventions were not part of the resident's care plan. The facility's restraint use policy prohibits the use of physical restraints for discipline or convenience and specifies that fastening fabric or clothing to restrict a resident's movement meets the definition of a physical restraint. The CNA acknowledged having received training on abuse, neglect, restraints, and resident rights, but did not recognize the actions as inappropriate. The facility's internal investigation determined that the resident's rights were violated, and the actions constituted both the use of a restraint and resident abuse.
Lack of COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to develop and implement a policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or information on obtaining the vaccine. The Infection Control Immunizations policy and the Employee Immunization/Vaccination Requirements policy did not include procedures for staff education on the COVID-19 vaccine. During interviews, the Infection Preventionist confirmed that staff had not been provided education on the COVID-19 vaccine since the previous year, and there was no information about COVID-19 in the new employee packet. Additionally, the Maintenance Director, a Licensed Practical Nurse, and a facility clerk all reported not receiving education on the COVID Spikevax within the past year.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across multiple units and areas, as observed during an environmental tour. Deficiencies included missing ceiling tiles, broken and dirty fixtures, and inadequate water temperatures in resident rooms. The whirlpool room had torn flooring and damaged cabinets, while several resident rooms had issues with baseboard heaters, dirty floors, and broken fixtures. The laundry room was also found to be in disrepair, with two out of three dryers non-operational, one of which had been out of order for over two years. These issues were confirmed by the Administrator, Maintenance Director, and Housekeeping Account Manager. Additionally, a strong urine odor was detected in a resident's room, attributed to a frequently leaking foley bag that had potentially absorbed into the flooring. Despite daily cleaning efforts, the odor persisted. Furthermore, two wash basins were observed on the bathroom floor under the sink, indicating a lack of proper storage or maintenance. These findings were confirmed with the Director of Nursing, highlighting ongoing issues with facility maintenance and cleanliness.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, as required by their policy. Resident #180, who was admitted with chronic obstructive pulmonary disease (COPD) and respiratory failure, had active orders for Trelegy Ellipta and continuous oxygen therapy. However, the care plan initiated on 11/20/24 did not include goals and interventions for the resident's respiratory needs. Similarly, Resident #80, admitted with sleep apnea, had orders for CPAP and PRN oxygen, but the baseline care plan initiated on 11/22/24 lacked evidence of goals and interventions for respiratory needs. Interviews with the Infection Preventionist and Quality Improvement Specialist confirmed these deficiencies. Resident #23, admitted with dementia and behavioral disturbances, had a care plan initiated on 10/10/24 that did not address goals and interventions for dementia needs. Additionally, Resident #27, admitted with chronic heart failure, respiratory failure, hypertension, and COPD, did not have a baseline care plan initiated at all. These findings were confirmed through interviews with facility staff, including the President of Clinical Operations and the Quality Improvement Specialist, highlighting a systemic issue in the facility's adherence to its baseline care plan policy.
Failure to Monitor Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to adequately monitor a resident after an unwitnessed fall, which was identified as a deficiency during a review. According to the facility's Fall Management Policy, a fall incident report should be completed after any fall, whether witnessed or not, and a post-fall observation tool should be used to identify potential causes of the fall. Additionally, documentation must be completed in the nurse's notes on each shift for three shifts following the fall. However, for Resident #5, who self-reported a fall in the bathroom, there was no evidence of a fall incident report, post-fall observation tool, or continued monitoring for further injuries or neurological changes. Resident #5, who has a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment, reported the fall to the nursing staff. Despite the resident's report of mild pain in the left knee, the medical record lacked the required documentation and monitoring as per the facility's policies. The Quality Improvement Specialists confirmed the facility's failure to complete the necessary documentation and monitoring for the resident's unwitnessed fall.
Improper Storage of Chemicals in Unlocked Utility Room
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During the survey, it was observed that various chemical products, including Rapid Multi Surface Disinfectant Cleaner, Enzymatic Foul Odor Digester, Germs Be Gone Hand Sanitizer Gel, and GelRite Instant Hand Sanitizer, were stored in an unlocked soiled utility room. These chemicals have specific first aid measures outlined in their Safety Data Sheets, indicating potential harm if they come into contact with eyes, skin, or if ingested or inhaled. The presence of these unsecured chemicals posed a risk, especially considering the facility had residents who were confused, compromised, and vulnerable, as confirmed by the Acting Director of Nursing and Infection Preventionist. On two separate days of the survey, the surveyor observed the same issue of unsecured chemicals in the soiled utility room. The Acting Director of Nursing and Infection Preventionist acknowledged that the chemicals were not stored safely behind a locked door. Additionally, the Quality Improvement Specialist confirmed the findings during an interview. The repeated observation of unsecured chemicals over multiple days highlights a failure in maintaining a safe environment for residents, particularly those who may be at risk of accessing these hazardous substances.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to provider orders for respiratory care for three residents. Resident #180, diagnosed with COPD and respiratory failure, had a nebulizer left unbagged on the bedside table, contrary to facility policy requiring respiratory equipment to be stored in a clean bag. Additionally, Resident #180's oxygen concentrator was set at 1.5 liters per minute, despite an active order for 3 liters per minute. These observations were confirmed by the Acting Director of Nursing/Infection Preventionist and a Quality Improvement Specialist. Resident #14, with diagnoses including COPD and asthma, was observed receiving oxygen at 2.5 liters per minute, although the active order specified 3 liters per minute. Similarly, Resident #80, diagnosed with sleep apnea, had a CPAP face mask stored improperly in an open drawer instead of being bagged. These deficiencies were confirmed by the Acting Director of Nursing/Infection Preventionist during observations with surveyors.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour conducted with the Food Service Director. The inspection revealed several deficiencies, including dusty and dirty hood system filters, wall air conditioning units, and walls above and below these units. Additionally, the ceiling grid hangers were found to be rusty and stained a yellowish color throughout the kitchen. The floor fan was also noted to be dusty and dirty, and the grease trap lid had chipped or missing paint, creating an uncleanable surface. These findings were confirmed by the Food Service Director during the interview.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) as outlined in its policy, which aims to improve antibiotic use, reduce adverse events, prevent resistance, and lead to better outcomes for residents. The policy specifies that the Infection Preventionist is responsible for monitoring and supporting antibiotic activities, tracking antibiotic therapy, reviewing resistance patterns, and monitoring healthcare-acquired infections (HAIs) and multi-drug resistant organisms (MDROs). However, the facility did not have a system in place to monitor antibiotic use effectively, as evidenced by the lack of tracking systems to identify trends and antibiotic use, and the absence of a review of the monthly pharmacy antibiotic report by the Infection Preventionist. The facility's Quality Assurance & Performance Improvement Pharmacy quarterly reports for several quarters lacked a section on Antibiotic/Antimicrobial Stewardship Discussion, indicating that there was no evidence of a review of antibiotic use or the ASP during these meetings. Additionally, the Infection Preventionist and Acting Director of Nursing confirmed frequent urinary tract infections requiring antibiotics but admitted to not implementing any tracking systems for trends and antibiotic use. This deficiency has the potential to affect all residents receiving antibiotics, as the facility did not adhere to its policy and failed to monitor antibiotic use effectively.
Failure to Timely Notify Medical Provider and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a medical provider and the resident's representative following a significant incident involving a resident. The resident, who has a history of lumbar vertebra fracture and bone density disorder, and severe cognitive impairment, experienced a fall on 2/2/25 at 5:00 p.m. The medical provider was not notified until 20 hours later, on 2/3/25 at 1 p.m. The incident report lacked a detailed description, resident assessment, or notification to the resident's representative. Additionally, the nursing documentation completed on 2/3/25 at 4:06 p.m. confirmed the fall occurred in the dining room while the resident was using a walker, but it also failed to document any notification to the resident's representative. The Director of Nursing stated that the family was notified the day after the fall.
Deficiencies in Oral Hygiene and Personal Care for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living (ADL). Resident #10, who has a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, was observed with significant food and tartar buildup on their teeth. Despite the care plan indicating the need for extensive assistance with self-care, the resident was not receiving mouth care twice a day as required. Interviews with CNAs revealed that although mouth care was part of the daily routine, it was not consistently performed, and the resident's teeth were not brushed, only rinsed. This lack of proper oral hygiene was confirmed by a Quality Improvement Specialist who noted that the resident could brush their teeth independently with minimal setup assistance. Resident #7, also diagnosed with dementia and having a BIMS score of 3, was observed wearing clothes with dried food particles, indicating a failure to maintain personal hygiene and dignity. The care plan for Resident #7 also required extensive assistance with self-care. Despite this, the resident was left in dirty clothes after breakfast and before being put to bed, which was acknowledged as a dignity issue by both a CNA and the Quality Improvement Specialist. These observations highlight the facility's failure to ensure residents' basic hygiene needs were met, impacting their dignity and quality of care.
Insulin Administered Outside Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering doses of insulin outside of the physician's order parameters. Specifically, a resident with type 2 Diabetes Mellitus and Diabetic Polyneuropathy had a physician's order for Novolog Insulin to be administered only if blood sugar levels were above 110. However, the Electronic Medication Administration Record (EMAR) showed that nursing staff administered 6 units of Novolog insulin on multiple occasions in October, November, and December 2024, despite the resident's blood sugar levels being below 110 on those dates. This action was contrary to the physician's orders and the resident's nutrition care plan, which aimed to prevent complications related to diabetes by adhering to prescribed medications and treatments. The Quality Improvement Specialists confirmed these findings during an interview, noting the failure to follow physician orders and the care plan.
Recurrent Deficiencies in Resident Monitoring and Medication Management
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction for deficiencies identified during the Annual Long Term Care Survey Process for Federal Recertification. Specifically, deficiencies F684 and F757 were cited again during a follow-up survey. F684 was cited due to the facility's failure to document and adequately monitor a resident after an unwitnessed fall. Additionally, F757 was cited for the facility's failure to ensure that a resident's drug regimen was free from unnecessary medications. These deficiencies were confirmed during an interview with the President of Quality Improvement and Nursing Services and the Director of Nursing.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions during a lunch meal on the Cortland Unit. An LPN was observed exiting a room with a lunch tray, removing trash from the tray with bare hands, and placing it on a kitchen utility cart. The LPN then walked past a hand sanitizer station without using it and entered another resident's room, where she placed her bare hands on a resident's shoulder and a side table. After exiting the room, the LPN proceeded to the lunch cart, opened it with her bare hand, and retrieved another lunch tray without sanitizing her hands between resident contacts. During an interview, the Acting Director of Nursing/Infection Preventionist confirmed that it was expected for staff to sanitize their hands before and after resident contact.
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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