Orono Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Orono, Maine.
- Location
- 117 Bennoch Rd, Orono, Maine 04473
- CMS Provider Number
- 205031
- Inspections on file
- 24
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Orono Commons during CMS and state inspections, most recent first.
A resident with multiple antihypertensive medications (Carvedilol, Diltiazem, Enalapril, and Spironolactone) had physician orders requiring SBP and pulse checks with hold parameters (SBP <110 or HR <60) prior to administration. Over a multi-day period, staff documented these medications as given on the MAR without recording required vital signs on the MAR, and on numerous occasions when the vital signs record showed SBP values below the ordered threshold or lacked SBP documentation within the ordered administration windows. Some doses were also associated with blood pressure readings taken outside the prescribed time frames, yet still recorded as administered according to the MAR.
A resident developed a new pressure ulcer on the right big toe that was not documented or treated for eight days, despite facility policy requiring daily skin observation, prompt reporting, and wound management by nursing staff. The wound was only addressed after it was brought to staff attention by a family member and surveyor, revealing a breakdown in communication and documentation procedures.
Staff failed to use required PPE during high-contact care activities for a resident with pressure injuries, and soiled linens were handled and transported without proper containment, contrary to facility policy. The PPE cart was not accessible at the point of care, and staff only donned gowns after being prompted by the Administrator. Additionally, a staff member carried unbagged, soiled clothing through the hallway and left it uncontained in the dirty linen room due to a lack of available bags.
A resident who required total assistance with eating had 14 out of 24 meal records inaccurately or incompletely documented, with entries marked as supervision, independent, setup, or left blank, despite staff knowledge of the resident's needs.
Two residents who required pain management after recent surgeries did not receive timely or appropriate pain relief, despite having physician orders and medications available in the facility's emergency kit. One resident waited nearly six hours for pain medication after reporting severe pain, while another did not receive any pain relief and left the facility against medical advice to seek treatment elsewhere. Staff were unaware of medication availability and did not implement alternative interventions or notify providers of uncontrolled pain.
The facility did not ensure adequate direct care staffing on weekends, as confirmed by PBJ data and the Administrator, resulting in low weekend staffing for residents.
Surveyors identified multiple deficiencies in dietary services, including expired or undated thickened beverages and juices, improper use of hair restraints by staff, inadequate dishwasher sanitation temperatures, incomplete sanitation logs, soiled kitchen floors, improper food thawing and storage practices, insufficient air gap under the ice machine, uncleanable surfaces, and failure to maintain safe food holding temperatures. These issues were confirmed through direct observation and staff interviews.
Multiple residents admitted for skilled care did not have baseline care plans developed or implemented within 48 hours of admission. Clinical records and staff interviews confirmed that essential care instructions, including problems, goals, and interventions, were not documented in a timely manner, resulting in a lack of minimum healthcare information necessary for proper care during the initial period of their stay.
Multiple residents did not receive prescribed medications, including pain management and routine medications, even though these were available as stock or in the emergency kit. In addition, insulin was administered to a resident outside of the physician's specified blood glucose parameters. These deficiencies were confirmed through record reviews and staff interviews.
A resident's clinical records contained conflicting information regarding their code status, with the electronic record indicating DNR and the paper chart showing a POLST form for Attempt Resuscitation/CPR. During a review with a surveyor, an LPN was unable to clarify which directive was correct, confirming the inconsistency in the resident's advance directive documentation.
A resident with a new diagnosis of bipolar disorder was not referred to the State mental health authority for a required PASRR determination after the change in mental health status. The facility did not coordinate timely assessment or referral following the new diagnosis.
A resident receiving daily oxygen therapy had a provider order requiring regular assessment of respiratory rate, skin color, and breath sounds every shift. Review of clinical records showed no documentation that these assessments were completed as ordered, a fact confirmed by the DON, Administrator, and Clinical Market Advisor.
The facility did not notify state agencies, including DLC and APS, within the required 24-hour period after an alleged resident-to-resident abuse incident. Although the physician and resident representatives were informed promptly, the report to DLC was delayed and there was no evidence that APS was notified, as confirmed by the Administrator during a surveyor interview.
Surveyors found that hot foods, including cubed chicken, macaroni and cheese, and cubed potatoes, were served at cool to cold temperatures during meal service. Several residents reported receiving cold hot foods, and temperature checks by surveyors confirmed the deficiency. The District Manager acknowledged that the foods were not served hot.
The facility failed to maintain a clean and odor-free environment, with surveyors observing a persistent urine odor in a corridor and multiple maintenance issues such as torn flooring and furniture, chipped paint, and soiled bathrooms. These deficiencies were confirmed by the DON, Administrator, and Maintenance Supervisor, impacting the residents' comfort and safety.
A facility failed to follow its own policy and physician orders for oxygen administration for a resident. The resident was observed using oxygen at a higher rate than prescribed, and the facility did not maintain respiratory equipment cleanliness. The concentrator's filter was dusty, and the oxygen tubing was not changed weekly. Additionally, a humidifier bottle was used without a date label, contrary to the facility's policy.
The facility failed to maintain resident dignity by not responding promptly to call bells, leading to discomfort and incontinence for some residents. Additionally, meal service was inconsistent, with some residents waiting for their trays while others were served, due to issues with tray delivery from the kitchen.
The facility failed to complete neurological assessments and follow physician orders for several residents. Neurological evaluations were not conducted as required for residents with head injuries or unwitnessed falls. Additionally, vital signs were not taken as ordered before administering medications, and urgent diagnostic tests were delayed. A resident received excessive Acetaminophen, and insulin was administered unnecessarily. These deficiencies highlight a lack of adherence to medical orders and facility policies.
The facility failed to provide adequate staffing, resulting in delayed responses to call bells and unmet care needs for residents. One resident with a Cerebral Vascular Accident waited 50 minutes for toileting assistance, while another experienced incontinence due to delayed response. A CNA confirmed the lack of staff, impacting timely care. Residents reported waiting long periods for assistance, particularly at night, during a council meeting.
The facility experienced significant delays in meal services due to inadequate dietary staffing, affecting residents' timely access to meals. Observations showed consistent delays in breakfast and lunch services, with staff shortages exacerbating the issue. The Account Manager confirmed the staffing challenges, which also led to a shortage of meal components like salad.
The facility failed to serve meals at appropriate temperatures, with residents reporting that hot foods were not always hot. Observations showed delayed meal service, and test trays revealed unpalatable temperatures for both hot and cold items. These findings were confirmed with the Account Manager.
Surveyors identified multiple deficiencies in a LTC facility, including failure to monitor food temperatures, improper food storage, and plumbing issues. Food temperatures were not consistently checked, and various food items were found open, undated, or improperly stored. Additionally, improper air gaps in plumbing were observed, violating state codes and risking water contamination.
A facility failed to provide a resident with a second serving of their preferred meal, chop suey and salad, during lunch. The resident, who was experiencing significant weight loss and was on an appetite stimulant, requested more food but was informed by a CNA that none was left. The Food Service Director confirmed the shortage, explaining it was the last day before a delivery and they only prepared enough for one serving per resident.
A facility failed to create a specific care plan for a resident with PTSD. The resident's care plan mentioned PTSD under mood symptoms but lacked a tailored plan. The DON confirmed the absence of a PTSD care plan and noted that the LSW had not assessed the resident's PTSD.
A facility failed to provide trauma-informed care for a resident with PTSD. The resident's clinical record indicated an active PTSD diagnosis, but lacked details on the cause or potential triggers for re-traumatization. The DON confirmed the absence of a specific care plan for PTSD, and the LSW had not assessed the resident's condition, highlighting a deficiency in addressing the resident's trauma-related needs.
A facility failed to ensure timely physician review and signature of a resident's medication and treatment orders. The physician signed the orders 29 days late, beyond the allowed grace period. This deficiency was confirmed during an interview with the Senior DON by a surveyor.
The facility failed to label an opened Basaglar KwikPen (Lantus) with an open or discard date in a treatment cart on the Homestead unit. Additionally, expired medications, including Stool Softener and Aspirin with expiration dates of April 2024, were found in the medication storage rooms of both the Homestead and Riverview units. These deficiencies were confirmed by a surveyor during observations.
The facility failed to provide documented abuse training for a CNA hired in January 2024. During a review, it was found that there was no evidence of completed abuse training in the CNA's file. The DON confirmed the lack of documentation during an interview.
The facility failed to complete weekly pressure ulcer assessments for a resident, did not follow a physician's order for an urgent wound clinic referral for another resident, and neglected to provide a redistribution cushion as per a care plan for a third resident. These deficiencies were confirmed through record reviews and staff interviews.
The facility failed to provide written notification to two residents and/or their representatives regarding hospital transfers, and did not notify the Ombudsman of any transfers or discharges since January 2024. This was confirmed through record reviews and staff interviews.
The facility failed to provide written bed hold notices to residents or their representatives after hospital transfers. A resident transferred in March lacked documentation of a notice, confirmed by the Market Clinical Advisor. Another resident transferred in December also lacked notice documentation, confirmed by the Senior Director of Nursing. A third resident's record had a notice, but it wasn't provided to the representative, as confirmed by the DON.
The facility did not complete annual performance evaluations for two CNAs employed for over a year. The DON confirmed that evaluations for these CNAs had not been conducted since 2022, missing the required annual schedule.
The facility did not post nurse staffing information in a location accessible to residents for three days during a survey. The information was placed in a locked area, requiring a code for access, making it difficult for residents to view. This was confirmed during an interview with the DON.
The facility failed to provide timely baseline care plans to four residents, as required within 48 hours of admission. One resident with hemiparesis reported difficulty receiving timely assistance to the bathroom, and a CNA was unaware of the resident's toileting schedule. Another resident's care plan was completed four days post-admission. The Riverview Unit Manager confirmed not providing care plan summaries during meetings.
Failure to Follow Antihypertensive Hold Parameters and Vital Sign Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for multiple antihypertensive medications for one resident, specifically by not checking and documenting required vital signs and by administering medications outside of ordered blood pressure parameters and time frames. For Carvedilol, ordered twice daily with instructions to hold the dose if systolic blood pressure (SBP) was less than 110 or heart rate was less than 60, the record review for 12/10/25–12/23/25 showed that blood pressure and pulse were not documented on the MAR. During this period, the vital signs record showed multiple SBP readings below 110 (including 90, 95, 98, 105, 103, 104, 86, and 85) at times corresponding to medication administration, yet the MAR indicated the medication was given. On several dates there was no documented SBP in the ordered administration windows, but the MAR still showed that Carvedilol was administered. For Diltiazem, ordered once daily between 7 a.m. and 12 p.m. with instructions to hold if SBP was less than 110 or heart rate less than 60, the facility again did not document blood pressure and pulse on the MAR between 12/18/25–12/23/25. The vital signs record showed SBP values of 105, 103, and 86 during this period, all below the ordered SBP hold parameter of 110, yet the MAR documented that Diltiazem was given on those days. On other days within the same period, there was no documented SBP in the ordered administration window, but the MAR still reflected that the medication was administered. For Enalapril, ordered once daily between 4 p.m. and 7 p.m. with the same hold parameters (SBP less than 110 or heart rate less than 60), the MAR from 12/10/25–12/23/25 lacked blood pressure and pulse documentation. The vital signs record showed SBP readings below 110 (including 90, 95, 109, 90, 104, and 85) at or near the relevant times, yet the MAR indicated the medication was given. Some SBP readings were documented outside the ordered time window, and on several days there was no SBP documented in the 4 p.m.–7 p.m. window, but the MAR still showed administration. Similarly, for Spironolactone, ordered once daily between 7 a.m. and 12 p.m. with the same hold parameters, there was no blood pressure or pulse documented on the MAR between 12/18/25–12/23/25. During this time, the vital signs record showed SBP readings of 105, 103, and 86, all below the ordered threshold, or no SBP documented in the ordered time window, yet the MAR consistently indicated that Spironolactone was administered.
Failure to Initiate Timely Treatment and Documentation for New Pressure Ulcer
Penalty
Summary
The facility failed to follow its own Skin Integrity and Wound Management policy after a new pressure ulcer was observed on a resident's right big toe. Although the policy required nursing assistants to observe and report skin changes daily and for licensed nurses to evaluate, document, and initiate treatment for new wounds, these steps were not followed. The wound was first identified on the resident's right big toe, but no treatment or monitoring was started for eight days. Documentation in the clinical record on two occasions after the wound was present did not mention the wound, and no treatment orders were initiated during this period. Interviews revealed that staff were either unaware of the wound or assumed it was already being addressed due to another wound on the resident's left toe. A photo of the right big toe wound was taken by a nurse, but it was not entered into the clinical record, and no further documentation or action was taken. The wound was ultimately brought to the attention of nursing staff by a family member and a surveyor, at which point the facility acknowledged that the required process for wound identification, documentation, and treatment had not been followed.
Failure to Follow Enhanced Barrier Precautions and Proper Linen Handling
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, specifically in the areas of Enhanced Barrier Precautions (EBP) and linen handling. The facility's policy required the use of gown and gloves during high-contact care activities for residents with chronic wounds, in accordance with CDC guidance. On the day of survey, a resident with current pressure injuries and a care plan intervention for EBP was observed. Staff at the resident's bedside were not wearing the required PPE, and only donned gowns after being directed by the Administrator. Additionally, the PPE cart intended for EBP use was not positioned at the resident's room, but had been moved down the hallway, making it less accessible for staff compliance. Further observations revealed deficiencies in linen handling practices. A staff member was seen carrying soiled, loose clothing with a strong odor of urine down the hallway without placing it in a bag, contrary to the facility's policy that all used linen should be bagged at the point of use. The soiled clothing was later found unbagged in the dirty linen room. When questioned, a registered nurse stated that there were no bags available for the dirty linen. These actions and inactions demonstrate a failure to adhere to established infection control protocols, increasing the risk of communicable disease transmission.
Inaccurate Documentation of Eating Assistance
Penalty
Summary
The facility failed to ensure that a clinical record contained accurate and complete information for a resident who required total assistance with eating. The resident's care plan indicated a need for total assistance with activities of daily living, specifically eating, as documented in the care plan and its interventions. However, a review of meal documentation over an eight-day period revealed that 14 out of 24 meal entries were either blank or inaccurately recorded, with some meals marked as supervision, independent, setup, or substantial assist, contrary to the care plan requirements. Interviews with staff confirmed that the resident was indeed a total assist for eating, and the administrator acknowledged that staff were aware of this but had documented incorrectly.
Failure to Provide Timely Pain Management for Post-Surgical Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required such services following recent surgeries. One resident, admitted after a total hip replacement, reported severe pain (8 out of 10) upon arrival and did not receive any pain medication until nearly six hours later, despite having physician orders for multiple pain medications. The resident had to leave their room to seek assistance, and staff informed them that pain medications could not be given due to a lack of written scripts, even though the medications were available in the facility's emergency kit (Ekit). Documentation confirmed that the resident's pain was not addressed promptly, and the necessary medications were accessible but not administered as ordered. Another resident, admitted for skilled therapy after spinal surgery, also experienced severe, unrelieved pain upon admission, with a pain score of 10 out of 10 and associated symptoms such as elevated heart rate and inability to remain still. Despite having standing orders for morphine and acetaminophen, the resident did not receive any pain medication during their stay. The clinical record and nurse notes indicated that the resident became verbally angry about the lack of pain control and ultimately discharged against medical advice to seek pain relief at an emergency room. The facility's Ekit contained the ordered morphine, but it was not provided, and there was no evidence of any pharmaceutical or non-pharmaceutical interventions being implemented. Interviews with facility staff revealed a lack of awareness regarding the availability of pain medications in the Ekit and a failure to notify providers of uncontrolled pain or implement alternative pain management strategies. The documentation and staff statements confirmed that both residents experienced significant delays or omissions in pain management, despite the presence of physician orders and available medications.
Insufficient Weekend Staffing Documented by PBJ Report
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents on weekends during the first quarter of 2025, as evidenced by the Payroll Based Journal (PBJ) report. The PBJ data indicated that the facility triggered for low weekend staffing during this period. During an interview, the Administrator confirmed the accuracy of the PBJ report and acknowledged the low weekend staffing finding, with no additional information provided to dispute the data.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, preparation, and service within the facility. Thickened beverages and juices were found in unit refrigerators with dates indicating they were expired or lacking open dates, contrary to manufacturer instructions and facility policy. Staff interviews revealed that items were being dated based on receipt rather than when opened, and expired or undated items remained available for use. Additionally, a thawed Mighty Shake was found without a date, despite instructions to use within a specific timeframe after thawing. Further observations in the kitchen revealed that dietary staff were not consistently using hair restraints, with several aides and cooks working with unrestrained hair and facial hair. The dishwasher was found to be operating below the required sanitizing temperatures, and logs for monitoring sanitation were incomplete for most meal cycles. The kitchen floor was soiled, and there was no established cleaning schedule. A dented can of tuna was found in dry storage, and improper thawing practices were observed, with chicken stored above dough in a way that allowed runoff to drip onto food below. Additional issues included improper installation of plumbing fixtures, specifically an insufficient air gap under the ice machine, and uncleanable surfaces due to standing water and exposed concrete. Serving pans were wet-stacked, and serving utensils were stored in bins with accumulated food debris. Hot food items on the steam table were not maintained at safe holding temperatures, and undated thawed Mighty Shakes were found in the walk-in refrigerator. These deficiencies were confirmed through direct observation and staff interviews.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five out of ten sampled residents. Clinical record reviews revealed that for each of these residents, the required baseline care plan, which should include problems, goals, and interventions necessary to provide minimum healthcare information, was either not created or not implemented within the mandated timeframe. In several cases, the care plans were delayed by several days, with some not being completed until four days after admission. These findings were confirmed through interviews with facility staff, including the Regional Marketing Advisor, Administrator, Director of Nursing, and Market Clinical Advisor, who acknowledged the delays and lack of timely documentation. The residents involved were admitted for skilled care, and their clinical records lacked evidence of timely baseline care planning. The absence of these care plans meant that essential instructions for providing appropriate care were not available to staff within the first 48 hours of the residents' stay. The deficiency was consistently identified across multiple residents, as confirmed by both record review and staff interviews, indicating a pattern of non-compliance with regulatory requirements for timely care planning upon admission.
Failure to Administer Medications as Ordered and Follow Physician Parameters
Penalty
Summary
The facility failed to administer medications as ordered by physicians for four residents. In multiple instances, residents did not receive prescribed medications, including Aspirin, Quetiapine, Atorvastatin, Calcium Carbonate, Docusate, Levetiracetam, Metformin, Senna, Warfarin, and Morphine, despite these medications being available as stock or in the facility's emergency kit (RX Now system). Documentation and interviews confirmed that these medications were not given as ordered, and in some cases, the Medication Administration Record (MAR) incorrectly indicated that medications were on hold pending pharmacy delivery, even though they were available on-site. For one resident experiencing severe pain, Morphine was not administered as ordered, and for another, several routine medications were omitted. Additionally, the facility failed to follow specific physician parameters for insulin administration for one resident. Insulin was administered on seven occasions when the resident's blood glucose was below the threshold specified in the physician's order, which directed staff to hold the medication for blood glucose less than 110. These failures were confirmed through MAR reviews and staff interviews, indicating a pattern of not adhering to physician orders for medication administration.
Conflicting Advance Directive Documentation for Code Status
Penalty
Summary
The facility failed to ensure that a resident's advance directive regarding code status was accurately documented in the clinical record. Upon review, the resident's electronic medical record indicated a Do Not Resuscitate (DNR) order, while the paper chart contained a Physicians Orders for Life Sustaining Treatment (POLST) form indicating Attempt Resuscitation/CPR. During an interview, an LPN was unable to determine which directive was correct, and the surveyor confirmed that conflicting information existed in the resident's records regarding their code status. This discrepancy in documentation resulted in the resident's right to formulate and have an accurate advance directive not being honored, as required.
Failure to Notify State Mental Health Authority After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State mental health authority for a Pre-admission Screening and Resident Review (PASRR) after a resident was newly diagnosed with bipolar disorder. Record review showed that the resident's initial PASRR, completed in February 2022, did not require a Level II determination. However, after the resident received a new diagnosis of bipolar disorder in August 2024, there was no evidence in the clinical record that a referral for a new PASRR determination was made at that time. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the referral was not submitted until May 2025. The deficiency involved a resident who had a significant change in mental health status, specifically a new diagnosis of bipolar disorder, and the facility did not coordinate timely assessment or referral to the State mental health authority as required.
Failure to Document Ordered Respiratory Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care as ordered by the provider for one resident who uses oxygen therapy. The resident had a provider order for oxygen to be administered by nasal cannula at 2 liters per minute every shift, with instructions to maintain peripheral oxygen saturation (SPO2) between 88-93% and to evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds. Upon review of the clinical record, there was no documentation that the resident's respiratory rate, skin color, and breath sounds were evaluated every shift as ordered. This lack of documentation was confirmed by the surveyor with the DON, Administrator, and Clinical Market Advisor, who acknowledged that the required assessments were not recorded.
Failure to Timely Report Alleged Abuse to State Agencies
Penalty
Summary
The facility failed to notify the State Agencies, specifically the Division of Licensing and Certification (DLC) and Adult Protective Services (APS), within the required 24-hour timeframe following an allegation of abuse involving a resident-to-resident incident. According to the facility's Abuse Prohibition policy, such incidents must be reported to the appropriate authorities within 24 hours if they do not result in serious bodily injury. The incident in question occurred on 9/12/24, with the physician and resident representatives notified on the same day; however, the initial report to the DLC was not sent until 9/16/24, and there was no evidence that APS received the report at all. During an interview, the Administrator confirmed the lack of timely notification and absence of documentation supporting that the required reports were sent to the state agencies as mandated.
Hot Foods Served Below Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility's food service practices, specifically regarding the serving temperature of hot foods. During an initial tour, several residents reported that hot foods were being served cold. On two separate occasions, surveyors tested the temperatures of lunch trays at the end of meal delivery and found that items such as cubed chicken, macaroni and cheese, and cubed potatoes were served at temperatures ranging from 94.3 to 96.6 degrees Fahrenheit, which were described as cool to cold in taste. The District Manager of Health Services Group confirmed that the hot foods tested were not served at appropriate temperatures.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an environment with offensive odors and uncleanable surfaces. Over the course of the survey, a strong, foul odor of urine was consistently observed in the corridor outside a specific room, affecting the comfort of residents, including one who reported the odor seeping into their room. This issue persisted over multiple days, indicating a lack of effective cleaning and maintenance practices. During an environmental tour, several maintenance issues were identified, including torn and unsealed flooring, heavily soiled and stained bathroom areas, and furniture with torn surfaces, all of which created uncleanable conditions. These deficiencies were confirmed by the Director of Nursing, the Administrator, and the Maintenance Supervisor. The presence of chipped paint, missing fixtures, and sticky floors further contributed to the unsanitary and uncomfortable environment, failing to meet the residents' right to a safe, clean, and homelike setting.
Failure to Follow Oxygen Administration Protocols
Penalty
Summary
The facility failed to adhere to its own policy for oxygen use and humidification, as well as physician orders for oxygen administration, for Resident #168 over a four-day survey period. The resident was observed using portable oxygen with the regulator set at 3 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the facility's policy did not indicate the need for humidification at this flow rate, yet a humidifier bottle was attached to the concentrator without a date label. The clinical record lacked evidence of orders or treatments for humidification, cleaning the concentrator, or changing the tubing. Surveyors noted that the concentrator's filter was dusty, and the oxygen tubing extension connector was in contact with the floor, which was not cleaned or changed before use. Licensed Practical Nurse #1 confirmed the oversight during an interview. The facility also failed to change the oxygen tubing weekly as required by their policy. These observations and interviews highlighted the facility's failure to maintain respiratory equipment in a clean manner and to follow established protocols for oxygen administration.
Deficiencies in Timely Assistance and Meal Service
Penalty
Summary
The facility failed to maintain or enhance the dignity of residents by not responding to call bells in a timely manner, as evidenced by the experiences of three residents. One resident, diagnosed with Cerebral Vascular Accident with hemiplegia and hemiparesis, reported waiting fifty minutes for assistance after ringing the call bell due to an urgent need for a bedpan. Another resident, with a history of diabetes, atrial fibrillation, depression, and anxiety, experienced incontinence after waiting approximately an hour for assistance. This resident also reported not receiving a morning bath as preferred, with a CNA confirming the delay due to staffing issues. A third resident reported waiting one to two hours for assistance, particularly at night, which frequently resulted in discomfort. Additionally, the facility failed to serve meals to residents in a manner that maintained their dignity and respect. Observations revealed that residents seated at the same table were not served simultaneously, with one resident waiting 5 to 10 minutes for breakfast while another was being assisted. Similarly, during lunch, two residents were observed without their trays while others at the same table were served. The delay was attributed to issues with the delivery of meal trays from the kitchen, as confirmed by staff interviews.
Failure to Follow Physician Orders and Complete Neurological Assessments
Penalty
Summary
The facility failed to complete neurological assessments as directed by their policy for residents who sustained injuries to the head or had unwitnessed falls. Specifically, the Neurological Evaluation Flowsheet was not completed for several residents, including one who was found on the floor with a bruise on the forehead and another who reported hitting their head on the toilet. Additionally, a resident who experienced an unwitnessed fall did not have the required neurological evaluations completed as recommended by the provider. The facility also failed to follow physician orders for obtaining vital signs and medication administration. For instance, a resident had a physician order to administer Atenolol based on specific blood pressure and heart rate parameters, but there was no evidence that these vitals were taken prior to medication administration. Another resident had an order for orthostatic vital signs that was not completed correctly, as the resident was unable to stand, yet the order was not adjusted to reflect this. Furthermore, the facility did not order urgent diagnostic testing in a timely manner. A resident with a suspected occult hip fracture had an urgent CAT Scan ordered, but it was not scheduled until four days later. Additionally, a resident received more than the maximum recommended dose of Acetaminophen in a 24-hour period, and another resident was administered insulin doses that were not needed according to the physician's order. These failures indicate a lack of adherence to physician orders and facility policies, impacting the care provided to the residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all 73 residents on the Homestead and Riverview units, as evidenced by multiple incidents of delayed response to call bells and unmet care needs. One resident, diagnosed with a Cerebral Vascular Accident and requiring extensive assistance with toileting, reported waiting 50 minutes for a call bell response, resulting in significant discomfort. Another resident with diabetes and other conditions experienced incontinence due to a delayed response and reported not receiving a morning bath as preferred. A Certified Nurse Assistant confirmed the lack of staff, stating that she was unable to provide timely care due to her workload. Additional observations included a CNA being unable to promptly assist multiple residents during breakfast due to staffing shortages, and residents expressing concerns during a council meeting about not being assisted in a timely manner. One resident reported waiting up to two hours for call bell responses, particularly at night, and another mentioned waiting 1.5 hours to use the bathroom. These incidents highlight the facility's failure to ensure adequate staffing levels to meet the residents' needs for assistance with activities of daily living.
Inadequate Dietary Staffing Leads to Meal Service Delays
Penalty
Summary
The facility failed to provide adequate dietary staff to meet the dietary needs of residents in a timely manner for three out of four days during the survey. Observations revealed that meal services in the Homestead dining room were consistently delayed. On multiple occasions, breakfast and lunch trays were delivered late, with lunch trays being up to one and three-quarter hours late on one day. Residents expressed concerns about the consistent delays during weekdays, while meals were reportedly on time during weekends. The Account Manager acknowledged staffing issues, including being down two people due to an open part-time position and a chef calling out. This shortage led to the Account Manager stepping in to perform kitchen duties, which further impacted the timely preparation and delivery of meals. Additionally, there was a shortage of salad during one meal service because the Account Manager was unable to procure more ingredients, highlighting the strain on resources and staff. Nursing staff also expressed difficulties in planning resident care due to the meal service delays.
Inadequate Food Temperature Maintenance
Penalty
Summary
The facility failed to maintain appropriate food temperatures, resulting in meals being served at unsatisfactory temperatures. On one of the survey days, residents expressed concerns about the temperature of their meals, noting that hot foods were not always served hot. Observations revealed that lunch service was delayed, with meal trays being delivered up to one and three-quarter hours late. During a test tray evaluation, the temperature of the American Chop Suey was recorded at approximately 116.9 degrees Fahrenheit, and the Pineapple Crisp dessert was at 66.8 degrees Fahrenheit. These temperatures were deemed unpalatable by the surveyors, and the findings were confirmed with the Account Manager.
Food Safety and Plumbing Deficiencies in LTC Facility
Penalty
Summary
The facility failed to monitor food temperatures to prevent foodborne illness, as observed on one of the four days of the survey. On 5/19/24, a surveyor noted that food temperatures were not checked before serving meals to residents, and the last recorded food temperatures were from 5/2/24, indicating a lapse of seventeen days. During an interview, a staff member admitted to not consistently checking food temperatures daily, which could potentially lead to foodborne illnesses among residents. Additionally, the facility did not store, prepare, and serve food in accordance with professional standards for food service safety. On 5/19/24 and 5/20/24, surveyors observed various food items in the dry storage, walk-in refrigerator, and freezers that were open, undated, unlabeled, or improperly stored. These included opened packages of chips, white powder, Jello Cheesecake Filling mix, and peanut butter, among others. The dry storage area also had a sticky floor with a juice pump system nozzle lying on the floor, covered in a sticky substance. Expired disaster food storage items were also found, with use-by dates ranging from 2020 to 2023. The facility also failed to ensure that plumbing fixtures were properly installed to prevent backflow, as required by the Maine State Plumbing Code. On all four days of the survey, improper air gaps were observed on the drain lines of a sink used for food preparation and the ice machine. This direct connection of wastewater and potable water was confirmed to be in violation of the state rules, posing a risk of contamination to the facility's water supply.
Failure to Provide Resident's Meal Preference
Penalty
Summary
The facility failed to ensure that a resident's preference for a second serving of the main meal choice was available during a lunch meal service. On the specified date, a resident requested a second serving of chop suey and salad, which was part of the main menu choice for lunch. However, the Certified Nursing Assistant (C.N.A.6) informed the resident that there was no more chop suey and salad left after contacting the kitchen. The Food Service Director confirmed that they had run out of the main meal choice due to it being the last day before a delivery, and they were unable to offer seconds as they only prepared enough for one serving per resident. The resident involved had a history of weight loss and was receiving an appetite stimulant. The resident's admission weight was 117.2 pounds, and by the time of the incident, the weight had decreased to 102.1 pounds, indicating a significant weight loss over two months. The resident's care plan included a nutrition care area that highlighted the resident's nutritional risk due to poor intake, with an intervention to honor food preferences within the meal plan. Despite these measures, the resident did not receive the requested second serving, and no alternative was accepted by the resident.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan specifically addressing Post Traumatic Stress Syndrome (PTSD) for a resident diagnosed with PTSD. During a review of the resident's care plan, it was noted that PTSD was only mentioned as a problem under fluctuating mood symptoms, but there was no documented evidence of a care plan tailored to address PTSD. In an interview, the Director of Nursing (DON) confirmed the absence of a specific care plan for PTSD and stated that the Licensed Social Worker (LSW) had not conducted an assessment of the resident's PTSD.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to adequately address the needs of a resident with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). During a review of the resident's clinical record, it was noted that the Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, indicated an active diagnosis for PTSD. However, there was no information in the clinical record detailing the cause of the PTSD or identifying potential triggers for re-traumatization. Furthermore, the Director of Nursing (DON) confirmed that there was no specific care plan addressing PTSD, aside from a mention under fluctuating mood symptoms. The Licensed Social Worker (LSW) had not assessed the resident's PTSD, indicating a lack of trauma-informed care planning for this resident.
Physician's Delay in Signing Orders
Penalty
Summary
The facility failed to ensure that the physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. Specifically, for one resident, the physician signed the Physician Orders (block orders) on February 12, 2024, which were valid for 60 days. The subsequent orders required review and signature by April 22, 2024, including a 10-day grace period. However, the medical record lacked evidence of the physician's review and signature by this date. The physician eventually signed the orders on May 21, 2024, which was 29 days late, even considering the grace period. This deficiency was confirmed during an interview with the Senior Director of Nursing by a surveyor on May 22, 2024.
Medication Labeling and Expiration Issues
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey. In one of the treatment carts on the Homestead unit, a Basaglar KwikPen (Lantus) for a resident was found without an open or discard date, despite the requirement that Lantus is only good for 28 days once opened and kept at room temperature. Additionally, expired medications were found in the medication storage rooms of both the Homestead and Riverview units. Specifically, two bottles of Stool Softener with an expiration date of April 2024 were found in the Homestead unit, and two bottles of Aspirin with the same expiration date were found in the Riverview unit. These findings were confirmed by the surveyor at the time of observation.
Deficiency in Abuse Training for CNA
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically in the area of abuse prevention. This deficiency was identified during a review of employee files and an interview with the Director of Nursing. The review revealed that one of the Certified Nursing Assistants (CNA3), who was hired on January 29, 2024, did not have documented evidence of having completed the required abuse training. During an interview on May 22, 2024, the Director of Nursing confirmed the absence of documentation for CNA3's abuse training.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and follow-up care for residents with pressure ulcers. For one resident, weekly pressure ulcer assessments were not completed for specific weeks, as confirmed by the Riverview Unit Manager. Another resident had a physician order for an urgent wound clinic referral due to multiple progressive wounds, but the facility did not obtain the consult, as stated by the Director of Nursing. Additionally, a third resident's clinical record lacked weekly assessment documentation for a stage II pressure injury, and the resident did not have a redistribution cushion in their chair as per their care plan. The deficiencies were identified through record reviews, observations, and interviews with facility staff. The lack of documentation and failure to follow physician orders and care plans indicate lapses in the facility's wound care management. These issues were confirmed by surveyors during interviews with the unit managers and directors, highlighting the facility's failure to adhere to its own practices and physician directives for pressure ulcer care.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding the reasons for transfer or discharge to the hospital. This deficiency was identified for two residents who were hospitalized. One resident was transferred to the hospital in March 2024, and the clinical record lacked evidence of a written transfer/discharge notice being provided to the resident or their representative. Similarly, another resident was transferred to the hospital in December 2023, and there was no evidence of a written notice being given. Additionally, the facility failed to notify the Ombudsman of any transfers or discharges since January 2024, as confirmed by the Director of Nursing during an interview with a surveyor.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a written bed hold notice to residents or their representatives following transfers to an acute care hospital. This deficiency was identified for three residents during a survey. Resident #37 was transferred to the hospital on March 8, 2024, but there was no evidence in the clinical record of a written bed hold notice being provided. During an interview, the Market Clinical Advisor confirmed the absence of such documentation. Similarly, Resident #24 was transferred to the hospital on December 4, 2023, and the clinical record also lacked evidence of a written bed hold notice. The Senior Director of Nursing confirmed this finding during an interview. Additionally, Resident #71 was transported to the hospital on June 8, 2024, and although a bed hold notice was present in the record, it did not indicate that it was provided to the resident's representative. The Director of Nursing confirmed the absence of evidence that the notice was given to the representative during an interview.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two of four sampled Certified Nurse Assistants (CNAs) who had been employed for more than a year. CNA1, hired on February 1, 2020, did not have an annual performance evaluation completed by February 1, 2024. Similarly, CNA2, hired on August 14, 2017, did not have an annual performance evaluation completed by August 14, 2023. During an interview on May 22, 2024, the Director of Nursing (DON) confirmed that there were no annual performance evaluations for these CNAs after 2022, indicating a lapse in the facility's adherence to its evaluation schedule.
Failure to Post Nurse Staffing Information Accessibly
Penalty
Summary
The facility failed to post nurse staffing information in a prominent place that was readily accessible and visible to all residents for three out of four days during the survey. From May 19 to May 21, 2024, surveyors observed that the nurse staffing information was placed on a table in a room between the entrance door to the facility and an exit door leading outdoors. This area was noted to be locked at times, requiring staff to use a code to allow visitors in or out, making it inaccessible for residents to view the posting. On May 21, 2024, at 3:00 p.m., during an interview with the Director of Nursing, a surveyor confirmed that the staff posting was not accessible to residents for reviewing.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide residents and/or their representatives with a summary of the baseline care plan within 48 hours of admission for four out of five residents reviewed. Resident #37 and Resident #168 were admitted to the facility, but there was no evidence in their clinical records that a copy of the baseline care plan summary was provided to them or their representatives. During an interview, the Riverview Unit Manager confirmed that she did not provide a copy of the baseline care plan to the residents or their representatives during care plan meetings. Resident #63 was admitted with hemiparesis following a cerebral infarction, and the baseline care plan was completed after the 48-hour requirement. The care plan included a toileting schedule, but the resident reported difficulty receiving timely assistance to the bathroom. The Director of Nursing confirmed the care plan was not completed within 48 hours, and a CNA stated the toileting schedule was not on the resident's Kardex and was not followed. Similarly, Resident #270 was admitted with pneumonitis and other conditions, but the baseline care plan was completed four days after admission, as confirmed by the Director of Nursing.
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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