Russell Park Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 158 Russell St, Lewiston, Maine 04240
- CMS Provider Number
- 205052
- Inspections on file
- 21
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Russell Park Rehabilitation & Living Center during CMS and state inspections, most recent first.
The facility did not ensure that two authorized staff signed the controlled substance shift count sheets at each shift change for multiple medication carts, resulting in incomplete records for the receipt and disposition of controlled drugs, as confirmed by the DON and facility policy.
Two residents who smoked were not assessed for their ability to smoke safely, as required by facility policy. One resident was found with cigarettes and a lighter at bedside and reported occasional staff supervision while smoking outside, but had no documented assessment or contract. Another resident, who smoked independently, also lacked a completed smoking assessment, despite having cigarettes in their possession. The DON confirmed that these assessments, which determine if residents can keep smoking materials at bedside, were not completed as required.
Surveyors found that several residents with respiratory conditions were using oxygen tubing and nebulizer equipment that was not changed or stored according to physician orders and facility policy. Staff documented tubing changes as completed, but observations showed outdated tubing in use and improper storage of respiratory equipment, indicating a failure to maintain a sanitary environment and follow prescribed care schedules.
Surveyors observed unsanitary conditions in the kitchen, including food debris, dirt, and spillage on floors and equipment, as well as soiled dish racks. Additionally, a Dietary Aid with facial hair was found not wearing a beard restraint as required by facility policy, only applying it after being prompted by surveyors.
A review of CNA education records and staff interviews confirmed that several CNAs did not receive the required 12 hours of annual in-service training, including dementia care, resident rights, and abuse/neglect prevention, as mandated for the year. Documentation for these trainings was not available for any of the CNAs reviewed.
Surveyors found multiple deficiencies in facility maintenance and housekeeping, including stained and dirty caulking around toilets, damaged shower curtains, chipped paint on doors and heaters, uncleanable surfaces due to duct tape and marred walls, and a resident's electric wheelchair with food debris. These issues were confirmed by the Environmental Services Director and Administrator.
Staff did not consistently monitor or document urinary output for two residents with indwelling catheters, despite care plans requiring this intervention. Both residents had medical conditions necessitating catheter use, and their care plans specified monitoring and documentation of urine output, which was not carried out as written.
Annual performance evaluations were not completed for five CNAs employed for over a year, as confirmed by the DON and a review of employee records. Documentation for the required 2024 evaluations was missing for all affected staff.
The facility did not provide sufficient documentation to justify the ongoing use of psychotropic medications for two residents. One resident continued to receive multiple psychotropic drugs after a fall without a documented risk-benefit assessment, while another had a PRN order for Lorazepam that exceeded the 14-day limit without clinical justification.
A resident with a physician's order for 7 units of Aspart insulin was instead given 12 units of Humalog insulin. The nurse on duty could not verify the amount administered, and the error was later confirmed by the DON. The resident expressed anxiety and requested additional blood glucose checks after being informed of the incident.
Surveyors found that an LPN failed to label and properly dispose of open biologicals, including an unlabeled Basaglar insulin pen and an Epinephrine injection, as required by manufacturer instructions. The issue was confirmed and discussed with the DON.
Surveyors and the FSD observed a heavily soiled garbage storage area with food and trash debris behind three dumpsters, confirming the area was not maintained in a sanitary condition.
The Quality Assurance Committee failed to ensure the effectiveness of a corrective plan for a previously cited deficiency regarding the maintenance of a sanitary environment to prevent disease and infection related to respiratory care, resulting in the same issue being cited again during a follow-up survey, as confirmed by the Administrator and DON.
A facility failed to maintain accurate clinical records for a resident with a stage 4 pressure ulcer, as repositioning was not consistently documented or performed. Interviews confirmed the lack of compliance with repositioning orders. Additionally, another resident was prescribed psychotropic medications without appropriate diagnoses, violating the facility's policy. The DON confirmed these deficiencies with surveyors.
The facility failed to implement infection control precautions for residents with indwelling catheters, leading to multiple infections. A resident with a neurogenic bladder and another with a history of urosepsis were not placed on Enhanced Barrier Precautions or contact precautions despite having ESBL diagnoses. Staff were unaware of the infection status and necessary precautions. The DON confirmed the oversight and acknowledged the need for precautions for all residents with catheters.
The facility failed to ensure call bell accessibility for two residents. Observations showed one resident's call bell was hanging from the wall and attached to a wiffleball at the end of the bed, while another's was tucked under them, both out of reach. CNAs noted that one resident rarely uses the call bell, relying on their roommate to use it instead, and acknowledged that staff should ensure call bells are accessible.
Failure to Maintain Accurate Controlled Substance Shift Counts
Penalty
Summary
The facility failed to maintain an adequate system for recording the receipt and disposition of all controlled drugs, resulting in insufficient detail to enable accurate reconciliation. During a review of three medication carts (Cart A, Cart B & C, and the Nurse Treatment cart), it was observed that the required signatures from two authorized medication administrators were missing from the Shift Count pages on multiple dates. The facility's policy requires that incoming and outgoing nurses count all Schedule 2 controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Count Sheet. However, on numerous occasions, the required documentation was not completed as indicated by the absence of signatures, despite the facility's practice of counting controlled substances approximately three times a day at shift changes. The Director of Nursing Services confirmed the findings, acknowledging that a significant number of required signatures were missing from the narcotic books. The deficiency was identified through record review, observation, and staff interview, and it was corroborated by the facility's own policy dated 8/1/24, which outlines the procedures for inventory control of controlled substances. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Complete Smoking Assessments and Contracts for Residents
Penalty
Summary
The facility failed to complete required smoking assessments and contracts for two residents who were identified as smokers. One resident, who had been smoking since admission approximately two weeks prior, was observed with cigarettes and a lighter at the bedside. The resident confirmed that staff occasionally accompanied them to the designated outdoor smoking area. Review of the medical record showed no evidence of a smoking assessment or a signed smoking contract upon admission or after the facility became aware of the resident's smoking. The Director of Nursing Services (DNS) confirmed that the assessment was not completed until after the surveyor's inquiry. Another resident, also identified as a smoker, was found with multiple boxes of cigarettes in their room, including one in their shirt pocket and two on the windowsill. The resident was reported by an LPN to go out alone to smoke. Review of this resident's clinical record, who was admitted several months prior, also lacked evidence of a completed smoking assessment. The DNS confirmed that no assessment had been completed for this resident, and acknowledged that the assessment determines whether residents may keep smoking materials at bedside or require them to be secured. The facility's policy requires a smoking assessment upon admission or when a resident begins smoking, and quarterly thereafter.
Failure to Maintain Sanitary Respiratory Care Equipment and Adhere to Change Schedules
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to physician orders and facility policy regarding respiratory care for five residents requiring oxygen therapy or nebulizer treatments. Multiple residents were observed using oxygen tubing and nasal cannulas that were not changed according to the prescribed weekly schedule, with tubing dated well beyond the required change interval. Documentation on the Treatment Administration Record (TAR) indicated that tubing changes were recorded as completed, but direct observation showed otherwise. Additionally, nebulizer equipment was improperly stored, with one resident's nebulizer mask and tubing left unlabeled and on a dresser, and another resident's oxygen cannula left wrapped around a cylinder caddy handle instead of being stored in a protective bag as required by policy. Residents involved had significant respiratory diagnoses, including acute and chronic respiratory failure, hypoxia, COPD, metastatic lung cancer, and end-stage emphysema, necessitating strict adherence to respiratory care protocols. Staff interviews revealed inconsistent understanding and application of the facility's policy, with some staff stating tubing was changed every two weeks despite orders and documentation indicating weekly changes. The facility's own policy required nasal cannulas to be changed every two weeks and stored in a plastic bag when not in use, and nebulizer parts to be cleaned and stored properly, but these procedures were not consistently followed.
Failure to Maintain Kitchen Sanitation and Staff Compliance with Beard Restraints
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, as evidenced by observations of food debris and trash on the kitchen floor, under equipment, and shelving. Additional findings included dirt and debris in the hood system, the fan in the walk-in refrigerator, and the fly zapper. The reach-in refrigerator, walk-in refrigerator, and walk-in freezer all had dirt, debris, and spillage on their floors. Plastic coverings on racks containing clean dishes were found to be in poor condition and soiled with dry liquid residue. These conditions were confirmed by the Food Service Director during the survey. Furthermore, a Dietary Aid with facial hair was observed not wearing a beard restraint while in the kitchen, contrary to facility policy, and only applied the restraint after surveyor intervention. The facility's policy requires all employees to wear appropriate hair restraints to prevent hair from contacting exposed food.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) employed for more than one year received the required 12 hours of annual in-service education, including training in dementia care, resident rights, and abuse/neglect prevention. A review of employee education records for five CNAs revealed a lack of documentation showing completion of these mandatory trainings for the year 2024. Each CNA's file was specifically noted to be missing evidence of the required education hours and content areas. Interviews with the Business Office Manager and the Director of Nursing Services confirmed that there was no documentation available to demonstrate that the five CNAs had received the necessary annual in-service training. The deficiency was identified through both record review and staff interviews, with no evidence provided to show compliance with the training requirements for the specified period.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
During an environmental services tour, multiple deficiencies were observed throughout the facility, indicating a failure to maintain a safe, clean, and homelike environment for residents. In the A Unit shower/spa room, the caulking around the base of the toilet was stained and dirty, all four shower curtains were stained or ripped, and both the heater unit and entrance door had chipped or missing paint, creating uncleanable surfaces. Several resident rooms in the A Unit had issues such as missing or damaged privacy curtain hooks, chipped or marred walls with black marks, stained or dirty caulking around toilets, discolored flooring, dusty bathroom exhaust fans, and doors with chipped or missing laminate. A wash basin was also found sitting on the floor under a sink in one room. In the B Unit, similar issues were noted, including stained and dirty caulking and flooring around toilets, duct tape stuck to the bathroom floor creating uncleanable surfaces, and a baseboard heater with separated metal parts. Additionally, a resident's electric wheelchair was found to be dirty and dusty, with food crumbs and debris present. The C Unit also had a resident room with a door that had chipped, gouged, and missing laminate. These findings were confirmed by the Environmental Services Director and the Administrator during the tour.
Failure to Implement Care Plan Interventions for Indwelling Catheters
Penalty
Summary
The facility failed to implement care plan interventions for two residents who required indwelling urinary catheters. Both residents had documented medical conditions—one with obstructive uropathy and neuromuscular dysfunction of the bladder, and the other with neurogenic bladder and a history of urinary tract infections—that necessitated the use of indwelling catheters. Their care plans specifically included interventions to record the amount, color, and characteristics of urine, and to monitor and document urinary output. Record reviews and interviews revealed that staff did not consistently monitor or document urinary output for either resident, as required by their care plans. Documentation from CNAs and the Nurse Treatment Administration Record lacked evidence of this monitoring. Interviews with the Administrator and the Director of Nursing Services confirmed that urinary output was not documented unless there was a physician's order, despite the care plan directives. This resulted in the facility not following the established care plans for these residents.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for Certified Nursing Assistants (CNAs) as required, with no evidence of evaluations being conducted for five CNAs who had been employed for more than one year. Employee records for each of these CNAs, hired between 2002 and 2023, did not contain documentation of an annual performance evaluation for the year 2024. This deficiency was confirmed during an interview with the Director of Nursing Services, who acknowledged that the annual evaluations had not been completed for these staff members. No information regarding the medical history or condition of residents was provided in relation to this deficiency.
Failure to Justify and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation to justify the continued use of psychotropic medications for two residents. For one resident admitted in September 2024, the consultant pharmacist identified several medications, including Risperidone, Lorazepam, Fluoxetine, and Trazodone, as potential contributors to a recent fall. The pharmacist recommended that the physician evaluate these medications for their role in the fall and document a risk versus benefit assessment if therapy was to continue. The physician initially responded with 'Thank you. No change.' and later, after further inquiry, noted that the medications were being titrated for dementia and for safety/dignity, but did not provide a specific assessment or justification as recommended. For another resident, there was a provider order for Lorazepam 0.5 mg orally as needed for anxiety disorder, with no stop date, exceeding the required 14-day limit for PRN psychotropic medications. As of the date of review, the medical record did not contain evidence of clinical rationale to continue the medication beyond 14 days. These findings were confirmed through record review and interviews with the Director of Nursing Services.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
A physician's order was in place for a resident to receive 7 units of Aspart insulin subcutaneously three times daily. On one occasion, the resident returned from dialysis and a blood glucose check was performed. The nurse on duty administered insulin but was unable to verify the amount given when questioned by the charge nurse and the resident. The resident reported being told by the charge nurse that the wrong amount was given, but neither the nurse on duty nor the resident could specify the exact dosage at that time. Further review and interview with the Director of Nursing Services confirmed that the resident was given 12 units of Humalog insulin instead of the ordered 7 units of Aspart insulin. The nurse on duty also informed the night charge nurse of the situation, and the resident expressed anxiety and requested additional blood glucose monitoring. The physician's order was not followed, resulting in the administration of the incorrect type and dosage of insulin.
Failure to Properly Label and Dispose of Open Biologicals
Penalty
Summary
Surveyors observed that the facility failed to properly label and dispose of open biologicals in accordance with manufacturer specifications during an inspection of one of three medication carts. Specifically, an opened and unlabeled Basaglar (insulin) Kwik Pen was found, which, according to the manufacturer's instructions, should be discarded 28 days after first use, but lacked a date indicating when it was opened. Additionally, an Epinephrine injection was present with a manufacturer expiration date of 4/2025, but it was either undated or expired. These findings were confirmed by the LPN present at the time of observation and subsequently discussed with the Director of Nursing Services. No information about the residents involved or their medical conditions was provided in the report.
Unsanitary Garbage Storage Area Observed
Penalty
Summary
Surveyors, accompanied by the Food Service Director, observed a heavily soiled garbage storage area containing three trash dumpsters. Food and trash debris were noted behind all three dumpsters. This unsanitary condition was directly observed and confirmed during the survey. No information regarding residents or their medical history was included in the report.
Repeat Deficiency in Sanitary Environment for Respiratory Care
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. Specifically, the federal citation F695, related to failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection associated with respiratory care, was cited again during a follow-up survey. This repeat deficiency was confirmed through record review and interviews with the Administrator and the Director of Nursing.
Deficiencies in Clinical Record Accuracy and Psychotropic Medication Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a stage 4 pressure ulcer. The resident was supposed to be repositioned every two hours as per the provider's orders, but the documentation from July 11 to August 13 lacked evidence of compliance. Interviews with the resident, a Licensed Practical Nurse (LPN), Certified Nursing Assistants (CNAs), and the Director of Nursing confirmed that the repositioning was not consistently documented or performed as ordered. The resident expressed that staff did not follow the repositioning schedule, and the LPN and CNAs indicated that the documentation was either assumed or incomplete. Additionally, the facility did not ensure that psychotropic medication orders for another resident included appropriate diagnoses. The resident was prescribed several psychotropic medications, including Sertraline, Lorazepam, and Trazodone, without corresponding diagnoses as required by the facility's Psychoactive Medication Use Policy. The Director of Nursing confirmed with surveyors that the medications lacked appropriate diagnoses, which was a violation of the facility's policy.
Failure to Implement Infection Control Precautions for Residents with Catheters
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for residents with indwelling medical devices, specifically foley catheters. Three residents were identified as not being placed on Enhanced Barrier Precautions (EBP) or contact precautions despite having conditions that warranted such measures. Resident #1, who was admitted with a neurogenic bladder requiring a foley catheter, was not placed on EBP upon admission and later developed urosepsis secondary to a urinary tract infection. Despite a diagnosis of Escherichia coli with extended spectrum beta-lactamase (ESBL) activity, there was no evidence of contact precautions being implemented. Staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), were unaware of the resident's infection status and the necessary precautions. Similarly, Resident #3, with a history of urosepsis and a urinary catheter, was not placed on EBP upon admission and was later diagnosed with ESBL without subsequent contact precautions. Staff interviews revealed a lack of awareness regarding the resident's infection status and the required precautions. Resident #2, also with an indwelling catheter, was observed without EBP despite having a recent order for antibiotics due to a urinary tract infection. The Director of Nursing (DON) confirmed that residents with catheters had multiple infections and were not placed on appropriate precautions, acknowledging a gap in following CDC guidelines.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to make reasonable accommodations to ensure the call system was within reach for two residents. Observations on August 13, 2024, revealed that the call bell for Resident #2 was hanging from the wall and attached to a wiffleball at the end of the bed, making it inaccessible. Similarly, the call bell for Resident #1 was found tucked under the resident, also out of reach. Interviews with Certified Nursing Assistants (CNAs) indicated that Resident #2 rarely uses the call bell, relying instead on their roommate, Resident #1, to use it on their behalf. CNA #2 acknowledged that all staff should ensure call bells are within reach for all residents.
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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