Seal Rock Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Saco, Maine.
- Location
- 88 Harbor Drive, Saco, Maine 04072
- CMS Provider Number
- 205103
- Inspections on file
- 18
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Seal Rock Healthcare during CMS and state inspections, most recent first.
Failure to Document Advance Directive Information: The facility did not document that written information about the right to accept or refuse treatment and to formulate an advance directive, or appoint a surrogate, was provided for multiple residents reviewed. Record review showed missing evidence for several residents, and one resident’s chart lacked both an advance directive and documentation that the topic was ever discussed. The DSS told surveyors she had provided a list to the DON of residents with advance directives, but some records could not be found, and she later stated she had no documentation for these residents.
A CNA misappropriated a resident’s personal credit card and social security card, leading to multiple unauthorized charges at a motel, gas station, and Target. The resident also reported that the CNA took another resident’s debit card and that a third resident lost a necklace and money from a card. The Administrator and consultant stated the thefts were reported to police, and the CNA later was arrested after leaving the state.
An EZ Sit to Stand lift was observed missing both safety pins, and an RN confirmed the issue before the lift was removed from the unit. In a separate observation, an unsecured container of CaviWipes was found on a med cart with no staff in sight; an MTA confirmed the wipes should have been secured because vulnerable and ambulatory residents were on the unit.
The facility failed to ensure that a CNA completed the required yearly Abuse and Neglect and Resident Rights training, and also failed to verify completion of the required 12 hours of annual in-service education. Record review showed no evidence of these trainings for the year reviewed, and the DON confirmed the CNA lacked the required education. A Senior Healthcare Operations worker later confirmed the CNA worked 199.25 hours that year.
Failure to maintain resident room surfaces in good repair. During an environmental tour with the ADM and DOR, surveyors observed duct tape on a floor threshold between a resident room and bathroom, multiple wall gouges from a wheelchair, abrasions behind a lift chair, and a hole in a bathroom wall below a towel rack.
A facility failed to implement isolation and contact precautions for multiple residents with gastroenteritis symptoms, despite provider recommendations and evidence of a norovirus outbreak. Staff were not consistently informed about which residents required precautions, PPE was not made available, and appropriate signage was lacking, resulting in the spread of illness across several units.
Nursing staff did not promptly implement isolation or contact precautions for residents with GI symptoms, and PPE supplies were not made available or used as required. Despite multiple staff and residents exhibiting symptoms and a provider's warning about a potential norovirus outbreak, there was no consistent process for identifying affected residents or ensuring proper infection control measures, leading to the spread of illness throughout the facility.
Administration did not follow infection control protocols or the FNP's recommendations during a norovirus outbreak, resulting in the absence of isolation precautions, PPE, and outbreak management. Surveyors found no signage or enhanced precautions in place, and both staff and residents continued to be affected by GI symptoms across multiple units.
A resident tested positive for RSV, but the facility did not notify the resident's POA of this significant change in condition. The lack of notification was discovered when the resident was later hospitalized for mental status changes, and the hospital informed the POA of the earlier RSV diagnosis. Facility records confirmed there was no documentation of POA notification.
A resident with diabetes had repeated elevated blood glucose readings that exceeded the parameters set by a physician's order, but there was no documented evidence that the provider was notified as required. Interviews with the FNP and an LPN indicated uncertainty about whether notifications occurred, and the administrator confirmed the lack of documentation.
Failure to Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive, or appoint a surrogate, was provided and documented for 10 of 23 residents reviewed for advance directives. The residents identified were #1, #6, #8, #17, #36, #50, #89, #103, #107, and #110. For each of these residents, record review of the electronic and/or paper medical record lacked evidence that the facility offered, reviewed, or provided the required advance directive information to the resident and/or resident representative. Resident #1 was admitted in January 2026, Resident #6 in May 2015, Resident #8 in February 2024, Resident #17 in January 2026, Resident #36 in February 2026, Resident #89 in September 2017, Resident #103 in March 2026, Resident #107 in March 2026, and Resident #110 in March 2026. Resident #50’s record did not show an advance directive in place and also lacked documentation that advance directives were ever discussed. During the record review on 3/31/26, surveyors requested several advance directives from the Director of Social Services. In interviews on 4/1/26, the Director of Social Services stated she had given a list to the DON of residents who had advance directives, but some could not be found, and later presented a list stating she did not have documentation for advance directives for these residents.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to ensure a resident remained free from misappropriation of property when a CNA took the resident’s personal credit card and social security card on Christmas Eve 2025. Resident #89 reported that there were multiple unauthorized charges on the credit card, including charges at a motel, gas station, and Target, and stated that the credit card company removed the charges after the resident reported them. The resident also stated that the CNA took the debit card of another resident across the hall and that another resident lost a necklace and money from a card. During interviews, the Administrator stated that once Resident #89 reported the credit card charges, he contacted the local police department and initiated an investigation. The Senior Health Care Operations Consultant stated she was notified of the credit card theft on 1/2/26 and reported it to police, and that two other residents later reported credit card losses. The consultant also stated the CNA had worked only three times before leaving the state, and the CNA was later arrested in Mississippi and faced multiple charges.
Unsafe Lift Equipment and Unsecured Chemical Storage
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards when an EZ Sit to Stand Lift outside of a room was observed missing both of its safety pins. During the observation, Registered Nurse #1 confirmed that the lift was missing its safety pins and removed the lift from the unit. The Director of Nursing later confirmed that maintenance had taken the machine off the floor and ordered new pins. The facility also failed to ensure that chemicals were properly secured when an unsecured container of CaviWipes was observed on a medication cart outside of a room with no staff in sight. Medication Technician #1 confirmed that the wipes should have been in a secure location because vulnerable and ambulatory residents were on the unit. The Safety Data Sheet for CaviWipes states that inhalation, skin contact, eye contact, or ingestion may cause irritation or other symptoms.
CNA Training and Annual In-Service Education Deficiency
Penalty
Summary
The facility failed to ensure that CNA #1 completed the mandatory yearly Abuse and Neglect training and Resident Rights training for 2025, and also failed to monitor that the CNA completed the required 12 hours of annual in-service education for that year. CNA #1 was hired in June 2023, and review of the employee in-service/attendance record showed no evidence of Resident Rights training, Abuse and Neglect training, or the required 12 hours of continuing education for 2025. In interview, the DON confirmed that CNA #1 did not have the 12 hours of education, Abuse and Neglect training, or Resident Rights training, and stated that the CNA was a per-diem employee and she was unsure how many hours were worked in 2025. A later interview with the Senior Healthcare Operations worker confirmed that CNA #1 worked 199.25 hours in 2025.
Failure to Maintain Resident Room Surfaces in Good Repair
Penalty
Summary
The facility failed to adequately maintain maintenance services necessary to keep areas in good repair. During an environmental tour on 4/1/26 at 12:40 with the Administrator and Director of Maintenance, surveyors observed a floor threshold between a first-floor resident room and bathroom with duct tape on each side, creating an uncleanable surface. On the second floor, one resident room had multiple small gouges on the wall to the right of the entrance from a wheelchair, and abrasions on the wall behind the resident's lift chair from it rubbing the wall when it rises. Another resident room had a hole in the bathroom wall just below the towel rack.
Failure to Implement Infection Control Precautions During GI Outbreak
Penalty
Summary
The facility failed to identify and implement appropriate isolation and contact precautions for residents exhibiting symptoms of gastroenteritis, including norovirus, across multiple units. Despite clear evidence of a contagious outbreak, there was no posting or signage on resident doors to indicate infection or the need for PPE, and PPE supplies were not made available for staff or visitors. The Family Nurse Practitioner had notified the facility administration, DON, and ADON/IP via email about the outbreak and recommended immediate implementation of precautions, but these recommendations were not followed. Observations confirmed that even after a resident tested positive for norovirus, isolation signage and PPE carts were not present at the resident's room, and staff and visitors continued to enter without appropriate protective measures. Interviews with staff revealed a widespread lack of knowledge regarding which residents were experiencing GI symptoms and which required isolation precautions. Several CNAs, LPNs, and RNs were unaware of current cases or the need for PPE, often relying solely on door signage to indicate precautions, which was not consistently in place. Staff also reported challenges in obtaining PPE carts and signage, and there was confusion about reporting and communication regarding symptomatic residents. Housekeeping staff were similarly uninformed about which rooms required special precautions, and some staff members themselves had recently experienced GI symptoms but returned to work without clear protocols. The facility's infection prevention and control policy required the identification of infections, implementation of appropriate precautions, and staff education, but these measures were not effectively carried out. The outbreak spread to 17 out of 90 residents across six of seven units, with both the DON and ADON/IP out sick during the event. The lack of timely and effective implementation of infection control measures, failure to follow provider recommendations, and insufficient staff communication and education resulted in the continued spread of gastroenteritis symptoms among residents and staff.
Failure to Initiate Isolation and Contact Precautions During Norovirus Outbreak
Penalty
Summary
The facility failed to ensure that nursing staff immediately initiated isolation and contact precautions for residents exhibiting symptoms of gastroenteritis, such as diarrhea, vomiting, abdominal pain, and fever. Surveyors observed that there was no signage or posting regarding infection or symptoms on any doors, and no isolation or contact precautions were in place on any of the facility's units. The Administrator acknowledged that several residents and staff, including the DON and ADON/IP, were experiencing GI symptoms, but no immediate action was taken to implement appropriate precautions. Interviews with nursing staff revealed a lack of clarity and consistency in the process for initiating isolation precautions and the use of PPE. Several nurses and aides were aware of residents with GI symptoms but did not ensure that precaution signs or PPE carts were present outside affected residents' rooms. Some staff relied on others to set up PPE, while others cited challenges in finding PPE carts and signage. There was also confusion about which residents required isolation, and some staff did not receive reports on residents needing precautions. A Family Nurse Practitioner had notified facility leadership via email about the potential for a norovirus outbreak and recommended immediate implementation of isolation precautions, use of soap and water for hand hygiene, and enhanced cleaning protocols. Despite this warning and the growing number of symptomatic residents and staff, the facility did not act promptly to contain the outbreak, resulting in the spread of GI symptoms throughout the building and a confirmed case of norovirus.
Failure to Implement Infection Control Measures During Norovirus Outbreak
Penalty
Summary
Administration failed to follow the facility's Infection - Clinical Protocol policy and procedures by not implementing the Family Nurse Practitioner's (FNP) recommendations for isolation and contact precautions for residents exhibiting symptoms of gastroenteritis (GI), such as diarrhea, vomiting, abdominal pain, and/or fever. Despite being notified of a potential norovirus outbreak and receiving explicit instructions from the FNP to initiate isolation, use PPE, and enhance cleaning protocols, the facility did not post signage, restrict activities, or ensure the availability of PPE for affected residents. Surveyors observed that no isolation or contact precautions were in place on any units, and there was no visible communication about the outbreak upon entry to the facility. The FNP had provided a list of 30 residents across all units who had experienced or were experiencing GI symptoms, with the first cases reported several days prior to the survey. The FNP confirmed that she had notified the facility administration, DON, and ADON/IP via email about the outbreak and the need for immediate infection control measures, including stopping group activities and using soap and water for hand hygiene. However, the facility did not implement these recommendations, citing residents' rights as a reason for not restricting activities. Additionally, the facility's infection prevention and control program was not followed, as evidenced by the lack of outbreak management, failure to monitor employee health (with both the DON and ADON/IP out sick with GI symptoms), and absence of enhanced precautions or communication to staff and housekeeping. The facility's own policies required surveillance, reporting, outbreak management, and prevention measures, none of which were adequately executed, resulting in the spread of GI symptoms throughout the facility.
Failure to Notify POA of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's medical condition. The resident was tested for Respiratory Syncytial Virus (RSV) and received a positive result, but there was no evidence in the medical record that the POA was informed of this diagnosis. The issue came to light when the resident was later transported to the hospital due to mental status changes, and the hospital, not the facility, notified the POA of the prior RSV diagnosis. Review of the medical record confirmed the absence of documentation regarding POA notification, and this was acknowledged by facility staff during interviews.
Failure to Notify Provider of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to follow a physician's order for diabetes management for one resident. The resident had an active order for blood glucose monitoring once a week, with instructions to notify the provider if blood sugar levels were below 100 or above 200. Clinical records showed multiple instances where the resident's blood glucose readings were significantly above 200, specifically 285, 311, 298, and 253, but there was no documented evidence that the provider was notified as required. Interviews with the Family Nurse Practitioner and an LPN revealed uncertainty and lack of recall regarding provider notification for these elevated readings. The facility administrator confirmed that the clinical record did not contain evidence of communication with the provider regarding the elevated blood sugar levels.
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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