Sedgewood Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Falmouth, Maine.
- Location
- 22 Northbrook Dr, Falmouth, Maine 04105
- CMS Provider Number
- 205159
- Inspections on file
- 16
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sedgewood Commons during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently monitor or document medication refrigerator temperatures as required by CDC guidelines, with significant gaps in twice-daily temperature logs over a three-month period. This deficiency was confirmed through record review and staff interviews.
Surveyors found widespread deficiencies in housekeeping and maintenance, including off-track privacy curtains, misaligned closet doors, stained and damaged bathroom fixtures, and strong urine-like odors in multiple rooms and common areas. These issues compromised resident privacy and comfort, and were confirmed by facility leadership during an environmental tour.
An unsecured container of CaviWipes, a chemical cleaning product, was found on a bedside table in a resident's room. The SDS for CaviWipes details health hazards if improperly handled, and the product should not have been accessible in resident care areas, indicating a failure to maintain a hazard-free environment.
The facility failed to correct previously cited deficiencies, as surveyors again found that medication refrigerator temperatures were not monitored daily and that infection control protocols, specifically Enhanced Barrier Precautions, were not properly implemented. These issues persisted despite prior identification and a plan of correction.
A resident with a history of chronic diarrhea and prior C-diff colonization developed acute symptoms consistent with infectious diarrhea, but staff did not initiate transmission-based precautions or notify clinical leadership as required by policy. CNAs observed concerning changes but were told not to use precautions, and no signage or PPE was present. The Infection Preventionist and provider were unaware of the resident's condition until informed by surveyors, resulting in delayed infection control actions.
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
The facility failed to properly manage controlled substances, resulting in a medication error where a resident received another's morphine. The morphine bottle was not removed from use immediately, and the error was not documented. Additionally, controlled substances were logged by only one staff member, contrary to policy requiring two. This was confirmed by the Administrator and Unit Manager.
The facility failed to provide adequate housekeeping and maintenance services in two of three units. Observations included dirty shower chairs, cracked tiles, peeling wallpaper, and unlabeled urinals. The Director of Maintenance confirmed these findings.
The facility failed to complete annual performance evaluations for three CNAs. CNA #3, CNA #4, and CNA #5 had not received annual evaluations for multiple years, as confirmed by the Administrator, Clinical Market Advisor, and Market President.
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators. In the [NAME] House, a dormitory-style refrigerator with a freezer was used to store vaccines, and an out-of-range temperature was recorded without appropriate follow-up actions. In the [NAME] House, two opened and unlabeled vials of PPD were found, and the refrigerator had significant ice buildup, leading to incorrect storage of various vaccines.
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. A surveyor observed dust, debris, and staining on ceiling vents, and a sticky, dusty film on flat surfaces. Additionally, there was no documentation of food temperatures being taken during several meals.
The facility failed to provide residents and/or their representatives with the required Vaccine Information Statements (VIS) for the pneumococcal vaccines (PCV13, PCV15, and PCV20) prior to immunization. The omission was confirmed by the Infection Preventionist and the Marketing Clinical Advisor, who acknowledged that only the VIS for PPSV23 was being provided.
The facility failed to ensure residents and their representatives received education on the benefits, risks, and side effects of the COVID-19 vaccine before immunization. Additionally, staff were not provided formal education on the vaccine. The Infection Preventionist, Nurse Practice Educator, and Marketing Clinical Advisor confirmed the lack of educational materials and documentation, leading to the identified deficiency.
The facility failed to provide required training on Resident Rights for two CNAs, as confirmed by the Clinical Market Advisor. Both CNAs, hired in December 2023, had no documented training on this essential topic.
The facility failed to coordinate PASRR Level I and Level II assessments for a resident with Dementia and PTSD. The clinical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority. This was confirmed by the facility's Social Worker during an interview.
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. A resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that MDS Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker.
The facility failed to meet the personal hygiene preferences for a resident dependent on staff for ADL. The resident was observed with an unshaven face and long fingernails, despite expressing a preference for being clean-shaven. The CNA and Unit Manager confirmed the lack of specific documentation for completed nail care or shaving.
A facility failed to provide appropriate treatment for a resident's skin condition, as nursing staff did not identify or document a rash despite the resident's representative bringing in a cream from a dermatologist. The care plan's instructions to observe and report skin abnormalities were not followed, and the issue was only addressed after surveyor intervention.
The facility's Quality Assurance Committee failed to ensure the effectiveness of the POC for a deficiency related to housekeeping and maintenance services. Despite the POC, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms, leading to the recitation of the same deficiency tag F584.
Failure to Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to consistently monitor and document temperature controls for medication and vaccine refrigerators in two medication storage rooms. During observations, it was noted that these refrigerators contained various vaccines and multi-use vials, including Pneumococcal 20, influenza vaccinations, and Tuberculin Purified Protein. Review of the facility's temperature logs for the months of March, April, and May revealed significant gaps in documentation, with many days lacking evidence of the required twice-daily temperature readings. Specifically, one refrigerator was missing readings for 15, 24, and 25 days in March, April, and May, respectively, while another refrigerator was missing readings for 31, 28, and 30 days in the same months. During interviews, facility staff confirmed the findings and stated that they follow CDC guidelines for vaccine and medication storage, which require temperature checks and documentation at least twice daily. The lack of consistent temperature monitoring and documentation was confirmed by both the surveyor's review and staff interviews, indicating noncompliance with accepted professional standards and CDC guidelines for medication and vaccine storage.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain adequate housekeeping and maintenance services, resulting in unsanitary, disordered, and uncomfortable conditions in 36 out of 56 resident rooms and across all three units. Specific deficiencies included room divider curtains and window curtains being off track and unable to fully close, which compromised resident privacy in multiple rooms. Additionally, closet doors were misaligned and did not fully close in several rooms. Other maintenance issues included holes in walls, torn wallpaper, stained ceiling tiles, and damaged bathroom fixtures such as chipped sink countertops and toilets with visible stains or improper installation. Several rooms and common areas were noted to have strong urine-like odors and uncleanable surfaces due to damage or staining. These findings were confirmed during an environmental observation tour conducted with the Administrator and Maintenance Supervisor, who acknowledged the extent of the issues. The report documents that these conditions were present throughout the facility, affecting a significant number of resident rooms and common areas, and were not limited to isolated incidents. No information was provided regarding the medical history or specific conditions of the residents affected by these deficiencies.
Unsecured Chemical Cleaning Product Found in Resident Room
Penalty
Summary
A deficiency was identified when an unsecured container of CaviWipes, a chemical cleaning product, was observed on a bedside table in a resident's room. This incident occurred during a survey of one of the facility's units. The Safety Data Sheet (SDS) for CaviWipes outlines the potential health hazards associated with exposure, including the need for medical attention in cases of inhalation, skin contact, eye contact, or ingestion. The presence of this unsecured chemical in a resident care area demonstrated a failure to ensure that the environment was free from accident hazards related to the proper storage of chemicals.
Repeat Deficiencies in Medication Storage and Infection Control
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. During a follow-up survey, it was found that the same deficiencies, specifically F761 and F880, were still present. F761 involved the failure to monitor medication refrigerator temperatures on a daily basis, while F880 pertained to the failure to maintain an Infection Control Program by not applying appropriate interventions related to Enhanced Barrier Precautions. These deficiencies were observed and confirmed through record review and interviews, and were discussed with facility leadership during the exit conference.
Failure to Implement Timely Infection Control Measures for Suspected C-diff
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for the surveillance and prevention of gastrointestinal disease transmission in one resident. Despite facility policy requiring nursing staff to initiate transmission-based precautions for suspected infectious diarrhea and to notify the attending physician and Infection Preventionist, these steps were not followed when a resident exhibited three episodes of watery stool with significant mucous and foul odor. Certified Nursing Assistants observed changes in the resident's stool consistent with previous C-diff infection but were instructed not to use transmission-based precautions, and no signage or personal protective equipment was present outside the resident's room. The resident, who had a history of chronic diarrhea and prior C-diff colonization, was not placed on precautions despite acute changes in stool characteristics. Interviews with staff revealed confusion and lack of communication regarding the need for precautions, with CNAs expressing uncertainty about protocol and reporting that they were not informed of the resident's change in condition. The Infection Preventionist and Market Clinical Advisor were unaware of the resident's acute symptoms until informed by surveyors, and the facility provider confirmed that the changes in stool warranted precautions and further testing, but they had not been notified. The failure to recognize and respond to the resident's symptoms in a timely manner resulted in a delay in implementing appropriate infection control measures.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Medication Management Deficiency Involving Controlled Substances
Penalty
Summary
The facility failed to maintain a proper system for handling controlled substances, leading to a medication error involving two residents. A nurse administered a dose of morphine to one resident using another resident's morphine bottle and oral syringe. This incident was not documented in the Narcotics Logbook, and the morphine bottle continued to be used for six days after the error occurred. The Unit Director was unaware that the morphine bottle had not been removed from use immediately, and there was no evidence that the oral syringe was disposed of after the incident. Additionally, the facility did not comply with its policy requiring two licensed staff members to document the receipt of controlled substances from the pharmacy. The Narcotic Logbook showed that controlled substances, including morphine and fentanyl patches, were logged in by only one staff member on multiple occasions. This was confirmed by the Administrator and the Unit Manager, indicating a systemic issue in the management of controlled drugs at the facility.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for two of three units. During an environmental tour, several deficiencies were observed. In the first unit, the shower room had a laydown shower chair with an orange-colored coating under the chair edge and rim, a raised floor with cracks, and cove base peeling away from the wall. A resident's wheelchair seat was coated with dirt and debris. One bedroom door was sticking, making it difficult to open, and a wall light near another room door was missing its cover. Wallpaper was peeling and stapled to the wall in multiple locations. In the second unit, the shower room had a bariatric shower chair and laydown shower chair both with orange-colored coating under the chair edge and rim. One bathroom had cracked tiles and a black built-up substance around the base of the toilet. Another bathroom had a urine hat stored on top of the toilet, and a shared bathroom had an unlabeled urinal hanging on the toilet grab bars. The Director of Maintenance confirmed these findings during the tour.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled Certified Nursing Assistants (CNAs). CNA #3, hired on 3/4/20, had their last performance evaluation as a 90-day progress report completed on 8/14/20, with no evidence of annual evaluations for 2021, 2022, 2023, or 2024. CNA #4, hired on 5/11/15, had their last performance evaluation completed on 5/3/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. CNA #5, hired on 7/31/18, had their last performance evaluation completed on 9/26/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. During an interview on 3/27/24, the Administrator, Clinical Market Advisor, and Market President confirmed that staff performance evaluations had not been completed annually.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators surveyed. In the [NAME] House medication room, a dormitory-style refrigerator with a freezer was used to store influenza and pneumococcal vaccines. The recorded temperature for the refrigerator showed an out-of-range temperature of 70.8°F on 3/24/24. The Unit Manager was unaware of any actions taken following the discovery of the out-of-range temperature and could not confirm whether the vaccines were in the refrigerator at that time. Additionally, the Interim Director of Nursing (IDON) confirmed that the dorm-style refrigerator was inappropriate for storing vaccinations and that the vaccines were not removed at the time the out-of-range temperature was discovered. In the [NAME] House medication room, a surveyor found two opened and unlabeled vials of Purified Protein Derivative (PPD) used for tuberculosis testing, which should have been labeled with an open date and discarded 30 days after opening. The refrigerator also had significant ice buildup along the back inside surface and stored various vaccines, including pneumococcal, RSV, Spikevax (Covid-19), and influenza vaccines. The IDON confirmed the ice buildup and that the facility policy was not followed after the discovery of the out-of-range temperature, leading to incorrect storage of vaccinations. The facility's policy required immediate notification of maintenance and the Director of Nursing, moving medications to another refrigerator, and contacting the pharmacist for guidance, none of which were followed.
Kitchen Sanitation and Food Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. During an initial kitchen tour, a surveyor observed and confirmed with the cook the presence of dust, debris, and staining on the ceiling vents, as well as a sticky, dusty film on all flat surfaces in the kitchen. Additionally, there was a lack of documentation of food temperatures being taken during dinner on 3/23/24, all day on 3/24/24, all day on 3/25/24, and breakfast on 3/26/24.
Failure to Provide Required Vaccine Information Statements
Penalty
Summary
The facility failed to provide residents and/or their representatives with the Vaccine Information Statement (VIS) prior to administering the pneumococcal vaccine (Prevnar). The facility's Pneumococcal Vaccination policy and procedure, revised on 11/1/23, mandates that patients or their representatives be educated about the benefits and potential side effects of the vaccination through the VIS. However, during a review of the facility's admission packet, it was found that the VIS sheets for PCV13, PCV15, and PCV20 were missing. The Infection Preventionist (IP) confirmed that the required VIS sheets were not provided to residents or their representatives upon admission or prior to the administration of these vaccines. Further interviews revealed that the facility's Marketing Clinical Advisor also confirmed the omission of the Prevnar vaccine VIS sheets. The facility was only providing the Pneumococcal Polysaccharide vaccine (PPSV23) VIS sheet, neglecting to include the necessary VIS sheets for the other pneumococcal vaccines (PCV13, PCV15, and PCV20). This oversight led to residents and/or their representatives not receiving the required information about the risks and benefits of the vaccines before immunization.
Failure to Provide COVID-19 Vaccine Education to Residents and Staff
Penalty
Summary
The facility failed to ensure that each resident or their representative received education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine before immunizing residents. The facility's Infection Preventionist (IP) confirmed that the admission packet, which includes the COVID-19 vaccine education and consent form, lacked evidence of such education. Additionally, the IP admitted that staff were not provided formal education on the benefits and risks of the COVID-19 vaccine. This was corroborated by the Nurse Practice Educator (NPE), who stated that no education on COVID-19 vaccines had been conducted for staff, and a Registered Nurse (RN) in orientation confirmed she had not received any education on the new Spikevax COVID-19 vaccine. A Licensed Practical Nurse (LPN) also indicated uncertainty about receiving education on the new vaccine, typically only signing sheets when new information is released. The Marketing Clinical Advisor confirmed that residents and their representatives were not provided with the Vaccine Information Statement (VIS) education upon admission or prior to vaccine administration, and no educational materials were found in common areas of the facility. The facility's COVID-19 Vaccination policy and procedure, revised on 2/7/24, states that the facility will provide the opportunity to receive COVID-19 vaccinations following CDC recommendations and will obtain consent using the Patient Informed Consent or Declination COVID-19 form. However, the facility did not adhere to this policy, as evidenced by the lack of documented education for both residents and staff. The surveyor's interviews with various staff members, including the IP, NPE, RN, and LPN, revealed a consistent lack of formal education on the COVID-19 vaccine, specifically the new Spikevax vaccine. The Marketing Clinical Advisor's confirmation further highlighted the facility's failure to provide necessary educational materials to residents and staff, leading to the identified deficiency.
Lack of Resident Rights Training for CNAs
Penalty
Summary
The facility failed to implement and maintain an effective training program that includes training on Resident Rights for two of five Certified Nursing Assistants (CNAs) reviewed. Specifically, CNA #1, hired on 12/26/23, and CNA #2, hired on 12/4/23, had no documented training regarding Resident Rights. This deficiency was confirmed during an interview with the Clinical Market Advisor, who acknowledged the absence of documentation for the required annual training on Resident Rights.
Failure to Complete PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments for Pre-Admission Screening and Resident Review (PASRR) Level I and Level II programs for a resident diagnosed with Dementia and Post Traumatic Stress Disorder. The clinical record for the resident, who was admitted to the facility, lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. This deficiency was confirmed during an interview with the facility's Social Worker, who acknowledged that the PASRR Level I screening had not been completed and stated they would proceed with the PASRR at that time. The finding was later discussed with the Market President.
Failure to Review and Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. During an interview, a resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that Minimum Data Set (MDS) Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker during an interview.
Failure to Meet Personal Hygiene Preferences for Dependent Resident
Penalty
Summary
The facility failed to meet the personal hygiene preferences for a resident who is dependent on staff for Activities of Daily Living (ADL). On 3/26/24, a surveyor observed Resident #49 with an unshaven face and long fingernails with a dark substance under them. The resident, diagnosed with dementia and lower extremity amputation, was assessed to need staff assistance for personal hygiene, including nail care and shaving, as per the Minimum Data Set (MDS) assessment. The Certified Nursing Assistant (CNA) confirmed that the resident had not been shaved for several days and was unsure about the last time the nails were done, acknowledging the resident's dependence on staff for these tasks. On 3/27/24, the surveyor interviewed Resident #49 and the Resident Representative, who confirmed that the resident had still not been shaved or provided nail care. The resident expressed a preference for being clean-shaven, and the Resident Representative mentioned having requested shaving several days prior. The Unit Manager confirmed that there was no specific documentation for completed nail care or shaving, only for refusals, and there was no record of the resident refusing these services. The Unit Manager acknowledged that residents should be shaved daily if that is their preference.
Failure to Provide Appropriate Skin Condition Treatment
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for skin conditions. The deficiency was identified for a resident who had a rash and was observed scratching and itching several small, scabbed areas on the upper right arm. Despite the resident's representative bringing in a cream from a dermatologist, there was no evidence in the resident's skilled documentation from admission through the observation period that the nursing staff had identified or documented the rash. The care plan instructed nursing to observe the skin condition daily and report abnormalities, but this was not followed. The RN confirmed she was unaware of the rash and noted that skin checks are done weekly, relying on CNAs to report any concerns. The RN also acknowledged the need for a provider order to use the cream brought in by the family. The interim Director of Nursing confirmed that the resident's rash was only assessed after surveyor intervention. The lack of documentation and timely assessment of the resident's skin condition indicates a failure to provide appropriate treatment and care according to the resident's needs and the facility's care plan. This deficiency highlights a gap in communication and adherence to care protocols within the facility's nursing staff.
Failure to Maintain Sanitary Conditions
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for a deficiency identified during the annual Long Term Care Recertification Survey. The deficiency, cited under Federal citation F584, pertained to the facility's failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. Despite the POC indicating that resident rooms and bathrooms would be in a sanitary condition by a specified completion date, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms on the [NAME] unit. These observations led to the recitation of the same deficiency tag F584.
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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