Springbrook Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westbrook, Maine.
- Location
- 300 Spring St, Westbrook, Maine 04092
- CMS Provider Number
- 205068
- Inspections on file
- 24
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Springbrook Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities who was fully dependent on staff for transfers fell from a mechanical lift during a bed-to-wheelchair transfer when one sling loop was not properly secured to the hanger bar. Two CNAs were present, but the straps were not double-checked before the transfer, and the care plan was not updated to reflect the correct sling size. The resident sustained serious injuries, including fractured ribs, a fractured arm, and a lacerated spleen.
A resident who required full assistance for transfers was observed using a large (green) sling instead of the care-planned medium (purple) sling for mechanical lift transfers. Multiple CNAs relied on the Kardex and sling color coding to select sling size, but the resident was not in the correct sling as specified in the care plan, a fact confirmed by the Regional Administrator.
A resident with multiple comorbidities and full assistance needs had a care plan and Kardex that were not updated to reflect the correct size sling for mechanical lift transfers. Although staff used the appropriate blue (extra large) sling as determined by a transfer evaluation, the documentation continued to specify a green (large) sling, and this discrepancy was confirmed by the DON.
An LPN failed to maintain sterile technique while changing the dressing on a resident's stage 4 pressure ulcer with tunneling by using a piece of silver alginate dressing that had been placed on a non-sterile surface before insertion into the wound, contrary to facility policy and physician's orders.
A CNA-M administered another resident's medications after failing to use two required identifiers, relying instead on room and verbal confirmation. This error resulted in a resident experiencing hypotension and requiring transfer to the ER and subsequent admission to the critical care unit for monitoring and treatment.
The facility failed to maintain a safe, clean, and homelike environment, with deficiencies observed in four units and common areas. Issues included gouged and water-damaged walls, missing laminate, dirt and debris, and stained ceiling tiles. These deficiencies were noted during an environmental tour, highlighting inadequate housekeeping and maintenance services.
The facility failed to update care plans for residents requiring oxygen therapy, leaving them without documented focus, goals, or interventions for their respiratory needs. Additionally, a resident with limited vision and specific ADL requirements was not assisted according to their care plan, resulting in missed meals and lack of toileting support. These deficiencies highlight significant gaps in care planning and implementation.
The facility failed to provide adequate ADL care for two residents, leading to deficiencies in bathing and nutrition. A resident with multiple sclerosis and an amputation received only one shower in June, despite needing weekly assistance. Another resident, requiring help with eating, was observed with uneaten meals while sleeping, with no attempts by staff to assist. These issues were discussed with the facility's management.
A facility failed to manage respiratory care for a resident with COPD, with conflicting oxygen orders and undocumented adjustments. Another resident with a wound on the gluteal folds did not have provider notification or treatment orders. Additionally, a resident who experienced an unwitnessed fall did not receive required neurological assessments, as per facility policy.
A facility failed to ensure staff competency in tracheostomy care for a resident with complex medical needs. A charge nurse, lacking recent training, required coaching during a procedure and relied on others for deep suctioning, despite signing off on the task. The last competency testing was nearly two years prior.
The facility failed to properly store medications, with an unlocked medication cart found unattended and a resident's pills left on an overbed table. A CMT accessed the cart to prepare medication, and a charge nurse confirmed leaving pills unattended for a resident who forgot to take them.
A facility failed to follow a physician's order to refer a resident to a dentist for gingivitis and cleaning. The resident's clinical record showed no evidence of follow-up, and the Marketing Clinical Advisor confirmed that the referral had not been scheduled.
A facility failed to maintain accurate clinical records for a resident's ADL. The resident was observed sleeping through meals without staff cueing and did not eat, yet documentation inaccurately recorded 50% consumption and incorrect levels of assistance. These discrepancies were discussed with the Administrator.
A resident was observed in a common area sitting at a dining table in a wheelchair, naked from the waist down. Two CNAs present did not act to preserve the resident's dignity. An LPN was called to assist in removing the resident to their room. The DON confirmed these findings.
Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift, resulting in a resident falling from the lift sling onto the floor and sustaining significant injuries. During the transfer from bed to wheelchair, two CNAs were involved in applying the sling and operating the lift. One CNA moved the lift while the other guided the resident, but the resident rolled out of the sling and fell. Upon assessment, it was found that one of the sling loops had come off the lift hook, and the nurse on duty observed the loop hanging off the swing bar. The resident suffered a contusion, bleeding from the nose, fractured ribs, a fractured left arm, and a lacerated spleen, requiring hospital admission. The resident involved had multiple medical conditions, including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, and was fully dependent on staff for mobility and transfers. The care plan specified the use of a green full body sling with two staff for all transfers, but the lift-transfer evaluation indicated a blue (extra large) sling was required. The care plan and Kardex had not been updated to reflect this change. During interviews, staff could not confirm how many times the sling loops were checked before the transfer, and one CNA admitted that the straps were not double-checked on the day of the incident. Review of facility policies and manufacturer instructions revealed that staff are required to check that all sling straps are properly connected to the hanger bar before and after elevating the resident, and to lower the resident if any attachments are not secure. Both CNAs involved had completed required training and demonstrated competency in lift use. The lift and sling were found to be in good working order, with no broken parts, and had passed recent maintenance inspections. Despite these measures, the failure to ensure all sling loops were properly secured directly led to the resident's fall and subsequent injuries.
Failure to Follow Care Plan for Mechanical Lift Transfer Sling Size
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required transfers using a mechanical lift. According to the resident's most recent assessment and lift transfer evaluation, the resident was dependent on staff for transfers and required the use of a medium (purple) full body sling with the electric mechanical lift. The care plan and CNA Kardex both specified the use of a medium (purple) sling for all transfers, based on the manufacturer's guide and nursing assessment. Despite these documented requirements, observations on the day of the survey found the resident in a wheelchair with a large (green) sling underneath, which did not match the care plan instructions. Multiple CNAs interviewed confirmed that they determine sling size by the color indicated in the Kardex, but the resident was observed using the incorrect color and size. The Regional Administrator also confirmed during the review that the resident was not in the correct sling as per the plan of care.
Failure to Update Care Plan for Correct Sling Size During Transfers
Penalty
Summary
The facility failed to update a resident's care plan and Kardex to accurately reflect the correct size sling required for mechanical lift transfers. The resident, who had diagnoses including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, was dependent on staff for all transfers. Although a Lift-Transfer Evaluation determined that the resident required a blue (extra large) sling based on weight and height, the care plan and Kardex continued to instruct staff to use a green (large) sling. Staff interviews confirmed that the blue sling was being used in practice, but the documentation had not been revised to match this change. The DON confirmed that the care plan and Kardex were not updated to reflect the current transfer method.
Sterile Technique Breach During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency occurred when an LPN failed to maintain sterile technique during a dressing change for a resident with a stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, the LPN retrieved a piece of silver alginate dressing that had been resting on the non-sterile outer wrapper of the product packaging and inserted it into the tunneling wound using a sterile cotton-tipped applicator. The LPN acknowledged that the outer surface of the packaging was not sterile and that this action could have contaminated the dressing. Physician's orders required daily cleansing with Vashe solution, drying, and application of silver alginate to the wound bed. Facility policy directed that dressings be opened without contaminating and kept within the open packet or placed directly on top of a barrier.
Failure to Properly Identify Resident Leads to Medication Error and Hospitalization
Penalty
Summary
A medication error occurred when a Certified Nurse's Assistant - Medication Aide (CNA-M) administered medications intended for one resident to another resident. The CNA-M retrieved medication cards from a slot labeled for a specific room and bed, prepared the medications, and asked the resident in that room if they were the name on the medication card. The resident confirmed, and the medications were administered. Upon returning to the medication cart, the CNA-M realized the error and immediately notified the nurse. The CNA-M admitted to not verifying the resident's identity using the required two identifiers, such as the identification bracelet and photograph, as outlined in facility policy. The resident who received the incorrect medications was subsequently assessed and initially found to be stable, but was later transferred to the hospital for abnormal vital signs. The medications administered included several antihypertensive agents and other drugs, which led to a hypotensive episode requiring admission to the critical care unit for monitoring and treatment. Facility policy requires the use of at least two resident identifiers before medication administration, and specifically prohibits using room number or physical location as an identifier. The failure to follow these procedures directly resulted in the medication error and the resident's hospitalization.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions across four of its seven units, as well as in the clean utility room and the third-floor common area. During an environmental tour, several deficiencies were observed and confirmed. In the Wayside Unit, resident bathrooms had gouged and water-damaged walls with exposed sheetrock, and dirt and debris were found around the toilet base. The Saccarappa Unit had a resident room with a missing piece from the entrance door and an open area under the window sill. The Mayflower Unit had a resident room with peeling laminate and a chipped area on the entrance door, along with stained ceiling tiles in the common area and dirt and debris in the clean utility room. In the King Unit, multiple resident rooms had gouged walls, chipped or gouged doors, and loose or peeling wall cove base in bathrooms. Additionally, the kitchenette counter was missing laminate in several areas.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents requiring oxygen therapy and other essential care needs. Specifically, four residents receiving oxygen therapy did not have their care plans updated to include a focus, goal, or intervention related to their oxygen or CPAP therapy. This oversight was identified through observations and reviews of electronic medical records, which showed that orders for oxygen therapy were present but not reflected in the care plans. The lack of proper documentation and planning for these residents' respiratory care needs indicates a significant gap in the facility's care planning process. Additionally, the facility did not implement a care plan for a resident requiring assistance with Activities of Daily Living (ADL), nutrition, and incontinence. The resident, who has limited vision and requires specific assistance during meals, was observed sleeping at the dining table with uneaten meals served on regular plates, contrary to the care plan instructions. The certified nursing assistant (CNA) failed to wake the resident or assist with eating, and repeatedly approached the resident from the left side, which is against the care plan's guidance due to the resident's limited vision. This lack of adherence to the care plan resulted in the resident not receiving the necessary support for eating and toileting over an extended period.
Deficiencies in ADL Care for Bathing and Nutrition
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, leading to deficiencies in showering/bathing and nutrition. Resident #18, who has multiple sclerosis and an above-the-knee amputation, required extensive assistance for bathing, including a mechanical lift and two-person assistance. However, documentation revealed that Resident #18 received only one shower in June, despite the care plan indicating a need for weekly showers. There was no documentation of any refusal from the resident, and the issue was only addressed after the resident's family intervened. Resident #53, who requires supervision or touching assistance for eating, was observed sleeping at the dining room table with uneaten meals in front of them on multiple occasions. Despite the care plan indicating the need for assistance with eating, the CNA did not attempt to wake or assist the resident during meal times. The resident's guardian expressed concerns about the resident's eating habits and potential hunger-related behaviors. These observations were discussed with the facility's LPN Manager and Administrator, highlighting a failure to provide necessary nutritional support.
Deficiencies in Respiratory Care, Wound Management, and Fall Assessment
Penalty
Summary
The facility failed to properly manage the respiratory care of a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident had conflicting oxygen orders in their clinical record, with one order for 3 liters per minute and another for 2.5 liters per minute. Despite these orders, the resident's oxygen was set at 4 liters per minute, which was not documented or communicated to the provider. The charge nurse confirmed that the resident had been receiving 4 liters for a couple of months, indicating a lack of proper documentation and communication regarding the resident's oxygen needs. In another instance, the facility did not notify the provider or obtain orders for a resident with a wound on the gluteal folds. The wound was identified as moisture-associated skin damage, but there was no documentation of treatment steps taken by the staff. The charge nurse admitted to leaving a message for the skin care team but had not contacted the provider for an order since the wound assessment. This oversight highlights a failure in the facility's process for managing new wounds. Additionally, the facility did not conduct appropriate neurological assessments for a resident who experienced an unwitnessed fall. The resident was found on the floor after losing balance, but there was no evidence of continued neurological monitoring as required by the facility's policy. The Administrator was unable to provide documentation of neurological checks following the fall, indicating a lapse in adherence to the facility's falls management policy.
Inadequate Competency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for a resident on the Wayside Unit. The deficiency was identified when a surveyor observed a charge nurse performing tracheostomy care for a resident with a tracheostomy, who was dependent on staff for all activities of daily living and had a history of drug-resistant organisms. During the observation, the charge nurse expressed a lack of confidence in performing the procedure and required coaching from the Nurse Practice Educator (NPE) using a check-off sheet. The charge nurse initially did not perform deep suctioning until prompted by the surveyor, despite the resident showing signs of labored breathing and copious secretions. Further investigation revealed that the charge nurse had not received recent training on tracheostomy care, with the last skills fair and competency testing completed nearly two years prior. The charge nurse admitted to relying on other nurses to perform deep suctioning when needed, despite signing off on the treatment administration record as if they had performed the procedure themselves. The facility's assessment indicated that it provides care for respiratory treatments, including tracheostomy care, but the charge nurse's lack of recent training and competency testing contributed to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed by surveyors. On the Saccarappa House Unit, an unlocked and unattended medication cart was found in the hallway, which was later accessed by a Certified Medication Technician to prepare a resident's medication. Additionally, on the Wayside Unit, a resident was found asleep in bed with a cup of pills left unattended on the overbed table. The charge nurse confirmed that the pills were left there, as the resident had forgotten to take them.
Failure to Schedule Dental Referral
Penalty
Summary
The facility failed to follow through with a physician's order for a dental referral for a resident. The resident's clinical record included a physician's order dated March 18, 2023, instructing staff to refer the resident to a dentist for gingivitis and a cleaning. However, the clinical record lacked evidence of any follow-up with the dental referral. During an interview with the surveyor on July 17, 2024, the Marketing Clinical Advisor confirmed that the dental referral for the resident had not been scheduled.
Inaccurate Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident reviewed for Activities of Daily Living (ADL). During observations on two separate meal occasions, the resident was seen sleeping through both meals without any cueing from staff and did not consume any food or fluids. However, the certified nursing aid documentation inaccurately recorded that the resident consumed 50% of the meals. Additionally, the documentation incorrectly stated that the resident was under supervision with encouragement or cueing during one meal and was independent with no help or staff oversight during the other meal. These discrepancies were discussed with the Administrator during an interview.
Resident Dignity Not Maintained in Common Area
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. On April 25, 2024, at 8:20 a.m., a resident was observed in the common area of the Wayside Gardens Unit sitting at the dining table in a wheelchair, naked from the waist down. Two CNAs were present in the dining area serving other residents but did not take any action to address the resident's lack of clothing or preserve the resident's dignity. An LPN, who was nearby passing medications, was called to assist in removing the resident to their room. The Director of Nursing confirmed these findings upon arrival at the unit at 8:30 a.m.
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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