Stillwater Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 335 Stillwater Ave, Bangor, Maine 04401
- CMS Provider Number
- 205116
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Stillwater Health Care during CMS and state inspections, most recent first.
Expired and undated meds were found in the A Wing and B Wing treatment carts during surveyor observation with the DON. The carts contained expired acetaminophen suppositories, open insulin glargine and insulin lispro vials without clear open dates or expiration dates, and open Lantus Solostar pens with conflicting or missing dating, and the DON was unable to determine the expiration dates for several of the insulin products.
Kitchen sanitation and food storage deficiencies were observed during survey. A built-in air conditioner was heavily covered in dirt, grime, and dust webs, dented cans were found in dry storage, and multiple cartons of half and half with an expired best-by date were still available for use in the reach-in and walk-in refrigerators.
Incomplete and Inaccurate Clinical Records: Multiple residents had TAR entries showing identical vital signs and/or weights repeated over several consecutive days despite monthly monitoring orders. For one resident, the provider noted repeated BP readings that were exactly the same, and the DON stated the system was pulling prior results when staff did not enter new data; the surveyor confirmed the records were inaccurate.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
A resident’s ordered Testosterone Gel was not available during a med pass, and the RN stated it could not be given because the facility had none on hand. Record review showed the medication had been ordered for daily use for hypogonadism, but it was not administered for 7 days because it was unavailable. The DON reviewed the record and said he would need to look into why the medication was not received from pharmacy.
The facility failed to complete an annual review of its ICP and did not document any update or revision of the program. The IP stated she did not know whether the ICP had been reviewed, and the Administrator confirmed that no annual review had been completed.
A facility failed to maintain an effective CNA training program that included required dementia care education. Review of a CNA’s personnel record showed no documented dementia training in over 12 months, and the Administrator stated she could not find any documentation showing the required training had been completed.
Failure to notify the Ombudsman of resident transfers/discharges and to provide a written transfer/discharge notice to a resident and legal representative. One resident was transferred home with services, but the LSW said Ombudsman notifications had not been sent for any transfers or discharges. Another resident was transferred to the hospital for respiratory distress, and the record showed no written notice was given to the resident or representative; the DON confirmed the notice was not provided.
The facility failed to provide a summary of the baseline care plan to the resident or resident representative for 3 of 4 residents reviewed. Baseline care plans were completed within 48 hours of admission for each resident, but there was no evidence the summaries were given. The DON stated the facility does not provide a copy of the baseline care plan, and the surveyor confirmed the summaries were not received.
A facility failed to provide necessary two-person assistance for a resident, resulting in a fall and injuries. The resident, with a history of diabetes and amputation, was left unattended during care, leading to a fall. Another resident with Alzheimer's experienced multiple unwitnessed falls due to inadequate supervision, particularly during high-risk times. Staff interviews confirmed non-adherence to care plans and lack of targeted supervision strategies.
A resident with Alzheimer's Disease/Dementia experienced multiple falls over eight months, including a fracture, due to the facility's failure to re-evaluate and update fall interventions. Despite the facility's policy requiring continuous assessment and adjustment of fall prevention strategies, the current interventions were not re-evaluated or revised, as confirmed by the DON.
The facility did not maintain a comfortable air temperature, with thermostats set below the required range, leading to residents feeling cold. The Maintenance Director was unaware of the temperature regulation until informed by a surveyor, after which the thermostats were adjusted, and residents reported feeling warmer.
The facility failed to maintain proper respiratory care for residents, including empty oxygen tanks, incorrect oxygen settings, and unclean equipment. A resident's CPAP machine lacked scheduled cleaning and supply replacement, while two residents had issues with oxygen concentrators, including incorrect settings and unclean filters.
The facility was found to have insufficient direct care staff on weekends, as confirmed by the Administrator and a review of the Payroll Based Journal staffing report. This deficiency affected residents needing assistance with ADLs during the fourth quarter of 2024.
The facility failed to ensure proper food storage and labeling in the kitchen's walk-in refrigerator, with unlabeled beverages and exposed butter. Additionally, the vegetable sink had an improper air gap, and kitchen staff did not adhere to hygiene standards, with the FSD and aides not properly wearing hairnets and beard covers.
The facility failed to maintain an effective infection prevention and control program. A CNA was observed touching medication with her hands and using an unclean area during medication administration. Additionally, a CNA did not follow Enhanced Barrier Precautions for a resident with a leg wound, as she changed bed linens without wearing a gown, contrary to facility policy.
The facility failed to ensure that five CNAs completed mandatory training on abuse prevention and dementia management. Employee records showed that CNAs hired or rehired in 2023 and 2024 lacked documented training, and the Administrator confirmed the absence of such records.
The facility did not post nurse staffing information in an area visible to residents for four days during a survey. The information was placed outside the main entrance, which was not accessible to residents, as confirmed by a surveyor and acknowledged by the Administrator and DON.
A facility failed to maintain a resident's clinical record with the necessary Power of Attorney (POA) paperwork for two months after admission. Despite documentation indicating the resident had provided an Advance Directive, the surveyor could not find it in the electronic record. The LSW confirmed the absence of the POA paperwork, which was only obtained from the hospital after the surveyor's inquiry.
The facility failed to thoroughly investigate an alleged fall with major injury involving a resident. Despite the resident's claims of being thrown into bed by a group of people, there was no evidence that staff were interviewed, and the Director of Nursing confirmed the lack of a thorough investigation.
The facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with heart disease and Alzheimer's disease, who later sustained a fracture and was discharged to an acute care hospital. The deficiency was confirmed by the DON during an interview.
A facility failed to ensure complete and accurate clinical records for a resident's Nitroglycerin ointment treatment. The records lacked evidence of required blood pressure measurements before application, and treatments were sometimes held without documented reasons.
A resident received an overdose of Acetaminophen and Nitroglycerin ointment was applied despite low blood pressure, contrary to physician orders. These deficiencies were confirmed by a surveyor and the DON.
Expired and Undated Medications Found in Treatment Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from the available-for-use supply in 2 of 3 medication storage areas reviewed, specifically the A Wing treatment cart and the B Wing treatment cart. During observation with the DON, the A Wing cart contained a box of 12 rectal acetaminophen suppositories 650 mg with an expiration date of 01/2026, an open multi-use vial of insulin glargine 100 units/10 mL that was unlabeled with no open date or expiration date, and 2 open vials of insulin lispro 100 u/mL with an open date of 1/14/26 that had expired on 2/11/26 but remained available for use. In the B Wing cart, the surveyor and DON observed an open vial of insulin lispro 100 u/mL with conflicting open dates on the box and vial, an open and undated pre-filled insulin pen containing Lantus Solostar (insulin glargine) 100 u/mL, and another Lantus Solostar pen with conflicting open dates on the packaging and pen label; the DON was unable to determine the expiration dates for the insulin products.
Kitchen sanitation and expired food storage deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean manner during observations on 2 of 3 survey days. During the initial kitchen tour, a built-in air conditioner was observed to be heavily covered in dirt and grime, with dust webs extending from the top corners on both sides of the unit to the ceiling. In the dry food storage room, the surveyor and Food Service Director observed dented cans, including 2 cans of crushed pineapples in juice with dents near the bottom seal and 4 cans of mushrooms with dents near the bottom and top seals. In the reach-in refrigerator, a carton of half and half that was half empty and a full carton of half and half both had a best by date of 2/23/26 and were available for use. In the walk-in refrigerator, 2 full cartons of half and half with the same best by date were also available for use. On the second kitchen tour, the built-in air conditioner was still heavily covered in dirt and grime, and the dust webs were still present.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records contained complete and accurate information for 6 of 10 sampled residents. Record reviews showed that multiple residents had monthly vital sign and weight entries that were identical across several consecutive days, even though the orders directed that these measurements be taken once monthly during a 7-day window. For Resident #7, Resident #8, Resident #51, Resident #2, Resident #36, and Resident #17, the TARs documented repeated identical vital signs and/or weights over multiple days in February 2026, despite the orders specifying monthly monitoring. For Resident #8, the provider progress note dated 2/24/26 documented that blood pressures this month had been recorded three times as exactly 152/88, while prior systolic readings had ranged from the 100s to 120s over the previous 3 months. During interview, the DON stated the order directed vitals to be taken once per month but was unsure why the vitals appeared replicated over several days. For Resident #17 and the other reviewed residents, the DON stated the computer system was pulling information from previous results when new data was not entered by staff, and the surveyor confirmed the clinical record contained inaccurate information.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
Ordered Testosterone Gel Not Available for Administration
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was available for use for 1 of 4 residents observed during a medication administration pass. During observation, RN1 stated she could not administer Testosterone Gel to Resident #64 because the facility did not have any available. Record review showed an order dated 2/20/26 for Testosterone Transdermal Gel 20.25 mg per actuation, 1 pump transdermally once daily for hypogonadism, applied to the upper arm. The Medication Administration Record showed the medication was not available and had not been administered from 2/20/26 through 2/26/26, resulting in 7 missed doses. During interview, the DON reviewed the record and stated he would have to look into why the medication was not received from pharmacy.
Failure to Complete Annual Review of Infection Control Program
Penalty
Summary
The facility failed to complete an annual review of its Infection Control Program (ICP) and did not document any update or revision of the program if needed for 1 of 1 ICP reviewed. During an interview, the Infection Preventionist stated she did not know whether the ICP had been annually reviewed. A review of the ICP found no evidence that an annual review had been completed. The Administrator later confirmed that the facility had not completed an annual review of the ICP.
Missing Required Dementia Training for CNA
Penalty
Summary
The facility failed to implement and maintain an effective training program that included required dementia management education for nurse aides, based on employee record reviews and an interview with the Administrator. During review of CNA3’s personnel file, surveyors found that CNA3 was hired on 7/3/23 and had no documented dementia training in over 12 months. On 2/26/26 at 8:00 a.m., the Administrator stated she was unable to locate any documented trainings, and the surveyor confirmed that CNA3 did not have evidence of completing the mandatory dementia training within the past 12 months.
Failure to Notify Ombudsman and Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to notify the Ombudsman office at least monthly of transfer/discharges for Resident #63, who was transferred home with services on 12/29/25. During an interview on 2/26/26, the Licensed Social Worker stated she had not been sending notifications to the Ombudsman's office for any transfers or discharges. The facility also failed to provide a written transfer/discharge notice to Resident #61 and the resident's legal representative for a facility-initiated transfer to the hospital for respiratory distress. Review of the clinical record found no evidence that the resident or resident representative received the written transfer/discharge notice, and the Ombudsman Program was also not notified of the transfer/discharge. The Director of Nursing confirmed that the resident and resident representative did not receive a copy of the notice.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide the resident or resident representative with a summary of the baseline care plan for 3 of 4 residents reviewed for baseline care plans (R3, R5, and R61). For R3, a baseline care plan was completed within 48 hours of admission, but there was no evidence that a summary was provided to the resident or resident representative. For R5, a baseline care plan was also completed within 48 hours of admission, and there was no evidence that a summary was provided to the resident or resident representative. For R61, a baseline care plan was completed within 48 hours of admission, but there was no evidence that a summary was provided to the resident or resident representative. During interviews, the DON stated that the facility does not provide a copy of the baseline care plan to the resident or resident representative, and the surveyor confirmed that the summaries were not received.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to provide the necessary two-person assistance during activities of daily living for a resident, resulting in an avoidable accident. The resident, who had a history of diabetes mellitus, peripheral vascular disease, and a right above-the-knee amputation, was receiving incontinent care when a CNA left the resident unattended to change gloves. During this brief absence, the resident rolled out of bed, sustaining a laceration above the left eye and rib fractures, which required emergency room transfer and hospital admission. The care plan and Kardex clearly indicated the need for two-person assistance, which was not followed by the CNA. Another resident, diagnosed with Alzheimer's Disease/Dementia, experienced multiple unwitnessed falls, primarily in the late afternoon and evening. Despite having a care plan that included interventions such as non-skid footwear, fall mats, and keeping the call bell within reach, the resident continued to fall. The resident's falls were often unwitnessed, and the facility did not evaluate the times and causes of these falls to implement a plan for supervision during high-risk periods. Interviews with staff confirmed the lack of adherence to care plans and inadequate supervision during critical times. The CNA responsible for the first resident admitted to not following the care plan, while the Director of Nursing acknowledged the absence of a targeted plan to address the second resident's increased fall risk during specific times of the day. These deficiencies highlight a failure in providing adequate supervision and adherence to care plans, leading to preventable accidents and injuries.
Failure to Re-evaluate Fall Interventions for Resident
Penalty
Summary
The facility failed to re-evaluate and update fall interventions for a resident diagnosed with Alzheimer's Disease/Dementia who experienced multiple falls over an eight-month period. The resident had several unwitnessed falls, primarily occurring in the late afternoon and evening in their bedroom, resulting in injuries such as a fractured right femur. Despite these incidents, the care plan, initially developed in June and updated in September, did not include new or revised interventions to address the ongoing fall risk effectively. The facility's 'Fall Policy and Procedure' requires continuous evaluation and adjustment of interventions to prevent falls. However, the Director of Nursing confirmed that the effectiveness of the current fall interventions had not been re-evaluated, and no new strategies had been implemented to reduce the frequency of falls. This inaction is contrary to the facility's policy, which mandates re-evaluation and adaptation of interventions if falls persist, highlighting a deficiency in the facility's adherence to its own protocols.
Failure to Maintain Comfortable Air Temperature
Penalty
Summary
The facility failed to maintain a comfortable air temperature for residents over a period of three out of four survey days. During an initial tour of A-Wing and B-Wing, the air temperature was observed to be chilly. Multiple residents reported feeling cold, especially at night. On subsequent days, the air temperature continued to be chilly, with thermostats set at 70 degrees Fahrenheit, which is below the required range of 71 to 81 degrees Fahrenheit. The Maintenance Director was unaware of the temperature regulation and adjusted the thermostats only after being informed by the surveyor. Once the thermostats were adjusted to 73 degrees Fahrenheit, residents reported feeling warmer.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as observed during the survey. Resident #10 was found with an empty portable oxygen tank on two separate occasions, despite having a physician's order for continuous oxygen to maintain a saturation level of 90%. Additionally, the oxygen concentrator used by Resident #10 was observed with a heavily soiled air intake filter, contrary to the manufacturer's instructions for weekly cleaning. Similarly, Resident #15's oxygen concentrator was set below the physician-ordered range and was also found to be dusty, with an uncleaned air intake filter. Resident #1, who was admitted with an order for a CPAP machine for evening use, reported that the machine had not been cleaned or had supplies replaced in the three months since admission. The staff confirmed that there were no orders or scheduled treatments for cleaning or replacing the CPAP machine's supplies. These deficiencies highlight the facility's failure to maintain respiratory equipment in a sanitary manner and adhere to physician orders, potentially impacting the residents' respiratory health.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the fourth quarter of 2024. During an interview on January 14, 2025, the Administrator confirmed that the facility did not have enough staff to meet resident needs on weekends, affecting residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Food Storage, Labeling, and Staff Hygiene
Penalty
Summary
The facility failed to ensure proper food storage and labeling in the kitchen's walk-in refrigerator, as observed during a survey. A large cup of beverage was found without a label indicating the name or date, and a 1-pound brick of butter had a torn cover, exposing the butter and showing marks of scrapes and punctures. Additionally, the vegetable sink was found to have an improper air gap on the drainpipe, which is a violation of the State of Maine Rules and the Code of Federal Regulations regarding plumbing design to prevent contamination. Furthermore, the facility did not ensure that kitchen staff adhered to proper hygiene standards. The Food Service Director was observed with a hairnet that did not contain all her hair, and two kitchen aides/cooks were not wearing beard/mustache covers while performing food preparation and distribution tasks. These observations were confirmed with the Food Service Director during the survey, indicating a lapse in maintaining professional standards for food safety and hygiene.
Infection Control Deficiencies in Medication Administration and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate medication administration observations and a failure to adhere to Enhanced Barrier Precautions (EBP) for a resident with a wound. During a medication administration observation, a Certified Nursing Assistant - Medications (CNA-M1) was seen popping a pill from a medication card into her hand before placing it into a plastic cup, which is against the facility's policy that prohibits touching medication with hands. In another instance, CNA-M1 allowed a pill to fall onto the top of the medication cart, which is not considered a clean area, and then used two medication cups to pick it up and place it into a medication cup for administration. Additionally, the facility did not follow its Enhanced Barrier Precaution policy for a resident with a leg wound. A Certified Nursing Assistant (CNA2) was observed changing bed linens for the resident without wearing a gown, despite the presence of a sign indicating that gown and gloves must be worn for such tasks. The Director of Nursing (DON) later confirmed that the CNA2 was informed of the requirement to wear personal protective equipment (PPE) when changing bed linens for the resident.
Deficiency in CNA Training on Abuse and Dementia
Penalty
Summary
The facility failed to implement and maintain an effective training program for Certified Nursing Assistants (CNAs), specifically in the areas of abuse prevention and dementia management. This deficiency was identified through employee record reviews and interviews, revealing that five CNAs (CNA1, CNA2, CNA4, CNA5, and CNA6) did not complete their required training. CNA1 and CNA2, hired in 2023, had no documented training in over 12 months. CNA4, hired in 2024, lacked documented orientation and training on dementia, as well as reorientation following a performance correction notice. CNA5, rehired in 2024, and CNA6, hired in 2023, both lacked documented training on dementia. During an interview, the Administrator confirmed the absence of documented training for these CNAs.
Failure to Post Nurse Staffing Information in Visible Area
Penalty
Summary
The facility failed to post nurse staffing information in an area visible to residents for four consecutive days during the survey period. From January 14 to January 16, 2025, a surveyor observed that the required nurse staffing information was not displayed in a location accessible to residents. On January 16, 2025, during an interview with a surveyor, the Administrator and Director of Nursing stated that the nurse staffing information was posted outside the main entrance door to the facility. However, the surveyor confirmed that this location was not visible to residents, leading to the deficiency.
Missing Power of Attorney Paperwork in Resident's Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained the necessary Power of Attorney (POA) paperwork, resulting in a deficiency. The resident, identified as Resident #55, was admitted to the facility two months prior to the survey, with a family member designated as the POA. Despite the Acknowledgement of Important Information and Policies document indicating that the resident had provided the facility with a copy of the Advance Directive, the surveyor was unable to locate this document in the resident's electronic clinical record. During an interview, the Licensed Social Worker (LSW) confirmed that she did not have a copy of the Advance Directive or the POA paperwork. It was only after the surveyor's inquiry that the LSW obtained the POA paperwork from the hospital, confirming that it had been missing from the resident's clinical record for two months.
Failure to Investigate Fall with Major Injury
Penalty
Summary
The facility failed to ensure an alleged violation involving a fall with major injury was thoroughly investigated for one resident. The incident was reported to the Division of Licensing and Certification, indicating that the resident sustained a fracture and was discharged to an acute care hospital. The facility's policy required thorough investigation of all allegations, but there was no evidence that staff were interviewed. Interviews with a hospice registered nurse and a Certified Nursing Assistant revealed that the resident mentioned falling and being thrown into bed by a group of people. The Director of Nursing confirmed that the allegation was not thoroughly investigated.
Failure to Develop and Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for a resident who was admitted from a private residence with a history of heart disease and Alzheimer's disease and was receiving hospice services. The resident sustained a fracture and was later discharged to an acute care hospital. A review of the clinical record revealed no evidence of a baseline care plan being developed and implemented within the required timeframe. This deficiency was confirmed by the Director of Nursing during an interview with a surveyor.
Incomplete Clinical Records for Nitroglycerin Ointment Treatment
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident's treatment with Nitroglycerin ointment. Specifically, the clinical records for the resident lacked evidence of blood pressure measurements prior to the application of the Nitroglycerin ointment on multiple occasions, despite physician orders requiring blood pressure checks before administration. The Treatment Administration Record (TAR) showed that the treatment was administered without the necessary blood pressure documentation on several dates, and there were instances where the treatment was held without documented reasons for holding it. On 3/26/24, during an interview with the Director of Nursing, it was confirmed that the electronic system did not include specific directions to take the blood pressure, even though the physician's order included hold parameters for systolic blood pressure below 100. This oversight led to incomplete and inaccurate clinical records for the resident's treatment, as the required blood pressure checks were not consistently documented before administering the Nitroglycerin ointment.
Failure to Follow Medication Parameters
Penalty
Summary
The facility failed to ensure physician-ordered medications with specific parameters were followed for a resident. On 3/10/24 and 3/11/24, the resident received a total of 3925 milligrams of Acetaminophen within a 24-hour period, exceeding the prescribed limit of 3000 milligrams. This was confirmed by a surveyor and the Director of Nursing on 3/26/24. The clinical record indicated that the resident received both scheduled and PRN doses of Acetaminophen, leading to the overdose. Additionally, the facility did not adhere to the physician's order for Nitroglycerin ointment, which was to be held if the resident's systolic blood pressure was below 100. On 3/3/24 and 3/4/24, the resident's blood pressure was documented as below the threshold, yet the Nitroglycerin ointment was still applied. This was also confirmed by a surveyor and the Director of Nursing on 3/26/24.
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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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