Waterville Center For Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterville, Maine.
- Location
- 7 Highwood St, Waterville, Maine 04901
- CMS Provider Number
- 205120
- Inspections on file
- 24
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Waterville Center For Health And Rehab during CMS and state inspections, most recent first.
Surveyors identified that clinical records for several residents were incomplete or inaccurate, including missing documentation of ROM exercises, bathing, vital signs, and follow-up on physician orders. Staff confirmed that required entries were not made, and legal documents such as POA and Advance Directives were not present in the records despite being referenced in care plans.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A resident admitted with a specialized mental health diagnosis was not screened for PASRR Level I, and no evidence was found that the required documentation was submitted to the state authority prior to admission. This lapse was confirmed by facility leadership during surveyor interviews.
The facility did not ensure that care plans were reviewed and revised by the IDT within the required timeframe after each MDS assessment for several residents. In some cases, IDT meetings were delayed, held before the assessment was completed, or lacked evidence of timely review. Additionally, care plans were not updated to address current diagnoses and care needs, such as chronic pain, atrial fibrillation, genital herpes, and MRSA.
A facility failed to maintain complete and accurate clinical records for a resident with venous stasis ulcers and DVT. The resident's care plan indicated a risk for DVT, but physician orders lacked evidence of monitoring for DVT signs. Daily skilled assessments were incomplete or missing on several dates. The Unit Manager confirmed the lack of documentation and incomplete assessments during an interview.
A resident was found restrained in a wheelchair with a sheet, without a physician's order or proper documentation, leading to an immediate jeopardy situation. Staff interviews revealed confusion and lack of accountability, with some believing the family was responsible. The facility's Restraint Use policy was not followed, as there was no documentation or consent for the restraint.
The facility failed to report a suspected abuse incident involving a resident being restrained in a wheelchair, violating the resident's right to be free from physical restraint. Despite facility policies requiring immediate reporting to authorities, the incident was not reported to law enforcement or the State Survey Agency. Interviews with staff revealed confusion about the incident, with some believing the family was responsible. The failure to report within the required timeframe resulted in immediate jeopardy for all residents.
A facility failed to investigate an incident where a resident was allegedly restrained with a bedsheet, violating their right to be free from physical restraint. Despite awareness of the incident, staff could not recall specific details, and the facility's records lacked documentation of a comprehensive investigation. The resident, who had severe cognitive impairment, was unable to be interviewed, and the failure to investigate placed all residents at risk.
A resident with severe cognitive impairment and multiple diagnoses was found restrained to a wheelchair with a bedsheet, leading to increased anxiety and distress. The incident occurred when the facility was reportedly short-staffed, and the resident, who could independently transfer, experienced a change in condition. Hospice was notified, and new medication orders were issued to manage the resident's anxiety.
The facility failed to provide or obtain written information about the right to accept or refuse treatment and formulate an Advance Directive for eight residents with various medical conditions, including liver transplant and chronic kidney disease. This deficiency was confirmed by the Administrator and Social Worker during an interview.
The facility failed to maintain a sanitary and comfortable environment, with issues such as mildew, fruit flies, and maintenance problems observed in two units. Staff confirmed these findings during facility tours.
The facility failed to maintain a sanitary environment for respiratory care equipment for three residents. A resident's nebulizer and oxygen tubing were not labeled or bagged, and another resident's oxygen concentrator filter was heavily soiled. Additionally, a third resident's oxygen tubing was outdated, and the concentrator was missing a filter. Staff confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to maintain adequate staffing levels, affecting resident care. Interviews and record reviews revealed that residents missed scheduled baths and experienced delays in care due to insufficient staff. Staff reported challenges in managing care, particularly for residents requiring two-person assistance. The facility did not meet minimum staffing ratios on several occasions, as confirmed by the DON and surveyor.
The facility failed to ensure controlled medication counts were conducted and documented at shift changes on two units. The Harbor and Cove units' medication logs lacked evidence of counts by oncoming and outgoing nurses on multiple occasions. These deficiencies were confirmed by CNAs and the Administrator, with the DON acknowledging awareness of the issue due to a previous improvement plan.
The facility failed to properly label, store, and dispose of drugs and biologicals, with expired vaccines found in storage and controlled substances not securely locked. Additionally, there were significant gaps in monitoring medication refrigerator temperatures, contrary to facility policies.
The facility failed to serve meals at appropriate temperatures, with residents reporting lukewarm or cold food that often required reheating. Test trays confirmed that hot foods were served below the required 140 degrees Fahrenheit. Operational inefficiencies, such as delays in serving due to limited staff, contributed to the issue. The Interim Food Service Director acknowledged the inappropriate temperatures.
The facility failed to maintain a clean and sanitary kitchen, with issues such as a soiled fan, improper dishwasher temperatures, and unlabeled food. Staff were observed without hair protection, and documentation for dish machine and refrigerator/freezer temperatures was incomplete. The Administrator confirmed these deficiencies.
The facility failed to ensure residents' well-being due to multiple deficiencies in care and management, affecting all 91 residents. Issues included lack of access to personal funds, failure to provide medical rights information, unsanitary conditions, unnecessary restraints, inadequate staff training, and improper medication management. These failures highlight significant lapses in the facility's operations.
The facility failed to implement proper infection control measures for residents with wounds on enhanced barrier precautions (EBP). Over two days, surveyors observed a lack of necessary signage and PPE, aside from gloves, in the rooms of three residents. This issue was confirmed during a tour with the Memory Care Unit Manager, who acknowledged the oversight.
The facility failed to offer pneumococcal vaccinations to several residents as per their policy and CDC guidelines. Despite the policy requiring assessment and offering of the vaccine within thirty days of admission, records showed that five residents were not reviewed, offered, or received the vaccine. An LPN confirmed these findings during an interview.
The facility's kitchen dish machine was not maintained in safe operating condition, operating at only 110°F instead of the required 150°F. Despite being instructed to wash dishes by hand, staff continued using the malfunctioning machine, which leaked water and required the water to be turned off after each use to prevent flooding. The Director of Facilities Operations and Interim Food Service Director were aware of the issues, but the machine remained in use until the Administrator intervened.
A resident was denied access to personal funds due to incorrect deductions for the cost of care. The facility deducted $1,291.00 instead of the usual $1,251.00 for two months, leaving the resident without the allocated $40.00 per month for personal use. The issue was identified when the resident's guardian attempted to access the funds and found them insufficient. The Nursing and Operations Assistant confirmed the error, which was pending resolution with the Corporate office.
The facility did not complete required Maine background checks for a CNA and an RN before they began working with residents, contrary to its policy on preventing abuse, neglect, and misappropriation of resident funds or property. The CNA's check was completed 48 days after hire, and the RN's check was completed 295 days after hire, as confirmed by the HR Director.
The facility failed to issue written transfer or discharge notices to two residents or their legal representatives for facility-initiated transfers to a hospital. One resident with dementia and other conditions was transferred without notice, and another with multiple diagnoses, including chronic respiratory failure, also did not receive the required notice. The absence of documentation was confirmed by the administrator during a survey review.
The facility failed to issue written bed hold notices to two residents or their legal representatives upon transfer to a hospital. One resident, with dementia and other conditions, was transferred without receiving a notice. Similarly, another resident with multiple diagnoses, including chronic respiratory failure, was also transferred without a written notice. The facility administrator confirmed these omissions during interviews with surveyors.
The facility did not ensure that residents with specialized mental health diagnoses were referred for PASRR evaluation and determination. A resident with bipolar disorder, anxiety disorder, and depression was not re-evaluated for a PASRR Level II determination after their Convalescence Categorical exemption ended, as confirmed by the Administrator.
A facility failed to update and follow physician orders for a resident, leading to the continued administration of an incorrect acetaminophen dosage and lack of physical and occupational therapy. Staff interviews revealed unawareness of the new orders, which were filed without being addressed.
The facility did not complete annual performance evaluations for a CNA hired in 2021, missing evaluations for 2023 and 2024. This was confirmed by the Administrator during a surveyor interview.
A resident with muscle weakness and dysphagia was not provided with necessary adaptive eating equipment, such as a Kennedy cup and built-up utensils, as required by their care plan. Observations over several days showed the absence of these items on the resident's meal trays, and an LPN confirmed the lack of adaptive dishes.
The facility failed to maintain accurate clinical records and proper maintenance of oxygen equipment for three residents. One resident's records lacked evidence of medication administration or refusal, while two residents had inaccurate documentation regarding oxygen tubing changes. Additionally, one resident's oxygen concentrator was heavily soiled, and another's lacked a filter.
The facility did not provide required yearly education on Resident Rights for a CNA hired in 2022. The HR Director confirmed the CNA had not received the necessary training in 2023 and 2024.
The facility failed to ensure a CNA completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. Despite the facility's assessment indicating the necessity of at least 12 hours of in-service training per year, including dementia management and resident abuse prevention, CNA4, hired in 2022, had not received this training in 2023 and 2024, as confirmed by the HR Director.
The facility failed to provide mandatory training on its QAPI program to a CNA hired in 2022. A review of the CNA's education records showed no evidence of the required annual training, which was confirmed by the HR Director during a surveyor interview.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for multiple residents. For several residents, documentation was missing or inaccurate regarding range of motion (ROM) exercises and bathing, with no evidence that these activities were completed or refused on numerous dates. Interviews with facility management confirmed the absence of required documentation in the residents' records. In other cases, clinical records lacked documentation of significant clinical events and follow-up. One resident experienced low blood pressure and dizziness, but the initial low blood pressure reading, the re-check, and physician notification were not documented, despite staff confirming these actions occurred. Another resident had a physician order for a urinalysis due to suspected infection, but the record did not show that the sample was collected, sent, or refused, nor that the provider was notified of the inability to obtain the sample, as required. Additional deficiencies included the absence of required legal documentation, such as Power of Attorney (POA) and Advance Directives, despite care plans and meeting notes indicating their existence. There were also inconsistencies in documenting the timing and assessment of a resident's fall, with vital signs and neurologic checks not accurately recorded in relation to the incident. Facility staff acknowledged these documentation gaps during interviews.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Complete PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred to the appropriate state-designated authority for a Pre-admission Screening & Resident Review (PASRR) evaluation and determination. Record review showed that the resident was admitted from a hospital with a mental health diagnosis, but there was no evidence in the clinical record that a PASRR Level I screening was completed or submitted to the state authority prior to admission. This deficiency was confirmed during an interview with the Social Services Director and the Administrator, who acknowledged the absence of required PASRR documentation in the resident's record.
Failure to Timely Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT), including participation of the resident and/or their representative, within 7 days following each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for several residents, there was either a delay in holding the IDT meeting after the MDS assessment, the meeting was held before the assessment was completed, or there was no evidence that the meeting occurred within the required timeframe. For example, one resident's IDT meeting was held 17 days after the MDS assessment, another's was held 19 days after, and in some cases, the IDT meeting was held prior to the completion of the MDS. Interviews with facility staff confirmed that the scheduling of IDT meetings was based on the Assessment Reference Date (ARD), and not always aligned with the completion of the MDS as required. Additionally, the care plans for some residents were not updated to reflect current diagnoses and care needs. One resident's care plan did not specify the cause or location of chronic pain and failed to address the monitoring and management of atrial fibrillation, a history of genital herpes, and MRSA, despite these being active or relevant diagnoses. The Director of Nursing acknowledged that certain diagnoses had not been included or updated in the care plan, and there was no documentation explaining the omissions.
Incomplete Clinical Records and Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as evidenced by a review of the resident's care plan and physician orders. The resident, who was admitted with diagnoses including venous stasis ulcers and deep vein thrombosis (DVT), had a care plan indicating a history of DVT and a risk of developing another. However, the active physician orders lacked evidence of monitoring for DVT signs and symptoms. Additionally, daily skilled assessments on specific dates were incomplete, missing cardiovascular and skin assessments, and some assessments were not completed at all. During an interview, the Unit Manager confirmed the absence of documentation for DVT monitoring and incomplete skilled assessments, which did not meet the facility's expectations for comprehensive resident monitoring.
Failure to Ensure Resident's Right to Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to remain free from physical restraints, resulting in an immediate jeopardy situation. An anonymous complaint was received alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was revealed that a resident was found in a wheelchair with a sheet double-knotted around their waist, effectively acting as a restraint. This incident occurred without a physician's order, evaluation, assessment, monitoring, or informed consent, and there was no documentation in the clinical record regarding the medical need for such a restraint. Interviews with staff members revealed a lack of clarity and accountability regarding the incident. The Life Enrichment and Pastoral Care staff member and RN1 were unable to recall specific details about the resident or the staff involved. CNA-M2 mentioned that CNA3 was placed on administrative leave due to the incident but returned quickly, with the belief that the family had restrained the resident. The Director of Nursing, who was not present at the time of the incident, provided partial notes and witness statements from CNA6 and CNA7, confirming the use of a sheet as a restraint. The facility's Restraint Use policy requires specific documentation and consent, none of which were present in this case.
Failure to Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. This failure resulted in the facility not protecting a resident from potential harm by not reporting an incident of possible abuse, which involved the violation of the resident's right to be free from physical restraint. The incident was not reported to law enforcement or the State Survey Agency (SA) as required by regulations. The facility's policy on abuse, neglect, and misappropriation of resident funds or property required immediate reporting of such incidents to the Administrator or designee, who would then notify the State Agency within 24 hours. However, this protocol was not followed. The incident involved a resident who was allegedly restrained in a wheelchair, which was reported anonymously to the State of Maine, Division of Licensing and Certification. Interviews with staff members revealed a lack of clarity and communication regarding the incident, with some staff members believing the family had restrained the resident. The Director of Nursing and other key personnel confirmed that the incident was not reported to the appropriate authorities. The facility's failure to report the incident within the required timeframe and to conduct a follow-up investigation within five working days resulted in immediate jeopardy for all residents, as the facility did not ensure the implementation of policies to report suspected crimes against residents.
Failure to Investigate Restraint Incident
Penalty
Summary
The facility failed to fully investigate an incident involving possible abuse and the use of an unnecessary physical restraint on a resident, identified as Resident #99 (R99). The incident was reported through an anonymous complaint alleging that CNAs were tying residents to chairs due to short staffing. Interviews with staff members revealed that there was awareness of the incident, but no one could recall specific details about the resident or the staff involved. The facility's policy required a thorough investigation, including interviews with the resident, accused, and potential witnesses, but this was not completed. The Director of Nursing (DON) provided partial notes and a visitor log, but these documents did not clarify who restrained R99 or when the restraint occurred. The notes indicated that R99 was able to transfer independently from bed to chair, and the visitor log showed only one visitor on the day of the incident. Staff interviews revealed that R99 was last seen in a wheelchair without restraint, but later found restrained with a bedsheet. The facility's records lacked documentation of the incident or a comprehensive investigation. The incident was not fully investigated by the Unit Manager, Director of Clinical and Quality Assurance, or the Interim Director of Nursing at the time. The resident had severe cognitive impairment and was unable to be interviewed. The facility's failure to investigate the incident violated the resident's right to be free from physical restraint, as outlined in S483.12, and placed all residents at risk. Immediate jeopardy was identified, and the facility was notified of this status.
Resident Restrained with Bedsheet Leading to Increased Anxiety
Penalty
Summary
The facility failed to protect and promote a resident's right to be free from physical restraints, as required by S483.12. An anonymous complaint was received by the State of Maine, Division of Licensing and Certification, alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was found that a resident, who was admitted on hospice with severe cognitive impairment and multiple diagnoses including dementia and anxiety disorder, was restrained to a wheelchair using a bedsheet tied in a double knot. The incident report indicated that the resident was found restrained at 6:30 p.m. and was observed resisting the restraint by attempting to stand. The Director of Nursing, who was not present at the time of the incident, provided surveyors with documentation including witness statements and a visitor log. The resident, who was able to independently transfer from bed to chair, experienced a change in condition at the time of the incident, leading to increased anxiety and agitation. Hospice was notified, and new medication orders were given to address the resident's severe anxiety. The use of the physical restraint resulted in increased anxiety and distress for the resident, as confirmed by interviews with facility staff and surveyors.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide or obtain written information concerning the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive for eight residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not adhere to its policy of ensuring that residents or their representatives were informed about their rights regarding medical treatment and Advance Directives. The facility's policy requires the Social Service Department to document whether a resident has an Advance Directive and to provide information about Maine's Advance Directive laws if one is not present. The residents affected by this deficiency had various medical conditions, including recent liver transplant, chronic kidney disease, heart failure, diabetes mellitus, COPD, and others. Despite these significant health issues, there was no evidence in their clinical records that the facility provided the necessary information about their rights to accept or refuse treatment or to formulate an Advance Directive. During an interview, the Administrator and Social Worker confirmed the findings, indicating a systemic issue in the facility's admission process and documentation practices.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in two of its units, the Mountain Top Unit and the Harbor Unit, as observed during three facility tours. On the Mountain Top Unit, issues included a pile of wet towels under an ice machine, stripped flooring, and peeling cabinet laminate, with visible mildew on the wall and floor. Additionally, fruit flies were observed in the Blueberry dining room and in a resident's room, with staff confirming these findings. On the Harbor Unit, a fly was observed in a metal container with a partially covered trifle cake during lunch service. Further observations during an Environmental Tour revealed additional maintenance issues. The shower room had non-skid tape peeling up, a resident's bathroom wall had chipped paint, and a wheelchair armrest was torn. Another resident's room had a dusty ceiling vent. These findings were confirmed by the Administrator and the Director of Facilities Operations during the tour.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment, impacting three residents. For Resident #251, a nebulizer was observed on a bedside table with tubing connected to a mask, neither labeled nor bagged, and an oxygen concentrator with nasal cannula/tubing was found lying on the floor, undated and unbagged. There was no evidence of an active order for oxygen or nebulizer use for this resident. During interviews, both a registered nurse and the unit manager confirmed that the equipment was not properly stored or labeled, which was against the facility's expectations. For Resident #3, the oxygen concentrator's filter was heavily soiled, and the oxygen tubing was dated from several weeks prior, with the nebulizer mask and tubing not stored in a sanitary manner. Similarly, Resident #47's concentrator was missing its filter, and the oxygen tubing was labeled with a date from over a month ago. A registered nurse confirmed these findings, noting that the tubing should be changed weekly, but it had not been updated as required. These observations indicate a failure to adhere to the facility's policy on maintaining clean and properly stored respiratory equipment.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by multiple interviews and record reviews. Certified Nursing Assistant #2 reported difficulties in providing timely care due to understaffing, with a nurse covering two floors and a medication assistant present. A resident expressed that they had missed three consecutive baths in the past month due to staff unavailability, despite their care plan indicating a need for extensive assistance with personal hygiene and scheduled showers twice a week. Another resident mentioned missing shower days when only two aides were available for 28 residents, highlighting the challenge of managing care during meal times. Interviews with staff further revealed delays in care, with residents potentially sitting in incontinence for extended periods before receiving assistance. The Cove Unit, in particular, faced challenges due to the high number of residents requiring two-person assistance, including those needing a Hoyer lift. The facility's staffing schedules confirmed that minimum staffing ratios were not met on several occasions, and the Director of Nursing acknowledged the ongoing efforts to address staffing issues. The surveyor confirmed that the facility was not staffing based on the residents' needs, impacting the quality of care provided.
Failure to Document Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that controlled medication counts were conducted and documented by authorized personnel at the change of shifts on two of the three units observed for medication storage, specifically the Cove and Harbor units. The bound controlled medication book labeled Harbor Log #119 showed no evidence of controlled medication counts being conducted by the oncoming nurse on several occasions, including on 8/17/24 at 18:20 and by the outgoing nurse on 8/17/24 at 5:40 a.m., 8/18/24 at 6:00 a.m., and 8/28/24 at 6:00 a.m. These findings were confirmed by a Certified Nursing Assistant-Medications (CNA-M1) during an interview with a surveyor. Similarly, the bound controlled medication book labeled Cove #21 lacked evidence of controlled medication counts being conducted by the oncoming nurse on multiple dates, including 7/26/24 at 18:00, 7/27/24 at 5:30 a.m., and 9/3/24 at 21:00, among others. Additionally, there was no evidence of counts being conducted by the outgoing nurse on several dates, including 7/5/24 at 5:30 a.m., 7/11/24 at 18:00, and 9/4/24 at 5:30 a.m. These findings were confirmed by another Certified Nursing Assistant-Medications (CNA-M2) and the facility's Administrator during a review with a surveyor. The Director of Nursing acknowledged that controlled medication should be counted during each shift change and was aware of the issue due to a previous performance improvement plan that was not followed through.
Deficiencies in Medication Storage and Temperature Monitoring
Penalty
Summary
The facility failed to comply with proper labeling, storage, and disposal of drugs and biologicals, as well as maintaining appropriate storage temperatures for medications and vaccines. During observations, it was found that expired vaccines and medications were stored alongside unexpired ones, making them available for use. Specifically, expired doses of the Moderna and Pfizer COVID-19 vaccines were found in the vaccination refrigerator on the Cove Unit. Additionally, the facility did not store controlled substances in a permanently affixed and double-locked compartment, as required. In the Cove Medication Room, controlled substances like Lorazepam were found in an unlocked, unaffixed metal box, and similar issues were observed in the Harbor Medication Room. The facility also failed to monitor and record medication refrigerator temperatures consistently. Temperature logs for the Cove and Harbor Units revealed significant gaps in daily temperature monitoring, with some refrigerators only having temperatures recorded on a few days each month. This lack of consistent monitoring could lead to improper storage conditions for medications and vaccines, potentially affecting their efficacy. The facility's policies on storage and expiration dating of medications and biologicals were not adhered to, as evidenced by the observations and record reviews conducted during the survey.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures, resulting in meals being served at unappetizing temperatures. During observations and interviews, residents consistently reported that their meals were often lukewarm or cold, with some stating that the food had to be reheated before it was palatable. Test trays confirmed these complaints, with hot foods such as potato salad, beans, and hamburgers being served at temperatures significantly below the facility's policy of maintaining food at 140 degrees Fahrenheit. The Interim Food Service Director acknowledged that the temperatures were inappropriate and confirmed that the meals would not be palatable at those temperatures. The issue was further compounded by operational inefficiencies, such as delays in serving meals due to limited staff availability and logistical challenges. For instance, food carts were observed sitting in dining areas for extended periods before being served, leading to further cooling of the meals. Residents and family members expressed dissatisfaction with the quality and temperature of the food, and these concerns were documented in Resident Council Meeting Minutes, indicating that the problem was ongoing and had been previously reported without resolution.
Deficiencies in Kitchen Sanitation and Documentation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a kitchen tour and subsequent observations. Specific issues included a heavily soiled wall-mounted fan, food disposals with dried food and liquid residue, a high-temperature dishwasher that failed to reach the required 150°F, dusty and dirty ceiling air vents and tiles, and a standing floor mixer with chipped paint. Additionally, the walk-in freezer contained ice build-up on food items, and several food items were found unlabeled and undated. Staff were also observed not wearing appropriate hair protection, which was confirmed by the Kitchen Supervisor and Interim Food Service Director. The facility's documentation practices were also found lacking, with missing records for dish machine temperatures, kitchen and unit refrigerator/freezer temperatures, and sanitizing testing logs over several months. The surveyor requested these logs multiple times before receiving them, and upon review, found numerous days where monitoring and documentation were not completed. The Administrator confirmed the absence of daily monitoring and documentation for these critical areas, which are essential for ensuring food safety and sanitation standards are met.
Multiple Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility failed to administer its operations in a manner that ensured residents could attain or maintain their highest practicable well-being. This was evidenced by multiple deficiencies cited during a recertification survey. The deficiencies spanned various aspects of resident care and facility management, including resident rights, freedom from abuse, neglect, and exploitation, admission and discharge procedures, resident assessments, quality of life and care, nursing services, pharmacy services, food and nutrition services, administration, infection control, physical environment, and training requirements. These failures affected all 91 residents in the facility, as the administration did not follow the facility assessment to ensure staff education, training, and competencies were completed. Specific incidents included the failure to provide a resident access to personal funds, failure to provide residents or their representatives with written information about their rights to accept or refuse medical treatment, and failure to maintain a sanitary and comfortable environment in certain units. Additionally, the facility did not protect a resident from unnecessary physical restraints, which resulted in immediate jeopardy and potential harm to all residents. The facility also failed to conduct required background checks for new employees and did not report or investigate incidents of possible abuse, including the use of unnecessary restraints. Other deficiencies involved the failure to issue proper transfer or discharge notices, ensure specialized mental health evaluations, update physician orders, maintain a sanitary environment for respiratory equipment, and provide sufficient staffing. The facility also failed to ensure proper medication management, serve food at appropriate temperatures, maintain kitchen cleanliness, and complete necessary staff training. These deficiencies highlight significant lapses in the facility's ability to provide safe and effective care to its residents.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of enhanced barrier precautions (EBP) for residents with wounds. Over two days of observation, surveyors noted the absence of necessary signage and personal protective equipment (PPE) other than gloves in the rooms of three residents who were on EBP due to their wounds. This deficiency was observed consistently across multiple rooms and confirmed during a tour of the Memory Care Unit with the Unit Manager, who acknowledged the absence of required signage and PPE for these residents.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with their policy and CDC recommendations. The policy required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within thirty days unless medically contraindicated or previously vaccinated. However, for five residents reviewed, there was no evidence that they were reviewed, offered, or received the pneumococcal vaccine as per CDC guidelines. Specifically, the immunization records for these residents showed lapses in adherence to the vaccination policy. One resident admitted in December 2023 had no evidence of being reviewed or offered the vaccine. Another resident, admitted in August 2024, had a consent signed for vaccination but had not received it by September 2024. Similar issues were found with three other residents, where records did not show compliance with the vaccination policy. An interview with the LPN Memory Care Unit Manager confirmed these findings.
Dish Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen's high-temperature dish machine in good repair and safe operating condition. During a kitchen tour, it was observed that the dish machine was operating at only 110 degrees Fahrenheit, below the required 150 degrees Fahrenheit for proper cleaning and sanitizing. The Kitchen Supervisor acknowledged the machine's issues, including inaccurate temperature readings and water leakage, which required the water to be turned off after each use to prevent flooding. Despite these problems, the dish machine continued to be used by the kitchen staff. Interviews with the Director of Facilities Operations and the Interim Food Service Director revealed that the dish machine had been serviced two weeks prior, but additional parts were needed for full repair. The Interim Food Service Director had instructed staff to wash dishes by hand in a three-bay pot sink, but was unaware that the dish machine was still in use. The Administrator confirmed the ongoing use of the malfunctioning dish machine and stated it would not be used until fixed. A subsequent work log indicated further issues with the machine, including a non-functioning booster and timer.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide a resident access to personal funds, specifically for Resident #47 (R47). On two occasions, the facility deducted an incorrect amount for the cost of care, leaving R47 without the $40.00 per month allocated for personal use. This discrepancy was noted when R47 reported not receiving the funds for two months and expressed frustration over the situation. The financial statements showed that the facility deducted $1,291.00 instead of the usual $1,251.00 for the cost of care in August and September, without any explanation for the increased charge. The issue was further highlighted when R47's guardian attempted to access the funds for shopping purposes but found insufficient money in the account. The Nursing and Operations Assistant acknowledged awareness of the error when the guardian raised the concern. An email was sent to the Corporate office to address the error, but compensation was delayed pending a response, resulting in R47 not having access to $80.00 of personal funds that were deducted without explanation.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to adhere to its own policy regarding the prevention of abuse, neglect, and misappropriation of resident funds or property by not completing required Maine background checks for new employees before they began working. Specifically, two employees, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), were allowed to work with residents without having their background checks completed. The CNA was hired and started working on June 12, 2023, but their background check was not completed until July 30, 2023, which was 48 days after their hire date. Similarly, the RN was hired on November 6, 2023, but their background check was only completed on September 13, 2024, 295 days after their hire date. This oversight was confirmed during an interview with the Human Resource Director, who acknowledged that the employees were working with residents prior to the completion of their background checks.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to residents or their legal representatives for facility-initiated transfers to an acute care hospital. This deficiency was identified for two residents during a survey. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024, without receiving the required written notice. The clinical record review confirmed the absence of this documentation. Similarly, the second resident, with diagnoses such as Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred on July 22, 2024, also without a written notice being provided. The administrator confirmed the lack of documentation for both cases during the survey review.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their legal representatives upon transfer to an acute care hospital, as required. This deficiency was identified in the cases of two residents. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024. A review of the resident's clinical record showed no evidence that a written bed hold notice was provided. The facility administrator confirmed this omission during an interview with a surveyor on September 11, 2024. Similarly, the second resident, with diagnoses including Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred to a hospital on July 22, 2024. A review of this resident's clinical record also lacked evidence of a written bed hold notice being issued. The administrator confirmed this deficiency during an interview with a surveyor on September 12, 2024.
Failure to Conduct PASRR Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents with specialized mental health diagnoses were referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review (PASRR) evaluation and determination. This deficiency was identified for three residents reviewed for PASRR evaluation. One resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and depression, had a PASRR Level I with a Convalescence Categorical exemption, which is a time-limited 30-day exemption. However, the resident's clinical record lacked evidence of a re-evaluation for a PASRR Level II determination after the convalescent period ended. This was confirmed during an interview with the Administrator.
Failure to Update and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that physician orders were updated and followed for a resident reviewed for unnecessary medications. On September 12, 2024, during a clinical record review, it was found that a new physician order dated September 4, 2024, for the resident included discontinuing acetaminophen 650 mg three times daily, starting acetaminophen 1 g three times daily for chronic pain, and initiating physical and occupational therapy evaluations and treatments for decreased mobility. However, the clinical record lacked evidence that these orders were reviewed or updated by a provider. Interviews with staff revealed a lack of awareness and action regarding the new orders. A registered nurse on the Memory Care Unit was unaware of the updated orders and continued administering the previous dosage of acetaminophen. The unit manager confirmed that the orders were filed without being addressed. This oversight resulted in the facility not following the physician's updated orders for medication and therapy, as confirmed by a surveyor during an interview with the unit manager.
Failure to Conduct Annual Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a Certified Nursing Assistant (CNA) who was hired on July 1, 2021. The deficiency was identified during a performance evaluation review and interview, revealing that the CNA did not receive evaluations for the years 2023 and 2024. This was confirmed by the Administrator during an interview with a surveyor on September 13, 2024.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment and utensils for a resident with specific nutritional needs. The resident, who was admitted with diagnoses including generalized muscle weakness, dysphagia, and protein-calorie malnutrition, had a care plan that required the use of adaptive equipment such as a Kennedy cup, rimmed plate, and built-up utensils during meals. Despite these documented needs, observations over several days revealed that the resident's meal trays consistently lacked the required adaptive equipment. A surveyor noted the absence of these items during multiple meal observations, and an LPN confirmed that the resident had not been using the adaptive dishes as directed by the care plan and dietary communication slip.
Inaccurate Clinical Records and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for three residents. For one resident, the clinical record lacked evidence of administration or refusal of multiple medications on specific dates, including Bupropion, Famotidine, Apixaban, Carvedilol, Timolol Maleate, Sevelamer carbonate, Tramadol, and Insulin Lispro. The Director of Nursing confirmed these findings during a record review with a surveyor. Additionally, the facility did not maintain accurate documentation for two residents using oxygen concentrators. One resident's oxygen concentrator was heavily soiled, and the tubing was dated incorrectly, with the Registered Nurse confirming that the tubing had not been changed as documented. Another resident's oxygen tubing was labeled with an outdated date, and the filter was missing from the concentrator. The Registered Nurse confirmed that the documentation of tubing changes was inaccurate.
Deficiency in Resident Rights Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included training on Resident Rights for one of the Certified Nursing Assistants (CNA) reviewed. CNA4, who was hired on June 27, 2022, had not received the required yearly education on Resident Rights since her hiring date. This deficiency was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Required Yearly Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. A review of the facility's assessment for 2024-2025 indicated that in-service training for new aides must be sufficient to ensure the continuing competence of nurse aides, with a minimum of 12 hours per year, including dementia management and resident abuse prevention training. Additionally, for nurse aides providing services to individuals with cognitive impairments, the training must address the care of the cognitively impaired. CNA4, who was hired on June 27, 2022, had not received the required yearly education for Abuse, Neglect, Exploitation, and Misappropriation of Property since being hired. This was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI). This deficiency was identified during a review of employee files, specifically for a Certified Nursing Assistant (CNA) who was hired on June 27, 2022. The review revealed that the CNA's education records did not contain evidence of receiving the required annual training on the facility's QAPI program. During an interview with a surveyor, the Human Resource Director confirmed that the CNA had not received the necessary in-service training in 2023 and 2024.
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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