Cedar Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Skowhegan, Maine.
- Location
- 23 Cedar Ridge Drive, Skowhegan, Maine 04976
- CMS Provider Number
- 205060
- Inspections on file
- 19
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Ridge Center during CMS and state inspections, most recent first.
Multiple residents experienced significant delays in receiving assistance with ADLs, including toileting and changing, due to insufficient nursing staff. Residents reported waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions. Staff confirmed frequent short staffing, with some shifts covered by only one CNA and a nurse, leading to incomplete care and missed tasks such as baths and repositioning. Staffing schedules showed that minimum staffing requirements were not met for the majority of days reviewed.
A resident who transitioned from Medicare to private pay was not provided with consistent discharge planning or assistance with alternative placement, despite being assessed as appropriate for a lower level of care. The facility did not document an active discharge plan for several months, failed to communicate effectively with the POA, and staff threatened to contact APS when the POA attempted to arrange a transfer. Leadership acknowledged a lack of proactive discharge planning and indicated the resident would remain until funds were depleted, without evidence of equal access to services regardless of payor source.
The facility failed to develop and implement care plans for PTSD for three residents diagnosed with the condition. A resident admitted with PTSD lacked a documented care plan with goals, interventions, and triggers. Similarly, two other residents with PTSD diagnoses did not have care plans addressing their condition. The Market Clinical Advisor confirmed the absence of necessary components in the care plans for these residents.
The facility failed to maintain respiratory equipment in a sanitary manner, with observations of oxygen machines, nasal cannulas, and tubing improperly stored on the floor, on a wheelchair, and on a light fixture. An LPN and RN confirmed these items should be bagged and stored properly when not in use. Additionally, a resident was found sleeping on top of an unbagged nasal cannula, which should have been stored in a plastic bag.
The facility failed to maintain accurate records for controlled drugs and did not ensure proper documentation of shift counts across four units. Additionally, a resident requiring IV antibiotics did not receive the medication for three days due to supply issues, and the facility lacked an effective emergency pharmacy plan.
The facility failed to maintain a clean and sanitary kitchen, with food crumbs and debris found on various surfaces, and improperly stored food items in the refrigerator, freezer, and dry storage room. Additionally, the emergency food supply was stored alongside unsecured chemicals, posing a contamination risk. These issues were observed and reviewed with facility staff.
The facility failed to clearly communicate the terms of binding arbitration agreements to residents or their representatives. Several residents, including those who were cognitively intact, were unaware they had signed such agreements and did not receive education on their implications. The Admissions Director confirmed that arbitration agreements were embedded in admission documents and not thoroughly explained, with signatures applied automatically. Additionally, not all residents' records were checked for advanced directives before signing.
The facility failed to implement Enhanced Barrier Precautions for two residents with multi-drug resistant organisms, as required by their care plans. Signage indicating the need for precautions was missing, and staff were unaware of the necessary PPE. The Director of Nursing confirmed the signs had been removed, and the Senior Administrator cited guidance allowing discretion in precautions, leading to a deficiency in infection control practices.
The facility failed to provide sufficient staffing, particularly on weekends, leading to delayed assistance for residents with ADLs. A resident experienced incontinence after waiting 30 minutes for help, while another with PTSD was left in distress in the bathroom. A family member found a resident unattended with the call light on, and another resident was left wet all night due to a leaking catheter. These incidents highlight the facility's inability to meet residents' needs due to inadequate staffing.
The facility failed to maintain resident dignity by not serving all residents at the same table simultaneously during meal service. Observations and staff interviews revealed that meals were organized by room number, leading to staggered service times at tables. Despite resident concerns and discussions about changing the meal delivery order, no changes had been implemented.
A facility failed to update a care plan for a resident diagnosed with PTSD. Despite the diagnosis being made, the care plan lacked goals, interventions, or triggers for PTSD. This oversight was confirmed by the Market Clinical Advisor during an interview.
A facility failed to monitor a resident for behaviors and side effects of psychotropic medications, despite having active orders for anxiety and depression treatment. The resident's clinical record lacked documentation of necessary monitoring, which was confirmed by the Market Clinical Advisor during a review.
The facility did not properly label and dispose of insulin pens in the Scotch Pine House unit. An RN found an Aspart Insulin Flex Pen with an incorrect date and an undated Insulin Glargine-yfgn Solution Pen, both of which should have been discarded after 28 days according to manufacturer instructions.
A facility failed to notify a resident and their representative before changing the resident's room. A complaint was received, and during an interview, the resident and their family member confirmed they were not informed prior to the move. The clinical record lacked evidence of notification, and this was confirmed by the Market Clinical Advisor.
The facility failed to provide 8 residents with written information about their rights to accept or refuse treatment and to formulate an advance directive, as required by policy. The deficiency was confirmed by the Market Clinical Advisor, who noted the absence of documentation in the residents' medical records.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted with a Deep Tissue Injury. The care plan lacked necessary goals and interventions for wound management, as required by facility policy. This deficiency was confirmed by the interim DON during a review.
A facility failed to maintain complete and accurate clinical records for a resident with a Deep Tissue Injury on the coccyx. The resident's Wound Evaluations indicated treatments that lacked corresponding provider orders, contrary to facility policy. Interviews with staff confirmed the absence of required orders, highlighting a deficiency in record-keeping and adherence to wound management protocols.
A resident received excessive doses of Ativan within 7 hours, contrary to the expected practice of administering it every 8 hours. The facility failed to document behavioral symptoms or non-pharmacological interventions before administering the medication and did not monitor for adverse effects. The resident's representative noted the resident appeared sedated and incoherent.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician and the resident's representative immediately, as required by their Falls Management Policy. The fall was reported to the nurse late, and the representative only learned of the incident the next day from a CNA. The resident was in pain and was later found to have a fractured leg after being transported to the hospital.
A facility failed to implement a baseline care plan within 48 hours for a resident with multiple health conditions, including cardiovascular accident, hemiparesis, and neurogenic bladder. The care plan addressing immediate needs such as anticoagulant and antianxiety medication use, as well as other health concerns, was delayed by eight days. This deficiency was confirmed by the interim DON.
A resident experienced a fall due to the facility's failure to follow the care plan requiring a two-person assist transfer. A CNA attempted the transfer alone, resulting in the resident losing balance and falling. Additionally, the care plan inaccurately reflected the resident's advanced directive as Full Code, despite hospital records indicating a DNR status. The interim DON confirmed these deficiencies.
A facility failed to update a resident's care plan to reflect their current COVID-19 status and necessary precautions. Although the resident's medical record and room signage indicated confirmed infection and required PPE, the care plan was not revised accordingly. The DON confirmed this oversight during an interview.
The facility failed to provide a sanitary environment for respiratory care for two residents. A resident's nebulizer equipment was improperly stored and unlabeled, with no record of recent maintenance. Another resident's oxygen tubing was overdue for replacement, and the concentrator filter was dusty, contrary to facility policy. These issues were confirmed by staff.
A facility failed to accurately document the maintenance of oxygen equipment for a resident. Observations revealed outdated oxygen tubing and a dusty concentrator filter, despite records indicating recent maintenance. A nurse confirmed the tubing should be changed weekly, highlighting a discrepancy in documentation.
A facility failed to adhere to infection control protocols when two CNAs entered a resident's room under contact and airborne precautions without wearing the required PPE. Despite clear signage and available PPE, the CNAs mistakenly believed the resident was off precautions. This oversight was confirmed by an RN and discussed with the DON and Administrator.
A resident's bed rail was found broken and stuck in the up position, with the issue reported multiple times to nursing staff without resolution. Maintenance staff confirmed the malfunction but had no work order to address it. The deficiency was discussed with the Administrator.
A resident's dignity was compromised when their uncovered urine-filled Foley catheter bag was visible to passersby in the hallway and dining area. The resident expressed embarrassment and a desire for the bag to be covered. A surveyor observed this on one day, and a nurse confirmed the visibility of the bag.
A facility failed to assess and document a resident's ability to self-administer medication, as required by policy. The resident, with mild to moderately impaired cognition, was observed with eczema cream on their bedside table, despite an active order stating they may not self-administer medications. Interviews with staff confirmed the resident was given cream for self-administration without the necessary order, leading to a deficiency finding.
The facility failed to update and implement care plans for three residents, leading to deficiencies in monitoring their medical needs. A resident on Venlafaxine lacked side effect monitoring, another on Tacrolimus had no care plan goals for the medication, and a third with multiple diagnoses had no interventions for Furosemide use. These issues were confirmed by staff and discussed with the DON.
A facility failed to review and revise a care plan by the interdisciplinary team (IDT) for a resident after each assessment. The facility's policy requires a comprehensive care plan to be developed and reviewed by the IDT, including the resident and/or their representative, after each MDS assessment. However, the clinical record showed no care plan meeting was held following a quarterly MDS assessment, with the last documented IDT meeting occurring months earlier. This was confirmed by a Social Worker during an interview.
A facility failed to monitor and document behaviors for a resident on antipsychotic and antianxiety medications. The facility's policy requires behavior monitoring, but records lacked evidence of such monitoring. The DON stated that CNAs document behaviors and inform the charge nurse, but there was no regular documentation in the MAR/TAR, relying instead on staff trust.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, staffing schedule reviews, and direct observations. Residents reported excessive wait times for assistance with activities of daily living (ADLs), including toileting, changing, and ambulation. Several residents described waiting over an hour for call bells to be answered, resulting in soiling themselves and remaining in soiled conditions for extended periods. Staff confirmed that they were frequently short-staffed, with some shifts having only one CNA and a nurse covering the entire unit, leading to delays and incomplete care such as missed baths and repositioning. Staffing schedules reviewed showed that minimum staffing requirements were not met for 23 out of 31 days reviewed. Specific incidents included a resident being left on a bedpan for several hours overnight, ultimately having to remove it themselves, which resulted in a spill that was discovered by the nurse. Other residents reported being told by staff to limit their use of call bells due to short staffing, and some residents experienced a decline in mobility because staff were unable to assist with walking. Staff interviews corroborated these accounts, stating that care was not being provided in a timely manner and that residents were sometimes left in soiled beds. The deficiency was discussed with the Director of Nursing and the Administrator.
Failure to Ensure Equal Access and Discharge Planning Regardless of Payment Source
Penalty
Summary
The facility failed to ensure equal access to services and assistance with alternative placement for a resident whose payor source changed from Medicare Part A to private pay. The resident was admitted for skilled nursing services and, after Medicare coverage ended, continued to reside at the facility as a private pay resident. Assessments indicated that the resident no longer met the medical eligibility for nursing home level of care and was appropriate for a lower level of care, such as assisted living. Despite this, there was no active discharge plan documented in the clinical record for several months, and the facility did not provide evidence of consistent discharge planning or assistance with alternative placement. Documentation showed that the resident and their POA were informed about the need to move to a lower level of care, and a bed was available at an assisted living facility, but the resident refused to move. The resident's cognitive status declined over time, as indicated by BIMS scores, but the facility continued to allow the resident to remain without a documented discharge plan. The POA reported that the facility staff threatened to contact Adult Protective Services (APS) if attempts were made to move the resident, and staff confirmed that APS was contacted due to concerns about the resident's mental health and threats of self-harm during discussions about transfer. Interviews with facility leadership revealed a lack of communication with the POA regarding discharge planning and an absence of proactive steps to prepare for the resident's discharge, despite the resident being assessed as appropriate for a lower level of care months earlier. The facility indicated that if the resident's funds were depleted, they would be considered "days awaiting placement" pending Mainecare, and would need to accept an available assisted living facility within a certain distance. However, there was no evidence that the facility had actively assisted with alternative placement or ensured equal access to services regardless of payment source.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans addressing Post-Traumatic Stress Disorder (PTSD) for three residents diagnosed with PTSD. Resident #1, admitted with a diagnosis of PTSD, lacked a documented care plan that included goals, interventions, and triggers related to PTSD. Similarly, Resident #5, also diagnosed with PTSD, did not have a care plan addressing their condition. Resident #51's medical record indicated a diagnosis of PTSD, yet there was no evidence of a care plan for PTSD. During an interview, the Market Clinical Advisor confirmed that the current care plans for these residents did not include necessary components to address PTSD.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner, as observed over three days of the survey. On the Blue Spruce Unit, a portable oxygen machine, nasal cannula, and tubing were found on the floor next to the exit door, which was confirmed by both an LPN and an RN as inappropriate storage. Additionally, oxygen tubing and a nasal cannula were observed hanging on a wheelchair handle instead of being stored in a bag, as confirmed by the same LPN and RN. These items had not been used by a resident for 2 to 3 days, yet were not stored properly. Further observations revealed that Resident #474's nasal cannula tubing was draped over a light fixture above the bed, with the prongs in direct contact with the fixture. In another instance, Resident #31's nasal cannula was found unbagged at the head of the bed, with the oxygen concentrator's storage bag empty and dated from a previous day. During a follow-up, the nasal cannula was found tucked between the resident's sheets, and the resident was observed sleeping on top of it. An RN confirmed that nasal cannulas should be stored in a plastic bag when not in use, and that tubing and bags are changed weekly.
Deficiencies in Controlled Substance Documentation and IV Antibiotic Availability
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs and did not ensure that two authorized individuals signed the Shift Count page at the change of each shift. This deficiency was observed across four units: Hickory, Elm, Blue Spruce, and Scotch Pine. The review of the Controlled Substance Books and Shift Counts revealed multiple instances where the required signatures were missing, indicating that the controlled substances count was not properly documented on several dates. This lack of documentation was confirmed during an interview with the Director of Nursing. Additionally, the facility failed to provide adequate pharmaceutical services to meet the needs of a resident requiring intravenous antibiotics. The resident, who was admitted with acute osteomyelitis and other serious conditions, did not receive the prescribed IV antibiotic Aztreonam for three days due to the pharmacy's supply issues. The facility's Market Clinical Advisor was unaware of local pharmacies that could handle emergency orders, and the contracted emergency pharmacy did not provide IV medications. This resulted in the resident missing seven doses of the prescribed medication.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. Various issues were noted, including food crumbs and debris on surfaces such as the metal storage cart, double-door oven, stovetop burner plates, and metal food prep table. Additionally, the air conditioner unit and oscillating fans were covered in dust and debris, and the floors throughout the kitchen were littered with food crumbs and debris. The reach-in refrigerator contained unlabeled and undated sliced fruit, and the walk-in refrigerator had several items, including a container of beef-flavored base and a metal bowl of iceberg lettuce, that were either undated, unlabeled, or uncovered. The walk-in freezer and dry storage room also contained improperly stored food items, such as an open bag of potato wedges and a plastic bag of flour-like substance, both unlabeled and undated. Furthermore, the facility's emergency food supply was improperly stored in the Central Supply Room, alongside unsecured chemicals such as Ecolab Grease Strip Plus and Oasis Multi-Quat Sanitizer. This storage arrangement posed a risk of contamination, as the emergency food supply was placed on open shelving next to and directly across from shelves containing these chemicals. These findings were reviewed with the facility's Dietary Aide, Food Services Account Manager, Dietary District Manager, Administrator, and interim Director of Nursing Services.
Failure to Communicate Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives. This deficiency was identified for four out of five residents reviewed for arbitration agreements. During interviews, residents and their representatives expressed that they were unaware of signing arbitration agreements and did not receive any education on what these agreements entailed. For instance, Resident #35, who was cognitively intact, stated that their child signed the admission paperwork, and they were not informed about the arbitration agreement. Similarly, Resident #46 and Resident #57, both cognitively intact, were unaware of having signed such agreements and expressed that they would not have signed if they understood the implications. In the case of Resident #331, who had moderate cognitive impairment, the spouse believed they had signed the admission paperwork but did not recall any explanation of arbitration agreements. The resident's medical record indicated a BIMS score of 8, suggesting moderate cognitive impairment, yet the arbitration agreement was embedded within the admission document and signed by the resident. The spouse confirmed that Resident #331 was not cognitively intact at the time of signing and could not comprehend the agreement. The facility's Admissions Director confirmed that arbitration agreements were included within the admission agreements, which were completed on a tablet. However, the Director admitted to not explaining the arbitration agreements thoroughly, including the residents' right to revoke the agreement within 30 days. The process involved sending the admission agreement via email, where the signature was automatically applied throughout the document. The Director also acknowledged that not all residents' records were checked for advanced directives before signing, indicating a lack of due diligence in ensuring residents or their representatives understood the agreements they were entering into.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and staff awareness regarding Enhanced Barrier Precautions for two residents on the Elm House unit. Resident #327, who was admitted with a colonization of Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CRE), did not have the required signage indicating the need for Enhanced Barrier Precautions. A Registered Nurse initially stated that no special precautions were necessary, and a Certified Nursing Assistant (CNA) was unaware of the need for specific personal protective equipment (PPE) when caring for the resident. Similarly, Resident #331, who required Enhanced Barrier Precautions due to colonization with Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), and Extended Spectrum Beta-Lactamase (ESBL), also lacked appropriate signage. Interviews with the resident's spouse and two CNAs revealed that staff were not informed about the necessary precautions. The clinical records for both residents clearly indicated the need for Enhanced Barrier Precautions, which were not being followed as per the facility's policy. The facility's policy, revised in December 2024, required Enhanced Barrier Precautions for residents with multi-drug resistant organisms, yet these were not implemented effectively. The Director of Nursing acknowledged that the signs had been removed after being posted, and the Senior Administrator mentioned guidance from the Maine CDC allowing discretion in the use of Enhanced Barrier Precautions. However, the lack of consistent implementation and staff awareness led to the deficiency in infection control practices.
Inadequate Staffing Leads to Delayed Resident Care
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 confirmed by the facility's Administrator during an interview with a surveyor, where it was acknowledged that the facility did not have enough staff to meet resident needs on weekends. The Payroll Based Journal staffing report indicated low weekend staffing during the fourth quarter of 2024. This staffing shortage affected residents' ability to receive timely assistance with Activities of Daily Living (ADLs). Multiple residents and a family member reported incidents of delayed response to call bells and inadequate assistance. One resident had to wait 30 minutes after using the call bell, resulting in incontinence due to the lack of staff. Another resident, who requires a sit-to-stand lift for transfers, experienced extended wait times due to insufficient staff available to assist. A family member reported that a resident was left unattended with the call light on, and another resident with PTSD expressed distress over being left in the bathroom for 20 minutes. Additionally, a resident was left wet all night due to a leaking catheter, as no staff responded to the call bell. These incidents highlight the facility's failure to provide adequate staffing to meet the residents' needs effectively.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service by not serving all residents seated at the same table simultaneously. During a dining observation, it was noted that residents at a table were served at different times, with one resident receiving their meal significantly later than others at the same table. This practice was inconsistent with the facility's stated procedure of serving complete tables before moving on to other tables or room service. The issue was highlighted in Resident Council Meeting Minutes, where concerns were raised about the order of meal service. Staff interviews confirmed that meals are typically organized by room number, which affects the order of service in the dining room. Despite discussions about changing the meal delivery order to align with dining room seating, no changes had been implemented. The Director of Nursing acknowledged the issue had been brought to the Quality Assurance and Performance Improvement meeting, but no performance improvement process was in place at the time of the surveyor's exit.
Failure to Update Care Plan for PTSD
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident was admitted to the facility on December 23, 2021, and was diagnosed with PTSD on April 14, 2023. However, the clinical record review revealed that the care plan did not include goals, interventions, or triggers related to PTSD. This deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the care plan had not been updated to address the resident's PTSD needs.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to demonstrate evidence of behavior monitoring and monitoring for side effects of psychotropic medications for a resident diagnosed with anxiety and depression. The facility's policy on medication management requires evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, including adverse consequences of medications. However, the clinical record of the resident lacked evidence of a provider order or monitoring for behaviors and side effects related to the use of psychotropic medications. The resident was admitted with diagnoses of anxiety and depression and had active physician orders for several psychotropic medications, including Clonazepam, Mirtazapine, Escitalopram Oxalate, and Hydroxyzine HCl. Despite these orders, there was no documentation of behavior monitoring or monitoring for side effects in the resident's clinical record. This deficiency was confirmed during an interview with the Market Clinical Advisor, who reviewed the resident's entire clinical record and acknowledged the lack of necessary monitoring documentation.
Improper Labeling and Disposal of Insulin Pens
Penalty
Summary
The facility failed to comply with proper labeling and disposal protocols for biologicals in the Scotch Pine House unit. During an observation of the treatment cart with a Registered Nurse (RN), it was found that an opened Aspart Insulin Flex Pen was dated incorrectly, and an opened Insulin Glargine-yfgn Solution Pen was undated. Both insulin pens had manufacturer instructions indicating they should be discarded after 28 days of first use. The RN confirmed that the insulin pens were either expired or undated, indicating a lapse in adherence to manufacturer specifications for medication storage and disposal.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to appropriately notify a resident and their representative in a timely manner before changing the resident's room. A complaint was received by the Division of Licensing and Certification regarding a room change that occurred without proper notification. During an interview, a resident and their family member confirmed that they had not received any notification prior to the room change. A review of the resident's clinical record showed that the resident was moved from the Elm Unit to the Hickory Unit, but there was no evidence of any notification about the room change. This information was confirmed during an interview with the Market Clinical Advisor.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for 8 out of 16 residents reviewed for advanced directives. The facility's policy on Health Care Decision Making, revised on 1/8/24, mandates that residents be informed and provided with written information about their rights concerning medical treatment and advance directives. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the electronic medical records of the affected residents. The deficiency was confirmed during an interview with the Market Clinical Advisor, who acknowledged that the residents' medical records lacked evidence of advance directives or documentation that the residents or their representatives had been offered assistance to formulate an advance directive. This oversight affected residents who were admitted on various dates, and there was no evidence that the facility approached these residents or their representatives to discuss or provide information about advance directives, as required by the facility's policy.
Failure to Implement Baseline Care Plan for Resident with Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a Deep Tissue Injury. According to the facility's policy, a baseline person-centered care plan must be created within 48 hours of admission, including necessary healthcare information such as initial goals, physician orders, and interventions. However, upon review, it was found that the care plan for the resident, who was admitted with a Deep Tissue Injury on the coccyx, did not include goals and interventions for wound management. This deficiency was confirmed by the interim Director of Nursing during a review of the resident's care plan.
Incomplete Clinical Records for Wound Treatment
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident with a wound. The resident was admitted with a diagnosis of Deep Tissue Injury on the coccyx. Upon review of the resident's Wound Evaluation dated 12/11/24, it was noted that the wound was present on admission, and the treatment included cleansing with soap and water, with no dressing applied. A subsequent Wound Evaluation on 12/18/24 indicated that the wound was deteriorating, and the treatment included a generic wound cleanser and a primary dressing of zinc oxide covered with optifoam. However, the clinical record for the resident lacked evidence of a provider order for the treatments indicated in the Wound Evaluations dated 12/11/24 and 12/18/24. Interviews with the RN and PA-C revealed that it was expected for a provider order to match the treatments listed in the resident's Wound Evaluation assessment. The interim DON confirmed that the resident's clinical record did not contain a provider order for the treatments documented, indicating a failure to adhere to the facility's policy on Skin Integrity and Wound Management.
Excessive Ativan Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering excessive doses of Ativan within a short period and not monitoring for psychotropic medication side effects. A resident, who was admitted with a history of cardiovascular accident, depression, and anxiety, was prescribed Ativan to be taken three times daily as needed. However, the resident received 3 mg of Ativan within 7 hours, with doses administered at 8:00 p.m., 10:27 p.m., and 3:00 a.m. the following day. The medical record lacked evidence of behavioral symptoms justifying the PRN doses and did not document any non-pharmacological interventions attempted before administering the medication. Additionally, there was no documentation of monitoring for potential adverse consequences of Ativan use. The resident's representative expressed concerns about the resident's condition, noting that the resident appeared sedated and incoherent. The facility's Interim Director of Nursing and the PharMerica pharmacist both indicated that the expectation for administering medication three times daily is every 8 hours, which was not followed in this case.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to adhere to its Falls Management Policy and Procedure by not notifying a resident's physician and representative immediately after an unwitnessed fall. The policy requires that the physician and the resident's representative be informed of any fall, along with the physical findings and extent of injuries. In this case, a resident experienced a fall out of bed, which was not reported to the physician or the resident's representative until the following day. The resident's representative discovered the fall from a Certified Nurses Aide (CNA) and requested immediate hospital transport, where it was confirmed that the resident had a fractured leg. The Director of Nursing (DON) confirmed that the fall occurred in the late afternoon or early evening, but the CNA did not inform the nurse until later that night. Consequently, the physician and the resident's Power of Attorney (POA) were not notified until the next day. The resident was in visible pain, and upon hospital evaluation, a fracture was diagnosed. The medical record lacked evidence of timely notification to the physician and the resident's representative, highlighting a breach in the facility's protocol for managing falls.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident diagnosed with a cardiovascular accident with left side hemiparesis, requiring anticoagulant treatment, dysarthria with modified diet texture, thrombocytopenia, depression, anxiety with ordered antianxiety medications, and neurogenic bladder with an indwelling supra-pubic catheter. Upon review of the resident's clinical record, it was found that there was no evidence of a baseline care plan addressing the immediate health and safety needs related to the use of anticoagulant and antianxiety medications. Additionally, care plans for activities of daily living, impaired swallowing, cognitive loss, chronic pain, indwelling supra-pubic catheter, and risk of falls were not initiated until eight days after admission. This deficiency was confirmed during an interview with the interim Director of Nursing.
Failure to Follow Care Plan and Inaccurate Advanced Directive
Penalty
Summary
The facility failed to ensure that a care plan was followed for a resident requiring a two-person assist transfer, resulting in a fall. The incident occurred when a CNA attempted to transfer the resident to a commode with only one staff member assisting, contrary to the care plan's requirement for two-person assistance. During the transfer, the resident lost balance and fell, despite the CNA's attempt to catch them. This incident was confirmed by the interim Director of Nursing, who acknowledged that the care plan was not adhered to, leading to the resident's fall. Additionally, the facility did not maintain an accurate care plan regarding the resident's advanced directive code status. The resident's medical records from the hospital indicated a Do Not Resuscitate (DNR) status, which was also reflected in the hospital discharge summary and treatment directives. However, the care plan initiated by the facility inaccurately listed the resident's code status as Full Code. This discrepancy was confirmed by the interim Director of Nursing, highlighting a failure to ensure the care plan accurately reflected the resident's advanced directives.
Failure to Update Care Plan for COVID-19 Precautions
Penalty
Summary
The facility failed to revise the care plan to reflect a resident's current status concerning infection prevention and control. Specifically, the care plan for a resident diagnosed with COVID-19 was not updated to include the necessary precautions and status changes. The resident's electronic medical record indicated a confirmed COVID-19 infection with specific isolation precautions and personal protective equipment (PPE) requirements, including gloves, gown, N95 respirator, and eye protection. Despite these requirements being observed on signage and a PPE cart outside the resident's room, the care plan lacked evidence of being updated to reflect these changes. The Director of Nursing confirmed the care plan's deficiency in an interview.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, specifically concerning the use of nebulizers and oxygen equipment for two residents. For Resident #4, the nebulizer tubing and mouthpiece were found unlabeled and stored improperly on a bedside table without a treatment bag. The resident's medical record did not document a recent nebulizer treatment or any provider's order to change the nebulizer tubing, indicating a lack of adherence to the facility's policy requiring daily replacement and proper storage of nebulizer equipment. For Resident #6, the oxygen nasal cannula tubing was observed with a date indicating it had not been changed since 8/25/24, and the oxygen concentrator filter was coated with a thick layer of dust. This was confirmed by both a surveyor and an RN, who acknowledged that the tubing should have been changed weekly, and the filter cleaned regularly. The Director of Nursing confirmed these observations, highlighting a failure to follow the facility's procedures for maintaining respiratory equipment.
Inaccurate Documentation of Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to accurately document the Treatment Administration Record (TAR) for a resident using oxygen. On two separate occasions, a surveyor observed the resident using oxygen via nasal cannula with tubing dated from a previous week and a concentrator filter coated with dust. Despite nursing documentation indicating that the oxygen tubing was changed and the filter cleaned on a more recent date, the observations contradicted this record. A registered nurse confirmed that the tubing should be changed weekly, specifically on Sunday nights. This discrepancy was discussed with the Director of Nursing.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident observed during a survey. On the morning of September 3, 2024, two surveyors noted that a resident was under contact and airborne precautions, requiring the use of an N95 mask, gown, face shield, and gloves when entering the room. Despite clear signage and the availability of personal protective equipment (PPE) on a cart outside the resident's door, two Certified Nursing Assistants (CNAs) entered the room without donning the required PPE. Upon exiting, the CNAs admitted to not using the necessary protective gear, mistakenly believing the resident was no longer under precautions. The Registered Nurse confirmed the oversight, stating that the resident was to remain on precautions until September 4, 2024. This incident was discussed with the Director of Nursing and the Administrator later that day.
Failure to Maintain Resident's Bed in Safe Condition
Penalty
Summary
The facility failed to maintain a resident's bed in good repair and safe operating condition, as evidenced by a broken bed rail that was stuck in the up position. This issue was observed during a survey, where the resident's representative demonstrated the malfunctioning right side rail, which could not be lowered. The representative reported having informed the nursing staff multiple times over the past few weeks, but no action had been taken to address the issue. The left side rail was functioning properly, indicating the problem was isolated to the right side. Further interviews revealed that a CNA/Medication Tech was aware of the issue when the resident returned from a hospital evaluation following a fall. The ambulance crew and the CNA were unable to operate the right side rail. Maintenance personnel attempted to fix the rail but were unsuccessful and confirmed they had no work order for the repair. The deficiency was discussed with the facility's Administrator, highlighting a lack of communication and follow-up on maintenance requests.
Resident Dignity Compromised by Visible Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by allowing an uncovered urine-filled Foley catheter bag to be visible to passersby. On May 7, 2024, at 9:20 a.m., a surveyor observed the catheter bag hanging on the side of the bed, visible from the hallway and dining room. The resident expressed a desire for the bag to be covered, indicating embarrassment if it were seen by others. At 9:30 a.m., a Registered Nurse confirmed the visibility of the catheter bag to those passing by in the hallway and dining area. The issue was discussed with the Administrator on May 8, 2024, at 8:15 a.m.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to complete a Self-Administration of Medication Assessment for a resident reviewed for medication administration. The facility's policy requires an evaluation for safe and clinically appropriate capability for self-administration of medications, along with a physician or advanced practice provider order and care planning for self-administration and medication self-storage. However, the resident in question, who has mild to moderately impaired cognition, was observed with a plastic jar of A&D ointment on their bedside table, which they indicated was their eczema cream. The resident's care plan lacked evidence of their ability to self-administer medications, and their electronic medical record had an active order stating that the resident may not administer their own medications. During interviews, a CNA indicated that the resident self-administers their eczema cream, and an RN confirmed that the resident was given Triamcinolone Acetonide External Cream for self-administration without an order for self-administration in the clinical record. This discrepancy between the facility's policy and the actual practice observed by surveyors led to the identification of a deficiency in the facility's medication administration process.
Deficiencies in Care Plan Implementation and Monitoring
Penalty
Summary
The facility failed to update and implement comprehensive care plans for three residents, leading to deficiencies in monitoring and addressing their medical needs. Resident #1, who was prescribed Venlafaxine for depression, had no evidence of side effect monitoring in their clinical record, despite the care plan indicating a need for such monitoring. This oversight was confirmed by two registered nurses during a survey. Resident #4, who had a recent liver transplant and was on Tacrolimus to prevent organ rejection, lacked goals and interventions related to this medication in their care plan, which was initiated in 2021. Resident #6, with multiple diagnoses including congestive heart failure, dementia, and anxiety, had a care plan that did not include goals and interventions for the use of Furosemide, a diuretic prescribed for heart failure. Additionally, there was no evidence of monitoring for behaviors and side effects related to their psychiatric conditions and medications. These deficiencies were confirmed by a registered nurse and discussed with the Director of Nursing during the survey.
Failure to Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) for one of the sampled residents, Resident #6, after each assessment. According to the facility's policy on Person-Centered Care Plan, a comprehensive, individualized care plan should be developed and reviewed by the IDT, including the resident and/or their representative, after each Minimum Data Set (MDS) assessment. However, the clinical record for Resident #6 showed that a care plan meeting was not held following the quarterly MDS assessment dated January 23, 2024. The last documented IDT meeting for this resident was on October 23, 2023. This deficiency was confirmed during an interview with the Social Worker, who acknowledged that an IDT meeting should have been conducted within seven days of the MDS assessment.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of antipsychotic and antianxiety medications for a resident. The facility's policy on psychotropic medication use requires staff to monitor and document the resident's behavior using a behavioral monitoring chart or assessment record. However, a review of the resident's care plan and clinical records revealed a lack of evidence that the resident was being monitored for behaviors or side effects associated with the medications prescribed for anxiety and delusions. During an interview, the Director of Nursing (DON) indicated that behavior monitoring was documented by exception, with Certified Nursing Assistants (CNAs) responsible for documenting behaviors and informing the charge nurse, who should then include it in a progress note. The DON admitted that there was no regular documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) by nurses, relying instead on trust in the staff. This lack of documentation raises concerns about how the effectiveness of the medications is assessed and whether a Gradual Dose Reduction is justified.
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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