Eastside Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 516 Mt Hope Avenue, Bangor, Maine 04401
- CMS Provider Number
- 205106
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eastside Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors and facility leadership observed standing water in two basement areas, one beneath the kitchen and another below resident rooms. The Maintenance Director explained that the water originated from leaks at the loading dock and windows, as well as landscaping that directed runoff toward the building.
Surveyors and the Food Service Director confirmed that food was not stored, prepared, or served according to professional standards, as food debris was found on kitchen floors, utensils were partially buried in debris, and various food items were stored directly on the floor in both dry and cold storage areas.
A resident with dysphagia and a physician order for a minced and moist diet was given a roll, which is not permitted under IDDSI Level 5 guidelines. After attempting to eat the roll, the resident experienced vomiting and difficulty swallowing, resulting in another ED visit. Facility staff confirmed the dietary order was not followed.
Surveyors found that garbage and refuse were not properly disposed of, with trash bags left on the ground next to dumpsters, a dumpster lid with broken hinges, and uncovered trash barrels containing debris and frozen items near the loading dock. These conditions were confirmed by the Regional Director of Clinical Operations.
Surveyors found that slings used for resident transport were improperly stored on the floor and on wall hooks where they touched the floor and a lint-filled garbage can. Additionally, there was a buildup of lint behind the dryer and the laundry room floor was covered with dirt and debris, all of which were confirmed by the Regional Director of Clinical Operations.
A resident experienced severe pain due to constipation after the facility failed to monitor bowel movements and initiate the Bowel Regime protocol. Despite receiving scheduled Miralax and Senna plus, the resident did not have a bowel movement for 16 shifts, leading to significant distress. The facility's policy required CNAs to document bowel movements and Licensed Nurses to review alerts, but this was not done. The issue was only addressed after a medical provider was called, who ordered a suppository and x-ray, confirming constipation.
The facility did not maintain adequate staffing levels on weekends during the fourth quarter of 2024, as indicated by a PBJ report. The Administrator confirmed the issue, attributing responsibility for the PBJ data to Human Resources, who did not provide evidence to refute the low staffing findings.
The facility failed to provide written information on advance directives to four residents, as confirmed by the Administrator. Clinical records lacked evidence of offering advance directives or obtaining Power of Attorney paperwork, indicating a systemic issue in ensuring residents' rights to make informed care decisions.
The facility was found deficient in maintaining a safe and sanitary environment, with issues such as a torn vinyl door covering, broken wood trim, broken blind slats, chipped paint, and cracked wheelchair arms. These deficiencies were observed during a survey, highlighting inadequate housekeeping and maintenance services.
A resident with mental health diagnoses was not referred for a PASRR Level II evaluation after a 30-day exemption expired. The resident's record lacked evidence of re-evaluation for 8 months, which was confirmed by the DON.
A resident did not receive a scheduled dose of the antibiotic Meropenem for an ESBL infection, despite the medication being available in the facility's emergency supply. Additionally, the facility failed to administer Normal Saline Flushes as ordered, with no documentation of these treatments in the resident's EMAR.
The facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. This notice is essential for informing residents about their potential financial responsibility for services not covered by Medicare. The oversight was confirmed by the facility's Administrator.
A facility failed to develop a care plan for a resident's Atrophic Vaginitis, a condition requiring daily treatment as per physician orders. Despite documentation of the condition in physician progress notes and the resident experiencing symptoms, the care plan lacked any related problem, goal, or interventions. The DON confirmed the absence of this information during a surveyor interview.
A facility failed to follow physician orders for a resident requiring a low sodium diet and assistance to get out of bed for meals. The resident received a regular diet with salt packets and was not assisted out of bed for meals until 11 days after the order was given. Interviews and record reviews confirmed these discrepancies.
The facility failed to ensure a safe environment by having baseboard heaters with exposed heating elements in five rooms and the B-Unit dining room. One room also had a torn mattress bumper, creating an uncleanable surface. These hazards were observed and discussed with the DON.
A facility failed to follow a Physician Assistant's order for a neurological follow-up for a resident with post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. The Administrator confirmed the absence of evidence that the order was followed.
Standing Water Observed in Basement Areas Due to Leaks
Penalty
Summary
Surveyors observed and confirmed the presence of standing water in two separate basement areas of the facility during an environmental tour. One area of standing water was located in a basement storage room beneath the kitchen, which the Maintenance Director attributed to water leaking in from the loading dock and traveling through the wall. Another area of standing water was found in the basement space below resident rooms, which the Maintenance Director stated was due to leaking windows and landscaping that directed snow melt and runoff water toward the building. These conditions were directly observed and confirmed by surveyors and the Regional Director of Clinical Operations during the survey. No specific residents or staff were identified as being directly affected at the time of the deficiency, and no additional medical history or resident conditions were mentioned in the report.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen sanitation during a tour of the facility's kitchen and food storage areas. Food debris was found on the floor under kitchen surfaces and shelves in the meal preparation area, not related to the current meal service. Behind the stove, a large pile of food debris was present against the wall, with cooking utensils partially buried in it. In the dry food storage area, loose fries and a biscuit were found on the floor. The walk-in freezer contained food debris, including a fish filet and loose fries on the floor, and an open box of green beans stored directly on the floor, along with boxes of hamburger patties, chicken breasts, and creamer stacked and stored on the floor. In the walk-in refrigerator, a large mesh bag of onions was also stored on the floor. These observations were confirmed by both the surveyor and the Food Service Director, indicating that food was not stored, prepared, or served in accordance with professional standards for food service safety.
Failure to Provide Physician-Ordered Minced and Moist Diet
Penalty
Summary
A resident with a history of dysphagia and recent emergency room visits for increased cough, congestion, and concerns for aspiration pneumonia was placed on a physician-ordered minced and moist diet with thin liquids. The order, based on the IDDSI Level 5 guidelines, specifically excluded regular, dry bread, sandwiches, or toast. Despite this, the resident was provided a roll for lunch while on the modified diet. Following the consumption attempt, the resident was unable to swallow secretions and vomited upon swallowing food or drink, which led to another emergency department visit. Interviews with facility staff, including the Rehab Director and Director of Nursing, confirmed that the dietary order was not followed and that bread is not permitted on the minced and moist diet per IDDSI standards.
Improper Disposal of Garbage and Refuse Observed
Penalty
Summary
Surveyors observed several deficiencies in the disposal of garbage and refuse at the facility. On the survey day, multiple bags of trash were found stored on the ground next to the facility dumpsters, rather than inside them. The hinges on the lid of one dumpster were broken, preventing the lid from covering the refuse. Additionally, in the outside area by the loading dock, a used food container was seen frozen in the snow on top of a snow-covered cooler, and a round trash barrel without a lid was found containing trash and debris, with a milk crate frozen in place and ice accumulating over the edges of the barrel. These findings were confirmed during an interview with the Regional Director of Clinical Operations.
Infection Control Deficiency in Laundry Room Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices in the laundry room. Specifically, there was a buildup of lint behind the dryer, and the floor was covered with dirt and debris. Slings used for resident transport were found piled on the floor between a door and a wall, and additional slings were hanging on wall hooks near the dryer in such a way that parts of the slings were touching the floor and the inside of a lint-filled garbage can. These observations were confirmed during a tour and interview with the Regional Director of Clinical Operations, who acknowledged the improper storage of slings on the floor and on hooks where they touched the floor.
Failure to Monitor and Initiate Bowel Regime Protocol
Penalty
Summary
The facility failed to monitor a resident's bowel movements and initiate the Bowel Regime protocol, resulting in significant discomfort for the resident. The resident, identified as R46, did not have a bowel movement for 16 shifts, leading to severe pain and distress. The facility's policy required Certified Nursing Assistants (CNAs) to document bowel movements accurately and for Licensed Nurses to review clinical alerts daily to identify residents needing bowel regime interventions. However, this protocol was not followed for R46, who was already receiving scheduled Miralax and Senna plus but did not receive additional PRN bowel regime medications until the situation escalated. On the day of the incident, a surveyor observed R46 in significant pain, crying out for help due to constipation. Despite the resident's visible distress, the facility staff did not initiate the bowel protocol until a medical provider was called, who then ordered a suppository and an abdominal x-ray. The x-ray confirmed a non-obstructive bowel gas pattern with fecal residue, correlating with clinical constipation. Interviews with staff revealed that the CNAs and nurses did not document or act on the lack of bowel movements, and the Director of Nursing confirmed the protocol was not initiated as required. The medical provider noted that R46 had a history of constipation and minimal oral intake, which contributed to the issue. Despite this, there were no nursing complaints or actions taken from the last medical review until the incident. The failure to follow the bowel regime protocol and the lack of communication between nursing staff and medical providers led to the resident's prolonged discomfort and pain.
Insufficient Weekend Staffing in Q4 2024
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents during weekends in the fourth quarter of 2024. A Payroll Based Journal (PBJ) report indicated that the facility triggered for low weekend staffing during this period. During an interview, the Administrator acknowledged the issue and stated that Human Resources was responsible for the PBJ data. However, Human Resources did not provide any additional information to dispute the PBJ report findings, which confirmed low weekend staffing levels.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information to formulate an advance directive or appoint a surrogate. This deficiency was identified for four out of seven residents reviewed for advance directives. Specifically, the clinical records of these residents lacked evidence that the facility had provided or obtained the necessary documentation regarding the right to formulate an advance directive or appoint a surrogate. The residents involved were admitted to the facility between January and February 2025, with one resident having been admitted as early as 2020. During interviews with surveyors, the facility's Administrator confirmed the absence of evidence in the clinical records regarding the offering of advance directives or obtaining Power of Attorney paperwork, if applicable. This lack of documentation was consistent across the reviewed records, indicating a systemic issue in the facility's process for ensuring residents' rights to make informed decisions about their care and treatment preferences.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. On the first day of the survey, a torn vinyl covering on the inside of a bathroom door was noted, which was later removed by the Interim Maintenance Director. On the second day, an environmental tour revealed additional issues: broken wood trim behind a bed, broken blind slats in two rooms, chipped paint in a bathroom, and cracked, uncleanable wheelchair arms for a resident. These observations indicate a lack of adequate housekeeping and maintenance services necessary to keep the building and resident equipment in good repair and sanitary condition.
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred for a Pre-Admission Screening & Resident Review (PASRR) Level II evaluation after the expiration of a Convalescence Categorical exemption. The resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder, had a PASRR Level I evaluation dated 5/10/24, which granted a 30-day exemption. However, the resident's clinical record did not show evidence of a PASRR Level II re-evaluation after the exemption period ended on 6/11/24, leaving an 8-month gap without the necessary assessment. This deficiency was confirmed during an interview with the Director of Nursing Services, who acknowledged the oversight.
Failure to Administer IV Antibiotics and Saline Flushes as Ordered
Penalty
Summary
The facility failed to follow hospital discharge orders for a resident who required intravenous administration of the antibiotic Meropenem for the treatment of bilateral pyelonephritis with an ESBL infection. Despite having an emergency supply of the medication available, the resident did not receive the scheduled dose at 9:00 p.m. on the day of admission. Interviews with the Administrator, DON, and Infection Preventionist confirmed the availability of the medication in the emergency kit, yet there was no documentation in the clinical record or EMAR indicating that the resident received the required dose. Additionally, the facility did not adhere to physician orders for administering Normal Saline Flushes before and after each medication administration. The resident's EMAR lacked evidence of the Normal Saline Flush being completed as ordered from the date of admission to several days thereafter. This was confirmed during a review of the EMAR with a registered nurse, indicating a failure to provide the necessary intravenous care as prescribed.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. Resident #24's Medicare Part A services ended on December 20, 2024, and Resident #36's services ended on December 26, 2024. However, there was no evidence that either resident received the required SNFABN, which would have informed them of their potential financial responsibility for continued skilled services not covered by Medicare. This oversight was confirmed by the facility's Administrator during an interview with the surveyor on February 25, 2025.
Failure to Develop Care Plan for Atrophic Vaginitis
Penalty
Summary
The facility failed to develop a care plan for a resident's current medical problem of Atrophic Vaginitis, which required physician-ordered treatment. The resident's clinical record, reviewed on January 2, 2025, indicated that Atrophic Vaginitis was identified as a current problem in physician progress notes dated October 1, 2024, and December 5, 2024. The condition required daily treatment with creams and a gel, and the resident experienced vulva pain and vulvovaginal irritation. Despite this, the care plan lacked any problem, goal, or interventions related to the Atrophic Vaginitis. The Director of Nursing confirmed the absence of this information in the care plan during an interview with the surveyor.
Failure to Follow Physician Orders for Diet and Mobility Assistance
Penalty
Summary
The facility failed to follow physician orders for a resident who required a low sodium diet and assistance to get out of bed for meals. On 4/8/24, the resident's cardiologist ordered a low sodium diet, but the resident continued to receive a regular diet with salt packets on their meal trays from 4/15/24 to 4/22/24. Additionally, the same cardiologist ordered the resident to be assisted out of bed and into a chair for meals starting on 4/8/24. However, this order was not followed until 4/19/24, as indicated by the resident's Treatment Administration Record (TAR). Interviews with the resident and the Food Service Supervisor confirmed these discrepancies, and the Director of Nursing acknowledged the oversight during a discussion with the surveyor on 4/22/24.
Exposed Heating Elements in Baseboard Heaters
Penalty
Summary
The facility failed to ensure that the resident's environment was free from accident hazards related to baseboard heaters in disrepair with heating elements exposed. During observations on 4/22/24 between 11:30 a.m. and 11:50 a.m., it was noted that five rooms had baseboard heaters with missing connectors, exposing heating elements. Additionally, one room had a baseboard heater with an end cap off and a mattress bumper torn, creating an uncleanable surface. The B-Unit dining room also had baseboard connectors missing, exposing heating elements. These findings were discussed with the Director of Nursing at 12:45 p.m. on the same day.
Failure to Follow Physician Assistant's Order for Neurological Follow-Up
Penalty
Summary
The facility failed to follow a Physician Assistant's order for a resident. The resident had an order dated 3/14/24 for a neurological follow-up due to post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. Upon review of the clinical record on 4/9/24, there was no evidence that an appointment with neurology had been made. The Administrator confirmed the absence of evidence that this order was followed during an interview with the surveyor on the same day.
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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