Hibbard Skilled Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover Foxcroft, Maine.
- Location
- 1037 West Main Street, Dover Foxcroft, Maine 04426
- CMS Provider Number
- 205004
- Inspections on file
- 28
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Hibbard Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s clinical record was found to be incomplete and inaccurate when staff documented pacemaker monitor checks on the TAR using a code indicating “drug not available,” which was inappropriate for this treatment and acknowledged as incorrect by the RN. In addition, a surveillance UA dip ordered to verify resolution of a UTI was signed off as completed, but no UA result was documented in the record or attached to the physician order, and the RN reported he performed the test but did not chart or file the machine-generated results.
A resident with dementia, visual loss, and a history of falls was not provided with hip protectors as required by their care plan and physician orders. Staff interviews revealed a lack of awareness and follow-through regarding this intervention, and it was confirmed during the survey that the resident was not wearing hip protectors, despite being at high risk for falls.
A resident with chronic leg ulcers was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy, despite ongoing wound care orders and a care plan indicating EBP should be followed. Staff interviews revealed confusion about the resident's precaution status, and no EBP signage was posted outside the room.
A resident's clinical record and care plan contained inaccurate information regarding the location of a venous ulcer for several months. Although treatment and physician notes consistently referenced the right lower leg, nursing documentation and the care plan incorrectly identified the left lower leg as the site of the wound. The error persisted through multiple care plan revisions and was confirmed by nursing staff during a record review.
The facility did not provide or document adequate assistance and follow-up for several residents and their representatives regarding the completion of advanced directives, including cases involving cognitively impaired individuals and those whose families were involved in decision-making. Staff interviews confirmed the lack of documentation and follow-up in the clinical records.
The facility did not ensure that two residents received required PASRR-related services or referrals after changes in mental health status or diagnosis. One resident did not receive or have documented specialized services as recommended in their PASRR Level II, while another was not referred for a new PASRR Level II after new suicidal behaviors and a new schizophrenia diagnosis. Staff interviews and record reviews confirmed these deficiencies.
A resident with recent surgical wounds and pressure ulcers received wound care from an RN without documented physician orders for the right arm surgical incision and left heel pressure ulcer. Review of the clinical record confirmed the absence of necessary orders, and the RN acknowledged the oversight during a surveyor review.
Two residents with PTSD did not receive timely trauma-informed assessments, individualized care planning, or appropriate behavioral health referrals, despite documented episodes of suicidal ideation and psychiatric symptoms. Facility staff did not complete required trauma assessments or make necessary referrals to counseling or external providers, resulting in unmet mental health needs.
The facility did not consistently monitor and record temperatures in the walk-in refrigerator and freezer as required by policy, with multiple missing entries over two months. The Dietary Manager confirmed the lapses in temperature logging, citing challenges with staff compliance.
The facility failed to assess and document the clinical appropriateness of self-administration of medications for two residents. In both cases, medications were kept at bedside and self-administered without required IDT assessments, physician orders, or care plan documentation, as confirmed by staff interviews and record reviews.
A resident with multiple complex medical conditions, including recent surgery, wounds, and use of anticoagulants, was admitted without a baseline care plan developed and implemented within 48 hours. The care plan did not address the resident's immediate needs such as cardiac issues, pain, wound care, diabetes, or therapy services, despite active physician orders and observed bleeding from a surgical site.
A resident with ALS on hospice care, who actively smokes and declined smoking cessation, did not have a Safe Smoking Evaluation completed as required by facility policy. The absence of this evaluation was confirmed by both the resident and the Skilled Nursing Manager.
A resident with a Foley catheter and urinary retention showed signs of a possible UTI, including a foul-smelling, sediment-filled catheter bag and a change in mental status. Although nursing staff documented the need for a urinalysis to rule out infection, there was no evidence that a physician was notified or that the urinalysis was completed.
Two residents with significant pain needs did not receive appropriate pain management due to failures in monitoring medication interactions and ensuring timely access to prescribed pain medications. One resident experienced unmanaged pain and severe drug interaction warnings were not addressed, while another resident went extended periods without pain medication due to stock issues, resulting in distress and inability to tolerate necessary care.
Surveyors found expired, unlabeled, and improperly stored medications on a treatment cart, including open and undated normal saline, expired wound dressing and arthritis relief cream, unrefrigerated insulin vials, and an opened package of lidocaine jelly in an unsealed bag. An LPN confirmed these items were available for use and could not verify how long the insulin had been unrefrigerated.
Surveyors observed that a resident's wound dressing change was performed in a room where soiled linens were left unbagged on the floor, and a pillow with a blood-stained pillowcase was used to support the resident's leg. The RN stepped on the soiled gown while washing hands and did not bring adequate supplies, and staff failed to remove the soiled linens throughout the observation, resulting in a breakdown of infection control practices.
Two residents were not offered the updated PCV20 vaccine as required by facility policy and CDC recommendations. Documentation showed that both had received earlier pneumococcal vaccines, but there was no evidence that PCV20 was offered, administered, or refused. The Administrative Coordinator believed prior vaccination with PCV13 was sufficient, leading to the omission.
The facility did not thoroughly investigate injuries of unknown origin for two residents, including a case involving multiple fractures after a hospital stay and another involving a large hematoma following an unwitnessed fall. Required interviews and documentation were missing, and there was insufficient evidence that the incidents were properly assessed or investigated as potential abuse or neglect.
Surveyors identified incomplete and inaccurate clinical documentation for five residents, including missing provider assessments after resident altercations, care plans not updated for behavioral issues, discrepancies in psychotropic medication diagnoses, and inconsistent documentation of physician orders and treatments such as I&O, weights, wound care, and insulin administration. Staff interviews confirmed these documentation lapses.
A resident with functional quadriplegia sustained a second-degree burn after accidentally spilling hot coffee on their thigh. Despite this incident, the care plan was not updated to address the new safety risk related to the resident independently handling hot beverages, as confirmed by the DON.
A facility failed to update the care plan for a resident with chronic constipation and dementia. Despite having multiple physician orders for bowel management, the resident was transferred to acute care for constipation and fecal impaction. Upon return, the care plan was not updated to reflect new orders, including discontinuing Ducosate and adding Miralax. The administrator confirmed the care plan did not address the resident's constipation issues.
A resident experienced a skin tear incident, but the facility failed to document the event accurately and timely as required by their policy. The incident occurred when the resident attempted to stand from a wheelchair and hit their leg, causing a skin tear. The clinical record lacked an Accident/Incident report, and a late entry was made weeks later, which was not documented correctly.
The facility failed to prevent COVID-19 transmission by allowing fans and air conditioners to blow air from infected residents towards their uninfected roommates. Staff recognized the need for closed doors but overlooked the direction of airflow within rooms.
The facility failed to maintain a clean and well-repaired environment, with surveyors noting chipped furniture, soiled fans, and torn chairs. Uncleanable surfaces and persistent odors were observed, indicating inadequate housekeeping and maintenance services.
The facility failed to follow physician orders for medications and treatments for several residents. A resident did not receive Prazosin for 25 days due to pharmacy issues, while another missed multiple doses of various medications due to unavailability and prescription renewal problems. Additionally, a resident's Eliquis was held and restarted incorrectly, another received unnecessary insulin, and daily weight checks were not completed for a resident. These issues were confirmed by staff and surveyors.
A facility failed to accurately code the MDS 3.0 for a resident, resulting in a deficiency. The resident had a Level II PASRR and PTSD, but these were not correctly reflected in the admission and annual MDS assessments. The error was confirmed during a review and interview with the MDS Coordinator, who acknowledged the inaccurate entry of information into the resident's clinical record.
A facility failed to create a care plan for a resident with PTSD, as identified during a survey. The resident's records confirmed the PTSD diagnosis and a past trauma assessment, but no care plan was found to address potential triggers or interventions for re-traumatization. This deficiency was confirmed during an interview with a surveyor.
A facility failed to follow physician orders for a resident's positioning needs, as a wedge pillow prescribed to maintain proper positioning and prevent shoulder issues was not in use. The resident reported difficulty maintaining position and reaching items without the pillow, which had been missing for some time. Observations confirmed the absence of the required support equipment, despite clinical records and care plans indicating its necessity.
A facility failed to maintain an oxygen concentrator per manufacturer's directions for a resident using oxygen. The concentrator was observed missing the cabinet filter compartment, which is necessary for proper operation. This issue persisted over several days, indicating non-compliance with the maintenance schedule.
A facility failed to complete a physician-ordered urinalysis for a resident. The order was placed due to suspected infection symptoms, but there was no evidence of urine collection until a later date. The LTC Manager confirmed the oversight during an interview.
The facility failed to accurately document weights for two residents reviewed for weight loss concerns. One resident's record showed a 51% weight loss over 30 days with fluctuating weights, while another resident's record indicated significant weight loss despite high meal consumption. The LTC Manager confirmed inaccuracies in the recorded weights.
A facility failed to inform a resident's representative about two new Stage II pressure ulcers. A nurse's note documented the ulcers, but there was no evidence that the resident's son was notified. The Administrator confirmed the lack of notification.
Incomplete and Inaccurate Documentation of Pacemaker Monitoring and Urinalysis Results
Penalty
Summary
The deficiency involves incomplete and inaccurate clinical records for a resident related to pacemaker monitoring and urinalysis documentation. On review of the February Treatment Administration Record (TAR), the order to check that the resident’s pacemaker monitor was plugged in once per evening shift was documented on two dates with staff initials and a code of “2,” indicating “drug not available,” which was not appropriate for this type of treatment. During interview, the RN who documented these entries acknowledged that both entries were incorrect and could not explain why the “drug not available” code was used for the pacemaker monitor check, and the surveyor confirmed this inaccurate documentation. Additionally, the TAR contained an order for a surveillance urinalysis (UA) dip with instructions to follow up with a culture if positive to ensure a urinary tract infection was resolved. The TAR showed staff initials indicating the UA dip was performed on one date, but the clinical record and the corresponding physician order lacked any evidence of the UA dip result. In an interview, the Skilled Unit Manager reported that the RN who performed the treatment stated he completed the UA dip but did not chart the result because nothing appeared in the system for him to document after signing off the treatment, nor did he print and file the machine-generated results with the physician order. The surveyor confirmed the absence of documentation for the UA dip result in the record.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive care plan for fall prevention. The resident, who has diagnoses including dementia, visual loss, and a history of falls, was identified as high risk for falls due to factors such as poor balance, unsteady gait, blindness, and dementia. The care plan and physician orders specified that the resident should have hip protectors in place at all times unless being laundered. However, during the survey, it was observed that the resident was not wearing hip protectors as required. Interviews with staff revealed a lack of awareness and follow-through regarding the use of hip protectors for this resident. A CNA stated she was only aware of fall mats and a low bed as interventions, and upon inspection, confirmed the absence of hip protectors. An RN acknowledged that the resident was supposed to have hip protectors but had not had them since transferring to the current unit several months prior. The LTC manager also confirmed the resident should have had hip protectors in place but was unsure why they were not being used.
Failure to Follow Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to maintain its Infection Control Program by not following its own Enhanced Barrier Precautions (EBP) policy for a resident with chronic wounds. According to the facility's policy, EBPs are required for residents with wounds, and these precautions should remain in place for the duration of the wound or the resident's stay. The policy also requires staff training and the posting of signage outside the resident's room indicating the type of precautions and required PPE. During the survey, it was observed that there was no EBP sign posted outside the room of a resident with chronic right leg ulcers, and a Certified Nursing Assistant confirmed that the resident was not on any type of precautions, despite the care plan indicating the need to follow EBP. Further review of the resident's medical records showed ongoing physician orders for wound care and documentation of wound treatments provided by a Registered Nurse. Interviews with staff revealed confusion regarding the resident's EBP status, with the nurse stating that the resident was previously on EBP but was removed when the wounds improved, and the Infection Preventionist indicating that EBP was not needed if the wound was not draining. These actions and inactions resulted in the facility not adhering to its own infection control policy for residents with wounds, as required.
Inaccurate Documentation of Venous Ulcer Location in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained accurate and complete information regarding the location of a venous ulcer over a seven-month period. Documentation provided to the surveyor indicated that the resident had a chronic ulcer being treated on the right lower extremity, and physician progress notes consistently referenced treatment for right lower leg wounds. However, a progress note written by a registered nurse on 10/3/25 incorrectly documented treatment on the left lower leg and noted a new abrasion on that leg. The care plan also inaccurately identified the left lower leg as the site of the venous wound, despite ongoing treatment and documentation indicating the wound was on the right lower leg. Further review of the care plan revealed that the focus on the left lower leg had been in place since 10/2/24 and was revised multiple times, but continued to reference the incorrect extremity. The goals and interventions under this focus were also updated without correcting the error. During the record review, the registered nurse confirmed that the resident had never had a venous wound on the left leg and acknowledged the documentation error in both the care plan and the progress note. The surveyor verified that the clinical record and care plan did not accurately reflect the correct location of the venous wound.
Failure to Assist and Document Follow-Up on Advanced Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received appropriate assistance and follow-up regarding the completion of advanced directives, as required by facility policy. For five out of seven residents reviewed, documentation was lacking to show that staff offered or followed up on assistance to complete advanced directives or to ensure that residents' wishes regarding the right to accept or refuse medical or surgical treatment were addressed. In several cases, residents indicated they did not have an advanced directive and either planned to look into it or had a family member working on it, but there was no evidence in the medical record of further follow-up or documentation of outcomes. One resident with cognitive impairment and a listed representative declined to have an advanced directive, but there was no documentation that the representative was followed up with regarding the resident's rights. In other cases, residents or their families stated they would provide or were working on the necessary documents, but the clinical records did not reflect any follow-up or confirmation of completion. Interviews with facility staff, including the Social Services Director and Licensed Social Worker, confirmed the absence of documented notes or evidence of follow-up actions related to advanced directives for these residents.
Failure to Coordinate PASRR Services and Referrals After Mental Health Changes
Penalty
Summary
The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for two residents. For one resident, the PASRR Level II evaluation recommended specialized services including individual therapy, neuropsychiatric evaluation, rehabilitative therapies, and supportive counseling. However, the clinical record did not show evidence that these services were offered, provided, refused, or addressed in the resident's assessments or care planning. Interviews with facility staff confirmed the absence of appointments, referrals, or documentation related to these specialized services. For another resident, the clinical record indicated a history of suicidal talk and behaviors, a new diagnosis of schizophrenia, and recent incidents of suicidal ideation. Despite these changes, there was no evidence that the facility referred the resident for a new PASRR Level II determination as required after a significant change in mental health status or diagnosis. The PASRR assessment was not updated to reflect the resident's current condition, and required services such as psychiatric evaluation and individual therapy were not documented as provided or addressed in the care plan.
Wound Care Provided Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders for the treatment of a surgical wound and a pressure ulcer for a resident who was recently admitted with multiple complex wounds, including surgical incisions and pressure ulcers. During an observation of dressing changes, a registered nurse performed wound care on the resident's right arm surgical incision and left heel pressure ulcer without documented physician orders for these treatments. A review of the clinical record and Treatment Administration Record confirmed the absence of orders for these specific wound care treatments. The nurse acknowledged the lack of orders and was unable to locate any active orders for the required wound care.
Failure to Provide Trauma-Informed Care and Timely Behavioral Health Referrals for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD), as evidenced by multiple missed opportunities to assess, refer, and address the mental health needs of two residents. One resident had a documented history of suicidal ideation, hallucinations, and an active diagnosis of PTSD, yet there was no evidence of timely referrals for behavioral health services, counseling, or follow-up with external providers such as Acadia or the VA. Despite repeated episodes of suicidal speech and behavior, as well as recommendations for mental health counseling, the facility did not initiate appropriate referrals or interventions from admission through several months of the resident's stay. Clinical documentation revealed that the resident experienced severe psychiatric symptoms, including visual hallucinations and multiple expressions of suicidal intent, but the facility's response was limited to medication administration and basic medical workup. There was no documentation that the resident's PTSD was addressed during these episodes, nor that a trauma-informed assessment was completed. The Pre-admission Screening and Resident Review (PASRR) also indicated a need for individual therapy, but no evidence was found that the facility made the required referrals until several months later. A second resident with an active PTSD diagnosis also did not receive a trauma-informed care plan that identified or addressed their specific triggers. The social services staff confirmed that trauma assessments were not completed based on the resident's current diagnosis, and the care plan lacked individualized interventions related to PTSD. The facility's own policy required in-depth assessment and care planning to minimize re-traumatization, but these steps were not followed for either resident.
Failure to Monitor and Record Food Storage Temperatures
Penalty
Summary
The facility failed to consistently monitor and record temperatures in the walk-in refrigerator and freezer as required by its own food storage policy, which mandates that temperatures be checked and logged twice daily to ensure food safety. Specifically, temperature logs for January and February 2025 showed missing entries for both the refrigerator and freezer on multiple dates and times, with no evidence that temperatures were taken or recorded as required. The Dietary Manager confirmed these omissions during a review of the logs, stating that there were difficulties ensuring compliance with the logging process by the cook responsible at the time. These findings were also acknowledged during an interview with the Administrator.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for two residents to self-administer medications and keep medications at bedside. For one resident, a medication technician stated there was an order for self-administration, but the care plan did not reflect this, and there was no documented assessment or care plan intervention for self-administration. The resident's clinical record lacked evidence of a self-administration assessment, a physician order for self-administration, and documentation in the care plan. The Long Term Care Unit Manager confirmed these findings during a review of the resident's record. For another resident, a bottle of eye drops was observed at bedside, but the clinical record did not contain an order for self-administration, an IDT assessment, or care plan documentation for self-administration. The medication administration record also lacked evidence of administration of the eye drops. The resident reported self-administering the drops, and an LPN confirmed that the record lacked the required order and assessment for self-administration. These findings were discussed with facility staff and confirmed through interviews and record review.
Failure to Develop and Implement Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with multiple complex medical conditions. The facility's policy requires a baseline care plan to be created within 48 hours to address immediate health and safety needs, including initial goals, physician and dietary orders, therapy and social services, and any relevant recommendations. However, for one resident recently admitted with diagnoses such as coronary artery disease, chest pain, COPD, diabetes, neuropathy, acute and chronic pain, peripheral artery disease, recent lower extremity bypass surgery, surgical incisions, arterial wound, and stage 2 pressure ulcers, the baseline care plan did not include goals or interventions for these conditions. Observation revealed the resident had active bleeding through a dressing on the left lower extremity and reported being on two anticoagulants. Review of the clinical record showed multiple active physician orders for pain management, COPD, chest pain, DVT prophylaxis, blood glucose monitoring, and wound care. Despite these needs, the baseline care plan lacked evidence of interventions for the resident's cardiac issues, anticoagulant use, COPD, diabetes, pain, wound care, nutrition, or therapy services. These concerns were confirmed during an interview with the Director of Nursing.
Failure to Complete Safe Smoking Evaluation for Resident Who Smokes
Penalty
Summary
The facility failed to complete a Safe Smoking Evaluation for a resident who actively smokes cigarettes. According to the facility's Smoking Policy, each resident's smoking status must be evaluated upon admission, including an assessment of their ability to smoke safely with or without supervision, documented through a completed Safe Smoking Evaluation. A review of the resident's clinical record showed no evidence that this evaluation was performed, despite the resident having a diagnosis of Amyotrophic Lateral Sclerosis (ALS), being on hospice for palliative care, and declining smoking cessation. The resident confirmed during an interview that they continue to smoke when able, and the Skilled Nursing Manager acknowledged that the required evaluation had not been completed.
Failure to Notify Physician of Suspected UTI in Catheterized Resident
Penalty
Summary
The facility failed to notify the physician of a suspected urinary tract infection (UTI) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including benign prostatic hyperplasia, urinary retention, obstructive uropathy, and a Foley catheter, exhibited signs suggestive of a UTI, such as a catheter bag full of sediment and a foul odor. A nursing progress note documented the need to rule out a UTI and recommended a urinalysis, but there was no evidence in the clinical record that the physician was notified or that a urinalysis was performed. Additionally, the resident's representative reported being informed by staff about plans to check for a UTI due to a change in mental status, but received no follow-up information.
Failure to Implement and Monitor Safe Pain Management Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with significant pain needs. For one resident with chronic pain related to end-stage liver failure, the care plan identified the need for pain management, and the resident was prescribed both oxycodone and a buprenorphine transdermal patch. Multiple severe drug interaction warnings were triggered in the electronic medical record regarding the concurrent use of these medications, but there was no evidence that these warnings were reviewed or discussed with the provider. The resident continued to report increased pain and even exhibited suicidal behaviors due to unmanaged pain, yet the facility did not monitor or revise the pain management interventions as necessary. Another resident, recently admitted with acute and chronic pain following lower extremity bypass surgery and with multiple wounds, had orders for both scheduled and PRN oxycodone. The resident reported not receiving pain medication for extended periods, including a 12-hour gap, due to the medication not being available in the facility. The resident expressed distress and was unable to tolerate dressing changes due to inadequate pain control. Documentation confirmed gaps in pain medication administration, and staff interviews revealed confusion about medication availability and stock management. In both cases, the facility did not ensure that pain management interventions were implemented, monitored, or revised as needed. There was a lack of communication regarding medication interactions and failures in ensuring timely access to prescribed pain medications, resulting in unmanaged pain for both residents.
Expired and Improperly Stored Medications Found on Treatment Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and removal of expired or improperly stored medications from a treatment cart. Specifically, the cart contained an open, unlabeled, and undated bottle of normal saline irrigation fluid; an open, unlabeled tube of hydrophilic wound dressing with an expiration date of 3/31/25; two sealed multi-use vials of insulin (glargine and lispro) labeled for refrigeration but found unrefrigerated, with the LPN unable to determine how long they had been out; a tube of arthritis relief cream expired as of 1/2025; a tube of triamcinolone acetonide labeled to be discarded after 11/28/24; and an opened package of lidocaine jelly in an unsealed zip lock bag dated 4/4/25. These items were available for use on the cart at the time of the surveyor's review, and the LPN confirmed their presence and status.
Failure to Maintain Infection Control During Wound Care and Linen Handling
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices during a wound dressing change and in the handling of soiled linens. During the dressing change for Resident #333, a soiled gown and an open trash bag containing soiled linen were found unbagged and lying on the floor under the sink. The registered nurse performing the dressing change stepped on the soiled gown while washing her hands and then proceeded with the dressing change without addressing the contamination. Additionally, a pillow with a dried blood-stained pillowcase, which the resident reported using for sleep, was used to support the resident's leg during the procedure. The pillowcase was only changed after the surveyor intervened. Throughout the observation, multiple staff members entered and exited the room but did not remove the soiled linens from under the sink. The registered nurse admitted to not bringing adequate supplies for the dressing change, as the resident was previously able to support their own leg. These actions and inactions resulted in a failure to provide a sanitary environment and to prevent the potential development and transmission of infection, as required by the facility's infection prevention and control program.
Failure to Offer Updated Pneumococcal Vaccination per Policy and CDC Guidelines
Penalty
Summary
The facility failed to offer the updated Pneumococcal Conjugate Vaccine (PCV20) to two residents, despite both the facility's policy and current CDC recommendations requiring assessment and offering of the vaccine. According to the facility's policy, residents are to be assessed for pneumococcal vaccination status upon or prior to admission, and the appropriate vaccine series should be offered within thirty days unless contraindicated or already completed. Documentation review revealed that one resident had previously received PCV13 in 2016 and PPSV23 in 2018, while another had received PCV13 in 2018 and refused PPSV23 in 2022. In both cases, there was no evidence in the clinical records that PCV20 was offered, administered, or refused. During an interview, the Administrative Coordinator stated that PCV20 was not offered to these residents because she believed that receipt of PCV13 meant the residents were up to date with pneumococcal vaccinations. This belief was contrary to both CDC recommendations and the facility's own policy, which require consideration of PCV20 administration based on the timing and type of previous pneumococcal vaccines. The surveyor confirmed that the required vaccine was not offered as indicated by policy and CDC guidelines.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents, as required by its own policies and federal regulations. In the first case, a resident returned from an acute care hospital and was noted to have a swollen, warm left knee, with subsequent imaging revealing a femoral fracture. The resident later also complained of wrist pain, which was found to be an acute angulated right distal radial fracture. Although the facility's 5-day investigation follow-up indicated that interviews were conducted with staff, the resident, and a family member, there was no written documentation to support that these interviews took place. Additionally, the clinical record lacked evidence that the injury was noted in the emergency department, and the facility was unable to determine whether the injuries occurred in the facility or during the hospital stay. In the second case, another resident sustained a large hematoma near the left eye, with no known history of a fall at the time of the incident. The facility's report later noted that the resident had an unwitnessed fall prior to the bruise being noticed, but the bruise was not observed during the initial assessment following the fall. The resident also exhibited increasing confusion and an unsteady gait. The facility's follow-up documentation did not provide evidence of a thorough investigation into the injury of unknown origin. The LTC Unit Manager confirmed that comprehensive investigations were not conducted for these incidents and acknowledged a lack of familiarity with the required follow-up procedures.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents, as evidenced by multiple deficiencies in documentation and care planning. For five residents, there were missing or inaccurate entries in the medical records, including lack of provider assessments, incomplete care plans, and discrepancies in medication documentation. In one instance, after a reported altercation between two residents, the clinical record lacked evidence that both residents were assessed by a provider, and the care plans were not updated to reflect new or ongoing behavioral issues. Additionally, documentation for one resident was found to be a direct copy and paste from another resident's note, further indicating incomplete and inaccurate record-keeping. Another resident's clinical record showed inconsistencies regarding the diagnosis and use of psychotropic medication. The record indicated a new diagnosis of schizophrenia without evidence of an evaluation to confirm this diagnosis, and the provider was unable to explain the origin of the diagnosis. Furthermore, the social services documentation inaccurately stated that the resident was not receiving psychotropic medications, despite evidence to the contrary, and the PASRR contained incorrect information about the resident's medical condition. Additional deficiencies were found in the documentation of physician orders and treatment administration. For one resident with a Foley catheter, intake and output measurements and weekly weights were not consistently recorded as ordered. Another recently admitted resident with wounds and diabetes had missing documentation for wound care treatments and insulin administration, with no evidence that treatments were given, held, or refused on several occasions. These findings were confirmed through record reviews and staff interviews, highlighting incomplete and inaccurate clinical documentation for multiple residents.
Failure to Update Care Plan After Resident Burn Incident
Penalty
Summary
The facility failed to update and revise a resident's care plan to address a new safety concern after the resident, who is a functional quadriplegic, accidentally spilled hot coffee on their right lateral thigh, resulting in a second-degree burn. The resident had previously been able to handle their own coffee cup independently. Despite this incident, a review of the resident's current care plan showed that it did not address the new potential safety risk associated with the resident independently handling hot beverages. The Director of Nursing Services confirmed in an interview that the care plan had not been updated to reflect this safety issue.
Failure to Update Care Plan for Constipation Management
Penalty
Summary
The facility failed to update the care plan for a resident with a history of dementia and chronic constipation. The resident had multiple physician orders for bowel management, including a high fiber diet and various laxatives. Despite these measures, the resident was transferred to acute care for evaluation and treatment of constipation and fecal impaction. Upon returning to the facility, the resident's care plan was not updated to reflect the new orders, which included discontinuing Ducosate and adding Miralax. On review, it was found that the current care plan did not address the resident's constipation or potential for fecal impaction. The facility's administrator confirmed that the care plan had not been updated to reflect the resident's increasing problem with constipation. This oversight indicates a failure to adequately manage and document the resident's bowel management needs, leading to a deficiency in care planning.
Incomplete Documentation of Skin Tear Incident
Penalty
Summary
The facility failed to ensure that a clinical record contained complete and accurate information for a resident who experienced a skin tear incident. The facility's policy on Accidents & Incidents required that all incidents be promptly documented and reported, including details such as the date, time, nature of the injury, and any corrective actions taken. However, in the case of the resident with a skin tear, there was no evidence of an Accident/Incident report being completed at the time of the incident. The clinical record only included a nurse's note indicating that the resident's representative was notified of the skin tear, but lacked comprehensive documentation of the incident. Further investigation revealed that the LTC Unit Manager was unable to find any documentation of the incident in the computer system, and there was no record of the wound or the dressing applied. A late entry incident charting was completed several weeks after the incident, but it was not documented timely or correctly. Interviews with staff indicated that the skin tear occurred when the resident attempted to stand up from a wheelchair and hit their leg on the wheelchair frame. The lack of timely and accurate documentation of the incident and the wound care provided constitutes a deficiency in maintaining complete and accurate medical records in accordance with professional standards.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of COVID-19 among residents. During a survey, it was observed that three residents who tested positive for COVID-19 were in rooms with fans or air conditioners blowing air towards their roommates, who were negative for the virus. Specifically, one resident's room had an air conditioner blowing towards the roommate, while two other rooms had fans blowing air towards their respective roommates. The staff, including the Administrator, acknowledged that the doors should remain closed and fans should not blow towards the hallway. However, they did not consider the direction of airflow within the rooms, which could potentially facilitate the spread of the virus to roommates who were not infected. This oversight in infection control measures contributed to the deficiency identified by the surveyors.
Inadequate Housekeeping and Maintenance in LTC Facility
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an environment that was not in good repair or sanitary condition. During environmental tours, surveyors observed several deficiencies, including chipped and missing veneer on bedside tables and dresser drawers, which created uncleanable surfaces. Additionally, fans in multiple rooms were soiled with dust, and fall safety floor mats had soiled and cracked covers. The cove base on the floor was detached from the wall, and room divider curtains were soiled. In the locked unit, torn cloth chairs were found around tables and in hallways, and some chairs had wet spots or dried soiled areas. Specific rooms had small holes in walls, chipped headboards, and soiled bed rails. Baseboard register covers were unsecured, and a bathroom had a persistent urine odor with bulging drywall. Other issues included a soiled chair cover, a soiled arm of a blue chair, and a bent window screen. These observations indicate a lack of proper maintenance and cleaning, compromising the residents' right to a safe, clean, and comfortable environment.
Failure to Follow Physician Orders for Medications and Treatments
Penalty
Summary
The facility failed to ensure that physician orders for medications and treatments were followed for several residents. Resident #39 did not receive Prazosin for 25 days due to the facility's inability to obtain the correct dose from the pharmacy. Resident #22 missed multiple doses of various medications, including Cranberry capsules, Mirabegron, Calcium with Vitamin D3, Memantine, and Tramadol, due to unavailability and prescription renewal issues. Resident #77 also missed a dose of Trazodone because it was not available. The Long Term Care Manager acknowledged ongoing issues with medication availability. Resident #55's Eliquis was held one dose too early and restarted one dose too late, contrary to physician orders. Resident #49 received insulin when it was not needed, as the blood sugar level was below the threshold for administration. Additionally, Resident #50's daily weight checks were not completed as ordered on several occasions, with no evidence of refusal by the resident. These deficiencies were confirmed through interviews with facility staff and surveyors.
Inaccurate MDS Coding for PASRR and PTSD
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) 3.0 for a resident, leading to a deficiency in the assessment process. The resident, who had a state Level II Preadmission Screening and Resident Review (PASRR) and a diagnosis of Post Traumatic Stress Disorder (PTSD), was inaccurately coded in both the admission and annual MDS assessments. The clinical record review revealed that the resident's PASRR Level II, dated 5/2/23, indicated the need for Level II services and documented the PTSD diagnosis. However, the MDS assessments were incorrectly coded to reflect that the resident did not have a Level II PASRR or PTSD. This error was confirmed during an interview with the MDS Coordinator, who acknowledged the inaccurate entry of information into the resident's clinical record, affecting both the admission and annual MDS assessments.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), as identified during a survey. The resident's clinical record included a Level II PASRR and physician progress notes confirming the PTSD diagnosis and a trauma assessment completed a year prior, indicating a past traumatic experience. However, upon review, the Long Term Care (LTC) Manager was unable to locate a care plan addressing potential PTSD triggers or interventions for staff to follow if the resident displayed signs of re-traumatization. This deficiency was confirmed during an interview with a surveyor.
Failure to Follow Physician Orders for Positioning Equipment
Penalty
Summary
The facility failed to adhere to physician orders for a resident's positioning and mobility needs. A resident, identified as R50, was observed on multiple occasions without the prescribed wedge pillow, which was necessary to maintain proper positioning and prevent the resident from lying on their right side due to a shoulder condition. The resident expressed difficulty in maintaining position and reaching items during meals without the wedge pillow, which had been missing for some time. The clinical records confirmed a doctor's order for daily use of the wedge pillow, and the Plan of Care Summary specified the need for positioning support to prevent the resident from lying on the right side. Despite these directives, the wedge pillow was not in use during the surveyor's observations, and the Skilled Nursing Facility Manager confirmed the absence of the required support equipment.
Oxygen Concentrator Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that an oxygen concentrator was operated and maintained according to the manufacturer's directions for a resident using oxygen. The deficiency was identified when a surveyor observed the oxygen concentrator in the resident's room missing the cabinet filter compartment, which is essential for proper operation as per the manufacturer's manual. The manual explicitly states that the concentrator should not be operated without the filter installed. This issue was observed on multiple occasions over several days, indicating a lack of adherence to the prescribed maintenance schedule, which included cleaning the filter and changing the tubing weekly.
Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis was completed for a resident. The physician had ordered a urinalysis on June 17, 2024, suspecting an infection due to the symptoms the resident was experiencing. The order was entered into the computer system to be completed the following day, June 18, 2024. However, the clinical record did not show any evidence that the urine was collected for testing until a subsequent order was received and collected on July 7, 2024. During an interview on July 11, 2024, the Long Term Care Manager confirmed that there was no evidence of the urine being collected and tested on the initially ordered date. This oversight resulted in a delay in the diagnostic process for the resident's suspected infection.
Inaccurate Documentation of Resident Weights
Penalty
Summary
The facility failed to accurately document resident weights for two residents who were reviewed for weight loss concerns. For one resident, the clinical record showed a significant weight loss of 51% over 30 days, with weights fluctuating between 148.4 pounds and 216 pounds over a two-month period. The Registered Dietician noted the difficulty in assessing trends due to these discrepancies. During an interview, the Long Term Care Manager confirmed that several of the weights were inaccurate and acknowledged that a re-weigh should have been conducted. For the second resident, the clinical record indicated a significant weight loss in April, with a 13.7% decrease over 30 days and 14.8% over 90 days. The Registered Dietician questioned the accuracy of the weight, as the resident was consuming 75-100% of meals on average. The Long Term Care Manager noted that the weights did not seem correct, particularly the weight recorded in April, and suggested that the resident probably did not experience such a significant weight loss.
Failure to Notify Resident's Representative of New Pressure Ulcers
Penalty
Summary
The facility failed to inform a resident's representative about the development of two new Stage II pressure ulcers. On October 18, 2023, a nurse's note documented the presence of two new open skin areas on a resident: one on the right buttocks/leg crease and another on the upper back side of the right leg. However, there was no evidence in the clinical record that the resident's representative, specifically the son, was notified of these new pressure ulcer areas. This was confirmed during an interview with the Administrator on July 10, 2024, who acknowledged that the son was never informed of the new pressure ulcers.
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The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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