St Mary's D'youville Pavilion
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 102 Campus Ave, Lewiston, Maine 04240
- CMS Provider Number
- 205053
- Inspections on file
- 20
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at St Mary's D'youville Pavilion during CMS and state inspections, most recent first.
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.
Surveyors found that the facility did not maintain clean and sanitary conditions in two units and the laundry rooms, with dusty fans and air conditioning units, dirty air filters, marred hallway walls, broken or chipped baseboard heaters, privacy curtains in disrepair, and commode buckets left on bathroom floors. Facility leadership confirmed these findings during the environmental tour.
Surveyors observed multiple instances where respiratory care equipment, including oxygen tubing, nasal cannulas, and nebulizer components, were unlabeled, undated, and improperly stored in resident rooms. Staff interviews confirmed inconsistent practices and a lack of documentation for regular cleaning or replacement of this equipment, resulting in a failure to maintain a sanitary environment and prevent infection transmission.
Two residents requiring hemodialysis did not receive appropriate monitoring or care planning for their dialysis access sites. One resident with an AVF reported no assessment or monitoring by staff, and documentation lacked orders or interventions for site monitoring or emergency response. Another resident with a dialysis catheter stated staff did not check the site after dialysis, and the care plan did not address regular monitoring or emergency procedures. Nursing staff interviews confirmed a lack of routine assessment and absence of facility policy for dialysis care.
Two residents with active PTSD diagnoses did not have their trauma histories, triggers, or preventive interventions assessed or documented in their clinical records or care plans. Staff confirmed the absence of trauma-informed care planning and screenings for these residents.
A resident admitted with a right ankle fracture and requiring daily anticoagulant injections did not have a baseline care plan developed and implemented within 48 hours of admission. The medical record lacked the necessary instructions to ensure proper care for the resident's immediate needs.
A resident with CHF and respiratory illness was observed receiving oxygen at 3 LPM via nasal cannula, despite a provider order and care plan specifying 4 LPM to maintain target oxygen saturation levels. Multiple observations, record reviews, and staff interviews confirmed the discrepancy between the ordered and administered oxygen flow rates.
A resident who used tobacco products and had poor vision or blindness was found with a lighter in their room, and their smoking safety assessment was incomplete. The assessment noted the resident was unable to extinguish tobacco safely, but required clinical interventions and supervision were not documented or implemented. Staff interviews confirmed that residents were not observed while smoking, and the facility relied on education about its non-smoking policy rather than conducting proper safety assessments.
Two unlocked and unattended medication carts were found in a hallway across from the nurses station, with staff present nearby but not monitoring the carts. A surveyor was able to open and inspect the carts without staff intervention, and only after being notified did a nurse secure the carts. This allowed unauthorized access to medications.
The facility did not provide evidence that all required members attended two quarterly QAPI meetings, with the Medical Director missing from one meeting and the Administrator, DON, and Infection Preventionist absent from another, as confirmed by attendance records and staff interview.
A facility failed to implement an infection control program for a resident on contact precautions for ESBL. Two CNAs entered the resident's room wearing only masks, despite instructions to wear gowns, gloves, and goggles if necessary. The LPN intervened to correct the PPE use after a surveyor's observation. The resident's contact precaution status was confirmed by the RN, and the DON later educated the CNAs on PPE requirements.
The facility failed to provide adequate housekeeping and maintenance services, resulting in uncleanable surfaces, dusty and dirty fans, improperly stored commode buckets and bed pans, and heavily marked walls and doorframes. These deficiencies were confirmed by the Plant Operations Manager during an environmental tour.
The facility failed to develop or implement care plan interventions for six residents, leading to various deficiencies. These included missing safety measures for fall prevention, lack of required eye protection during care, unrecorded pressure-reducing devices, undocumented psychotropic medication plans, and incomplete hospice care plans. Staff misunderstandings about the inclusion of interventions in care plans contributed to these issues.
The facility failed to revise care plans for three residents to reflect their current needs, including Hospice services, suicidal ideation, and antidepressant medication. This was confirmed by various staff members.
The facility failed to follow a physician's order for obtaining daily weights for a resident with edema and did not make a referral to a specialist for a resident with depression as ordered. The deficiencies were confirmed through clinical record reviews and staff interviews.
The facility failed to maintain kitchen cleanliness and proper food handling. Observations included staff not wearing facial hair protection, dirty ceiling vents, wet stacked glasses, and improperly stored food items. During lunch service, a dietary aide/server did not follow proper hand hygiene, leading to potential cross-contamination. Additionally, the facility did not consistently monitor and document dish machine and refrigerator/freezer temperatures.
The facility failed to maintain and implement an infection control program for two residents with MRSA. One resident with respiratory MRSA did not consistently receive care with appropriate eye protection, and another resident with MRSA in the urine did not have consistent Transmission-Based Precautions in place. Staff provided conflicting information, and the facility did not adhere to its own Infection Prevention and Control Plan.
The facility failed to ensure a resident's advance directive regarding CPR was accurately documented. Despite the resident's request to change their Code Status to CPR, the clinical record still indicated No CPR, and the necessary documentation was missing. The facility did not follow its own policy for updating advance directives.
A facility failed to conduct a comprehensive MDS 3.0 assessment within 14 days after a resident began receiving hospice services. The resident's most recent assessment was completed before the initiation of hospice, and no new assessment was conducted within the required timeframe. This was confirmed by the DON.
The facility failed to develop and implement a baseline care plan within 48 hours for a new admission requiring TBP. A resident admitted with sepsis, acute kidney injury, and recurrent C-Diff did not have a care plan initiated for 63 days, despite physician orders for treatment. This deficiency was discussed with the Assistant Director of Nursing.
The facility failed to ensure that a pharmacist identified the lack of a psychiatric evaluation for a resident prescribed Sertraline for depression. Despite multiple medication reviews, the required evaluation was not completed, as confirmed by the RN Manager.
The facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for a resident. The resident had been receiving Quetiapine since November 2022, but there was no documentation of a GDR attempt or clinical contraindication between November 2022 and January 2024. This was discussed with the Assistant Director of Nursing.
The facility failed to maintain sanitary conditions in resident rooms and bathrooms and did not ensure proper food labeling in the kitchen. Despite a Plan of Correction, issues with storage of bed pans/commode buckets, dusty exhaust fans, and unlabeled food items persisted, leading to the recitation of deficiencies F584 and F812.
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.
Failure to Maintain Cleanliness and Repair in Resident and Laundry Areas
Penalty
Summary
The facility failed to maintain adequate maintenance and housekeeping services necessary to ensure a safe, clean, and homelike environment for residents. During an environmental tour, surveyors observed multiple deficiencies across two of three units and the laundry rooms. In the laundry rooms, both clean and soiled linen areas had wall-mounted fans and air conditioning units that were dusty and dirty, and the ceiling air system had filters that were also dusty and dirty. On the 3rd and 4th floor units, hallway walls were marred with black marks, and several resident rooms had privacy curtains in disrepair, missing hooks, and hanging down. Multiple baseboard heating units in resident rooms were broken, chipped, or had missing paint and were marred with black marks. Additionally, some resident rooms had commode buckets left on the bathroom floor, including one that was unbagged. These findings were confirmed by the Administrator, QAPI Manager, and 3rd Floor Unit Manager during the tour.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment, as evidenced by multiple observations of unlabeled and undated oxygen tubing, nasal cannulas, and nebulizer components stored improperly in resident rooms. On several occasions, respiratory equipment such as nebulizer pipes, oxygen tubing, and masks were found either lying on bedside dressers, hanging off machines, or stored in drawers without proper labeling or dating. In some cases, the equipment was not in use for extended periods, and there was no documentation of regular cleaning or scheduled replacement. Residents reported infrequent use of the equipment, and staff interviews confirmed a lack of consistent procedures for changing and storing respiratory care items. Record reviews and staff interviews revealed that the facility did not document the weekly changing of oxygen tubing, nasal cannulas, or nebulizer masks in the Treatment Administration Record (TAR). The RN unit manager acknowledged the absence of documentation and stated that the facility was in a transition period due to the departure of the respiratory therapist, resulting in inconsistent practices. The lack of proper labeling, dating, and storage of respiratory care equipment was observed for multiple residents over several days, with no evidence of adherence to infection control protocols.
Failure to Monitor and Care Plan for Dialysis Access Sites
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring hemodialysis. One resident with an arteriovenous fistula (AVF) reported that staff had never assessed or monitored the AVF site, despite a history of bleeding episodes requiring hospitalization. The resident's medical record confirmed a diagnosis of end-stage renal disease with an AVF and orders for hemodialysis, but there were no documented orders or interventions for assessment or monitoring of the AVF site. The care plan lacked interventions for monitoring the AVF for bruit and thrill, as well as emergency interventions for bleeding, and there was no evidence of nursing care or assessment in the medication and treatment administration records. The Director of Nursing confirmed the absence of a policy or procedure for nursing care and monitoring of hemodialysis residents. A second resident with a dialysis catheter in the right upper chest area stated that staff only looked at the site on dialysis days and that the dialysis center staff managed the dressing. Upon return from dialysis, facility staff did not check the catheter site. The resident's care plan included some interventions for dialysis but did not address regular monitoring of the access site or specify emergency procedures for complications. The medication and treatment administration records also lacked documentation of monitoring for the dialysis access site. Interviews with nursing staff revealed that they did not routinely assess or monitor the dialysis access sites, either AVF or catheter, and were unaware of the need for such monitoring. The care plans for both residents did not include necessary information or interventions for monitoring the dialysis access sites or emergency procedures, and there was no facility policy or procedure in place to guide staff in providing appropriate care for residents receiving hemodialysis.
Failure to Assess and Care Plan for PTSD Triggers and Interventions
Penalty
Summary
The facility failed to properly assess and document trauma-related triggers and interventions for residents with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). For one resident, the clinical record did not contain information regarding the cause of PTSD, potential triggers for re-traumatization, or measures to avoid such triggers. Additionally, the resident's care plan lacked evidence of trauma-informed planning, including identified triggers and interventions to prevent re-traumatization. These findings were confirmed by the Administrator and the Director of Social Services during the survey. Similarly, another resident with an active PTSD diagnosis did not have documentation in the clinical record identifying the cause of PTSD, potential triggers, or preventive measures. The care plan only mentioned PTSD as a problem without including specific goals, triggers, or trauma interventions. The Unit Manager and a Licensed Social Worker confirmed that this resident had not received a psych/PTSD/trauma screening or assessment.
Failure to Develop 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 one resident who was admitted with a primary diagnosis of a fall resulting in a right ankle fracture and required daily Lovenox (anticoagulant) injections. As of March 26, 2025, the resident's medical record did not contain evidence of a baseline care plan that included the necessary instructions to provide minimum healthcare information for proper care in this area. This deficiency was identified through interview and record review and was discussed with the Director of Nursing.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order and care plan for oxygen therapy for one resident with a history of congestive heart failure and respiratory illness. Observations on multiple occasions showed the resident receiving oxygen at 3 liters per minute (LPM) via nasal cannula, while the provider's order and care plan specified oxygen at 4 LPM to maintain specific oxygen saturation levels. Nursing documentation also indicated the resident was on 3 LPM on several dates, and both the RN unit manager and surveyor confirmed the oxygen was set at 3 LPM during their review, despite the standing order for 4 LPM. This deficiency was identified through direct observation, record review, and staff interview, demonstrating a failure to provide care according to the physician's order and the resident's care plan.
Failure to Complete Smoking Safety Assessment for Resident
Penalty
Summary
A deficiency was identified when the facility failed to complete a smoking assessment of a resident's capabilities and deficits to determine safety. During an interview, a RN found a lighter in the resident's open nightstand drawer and explained that it was a hazard, stating the resident could only obtain the lighter before going out to smoke. The resident indicated plans to smoke after breakfast. Review of the resident's Smoking Safety Interaction form showed that the resident used tobacco products, had poor vision or blindness, and was unable to extinguish tobacco safely. However, the section of the form addressing clinical suggestions and interventions, such as applying a smoking apron, setting up a cigarette holder, staff assistance to extinguish cigarettes, referral to the interdisciplinary team, and ensuring eyeglasses are worn, was not completed. Further interviews with the RN unit manager revealed that the facility did not observe residents while smoking and relied on educating them about the non-smoking policy, despite acknowledging residents' rights to smoke in a designated area. The facility's policy encouraged residents not to smoke but recognized their right to do so safely. The Director of Nursing confirmed that there was a lack of a completed safety assessment regarding the resident's abilities and the need for supervision while smoking.
Unlocked Medication Carts Left Unattended in Hallway
Penalty
Summary
On 3/25/25 at 9:15 a.m., two unlocked medication carts were observed in the hallway across from the nurses station on the 3 [NAME] Unit. At the time of the observation, two staff members were located behind the nurses station and one staff member was seated at the nurses station. The surveyor was able to open both medication carts and go through each drawer without any staff intervening or responding. One of the identified nurses left the area, and only after the surveyor informed the remaining nurse about the unlocked carts did she get up and lock them, confirming the finding. This situation resulted in medications being accessible to residents and unauthorized persons, in violation of proper medication storage protocols.
QAPI Meeting Attendance Lacked Required Members
Penalty
Summary
The facility failed to provide evidence that the required members of the Quality Assessment and Assurance (QAA) group attended two of the four quarterly Quality Assurance and Performance Improvement (QAPI) meetings reviewed. Specifically, the attendance sheet for the April 2024 QAPI meeting did not show that the Medical Director was present. Additionally, the July 2024 QAPI meeting attendance sheet lacked documentation of attendance by the Administrator, Director of Nursing, and Infection Preventionist. These findings were confirmed through review of attendance records and an interview with the QAPI Manager.
Inadequate PPE Use for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain and implement an infection control program to prevent the transmission of disease and infection for a resident on contact precautions. A surveyor observed two Certified Nursing Assistants (CNAs) entering the room of a resident on contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) wearing only masks, despite a sign on the door instructing staff to wear gowns, gloves, and goggles if there is a high chance of liquid exposure. The CNAs were not wearing the required Personal Protective Equipment (PPE) for direct care, which was available in a yellow precaution bag outside the resident's door. Upon intervention by the surveyor, the Licensed Practical Nurse (LPN) instructed the CNAs to don the appropriate PPE. The Registered Nurse confirmed the resident's contact precaution status, and the Director of Nursing later educated the CNAs on PPE requirements.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. During an environmental tour, several deficiencies were observed in the laundry rooms and on the 3rd floor. In the soiled laundry linen room, a wall fan was found to be dusty and dirty, the cement floor had chipped and missing paint, and non-skid floor tape was missing pieces, creating uncleanable surfaces. The clean laundry linen room had three dusty and dirty wall fans, and the cement floor also had chipped and missing paint. Additionally, the laundry room had 30 broken or missing floor tiles, and the cement floor behind and under the washing machines had chipped and missing paint, creating uncleanable surfaces. On the 3rd floor east, the wheelchair scale had ripped and missing non-skid surface tape, making it uncleanable. On the 3rd floor west, two sit-to-stand patient lifts had missing and chipped paint and rusty areas in the foot base areas, creating uncleanable surfaces. Several resident rooms and common areas were also found to be in poor condition, with dusty and dirty exhaust fans, unmarked urinals, commode buckets, and bed pans stored improperly, and heavily marked walls and doorframes. The Plant Operations Manager confirmed these findings during the tour. Specific observations included a dusty and dirty wall fan in a resident room, debris in a shower light lens, and a large brown stain on a hallway ceiling tile. The bathroom in one resident room, shared by four residents, had an unmarked urinal hanging on the grab bar behind the toilet, and the bathroom exhaust fan was dusty and dirty. Another resident room's bathroom had two commode buckets sitting on the floor under the sink and a bed pan stored on the handrail by the toilet. Additionally, two hallway ceiling vents were found to be dusty and dirty. These deficiencies indicate a failure to maintain a safe, clean, comfortable, and homelike environment for the residents.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop or implement care plan interventions for six residents, leading to various deficiencies. For Resident #2, who has muscle weakness and a history of falls, the care plan required floor mats on both sides of the bed for fall safety. However, a surveyor observed the resident in bed without the floor mats, and a registered nurse confirmed the mats were not in place. Resident #20, diagnosed with quadriplegia and MRSA in the respiratory tract, had a care plan that required staff to wear eye protection during procedures with risk of splashes or droplet contamination. Despite this, two CNAs were observed providing care without eye protection, and the resident confirmed that staff mostly did not wear eye protection unless there was a COVID-19 case on the unit. The Director of Nursing confirmed the care plan was not followed for eye protection use. Resident #166 was observed on a pressure-reducing mattress, but the care plan did not include this intervention. The rehab unit manager mistakenly believed that interventions listed in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) were part of the care plan. Similarly, Resident #101 had orders for heel protectors and turning every two hours, which were documented in the MAR and TAR but not in the care plan. Resident #52, who was on the psychotropic medication Quetiapine Fumarate, lacked a comprehensive care plan addressing the use, goals, and interventions for the medication. Lastly, Resident #173, who was receiving hospice services, did not have a hospice care plan developed with goals and interventions for end-of-life care from the onset of hospice services until the resident's death. The Director of Nursing confirmed that a comprehensive assessment should have been completed within 14 days after the resident began hospice services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans to reflect the current needs of three residents. Resident #104, who was initiated on Hospice for terminal Parkinson's Disease, had a Significant Change in Status MDS assessment completed and IDT meetings held, but the care plan was not revised to reflect Hospice services. This was confirmed by the Assistant Director of Nursing. Resident #135 exhibited verbal outbursts and suicidal ideation, with progress notes indicating increased antidepressant and antipsychotic medication. However, the care plan was not updated to reflect these changes, as confirmed by the Licensed Social Worker and the Nurse Manager on the Memory Unit. Resident #144 had a physician order for an antidepressant medication, but the care plan was not revised to include this medication. This was confirmed by two MDS coordinators. The lack of timely care plan revisions for these residents indicates a failure to address their current medical and psychological needs adequately.
Failure to Follow Physician Orders for Daily Weights and Specialist Referral
Penalty
Summary
The facility failed to follow a physician's order for obtaining daily weights for a resident with edema. The clinical record review revealed that the resident's weights were not taken on multiple dates between 10/13/23 and 1/21/24, despite a physician's order dated 10/12/23 for daily morning weights. This was confirmed by the Assistant Director of Nursing during an interview on 1/24/24, who acknowledged that the weights had not been taken as ordered. Additionally, the facility failed to follow a physician's order for making a referral to a specialist for a resident with depression. The clinical record showed a physician's order dated 9/13/23 for a psychiatric evaluation, but there was no evidence that the appointment was made. A nurse's note from 9/20/23 indicated that the referral was pending due to a lack of recent notes addressing depression. This was confirmed by the Registered Nurse Minimum Data Set Coordinator and the RN Manager of 4 East unit during interviews on 1/24/24. The RN Manager stated that an SBAR was made in September, but no response was received from the doctor, and the order for the psychiatric evaluation was eventually discontinued on 1/24/24.
Facility Fails to Maintain Kitchen Cleanliness and Proper Food Handling
Penalty
Summary
The facility failed to maintain the kitchen in a clean manner, as observed on 1/22/24. Specifically, four male kitchen staff were not wearing facial hair protection, and there were dusty, dirty, and rusty ceiling vents above clean dish storage shelves. Additionally, 30 plastic glasses were wet stacked, and the auto bag machine had chipped paint and rust, creating an uncleanable surface. The dish room had stained ceiling tiles and dirty vents. Furthermore, several food items in Refrigerator/Cooler #3 and Freezer #3 were unlabeled, undated, and improperly stored, with some items showing large amounts of ice crystals. These findings were confirmed by the Food Service Director during the initial tour of the kitchen. During lunch service on the 3rd floor [NAME] dining room, a dietary aide/server was observed handling and serving food without a hair restraint. The aide also failed to change gloves or wash and sanitize hands between tasks, leading to potential cross-contamination. The aide touched various surfaces and food items with the same gloved hands, including a cleaning towel, cupboards, dishes, rolls, biscuits, bread, meat patties, peanut butter, a muffin, cheese slices, and a phone. The dietary aide/server confirmed that his procedure did not prevent possible cross-contamination of foods. The facility also failed to monitor and document dish machine and refrigerator/freezer temperatures consistently. The main kitchen dish machine wash and rinse temperatures were not monitored and documented on multiple dates in October, November, December 2023, and January 2024. Additionally, the dish machine temperatures were recorded below the required 180 degrees Fahrenheit on several occasions. The facility also failed to monitor and document refrigerator and freezer temperatures on numerous dates across different units and storage areas. These findings were confirmed by the Food Service Director during an interview on 1/23/24.
Failure to Implement Infection Control Program for MRSA
Penalty
Summary
The facility failed to maintain and implement an infection control program to prevent the transmission of Methicillin Resistant Staphylococcus Aureus (MRSA) for two residents. Resident #20, diagnosed with quadriplegia, tracheostomy, and chronic respiratory failure, had MRSA colonized in his/her sputum. Despite the care plan instructing staff to wear masks and face shields during procedures with risk of splashes or droplet contamination, two CNAs were observed providing care without eye protection. The RN Manager later confirmed the need for eye protection, but it was not consistently used, as evidenced by the resident's statement and observations made by the surveyors. Additionally, the resident had not been tested for MRSA in a year and a half, despite receiving regular antibiotic nebulizer treatments for respiratory MRSA. Another resident, #148, had MRSA in the urine and was readmitted to the facility with a hospital discharge diagnosis indicating the same. However, the required Transmission-Based Precautions (TBP) were not consistently in place. Surveyors observed that the TBP cart and signage were missing for several hours, and staff provided conflicting information about the presence and necessity of TBP. The RN Manager and other staff members were unsure about the implementation of TBP, leading to a lapse in infection control measures. The facility's Infection Prevention and Control Plan, revised in January 2024, mandates following the Centers for Disease Control and Prevention Guidelines for Transmission-Based Precautions. Despite this, the facility failed to ensure consistent use of PPE and TBP for residents diagnosed with MRSA, thereby not adhering to their own policies and potentially risking the transmission of infection among residents and staff.
Failure to Accurately Document Advance Directive
Penalty
Summary
The facility failed to ensure a resident's right to formulate an advance directive regarding CPR or Code Status was accurately reflected in the clinical record. Resident #108 had requested a change in their Code Status to CPR, but the clinical record still indicated No CPR. This discrepancy was discovered during an interview with a Unit Secretary, who recalled the resident's request but noted that the chart had not been updated. The Unit Manager confirmed that Resident #108 was capable of making their own decisions, and the resident reiterated their desire for CPR during an interview with the surveyor. However, the clinical record did not reflect this change, and the staff was unaware of the request. The facility's policy on Advanced Healthcare Directives requires that any revocation of an advance directive be documented in the medical record, including a detailed statement of the revocation and notification to the physician. Despite this policy, the medical record for Resident #108 lacked the necessary documentation to support the change in Code Status. The Administrator and Director of Nursing confirmed that the clinical record was inaccurate and that the facility had not followed its own policy for changing the Code Status.
Failure to Conduct Timely MDS 3.0 Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition and hospice services were initiated. The resident began receiving hospice services on 10/5/23, but the most recent comprehensive MDS 3.0 assessment was completed on 9/7/23, and no new comprehensive assessment was conducted within the required 14-day period. This deficiency was confirmed by the Director of Nursing on 1/26/24.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented within 48 hours for a new admission requiring Transmission Based Precautions (TBP). Resident #160 was admitted with diagnoses of sepsis, acute kidney injury, and recurrent Clostridioides Difficile (C-Diff), which necessitated contact precautions. Despite physician orders for Fidaxomicin to treat septicemia and later C-Diff, the clinical record lacked evidence of a baseline care plan within the required timeframe. The care plan for C-Diff was not initiated until 63 days after admission. This deficiency was discussed with the Assistant Director of Nursing by a surveyor.
Failure to Ensure Psychiatric Evaluation for Resident on Antidepressant
Penalty
Summary
The facility failed to ensure that the pharmacist provided services to identify that a physician's order for a psychiatric evaluation was completed for one resident reviewed for unnecessary medications. Specifically, a physician's order dated 9/13/23 for the resident to start Sertraline 50 milligrams daily for depression and to have a psychiatric evaluation for depression was not followed up. As of 1/23/24, the medical record lacked evidence of the psychiatric evaluation. The pharmacist reviewed the resident's medication regimen on four separate occasions between 9/29/23 and 12/26/23 but did not identify the missing psychiatric evaluation. This deficiency was confirmed with the Registered Nurse Manager on 1/24/24.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for one resident. The resident's Physician Order Sheet indicated that the resident had been receiving Quetiapine 25 mg every morning and Quetiapine 50 mg twice daily since November 26, 2022. Between November 26, 2022, and January 25, 2024, there was no documentation in the clinical record that a GDR was attempted or that a GDR was clinically contraindicated for the resident. This finding was discussed with the Assistant Director of Nursing on January 26, 2024, at 11:15 a.m.
Failure to Maintain Sanitary Conditions and Proper Food Labeling
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, as well as ensure foods were dated and/or labeled in a freezer and refrigerator. During the annual Long Term Care survey, deficiencies were cited at F584 for the facility's failure to maintain sanitary conditions in resident rooms and bathrooms, and at F812 for the failure to date and label food items in the kitchen. The Plan of Correction (POC) indicated that the facility would clean ceiling fans weekly, store bed pans/commodes appropriately, and ensure kitchen staff would date and label items in the refrigerator and freezer, with a completion date of 3/11/24. During a re-visit survey, it was found that the facility had not effectively implemented the POC. Resident bathrooms on the 3rd Floor [NAME] unit were still found to have issues with the storage of bed pans/commode buckets and dusty/dirty exhaust fans. Additionally, several rooms had unlabeled personal items and medicated powder stored around the sink. In the kitchen, freezer #3 and refrigerator/cooler #2 still contained unlabeled and undated food items. These ongoing issues led to the recitation of the same tags, F584 and F812, indicating that the POC was not effective in addressing the deficiencies.
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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