Durgin Pines

In the surveyor’s words

From the most serious findings on record at Durgin Pines, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578Mar 12, 2025

  Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 5 of 5 residents reviewed. (#10, #15, #18, #23, #47) Findings: 1. Resident #18 was admitted in January of 2025. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #23 was admitted in February of 2025. […]

• No harm, potential for more than minimal, patternF657Mar 12, 2025

  Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 7 of 9 reviewed for care planning. (Resident #1, #49, #40, #32, #13, #55 and #3). Findings: 1. On 3/10/25 at 11:34 a.m., during an interview, Resident #1 stated he/she is not invited or remembers having care plan meetings. Review of Resident #1's IDT care plan meeting notes stated IDTs occurred on 4/24/24, 7/24/24, 10/23/24, 11/22/24 and on 3/5/25. The medical record lacked evidence that he/she was invited and/or participated in his/her IDT meetings. 2. […]

• No harm, potential for more than minimal, patternF689Nov 29, 2022

  Based on interviews, record review, and facility policy, the facility failed to adequately supervise and completely investigate successful elopements of 2 of 3 residents reviewed for elopement. (Resident's #1 and #2) This failure resulted in Resident #1 eloping from the secured unit resulting in a facility wide search. Resident #2 eloped from the skilled unit where, he/she was found outside on the walking path by a staff member. In addition, the facility failed to thoroughly investigate elopements to include root cause analysis. Findings: The Department of Licensing & Certification received the following facility reported incident reports: -On 11/16/22 at 04:00 Resident #1 eloped from the locked unit and was found in the facility entryway stuck between the double doors. […]

• No harm, potential for more than minimal, isolatedF557Jun 10, 2026

  Based on observation and interview, the facility failed to ensure a resident was treated with respect and dignity regarding personal privacy. Facility staff exposed a resident's bare leg and wound dressing, and initiated a clinical dressing removal in a public area of the facility. This affected 1 of 1 resident observed for dignity during treatments (Resident #3 [R3]).Finding: On 6/9/26 at approximately 10:45 a.m., Resident #3 (R3) was observed sitting in a wheelchair at the nurses' station of the Marion's Way unit. R3's right pant leg was pulled up, exposing his/her bare lower leg and an active wound dressing. At the same time, Registered Nurse #1 (RN #1) was observed standing at the public nurses' station cutting the dressing off R3's right lower leg using bandage scissors. […]

• No harm, potential for more than minimal, isolatedF628Jun 10, 2026

  Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all the resident's pre- and post-discharge medications for 1 of 1 residents reviewed for discharge to the community (Resident #79).Finding: On review of Resident #79's clinical record, a surveyor noted an admission date of 5/6/26. The record indicated that on 5/13/26, Resident #79 and family decided to return to the resident's previous assisted living facility (ALF) with hospice services. On 5/15/26, Resident #79 discharged back to the ALF with referrals for hospice services. […]