A Winthrop nursing home with a history of federal fines has been placed on a national list of facilities with “serious quality issues” after two residents wandered off in separate incidents last year and one of them was struck and killed by a vehicle.

Heritage Rehabilitation and Living Center, a 28-bed nursing home, was listed as a “special focus facility” earlier this year by the U.S. Centers for Medicare and Medicaid Services (CMS). That means Heritage will be subject to twice as many inspections and could face penalties if it fails to improve.

“Our nursing homes take care of a very vulnerable population of people (so) protection of both quality of care and quality of life is just so important,” said Brenda Gallant, Maine’s long-term care ombudsman. “The regulations are there to protect residents. So when there are deficiencies of a serious nature, they need to be addressed and then improvements must be made to protect residents.”

Heritage is owned by North Country Associates, Maine’s largest long-term care provider. Neither Heritage’s administrator nor North Country Associates responded to questions.

On a rainy night in November, police found a shoeless Heritage resident wandering along the side of the road about a mile from the facility, according to a  Department of Health and Human Services report.

When police brought the resident back to the facility, staff “had no idea the resident was missing or how long the resident had been gone,” the inspection report said. Heritage was fined $109,600.

Less than a month later, on Dec. 6, another Heritage resident wandered off and was struck and killed by a pickup truck a half-mile away on Route 202.

Donna Driscoll, 56, was recovering from a broken leg and about to be transferred to a memory care facility in Falmouth before she died, her family told WGME at the time. She had a history of wandering and wore an ankle monitor that was supposed to prevent the doors from opening if she tried to leave.

The ankle monitor was how police learned she was a Heritage resident, according to a DHHS report. When police went to the facility, staff initially assured the officer all their residents were there. But when police asked them to check, they noticed a resident was missing.

The wander guard should have prompted the doors to lock if she got too close. A company later checked the system and found it was functioning properly.

There were 24 residents and four staff present at the time, including the director of nursing.

Heritage also was cited for failing to have a written transfer agreement with a local hospital, and failing to ensure staff members completed training on abuse, neglect, dementia care, and exploitation and misappropriation of resident property.

The incidents contributed to the decision by regulators to list Heritage as a special focus facility, DHHS spokeswoman Jackie Farwell confirmed. The decision was based on a “persistent pattern of poor quality on a facility’s last three standard surveys and complaints,” rather than a single event.

Nursing homes are required to meet federal regulations on all aspects of care, including staffing, medication, activities and food, said Gallant, the long-term care ombudsman. Officials send a report to the facility on how it can improve and the facility has to respond with explanations of how it will correct those problems.

Citations for “deficiencies” of varying severity during an annual inspection are common. The national average for such deficiencies for a nursing home is six or seven, according to CMS.

Nursing homes that have more problems, more serious problems or a pattern of problems over a long period are placed in the Special Focus Facility program. These facilities are then inspected every six months.

CMS uses progressively stricter enforcement measures to bring the facility into compliance, an agency spokesperson told The Maine Monitor. If the facility hasn’t corrected its noncompliance after three months, CMS is required by law to deny Medicare payments for new resident admissions. If it’s still out of compliance after six months, CMS is required to terminate its participation with Medicare and Medicaid.

But a nursing home doesn’t have to be a special focus facility to face penalties for deficiencies, Gallant said.

Most nursing homes improve their quality of care within two years, but about 10 percent are eventually terminated from Medicare and Medicaid.

“The Centers for Medicare & Medicaid Services is committed to improving the quality of care and quality of life for all nursing home residents,” the spokesperson said. “Patient health and safety, access to reliable, high-quality care and the treatment of all residents in nursing homes with dignity and respect is the top priority for all of our efforts.”

Heritage was placed on the federal list in February. It is the only Maine nursing home currently listed as a special focus facility.

Marshwood Center in Lewiston was a special focus facility in December 2019 but made enough improvements to be removed from the program.

To “graduate” from the program, a facility must complete two consecutive inspections with evidence of improved quality of care, with no citation indicating harm or potential for serious harm to residents, Farwell said.

Gallant said families often have to make quick decisions during a crisis on where to send their loved ones. They may not know about resident protections and publicly available information on facilities.

Inspection reports and ratings for all of Maine’s facilities are available on the CMS website. It includes ratings for health inspections, staffing and quality measures, as well as information on COVID-19 vaccination rates, fire safety inspections and penalties.

Gallant also encouraged families to ask nursing home administrators about cited deficiencies and the steps they are taking to address them. And they can tour facilities to observe staff interactions with residents.

Residents and family members often are hesitant to complain out of fear of retaliation from the facility, Gallant said, but she has never seen any kind of retaliation. They are able to solve problems in a “respectful way.”

“It’s a good thing that there’s a focus on care and on quality improvement. And for residents, it’s important that we do everything we can to ensure that older and disabled individuals that are served in nursing homes have the highest quality of care – quality of life – possible. It’s what we would want for our loved ones or for ourselves.”

This story was originally published by The Maine Monitor. The Maine Monitor is a local journalism product published by The Maine Center for Public Interest Reporting, a nonpartisan and nonprofit civic news organization.

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