Dexter Health Care: Nurse Mimicked Dementia Patient - ME
The incident at Dexter Health Care began around 8:30 a.m. on August 16 when the resident returned from breakfast and became agitated, wanting to leave the facility. Instead of following the care plan's instruction to "approach/speak in a calm manner," Registered Nurse #1 repeatedly removed the resident from the front door and took them back to their room while both parties yelled at each other.
The resident's care plan specifically called for staff to "distract resident from wandering by offering pleasant diversions, structure activities, food, conversation, television, book." But the section listing the resident's preferences was left blank, leaving staff without guidance on what might calm the person.
Certified Nursing Assistant #4 witnessed the nurse removing the resident from the front door "numerous times" and observed both the nurse and resident yelling at each other throughout the morning.
The confrontation escalated over two hours. The resident, who has dementia and is considered an elopement risk, kept saying "this is a prison" and insisting they had "the right to go out." Their yelling became disruptive to other residents.
Around 10:30 a.m., Certified Nursing Assistant #1 intervened after witnessing the registered nurse mimicking the resident's arm flapping movements and challenging them to violence.
"I thought the resident was provoked with the nurse adding to his/her being aggressive," the nursing assistant told inspectors. She took the resident back to their room to defuse the situation.
Another nursing assistant described the resident as someone who "gets triggered easily and you have to let him/her be." She explained that when someone is agitated, "you got to leave them alone for a bit."
The solution, she noted, was simple: "All you had to do was take him outside, but it was a busy time for us."
The resident's behavior problems were well-documented. Their care plan, initiated in December 2024, identified them as having "a behavior problem related to dementia" and outlined interventions to "minimize potential for the resident's disruptive behaviors by offering tasks which divert attention."
Federal inspectors found the facility failed to implement this care plan during the August 16 incident. The nurse's actions directly contradicted the written instructions to use calm approaches and diversion techniques.
The first nursing assistant who intervened described the resident as someone who "gets in his/her moods but can be easy to calm down but not like that Saturday." She attributed the resident's prolonged agitation to the nurse's confrontational approach.
Staff members agreed the resident could have been calmed by taking them outside, which aligned with their expressed desire to leave. But the facility was short-staffed that morning, leaving the registered nurse to handle the situation alone.
The facility reported the incident to state regulators two days later on August 18. Their investigation included written statements from multiple staff members who witnessed the confrontation.
Registered Nurse #1 worked her final shift on August 17, one day after the incident. The facility terminated her employment effective August 28.
Following the incident, administrators developed a new section for the resident's care plan addressing their "potential to be physically aggressive." The updated plan included an intervention requiring "staff take turns taking resident outside one on one."
The facility also initiated mandatory education for all staff on "challenging behaviors in dementia care and aggressive or violent behavior," starting August 19 with completion required by August 29.
The resident's original care plan had been revised as recently as June 13, suggesting ongoing challenges with their exit-seeking behavior. The December 2024 initiation date indicated the facility had been managing these behaviors for eight months before the August confrontation.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to few residents. But the incident highlighted gaps between written care protocols and actual staff implementation during crisis situations.
The registered nurse's termination came eleven days after the incident, following the facility's internal investigation. Staff members who witnessed the confrontation provided written statements documenting both the nurse's inappropriate responses and the resident's escalating distress throughout the morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dexter Health Care from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Dexter Health Care in Dexter, ME was cited for violations during a health inspection on August 26, 2025.
The incident at Dexter Health Care began around 8:30 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.