Dexter Health Care: Nurse Mimicked Dementia Resident - ME
The resident, identified only as Resident 1 in the report, has dementia and had been flagged as an elopement risk since December 2024. That morning, he returned from breakfast around 8:30 a.m. and began trying to leave through the front door. What followed, according to written statements and interviews collected during the August 26 inspection, was not a calm redirection. It was a confrontation that lasted until at least 10:30 a.m.
A certified nursing assistant who witnessed the incident told inspectors that Resident 1 "gets in his/her moods but can be easy to calm down, but not like that Saturday." She said she believed the resident was provoked, with the nurse "adding to his/her being aggressive." At around 10:30 a.m., she stepped in herself, walked between the nurse and the resident, and took him back to his room, after watching the nurse mimic his flapping arms and tell him to go ahead and hit her.
A second nursing assistant was more direct about what should have happened. "R1 wanted to go outside," she told inspectors. "He/she kept yelling and saying this is a prison and he/she has the right to go out." She said the resident gets triggered easily and the right response is to leave him alone for a bit. "If someone is wound up, you got to leave them alone for a bit." She said the whole situation could have ended simply: "All you had to do was take him outside, but it was a busy time for us."
The facility's own care plan, reviewed by inspectors on August 26, listed two relevant areas. One addressed the elopement risk, with interventions including distraction through conversation, food, television, and activities. The line for the resident's personal preferences read: IS BLANK. It had been in the care plan since December 2024 and revised as recently as June 2025, eight weeks before the incident, without anyone filling in what this particular person actually liked or responded to.
The second care area noted a behavior problem related to dementia and included a specific instruction: approach and speak in a calm manner. A nurse yelling back, mimicking arm movements, and daring a resident to strike her is not a calm manner.
The nurse's last day at the facility was August 17, the day after the incident. Her termination was processed on August 28.
The facility reported the incident to Maine's Division of Licensing and Certification on August 18, two days after it occurred. Inspectors arrived eight days later. By then, the facility had already added a new care plan entry noting that the resident has the potential to be physically aggressive and instructing staff to take turns taking him outside one on one. Staff education on challenging behaviors in dementia care had begun on August 19, with a completion deadline of August 29.
Inspectors cited the facility for failing to fully develop and implement a care plan for a resident who was agitated and trying to leave, noting the blank preferences field and the nurse's conduct as the core failures. The level of harm was classified as minimal harm or potential for actual harm.
The resident spent at least two hours that Saturday morning trying to get out a door, telling anyone who would listen that he had the right to go outside, that the place felt like a prison. The nursing assistant who finally ended it did so by walking him back to his room. Whether anyone took him outside after that, the inspection report does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Dexter Health Care in Dexter, ME was cited for violations during a health inspection on August 26, 2025.
The resident, identified only as Resident 1 in the report, has dementia and had been flagged as an elopement risk since December 2024.
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.