Aroostook Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mars Hill, Maine.
- Location
- 15 Highland Ave, Mars Hill, Maine 04758
- CMS Provider Number
- 205018
- Inspections on file
- 18
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Aroostook Health Center during CMS and state inspections, most recent first.
The facility failed to implement a comprehensive Water Management Plan to prevent Legionella growth, lacking necessary control measures and documentation. Additionally, two residents with Foley catheters had their urinary drainage bags resting on the floor, contrary to the facility's infection control policy, as confirmed by staff.
The facility failed to maintain sanitary conditions in the kitchen, with wet stacked dishware and insufficient sanitizer concentration in the three-bay sink. Additionally, expired chocolate pudding was used in medication administration, with an LPN unaware of its expiration status. The Food Service Supervisor confirmed the pudding was used three days beyond its expiration date.
The facility failed to notify physicians when residents were eligible for the PCV20 vaccine and did not offer Pneumococcal vaccinations upon admission or annually as per CDC guidelines. A resident's last vaccine was in 2015, another in 2016, and a third in 2014, with no evidence of physician notification or timely consent for vaccination.
A deficiency was noted when a CNA failed to communicate respectfully with residents during a Bingo game. The CNA argued with a resident, ignored their attempts to communicate, and spoke sharply to another resident. This behavior was confirmed by the DON, indicating a failure to uphold resident dignity and respect.
A facility failed to update a PASRR for a resident with a current diagnosis of PTSD. The PASRR Level I Screen did not include the PTSD diagnosis and was not forwarded to the State-designated authority for a Level II assessment. This was confirmed during an interview with the DON.
A resident's care plan was not updated to reflect current needs for fall prevention. Despite the care plan indicating the use of padded hip protectors due to osteoporosis, staff confirmed the resident does not wear them. This discrepancy was identified during a review of the care plan.
A facility failed to assess and address a resident's PTSD, resulting in a deficiency in trauma-informed care. The resident's clinical record lacked details on PTSD causes, triggers, and preventive measures. The Clinical Supervisor confirmed the absence of a specific care plan and Trauma Assessment for the resident.
A facility failed to label opened insulin and inhalers with an open date in a medication cart on the South wing. A surveyor and an LPN observed an opened Basaglar Kwik Pen (Lantus, insulin) and a Spiriva Respimat inhaler without open or discard dates. Interviews with the LPN and Clinical Supervisor confirmed the lack of labeling, acknowledging that the medications should have been labeled according to manufacturer's directions.
The facility failed to maintain accurate advanced directives for two residents, leading to discrepancies in their code status. One resident's record showed conflicting DNAR and Full Code instructions, while another's physician order for Full Code contradicted their advanced directive to not be kept alive. These inconsistencies were confirmed by staff and surveyors.
The facility failed to provide adequate oral care for three residents, as observed during a complaint investigation. One resident with dentures reported infrequent cleaning due to staff discomfort, while another with natural teeth had not received oral care that day, resulting in bad breath. A third resident's dentures were unclean before a meal. Care plans indicated the need for assistance, but oral care was not completed as planned.
Deficiencies in Water Management and Infection Control
Penalty
Summary
The facility failed to fully develop and implement a Water Management Plan to prevent the growth and spread of Legionella and other water-borne pathogens. The plan lacked a Control Measures section that identified monitoring procedures, control limits, and corrective actions. There was no written documentation of areas checked to ensure control measures were within normal limits or evidence that the program was reviewed to verify and validate its effectiveness. The last water test for Legionella was conducted in June 2023, and the facility discovered that the contract for testing had been canceled, with a new contract only established on October 17, 2024. Additionally, the facility's maintenance staff performed daily temperature checks and water flushing, but these actions were not documented. The facility also failed to maintain an Infection Control Program to prevent catheter-associated urinary tract infections (CAUTI) for two residents with Foley catheters. The facility's policy stated that urine collection containers should not rest on the floor or a grossly contaminated surface. However, observations revealed that the urinary catheter drainage bags of two residents were resting on the floor, which was confirmed by the Director of Nursing, the Administrator, and a charge nurse. These observations indicated a failure to adhere to the facility's policy and maintain proper infection control practices.
Sanitation and Expired Food Deficiencies in Kitchen and Medication Administration
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. On one occasion, mixing bowls and a colander were found wet stacked, which is not in accordance with sanitary storage practices. Additionally, the facility did not correctly follow the three-step process for manually washing, rinsing, and sanitizing dishware. The sanitizing solution in the three-bay sink was found to be at an insufficient concentration on two separate days, with test strips indicating a level of 170 PPM instead of the required 272 PPM. The test strips used were also expired, which may have contributed to inaccurate readings. The automatic dispenser system managed by Eco Lab was found to have a malfunctioning pump and a cracked aspirator, leading to incorrect sanitizer levels. Furthermore, the facility did not ensure that food was removed from use by its expiration date. A surveyor observed an open container of chocolate pudding on a medication cart, which was used to administer medications to residents, including one identified as R41. The pudding was given to residents three days beyond its expiration date. The LPN responsible was unaware of the pudding's expiration status, and the Food Service Supervisor later confirmed that pudding used for medications is only good for five days from the date made.
Failure to Notify Physicians and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to notify the physician when residents were eligible to receive the PCV20 vaccine and did not ensure that residents were offered Pneumococcal vaccinations upon admission, annually, or in accordance with CDC recommendations. This deficiency was identified for three out of five residents reviewed for immunizations. The facility's policy, last revised on May 2, 2023, required that long-term care patients be screened for influenza and Pneumococcal immunization upon admission and annually thereafter. However, the facility did not adhere to this policy. For Resident #19, the clinical record indicated that the last Pneumococcal vaccine was received in 2015, and the PneumoRecs VaxAdvisor website recommended a dose of PCV20 or PCV21 at least five years after the last dose. Similarly, Resident #33's record showed the last vaccine was in 2016, with the same recommendation. Resident #14's record indicated a dose of PPSV23 was given in 2014, and the VaxAdvisor recommended a dose of PCV15, PCV20, or PCV21 at least one year later. The Director of Nursing confirmed that there was no evidence the provider was notified about the eligibility of Residents #19 and #33 for the vaccine, and for Resident #14, the consent for the vaccine was only sent to the family recently, not at the time of admission.
Deficiency in Resident Communication and Dignity
Penalty
Summary
A deficiency was identified in the facility's handling of resident interactions, specifically concerning the manner in which a Certified Nursing Assistant (CNA) communicated with residents during a Bingo game. On October 15, 2024, at 2:00 p.m., a surveyor observed CNA1 engaging in an argument with a resident, subsequently ignoring the resident's attempts to communicate while continuing to call Bingo numbers. Additionally, when another resident asked a question, CNA1 responded with irritation and a sharp tone, instructing the resident to have patience. These actions were confirmed in an interview with the Director of Nursing, who acknowledged that the residents were not spoken to in a dignified manner, highlighting a failure to maintain and promote resident dignity and respect.
Failure to Update PASRR for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) was updated for a resident with a current diagnosis of Post Traumatic Stress Disorder (PTSD). During a review of the resident's clinical record, it was found that the PASRR Level I Screen, dated April 25, 2024, did not include the resident's current diagnosis of PTSD. The PASRR Level I Screen had a letter attached indicating no reason for a Level II assessment, but it lacked evidence of being updated and resubmitted to include the PTSD diagnosis. Consequently, the PASRR was not forwarded to the State-designated authority to determine if a Level II assessment was necessary. On October 16, 2024, during an interview with the Director of Nursing, it was confirmed that the resident's diagnosis of PTSD was not included on the PASRR for a Level II determination.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update the care plan of a resident, identified as Resident #19, to reflect their current needs regarding fall prevention. The resident's care plan, last revised on October 9, 2024, included interventions for osteoporosis, such as wearing padded hip protectors to prevent hip fractures. However, during interviews conducted on October 16, 2024, both a Certified Nursing Assistant and a Clinical Supervisor confirmed that the resident does not wear hip protectors. This discrepancy was noted during a review of the resident's care plan, indicating that it was not updated to reflect the resident's current needs for fall prevention.
Deficiency in Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess and address a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD), leading to a deficiency in providing trauma-informed care. The resident, identified as R16, was admitted with an active diagnosis of PTSD, as noted in the Minimum Data Set (MDS) 3.0. However, the clinical record lacked information on the causes of R16's PTSD, potential triggers for re-traumatization, and measures to avoid such triggers. During an interview, the Clinical Supervisor acknowledged the absence of a care plan specifically addressing PTSD, confirming that no Trauma Assessment had been completed for R16. Additionally, a review of the Clinical Admission form revealed that it did not specify the causes of PTSD, potential triggers, or preventive measures, further highlighting the deficiency in trauma-informed care for the resident.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to ensure that opened insulin and inhalers were labeled with an open date in one of the medication/treatment carts located in the South wing. During an observation, a surveyor and an LPN found an opened Basaglar Kwik Pen (Lantus, insulin) for Resident #6 that lacked an open or discard date. Lantus is effective for 28 days once opened and kept at room temperature. Additionally, an opened Spiriva Respimat inhaler for Resident #32 was also found without an open or discard date. The Spiriva Respimat inhaler is good for 3 months after first use or when the locking mechanism is engaged, whichever comes first. In interviews conducted shortly after the observations, both the LPN and the Clinical Supervisor confirmed that the medications were not labeled with an open or discard date. The Clinical Supervisor acknowledged that the Basaglar Kwik Pen Lantus and the Spiriva Respimat inhaler should have been labeled with an open date and discard date to ensure they were used according to the manufacturer's directions.
Inaccurate Advanced Directives in Resident Records
Penalty
Summary
The facility failed to ensure the accuracy of residents' advanced directives regarding code status in their electronic medical records. For one resident, the medical chart indicated a Do Not Attempt Resuscitation (DNAR) status, yet the electronic record contained conflicting instructions, stating both DNAR and Full Code, which means providing CPR. This discrepancy was confirmed by a surveyor during an interview with the Registered Nurse and the Clinical Supervisor, who acknowledged the unclear code status and the need for clarification with the provider. Another resident's electronic record showed a physician order for Full Code status, which contradicted the resident's advanced directive signed prior to admission, indicating a wish not to be kept alive with treatment. This inconsistency was confirmed during an interview with the Clinical Supervisor and a surveyor, who noted the mismatch between the signed physician orders and the resident's advanced directives.
Failure to Provide Adequate Oral Care
Penalty
Summary
The facility failed to provide adequate oral care for three out of six residents observed during a complaint investigation. On the day of the investigation, a surveyor noted that the facility was not offering or providing daily oral care to residents. One resident with dentures reported that staff rarely cleaned their dentures, citing that some staff members were uncomfortable handling false teeth. This resident expressed difficulty in cleaning their dentures independently due to physical limitations and a desire for daily cleaning to prevent food from getting stuck and causing an unpleasant taste. Another resident with natural teeth was observed to have not received oral care that day, as evidenced by bad breath and the resident's inability to recall the last time staff assisted with brushing. This resident's care plan included oral care under dental and nutritional problems, indicating a need for assistance. A third resident with dentures was also observed to have unclean dentures before a meal, with visible substances on and between the teeth. This resident's care plan required staff to provide mouth care as part of personal hygiene, with the resident needing limited to extensive assistance. The surveyor confirmed with the Director of Nursing and the Administrator that oral care was not completed as care planned for these residents.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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