Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aroostook Health Center during CMS and state inspections, most recent first.
Failure to Serve Dining Room Residents Promptly: During meal service, several residents were seated in the dining room without meals while other residents at their tables had already been served. Surveyors observed staff serving meals to others first, and staff stated the trays were on another cart or in the kitchen and that they did not know who would be eating in the dining room. In a separate breakfast observation, one resident was still waiting for a tray while tablemates had already received breakfast, and staff were not leaving the dining room to retrieve the meals.
Advance directive information was not properly documented for two residents. Staff completed an acknowledgment form indicating each resident had an advance directive and had provided a copy, but no copy was found in either clinical record and there was no evidence that the residents or their representatives were offered or declined advance directives. The SW and NS relied on resident statements without verifying the records, and the DON stated staff need education on the difference between an advance directive and a POLST.
Failure to maintain a clean, safe, and homelike environment. Surveyors observed exposed wires from unattached call lights, missing covers on a thermostat and light switch, unpainted and unfinished hallway surfaces, dirty resident room floors, warped dining room ceiling fan blades, cracked and soiled floor drain areas, marred and stained resident room walls, chipped over-bed tables, and unframed phone boxes with exposed sheetrock edges. The DON, Administrator, and Corporate Health Operations Consultant confirmed several of the findings during the tour.
Failure to Provide Written Transfer and Bed Hold Notices: The facility did not provide written transfer/bed hold notices to two residents and their representatives after facility-initiated transfers to an acute care facility. Records showed the notices were completed, but documentation only supported verbal notice for one resident and did not show a written copy was given for the other; staff could not confirm written delivery. The BOM also stated the Ombudsman was notified quarterly instead of monthly of transfer/discharges.
A facility failed to follow provider orders for two residents. One resident with a history of gastric ulcers, epigastric pain, and early satiety had an ordered EGD and General Surgery referral that were not documented as sent or completed, despite repeated notes that the consult was still pending. Another resident with a choking-risk order to be OOB for all meals was observed eating in bed and unmonitored during multiple meals, with no evidence of refusal documented.
Missing Annual Performance Evaluations for CNAs: The facility failed to complete annual performance evaluations for 4 of 5 sampled CNAs. Record reviews showed each affected CNA had an earlier evaluation on file, but no evidence of a subsequent evaluation within the required 12-month period. During an interview, the DON confirmed there was no evidence the evaluations were completed within 12 months.
Expired medications were found available for use in the Main med storage room and Main med storage refrigerator, including Hemorrhoidal Hygiene Pads, Milk of Magnesium, and two Humira pens. The facility also had no temperature log documentation for the Main med refrigerator and the Station 1 immunization refrigerator, and the DON confirmed refrigerator temperatures had not been monitored.
Failure to follow EBP, glove, and soiled linen procedures occurred when staff provided personal care to a resident on EBP without a gown, an LPN continued care with soiled gloves after a brief change and touched other items before removing them, and soiled linen was carried down the hallway unbagged. In another instance, two staff assisted a resident with an open MRSA wound while wearing gloves but no gowns, despite the resident’s care plan requiring EBP for high-contact care.
Failure to Monitor Antibiotic Use: The facility did not implement its ASP antibiotic use protocols and monitoring system for 2 of 3 months reviewed. The policy required antibiotic usage and outcome data to be collected on a facility-approved tracking form and all clinical infections treated with antibiotics to be reviewed by the IP or designee. During the DON and surveyor review, September was the last completed surveillance form, and the October and November antibiotic stewardship spreadsheets were not completed for review.
Failure to Maintain a Qualified IP: The DON stated the IP position was open after the previous IP left, and she was the only staff member with proper IP training while working fulltime as DON. The Antibiotic Stewardship spreadsheet had not been updated since the last completed month, and the facility did not have a qualified IP working at least 20 hours per week in the IP role.
A resident with a choking risk, underweight status, and a care plan for nutritional concerns was observed eating breakfast and lunch in bed without supervision. The record showed provider orders for OOB for all meals and meal monitoring, but surveyors found the resident eating independently and unmonitored instead of being OOB as ordered and reflected in the care plan.
A resident’s care plan was not updated to reflect current pressure ulcer needs. The resident had a stage II pressure ulcer, active orders for wound treatment and enhanced barrier precautions, but the record lacked a FOCUS and/or interventions for the pressure ulcer and enhanced barrier precautions even after the DON reviewed the care plan.
A resident's chart lacked copies of pharmacist medication regimen review recommendations, and the facility did not follow up on the recommendations or obtain provider signature. During record review, the DON stated the pharmacist reported that not all reviews were sent for the month, and it was also found that an earlier review was missing from the resident's clinical record.
Duplicate lorazepam orders resulted in a resident receiving an unnecessary medication. The DON stated an older lorazepam order should have been discontinued when a new order was entered, but the MAR showed the resident received additional doses from the duplicate order. The surveyor confirmed the finding with the DON.
Food service safety deficiencies were identified when surveyors found expired or improperly labeled beverages available for use, no thermometers in the refrigerator or freezer for routine monitoring, a heavily soiled ice machine filter, and an ice machine drainage pipe without a 1-inch air gap to prevent backflow. The DON confirmed the missing thermometers and the improperly stored open juice and Clamato in the Skilled Kitchenette, and surveyors also noted the same thermometer issue in the Assisted Dining Room kitchenette.
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.
Failure to Serve Dining Room Residents Promptly
Penalty
Summary
The facility failed to promote care to residents in a manner that maintained each resident’s dignity during meal service for 2 of 3 days of survey. During a dining room observation, two surveyors saw staff serve meals to residents while R2, R4, and R5 remained seated at separate tables with other residents and had not yet received their meals. At 11:46 a.m., all other residents had been served except R2, R4, and R5. The Nurse Manager stated that their trays came on another cart and staff never knew who was going to eat in the dining room. The residents were later observed with their meals at 11:54 a.m. During a separate breakfast observation, R18 was seated at a table without a meal while tablemates had already been served, and R21 was waiting for a breakfast tray. Staff were observed not leaving the dining room to get the meal trays, and staff stated the meals would either be in the kitchen or on another meal cart. These observations were confirmed with staff at the time and again during the exit conference.
Advance Directive Information Not Properly Documented
Penalty
Summary
The facility failed to ensure that written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive, or appoint a surrogate, was provided and documented for 2 of 3 residents reviewed for advance directives. For one resident admitted in March 2024, the clinical record contained no copy of an advance directive from admission through the time of survey. A Social Worker stated that on or about 10/2/25 all residents received an Acknowledgement of Important Information and Policies form, and that the advance directive section was checked indicating the resident did have an advance directive and had provided a copy, but no such document was found in the record. The Nursing Supervisor stated she reviewed the document with the resident and did not follow up with the family or check the record to verify whether an advance directive existed, relying on the resident’s statement that one was in place. For another resident admitted in October 2024, the Social Worker could not find evidence that advance directives were offered or declined by the resident or resident representative. The same Acknowledgement of Important Information and Policies form was reported as completed for this resident with the advance directive section checked to indicate the resident had an advance directive and had provided a copy, yet no copy was found in the clinical record from admission through the survey date. The Social Worker stated he was unsure whether the form was incorrectly documented, and later reported that no additional information had been found showing the resident was offered an advance directive. The DON stated that staff need education on what an advance directive is, noting that some staff think it is the same as a POLST.
Failure to Maintain a Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to adequately maintain maintenance and housekeeping services necessary to keep the environment in good repair and homelike on 3 of 3 survey days. On entrance to the facility, surveyors observed emergency light fixtures and call lights not attached to the walls with visible wires, a thermostat without a cover, wallpaper removed leaving primed and unpainted surfaces in the hallways, a light switch without a cover near station 1, and resident room floors with a buildup of dirt and grime visible from the hallway. During resident interviews, additional concerns were noted with walls that were dirty and marred. Surveyors also observed 3 ceiling fans in the dining room, with 2 of the fans having warped blades. Floor drain covers in the hallway near the conference room and near station 1 were cracked, broken, and surrounded by heavily soiled tiles, creating uncleanable surfaces. On a later tour with the Administrator and Corporate Health Operations Consultant, surveyors observed unpainted and exposed drywall paste in the hallways, marred and stained walls in multiple resident rooms, a missing thermostat cover, chipped and uncleanable over-bed tables, and phone boxes in the hallways that were not framed and had exposed sheetrock edges. The observations were confirmed by the surveyor during the tour.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to issue a written transfer/bed hold notice to residents and their legal representatives for facility-initiated transfers/discharges to an acute care facility for 2 of 4 sampled residents, Resident #1 and Resident #33. The facility policy, Bed Holds and Returns, revised 3/2025, stated that residents and representatives are to receive written information about bed-hold policies at least twice, including well in advance of any transfer and at the time of transfer or within 24 hours if the transfer is an emergency. For Resident #1, the clinical record showed a transfer to the hospital on 11/4/25 and a bed hold notice dated the same day that included the transfer/discharge reason and bed hold information, but the notice only documented that it was given verbally and did not show that a written copy was provided to the resident. During interview, the Business Office Manager confirmed this finding. For Resident #33, the clinical record showed a transfer and hospital admission on 11/23/25, and the bed hold notice dated that day included the transfer/discharge reason and bed hold information, but the record did not show that a written copy was provided to the resident. The Business Office Manager stated that she emailed a copy to the resident representative, while the Nursing Supervisor stated she completed the bed hold/transfer notice but could not say that a copy was given to the resident. During interview, the surveyor confirmed that a written copy of the notice was not provided to both the resident and resident representative. In addition, the Business Office Manager stated that the Ombudsman office was notified quarterly rather than monthly of transfer/discharges, with the last listing sent for transfer/discharges through September.
Failure to Follow Provider Orders for GI Referral and Meal Positioning
Penalty
Summary
The facility failed to ensure physician orders were followed for two residents reviewed for nutrition. For one resident with a history of gastric ulcers, epigastric abdominal pain, excessive burping, decreased appetite, and early satiety, the provider ordered an EGD and a referral to General Surgery after an acute visit for suspected recurrent ulcer disease. The record shows repeated provider notes over the following months stating the resident was still awaiting the General Surgery consultation and that staff would look into the referral, but the clinical record lacked evidence that the referral was sent or that the resident was seen by General Surgery, resulting in a 1-year delay. For another resident, provider orders required the resident to be out of bed for all meals due to choking risk, with a regular texture diet and extra gravies for hydration and nutrition. Surveyors observed the resident eating breakfast and lunch independently and unmonitored while in bed on multiple occasions. Review of the clinical record showed the active order for out-of-bed meals, but there was no evidence that the resident refused to get out of bed for meals. During interview, the Nurse Manager and surveyor confirmed the resident was at risk for choking with meals and had not been out of bed for all meals or monitored with meals as directed by the provider orders and care plan.
Missing Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations at least every 12 months for 4 of 5 sampled CNAs: CNA1, CNA2, CNA3, and CNA4. Employee record reviews showed that CNA1 was hired on 4/14/24 and had a performance evaluation covering 4/14/24 through 9/30/24, but the facility could not provide evidence of another evaluation completed between 10/1/24 and 9/30/25. CNA2 was hired on 6/18/23 and had a performance evaluation for 10/1/23 through 9/30/24, but no evidence of an annual evaluation between 10/1/24 and 9/30/25. CNA3 was hired on 4/14/24 and had a performance evaluation for 4/14/24 through 9/30/24, but no evidence of another evaluation between 10/1/24 and 9/30/25. CNA4 was hired on 8/18/24 and had a performance evaluation for 8/18/24 through 11/15/24, but no evidence of an annual evaluation between 11/16/24 and 11/15/25. In an interview on 12/17/25 at 12:07 p.m., the DON confirmed there was no evidence that performance evaluations were completed within 12 months for these four CNAs.
Expired Medications and Missing Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were removed from available supply in the Main medication storage room and Main medication storage refrigerator. During observation and review with a CNA-M, a surveyor found one container of Hemorrhoidal Hygiene Pads with an expiration date of 9/2025, one bottle of Geri Care Milk of Magnesium with an expiration date of 10/2025, and two Humira 40 mg/0.8 ml pens with expiration dates of 10/17/25 in the main medication storage refrigerator, all available for use. The facility also failed to monitor medication storage refrigerator temperatures for two medication storage refrigerators: the Main medication room-main medication storage refrigerator and the Station 1 medication room-Station 1 immunization storage refrigerator. During observation with the DON, the surveyor found no temperature log sheets, and the DON stated she had been taking temperatures but had not for a while and could not find the log sheets. The DON confirmed there was no evidence of documentation showing that refrigerator temperatures had been monitored.
Failure to Follow EBP, Glove, and Soiled Linen Procedures
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to Enhanced Barrier Precautions (EBP), changing soiled gloves during resident care, and linen handling. The facility policy stated that EBP requires targeted gown and glove use during high-contact resident care activities, including hygiene, linen changes, brief changes, device care, and wound care. The laundry policy stated that contaminated laundry is to be bagged or contained at the point of collection and that leak-resistant containers or bags are used for linens contaminated with blood or body substances. Resident #38 was documented as being on EBP, with a care plan directing staff to use gowns and gloves for all personal care. On 12/16/25, a CNA entered the resident’s room and provided washing care without wearing a gown, and later stated she was not aware the resident was on EBP. During another observation, an LPN changed a resident’s soiled brief and then continued care while wearing the same soiled gloves, including touching the resident’s leg, changing the wound dressing, rearranging the bed sheet, touching the bedside table, and opening the privacy curtain before removing the gloves. The LPN confirmed the gloves were not removed after becoming soiled before touching other items. Also, a CNA was observed carrying soiled linen down the hallway without bagging it, and later confirmed the linen had been carried unbagged. On 12/17/25, two staff assisting Resident #41 to the bathroom were observed wearing gloves but not the gowns required for EBP; the resident had an open MRSA wound that was not covered with a dressing, and the care plan directed staff to use EBP for high-contact care activities.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, including antibiotic use protocols and a system to monitor antibiotic use, for 2 of 3 months reviewed, October and November. The facility policy, Antibiotic Stewardship - Review and Surveillance of Antibiotic use and Outcomes, revised 3/2025, stated that antibiotic usage and outcome data would be collected and documented on a facility-approved antibiotic surveillance tracking form and used to guide improvement in individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The policy also required all clinical infections treated with antibiotics to be reviewed by the Infection Preventionist or designee, and all resident antibiotic regimens to be documented on the facility-approved tracking form with information including resident name and medical number, unit and room number, symptom onset date, antibiotic name and start date, pathogen identified, infection site, culture date, stop date, total days of therapy, outcome, and adverse events. During the antibiotic stewardship review, the DON and surveyor reviewed September's antibiotic surveillance tracking form, which was the last month completed, and confirmed that October and November's antibiotic stewardship surveillance spreadsheets were not completed for review.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to function as the Infection Preventionist responsible for the Infection Control Program, and the role was not being completed after the previous IP left on 10/8/25. During an interview on 12/15/25, the DON stated that the IP position was open. On 12/17/25, the DON stated that she worked fulltime as DON, that she was the only staff member in the facility who had completed the proper IP training, and that the previous IP had left on 10/8/25. Record review on 12/17/25 showed the Antibiotic Stewardship spreadsheet had not been updated since September, the last completed month documented. On 12/18/25, the Administrator stated that part-time hours were considered 20 hours per week, and the surveyor confirmed that the facility did not have a qualified IP working a minimum of 20 hours per week in the IP role, even though the position was open.
Failure to Follow Meal Supervision and OOB Orders
Penalty
Summary
The facility failed to implement a Comprehensive Care Plan that addressed the physical needs of 1 of 3 residents reviewed for nutrition, Resident #39. Record review showed active provider orders dated 11/09/25 for Out of Bed for all meals due to choking risk, and a diet order dated 11/13/25 for regular texture with Out of Bed for all meals and extra gravies for hydration and nutrition. The resident was also listed on the facility’s Feeding Assistance list. Surveyor observations on 12/15/25 at 9:28 a.m., 12/16/25 at 8:37 a.m., and 12/16/25 at 12:07 p.m. showed Resident #39 in bed eating breakfast and lunch independently and unmonitored. The care plan identified a nutritional problem related to cognition and underweight status with a BMI of 17.3, and included interventions to monitor for signs and symptoms of dysphagia, encourage meals in the dining room for socialization and supervision, and provide the ordered diet. During interview on 12/16/25 at 12:21 p.m., the Nurse Manager and surveyor reviewed the record and confirmed the resident was at risk for choking with meals and had not been Out of Bed for all meals or monitored with meals as directed by the provider orders and care plan.
Care Plan Not Updated for Current Pressure Ulcer Needs
Penalty
Summary
The facility failed to ensure that R1’s care plan was updated to reflect current needs related to a pressure ulcer. During an interview, R1 stated that staff were treating a sore on the tail end. The clinical record showed a quarterly MDS coded to indicate one stage II pressure ulcer. On record review, the surveyor could not find a FOCUS for a current pressure ulcer or enhanced barrier precautions, even though active physician orders were in place for treatment of a pressure injury and enhanced barrier precautions. When the DON reviewed the care plan, the pressure ulcer care area had been updated from healed to currently having a stage II pressure ulcer, but the care plan still did not include a FOCUS and/or interventions for enhanced barrier precautions.
Missing Pharmacist Medication Review Documentation and Follow-Up
Penalty
Summary
The facility failed to follow up on pharmacist medication regimen recommendations and failed to keep all copies of Medication Reviews in the resident's clinical record for 1 of 5 residents reviewed for unnecessary medications, Resident #5. During record review on 12/17/25, there was no evidence that the facility followed up on the pharmacist's medication regimen recommendations. The resident's clinical record contained a note from the pharmacist stating that a review was completed and to see recommendations, but the record lacked copies of those recommendations. During an interview and review of the record with the DON, she stated the pharmacist told her the facility failed to send all reviews for November. It was also discovered that the October review was not in the resident's clinical record, and the recommendation was not reviewed and was not signed by the provider. The surveyor confirmed the finding during the interview.
Duplicate Lorazepam Orders Led to Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident was free from an unnecessary medication when Resident #7 had duplicate active orders for lorazepam. On 12/17/25, the surveyor reviewed the resident’s clinical record and found active provider orders for lorazepam 0.5 mg by mouth one time a day for anxiety dated 6/25/25, lorazepam 0.25 mg by mouth two times a day for anxiety dated 6/25/25, and another lorazepam 0.5 mg by mouth one time a day for anxiety dated 12/4/25. During an interview, the DON stated the lorazepam order for 0.5 mg once daily dated 6/25/25 should have been discontinued when the new order was placed on 12/4/25. Review of the MAR showed the resident received an additional dose of lorazepam related to the duplicate order on 12/7/25 and 12/14/25.
Food Storage and Kitchenette Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by leaving expired or improperly labeled food products available for use, not having thermometers in refrigerators or freezers for routine monitoring, and not ensuring proper plumbing installation to prevent backflow. During an observation of the Assisted Dining Room kitchenette, surveyors and the MDS nurse were unable to locate a thermometer in the refrigerator or freezer, and the ice machine filter was heavily soiled with dust and debris. During an observation of the Skilled Kitchenette, the DON confirmed that the refrigerator did not have a thermometer for routine monitoring, an open 60-ounce bottle of Ocean Spray Orange Juice had an open date of 11/19/25 and was 13 days past the label instruction to use within 2 weeks of opening, an open 64-ounce bottle of Clamato was labeled with an open date of 9/29/25 but had no expiration date, and the surveyor and DON were unable to find a thermometer in the refrigerator or freezer. The ice machine drainage pipe also did not have a 1-inch air gap to prevent backflow.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mars Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maine Veterans Home - Caribou | 23.8 mi | ★★★★★ | 5 | 0 |
| Caribou Rehab And Nursing Center | 25.3 mi | ★★★★★ | 1 | 0 |
| Madigan Estates | 27.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.