Caribou Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Caribou, Maine.
- Location
- 10 Bernadette St, Caribou, Maine 04736
- CMS Provider Number
- 205117
- Inspections on file
- 21
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Caribou Rehab And Nursing Center during CMS and state inspections, most recent first.
Three residents experienced avoidable falls with two sustaining major injuries due to staff failing to provide required assistance during bed mobility, improper use of a mechanical lift in a cramped room, and omission of wheelchair footrests during transport. These incidents occurred despite care plans and facility policies outlining necessary safety measures.
Staff failed to secure medication and treatment carts, leaving them unlocked and unattended in areas accessible to residents, including those with cognitive impairment. On multiple occasions, carts containing medications, syringes, and other medical supplies were left without proper locking mechanisms, and a resident was observed approaching and touching an unlocked medication cart while staff were not present.
A review of the facility's water management program revealed it lacked documented control measures, monitoring protocols, and testing procedures to prevent the growth and spread of legionella and other water-borne pathogens. This deficiency was confirmed during an interview with maintenance staff.
A staff member was seen pulling a resident backwards in a wheelchair, causing the resident's feet to drag on the floor, and on another occasion, a staff member stood while assisting a resident to eat. Both incidents were confirmed by facility staff and did not uphold resident dignity during transportation and meal assistance.
A resident was observed keeping and self-applying a medicated antifungal powder at bedside without evidence that the IDTM had assessed and determined clinical appropriateness for self-administration, despite a physician's order and an LPN's evaluation.
A resident's advance directive for DNR/DNI was not accurately reflected in the EHR, which incorrectly listed the code status as full code, while the paper record indicated DNR/DNI. This discrepancy was confirmed during a review by a surveyor and the ADON.
A resident developed a new stage III pressure ulcer on the posterior left foot, but the care plan was not updated to reflect this change or the necessary skin care interventions. Review with the ADON confirmed the care plan did not address the resident's current wound status or treatment needs.
A resident did not receive insulin according to the prescribed sliding scale, with staff administering incorrect doses and failing to notify the physician when blood sugar levels exceeded the ordered threshold. Documentation did not show that the physician was contacted or that appropriate orders were obtained.
Surveyors identified multiple instances of improper food storage and handling, including open and undated food items in the freezer, exposed raw meat, expired milk, undated juice containers, and moldy raspberries in the refrigerator. These deficiencies were confirmed by dietary and nursing staff during the survey.
A resident who previously received PCV13 and PPV23 was not offered the updated PCV20 vaccine as recommended by the CDC. Review of clinical records and staff interviews confirmed the absence of documentation or evidence that the updated pneumococcal vaccine was offered.
A resident with dementia, identified as an elopement risk and wearing a wander guard, exited the facility through an unlocked and non-alarmed door. The wander guard did not activate, and the resident remained outside for over thirty minutes before being found by staff after a visitor reported the incident. Staff interviews and video footage confirmed the failure of both door security and monitoring procedures.
Surveyors found that the facility failed to maintain clean oxygen concentrator filters for several residents over a three-day period. Despite a weekly cleaning task assigned to the Charge Nurse, the filters remained heavily soiled with dust and debris. Interviews with staff, including a RN and the DON, confirmed the issue, highlighting a lapse in maintaining respiratory equipment cleanliness.
Expired medications were found in the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. Observations revealed expired Prochlorperazine, Premarin, Acetaminophen, Hydrocodone, Bisacodyl, saline nose spray, and Loratadine, which were available for use despite being past their expiration dates. These findings were confirmed by RNs during the survey.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over several days, surveyors observed that only gloves were used as PPE, with no signage or documentation of EBP. Interviews revealed that staff were unaware of EBP protocols, and residents reported inadequate protective measures during catheter care.
A facility failed to transmit a resident's quarterly MDS to the State MDS database within the required timeframe. The MDS, completed in mid-May, was due by the end of May but was not submitted until late June, 26 days late. The MDS Coordinator was unaware of the delay until informed by a surveyor.
The facility failed to provide annual Infection Control training for a CNA, as required by their program standards. The CNA's last documented training was in December 2022, and the required training for 2023 was not completed until June 2024. This deficiency was confirmed through employee file reviews and staff interviews.
A resident requiring a two-person assist transfer was improperly transferred by a CNA with the help of a non-family member visitor, resulting in a fracture. The CNA was aware of the transfer requirements but proceeded due to the resident's insistence and the absence of another staff member.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from accident hazards and provided with adequate supervision and assistance devices to prevent accidents, resulting in three avoidable falls, two of which caused major injuries. In one case, a resident with hemiplegia and a history of cerebral infarction required extensive assistance for bed mobility and personal care. During peri-care, a CNA turned away from the resident to dispose of a soiled brief, leaving the resident unattended. The resident, unable to control movement due to hemiplegia, rolled out of bed and sustained a displaced fracture of the right femoral neck and a laceration to the forehead. In another incident, a resident dependent on a mechanical lift (Hoyer) for transfers due to multiple sclerosis was being transferred by two CNAs. The staff failed to open the legs of the Hoyer lift because of space constraints in the resident's room, which was too small to allow proper maneuvering. As a result, the resident slipped out of the sling and fell to the floor, sustaining an abrasion to the upper back. The care plan for this resident specified total dependence on two staff for Hoyer transfers and highlighted the need for adequate space and proper use of equipment. A third resident suffered a fall with major injury during wheelchair transport when a CNA failed to attach footrests to the wheelchair. The resident, who was unable to lift their legs, fell forward from the wheelchair and sustained a nasal bone fracture. Facility policy and posted signage required the use of footrests during all wheelchair transports to prevent injury, but this protocol was not followed, directly leading to the fall.
Unsecured Medication and Treatment Carts Accessible to Residents
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications and medical equipment on multiple occasions. On one occasion, a CNA-M left an unlocked and unattended medication cart in the dining/activity area of a locked Special Care Unit for residents with advanced cognitive impairment. While the CNA-M was administering medications to a resident seated away from the cart, another resident in a wheelchair approached the cart, placed a hand on the lock and a drawer, and then moved away. The CNA-M admitted to not keeping the cart keys with her and confirmed the cart was left unlocked and unattended, a fact also verified by the ADON. On two separate days, a treatment cart containing syringes, lancets, medicated creams, ointments, and powders was observed left unattended and unlocked in a resident hallway. Multiple residents and staff passed by the cart, and the Charge Nurse confirmed the cart did not have a lock. On another occasion, the same type of cart was secured only with a swivel snap hook, not a locking device, and was accessible to residents. The DON acknowledged that the cart required a lock to secure the drawers, and surveyors confirmed the lack of proper security for the treatment cart and its contents.
Deficient Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive water management program aimed at preventing the growth and spread of legionella and other water-borne pathogens. During a review of the facility's Water Management Program policy and related documentation, it was found that the program did not include evidence of specific control measures to prevent the growth of opportunistic waterborne pathogens, nor did it outline how these measures would be monitored. Additionally, there was no documentation of testing protocols for these control measures, including details on monitoring frequency, acceptable control limits, required interventions if limits were exceeded, or criteria for when water testing for legionella should occur. This deficiency was confirmed during an interview with the facility's maintenance staff.
Failure to Maintain Resident Dignity During Transportation and Meal Services
Penalty
Summary
On one occasion, a staff member was observed pulling a resident backwards in their wheelchair in a hallway, resulting in the resident's feet dragging on the floor. This incident was confirmed by the Assistant Director of Nursing. On a separate occasion during lunch service, a staff member was seen standing while assisting a resident to eat, which was confirmed by Activities staff present at the time. These actions did not maintain the dignity and respect of the residents during transportation and meal services.
Failure to Complete IDTM Assessment for Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team meeting (IDTM) group failed to determine if it was clinically appropriate for a resident to self-administer and keep a medicated antifungal powder (Desenex) at bedside. Observation revealed the powder on the resident's nightstand, and the resident reported self-applying the powder as needed. Although there was a physician's order allowing the resident to self-administer the medication and keep it at bedside, and an LPN had evaluated the resident for safe application, there was no evidence that the IDTM had completed the required assessment to determine clinical appropriateness for self-administration, as required by facility policy.
Inaccurate Documentation of Advance Directive in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive regarding cardiopulmonary resuscitation (code status) was accurately documented in the clinical record. Upon review, the resident's electronic health record (EHR) listed the code status as FULL CODE, while the paper health record, specifically the hospital discharge summary, indicated DNR/DNI (do not resuscitate/do not intubate). During a joint review of the records by a surveyor and the Assistant Director of Nursing (ADON), it was confirmed that the EHR should have reflected DNR/DNI, not full code. The discrepancy between the electronic and paper records resulted in the resident's wishes regarding resuscitation not being clearly and accurately documented in the EHR.
Failure to Update Care Plan for New Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident after the discovery of a new stage III pressure ulcer on the posterior of the left foot. Record review showed that the resident's care plan had last been revised for skin alteration on 6/9/25, but there was no evidence that it was updated to address the new pressure ulcer and the associated skin care needs. During an interview, the Assistant Director of Nursing confirmed that the care plan did not reflect the resident's current wound status or the care required for treatment. This deficiency was identified through clinical record review and staff interview, focusing on the lack of timely care plan updates following a significant change in the resident's condition.
Failure to Follow Physician Orders for Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for the administration of sliding scale insulin for one resident. The resident had a physician order specifying the amount of insulin to be administered based on finger stick blood sugar (FSBS) results, with instructions to call the physician if the FSBS exceeded a certain threshold. On one occasion, the resident's FSBS was recorded as 563, but staff administered 15 units of insulin without contacting the physician as required by the order. On another occasion, the resident's FSBS was 288, but only 3 units of insulin were administered instead of the 6 units specified in the order. These discrepancies were confirmed through record review and interview with the Assistant Director of Nursing. The clinical record did not contain evidence that the physician was notified or that a new order was obtained for insulin administration when the FSBS exceeded the ordered range, and the insulin doses given did not always match the sliding scale instructions.
Improper Food Storage and Handling Practices Observed
Penalty
Summary
Surveyors observed multiple instances of improper food storage, preparation, and service that did not meet professional standards for food safety. On two separate days, the walk-in freezer contained several open and exposed food items, including veggie lasagna, pasta with meat sauce showing freezer burn, pizza with partially peeled plastic wrap, raw Philly chicken slices, and various packages of vegetables and meats that were open and undated. Additionally, in the dayroom refrigerator, there was a half gallon of milk past its expiration date, several open and undated containers of juices, and a pint of raspberries that were shriveled and moldy. These conditions were confirmed by the Dietary Supervisor and a CNA during the survey observations. No information about specific residents or their medical conditions was provided in relation to the deficiency.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the updated pneumococcal vaccination (PCV20) to one resident, despite CDC recommendations indicating that a dose should be considered at least five years after the last pneumococcal vaccine. Record review showed that the resident had previously received PCV13 in 2015 and PPV23 in 2017, but there was no documentation that the updated vaccine was offered. During interviews, the Assistant Director of Nursing confirmed that there was no evidence of the PCV20 being offered, and the Director of Nursing/Infection Preventionist stated that the facility follows CDC recommendations for pneumococcal vaccinations.
Failure to Monitor Exit Doors and Alarm Systems Resulting in Resident Elopement
Penalty
Summary
A resident with a diagnosis of dementia, identified as an elopement risk and equipped with a wander guard alert device, was able to exit the facility unnoticed. The resident left through an unlocked and non-alarmed door, and the wander guard did not activate an alarm or lock the door as intended. The resident was outside for approximately thirty-three minutes before being found by staff, after a visitor alerted them to the resident's presence outside in a wheelchair near the gazebo across the employee parking lot. Facility records and video surveillance confirmed that the resident exited through the D Wing door without staff awareness. Interviews with staff, including an LPN and the DON, corroborated that the alarm system failed to function and that the door was not secured. The resident was assessed after being returned to the facility and was found to have no lasting effects from the incident. The deficiency resulted from the lack of monitoring and failure of safety devices intended to prevent elopement for residents at risk.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice by not ensuring that the oxygen concentrator filters for several residents were clean. Over the course of three days, surveyors observed that the oxygen concentrator filters for multiple residents, including Resident #33, Resident #13, Resident #35, Resident #24, and Resident #48, were heavily soiled with dust and debris. These observations were made repeatedly, indicating a persistent issue with the cleanliness of the respiratory equipment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that cleaning the filters on the oxygen concentrators was supposed to be a weekly task assigned to the Charge Nurse. Despite this, the filters remained dusty, as verified by both the surveyor and the Director of Nursing during their observations. This indicates a failure in the facility's process to maintain the respiratory equipment in a clean and safe condition for the residents.
Expired Medications Found in Medication Storage and Cart
Penalty
Summary
The facility failed to ensure that expired medications were removed from the available supply in both the B Wing Medication Cart and the Medication Storage Rooms for B Wing and C-D Wing. During an observation on June 24, 2024, the surveyor found several expired medications in the C-D Wing Medication Storage Room, including Prochlorperazine suppositories, Premarin vaginal cream, Acetaminophen suppositories, and a blister pack of Hydrocodone and Acetaminophen. These medications were available for use despite their expiration dates having passed, with some dating back to February 2024. Further inspection of the B-Wing Medication Storage Room revealed additional expired medications, such as Bisacodyl suppositories, Deep Sea Premium Saline nose spray, Acetaminophen suppositories, Pain Relief Acetaminophen/Aspirin/Diphenhydramine, and Loratadine. The B-Wing Medication Cart also contained a bottle of Loratadine that had expired in December 2023. These findings were confirmed by Registered Nurses present during the observations, indicating a lapse in the facility's medication management protocols.
Inadequate Infection Control for Foley Catheter Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with urinary Foley catheters. Over the course of three days, surveyors observed that there was no personal protective equipment (PPE) other than gloves, nor was there signage notifying of EBP for residents with urinary Foley catheters. This was noted for multiple residents, including Resident #48 and Resident #10. Additionally, there was no documentation available pertaining to the use of EBP, and the Director of Nursing confirmed that the facility did not have a plan in place for the use of EBP for residents with urinary Foley catheters. Interviews with staff and residents further highlighted the deficiency. Resident #48 reported that staff emptied the urinary Foley catheter bag without wearing a protective gown. A registered nurse admitted to not knowing what EBP were and stated that only gloves were worn during urinary Foley catheter care, with sterile equipment used only during insertion. These observations and interviews indicate a lack of adherence to infection control protocols, specifically regarding the use of EBP for residents with urinary Foley catheters.
Delayed Transmission of MDS to State Database
Penalty
Summary
The facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within the required 14 days of completion for a resident. The quarterly MDS for the resident, with a target date of May 16, 2024, was completed on May 17, 2024. This assessment was supposed to be submitted by May 31, 2024, but was not transmitted until June 26, 2024, resulting in a delay of 26 days. During an interview on June 26, 2024, the MDS Coordinator admitted to just submitting the resident's quarterly MDS and expressed uncertainty about why it was not transmitted earlier. The coordinator was unaware of the transmission failure until questioned by the surveyor.
Deficiency in Annual Infection Control Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included annual training on the Infection Control program standards, policies, and procedures for one of the five Certified Nursing Assistants (CNA) reviewed. Specifically, CNA1's employee file and Inservice record showed that the last documented Combined Inservice, which included training on the Infection Control program standards, was completed on December 6, 2022. During an interview with a surveyor, the Clinical Assistant confirmed the absence of evidence that CNA1 completed the required training in December 2023. The Staff Educator later stated that CNA1 completed the Infection Control training on June 25, 2024, but acknowledged that it should have been completed in 2023, which it was not. The surveyor confirmed these findings during the interviews.
Failure to Provide Appropriate Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident who required a two-person assist transfer received the appropriate assistance. On 4/23/24, a CNA transferred a resident with the help of a non-family member visitor instead of another staff member. The resident, who was identified as needing a two-person assist transfer, later complained of pain in the right knee to right ankle area. An X-ray revealed an acute to subacute non-displaced fracture of the lower tibial shaft, complicated by severe osteoporosis. The CNA admitted to the surveyor that he was aware of the resident's transfer requirements but proceeded with the transfer due to the resident's insistence and the absence of his teammate who was at lunch. Interviews with other staff members, including another CNA and an LPN, confirmed that the resident was indeed a two-person assist transfer. The Physical Therapist also noted that the resident had been evaluated as needing a two-person assist transfer at a previous facility. The incident was reported to the Director of Nursing, and the facility's investigation confirmed the deficiency. The resident was subsequently assessed, and an X-ray was ordered, revealing the fracture. The resident's transfer method was changed to a Hoyer lift following the incident.
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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