Cedars Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Maine.
- Location
- 630 Ocean Avenue, Portland, Maine 04112
- CMS Provider Number
- 205003
- Inspections on file
- 16
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Cedars Nursing Care Center during CMS and state inspections, most recent first.
Surveyors found that housekeeping and maintenance services were inadequate, resulting in dust-coated fans, exposed sheetrock, gouged walls, broken fixtures, and torn carpets throughout all wings and common areas. These conditions were observed and confirmed by facility leadership, indicating a failure to provide a clean, safe, and comfortable environment for residents.
The facility did not complete required annual performance evaluations for five CNAs, with no evidence of evaluations for the year 2024 for staff hired in various years. This was confirmed by the DON during the survey.
Surveyors found that staff across three units were unable to consistently identify or implement correct Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). PPE was present on resident doors without clear signage, and staff interviews revealed confusion about when and how to use PPE, as well as misunderstanding of color-coded indicators. The facility's EBP improvement plan had not been updated or used to assess staff competency since its initiation, and the Infection Preventionist confirmed ongoing issues with staff understanding of these protocols.
A review of CNA education records revealed that several CNAs did not complete mandatory annual Resident Rights training, and two did not meet the required 12 hours of annual in-service education. These deficiencies were confirmed by the DON.
A resident with limited mobility and an ADL self-care deficit was not assisted by staff with shaving, despite a care plan indicating the need for help with personal hygiene. The resident had not been offered assistance and expressed discomfort with the lack of grooming.
A resident admitted with a closed fracture and requiring daily anticoagulant injections did not have a baseline care plan developed and implemented within 48 hours of admission. The medical record lacked necessary instructions for proper care, and this deficiency was confirmed with the DON.
A resident was not invited to or involved in their interdisciplinary team (IDT) care plan meetings, despite documentation of multiple meetings. The resident stated they were unaware of care plan meetings, and the medical record lacked evidence of their participation.
Surveyors identified multiple sanitation issues, including sticky substances on the walk-in fridge and freezer floors, stained and dust-laden ceiling tiles above clean dish areas, and heavy dust and grease on kitchen surfaces. In a kitchenette, a black powdery substance was found on a freezer shelf and an open, unlabeled, undated fruit container was present in the refrigerator. The Food Service Manager confirmed that ceiling cleaning was infrequent and acknowledged the presence of removable dust and debris.
The facility failed to maintain adequate housekeeping and maintenance services, resulting in stained ceiling tiles, cobwebs, debris on the floor, and an IV pole with stains and debris. These deficiencies were confirmed with the Maintenance Supervisor during a facility tour.
The facility failed to update care plans for two residents with changing medical needs. One resident's care plan did not reflect current treatment for edema, and another resident's care plan did not align with current recommendations for limited range of motion due to pain and ill-fitting splints.
The facility failed to follow physician orders for wound care for two residents and did not obtain a required urine sample or conduct neurological checks for a resident after a fall. One resident did not receive updated wound care after their ulcer healed, and another did not have moisturizer applied as ordered. Additionally, post-fall protocols were not followed for a resident exhibiting increased confusion and urinary frequency.
The facility failed to properly date and dispose of open medications and ensure expired medications were removed from use. Observations revealed expired and improperly stored medications, including an unlabeled Tuberculin Purified Protein vial and medications left unsafely on a resident's nightstand without proper assessment.
The facility failed to maintain kitchen sanitation and proper food handling. Observations included an unlabeled pan of green beans, a Dietitian with uncontained hair, a food server improperly wearing a hair net, and dust on the kitchen ceiling. These issues were confirmed with the DON.
A facility failed to implement a nutrition care plan for a resident receiving tube feedings. An RN administered medication and a feeding bolus via gastrostomy tube without confirming tube placement or checking gastric residual volume, stating there were no orders to do so. This was discussed with the President of Nursing.
A facility failed to confirm G-tube placement and check gastric residual volume before administering a feeding bolus and medication to a resident. The nurse stated there were no orders to perform these checks, and the resident confirmed that these procedures were not followed.
The facility failed to maintain a sanitary environment for respiratory care equipment for two residents. A nebulizer pipe was improperly stored with other items, and an oxygen concentrator's nasal cannula was not stored in a plastic bag. The facility lacked a policy for proper storage of these items.
The facility failed to conduct an annual review of its IPCP. Various policies within the program lacked dates indicating a review and/or revision was completed. The DON confirmed that while the facility reviews its policies and procedures, the policies were unsigned and there was no evidence to show that the policies related to the IPCP were reviewed and revised annually.
The facility failed to ensure that a resident was reviewed and offered a pneumococcal vaccination in accordance with CDC recommendations. The resident's immunization record lacked evidence of review or offer of the vaccine, which was confirmed by the DON.
Failure to Maintain Sanitary and Orderly Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all three wings and common areas over a three-day period. Specifically, multiple fans in the hallways were found coated with thick layers of dust, and this was acknowledged by the Director of Nursing. During an environmental tour, several resident rooms were found with uncleanable surfaces due to exposed joint compound and sheetrock, gouged walls, chipped paint exposing metal flashing, and a broken lamp. Some rooms had makeshift repairs, such as a plastic wall protector attached with medical tape and a gouged laminate plank creating a hole in the floor. Additionally, stained and torn carpets were observed in the common area hallways near the elevators. These conditions were directly observed by surveyors and discussed with facility leadership, including the Chief Operating Officer and the Director of Nursing. The findings indicate that housekeeping and maintenance services were not adequately provided, resulting in unsanitary and disordered conditions throughout the facility. No specific residents' medical histories or conditions were mentioned in relation to the observed deficiencies.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five sampled Certified Nursing Assistants (CNAs), as required. Specifically, there was no evidence of completed annual performance evaluations for the year 2024 for CNAs hired in April 2023, June 2005, March 2017, November 2003, and October 2020. This deficiency was identified through performance evaluation reviews and interviews, and was confirmed with the Director of Nursing on 6/24/25 at 2:07 p.m. No information regarding the medical history or condition of any residents was provided in relation to this deficiency.
Staff Lacked Competency in Infection Control Precautions
Penalty
Summary
The facility failed to ensure staff competency in Infection Control, specifically regarding Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP), across three units. Surveyors observed that PPE was present on resident doors without appropriate signage indicating when or what PPE should be used. Multiple staff members, including RNs, CNAs, and Environmental Services workers, were unable to correctly identify the type of precautions in place or the correct use of PPE. Some staff relied on verbal reports or care plans for information, but there was confusion and inconsistency in understanding the difference between TBP and EBP. In several instances, staff either did not know the reason for PPE placement or misunderstood the requirements for donning PPE, with some believing PPE was only necessary for certain activities or misinterpreting color-coded indicators. Record review revealed that the facility's Enhanced Barrier Precautions Performance Improvement Plan had not been reviewed or revised since its last update, and there was no evidence of ongoing staff competency assessments or knowledge checks since the plan's initiation. The Infection Preventionist acknowledged ongoing issues with staff understanding of TBP and EBP, despite the implementation of the improvement plan. These findings demonstrate a lack of effective implementation and staff education regarding infection control protocols, as evidenced by direct observations and staff interviews.
Failure to Provide Required CNA Training on Resident Rights and Annual In-Service Education
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received mandatory annual training on Resident Rights, as evidenced by a review of employee education records for five CNAs. None of the five CNAs reviewed had documentation of completing the required Resident Rights training for the current year. Additionally, two of these CNAs did not have evidence of completing the required 12 hours of annual in-service education for the year. These findings were confirmed through record review and interview with the Director of Nursing.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
Staff failed to maintain a resident's dignity by not assisting with personal grooming, specifically shaving, despite the resident's care plan indicating a need for assistance with personal hygiene due to limited mobility. On one of the survey days, the resident was observed with long facial hair on the chin and upper lip and reported not having shaved since admission because he did not have a shaver. The resident stated that staff had not offered or asked if he would like assistance with shaving, and expressed that the facial hair bothered him. The care plan in place required staff to assist with personal hygiene, but this intervention was not implemented prior to surveyor intervention.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was newly admitted with a closed fracture of the upper and lower end of the left fibula and required daily Enoxaparin injections. Record review showed that as of June 25, 2025, the resident's medical record did not contain evidence of a baseline care plan that included the necessary instructions to provide minimum healthcare information for proper care in this area. This deficiency was confirmed during an interview with the Director of Nursing on the same day. The lack of a baseline care plan meant that essential instructions for the resident's care, particularly regarding the administration of anticoagulant therapy, were not documented or available to staff within the required timeframe after admission.
Failure to Involve Resident in Interdisciplinary Care Plan Review
Penalty
Summary
The facility failed to ensure that the care plan was reviewed and revised by an interdisciplinary team (IDT) with the participation of the resident, as required. One resident reported never having heard of care plan meetings, and a review of the medical record showed that while IDT meetings were held on several occasions, there was no evidence that the resident was invited to or participated in these meetings. The deficiency was confirmed through interviews and record review, and the lack of resident involvement in care planning was discussed with the Director of Nursing.
Sanitation Deficiencies in Kitchen and Kitchenette Areas
Penalty
Summary
Surveyors observed and confirmed multiple sanitation deficiencies in the facility's kitchen and kitchenette areas. In the main kitchen, the floor of the walk-in refrigerator and freezer was found to have a sticky substance, and several ceiling tiles were stained with a heavy concentration of dust buildup above the clean dish area, exit, and dish machine. A flat surface near the kitchen entrance was covered in a thick layer of dust and grease. In a kitchenette, a black powdery substance was found on the top shelf of the freezer door, and an open, unlabeled, and undated container of fruit was present in the refrigerator. The Food Service Manager acknowledged that ceiling cleaning was scheduled only annually and agreed that this frequency was insufficient, as demonstrated when dust and debris were easily wiped off the ceiling during the surveyor's inspection. No specific residents were directly involved or affected as described in the report, and no medical history or resident condition was mentioned in relation to the deficiency.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain adequate housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment for residents in three residential units. During a facility tour with the Maintenance Supervisor, several deficiencies were observed, including stained ceiling tiles in various locations, cobwebs attached to light fixtures, debris stuck to the floor, and an IV pole with stains and debris. Additionally, a unit exit door had a buildup of sticky material from glue residue. These findings were confirmed with the Maintenance Supervisor during the tour.
Failure to Update Care Plans for Residents with Changing Medical Needs
Penalty
Summary
The facility failed to revise the care plan to reflect the current status of two residents. For Resident #21, the care plan initiated on 2/22/21 for edema did not reflect the current treatment of compression wraps with kerlix and coban, as observed on 4/1/24. The resident's medical record indicated a new wound identified on 2/21/24 and a provider order for wound care, but the care plan was not updated to include these changes. The Registered Nurse confirmed that the resident was no longer using ted hose, which was still listed in the care plan, indicating a lack of updates to reflect the resident's current needs and treatment for edema. For Resident #8, the care plan last revised on 3/9/24 did not reflect the resident's current condition regarding limited range of motion. The resident reported that splints for the arm and leg no longer fit due to weight loss, and staff interviews confirmed that the resident was not wearing the splints or receiving passive range of motion (PROM) as prescribed. The Rehabilitation Manager and Director of Nursing confirmed that the care plan was outdated and did not reflect the current recommendations to avoid using the splints and performing PROM due to the resident's pain and risk of pressure ulcers. The care plan failed to be revised to align with the resident's current needs and therapy recommendations.
Failure to Follow Physician Orders for Wound Care and Post-Fall Protocol
Penalty
Summary
The facility failed to ensure proper wound care and adherence to physician orders for two residents with skin conditions and one resident with a fall incident. For Resident #21, the wound nurse did not update the treatment orders after the venous ulcer on the right foot healed, leading to the continued use of outdated wound care procedures. The wound nurse confirmed that the wound was documented as healed on 2/29/24, but the orders were not updated to reflect the current treatment needs. Additionally, Resident #30 had extremely dry, scaly skin on their arms, and despite having a physician order to apply moisturizer twice daily, the staff failed to follow this order. The Treatment Administration Record inaccurately documented that the moisturizer was applied, and the RN responsible was unaware of the existing order, leading to the resident not receiving the necessary skin care treatment. For Resident #3, the facility did not follow the physician's order to obtain a urine sample and conduct neurological checks after the resident experienced a fall and exhibited increased confusion and urinary frequency. The medical record contained an order dated 3/30/24 to obtain a urine sample to rule out a urinary tract infection and to perform neurological checks. However, during an interview on 4/3/24, the President of Nursing confirmed that the urine sample was not obtained, and the neurological checks were not completed, indicating a failure to follow through with the prescribed post-incident actions.
Improper Medication Storage and Expired Medications
Penalty
Summary
The facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and ensure expired medications were removed from the supply available for use. During an observation of medication storage on the [NAME] Neighborhood, a Certified Medication Technician was found to have an opened bottle of multivitamins with minerals that had expired in 3/24, and the medication room refrigerator contained an influenza vaccine with a temperature log showing recordings only once daily and 11 days without monitoring. Additionally, on the [NAME] Neighborhood, an opened bottle of Tuberculin Purified Protein was found unlabeled without an opened date, contrary to manufacturer instructions that it should be discarded after 30 days. These findings were discussed with the President of Nursing on 4/2/24 at 10:02 a.m. Furthermore, a surveyor observed medications left unsafely on top of a resident's nightstand, including a Spiriva inhaler, two Combivent inhalers, and a Flonase inhaler. The resident confirmed that the nurses left the medications there. An interview with the unit manager revealed that the resident had not been assessed to safely keep medications at the bedside, nor were those medications being stored safely. This indicates a failure to ensure proper medication storage and safety protocols were followed in the facility.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner. During an initial tour of the kitchen, a surveyor observed a pan of green beans in the refrigerator that was unlabeled and undated. Additionally, the Dietitian was seen walking through the kitchen with her hair uncontained and uncovered. The Food Service Director was present and aware of these findings. On a subsequent observation, a food server with long hair was seen wearing a hair net improperly, as her hair was not fully contained. The staff member stated she worked in Medical Records and was trained to serve meals. Later, a return observation to the kitchen revealed a light amount of dust on and hanging from approximately one-quarter of the kitchen ceiling. These findings were confirmed with the Director of Nursing.
Failure to Implement Nutrition Care Plan for Tube Feeding
Penalty
Summary
The facility failed to implement a care plan in the area of nutrition for a resident receiving tube feedings. The resident's nutrition care plan, revised on 3/2/24, instructed nursing staff to verify the tube placement before administering any medications, tube feedings, or flushing the tube. On 4/1/24 at 12:01 p.m., a Registered Nurse (RN) was observed administering medication and a feeding bolus via gastrostomy tube (GT) without confirming the placement of the G-Tube or checking the gastric residual volume (GRV). During an interview, the RN stated that she did not check the placement or residual because there were no orders to do so. This issue was later discussed with the President of Nursing at 4:11 p.m. on the same day.
Failure to Confirm G-Tube Placement and Check Residuals
Penalty
Summary
The facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for one resident reviewed for tube feeding. During an observation, a registered nurse administered a feeding bolus and medication via a gastrostomy tube without confirming the placement of the G-tube or checking the gastric residual volume (GRV) prior to administration. The nurse stated that there were no orders to perform these checks. The resident confirmed that nursing staff did not ensure the G-tube was in the correct place or check residuals before administering feedings or medications. This deficiency was discussed with the President of Nursing.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection related to respiratory care for two residents. For Resident #21, a nebulizer pipe with tubing was observed stored in a basin along with an exercise band and socks. The resident mentioned that the nebulizer had not been used for a long time. The Registered Nurse (RN#1) later discarded the nebulizer pipe. The President of Nursing confirmed that the last nebulizer order for Resident #21 was in March 2020 and stated that nebulizers should be rinsed, dried, and stored in a bag when not in use. For Resident #170, an oxygen concentrator with a nasal cannula tubing was observed unlabeled and hanging off the knob of the concentrator. The resident stated that oxygen was only used at night. The next day, the nasal cannula was dated but still improperly stored. RN#1 could not explain the discrepancy and mentioned that oxygen tubing is often wrapped up and not stored in bags. The President of Nursing confirmed that nasal cannulas should be stored in plastic bags when not in use. The facility was unable to provide a policy and procedure for the storage of oxygen tubing and nebulizer supplies when used intermittently.
Failure to Conduct Annual Review of IPCP
Penalty
Summary
The facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). During a review of the facility's IPCP policy and procedures, a surveyor noted that various policies within the program lacked dates indicating a review and/or revision was completed. The undated policies included Infection Control, Pneumococcal Immunization for Resident with Prevnar 13 and Prevnar 23, Infection Control: Influenza Vaccination for Residents, Administration of Covid-19 Vaccine, Coronavirus Pandemic Strategies to Mitigate Healthcare Personnel Staffing Shortages, Influenza Protocol, and Transmission Based Precautions. The Director of Nursing confirmed that while the facility reviews its policies and procedures, the policies were unsigned and there was no evidence to show that the policies related to the IPCP were reviewed and revised on an annual basis.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was reviewed and offered a pneumococcal vaccination in accordance with CDC recommendations. During a review of the resident's immunization record, the surveyor found no evidence that the resident, who is over the age of [AGE], was reviewed, offered, or received a pneumococcal conjugate vaccination. This was confirmed by the Director of Nursing during an interview, who acknowledged the lack of documentation in the resident's record.
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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