Clover Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Maine.
- Location
- 440 Minot Ave, Auburn, Maine 04210
- CMS Provider Number
- 205063
- Inspections on file
- 21
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Clover Health Care during CMS and state inspections, most recent first.
The facility failed to ensure its infection prevention and control program included clearly visible entrance signage alerting visitors to an active coronavirus outbreak. The DON informed surveyors of multiple active coronavirus cases on two units and instructed them to wear masks, but when the survey team entered earlier there was no clearly visible outbreak notice at the entrance. A sign requiring all visitors to wear masks was later shown to surveyors on the top of the reception desk, but it was not readily visible upon entry.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not provide required behavioral health and trauma-informed care training to new and existing staff, despite a significant portion of residents having psychiatric or mood conditions. Staff files lacked documentation of this training, and facility leadership confirmed the lapse was due to staff turnover and issues with the learning platform. The facility's behavioral health policy was also inaccessible during the review.
A resident with MS, muscle weakness, and a Stage III pressure ulcer, who required total assistance by two staff for transfers and repositioning, experienced a fall with injury after a CNA, unfamiliar with the care plan and lacking proper information, attempted to reposition the resident alone and left the bed in a raised position. The CNA did not review the care plan or Kardex and relied on inconsistent verbal instructions, resulting in the resident being left unsafely and subsequently falling.
Surveyors found that hot water temperatures in several resident rooms exceeded 120°F, with no consistent monitoring or documentation by staff. Hazardous cleaning chemicals were left unsecured in a resident's room, and a resident assessed as needing supervision and a protective apron while smoking was observed without these safety measures. Staff interviews confirmed lapses in awareness and adherence to safety protocols.
The facility did not provide or document the provision of written information about the right to formulate an advance directive to multiple residents or their representatives. Record reviews and staff interviews confirmed that neither information nor assistance regarding advance directives was offered, and staff lacked understanding of what advance directives include beyond CPR.
Surveyors found that the facility did not provide adequate housekeeping and maintenance services, resulting in uncleanable surfaces, chipped and missing paint, stained ceiling tiles, and dirty equipment across all units. These deficiencies were confirmed by staff and affected both common areas and resident rooms.
The facility did not ensure that care plans were reviewed and revised by an IDT within 7 days after MDS assessments for several residents. Record reviews and staff interviews confirmed that required IDT meetings were either delayed or not documented, resulting in noncompliance with care planning regulations.
Annual performance evaluations were not completed for five CNAs who were all hired on the same date, with no documentation available to confirm evaluations for the required period. Administration reported that all staff were considered new hires after a change in ownership, but no performance reviews had been conducted as required.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with staff failing to wear required facial hair protection, unclean surfaces and equipment, undated food items, and an improperly installed ice machine lacking an air gap. Additionally, required temperature monitoring and documentation for dishwashing and refrigeration were incomplete or missing for several months, with dish machine rinse temperatures often below the required level for sanitization. The Food Service Director confirmed these findings.
The facility's QA Committee failed to ensure that corrective actions for previously cited deficiencies were effective, resulting in repeat citations for inadequate assessment and monitoring of a resident after an unwitnessed fall, and for not maintaining kitchen cleanliness or proper food labeling and dating.
The facility did not ensure that all staff received required training on the Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by missing documentation for several certified nurse assistants. This training was mandated by facility policy to be included in both orientation and annual education, but records showed it was not completed or documented for the staff reviewed.
The facility did not follow physician orders for urine collection prior to surgery for a resident with complex medical needs, resulting in the cancellation of a scheduled procedure due to incomplete lab paperwork. Additionally, the facility failed to document or perform required neurological and vital sign monitoring after unwitnessed falls for another resident with dementia and mobility issues.
A resident's clinical records were found to be incomplete, with missing documentation for multiple ADL care tasks such as bathing, elimination, oral hygiene, toileting, scheduled toileting programs, and eating across several shifts. These gaps in recordkeeping were identified during a review and confirmed by staff.
Six residents were served their evening meal on trays in the dining room, which was confirmed by the Regional Director of Operations as not being homelike, dignified, or respectful.
A resident with a mental health diagnosis was admitted under a short-term PASRR exemption, but when their stay extended beyond the initial period, the facility did not refer them for the required PASRR Level II evaluation. Review of records confirmed the absence of this referral after the resident's status changed to long-term.
A resident admitted with a history of falls, mobility issues, and muscle weakness required significant assistance with ADLs, but the facility did not develop or implement a baseline care plan with appropriate goals and interventions within 48 hours of admission. Staff interviews and care plan review confirmed the omission.
Two residents did not have complete care plans addressing their specific needs. One resident, assessed as safe to smoke only with supervision, did not have this requirement documented in their care plan. Another resident using a CPAP device lacked a care plan for its use. These deficiencies were confirmed by facility leadership.
Surveyors found that two residents did not receive proper infection control for their respiratory care equipment. A nebulizer mask and tubing were left unbagged on a bedside table, and a CPAP machine lacked documentation of cleaning or maintenance.
A resident with end-stage renal disease and an AV fistula did not receive required monitoring and assessments of the dialysis access site, as well as pre- and post-dialysis evaluations, according to facility policy. Interviews with the resident, an LPN, and the DON confirmed that staff did not routinely check the fistula or perform necessary assessments before or after dialysis treatments, and documentation of these actions was absent from the clinical record.
Food and trash were found on the ground outside the back kitchen door, and a dumpster was left open with trash exposed and additional trash scattered around it. These unsanitary conditions were observed and confirmed by the FSD.
A nurse provided high-contact care to a resident on Enhanced Barrier Precautions (EBP) without wearing the required PPE, including gown, gloves, or face mask, after re-entering the room to assist with positioning the resident's leg during intravenous medication administration.
Surveyors found that medications were improperly stored in a refrigerator with significant ice buildup, and a resident was self-administering Tylenol without a physician's order or completed safety assessment by the IDT, as confirmed by an LPN and the DON.
The facility failed to maintain adequate maintenance and housekeeping services, leading to unsanitary conditions in two units. Surveyors observed heavily soiled sit-to-stand patient lifts and a commode lid on the floor in the [NAME] Unit, along with broken window shades in several resident rooms. These issues were confirmed by an RN and a CNA and discussed with the Administrator.
The facility failed to maintain sufficient staffing levels, impacting resident care. A resident reported needing assistance with ambulation and toileting, but due to staff shortages, they often had to use a bedpan. Staff interviews confirmed that the facility was frequently understaffed, leading to incomplete care tasks such as baths and grooming. The facility did not meet state staffing requirements for 19 out of 53 days reviewed, and the administrator acknowledged the issue.
The facility failed to maintain proper infection control practices, as observed on two units. A CNA was seen carrying soiled linen unbagged, contrary to policy, and another CNA carried clean linen against her body, placing it in a soiled hamper. These actions were confirmed as infection control issues by RN #1 and the Administrator.
A facility maintenance staff member entered a resident's room without knocking or announcing his presence, which was identified as a dignity issue. The staff member acknowledged the oversight, and the facility's Administrator confirmed the breach of protocol.
The facility failed to ensure a safe environment by not addressing a trip hazard in the [NAME] unit. Surveyors observed a missing section of linoleum flooring with edges coming up, creating a potential trip hazard. A CNA confirmed the hazard and noted the presence of ambulatory residents. The Administrator also acknowledged the hazard.
The facility failed to maintain proper food temperatures and assess residents' dietary needs, leading to cold, unpalatable meals. Interviews with residents and staff highlighted consistent issues with food being served cold, requiring reheating by nursing staff. The kitchen supervisor confirmed that food temperatures were not monitored on the units, and regular meals were served without proper dietary assessments.
Failure to Post Clearly Visible Signage for Active Coronavirus Outbreak
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring clearly visible signage at the entrance to alert visitors of an active respiratory (coronavirus) outbreak. On the survey date at 7:45 AM, the DON informed surveyors that there was an active coronavirus outbreak, with thirteen active cases on one unit and one active case on another unit, and instructed the surveyors to wear masks. The surveyors noted that when they entered the facility earlier that morning at 7:00 AM, there was no clearly visible signage at the entrance alerting visitors to the outbreak. When questioned, the DON directed the surveyor to a sign taped to the top of the reception desk stating that all visitors must wear masks, but observation confirmed that this sign was not readily visible upon entry into the facility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective behavioral health training program for both new and existing staff, as required by its own facility assessment and policy. Specifically, a review of six Certified Nursing Assistants' (CNAs) education files revealed no evidence that behavioral health or trauma-informed care training had been provided since February. The facility's resident profile indicates that 35-65% of its population is admitted with psychiatric or mood conditions, necessitating specialized care and interventions. Despite this, staff files for CNAs hired between March and July showed no documentation of required behavioral health training. Interviews with the Interim Director of Nursing, Administrator, and Director of Nursing confirmed the absence of this training, attributing it to the departure of the previous Social Worker and a lapse in the facility's learning platform. Further review found that the facility's behavioral health services policy, which outlines the need for staff to recognize psychological distress, implement and monitor care plan interventions, and follow protocols for mental disorders and trauma, was not accessible due to a transition between policy portals. The policy statement provided lacked an initial or revision date, and there was no evidence that staff were qualified or competent in behavioral health and trauma-informed care as required. The deficiency was identified through record reviews, staff interviews, and examination of facility policies.
Failure to Implement and Communicate Resident Care Plan Leads to Fall with Injury
Penalty
Summary
The facility failed to implement a resident's care plan for a resident with multiple complex medical needs, including Multiple Sclerosis, muscle weakness, and a Stage III pressure ulcer. The resident was dependent on staff for transfers, bed mobility, and personal hygiene, requiring total assistance by two staff members and the use of a mechanical lift. Despite these documented needs, a CNA assigned as a float was not adequately informed about the resident's care requirements and did not review the care plan or Kardex. The CNA relied on verbal instructions from other CNAs and was unaware of the resident's diagnosis or specific care needs. On the day of the incident, the CNA turned the resident alone, left the resident positioned on their side, and exited the room to get a nurse, leaving the bed in a raised position. Upon returning, the resident was found on the floor, having fallen from the bed. Interviews revealed that the CNA had never accessed the care plan or Kardex and believed only nurses had access to these documents. There was inconsistency in the information provided to the CNA by nursing staff, and the CNA did not have a clear understanding of the resident's needs or the proper procedures for safe repositioning and transfer. The administrator acknowledged that staff were not following care plans, which directly contributed to the resident's fall and injury.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision within the facility. On several units, hot water temperatures accessible to residents were found to be above the facility's policy limit of 120 degrees Fahrenheit, with readings as high as 131.1 degrees. Staff interviews revealed that water temperatures were not being regularly monitored or documented, and the Director of Plant Operations had not calibrated his thermometer or maintained consistent records. The last documented temperature checks were from several months prior, and the facility was unaware of the ongoing issue until informed by surveyors. Staff also reported experiencing excessively hot water but did not report it to management. Additionally, a surveyor observed an unsecured container of PDI Sani-Cloth Bleach Germicidal Disposable Wipes left in a resident's room, making hazardous chemicals accessible to residents. The Facility Administrator confirmed that such chemicals should not be available for resident use and removed the item after being notified by the surveyor. The facility also failed to provide required supervision and safety equipment for a resident assessed as needing assistance while smoking. The resident was observed smoking outside without a protective apron and with only intermittent staff supervision, despite assessments indicating the need for both. Interviews with staff confirmed that the resident often smoked alone and that staff were unaware of the requirement for a protective apron during smoking activities.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide or document the provision of written information regarding the right to formulate an advance directive to residents and/or their representatives. Record reviews for 13 out of 14 residents revealed no evidence that such information was offered, reviewed, or provided at the time of admission or thereafter. This deficiency was confirmed through interviews with the Clinical Reimbursement Manager and the Social Services Assistant, both of whom acknowledged the absence of documentation and the lack of discussion or provision of advance directive information. The Social Services Assistant further stated she did not know what an advance directive includes beyond cardiopulmonary resuscitation (CPR). The affected residents were admitted over a span of several years, and both electronic and paper medical records were reviewed for evidence of compliance. In each case, there was no documentation that residents or their representatives were asked to provide a copy of their advance directives, nor were they given information or assistance to formulate one if they did not have it. The deficiency was identified through both record review and staff interviews, with staff confirming the lack of process and understanding regarding advance directives.
Failure to Maintain Sanitary and Homelike Environment Across All Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all four units during two separate facility tours. Specific deficiencies included uncleanable surfaces due to ripped duct tape on laundry carts, chipped and missing paint on floors, heaters, and door frames, as well as missing lens covers on bathroom lights. Additional findings included food debris and dirt on patient lifts, marred and stained walls and doors, and unbagged or dirty equipment such as bedpans and plungers left in resident rooms and bathrooms. Several ceiling tiles were noted to be stained, cracked, or broken, and some furniture and equipment had surfaces that were worn, ripped, or otherwise uncleanable. These observations were confirmed through interviews with facility staff, including the Food Service Director, Administrator, Director of Plant Operations, Assistant Director of Plant Operations, Housekeeping Supervisor, and Regional Director of Operations. The deficiencies were present in both common areas and resident rooms, affecting the overall sanitary and orderly condition of the environment. No specific residents' medical histories or conditions were mentioned in relation to the deficiencies, but the findings were consistent across multiple units and areas within the facility.
Failure to Conduct Timely IDT Care Plan Reviews After MDS Assessments
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT) within 7 days following the completion of each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for five out of seven residents reviewed, there was no evidence that an IDT meeting occurred within the required timeframe after the most recent MDS assessments. The clinical records for these residents showed that the last IDT meetings were held outside the 7-day window or were missing entirely following the assessments. Interviews with facility staff, including the Social Service Assistant and the Area Manager of Clinical Reimbursement, confirmed that the required IDT meetings did not occur within the mandated period after MDS completion. The deficiency was identified through both record review and staff interviews, which substantiated that the care planning process was not conducted in accordance with regulatory requirements for timely interdisciplinary review and revision.
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) who were all hired on the same date. Documentation confirming the completion of annual performance evaluations for the year following their hire was not available for any of these employees. During an interview, the Administrator and Regional Director of Operations explained that when the previous administration sold the company, all employee records were taken, and all staff were considered new hires as of the same date. Despite this, none of the required performance reviews for the relevant period had been completed at the time of the surveyor's review.
Multiple Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to food safety and sanitation. During a kitchen tour, it was observed that two kitchen staff members with facial hair were not wearing required facial hair protectors. The kitchen environment was found to be unclean, with six ceiling tiles stained, a fan in the dish room covered in dust, seven ceiling vents dusty and two of them rusted, and 16 ceiling tiles around vents with significant dust buildup. The wall above the reach-in freezer and refrigerator was heavily soiled with dust, and the dry storage room floor had chipped or missing paint, with trash and debris present throughout the room and under shelving. Additionally, a package of whipped topping in the reach-in refrigerator was not dated as required by manufacturer instructions, and the ice machine lacked a proper air gap, violating state plumbing code and federal regulations intended to prevent contamination. Further review of facility policies revealed that dish machine temperatures were to be monitored and recorded at each meal, and refrigerator and freezer temperatures were to be logged twice daily. However, documentation for both the dish machine and refrigeration units was incomplete or missing for several months. Specifically, there were numerous days with missing or low rinse temperatures for the dish machine, which were confirmed to be below the required 180 degrees Fahrenheit for effective sanitization. Temperature logs for various refrigerators and freezers, including those in the kitchen and on units, were also missing for multiple days across several months. The Food Service Director confirmed the findings of missing documentation and inadequate temperature monitoring. The lack of proper installation of the ice machine, failure to date food items, and insufficient cleaning and maintenance of kitchen surfaces and equipment contributed to the facility's failure to maintain a clean and sanitary food service environment as required by professional standards and regulatory codes. No widespread outbreak of illness was reported during the period in question.
Repeat Deficiencies in Resident Monitoring and Kitchen Sanitation
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. Specifically, the same deficiencies—F684 and F812—were cited again during a follow-up survey. F684 was cited due to the facility's failure to adequately assess and monitor a resident after an unwitnessed fall. F812 was cited for the facility's failure to maintain the kitchen in a clean and sanitary manner and to ensure that foods were properly labeled and dated. These deficiencies were confirmed through record review and interviews, and the findings were discussed with the Executive Director and interim DON during the exit conference.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to all staff, as required by its own policy. Record reviews showed that five certified nurse assistants did not have evidence of receiving QAPI training, which should have included education on QAPI principles, staff roles, communication with the program, and participation in performance improvement projects. The facility's policy specified that all staff, including contracted staff, must be educated on QAPI during orientation and annually, but this requirement was not met for the employees reviewed. The Administrator and Regional Director of Operations confirmed the lack of documentation for this mandatory training during an interview with the surveyor.
Failure to Follow Physician Orders and Inadequate Post-Fall Monitoring
Penalty
Summary
The facility failed to follow physician orders for urine collection for a resident with multiple complex medical conditions, including Multiple Sclerosis and an indwelling urinary catheter. The Family Nurse Practitioner at a urology center ordered a clean catch urine collection for urinalysis and culture a week prior to a scheduled surgery. Although the specimen was collected and sent to the lab, the accompanying paperwork was not completed by facility staff, resulting in the lab being unable to process the specimen. This failure led to the cancellation of the resident's scheduled surgery, as the preoperative requirements were not met. Additionally, the facility did not adequately assess and monitor another resident after unwitnessed falls. Facility policy required neurological and vital sign monitoring at specific intervals following an unwitnessed fall. However, review of the clinical record for a resident with dementia and mobility difficulties showed no evidence that neurological or vital sign monitoring was completed or documented after two separate unwitnessed falls. Interviews with staff confirmed that the required monitoring was not performed or recorded in the resident's records.
Incomplete Clinical Documentation for ADL Care
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as required by accepted professional standards. Record review revealed multiple instances of missing documentation for activities of daily living (ADL) care, including bathing/showering, elimination (urinary and bowel), oral hygiene, toileting hygiene, scheduled toileting programs, and eating. These omissions occurred across both day and night shifts on various dates. The lack of documentation was identified during a review of the resident's medical record and was confirmed through interview with facility staff.
Failure to Provide Homelike and Dignified Meal Service
Penalty
Summary
During the evening meal on one of the units, six residents were observed eating their dinner in the dining room with their meals served on trays. This method of meal service was noted to be neither homelike nor respectful, failing to promote the residents' dignity. The Regional Director of Operations confirmed during observation and interview that serving meals on trays in this manner did not support a homelike environment or demonstrate dignity and respect for the residents.
Failure to Refer Resident for PASRR Level II Evaluation After Exemption Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a specialized mental health diagnosis, specifically Post-Traumatic Stress Disorder, who was initially admitted under a 30-day convalescence categorical exemption, was properly referred for a PASRR Level II evaluation after their stay extended beyond the expected short-term period. Clinical record review showed that while the initial PASRR Level I was completed and the exemption applied, there was no evidence that the required referral to the State Mental Health Authority was made once the resident's status changed to long-term. This lapse was confirmed during an interview with the Area Manager of Clinical Reimbursement.
Failure to Develop Baseline Care Plan for ADLs Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was recently admitted with repeated falls, difficulty walking, muscle weakness, and a need for assistance with personal care. The admission Minimum Data Set indicated the resident required substantial to maximal assistance with activities of daily living (ADLs). However, review of the care plan initiated on 4/2/25 showed it lacked documented goals and interventions for ADLs. During interviews, a CNA confirmed the resident needed help with toileting and ambulation, and the DON acknowledged that the care plan did not address these needs.
Failure to Develop Comprehensive Care Plans for Smoking and Respiratory Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. One resident, admitted in May 2018, was assessed as safe to smoke with supervision according to a Smoking Safety Screening completed in November 2024; however, the resident's care plan did not include any documentation of the need for supervised smoking. Another resident, admitted in March 2025, had physician orders for the use of a Continuous Positive Airway Pressure (CPAP) device since mid-March 2025, but there was no evidence of a care plan addressing CPAP usage in the medical record. These omissions were confirmed with facility leadership during the survey.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary environment for respiratory care equipment for two residents. For one resident, a nebulizer mask and tubing were repeatedly found unbagged and left on the bedside table, despite an active physician order for nebulizer treatments as needed. The medication administration record indicated the last use of the nebulizer was on 4/23/35, but the equipment remained exposed and improperly stored during multiple surveyor visits. For another resident using a CPAP machine since 3/13/25, there was no documentation in the medical record to show that the CPAP had been cleaned or maintained, and facility staff were unable to provide evidence of any cleaning having occurred.
Failure to Monitor and Assess Dialysis Access Site and Treatments
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident with end-stage renal disease who was dependent on hemodialysis and had an arteriovenous (AV) fistula in the right arm. Facility policy required staff to assess and document the condition of the dialysis access site every shift, including checking for signs of infection, monitoring the color and temperature of the fingers, presence of radial pulse, and assessing for thrill and bruit at the fistula site. Additionally, staff were required to complete pre- and post-dialysis assessments and document these in the resident's record. However, review of the resident's medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed no evidence that these assessments or monitoring were performed or documented. Interviews with the resident, an LPN, and the Director of Nursing confirmed that staff did not routinely check the resident's fistula or perform assessments before or after dialysis treatments. The resident reported that nurses did not check the fistula or monitor him after returning from dialysis. The LPN stated that no assessment or vital signs were taken after dialysis unless required for medication administration. The DON acknowledged that pre- and post-dialysis assessments were not being completed and that the clinical record lacked documentation of required monitoring and assessments for the dialysis access site.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition, as evidenced by food and trash observed on the ground outside the back kitchen door and an open dumpster with trash exposed and additional trash on the ground around it. These conditions were directly observed by a surveyor and confirmed by the Food Service Director during the survey. No information about residents or their medical conditions is included in the report.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective Infection Control Program to prevent the spread of infection related to Enhanced Barrier Precautions (EBP) for a resident receiving intravenous medication. A sign posted outside the resident's room indicated that staff were required to wear personal protective equipment (PPE), including a gown, gloves, and face mask/eye protection, when providing care. During an observation, a registered nurse wore PPE while administering intravenous medication but removed her PPE to leave the room and retrieve a clean pillowcase. Upon returning, she did not don new PPE and proceeded to provide high-contact care by placing a pillow under the resident's right thigh and handling the leg with both hands. The nurse confirmed in an interview that she provided this care without wearing the required PPE, despite the resident being on EBP.
Improper Medication Storage and Lack of Self-Administration Assessment
Penalty
Summary
Surveyors observed that drugs and biologicals were not stored in accordance with professional standards. In the medication storage room on the [NAME] Unit, a dormitory-style refrigerator with significant ice buildup was being used to store several medications, despite this type of refrigerator being inappropriate due to temperature fluctuations. This failure to use proper storage equipment for medications was directly observed by the surveyor and the Director of Nursing (DON). Additionally, a resident was found to have a bottle of extra strength Tylenol, 500 mg, on their bedside table and reported self-administering the medication as needed. There was no evidence in the resident's medical record of a completed safety assessment by the interdisciplinary team (IDT) or a physician's order permitting self-administration, as required by the facility's policy. An LPN confirmed the absence of both the order and assessment and subsequently removed the medication from the resident's room.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain adequate maintenance and housekeeping services, resulting in unsanitary conditions in two of its units. During an environmental tour, surveyors observed that sit-to-stand patient lifts in the [NAME] Unit were heavily soiled with food debris and dirt in the foot base area. This was confirmed by a Registered Nurse (RN #1). Additionally, a commode lid was found on the floor leaning against the wall in the [NAME] Unit, and broken window shades were observed in resident rooms #29, #35, #38, and #43. These findings were confirmed by a Certified Nursing Assistant (CNA #1) and discussed with the facility Administrator.
Staffing Deficiency Affects Resident Care
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, as required by state regulations. Interviews with residents and staff revealed that the facility was often staffed below the required state staffing ratios, affecting the quality of care provided. A resident reported that due to insufficient staff, they sometimes could not be assisted to walk or use the bathroom, resulting in the use of a bedpan. Staff members, including RNs, CNAs, and LPNs, confirmed the short staffing issue, noting that it led to delays in answering call bells and incomplete care tasks such as baths, nail care, and teeth brushing. The staffing schedules and daily resident census review indicated that the facility did not meet the minimum staffing requirements for 19 out of 53 days reviewed. Staff interviews highlighted that the shortage was exacerbated by the reliance on agency staff, which affected the continuity and quality of care. The facility's administrator confirmed the findings of insufficient staffing during a phone interview with a surveyor. The deficiency was documented under the State tag ST-T-0222, indicating non-compliance with the State of Maine Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities.
Improper Linen Handling Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by improper linen handling observed on two units during a survey. On the [NAME] Unit, a Certified Nursing Assistant (CNA #4) was seen carrying a small bag of soiled linen with a visibly soiled bundle of unbagged linen on top, which was not in compliance with the facility's policy requiring soiled laundry to be bagged. CNA #4 confirmed the linen was not bagged as required. Additionally, on the same unit, CNA #5 was observed carrying clean linen against her body and placing it in a soiled linen hamper, which was also confirmed as an infection control issue. These observations were discussed with RN #1 and the Administrator, who both acknowledged the infection control concerns.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident when a maintenance staff member entered the resident's room without knocking or announcing his presence. On the specified date and time, a surveyor observed a tall male facility worker, dressed in black jeans and a black shirt, entering the resident's room without following the proper protocol of knocking and requesting permission. The staff member moved a Velcro stop sign aside and entered the room, later exiting with a wheeled bag of tools. During an interview, the maintenance staff member acknowledged that he entered the room without knocking, recognizing it as a dignity issue. The facility's Administrator also confirmed that the staff member should have knocked and announced himself before entering the resident's room.
Trip Hazard Due to Unsecured Linoleum Flooring
Penalty
Summary
The facility failed to maintain a safe environment for residents by not addressing a trip hazard in the [NAME] unit (core 1). During a survey, two surveyors observed a section of linoleum flooring, approximately 2 feet by 1 foot, that was missing, with edges coming up, creating a potential trip hazard. A Certified Nursing Assistant (CNA #6) confirmed the hazard, noting that the desk previously in that area had been removed, and acknowledged the presence of ambulatory residents who could be at risk. The Administrator also confirmed the existence of the trip hazard and the presence of ambulatory residents in the unit.
Deficiency in Food Temperature and Dietary Assessment
Penalty
Summary
The facility failed to ensure that food served from the kitchen was maintained at adequate and proper hot temperatures throughout the meal service, resulting in cold and unpalatable meals for residents. Interviews with residents and staff revealed consistent complaints about the food being cold and mushy, requiring nursing staff to reheat meals before serving them to residents. The kitchen supervisor confirmed that food temperatures were only taken in the kitchen and not monitored on the units during meal service, leading to uncertainty about whether the food was held at appropriate temperatures until served. Additionally, the facility did not adequately assess and identify residents' nutritional needs and diets before meals were distributed from the kitchen. The kitchen supervisor admitted that due to incomplete meal tags and lack of information on new admissions, regular meals were served without consideration of individual dietary plans. This lack of coordination and communication between the kitchen and nursing staff contributed to the deficiency, as evidenced by a test tray that was found to be cold and unpalatable by surveyors.
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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