Cummings Health Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Howland, Maine.
- Location
- 5 Crocker Street, Howland, Maine 04448
- CMS Provider Number
- 205143
- Inspections on file
- 16
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cummings Health Care Facility during CMS and state inspections, most recent first.
The facility did not ensure the Food Service Supervisor was qualified for the position, as she lacked the necessary certification and was not enrolled in any qualifying course. Additionally, the facility used a consultant dietician who was not employed full-time, resulting in insufficient staffing for food and nutrition services.
The facility did not submit required direct care staffing information to CMS for a fiscal quarter, as the Administrator responsible for the submission missed the deadline by one day due to a staff change. This resulted in no staffing data being recorded for the quarter, affecting all 32 residents according to facility records and interviews.
Staff failed to maintain dignity and privacy for two residents during care. In one case, a resident was exposed to the parking lot during incontinence care due to open window curtains. In another, a CNA required a resident to say 'please' before assisting with a bathroom request, which was confirmed as not treating the resident with dignity and respect.
A resident did not receive required assistance or follow-up from facility staff to complete written information about their right to accept or refuse treatment or to formulate an advance directive, as required by facility policy.
A resident with a low albumin level and a new diagnosis of protein/calorie malnutrition did not have a dietician's recommendation for protein supplementation communicated to the provider or implemented. The DON confirmed that the recommendation was missed and not acted upon.
A resident with protein-calorie malnutrition and declining albumin levels did not receive a physician-ordered nutritional supplement, despite repeated documentation of the need for this intervention. The DON was unaware of how the order was missed, and the supplement was not provided as prescribed.
Physicians did not consistently review and sign medication and treatment orders at required visits for two residents. In one case, a physician failed to sign medication orders during a required 30-day visit for a newly admitted resident. In another case, a resident's medication orders were not reviewed or renewed at the next required visit, resulting in the orders being overdue by several days. The DON confirmed these lapses during interviews.
A resident with terminal cancer receiving Hospice services did not have a care plan that included goals or interventions reflecting collaboration and shared responsibilities between the facility and Hospice. The DON confirmed that Hospice responsibilities were not integrated into the care plan.
The facility failed to store food properly and maintain accurate temperature logs. Observations revealed dessert cups with ice buildup, unlabeled bins of flour and sugar, and open, undated bags of confectioner sugar and chocolate chips. Temperature logs for refrigeration equipment were incomplete for three days, as confirmed by the Food Safety Supervisor.
The facility did not have a water management program to prevent legionella and lacked policies for enhanced barrier precautions against multidrug-resistant organisms. The DON and Maintenance Technician were unaware of these policies, and the Administrator confirmed no risk assessment or procedures were in place.
The facility failed to offer Prevnar 20 vaccinations to three residents, as revealed by a survey. Clinical records showed no evidence of the vaccine being offered, received, or refused by these residents, contrary to the facility's policy. An interview with the DON confirmed this oversight.
The facility did not ensure a C.N.A. received the required 12 hours of annual in-service training, including abuse prevention, resident rights, and dementia care. A review of the C.N.A.'s file for the evaluation period showed no evidence of completed training in these areas, a finding confirmed by the Office Manager and Administrator.
A facility failed to complete a comprehensive MDS 3.0 assessment within 14 days after a resident experienced a significant change in condition when hospice services were discontinued. The resident's most recent MDS inaccurately indicated ongoing hospice services, and both the DON and MDS Coordinator confirmed that a significant change MDS was not completed as required.
A facility failed to follow its fall protocol and physician orders for a resident who was hospitalized. The resident's neurological assessments were not completed at required intervals after a fall, and the facility did not notify the Medical Provider when the resident's systolic blood pressure exceeded the prescribed threshold. An LPN admitted to missing the assessments, and the MDS Coordinator and DON confirmed the lack of documentation for notifying the Medical Provider.
The facility did not ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, during January and February 2024. Specific dates without adequate RN staffing were identified, indicating non-compliance with regulatory requirements.
The facility did not complete annual performance evaluations for two CNAs employed for over a year. One CNA, hired in 2018, was due for evaluation in 2024, and another, hired in 2009, was due in 2023. Both evaluations were incomplete as of July 2024, confirmed by a surveyor and the Administrator.
The facility failed to maintain a sanitary garbage storage area, as observed by a surveyor who noted a trash dumpster with an open lid and exposed trash bags. This was confirmed in an interview with the Administrator.
A resident in the facility was not offered the updated 2023-2024 COVID-19 vaccine, despite the facility's policy requiring it and CDC recommendations. The resident's last documented vaccination was in April 2022, and there was no evidence of an offer or refusal of the updated vaccine. The DON confirmed the oversight during a surveyor interview.
The facility did not provide quarterly statements for trust accounts to residents or their representatives. During an interview, a resident reported not receiving any statements, and the facility's Accountant confirmed the lack of documentation and routine issuance of these statements, except under specific conditions.
The facility did not post the most recent survey results in accessible locations for residents and families. A surveyor observed outdated survey results in the dining room and entrance foyer folders, with the most recent surveys missing. The Administrator confirmed the deficiency during the surveyor's observation.
A facility failed to accurately code the Annual MDS for a resident with a Level II PASRR. The resident's clinical record showed a PASRR indicating Level II services were needed, but the MDS was incorrectly coded to reflect otherwise. This error was confirmed by the MDS Coordinator during an interview.
Unqualified Food Service Supervisor and Insufficient Dietician Staffing
Penalty
Summary
The facility failed to ensure that the Food Service Supervisor (FSS) met the required qualifications for a Certified Food Service Director. During an interview, the FSS stated she had been in her role for about one year but did not possess the necessary qualifications and was not enrolled in any qualifying or Managerial Servsafe course. Additionally, the facility relied on a consultant dietician who visited monthly and was not employed full-time by the facility. These actions and inactions resulted in the facility not employing sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, potentially affecting all 32 residents.
Failure to Timely Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for fiscal year quarter 2 of 2025, as required. The Administrator, who is responsible for submitting staffing data based on payroll records, acknowledged that the submission for the quarter was made one day after the deadline due to a change in staff. As a result, the CASPER PBJ Staffing Data Report indicated that no data was submitted for the quarter, which was defined as a trigger for non-compliance. At the time of the survey, there were 32 residents living in the facility, as confirmed by both facility documentation and the Administrator during interviews. This deficiency was identified through record review and interviews, with the Administrator confirming both the number of residents and the late submission of required staffing data.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
On two separate days of survey, staff failed to maintain resident dignity and respect during care. In one instance, a resident who was dependent on staff for all activities of daily living was observed receiving incontinence care with the privacy curtain closed but the window curtains open, exposing the resident to the parking lot. This exposure was confirmed by both the surveyor and the charge nurse, who found the window curtains open while the resident was being cared for. The resident later stated a preference for the curtains to be closed during care, although they were not particularly bothered by the incident. In another instance, a certified nursing assistant (CNA) was overheard requiring a resident to say 'please' before assisting them to the bathroom. The resident expressed frustration, stating they only asked to use the bathroom. The CNA confirmed that she required the resident to say 'please' before providing assistance, citing the resident's verbal behavior. The surveyor confirmed with the CNA, as well as with the administrator and director of nursing, that the resident was not treated with dignity and respect during this interaction.
Failure to Assist Resident with Advance Directive Completion
Penalty
Summary
The facility failed to ensure that a resident and/or their representative received assistance or follow-up regarding the completion of written information about the right to accept or refuse medical or surgical treatment, formulate an advance directive, or appoint a surrogate. According to the facility's policy, the Social Service Director is responsible for assisting residents with advance directives and answering related questions. However, review of the resident's electronic medical record showed no evidence that such assistance or follow-up was provided, nor that the resident's wishes regarding advance directives were ensured.
Failure to Notify Physician of Dietician's Recommendation and Abnormal Lab Result
Penalty
Summary
The facility failed to notify a resident's physician of a significant health change and abnormal lab result, as well as a dietician's recommendation. Specifically, a nutrition note documented that the resident had a low albumin level, with a suggestion to add protein powder to their diet. Although the facility communicated with the provider regarding the low albumin and obtained a new diagnosis of protein/calorie malnutrition, the dietician's recommendation for protein supplementation was not communicated to the provider or implemented. The Director of Nursing confirmed that the dietician's handwritten note with the recommendation was not acted upon, resulting in the omission of the suggested dietary intervention for the resident.
Failure to Administer Ordered Nutritional Supplement
Penalty
Summary
A resident with a diagnosis of protein-calorie malnutrition and a documented decrease in albumin levels had a physician's order dated 5/29/25 for Boost nutritional supplement to be given twice daily between meals. Clinical record review revealed no evidence that the resident received the ordered supplement. Physician progress notes on 6/2/25 and 6/9/25 reiterated the need for the supplement to address ongoing malnutrition, but the provider was unaware that the supplement was not being administered as ordered. During an interview, the Director of Nursing was unable to explain how the order was missed, and it was confirmed that the resident had not received the prescribed nutritional support.
Physician Failure to Timely Review and Sign Medication Orders
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total programs of care and signed medication and treatment orders at each required visit for two residents. For one newly admitted resident, the physician completed the required 30-day visits and signed admission and medication orders at the first three visits, but during the third required 30-day visit, there was no evidence that the medication orders were signed. This lapse was confirmed by the Director of Nursing (DON) during an interview. For another resident, the last set of physician orders was signed and valid for 60 days, but at the subsequent physician visit, there was no evidence that the medication orders were reviewed and signed. The orders were due for renewal, including a 10-day grace period, but as of the survey date, they were six days overdue. The DON confirmed that the orders had not been signed during the last physician visit and were overdue at the time of the survey.
Failure to Integrate Hospice Collaboration into Care Plan
Penalty
Summary
The facility failed to incorporate the collaboration and shared responsibilities between the facility and Hospice into the care plan for a resident receiving Hospice services. Record review showed that the resident had terminal cancer and was documented as receiving Hospice care, with the care plan listing the name of the Hospice organization. However, there was no evidence in the care plan of specific goals or interventions that reflected the coordinated care between the facility and Hospice, nor were there interventions that identified or directed the division of care responsibilities. The DON confirmed during interview that Hospice responsibilities were not integrated into the facility's care plan.
Food Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner and maintain accurate temperature logs for refrigeration equipment. During an observation of the kitchen, it was noted that thirty chocolate and thirty-five vanilla Hormel Magic dessert cups in the freezer had a thick buildup of ice crystals, with one chocolate cup open. Additionally, two large bins of flour and sugar were found unlabeled and undated, and an open bag of confectioner sugar and a large open box of chocolate chips were not sealed or dated in the dry goods storage room. Furthermore, temperature logs for the walk-in freezer, walk-in refrigerator, and refrigerator/freezer were incomplete, with missing entries for three consecutive days. The Food Safety Supervisor confirmed these findings and stated that the temperatures were last recorded on 7/12/24, although they were supposed to be checked by the cook.
Deficiency in Infection Control Policies
Penalty
Summary
The facility failed to develop a water management program to prevent the growth and spread of legionella and other water-borne pathogens, and also failed to establish policies and procedures for enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms. During a review of the facility's infection control policies, the Director of Nursing (DON) admitted to the absence of a policy for enhanced barrier precautions. Additionally, the DON was unaware of a water management policy for legionella. The Maintenance Technician also confirmed the lack of a program to identify areas of standing water. The Administrator acknowledged that the facility had not completed a risk assessment to identify potential areas of microbial growth and lacked a policy or procedure for managing legionella and other water-borne pathogens.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer Pneumococcal Vaccinations (Prevnar 20) to three residents, as identified during a survey. Clinical record reviews on July 16, 2024, revealed that three residents, identified as R10, R28, and R32, had no documentation indicating they had received, been offered, or refused the Prevnar 20 vaccination upon admission. The facility's policy mandates that each resident should be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. However, an interview with the Director of Nursing (DON) confirmed that the Prevnar 20 vaccine was not offered to these residents, indicating a failure to adhere to the facility's immunization policy.
Deficiency in C.N.A. In-Service Training
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (C.N.A.) received the required minimum of 12 hours of annual in-service training, which should have included topics such as abuse prevention, resident rights, and dementia care. This deficiency was identified during a review of the employee file for C.N.A.1, covering the evaluation period from February 21, 2023, to February 21, 2024. The review, conducted by a surveyor along with the Office Manager and Administrator, revealed no evidence of completed training in the specified areas for C.N.A.1. The Office Manager and Administrator confirmed the absence of this training documentation at the time of the review.
Failure to Complete MDS After Significant Change
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a significant change in condition for a resident. This deficiency was identified during a review of the clinical record of a resident who had discontinued hospice services. The most recent MDS indicated that the resident was still receiving hospice services, despite the fact that hospice services had ended on June 3, 2024. During an interview, both the Director of Nursing (DON) and the MDS Coordinator confirmed that a significant change MDS was not completed when the resident came off hospice, which was required.
Failure to Follow Fall Protocol and Physician Orders
Penalty
Summary
The facility failed to adhere to its fall protocol and physician orders for a resident who was hospitalized. The facility's undated Falls Protocol required staff to initiate neurological checks if a resident sustained a head injury or had an unattended fall. These checks were to be conducted at specific intervals. However, for a resident who fell and bumped their head, the neurological assessments were not completed at the 9:45 a.m. and 10:15 a.m. intervals. The assessments were resumed later until the resident was sent to the hospital. During an interview, an LPN admitted to missing the assessments, assuming another staff member would complete them. Additionally, the facility did not follow physician orders regarding the monitoring of the resident's blood pressure. The resident had a physician order for Metoprolol with instructions to notify the Medical Provider if the systolic blood pressure exceeded 170. On two occasions, the resident's systolic blood pressure readings were significantly higher than the threshold, recorded at 181 and 267, but there was no evidence that the Medical Provider was notified. This was confirmed during an interview with the MDS Coordinator and the Director of Nursing, who could not find documentation of the required notifications.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, during the months of January and February 2024. This deficiency was identified through a review of the monthly schedules and interviews conducted by a surveyor, the Office Manager, and the Administrator on July 17, 2024. Specifically, the facility did not have an RN on duty for the required hours on January 9, January 11, January 29, February 9, February 10, and February 22, 2024. These findings indicate a lapse in staffing that did not meet the regulatory standards for RN coverage in the facility.
Failure to Complete Annual Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nursing Assistants (CNAs) who had been employed for more than one year. CNA #2, hired on May 9, 2018, was due for an evaluation by May 9, 2024, but there was no evidence of completion as of July 17, 2024. Similarly, CNA-M, hired on August 17, 2009, was due for an evaluation by May 9, 2023, yet no evaluation had been completed by July 17, 2024. These findings were confirmed during a review of employee files by a surveyor and the Administrator.
Improper Garbage Disposal Observed
Penalty
Summary
The facility failed to maintain a garbage storage area in a sanitary condition, which could prevent the harborage and feeding of pests. On July 17, 2024, at 7:40 a.m., a surveyor observed a trash dumpster with the top right lid open and two black bags placed on top of the dumpster, exposing trash. This observation was confirmed during an interview with the Administrator at 7:44 a.m. on the same day.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the updated 2023-2024 COVID-19 vaccine to a resident, identified as Resident #28 (R28), who was admitted on an unspecified date and is currently of an unspecified age. The clinical record review on July 16, 2024, revealed that R28's last documented COVID-19 vaccination was on April 28, 2022, with no evidence of being offered, receiving, or refusing the updated vaccine. The facility's policy mandates offering COVID-19 immunization to each resident unless medically contraindicated or already immunized. Despite the Director of Nursing (DON) using the CDC website as a resource, which recommends the updated vaccines, the surveyor confirmed on July 17, 2024, that the vaccine was not offered to R28.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements to residents or their representatives for trust accounts, as required. This deficiency was identified during a resident interview, where a resident stated they did not recall receiving any quarterly statements for their trust account. Further investigation revealed that the facility's Accountant confirmed the absence of documentation supporting the issuance of quarterly statements to the resident. The Accountant also admitted that quarterly statements were not routinely sent to residents unless accompanied by a cost of care statement or if the trust account balance became negative.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent surveys in a location that was readily accessible to residents, family members, and legal representatives. During an observation on 7/16/24, a surveyor found that the survey folder in the dining room contained outdated survey results from 2/11/20, despite multiple surveys being completed after that date. Additionally, the survey folder in the entrance foyer contained survey results from 5/11/23, even though a more recent survey was completed on 3/5/24. The Administrator confirmed the presence of two survey folders and acknowledged that neither contained the most recent survey results, as observed by the surveyor.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to ensure accurate coding of the Annual Minimum Data Set (MDS) 3.0 for a resident with a State Level II Preadmission Screening and Resident Review (PASRR). The deficiency was identified during a review of the clinical record of a resident, which included a PASRR dated March 4, 2020, indicating the resident qualified for Level II services. However, the resident's annual MDS, starting from August 12, 2022, was incorrectly coded in Section A1500 to indicate that the resident did not have a Level II PASRR. This error was confirmed during an interview with the MDS Coordinator, who acknowledged the inaccurate coding of the MDS.
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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