Eastport Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Eastport, Maine.
- Location
- 23 Boynton Street, Eastport, Maine 04631
- CMS Provider Number
- 205146
- Inspections on file
- 18
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eastport Memorial Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain safe, unobstructed egress routes when two of three ground-floor exits were blocked by significant snow accumulation, leaving only an employee entrance cleared. Surveyors observed deep snow on the front walkways and ramps, while 25 residents would have needed to be moved either through locked doors and narrow corridors to the side employee entrance or through the snow-obstructed front exits. Two maintenance staff were seen performing other tasks, and the Administrator reported that she had instructed maintenance to clear the egresses, but this had not yet been done.
The facility failed to maintain a documented, routine program for inspecting bed frames, mattresses, and bed rails for safety and entrapment risks. Although a resident’s bed and four other beds with air mattresses and side rails were observed by the DON and found to have proper mattress fit and no unsafe gaps, the Maintenance Supervisor stated that while he measures and assesses beds for proper fit and entrapment hazards when placing new mattresses, he does not document these assessments and does not perform regular, scheduled safety checks of all beds.
A facility did not notify a resident's current legal representative about a change in representative status and a significant change in the medical plan of care. Another family member presented a revoked POA and requested end-of-life care, which was implemented without verifying the legal status or informing the designated representative. The DON confirmed the failure to contact the appropriate legal representative regarding these changes.
A resident identified as an elopement risk exited the facility on two occasions after staff failed to fully implement the care plan, which required one-on-one supervision during exit-seeking behaviors. Instead, staff only redirected the resident multiple times, and no one sat with the resident as directed, resulting in unwitnessed elopements.
A resident with a known history of wandering and identified as an elopement risk was able to exit the facility on two occasions due to staff failing to ensure exit alarms were functioning and not providing adequate supervision. In one instance, the resident left through a door with a malfunctioning alarm, and in another, the resident exited through an alarmed door but staff presence was insufficient to prevent the elopement. Facility policy regarding immediate notification of elopements was also not followed.
The facility employed an unqualified Activity Director (AD) to manage activities for 24 residents. The Administrator and the AD confirmed that the AD had not completed the State-approved program required for qualification. The AD is currently enrolled in the program to meet the necessary requirements.
The facility's quality assurance committee failed to implement and ensure the effectiveness of the Plan of Correction for deficiencies identified during a survey. These included issues with comprehensive assessments, care plan updates, quality of care, and accident hazards. The facility lacked evidence of staff education and monitoring activities. Additionally, an Elopement/Wandering policy was not established, and respiratory care and drug storage deficiencies were not addressed, leading to repeated findings during a revisit survey.
A facility failed to complete an annual Comprehensive MDS 3.0 assessment for a resident on hospice care. The resident's admission MDS was completed, and quarterly assessments were conducted, but an annual Comprehensive MDS was not done. The Interim DON acknowledged the oversight, noting it had been 592 days since the last Comprehensive assessment.
A facility failed to complete a significant change in status MDS 3.0 assessment within 14 days after a resident transitioned to hospice care. The Interim DON confirmed that the required assessment was not completed following the resident's change in condition.
A facility failed to develop a comprehensive care plan for a resident with heart failure and afib. The care plan did not include management strategies for these conditions or the use of anticoagulant medication. An interview with the Interim DON confirmed the care plan lacked provisions for monitoring heart failure and afib.
The facility failed to follow a doctor's order for daily weight checks for a resident with heart failure and did not appropriately address a pharmacist's recommendation regarding the timing of a psychotropic medication for another resident. The misunderstanding of the pharmacist's recommendation was later clarified, but initially, the PMHNP declined the suggestion, thinking it was a request for a dose reduction.
A resident identified as an elopement risk exited the facility unnoticed during a fire alarm when the wander guard system was disabled. The resident was outside for three minutes in bare feet on a snowy day before being brought back inside. The incident was confirmed through video surveillance, and staff interviews indicated a lack of door monitoring during the alarm.
The facility failed to maintain physician-ordered oxygen settings and ensure the cleanliness of respiratory equipment for two residents. A resident's oxygen concentrator was set incorrectly at 3.5 LPM instead of the ordered 2 LPM, and the equipment was soiled. Another resident's oxygen concentrator had a heavily soiled air intake filter. These issues were confirmed by an LPN.
A facility failed to remove an expired vial of Novolog insulin from the medication storage room. An LPN and a surveyor found the vial, which was still in use 16 days past its expiration date. The LPN confirmed the expiration and discarded the vial.
The facility's Water Management Program lacked necessary testing protocols to prevent Legionella and other waterborne pathogens. A review revealed no evidence of control measures, acceptable test ranges, or monitoring procedures. The Maintenance Supervisor confirmed the absence of a plan or protocol for testing and monitoring waterborne pathogens.
A resident with bilateral sensorineural hearing loss was not provided with a hearing aid daily, as required by physician orders. Despite staff education, the resident often lacked the hearing aids, impacting communication. A family member noted staff's lack of knowledge on using the aids, and the DON admitted to not placing the aid on a specific day, with no system in place to ensure daily use.
Snow-Blocked Egresses Limit Safe Exit Routes
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards when two of three ground-floor egresses used by residents were blocked by snow and not easily passable. On the morning of 1/27/26 at 9:00 a.m., surveyors observed that the walkways to the two front entrance/egress doors were hindered by snow measuring approximately 15 inches at the street and approximately 4 to 6 inches on the walkways and ramps leading to these doors. The only walkway and door that had been shoveled free of snow was the employee entrance located at the left side of the building. To exit through the only unobstructed egress, the 25 current residents would have to be taken through one of two locked doors and navigated through narrow corridors to reach the side employee entrance, or alternatively attempt to exit through the front egresses that remained hindered by snow. During this time, two maintenance staff were observed inside the building performing other tasks. In an interview shortly after 9:00 a.m., the Administrator stated that she had asked the maintenance staff to clear the egresses of snow, but they had not yet done so.
Lack of Documented and Ongoing Bed Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document regular inspections of all bed frames and mattresses as part of a maintenance program to ensure mattress–bed frame compatibility and identify areas of entrapment. During an observation of one resident’s bed with the DON, the mattress was found to fit the bed frame appropriately, and no unsafe gaps were noted around the quarter bedrails; additional observations of four other residents’ beds with air mattresses and side rails also revealed no entrapment or safety issues. In an interview, the Maintenance Supervisor reported that he measures bed mattresses and frames to ensure proper fit and assesses the mattress, frame, and bed rails for gaps or entrapment hazards when placing a new mattress. However, he acknowledged that he does not document these assessments and does not have a regular, ongoing maintenance program for checking beds for safety, leading to the cited deficiency.
Failure to Notify Legal Representative of Changes in Resident Status and Care
Penalty
Summary
The facility failed to notify the current legal representative of a resident about a change in the resident's representative status and a significant change in the resident's medical plan of care. The resident's clinical record indicated that a family member was designated as the legal representative in 2017. However, during a physician visit, another family member presented a document claiming Power of Attorney (POA) and requested a transition to end-of-life care, which was acted upon without verifying the validity of the POA or notifying the original legal representative. Later, it was discovered that the POA presented had been revoked years earlier, and the original legal representative had not been informed of the changes until after they occurred. The DON confirmed that the facility did not contact the correct legal representative regarding the conflicting POA status and the changes to the resident's care plan.
Failure to Implement Comprehensive Elopement Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as an elopement risk, resulting in two separate incidents where the resident exited the building unwitnessed. The resident wore a wander guard bracelet intended to trigger secured exits, and the care plan directed staff to redirect the resident from exits and, when the resident was upset and attempting to leave, to have staff sit with the resident. However, during both incidents, staff only redirected the resident multiple times and did not provide the one-on-one supervision as outlined in the care plan. On both occasions, the resident was able to leave the facility without being witnessed, despite staff being aware of the resident's repeated exit-seeking behaviors. Interviews with staff and the DON confirmed that no one sat with the resident during these episodes, and staff were unable to provide adequate supervision, particularly during times of limited staffing. The care plan interventions were not fully implemented, as staff did not follow the directive to have someone sit with the resident when exhibiting elopement behaviors.
Failure to Provide Adequate Supervision and Maintain Secured Exits for Resident at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as an elopement risk, resulting in two separate incidents of elopement. The resident, who had a history of wandering behavior for at least four years and wore a wander guard bracelet, was able to exit the building on two occasions. In the first incident, the resident was observed multiple times attempting to open a Sunroom exit door. Staff redirected the resident several times but left the area unattended despite knowing the door's alarm system was not functioning due to a loose power connection. The resident ultimately managed to open the unsecured door and leave the building without staff witnessing the exit, and the alarm did not sound as required by facility policy. In the second incident, the same resident exited the building through a different door (Smoker's exit) that was equipped with an alarm. The alarm functioned properly, alerting staff, who then located and redirected the resident back inside. However, staff interviews revealed that the resident had made multiple attempts to elope that evening, and there were only three staff members present, which was insufficient to provide adequate supervision for the resident's known exit-seeking behavior. Additionally, the Charge Nurse failed to immediately notify the DON or Administrator of the elopement, contrary to the facility's Elopement and Wandering Policy. Both incidents demonstrate that the facility did not follow its own policies regarding secured exits and immediate notification of elopements. The failure to ensure that exit alarms were functioning and to provide adequate supervision for a resident with a known risk of elopement directly led to the resident being able to leave the facility on two occasions.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified Activity Director (AD) to manage resident-centered activities for all 24 residents. During an interview with a surveyor, the Administrator acknowledged that the current AD had not completed a State-approved program necessary to become qualified as an AD. Further confirmation came from the AD herself, who admitted she had not completed the required program or taken the exam to become an Activity Professional. Both the Administrator and the AD stated that the AD is currently enrolled in the program and is in the process of completing it to meet the qualification requirements.
Facility Fails to Implement Plan of Correction for Multiple Deficiencies
Penalty
Summary
The facility's quality assurance committee failed to ensure the implementation and effectiveness of the Plan of Correction (PoC) for deficiencies identified during the Recertification Survey. These deficiencies included issues with comprehensive assessments and timing, assessments after significant changes, care plan development and implementation, quality of care, and accident hazards. The facility lacked evidence that the PoC for these deficiencies was implemented, as there was no documentation of education provided to staff, education received by the MDS coordinator, or monitoring activities completed. During interviews with the Administrator and the Director of Nursing, it was confirmed that the facility did not implement the PoC for several deficiencies, including those related to comprehensive assessments, care plan updates, and quality of care. The facility also failed to establish and educate staff on an Elopement/Wandering policy, which was supposed to be in place by a specified date. The Director of Nursing indicated that the policy had not been approved by the board of directors, and staff had not received the necessary education, leaving a resident at risk of elopement. Additionally, the facility did not fully implement the PoC for respiratory care and the proper labeling and storage of drugs and biologicals. There was no evidence of education provided to staff, nor were there documented weekly audits or monitoring activities. These deficiencies were identified again during a revisit survey, indicating that the facility had not addressed the issues effectively by the anticipated date of compliance.
Failure to Complete Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete an annual Comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment in a timely manner for a resident receiving hospice care. The resident was admitted on an unspecified date, and the admission Comprehensive MDS assessment was completed and submitted on June 17, 2023. Subsequent quarterly MDS assessments were conducted on September 15, 2023, December 14, 2023, March 15, 2024, June 16, 2024, September 15, 2024, and December 16, 2024. However, there was no evidence of an annual Comprehensive MDS assessment being completed. During an interview on January 29, 2025, the Interim Director of Nursing acknowledged that the MDS completed on June 16, 2024, should have been an annual Comprehensive MDS assessment. At the time of the interview, it had been 592 days since the last Comprehensive assessment for the resident.
Failure to Complete Significant Change MDS for Hospice Transition
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's transition to hospice care. The deficiency involved a resident who was admitted to the facility and had an Admission MDS completed and submitted. However, when the resident transitioned to hospice level of care, the facility did not complete the required significant change in status MDS. This oversight was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the change in condition assessment was not completed for the resident after the transition to hospice care.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the physical needs of a resident who was admitted with diagnoses of heart failure and atrial fibrillation (afib). The care plan did not include management strategies for heart failure, afib, or the use of anticoagulant medication, which is essential for preventing blood clots. During a record review and interview with the Interim Director of Nursing, it was confirmed that the care plan lacked provisions for monitoring and managing heart failure, such as daily weight monitoring as ordered by the provider, and did not address the monitoring and management of afib, including the use of anticoagulant medication.
Failure to Follow Provider Orders and Address Pharmacist Recommendations
Penalty
Summary
The facility failed to adhere to a doctor's order for daily weight checks for a resident diagnosed with heart failure. The order, dated 1/16/25, required daily weight monitoring and notification to the provider if the resident's weight increased by more than 3 pounds in one day or 5 pounds in one week. However, upon review of the clinical records on 1/28/25, it was found that there was no evidence of daily weights being recorded as ordered. This deficiency was confirmed during an interview with the Interim Director of Nursing and a surveyor. Additionally, the facility did not appropriately address a pharmacist's recommendation regarding the timing of a psychotropic medication for another resident. The pharmacist suggested reviewing the timing of olanzapine doses due to the resident being awake much of the evening. The PMHNP initially declined the recommendation, misunderstanding it as a request for a gradual dose reduction. It was later clarified that the recommendation was to adjust the timing of the doses, not reduce them. This misunderstanding was confirmed during an interview with an LPN and a surveyor.
Resident Elopement Due to Unmonitored Door During Fire Alarm
Penalty
Summary
The facility failed to adequately monitor an unlocked and non-alarmed door, resulting in an elopement incident involving a resident identified as an elopement risk. The resident, who has diagnoses including Schizophrenia, Major Depressive Disorder, and Alzheimer's disease, was wearing a wander guard alert device. However, during a fire alarm test, the doors unlocked, and the wander guard system was disabled, allowing the resident to exit the building unnoticed. A staff member observed the resident outside, unattended, and alerted other staff members to bring the resident back inside. The incident occurred when the resident was outside for approximately three minutes, standing near the edge of the property with bare feet on a snowy day. The Interim Director of Nursing confirmed through video surveillance that the resident exited through the day room door during the fire alarm. The resident was assessed and treated for exposure to salt and gravel on their feet, with no lasting effects reported. Staff interviews revealed that the lack of monitoring during the fire alarm contributed to the resident's unnoticed elopement.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a physician-ordered oxygen setting and ensure the cleanliness of respiratory equipment for two residents. During an initial tour, a surveyor observed that the oxygen regulator on a resident's oxygen concentrator was set at 3.5 liters per minute (LPM), contrary to the physician's order of 2 LPM. Additionally, the concentrator was soiled with dried liquid and dust, and the air intake filter was heavily soiled with dust. Another resident was observed wearing oxygen via nasal cannula attached to an oxygen concentrator, which also had a heavily soiled air intake filter. These observations were confirmed by an LPN, who acknowledged the discrepancies in oxygen settings and the unsanitary condition of the equipment.
Expired Medication Not Removed from Storage
Penalty
Summary
The facility failed to remove an expired medication from the supply available for use in one of the two locations where medications are stored. During an observation, a surveyor and an LPN found an opened vial of Novolog insulin in the medication storage room, which was intended for a resident. The vial was labeled with an open date, indicating it was still being used 16 days after it should have been discarded, as Novolog is only good for 28 days once opened according to the manufacturer's directions. The LPN confirmed the expiration and discarded the vial upon discovery.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive Water Management Program to prevent the growth and spread of Legionella and other water-borne pathogens. During a review conducted on January 28, 2025, it was found that the facility's Water Management Program, last revised on May 24, 2022, lacked evidence of testing protocols necessary for water testing. Specifically, there were no protocols for control measures, acceptable test ranges, monitoring procedures, or interventions to be used if water tested positive for Legionella or other opportunistic waterborne pathogens. In an interview conducted on the same day, the Maintenance Supervisor admitted to the surveyor that there was no evidence of a plan or protocol in place for testing Legionella or other waterborne pathogens, nor were there any established acceptable test ranges or monitoring procedures.
Failure to Provide Daily Hearing Aid to Resident
Penalty
Summary
The facility failed to ensure that a resident with bilateral sensorineural hearing loss was provided with a hearing aid device daily. The resident was admitted with a diagnosis requiring the use of hearing aids, as per physician orders, to be installed in the morning and removed at bedtime. Despite staff education on the importance of hearing aids in the resident's care plan, the resident often did not have the hearing aids in place. A family member reported that staff were unaware of how to use the hearing aids, and the resident was observed without them during a visit. The Director of Nursing admitted responsibility for not placing the hearing aid on a specific day and acknowledged the absence of a system to monitor the daily use and care of the hearing aid.
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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