Fallbrook Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Maine.
- Location
- 91 Merrymeeting Dr, Portland, Maine 04103
- CMS Provider Number
- 205134
- Inspections on file
- 18
- Latest survey
- March 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fallbrook Commons during CMS and state inspections, most recent first.
A resident received double doses of pregabalin and oxycodone due to a documentation error. A nurse administered the medications outside the prescribed window and failed to sign them out in the EMAR. A med tech, unaware of the prior administration, gave the resident their bedtime medications, leading to the error. The resident was evaluated the next day, showing tachycardia but was otherwise stable.
A resident in an LTC facility potentially received double doses of pregabalin and oxycodone due to a documentation error. The medications were signed out by a nurse who left the facility early, and the EMAR was not updated. The medication technician also administered the medications, leading to concerns about double dosing. The facility's policy for medication administration documentation was not followed.
The facility failed to ensure dignified feeding assistance for residents. A CNA was observed standing over a resident without engaging in conversation during feeding. Another instance involved two CNAs standing over residents while assisting with feeding, confirmed by the Unit Manager.
The facility failed to inform and provide written information about the right to formulate an advance directive for four residents. Surveyors found that the clinical records of these residents lacked documentation of advance directives and evidence that they were informed of their rights. Forms present in the records were either unsigned, blank, or incomplete, indicating a lapse in the facility's responsibility to ensure residents were aware of their rights regarding advance directives.
The facility failed to ensure comprehensive interdisciplinary team (IDT) participation in care planning for multiple residents. Meetings often lacked essential team members such as the attending physician, registered nurse, and CNA, and did not consistently involve the resident or their representative. This deficiency was noted across several residents, with meetings frequently attended only by a registered nurse and nutrition services, or sometimes just one of these members, indicating a systemic issue in the care planning process.
The facility failed to maintain a sanitary environment for respiratory care, as observed in four residents whose oxygen and nebulizer tubing were unlabeled and undated, contrary to facility policy. The clinical records lacked documentation of weekly tubing changes, and observations showed improper storage of respiratory equipment. These deficiencies were confirmed by an LPN and the Director of Clinical Services.
The facility did not maintain proper records for controlled drugs, failing to conduct daily counts as required by policy. The Omnicell cabinet's controlled substances were not consistently counted by two licensed nurses, with numerous days missing counts over several months. This issue was identified during an observation and discussed with the Director of Clinical Services.
The facility failed to ensure proper temperature monitoring for biologicals in two refrigerators on Unit A and a vaccine refrigerator in the Infection Control office. The facility's policy requires monitoring twice daily, but logs showed only once daily monitoring with several missing entries from January to August 2024. The Director of Clinical Services confirmed the lack of consistent monitoring.
The facility failed to maintain sanitary conditions in food storage and preparation areas. Undated and unlabeled desserts and breakfast items were found, and kitchenettes had dirty appliances with incomplete temperature logs. The dish machine's temperature log was also incomplete after repairs, with bleach added without recording parts per million.
The facility's QAA committee meetings lacked attendance from required leadership figures, such as the administrator or owner, as confirmed by attendance records and the DON.
A facility failed to refer a resident with bipolar disorder for a PASRR Level II evaluation after their stay extended beyond the expected short-term period. Initially admitted for short-term convalescence, the resident's stay became long-term, but the necessary referral to the state authority was not made. This oversight was confirmed by the Director of Clinical Services.
A facility failed to develop a discharge summary with a recapitulation of a resident's stay. The resident was admitted for skilled services and later discharged to the community. The clinical record lacked evidence of the required documentation, as confirmed by the Director of Clinical Services during an interview.
A facility failed to follow physician's orders for a resident with Congestive Heart Failure, who was to be weighed weekly. The resident's clinical record lacked evidence of weighing on several specified dates. This deficiency was confirmed in an interview with the DON.
A facility failed to provide trauma-informed care for a resident with PTSD and a history of childhood sexual abuse. Despite the resident's clinical record indicating trauma history, the facility did not identify specific PTSD triggers or events that might cause re-traumatization. The care plan only noted the resident's preference for female caregivers, lacking further trauma-specific interventions. The Director of Clinical Services confirmed the absence of a comprehensive care plan addressing the resident's trauma history.
A resident with Down Syndrome and dementia was physically abused by a CNA during a 1:1 care session. The resident, who became agitated, grabbed the CNA's arm, prompting the CNA to slap the resident's arm and verbally retaliate. This incident was witnessed by another CNA, highlighting a failure to follow the facility's policy and the resident's care plan, which emphasized non-violent interventions for managing agitation.
The facility did not post the most recent survey results in an accessible location for residents and their families. A surveyor found the book meant to contain these results empty, and the Director of Clinical Services was unaware of the results' whereabouts or how long they had been missing.
The facility failed to provide the required CMS-10123-NOMNC and CMS-10055-SNF ABN forms to residents whose Medicare Part A Skilled services were discontinued. Two residents who remained in the facility after their benefits ended did not receive the necessary forms, and another resident discharged to home did not receive the CMS-10123-NOMNC form. This deficiency was identified during a surveyor's review and discussed with the DON.
The facility failed to provide written transfer or discharge notices to residents or their legal representatives for facility-initiated transfers to acute care facilities. Interviews with staff confirmed the absence of such documentation, and the DON was unaware of the requirement.
The facility failed to issue written bed hold notices to residents or their representatives upon transfer to a hospital. This deficiency was identified for five residents, with clinical records lacking evidence of such notices. The DON confirmed the absence of documentation during a survey.
Resident Receives Double Dose of Medications Due to Documentation Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when controlled medications were administered in excess of prescribed doses. On the evening of February 12, 2025, a resident received double doses of pregabalin 75 mg and oxycodone 10 mg. These medications were signed out of the narcotic/control book by a nurse who had left the facility earlier in the shift, and they were not signed out in the electronic medication administration record (EMAR). A medication technician, unaware that the medications had already been administered, gave the resident their bedtime medications, leading to the double dosing. The resident's clinical record indicated that the physician had ordered pregabalin 75 mg to be taken twice daily and oxycodone 10 mg three times daily. The error was discovered when the resident's provider was notified the following day, and the resident was evaluated for the medication error. The resident exhibited tachycardia but was otherwise stable. The facility's policy required documentation of controlled substances, which was not followed, as the nurse did not sign off the medications in the EMAR due to administering them outside the prescribed window. This oversight resulted in the resident receiving additional doses of the medications.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for medication errors. On a specific date, a surveyor noted a medication error report indicating that a resident had potentially received double doses of two medications, pregabalin and oxycodone. The medications were signed out of the narcotic/control book by a nurse who had left the facility earlier in the shift, and they were not signed out in the electronic medication administration record (EMAR). The medication technician reported that the nurse had administered the medications before leaving, but the technician also administered the bedtime medications, leading to concerns about double dosing. The resident's clinical record showed that the medications were prescribed to be administered twice and three times daily, respectively. However, discrepancies were found in the documentation, with the controlled medication book showing the medications signed out by both the nurse and the medication technician. The Nurse Manager confirmed that the nurse did not sign out the administration of the controlled medications in the EMAR, which was against the facility's policy. The Director of Clinical Services also confirmed the nurse's failure to follow the policy for medication administration documentation.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents requiring feeding assistance were aided in a dignified manner during dining observations. On August 19, 2024, a surveyor observed a Certified Nursing Assistant (CNA) standing over a resident while feeding them in the C-Unit dining room, without engaging in any conversation. This lack of interaction was confirmed with the CNA and the Director of Nursing. Additionally, on August 20, 2024, another surveyor observed two CNAs standing over residents while assisting with feeding, one in the Unit C dining room and another in the hallway at the nurse's station. These observations were confirmed with the Unit Manager.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information concerning the right to formulate an advance directive for four residents. During a survey, it was found that Resident #62's clinical record lacked an advance directive and documentation indicating that the resident was informed about their right to formulate one. Although an Advance Care Planning Tracking form was present, it was unsigned and mostly blank, except for the selection of Full Code. Similarly, Resident #65's record also lacked an advance directive and documentation of being informed about their rights. The form in their record was signed by a representative, but the section for the date of discussion was marked as none, with the rest of the form blank except for a Do Not Resuscitate (DNR) selection. Additionally, Resident #40's clinical record did not contain an advance directive or documentation of being informed about the right to formulate one. The Director of Nursing was unable to locate the necessary documentation for these residents. Furthermore, Resident #21's record also lacked documentation of an advanced directive discussion. After a thorough search, the charge nurse confirmed the absence of such documentation. These findings indicate a failure by the facility to ensure residents were informed and provided with the necessary information to formulate advance directives.
Inadequate Interdisciplinary Team Participation in Care Planning
Penalty
Summary
The facility failed to adequately review and revise care plans by an interdisciplinary team (IDT) for 16 out of 29 residents whose care plans were reviewed. The IDT meetings often lacked the presence of essential team members such as the attending physician, registered nurse, and certified nursing assistant responsible for the resident. Additionally, there was a lack of participation from nutrition services and, to the extent possible, the resident or their representative. This deficiency was noted across multiple residents, with meetings often attended only by a registered nurse and nutrition services, or sometimes just one of these members. For Resident #9, IDT meetings were held with limited attendance, often missing key team members. Similarly, Resident #13's records showed IDT meetings with only dietary and nursing staff present, and no documentation of resident or family participation. Resident #18's meetings also lacked comprehensive team attendance, with some meetings attended only by a registered nurse. This pattern of insufficient IDT participation was consistent across other residents, such as Resident #30, who had meetings with only a registered nurse and nutrition services, and Resident #31, who was unsure of their invitation to care plan meetings. Interviews with residents, such as Resident #31 and Resident #71, revealed that they were not aware of being invited to participate in their care plan meetings. The records for Resident #40, Resident #54, and others showed similar deficiencies, with meetings often attended by only one or two team members, lacking the full interdisciplinary approach required. This lack of comprehensive IDT involvement and resident participation in care planning was a consistent issue across the reviewed cases, indicating a systemic problem in the facility's care planning process.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by observations and record reviews for four residents. The facility's policy requires that nasal cannulas and nebulizer parts be changed weekly, labeled with the date and staff initials, and documented in the Treatment Administration Record (TAR). However, observations revealed that the oxygen and nebulizer tubing for Residents #30, #60, #93, and #70 were unlabeled and undated. Additionally, the clinical records lacked documentation of weekly tubing changes for these residents. Specific observations included Resident #30's oxygen nasal cannula tubing being unlabeled and undated, with the oxygen tubing connected to a CPAP machine resting on the floor. Resident #60's nebulizer tubing was found unlabeled and undated, with the mouthpiece hanging down the backside of the bedside dresser. Resident #93's nebulizer tubing was also unlabeled and undated, with the mask stored among personal belongings. Resident #70's oxygen tubing was undated, and the resident mentioned infrequent use. These deficiencies were confirmed through interviews with the LPN and the Director of Clinical Services, who acknowledged the lack of proper labeling and documentation.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that controlled drug records were maintained in order and that an account of all controlled drugs was kept to enable reconciliation. Specifically, the facility did not adhere to its policy requiring controlled medications in the Omnicell automated medication dispensing cabinet to be counted at least once daily by two licensed nurses. The accountability log sheet was not consistently signed off as complete. A review of the Daily Omnicell Controlled Substance Cycle Count logs from January 2024 through August 21, 2024, revealed numerous instances of missing daily counts. For example, in January 2024, counts were missing for 9 out of 31 days, and in June 2024, counts were missing for 22 out of 30 days. This deficiency was observed during a visit to the Unit A medication storage room and was discussed with the Director of Clinical Services.
Inadequate Temperature Monitoring of Biologicals
Penalty
Summary
The facility failed to ensure that biologicals were stored at appropriate temperatures in two observed refrigerators on Unit A. The facility's policy, revised on August 24, requires that medications and biologicals be stored at temperatures between 36 to 46 degrees Fahrenheit. During an observation on August 21, the Registered Nurse Manager acknowledged that the temperatures of the refrigerators, which contained insulin, Ozempic, and Tuberculin Purified Protein, should be monitored once or twice daily. However, the temperature logs from January to August 2024 showed that temperatures were only being monitored once daily, with several days missing temperature recordings each month. Additionally, the vaccine refrigerator in the Infection Control office was found to have inadequate temperature monitoring. This refrigerator contained influenza and pneumococcal vaccines. The temperature logs for July and August 2024 indicated that temperatures were monitored only once daily for several days each month. The Director of Clinical Services confirmed the lack of consistent temperature monitoring during the surveyor's observation.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas during observations. On August 19, 2024, undated and unlabeled desserts were found in the reach-in refrigerator, and undated packages of cheese and French toast were observed on a breakfast cart. On August 21, 2024, the Unit A kitchenette's freezer and refrigerator were found to be dirty, although items were labeled with resident names and dates. The Unit B kitchenette had a dirty refrigerator and lacked temperature log documentation for several days in July and August 2024. Additionally, the dish machine's temperature log was incomplete from June 7 to July 9, 2024, after the machine required repairs and the facility was instructed to add bleach without recording the parts per million. These issues were confirmed with the person in charge of the Dietary Department and the Food Service Consultant.
QAA Committee Lacks Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the required members. Specifically, the signed attendance lists for QAA meetings held on June 11, 2024, and July 2, 2024, revealed that the administrator, owner, board member, or another individual in a leadership role did not attend either meeting. During an interview on August 22, 2024, at 9:15 a.m., the Director of Nursing (DON) confirmed that the QAA committee meets weekly, but the Administrator or other leadership figures do not attend these meetings.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred to the appropriate state-designated authority for a PASRR Level II evaluation and determination. The resident was admitted with a diagnosis of bipolar disorder and initially had a PASRR Level I determination that did not require further evaluation due to the expectation of a short-term convalescence admission. However, the resident was not discharged after a short stay and continued to reside in the facility, assessed as needing nursing facility level of care. The clinical record lacked evidence of a referral for a PASRR Level II evaluation after the resident's stay changed from short-term to long-term. This deficiency was confirmed by the Director of Clinical Services during an interview.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary that included a recapitulation of the resident's stay for a resident reviewed for discharge. The resident was admitted to the facility for skilled services and was later discharged to the community. Upon review of the clinical record, there was no evidence that a recapitulation of the resident's stay was completed at the time of discharge. This deficiency was confirmed during an interview with the Director of Clinical Services, who was unable to find the necessary documentation in the resident's clinical record.
Failure to Follow Physician's Orders for Resident Weighing
Penalty
Summary
The facility failed to follow physician's orders for a resident with Congestive Heart Failure, who was supposed to be weighed weekly on Tuesdays and Thursdays. The Physician Order Summary sheet dated 4/9/24 specified this requirement. However, there was no evidence in the resident's clinical record that the resident was weighed on several specified dates: 4/18/24, 5/23/24, 6/6/24, 6/11/24, 7/11/24, 7/18/24, and 7/25/24. This deficiency was confirmed during an interview with the Director of Nursing on 8/21/24 at 3:30 p.m.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a known history of PTSD and childhood sexual abuse. Upon admission, the facility's policy required social services to assess residents for trauma history to ensure appropriate treatment and services. However, despite the resident's clinical record indicating a history of sexual abuse and PTSD, the facility did not identify specific PTSD triggers or events that might cause re-traumatization. The resident had expressed a preference for not having male caregivers, which was noted in the care plan, but no further trauma-specific interventions were documented. During an interview, the Director of Clinical Services confirmed the absence of a comprehensive care plan addressing the resident's trauma history, aside from the preference for female caregivers. The facility's failure to develop and implement a detailed care plan with trauma-specific interventions for the resident represents a deficiency in providing trauma-informed care, as required by their policy.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with a diagnosis of Down Syndrome, Conduct Disorder, Alzheimer's disease, and dementia with behavioral disturbance. The resident was receiving 1:1 care from CNA #4 when the incident occurred. According to the report, the resident became agitated and grabbed CNA #4's arm. In response, CNA #4 slapped the resident's arm and verbally retaliated by saying, "How do you like it?" This action was observed by another CNA, who confirmed the physical abuse and verbal response. The facility's policy states that residents should be free from all forms of abuse, including physical abuse. The care plan for the resident indicated specific interventions to manage agitation, such as guiding the resident away from distress and engaging calmly in conversation. However, these interventions were not followed, leading to the escalation of the situation. The incident was reported to the Division of Licensing and Certification, and the facility's failure to adhere to its own policies and care plan resulted in the deficiency.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that is easily accessible to residents, family members, and legal representatives. On August 22, 2024, at 9:05 a.m., a surveyor observed that the book containing the Latest Survey Results in the main lobby was empty. When questioned, the Director of Clinical Services was unaware of the location of the survey results and did not know how long the book had been empty.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Provider Non-Coverage (CMS-10123-NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055-SNF ABN) forms to residents whose Medicare Part A Skilled services were discontinued. Specifically, two residents who remained in the facility after their Medicare Part A benefits ended did not receive the necessary CMS-10123-NOMNC and CMS-10055-SNF ABN forms. Additionally, another resident who was discharged to home did not receive the CMS-10123-NOMNC form. These deficiencies were identified during a surveyor's review of a random sample of residents who had been discharged from Medicare Part A coverage. The surveyor discussed the missing forms with the Director of Nursing, highlighting the facility's failure to ensure residents were informed of their Medicare coverage status and potential liability for services not covered. This oversight affected the residents' ability to understand their appeal rights and financial responsibilities after the discontinuation of Medicare Part A benefits.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to issue a written transfer or discharge notice to residents or their legal representatives for facility-initiated transfers or discharges to an acute care facility. This deficiency was identified for five sampled residents who were transferred or discharged without receiving the required documentation. The clinical records for these residents lacked evidence of a written notice being provided, which is a necessary step in the transfer or discharge process. Interviews with facility staff, including the Director of Nursing (DON) and a registered nurse (RN), confirmed the absence of a written transfer or discharge notice. The DON acknowledged the lack of documentation and was unaware that providing such a notice was necessary. The RN mentioned that while a written notice is not used in this facility, they had experience using it in other facilities. This oversight indicates a systemic issue within the facility's procedures for handling transfers and discharges.
Failure to Issue Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to issue a written bed hold notice to residents or their representatives upon transfer to an acute care hospital. This deficiency was identified for five residents who were transferred to a hospital and subsequently admitted. The clinical records for these residents lacked evidence of a written bed hold notice being issued, which is a requirement to inform residents or their representatives about how long their bed will be held during their absence. Interviews with the Director of Nursing (DON) confirmed the absence of documentation for the issuance of bed hold notices for these residents. The DON was unable to locate any evidence that such notices were provided to the residents, their family members, or legal representatives at the time of transfer. This oversight was noted during a survey, highlighting a consistent failure in the facility's process for handling bed hold notifications.
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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