Forest Hill Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Kent, Maine.
- Location
- 25 Bolduc Ave, Fort Kent, Maine 04743
- CMS Provider Number
- 205176
- Inspections on file
- 19
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Forest Hill Manor during CMS and state inspections, most recent first.
A resident with orders for supplemental oxygen and CPAP/BIPAP treatments experienced multiple episodes of low oxygen saturation, but there was no documentation that the provider was notified as required. Additionally, provider orders lacked clarity regarding when and how CPAP/BIPAP and supplemental oxygen should be used, and the DON confirmed these gaps in documentation and order clarity.
The facility did not ensure adequate staffing levels on weekends, as identified in a review of the Payroll Based Journal staffing report for the fourth quarter of 2024. The Administrator confirmed that the facility lacked sufficient staff to meet resident needs, particularly affecting those requiring assistance with ADLs.
The facility failed to maintain a safe and clean environment, with observations of discolored and cracked flooring, dirt buildup, chipped paint, and broken trim in resident areas. A resident's wheelchair was also found with dirt and debris, indicating inadequate cleaning and maintenance.
The facility did not update care plans to include Enhanced Barrier Precautions (EBP) for two residents. One resident with heel wounds requiring daily dressing changes had an EBP sign, but the care plan did not address EBP needs. Another resident with VRE in the urine had orders for precautions, but the care plan lacked continuous EBP documentation. These deficiencies were confirmed by staff interviews.
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances exceeding 120 degrees Fahrenheit due to a faulty mixing valve. Additionally, blue floor tiles in the Skilled Unit hallway were lifting, creating a potential trip hazard. The Administrator acknowledged both issues, with plans to address the flooring hazard.
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, with issues such as soiled oxygen concentrator filters, missing filters, and outdated oxygen tubing. These deficiencies were confirmed through observations and interviews with the DON.
The facility failed to implement proper infection prevention measures, with staff not adhering to Enhanced Barrier Precautions (EBP) during care activities. Instances included staff not wearing protective gowns or gloves when required. Additionally, the facility did not fully implement a water management program to prevent Legionella and other pathogens, as necessary monitoring activities were not conducted.
A facility failed to promptly notify the Medical Provider and Resident Representative of abnormal lab results for a resident. The resident's blood work showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by the NP until 28 hours later. The RR requested an update on the results but was told to wait until the next day. The DON acknowledged that both the Medical Provider and RR should have been informed immediately.
A facility failed to develop a comprehensive care plan for a resident with Diabetes, as the care plan lacked goals and interventions for managing the condition and the use of insulin. This was confirmed during a review with the Residential Care Coordinator.
A facility failed to follow physician orders for sliding scale insulin for a resident. The resident's blood sugar levels were checked four times daily, but the Medication Administration Record (MAR) showed incorrect dosages of Novolin R insulin were administered on multiple occasions. Despite blood sugar levels indicating the need for 2 or 4 units, only 1 unit was given, as confirmed by the Resident Care Coordinator.
A facility failed to recognize and address significant weight loss in a resident, whose care plan required a daily nutritional supplement to maintain a target weight. Despite a decline from 184 lbs to 155 lbs over several months, the order for the supplement was dropped, and there was no evidence of notification to the medical provider or dietitian, nor were additional nutritional interventions initiated.
The facility failed to remove expired medications from its storage units. A surveyor found an expired box of Ayr Saline Nasal Gel in the skilled nursing unit and an expired bottle of GI Cocktail in the LTC unit's refrigerator, which was still available for a resident with a current order for its use. These findings were confirmed with the CNA responsible for medications, and the expired items were removed for destruction.
A facility failed to promptly notify a medical provider of abnormal lab results for a resident. Blood work ordered on a resident showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by a Nurse Practitioner until 28 hours later. The facility's protocol required checking the computer for results unless they were critical, in which case the lab would call. The DON stated the provider should have been informed by phone when the results were available.
A facility failed to offer a pneumococcal immunization to a resident, as required by their policy. The policy mandates offering the vaccine unless contraindicated, but a review of the resident's clinical record showed no evidence of an offer, declination, or receipt of the vaccine. The Infection Preventionist confirmed the absence of documentation, and the resident's representative consented to the immunization only after the surveyor's inquiry.
A resident with multiple cognitive impairments was sexually abused by a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt. The incident was witnessed by a CNA who reported it immediately. The resident was unable to consent due to their medical condition, and the staff member admitted to the inappropriate contact. The facility's policy on preventing sexual abuse was violated, and the incident was reported to the relevant authorities.
The facility failed to ensure that two unlicensed staff members completed mandatory training on abuse, neglect, exploitation, and misappropriation of resident property. A transporter and a handyman did not receive the required training within the past year, as confirmed by the DON during a surveyor interview.
A resident's preference for daily evening whirlpool baths was not followed, as they did not receive the baths for 7 days in the past month. The facility's documentation practices failed to specify the type of bath received, leading to a lack of evidence that the resident's care plan was adhered to.
The facility failed to follow physician orders to obtain a urine sample for a resident who had a change in mental status. Despite a provider order, the sample was not obtained, and there was no record of any attempt or completion.
Failure to Follow Physician Orders for Respiratory Care and Inadequate Documentation
Penalty
Summary
The facility failed to follow physician orders for respiratory care for one resident requiring supplemental oxygen and CPAP/BIPAP treatments. The resident's clinical record included a provider order to check oxygen saturation (SpO2) four times per shift and to notify the covering provider if SpO2 dropped below 90% while awake or below 88% when sleeping. Multiple nursing narrative notes documented SpO2 readings below these thresholds on several occasions, but there was no evidence in the clinical record that the covering provider was notified as required by the order. Additionally, the resident had orders for CPAP use at bedtime, but observations and interviews revealed unclear documentation regarding whether the resident should use CPAP or BIPAP at times other than bedtime, and whether supplemental oxygen should be attached to the CPAP/BIPAP machine during use. The Director of Nursing confirmed that the provider orders were not clear regarding the timing and method of CPAP/BIPAP use and that the required notifications to the provider were not documented when low SpO2 readings occurred.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the fourth quarter of 2024. During an interview with a surveyor, the Administrator confirmed that the facility did not have enough staff on duty to meet resident needs on weekends, affecting residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed discolored and cracked flooring in resident rooms, dining areas, common areas, and hallways, creating uncleanable surfaces. Dirt buildup was noted along the thresholds between hallways and resident rooms. Additionally, chipped paint and broken trim were observed in a resident's room, along with a soiled floor mat. Furthermore, a resident's wheelchair was found to have dirt and dried debris on both arms and wheels, indicating a lack of proper cleaning and maintenance.
Failure to Update Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to update and revise care plans to include Enhanced Barrier Precautions (EBP) for two residents. For one resident, an EBP sign was observed on the door, and the resident had wounds on both heels requiring daily dressing changes. However, the care plan did not address the need for EBP during care. This was confirmed during an interview with the Residential Care Coordinator. For another resident, an EBP sign was also observed, and the resident had orders for precautions due to Vancomycin-resistant Enterococci (VRE) in the urine. The care plan lacked evidence of the need for continuous EBP for this diagnosis, as confirmed by the Resident Care Coordinator.
Hot Water Temperature and Flooring Hazards
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances of temperatures exceeding the maximum allowable limit of 120 degrees Fahrenheit. On the first day of the survey, multiple rooms were found with hot water temperatures ranging from 120.4 to 124.8 degrees. Despite adjustments made by the facility after the initial findings, subsequent checks still revealed temperatures above the acceptable limit. The issue was attributed to a faulty mixing valve, which was identified and replaced on the second day of the survey. Additionally, the facility did not ensure that the flooring in the Skilled Unit hallway was free from hazards. Surveyors observed that blue floor tiles were lifting and becoming unglued, creating a potential trip hazard. The Administrator acknowledged the issue and mentioned that the tiles were located downstairs and that there were plans to replace them. These deficiencies indicate lapses in maintaining a safe environment for residents, as required by regulatory standards.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, leading to potential risks of disease and infection transmission. For one resident, the oxygen tubing was observed resting on the floor, and the oxygen concentrator filters were heavily soiled with dust and debris. The tubing had not been changed according to the facility's protocol, which requires a change every two weeks. The Director of Nursing (DON) confirmed these observations and acknowledged the failure to maintain the equipment properly. Another resident's oxygen concentrator was missing both side filters, and the oxygen tubing had not been changed since the beginning of January, despite the resident using oxygen every night. The manual for the oxygen concentrator specified that it should not be operated without the filters. A third resident also had oxygen tubing with a nasal cannula resting on the floor, and the tubing had not been changed in a timely manner per protocol. These deficiencies were confirmed through observations and interviews with the DON.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention measures during the survey period. On multiple occasions, staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents. For instance, a Unit Caretaker was observed changing linens for a resident on EBP without wearing a protective gown. Similarly, a Certified Nursing Assistant - Medications (CNA-M) administered eye drops to a resident without wearing gloves, contrary to the guidelines outlined in the Lippincott Nursing Procedures. Additionally, two CNAs assisted a resident with repositioning in bed without wearing the required protective gown and gloves, and a Registered Nurse (RN) assisted a resident with toileting hygiene without wearing a gown, despite the resident being on EBP for Vancomycin-Resistant Enterococcus (VRE). The facility also failed to fully develop and implement a water management program to prevent the growth and spread of Legionella and other water-borne pathogens. The Water Management Program required monitoring activities such as checking hot water temperatures at faucets and cleaning showerheads, but these were not being conducted. The Forest Hill Maintenance Specialist only checked the water temperatures in the boiler room and did not perform other necessary monitoring tasks. The Administrator confirmed that the facility was not monitoring the action items identified in the Water Management Policy, except for the ice machine and boiler room checks.
Failure to Timely Notify Medical Provider and Resident Representative of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the Medical Provider in a timely manner regarding abnormal laboratory results for a resident who was reviewed for hospitalization. The resident had blood work done, including a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), which showed abnormal results. These results were available on the morning of January 21, 2025, but were not reviewed by the Nurse Practitioner until 28 hours later. The Director of Nursing acknowledged that the Medical Provider should have been informed of the abnormal results immediately by telephone. Additionally, the facility did not promptly inform the Resident Representative (RR) about the abnormal lab results when requested. The RR asked for an update on the blood work results on the evening of January 21, 2025, but was told that the results would be reviewed by the doctor the following day, and the RR would be informed afterward. The Director of Nursing admitted that the RR should have been given the information at the time of the request, as the RR could have decided to transfer the resident to the hospital for further evaluation.
Failure to Develop Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with Diabetes. The resident was admitted to the facility and had a current physician order for Novolin R insulin sliding scale. However, upon review of the resident's care plan, it was found that there was no evidence of goals and interventions related to the management of Diabetes and the use of insulin. This deficiency was confirmed during a review of the care plan with the Residential Care Coordinator, indicating that the treatment of the resident's Diabetes was not addressed in the care plan.
Failure to Administer Correct Insulin Dosage
Penalty
Summary
The facility failed to ensure that physician orders for sliding scale insulin were followed for a resident. The clinical record review revealed that the resident's blood sugar levels were checked four times a day, and the sliding scale insulin coverage was to be administered according to specific blood sugar ranges. However, on multiple occasions, the resident received an incorrect dosage of Novolin R insulin, as documented in the Medication Administration Record (MAR). For instance, when the resident's blood sugar levels indicated the need for 2 or 4 units of insulin, the MAR showed that only 1 unit was administered. The discrepancies in insulin administration occurred on several dates, with the resident consistently receiving less insulin than prescribed. The surveyor confirmed these findings during an interview with the Resident Care Coordinator, who reviewed the MAR and acknowledged the incorrect dosages. This failure to administer the correct insulin dosage as per the physician's orders constitutes a deficiency in the facility's care for the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to recognize and address a significant weight loss in one resident, who was part of a sample reviewed for nutrition. The resident's care plan, revised in late November, indicated a need for a nutritional supplement once a day to address weight loss, with a goal to maintain a body weight within 3 lbs of 179 lbs. However, the resident's weight continued to decline from 184 lbs in early September to 155 lbs by mid-February. During an interview, the Director of Nursing acknowledged that the dietician had ordered a supplement, but the order had been dropped. The clinical record lacked evidence that the nursing staff had notified the medical provider or registered dietitian, nor had they initiated additional nutritional interventions to address the ongoing weight loss.
Expired Medications Found in Storage Units
Penalty
Summary
The facility failed to ensure the removal of expired drugs and biologicals from its medication storage units. During an inspection of the medication storage room on the skilled nursing unit, a surveyor found a box of Ayr Saline Nasal Gel that had expired on July 24. Additionally, in the medication storage refrigerator on the long-term care unit, a surveyor discovered a bottle of GI Cocktail, labeled with a discard date of February 2, which was still available for use. This bottle was associated with a resident who had a current physician's order for the GI Cocktail to be administered twice daily as needed for dyspepsia. These findings were confirmed with the Certified Nursing Assistant responsible for medications, and the expired items were immediately removed for destruction.
Failure to Timely Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the medical provider of abnormal laboratory results in a timely manner for a resident who was reviewed for hospitalization. On January 21, 2025, the resident had blood work and a chest x-ray ordered by the doctor. The blood work, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), was completed and the results were available by 9:23 a.m. the same day. The results showed abnormal values, including a high white blood cell count, sodium level, and potassium level. However, the facility's documentation indicated that these results were not reviewed by a Nurse Practitioner until 28 hours later, on January 22, 2025, at 1:44 p.m. During interviews, the Registered Nurse stated that results must be checked on the computer unless they are critical values, which would prompt a call from the laboratory. The Director of Nursing acknowledged that the medical provider should have been informed of the abnormal results by telephone when they were available.
Failure to Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumococcal immunization, as required by their policy. The policy, last revised in February 2012, mandates that all patients be offered the vaccine unless contraindicated due to health history, with administration following a standing order. During a review of the clinical record for one resident, the surveyor found no evidence that the resident was offered, declined, or received the pneumococcal immunization. An interview with the Infection Preventionist confirmed the absence of any record of offering, history of receiving, or declination of the vaccine in the resident's clinical record. The resident's representative consented to the immunization only after the surveyor inquired about the vaccination status.
Resident Sexual Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt, touching the resident's breasts. This incident was reported by a Certified Nursing Assistant (CNA1) who entered the resident's room and witnessed the inappropriate contact. The resident involved had multiple diagnoses, including generalized anxiety disorder, major depressive disorder, PTSD, agitation, dementia, major neurocognitive disorder, Alzheimer's disease, and vascular dementia, and was incapable of consenting to sexual activity. The facility's investigation revealed that the Transporter, Activities staff admitted to the inappropriate contact and acknowledged that the resident was not in a normal state of mind and could not consent. The resident did not exhibit outward signs of emotional distress following the incident, but the situation was a clear violation of the resident's dignity and the facility's policy that residents will be free from sexual abuse. The incident was reported to the Maine Department of Health and Human Services, Division of Licensing and Certification, and was identified as Immediate Jeopardy at past non-compliance.
Deficiency in Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically regarding mandatory education on abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during a review of facility staff education records, which revealed that two unlicensed staff members, a transporter in activities and a handyman in housekeeping and engineer services, did not complete the required training within the past year. The transporter was hired on March 28, 2016, and the handyman was hired on January 5, 2023. The Director of Nursing confirmed during an interview with a surveyor that the mandatory training had not been completed for these staff members within the required timeframe.
Failure to Follow Resident's Bathing Preferences
Penalty
Summary
The facility failed to adhere to a resident's care plan preference for daily evening whirlpool baths. The resident, identified as R1, reported to a surveyor that they were supposed to receive whirlpool baths every evening as per their care plan but did not receive them for 7 days in the past 31 days. The resident only refused the whirlpool bath twice, once due to illness and once due to returning late from an outing. The resident's care plan, last evaluated on 8/27/24, confirmed the request for a daily evening whirlpool bath, with the option to decline if necessary. The facility's documentation practices were found to be inadequate in reflecting the type of bathing the resident received. The facility's decision to document bathing according to Section GG of the MDS 3.0 did not specify the type of bath, leading to a lack of evidence that the resident received any whirlpool baths in the past 31 days. Interviews with the Registered Nurse and the Administrator confirmed the absence of documentation for whirlpool baths, highlighting a deficiency in following the resident's care plan and preferences.
Failure to Follow Physician Orders for Urine Sample
Penalty
Summary
The facility failed to follow physician orders to obtain a urine sample for a resident who was being reviewed for resident-to-resident abuse. The medical record showed a provider order dated 4/18/24 to obtain a urinalysis due to a change in the resident's mental status. However, as confirmed by the Administrator during an interview on 4/23/24, the urine sample was not obtained five days after the order was given, and there was no record of any attempt or completion of the urine sample.
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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