High View Rehabilitation And Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madawaska, Maine.
- Location
- 517 Riverview St, Madawaska, Maine 04756
- CMS Provider Number
- 205114
- Inspections on file
- 17
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at High View Rehabilitation And Living Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to identify and address hazards related to bed safety, resulting in one resident sustaining a skin tear from striking an exposed bed frame and another resident being at risk of entrapment due to an ill-fitting mattress and exposed bed frame. Staff were unfamiliar with safety measurement tools and did not follow inspection protocols, leading to unaddressed risks and an immediate jeopardy situation for all residents.
A resident with hemiplegia and osteoporosis was found with a 10-inch gap between the mattress and bed rail due to an improperly sized mattress, far exceeding FDA recommendations. The facility also failed to regularly inspect and monitor bed rails for all residents using them, and staff were unaware of proper measurement procedures, creating a risk of entrapment.
Surveyors found that the facility did not properly inspect or maintain bed frames, mattresses, and bed rails, resulting in exposed gaps and mechanical parts that created entrapment risks for several residents. Staff were not trained to use the required measurement device or to recognize unsafe bed equipment, and recent inspections failed to assess mattress and bed frame compatibility. Observations included residents with improperly fitting mattresses, exposed sharp edges, and gaps that could entrap body parts.
Surveyors found multiple areas of building disrepair, including chipped paint, unpainted walls, water leaks managed with makeshift trash bag funnels, out-of-order bathrooms, and uncleanable surfaces with accumulated debris. Facility staff confirmed these issues, some of which had persisted for weeks or months, affecting residents' living spaces and comfort.
Surveyors found that the facility failed to maintain kitchen cleanliness, properly label and discard food items, and consistently document food temperatures, with multiple instances of dirt buildup, unlabeled and expired foods, and incomplete temperature logs confirmed by the Food Service Supervisor.
The facility did not notify the CDC of a Norovirus outbreak affecting several residents with symptoms such as nausea, vomiting, and diarrhea, as required by policy. Additionally, the Legionella Water Management Program lacked testing protocols, documentation, and validation measures for water-borne pathogens.
Three residents who had previously received earlier pneumococcal vaccines were not offered the updated PCV20 or PCV21 vaccine as recommended by CDC guidelines. Facility policy required assessment and offering of the vaccine, but documentation and interviews confirmed this was not done for these individuals.
A resident over 6 feet tall was found to have a bed and mattress that were too short, resulting in a 3-inch gap at the foot of the bed and the resident's feet hanging over the edge. The facility had not provided a properly sized bed as previously indicated, and the gap was temporarily filled with a rolled-up blanket.
A resident with a history of non-ST elevation MI was given Eliquis by an RN during a period when the medication was ordered to be held for a scheduled procedure. The error was discovered after administration, resulting in the cancellation and rescheduling of the procedure and necessitating another medication hold.
A resident receiving oxygen therapy was observed using an oxygen concentrator with a very dusty filter on two separate days. Despite manufacturer instructions and facility policy requiring regular cleaning of the filter, staff did not ensure the filter was maintained in a sanitary condition, as confirmed by surveyor observation and the DON.
A resident with an active diagnosis of PTSD did not have a trauma-informed care plan or identified triggers documented in their care plan. The MDS confirmed the psychiatric diagnosis, but the care plan lacked necessary trauma-informed interventions, as acknowledged by the DON during the survey.
The facility was cited for repeat deficiencies, including failure to maintain kitchen sanitation and discard expired foods, lack of a water management program to prevent Legionella and other pathogens, and not offering the updated Pneumococcal vaccine to three of five residents. The Quality Assurance Committee did not ensure ongoing monitoring beyond three months, leading to recurrence of these issues.
A facility failed to notify a physician of a resident's change of condition before transferring the resident to the hospital on two occasions. The resident showed signs of distress, such as confusion and slurred speech, but the medical provider was not informed prior to the transfers. The RN involved was unaware of the requirement to notify the provider before hospital transfers.
A resident experienced a delay in being transferred to the hospital after a change in condition was reported. The resident exhibited slurred speech, and although the Nurse Manager prepared the necessary paperwork, the RN delayed calling EMS due to being overwhelmed with other tasks. The EMS was called almost 1 3/4 hours after the initial report, despite being located only 0.5 miles from the facility.
The facility failed to have a qualified Food Service Director for three consecutive days of the survey. The Administrator was temporarily filling the role, and none of the dietary staff, including the Administrator, had serve safe certifications. This deficiency has the potential to affect all residents.
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Surveyors observed unsanitary conditions, including uncleanable portions of the floor, dented cans, undated and open food packages, and expired food items. Serving pans were stored unsanitarily, and the Cook was observed preparing food without a hairnet or beard restraint. These conditions persisted over the three-day survey.
The facility failed to implement its Legionella Water Management Program by not having measures in place to assess and monitor areas where Legionella and other waterborne pathogens could grow and spread. This was confirmed during a policy review and an interview with the Administrator.
The facility failed to offer the influenza vaccination to four residents and did not offer the updated Pneumococcal vaccination to five residents, as per facility policies and CDC recommendations. The DON confirmed that assessments and vaccinations were not conducted within the required timeframes.
The facility failed to follow CDC guidelines and offer the updated 2023-2024 COVID-19 vaccine doses to four residents. Clinical records and interviews confirmed that the updated vaccinations were not offered, despite the facility's policy indicating adherence to CDC recommendations.
A resident experienced a choking event, and although the incident was documented and aspiration precautions were initiated, the facility failed to notify the physician of the change in status. The interim DON confirmed that the provider was not informed until two days later, acknowledging that staff should notify the provider immediately after such incidents.
The facility failed to document the reason for a resident's transfer to a hospital and did not provide written notification to the resident or their representative. The transfer form was incomplete, and the responsible nurse did not mail or give a written copy of the notice after it was signed.
The facility failed to provide a written bed hold notice to a resident and their representative after a hospital transfer. Although the Bed Hold Notification form was signed, the section indicating who received the notice was left blank. A nurse admitted to calling the Resident Representative but did not mail or provide a written copy of the notice.
The facility failed to complete required neuro assessments for a resident who fell and hit their head and did not follow physician orders for topical treatments during ADL care for another resident. The necessary neuro checks were not performed due to a failure to enter the task into the computer system, and the observed care did not align with the physician's orders for topical treatments.
The facility failed to ensure that the pharmacist identified an irregularity in the drug regimen review for a resident on Olanzapine. The resident had a physician order for AIMS testing every six months, but the last test was completed nearly a year ago. This lapse was not identified by the pharmacist in their monthly reviews, as confirmed during a clinical record review with the MDS nurse.
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test every 6 months for a resident on Olanzapine, as required by the physician's order. The last documented AIMS test was nearly a year old, and the missed test was confirmed by the MDS Nurse.
Failure to Identify and Address Bed Safety Hazards Resulting in Resident Injury and Entrapment Risk
Penalty
Summary
The facility failed to identify and address hazards in the resident environment, specifically related to bed safety, which resulted in avoidable accidents and injuries. One resident sustained a skin tear on the right arm after falling and striking an exposed, uncovered section of the bed frame where the mattress did not fully cover the frame. The exposed area included a mechanical hinge, screw, and sharp metal edges due to missing plastic caps. The resident self-reported the incident, and clinical documentation confirmed the injury and subsequent pain during wound care. Observations by surveyors and interviews with staff confirmed that the mattress was not the correct size for the bed frame, leaving hazardous areas exposed. Another resident was observed lying in bed with several inches of the bed frame exposed on both sides of the mattress, creating multiple areas for possible entrapment of body parts. The bed rail at the resident's head was measured to be 10 inches from the mattress, exceeding recommended safety limits and presenting a risk of entrapment. The maintenance supervisor acknowledged that the bed frame was wider than the mattress and that staff had independently adjusted bed equipment without proper oversight or knowledge of safety requirements. The administrator confirmed that staff had made changes to bed mattresses without notifying administrative staff, and the risk for accidents or injuries associated with exposed bed frames was not identified by staff. The facility's Bed Safety policy required regular inspection of beds and related equipment, adherence to FDA guidelines for bed system dimensions, and reporting of injuries related to bed equipment. However, maintenance staff were unfamiliar with the proper use of measurement tools and the required safety dimensions. Documentation and interviews revealed that inspection protocols were not effectively implemented, and hazards were not reported or addressed, resulting in an immediate jeopardy situation for all residents.
Failure to Ensure Safe Bed Rail Dimensions and Monitoring
Penalty
Summary
The facility failed to ensure that a resident's bed dimensions were appropriate, resulting in a 10-inch gap between the mattress and the bed rail. This gap was observed when the resident, who has hemiplegia and hemiparesis affecting the left side and osteoporosis, was found lying in bed with the mattress smaller than the bed frame and offset, creating a wedge-shaped gap. The resident's care plan indicated limited mobility, risk for falls, and use of bed rails for independent mobility, with dependence on two staff for turning and repositioning. The FDA recommends a maximum gap of less than 4 3/4 inches between the bed rail and the compressed mattress, but the observed gap was significantly larger. Additionally, the facility failed to regularly inspect and monitor bed rails for all residents using them, affecting 35 out of 35 residents with bed rails. During an interview, the Maintenance/Housekeeping/Laundry Supervisor acknowledged having a tool to measure bed rail gaps but did not know how to use it or the correct measurements. The surveyor confirmed that the mattresses did not fit the bed frames, creating the potential for entrapment of body parts.
Failure to Identify and Address Bed Entrapment Hazards
Penalty
Summary
The facility failed to conduct effective inspections of bed frames, mattresses, and bed rails to identify and address risks of entrapment for residents. Maintenance staff did not ensure that mattresses were compatible with bed frames, resulting in exposed gaps and mechanical parts that could entrap body parts. The facility's bed safety policy required inspections using a specific measurement device, but staff were not trained on its use or aware of the required safety measurements. Recent bed inspections only evaluated electrical mechanics and did not assess mattress and bed frame compatibility or potential entrapment hazards. Surveyors observed multiple instances where residents were at risk due to improper bed equipment. One resident with hemiplegia and osteoporosis was found in a bed with exposed frame holes and a bed rail positioned in a way that created entrapment risks. Another resident had a mattress that was too small for the frame, exposing sharp metal edges and mechanical parts, and was observed with a skin tear. A third resident's mattress was too short, leaving a significant gap at the foot of the bed. Interviews with staff confirmed a lack of knowledge and training regarding proper bed safety inspections.
Failure to Maintain Safe and Homelike Environment Due to Building Disrepair
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain the building in good repair over a four-day period. Specific deficiencies included chipped paint around room placards, large unpainted areas around a camera installation near the nurse station, and a transition strip between the hall and sitting area that created uncleanable surfaces with accumulated dirt and debris. Additionally, the ceiling outside a resident room was discolored with large pieces of peeling paint hanging down, and a closet door was displaced from its track with broken support, resulting in paint chips falling onto resident clothing below. Further observations revealed that a resident bathroom had a trash bag taped to the ceiling to funnel a steady leak of water into a trash barrel, with paint chips and insulation debris present in the standing water. The bathroom had been in this condition over the winter and was not scheduled for repair until warmer weather. Another resident bathroom was out of order for two weeks due to a leaking toilet seal, and the resident did not use the toilet. These conditions were confirmed by interviews with the Administrator and the Maintenance, Housekeeping, and Laundry Supervisor.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen sanitation and food handling practices over four days. The kitchen was not maintained in a clean manner, with dirt buildup found under dish storage racks and stoves, food splatter on walls behind the stove and meat slicers, and grime around pipes. The warewasher room had soiled tiles and dirt buildup in grout lines. Additionally, the facility failed to properly label thawed nutritional shakes with thaw dates, did not discard expired foods, and did not label or date opened foods. Unlabeled and unidentified food items, including bags of crumbs and cereals without expiration dates, were also found in storage areas and on serving carts. The facility also failed to consistently monitor and document food temperatures for proper cooked and serving temperatures, with 94 out of 99 meals lacking complete temperature records for the reviewed period. These deficiencies were confirmed through interviews with the Food Service Supervisor and review of food temperature logs. No specific residents or patient conditions were mentioned in relation to these deficiencies.
Failure to Report Norovirus Outbreak and Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to notify the Centers for Disease Control and Prevention (CDC) of an outbreak of Norovirus, as required by both facility policy and the Maine CDC Notifiable Diseases and Conditions List. The Infection Preventionist was responsible for reporting confirmed cases of state-specific reportable diseases, including any cluster or outbreak of illness with potential public health significance. Despite several residents exhibiting symptoms consistent with Norovirus, including nausea, vomiting, and diarrhea, the CDC was not notified at the time of the survey. The Director of Nursing confirmed that no testing for Norovirus had been conducted and that the CDC had not been contacted regarding the outbreak during the initial interviews. Additionally, the facility's Legionella Water Management Program was found to be incomplete. The program lacked evidence of established testing protocols, acceptable control measure ranges, documentation of testing results, and corrective actions for when control limits are not maintained. There was also no evidence that the effectiveness of the program was being validated through water testing for Legionella or other water-borne pathogens. These deficiencies were identified during a review of the program with facility leadership.
Failure to Offer Updated Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer the updated pneumococcal vaccination to three residents, as required by its own policy and CDC recommendations. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine is to be offered within thirty days if indicated. Documentation review revealed that three residents had previously received earlier versions of the pneumococcal vaccine (PCV13 and/or PPV23), but there was no evidence that they were offered the most recent pneumococcal vaccine (PCV20 or PCV21) in accordance with current CDC guidelines. The Nurse Manager-Infection Preventionist confirmed the absence of documentation indicating that these residents were offered the updated vaccine. Specifically, one resident had received PCV13 in 2019, another had received PCV13 in 2015 and PPV23 in 2011, and a third had received PCV13 in 2016 and PPV23 in 2007. In each case, CDC recommendations called for consideration of a dose of PCV20 or PCV21 after a specified interval, but there was no record that these recommendations were followed or that the residents were offered the updated vaccine. The facility uses the CDC's PneumoRecs VaxAdvisor tool to determine vaccine recommendations, but this process was not documented for the affected residents.
Failure to Provide Appropriately Sized Bed for Tall Resident
Penalty
Summary
A resident who is over 6 feet tall reported that their bed was too short and that the facility had previously told them a bed to fit their size would be provided, but this had not occurred. Upon observation, there was a 3-inch gap between the end of the mattress and the footboard, which had been filled with a rolled-up blanket, and the resident's feet hung over the edge of the mattress. The deficiency was confirmed during an interview with the Maintenance/Housekeeping/Laundry Supervisor, who acknowledged the issue and stated that a longer mattress had been ordered on the date of the survey. The facility failed to reasonably accommodate the resident's need for an appropriately sized bed, resulting in the resident having to use a bed and mattress that did not fit their height.
Failure to Hold Anticoagulant as Ordered Prior to Procedure
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order to hold Eliquis, an anticoagulant, for a resident scheduled for a medical procedure. The physician's order specified that Eliquis should be held from the morning of 3/22/25 until the afternoon of 3/24/25 due to a planned wart removal procedure. Despite this order, the medication administration record showed that Eliquis was administered to the resident on the evening of 3/23/25. The DON confirmed that the RN gave the medication during the hold period, only realizing the error when charting the medication. This error led to the cancellation and rescheduling of the resident's medical procedure and required the medication to be held again prior to the rescheduled procedure. The resident involved had a history of non-ST elevation myocardial infarction and was prescribed Eliquis as a blood thinner. The failure to adhere to the hold order was identified through clinical record review and staff interviews.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide oxygen therapy in a sanitary manner for a resident on two separate days during the survey period. Observations revealed that the oxygen concentrator filter used by the resident was very dusty on both occasions. The manufacturer's instructions for the Invacare Perfecto2 oxygen concentrator require regular inspection and cleaning of the cabinet filter, especially in environments with high dust or air pollutants. Additionally, the facility's own policy mandates that staff wash oxygen concentrator filters every seven days with soap and water. Despite these guidelines, the filter remained unclean, as confirmed by both surveyor observation and the Director of Nursing.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to identify and address the specific needs of a resident with an active diagnosis of Post-Traumatic Stress Disorder (PTSD). During a clinical record review, it was found that the resident's care plan, last updated on 2/19/25, did not include a trauma-informed approach or identify potential triggers related to the resident's PTSD. The quarterly Minimum Data Set (MDS) confirmed the active diagnosis of PTSD, but there was no evidence in the care plan that trauma-informed care or trigger identification had been incorporated. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a trauma-informed care plan for the resident.
Repeat Deficiencies in Sanitation, Water Management, and Vaccination
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the plan of correction for previously identified deficiencies, as evidenced by repeat citations during the most recent annual recertification survey. Specifically, deficiencies F812, F880, and F883 were cited again for the same issues as the prior survey. F812 involved failure to maintain the kitchen in a clean and sanitary manner and to discard expired foods. F880 was cited for failure to implement a water management program to monitor for and prevent the growth and spread of Legionella and other water-borne pathogens. F883 was cited for failure to offer the updated Pneumococcal vaccination to three out of five residents. The Administrator confirmed that monitoring related to the previous plan of correction was only conducted for three months and was not continued beyond that period, resulting in the recurrence of these deficiencies.
Failure to Notify Physician Before Hospital Transfer
Penalty
Summary
The facility failed to notify the physician of a resident's change of condition prior to transferring the resident to the hospital. On two separate occasions, a resident exhibited signs of distress, including increased confusion and slurred speech, but the medical provider was not informed before the resident was transferred to an acute care facility. On the first occasion, the resident was found attempting to eat a tea bag and was experiencing increased confusion, yet the medical provider was not notified before the transfer. On the second occasion, the resident had slurred speech and an increased respiratory rate, but again, the medical provider was not contacted prior to the transfer. During an interview, the registered nurse involved stated she was unaware of the requirement to notify the provider before hospital transfers.
Delayed Hospital Transfer After Resident's Condition Change
Penalty
Summary
The facility failed to transfer a resident to the hospital in a timely manner after a change in condition was observed. On the day of the incident, a Certified Nursing Assistant reported to an RN and the Nurse Manager that the resident was not looking well and had slurred speech. The Nurse Manager decided to send the resident to the emergency room and began preparing the necessary paperwork. However, there was a delay in calling Emergency Medical Services (EMS) because the RN was occupied with other tasks and did not call EMS immediately after the paperwork was completed. The EMS was eventually called almost 1 3/4 hours after the initial report of the resident's condition change. The RN assessed the resident and documented normal vital signs except for tachypnea, but did not find other stroke signs besides slurred speech. The delay in transferring the resident was attributed to the RN being overwhelmed with paperwork and other responsibilities. The EMS Care Report indicated that the unit was dispatched shortly after the call was made, and the EMS was located only 0.5 miles from the facility, highlighting the delay in initiating the transfer process.
Lack of Qualified Food Service Director and Serve Safe Certifications
Penalty
Summary
The facility failed to ensure they had a qualified Food Service Director for three consecutive days of the survey. On 4/29/24, a Dietary Aide stated that the facility did not have a Food Service Director and that the Administrator was temporarily filling the role. On 4/30/24, interviews with the Cook and two Dietary Aides revealed that none of them had serve safe certifications. Additionally, the Administrator confirmed on the same day that they did not possess a serve safe manager certificate. On 5/1/24, the Administrator confirmed again to a surveyor that the facility did not have a qualified Food Service Director. This deficiency has the potential to affect all residents in the facility.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. On multiple occasions, surveyors observed unsanitary conditions in the kitchen, including uncleanable portions of the floor, dented cans, undated and open food packages, and expired food items. Specifically, dented cans of mushroom pieces and cherry pie filling, open and undated packages of cereal and pork-flavored gravy mix, and expired bottles of Glucerna were found in the dry storage area. Additionally, an opened and undated bag of fully cooked ground Italian sausage was found in the walk-in freezer, and expired yogurt cups were used during breakfast service. These findings were confirmed with the Cook and other dietary aides present at the time of the observations. Further observations revealed that serving pans were stored in an unsanitary manner, face up and exposed to the environment with visible debris, and wet stacking of serving pans was noted. Portions of the kitchen floor were uncleanable, including a circular patch of concrete near the oven, circular slices in the linoleum, and broken tiles around a drain in front of the walk-in freezer. Food splashes were dried on the wall around and behind the stove top, and the Cook was observed preparing food without wearing a hairnet or beard restraint. These unsanitary conditions persisted over the course of the three-day survey, indicating a failure to maintain the kitchen in a clean and sanitary manner.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement the elements of its Legionella Water Management Program. Specifically, the facility did not have measures in place to assess and monitor areas where Legionella and other opportunistic waterborne pathogens could grow and spread. This deficiency was identified during a review of the facility's Legionella Water Management Program policy and an interview with the Administrator. The policy outlined the need to identify areas in the water system that could encourage bacterial growth, such as storage tanks, water heaters, filters, aerators, showerheads, hoses, and other equipment. Additionally, the policy required the identification of situations that could lead to Legionella growth, including construction, water main breaks, changes in municipal water quality, biofilm presence, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection. However, the facility did not have measures in place to monitor these areas and situations, as confirmed by the surveyor during the interview with the Administrator.
Failure to Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer the influenza vaccination to four out of five residents reviewed and did not offer the updated Pneumococcal vaccination to all five residents reviewed. According to the facility's policies, the influenza vaccine should be offered between October 1st and March 31st each year, and the Pneumococcal vaccine should be assessed and offered within thirty days of admission unless medically contraindicated or already vaccinated. However, the facility did not adhere to these policies, as confirmed by the Interim Director of Nursing/Infection Preventionist (DON) during a review of the residents' vaccination records. Specifically, the clinical records for residents R9, R15, R24, and R30 lacked evidence of offering the influenza vaccination. Additionally, the CDC recommendations for administering one dose of Prevnar 20 were not followed for residents R9, R15, R17, R24, and R30. The DON confirmed that the Pneumococcal assessments were not conducted within five days of admission, nor were the vaccines offered within thirty days of admission. This failure to comply with vaccination policies and CDC recommendations was identified during an interview and record review conducted on April 30, 2024.
Failure to Offer Updated COVID-19 Vaccinations
Penalty
Summary
The facility failed to follow CDC guidelines and offer the updated 2023-2024 COVID-19 vaccine doses to four residents. The facility's policy, revised in June 2023, indicated that vaccine recommendations and schedules should be consistent with CDC guidance. However, a review of clinical records and interviews revealed that the updated COVID-19 vaccinations were not offered to residents R15, R17, R24, and R30. Specifically, R15's last documented COVID-19 vaccination was on October 10, 2022, R17's on October 25, 2023, R24's on December 23, 2021, and R30's on June 4, 2021. The clinical records for these residents lacked evidence of offering the updated COVID-19 vaccination. During an interview with the Interim Director of Nursing/Infection Preventionist, it was confirmed that the updated 2023-2024 COVID-19 vaccinations were not offered to these residents. The facility's failure to offer the updated vaccinations is a clear deviation from the CDC's recommendations, which state that people aged [AGE] years and older should receive the updated COVID-19 vaccine doses to protect against serious illness from COVID-19. This oversight was identified during a review of the facility's clinical records, policy, and CDC guidelines.
Failure to Notify Physician of Choking Incident
Penalty
Summary
The facility failed to notify the physician of a change in status for a resident who experienced a choking event. On 4/29/24 at 11:36 a.m., a surveyor observed a CNA-M checking on a resident who was choking. The surveyor heard coughing sounds, almost vomiting, choking sounds, and more repetitive coughing. The CNA-M left to get the RN, who entered the room at 11:39 a.m. and assisted the resident, whose coughing then cleared. The RN attributed the incident to gravy going down the wrong pipe and documented the choking incident in a nurse note as a change of condition, initiating aspiration precaution monitoring for 72 hours. However, there was no evidence that the provider was notified of the incident at that time. On 5/1/24 at 10:30 a.m., the interim DON stated that the facility's practice includes placing residents on aspiration precautions for 72 hours following an aspiration event, but there is no formal policy. The DON confirmed that the provider had not been notified of the change in status until she called the provider during the interview with the surveyor. The DON acknowledged that staff should notify the provider after each incident and that the provider should have been informed while in-house the previous day.
Failure to Document and Notify Transfer Reason
Penalty
Summary
The facility failed to properly document and notify the reason for a resident's transfer to an acute care hospital. Resident R34 was admitted to the facility and later transferred to the hospital. The clinical record for R34 did not include the reason for the transfer on the transfer form, which was signed by the resident. Additionally, the section of the form indicating who received the written notice was left blank. During interviews, the Social Worker-Conditional mentioned that nurses are responsible for completing the transfer paperwork, and a Registered Nurse admitted to calling the Resident Representative but failing to mail or provide a written copy of the notice to the resident after it was signed. The form reviewed by the surveyor also lacked the reason for the transfer.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of a bed hold notice after a transfer to an acute care hospital. Resident 34 was admitted to the facility and later transferred to the hospital. The Bed Hold Notification form was signed by the resident, but the section indicating who received the written notice was left blank. During interviews, the Social Worker-Conditional mentioned that nurses complete the form during the transfer paperwork process. However, a Registered Nurse admitted that while she called the Resident Representative, she did not mail or provide a written copy of the notice to the resident after it was signed.
Failure to Complete Neuro Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to complete neurological assessments for a resident who fell and hit their head. The resident was found on the floor with a bruised and tender nose and was sent to the hospital for evaluation of a possible concussion. Despite the facility's protocol requiring neuro checks every shift for 72 hours after such an incident, no evidence of these assessments was found in the clinical record. During an interview, the Interim Director of Nursing and a Registered Nurse confirmed that the necessary neuro assessments were not completed due to a failure to enter the task into the computer system. Additionally, the facility did not follow physician orders for the application of topical treatments during ADL care for another resident. The surveyor observed a nurse applying Lantiseptic ointment and a CNA applying powder under the resident's breasts, but the clinical record revealed that the physician had ordered different treatments, including Caldesene Powder and Calmoseptine with stoma powder. The electronic Treatment Administration Record indicated that these treatments were marked as administered, but the actual observed care did not align with the physician's orders. The nurse confirmed that the documented administrations did not match the observed applications.
Failure to Identify Irregularity in Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the pharmacist identified an irregularity in the drug regimen review for a resident on psychotropic medication. Specifically, the resident was prescribed Olanzapine and had a physician order for Abnormal Involuntary Movement Scale (AIMS) testing every six months. However, the last AIMS test was completed nearly a year ago, and the pharmacist did not identify this lapse in their monthly medication reviews. This deficiency was confirmed during a clinical record review with the Minimum Data Set (MDS) nurse.
Failure to Complete AIMS Testing for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that an Abnormal Involuntary Movement Scale (AIMS) test was completed every 6 months for a resident on anti-psychotic medication, Olanzapine. The resident's current physician order required AIMS testing every 6 months, but the last documented test was completed almost a year prior. The electronic treatment administration record indicated that the AIMS test was due in November, but it was not completed. This deficiency was confirmed during an interview with the Minimum Data Set (MDS) Nurse.
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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