Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Katahdin Health Care Llc during CMS and state inspections, most recent first.
A resident’s ordered blood glucose checks and insulin doses were not completed on the evening shift on more than one occasion. The TAR showed that an LPN did not perform the 7:30 p.m. blood sugar check or give the ordered Humalog and Lantus insulin, and there was no documentation explaining why the treatments were missed.
Failure to Send Pharmacist MRR Irregularity Report: A resident's monthly medication regimen review identified a need to evaluate for potential GDR, but the CP did not ensure the irregularity report was sent to the DON or physician. The DON could not locate the physician response in the chart or the written request in the MRR binder, and the CP stated a computer issue prevented the report from being transmitted.
The facility failed to develop and implement baseline care plans within 48 hours for four newly admitted residents, each with significant health conditions such as diabetes, heart failure, COPD, and pressure ulcers. Interviews confirmed the delay in addressing these care needs, highlighting a systemic issue in timely care planning.
The facility failed to verify and clarify hospital discharge orders for three residents, leading to discrepancies in medication administration and treatment. Medications were given without physician orders, and some were continued despite being ordered to be discontinued. The DON confirmed that discharge orders were not verified, and previous orders were assumed to continue without clarification.
The facility was cited for deficiencies in food storage and staff hygiene. Nutritional supplements in refrigerators lacked thaw dates, and cereal bags in dry storage were not labeled with expiration dates. Additionally, a cook was observed with a hat that did not fully contain her hair, indicating improper use of hairnets. These issues were confirmed with the Food Service Director.
The facility failed to maintain complete and accurate clinical records for several residents, including missing or outdated information on code status and advanced directives. Discrepancies in physician order dates were also noted, indicating poor documentation practices.
The facility did not offer pneumococcal vaccinations to two residents as per CDC guidelines. One resident was not offered the PCV20 vaccine five years after their last dose, and another was not offered the vaccine one year after their last PPSV23 dose. The DON confirmed the oversight.
A facility failed to create a comprehensive care plan for a resident admitted with Hospice services, who required management for chronic pain and diabetes. Despite having physician orders for opioid pain medication and insulin, the care plan did not address these needs, as confirmed by an MDS nurse.
A facility failed to update a care plan for a resident with a pressure ulcer. The resident had a physician order for treatment of a pressure ulcer on the left lateral 5th digit toe, which initially developed and resolved, but reopened upon readmission. The care plan was not updated to reflect the reopened ulcer until 6 days after readmission, as confirmed by the DON.
A facility failed to maintain sanitary conditions for oxygen therapy equipment, as observed over two days. A resident was using a DeVilbiss 5 Liter Oxygen Concentrator with a dusty air filter. The DON confirmed the oversight, acknowledging that cleaning the filter had not been considered.
A facility failed to ensure a physician reviewed a resident's care program, including signing medication and treatment orders, in a timely manner. The resident's block orders were last signed on December 18, 2024, and required a review and signature by January 28, 2025. However, no further physician visits occurred, and the orders were 15 days overdue as of February 12, 2025. This was confirmed by the DON.
A facility failed to ensure that a resident's attending physician made the required visits. The resident was admitted and had a physician visit on December 18, 2024, but the next required visit, due by January 28, 2025, did not occur, making it 15 days late. This was confirmed by the DON during an interview.
Vaccines, including influenza, Prevnar 20, measles, and Covid-19, were improperly stored in a dormitory-style refrigerator with a built-in freezer compartment, contrary to CDC guidelines. An LPN and a surveyor observed this during an inspection, and the DON confirmed the facility's adherence to CDC recommendations, despite the improper storage.
The facility's Legionella Water Management Program was found deficient due to a lack of documentation verifying control measures and monitoring in identified areas, and the absence of water sample testing. Despite identifying potential Legionella growth areas and establishing control measures, the facility failed to implement a comprehensive verification process, as admitted by the Maintenance Supervisor.
The facility failed to follow physician orders for four residents, resulting in missed or improperly administered medications due to issues with timely medication orders, unavailability, and lack of proper authorization or documentation.
The facility failed to store, prepare, and serve food in accordance with professional standards, including improper storage of food items and inadequate sanitization of thermometers. Additionally, the sanitizer solution used was below the recommended concentration levels, increasing the risk of foodborne illness for all residents.
The facility failed to update the care plan for a resident who fell and sustained a fractured left lower leg, resulting in a change to non-ambulatory status. Despite the significant change, the care plan was not revised, and the MDS Coordinator confirmed the oversight.
The facility failed to ensure the presence of an RN for at least 8 consecutive hours a day, 7 days a week. A review of time cards and interviews confirmed the absence of RN coverage on two specific weekend dates. The DON acknowledged that an RN was on medical leave and admitted to not working on the specified dates, despite usually filling in on weekends.
The facility failed to complete physician-ordered lab tests for a resident. Despite a physician order to draw blood for five tests, there was no evidence that the blood draw was attempted or completed. The Clinical Supervisor confirmed that the bloodwork was not done and no documentation indicated any attempt.
The facility failed to provide annual dementia training for two CNAs. CNA4 had no documented dementia training since being hired, and CNA5 had no training recorded for 2023. This was confirmed during an interview with the Business Office Manager.
Missed blood glucose checks and insulin administration
Penalty
Summary
The facility failed to ensure that physician orders were followed for Resident #19, who had orders for blood glucose monitoring and insulin administration. On 3/2/26 and again on 3/10/26, the March TAR showed that the evening-shift blood sugar check at 7:30 p.m. was not completed, and the ordered insulin doses were not administered. The missed orders included sliding scale Humalog insulin before meals and at bedtime based on the 7:30 p.m. blood sugar result, as well as scheduled Lantus insulin 24 units at 8:00 p.m. During record review on 3/18/26, the surveyor and DON reviewed the TAR and confirmed that the treatments were not completed by LPN #1 on the evening of 3/2/26. The DON stated there was nothing documented to show why the treatments were not completed and said she had called LPN #1 and left a message. Later that day, the DON also stated that the same orders had not been completed for Resident #19 on 3/10/26.
Failure to Send Pharmacist MRR Irregularity Report
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist reported a medication regimen review irregularity to the DON and physician after completing the monthly review for one sampled resident, Resident #19, who was reviewed for unnecessary medications. The facility policy on Medication Regimen Reviews, revised 3/2025, stated that within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The electronic record showed that the CP completed the January MRR on 1/7/26 and documented, "Please evaluate for potential GDR [gradual dose reduction]. Thank you." On 3/18/26, the DON and surveyor reviewed the resident's paper chart and the DON could not find the physician's response to the CP's request. The DON also reviewed a binder containing January's MRRs and still could not locate the written request form for the resident. During a telephone interview, the CP stated that due to a computer issue she was unaware of until 3/18/26, the resident's January MRR irregularity written report was not sent anywhere, so neither the DON nor the physician received a copy for evaluation.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented within 48 hours for four residents admitted in the last 30 days. Resident #16 was admitted with multiple health conditions including diabetes mellitus, heart failure, and depression, but these care areas were not added to the baseline care plan within the required timeframe. Similarly, Resident #25, who was receiving hospice services and had conditions such as type 2 diabetes mellitus and COPD, did not have these needs addressed in a timely baseline care plan. Resident #31, with insulin-dependent diabetes and depression, also did not have a complete baseline care plan developed within 48 hours of admission. Additionally, Resident #37, who had acute and chronic respiratory failure, opioid abuse, and a Stage 2 pressure ulcer, did not have these critical care areas included in the baseline care plan within the required period. Interviews with the MDS nurse and the Director of Nursing confirmed these findings, indicating a systemic issue in the timely development of baseline care plans for newly admitted residents.
Failure to Verify Hospital Discharge Orders
Penalty
Summary
The facility failed to verify and clarify admission orders for three residents who returned from an acute care hospital stay, leading to discrepancies in medication administration and treatment. For Resident #3, the facility did not clarify discharge orders with a provider, resulting in the administration of medications and treatments that were not on the active Medication Administration Record (MAR) or Treatment Administration Record (TAR). Additionally, medications were given without a physician's order, and a dose reduction order for Risperidone was not followed. The Director of Nursing (DON) confirmed that the discharge orders were not verified, and the facility assumed continuation of previous orders without clarification. For Resident #17, the facility continued to administer medications that were ordered to be discontinued or held upon discharge from the hospital. The MAR indicated incorrect doses for several medications, and treatments were administered without current physician orders. The DON confirmed that the discharge orders were not verified with the provider, and the facility continued previous orders without reordering them by the physician. Resident #16's hospital discharge orders were not accurately entered into the facility's electronic record, resulting in the omission of a critical heart arrhythmia medication and incorrect dosing of an ulcer treatment medication. Additional medications were added to the facility's orders without being included in the hospital discharge orders. The DON confirmed that the hospital orders had not been signed by the facility's medical provider, and the orders were only clarified seven days after readmission.
Deficiencies in Food Storage and Staff Hygiene
Penalty
Summary
The facility was found to have several deficiencies related to food storage and staff hygiene during a survey. Observations revealed that nutritional supplements in the walk-in and reach-in refrigerators were not labeled with thaw dates, despite instructions indicating they should be used within 14 days of thawing. Additionally, bags of cereal in the dry food storage area were not labeled with expiration dates after being removed from their original packaging. Furthermore, during the survey, a cook was observed wearing a hat that did not fully contain her hair, indicating improper use of hairnets by kitchen staff. These findings were confirmed with the Food Service Director at the time of observation.
Deficiencies in Clinical Record-Keeping
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents. For Resident #6, there was no evidence of code status in the electronic record, and the information was only found in an old paper chart. Similarly, Resident #15's code status was not readily available in the electronic record and was only found in the paper chart. Resident #23's records indicated an advanced directive was provided, but it was not present in either the electronic or paper records, leading to a misunderstanding with the POA. Resident #25's records did not indicate whether an advanced directive was present, and the physician orders lacked information on code status or hospice care. Additionally, for Resident #16, there was a discrepancy in the dates of the signed physician orders, with the orders being signed before the resident's admission and before the orders were printed. These deficiencies highlight a lack of proper documentation and record-keeping practices, which are essential for ensuring accurate and complete clinical records for residents.
Failure to Offer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. Specifically, two residents, identified as R20 and R12, were not offered the PCV20 vaccine as recommended. R20's clinical record showed no evidence of being offered or receiving the PCV20 vaccine, despite the CDC's recommendation for administration at least five years after the last pneumococcal vaccine dose, which was given in 2017. Similarly, R12's record lacked evidence of being offered or receiving the PCV20 vaccine, although the CDC recommended a dose at least one year after the last PPSV23 vaccine, administered in 2017. The Director of Nursing acknowledged the oversight and confirmed that the residents had not been offered the vaccine.
Failure to Develop Comprehensive Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted while receiving Hospice services for a terminal illness. The resident had physician orders for opioid pain medication for chronic pain and required pain monitoring, as well as insulin for diabetes management. However, upon review of the resident's clinical record, it was found that the care plan did not address the resident's chronic pain or diabetes. This deficiency was confirmed during an interview with the MDS nurse.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident with a pressure ulcer. The resident had a physician order for treatment of a pressure ulcer on the left lateral 5th digit toe, which initially developed on 12/12/24 and resolved on 1/15/25. However, after being readmitted to the facility on 2/4/25 with the pressure ulcer reopened, the care plan was not updated to reflect this condition until 6 days later. The Director of Nursing confirmed that the care plan was not updated when the pressure ulcer first started and was also not updated upon the resident's readmission with the reopened ulcer.
Failure to Maintain Sanitary Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide oxygen therapy in a sanitary manner for a resident over two days of the survey. The deficiency was observed when a surveyor noted that a resident was using a DeVilbiss 5 Liter Oxygen Concentrator with a dusty air filter. This observation was made on two separate occasions, and the Director of Nursing confirmed the finding, admitting that cleaning the filter had not been considered and would be added to the orders when changing the tubing.
Physician's Delay in Signing Orders
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. The clinical record of a resident was reviewed and showed that block orders were last signed by the physician on December 18, 2024. The next block order, which included a 10-day grace period, required review and the physician's signature by January 28, 2025. However, there were no further visits from the physician, and as of February 12, 2025, the orders were 15 days overdue. This was confirmed in an interview with the Director of Nursing.
Physician Visit Requirement Not Met
Penalty
Summary
The facility failed to ensure that the attending physician made the required visits for a resident, as mandated by regulations. The clinical record review revealed that the resident was admitted on an unspecified date and had a physician visit on December 18, 2024. The subsequent 30-day physician visit, which included a 10-day grace period, was due on January 28, 2025. However, there were no further visits from the physician, resulting in the visit being 15 days late. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the last physician visit and written progress note were signed on December 18, 2024.
Improper Vaccine Storage in Dormitory-Style Refrigerator
Penalty
Summary
The facility failed to ensure proper storage of vaccines in accordance with CDC guidelines. During an observation, a surveyor and an LPN found that vaccines, including influenza, Prevnar 20, measles, and Covid-19, were stored in a dormitory-style refrigerator with a built-in freezer compartment. This type of refrigerator is not recommended for vaccine storage as per the CDC's Vaccine Storage and Handling Toolkit, which explicitly advises against using dormitory-style or bar-style combined refrigerator/freezer units for vaccine storage. The Director of Nursing confirmed that the facility follows CDC recommendations, yet the vaccines were still stored improperly.
Deficiency in Legionella Water Management Program
Penalty
Summary
The facility failed to fully develop and implement a comprehensive Legionella Water Management Program. During a review of the program, it was found that the facility identified potential areas for Legionella growth, such as sinks, showers, and water coolers, and established control measures like visual testing and temperature monitoring. However, the Maintenance Supervisor admitted to having no documentation to verify the control measures and monitoring in these identified areas. Additionally, the facility did not send water samples for testing, which is a critical component of ensuring the program's effectiveness. This lack of documentation and testing indicates a deficiency in the facility's infection prevention and control efforts.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to follow physician orders for four residents, leading to missed or improperly administered medications. Resident #15 did not receive Sucralfate for four days due to issues with timely medication orders from the pharmacy. The Clinical Supervisor confirmed the medication was not administered and acknowledged ongoing problems with medication procurement. Resident #4 had multiple instances where Lantus insulin was held without notifying the physician, contrary to standing orders. Additionally, Duloxetine and Tramadol were not administered as prescribed due to unavailability, despite being available in emergency stock. The LPN admitted to using nursing judgment to hold medications without proper authorization or documentation. Resident #19 did not receive Mucinex as ordered because the medication was not available, and the Clinical Supervisor was unaware of this issue. Resident #31 missed multiple doses of Sucralfate due to late administration and pharmacy delays. The LPN responsible for administering the medication confirmed the missed doses and cited issues with timely medication delivery and workload challenges. The physician was not notified of the held doses, and there was no documentation indicating the medication needed to be given before meals, leading to further confusion and missed doses.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During the initial tour of the kitchen, surveyors observed multiple instances of food being stored in an unsanitary manner. Specifically, in the dry storage area, an open and unlabeled bag of garlic bread sticks was found. In the walk-in freezer, an open and unlabeled bag of chicken patties and bread rolls were observed. Additionally, in the walk-in fridge, an open and unwrapped box labeled 15 pounds of sliced bacon was found. These findings were confirmed by Cook #1 and Cook #2 on separate occasions. The facility also failed to properly sanitize thermometers used for checking food temperatures. On one occasion, Cook #1 attempted to use a thermometer that had been dropped on the floor and then swirled in a red bucket containing sanitizer solution, which was not appropriate for sanitizing dishes. On another occasion, Cook #2 used alcohol wipes to sanitize the thermometer but then contaminated it by lifting a trash lid and wiping it with a towel before checking food temperatures. Additionally, the sanitizer solution used in the facility was found to be below the manufacturer's recommended concentration levels, which was confirmed by the Dietary Supervisor and Dietary Aid #1. These deficiencies have the potential to affect all residents in the facility by increasing the risk of foodborne illness.
Failure to Update Care Plan After Resident's Major Injury
Penalty
Summary
The facility failed to update the care plan for a resident who experienced a fall resulting in a major injury. The resident, who was observed sitting in a wheelchair with a cast on their left lower leg, had fallen and sustained a fractured left lower leg, rendering them non-ambulatory and wheelchair dependent. Despite the significant change in the resident's condition, the care plan had not been revised to reflect the new ambulation status. The Minimum Data Set (MDS) significant change form indicated that the care area related to falls was triggered and addressed in the care plan, but the care plan dated 1/23/24 lacked evidence of updates. The MDS Coordinator confirmed that the care plan was not updated after the fall with major injury, as it should have been.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of time cards and interviews for two specific weekend dates. On 3/11/24, a surveyor requested and reviewed the time cards for RNs for Sunday 2/25/24 and Saturday 3/9/24, confirming the absence of RN coverage for the required 8 consecutive hours on both dates. During an interview on 3/12/24, the Director of Nursing (DON) acknowledged that an RN who typically worked every other weekend was on medical leave and admitted that she did not work on the specified dates, despite usually filling in on weekends. The DON also mentioned that she does not punch a time card herself, further complicating the verification of her presence on those dates.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were attempted or completed for one resident. A physician order dated 1/14/24 required blood to be drawn for five laboratory tests on 1/16/24. However, there was no evidence in the clinical record that the blood draw was attempted or completed. During interviews, the LPN stated that the Clinical Supervisor is responsible for drawing blood. The Clinical Supervisor acknowledged that the resident was a difficult stick and that she would inform the Director of Nursing if she could not draw blood. Upon further investigation, the Clinical Supervisor confirmed that the bloodwork was not done, and there was no documentation to indicate any attempt was made.
Deficiency in Annual Dementia Training for CNAs
Penalty
Summary
The facility failed to implement and maintain an effective training program, specifically annual dementia training, for two of three Certified Nursing Assistants (CNAs) reviewed. CNA4, hired on December 15, 2022, had no documented dementia training in their employee file. CNA5, hired on December 31, 2021, had their most recent dementia training documented on August 13, 2022, with no training recorded for 2023. This deficiency was confirmed during an interview with the Business Office Manager on March 13, 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Millinocket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cummings Health Care Facility | 28 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.