Katahdin Health Care Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Millinocket, Maine.
- Location
- 22 Walnut Street, Millinocket, Maine 04462
- CMS Provider Number
- 205149
- Inspections on file
- 14
- Latest survey
- February 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Katahdin Health Care Llc during CMS and state inspections, most recent first.
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The facility failed to maintain complete and accurate clinical records for several residents, including missing or outdated information on code status and advanced directives.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.
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.
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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