Kennebunk Center For Health & Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kennebunk, Maine.
- Location
- 158 Ross Rd, Kennebunk, Maine 04043
- CMS Provider Number
- 205095
- Inspections on file
- 20
- Latest survey
- February 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kennebunk Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
A facility failed to evaluate and document the self-administration of medications for four residents, who were found with various creams and medications at their bedside without proper orders or evaluations. The facility's policy requires a self-administration evaluation, a physician's order, and a care plan, which were not completed, as confirmed by the DON.
The facility failed to properly store and label medications and treatments on two units. Several residents had unlabeled creams on their bedside tables, with some applying them independently. Medical records showed discrepancies in provider orders for these treatments. The DON confirmed the improper storage and removed the items.
A resident was found with a can of disinfectant spray on their bedside dresser, which they used for odor control. The DON was unaware of its presence and confirmed it should not have been accessible to the resident, indicating a failure to ensure the environment was free from accident hazards.
A resident was found with an unknown cream and applesauce on their bedside table, stating they applied the cream for arthritis pain themselves. The facility's records inaccurately documented that a nurse applied Voltaren Gel, which the resident confirmed they used independently. This discrepancy highlights a failure in maintaining accurate clinical records.
The facility failed to maintain a sanitary and comfortable environment across all units and the Laundry Room. Observations revealed black and brown substances around toilets, peeled caulking, and improperly stored items in shared bathrooms. The Laundry Room had significant dust and debris on fans, heaters, and pipes, with stained sinks and cobwebs. These issues indicate a widespread failure in housekeeping and maintenance services.
The facility failed to provide adequate ADL care for several residents, including bathing and oral hygiene. A resident with COPD did not receive proper ADL care, and documentation was lacking. Another resident was observed with poor oral hygiene despite care plan instructions. Additional residents reported not receiving regular showers, with missing or infrequent documentation in their EMRs. The DON confirmed the lack of documentation and care provided.
The facility failed to maintain sanitary conditions for respiratory care, with two residents' nebulizer equipment improperly stored and maintained. One resident's equipment was not changed per physician orders, and there was no record of filter changes. Another resident's equipment was unbagged and unlabeled. These issues were confirmed by the Regional Director of Clinical Operations.
The facility was found to have insufficient direct care staff on weekends, as confirmed by the Administrator and a review of staffing reports. This deficiency, identified during the fourth quarter of 2024, potentially affects all residents needing assistance with ADLs.
The facility's kitchen was found to be unsanitary, with debris and expired food items present. Staff failed to follow personal hygiene protocols, such as wearing hair restraints, and did not change gloves between handling different food items. Additionally, food temperatures were not monitored before serving.
The facility failed to ensure residents and their representatives were clearly informed about the terms and conditions of a binding arbitration agreement, which was included in the admission paperwork. The Admissions and Marketing Director did not adequately explain that signing the agreement was not mandatory for admission and that it would remain in effect unless rescinded within 30 days. Interviews revealed that residents and their representatives were unaware of the agreement's implications, leading to a deficiency in the facility's admission process.
The facility did not maintain adequate pharmaceutical services, as an expired medication card for Ondansetron HCL 4 mg was found in a medication cart on Eagle Wing. This expired medication was intended for a resident and was confirmed by an LPN. The issue was discussed with the DON.
A resident's choice to keep a sweater on was disregarded by staff, leading to a cracked tooth during its removal. Despite the resident's clear objection and physical resistance, staff removed the sweater, causing the injury. The incident was reported to the Department of Licensing and Certification, and the Director of Nursing confirmed the resident's rights were not respected.
A resident with a history of falls and diagnoses of COVID-19 and orthostatic hypotension experienced multiple unwitnessed falls without proper neurological monitoring as per facility policy. The facility's documentation showed repeated vital signs and incomplete evaluations, and the Director of Nursing confirmed these deficiencies.
The facility failed to document that Advance Directives were offered or reviewed with residents and/or their representatives, affecting 11 out of 14 residents reviewed. Interviews with staff confirmed the deficiency, with the social worker admitting to inconsistent documentation and follow-up, and the DON acknowledging missing documentation in residents' charts.
The facility failed to document controlled substance counts at shift changes in the Sagamore Unit, as required by policy. Over a period, multiple shifts lacked evidence of proper documentation by two authorized individuals, leading to an incident where a 30ml bottle of Ativan was unaccounted for. Interviews confirmed the lack of adherence to the correct process.
The facility failed to provide a separately locked compartment for controlled drugs, as required by regulations. This was discovered when a surveyor observed the absence of a separate locked box in the medication room's refrigerator. The issue was confirmed by the DON, following an incident where a bottle of Ativan was reported missing during a shift change.
Failure to Evaluate and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to determine if it was clinically appropriate for four residents to self-administer medications, as observed during a survey. Residents were found with various creams and medications at their bedside without proper documentation or orders for self-administration. Specifically, Resident #2 had an unknown cream, Resident #3 had Biofreeze and Voltaren gels, Resident #4 had Biofreeze and Triad Hydrophilic wound dressing paste, and Resident #5 had an unknown cream for arthritis pain. None of these residents had a documented physician order for self-administration, a self-administration evaluation, or a care plan for self-administration in their medical records. The facility's policy requires a self-administration evaluation by a licensed nurse, a physician's order for self-administration, and a person-centered care plan for residents who self-administer medications. However, these steps were not followed for the residents in question. The Director of Nursing confirmed that there should be an MD order and evaluation completed if a resident is self-administering medications. This oversight indicates a failure to adhere to the facility's policy and ensure the safe self-administration of medications by residents.
Improper Storage and Labeling of Medications and Treatments
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatments on two of the four units observed during the survey. On the Sagamore and [NAME] units, several residents had medicine cups with unknown and unlabeled creams on their bedside tables or dressers. Resident #5 had a medicine cup with an opaque cream left on the bedside tray table, which the resident stated was for arthritis pain and applied independently. Similarly, Resident #2 had an unlabeled cream for itching, and Resident #3 had an unlabeled cream on the bedside dresser. Resident #4's bedside dresser was cluttered with treatment supplies, including a pump bottle of Biofreeze and a tube of Triad Hydrophilic wound dressing paste. The review of medical records revealed discrepancies in the documentation of provider orders for the creams observed. Resident #2's record lacked evidence of a provider order for any cream treatment other than house stock lotions. Resident #3 had documented orders for Biofreeze and Voltaren gels, while Resident #4 had an order for Biofreeze but lacked documentation for the Triad Hydrophilic wound dressing paste. Resident #5's record contained an order for Voltaren gel. The Director of Nursing confirmed the improper storage of these unknown and unlabeled creams and removed them from the residents' rooms.
Improper Storage of Disinfectant Spray in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards due to improper storage of a chemical. During the survey, it was observed that a resident had a can of Great Value Disinfectant Spray Linen Scent on their bedside dresser. The resident mentioned using the spray for odor control, indicating it was their personal can. The Director of Nursing (DON) was unaware of the disinfectant's presence in the room and confirmed that it should not have been accessible to the resident. This oversight occurred on the day of the survey, as noted in the findings.
Inaccurate Clinical Records for Medication Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for medications. During an observation, a resident was found with a medicine cup containing an unknown cream and two cups of applesauce on a bedside tray. The resident stated that the nurse was giving medications but had to cut them in half due to their size. The resident also mentioned that the cream was for arthritis pain and that they applied it themselves. Later, the Director of Nursing (DON) and the surveyor observed the cream still on the bedside table, and the DON removed it. A review of the resident's provider order indicated that Voltaren External Gel was to be applied to the resident's hips twice daily. However, the Treatment Administration Records (TAR) inaccurately documented that the gel was applied at a time when the surveyor and DON were conducting a walkthrough, and the resident stated they applied the gel independently to their neck and groin. The resident confirmed that they only used the Voltaren when needed and that nursing staff did not apply it. This discrepancy between the TAR and the resident's account indicates a failure in maintaining accurate clinical records.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across all four units, including Windermere, Eagle, Sagamore, and Regena, as well as the Laundry Room. Observations revealed multiple deficiencies in housekeeping and maintenance services. In the Sagamore unit, shared bathrooms were found with black and brown substances around the base of toilets, peeled caulking strips, and various items improperly stored on the floor, such as commode buckets and basins. These observations were made over several days, indicating a persistent issue with cleanliness and maintenance. In the Laundry Room, surveyors noted significant dust and debris accumulation on fans, heaters, air vents, and pipes. The sink and eye wash station on the dirty linen side were heavily stained and soiled, with additional dust and cobwebs observed on windows and behind the hot water tank. Similar issues were found in other rooms, with heavy staining around toilets, dusty wall fans, stained heating units, chipped floor tiles, and basins stored on the floor. These findings highlight a widespread failure to provide a safe, clean, and homelike environment for residents.
Failure to Provide Adequate ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for six residents, as observed through a series of interviews, observations, and record reviews. Resident #126, admitted for skilled services following a Chronic Obstructive Pulmonary Disease exacerbation, did not receive appropriate ADL care, including bathing, dressing, and oral hygiene. Documentation for Resident #126 was lacking, with no evidence of ADL care being provided on specific shifts in March 2024. The Director of Nursing confirmed the absence of documentation, which could not suggest that the resident received the necessary care. Resident #6 was observed multiple times with thick debris on their teeth, indicating a lack of proper oral hygiene care. Despite the care plan instructing staff to monitor and provide mouth care, the CNA documentation inconsistently recorded oral care as completed. The Director of Nursing acknowledged the resident's need for assistance with oral hygiene during a joint observation with the surveyor. Additional residents, including Resident #230, Resident #64, Resident #226, and Resident #19, reported not receiving regular showers or baths. Documentation in their Electronic Medical Records (EMR) was either missing or showed infrequent bathing activities, with some residents expressing a desire for showers that were not accommodated. The Director of Nursing stated that CNAs are expected to document bathing activities and refusals, but the records did not reflect this practice.
Failure to Maintain Sanitary Respiratory Care Practices
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, specifically concerning the use and maintenance of nebulizer equipment for two residents. For one resident, the nebulizer machine was observed with the mouthpiece and tubing improperly stored and not changed according to physician orders. The tubing was dated from a previous month, and the facility's records showed inconsistencies with the scheduled changes. Additionally, there was no evidence of the nebulizer filter being changed as recommended by the manufacturer. The Director of Nursing was unable to provide a record of filter changes, indicating a lapse in following the manufacturer's maintenance guidelines. Another resident's nebulizer equipment was found unbagged and unlabeled on their bedside table during multiple observations. This lack of proper storage and labeling further demonstrates the facility's failure to adhere to sanitary practices for respiratory care equipment. The Regional Director of Clinical Operations confirmed these observations, highlighting the facility's oversight in maintaining a clean and safe environment for residents requiring respiratory care.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed excessively low weekend staffing during the fourth quarter of 2024. During an interview on January 15, 2025, the Administrator confirmed that the facility did not have enough staff to meet resident needs on weekends. This staffing shortfall has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The kitchen floor around and under the prep sink and the 3-bay sink was littered with crumbs, food, dirt, and debris. The air gaps for the kitchen prep sink and ice machine were not plumbed according to code requirements, risking food contamination. The tray line table, shelving unit, and dish washer hood exhaust were heavily soiled with dirt and debris. The walk-in freezer had a large brown ice puddle, a cookie wrapper, crumbs, and debris on the floor, while the walk-in refrigerator's fan was coated with dust, and contained expired food items. Additionally, the food mixer safety shield and cage were visibly soiled. During meal service, kitchen staff failed to adhere to personal hygiene standards. Several staff members, including cooks and dietary aides, were observed without proper hair restraints, despite having facial hair. One cook was seen handling multiple food items with the same pair of gloves, without changing them between tasks, which included handling grilled cheese sandwiches, steak, soup, fish, and chicken salad sandwiches. Furthermore, the facility did not monitor food temperatures prior to serving, as evidenced by the absence of recorded temperatures for several food items on the Kitchen Production Report.
Failure to Clearly Communicate Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives, and that signing such an agreement was not a condition of admission. During a survey, it was discovered that the arbitration agreement was included in the admission paperwork for all five residents reviewed. The Admissions and Marketing Director was responsible for having residents or their representatives sign the admission packet, which included the arbitration agreement. However, she did not adequately explain the agreement's terms, including the fact that it was not mandatory for admission and that it would remain in effect even after discharge and readmission unless rescinded within 30 days. Interviews with residents and their representatives revealed that they were not properly informed about the arbitration agreement. One resident's representative stated that she signed the paperwork under pressure and was not aware that the arbitration agreement was not a requirement for admission. Another resident did not recall signing the agreement and expressed that they would not have signed it had they understood its implications. The Admissions and Marketing Director admitted to not fully understanding the agreement's permanence and mistakenly believed a new agreement could be made with each admission. The facility's failure to clearly communicate the arbitration agreement's terms and conditions resulted in residents and their representatives signing the agreement without fully understanding its implications. The Administrator and the Admissions Coordinator were unaware that residents did not understand they had signed a binding agreement that limited their rights to choose a dispute resolution method. This oversight highlights a significant deficiency in the facility's admission process and communication with residents and their families.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to maintain adequate pharmaceutical services by not removing outdated medications from one of the three medication carts. During an observation, a surveyor found that a medication card for Ondansetron HCL 4 mg, intended for a resident, had expired. This expired medication was still present in the medication cart on Eagle Wing. The finding was confirmed with an LPN present at the time of the observation. The issue was subsequently discussed with the Director of Nursing.
Resident's Clothing Choice Ignored, Resulting in Injury
Penalty
Summary
The facility failed to respect a resident's choice regarding clothing, leading to an incident where a resident's tooth was cracked. On the night of April 12, 2024, two staff members attempted to remove a sweater from a resident who had expressed a desire to keep it on. Despite the resident's clear communication and physical resistance by biting down on the sweater, the staff proceeded with the removal, resulting in the resident's tooth breaking. This incident was reported to the Department of Licensing and Certification by Adult Protective Services, and the Director of Nursing confirmed the resident's rights were not upheld in this situation.
Failure to Conduct Neurological Monitoring After Falls
Penalty
Summary
The facility failed to adequately evaluate a resident after an unwitnessed fall and complete neurological assessments as per facility policy for a resident reviewed for falls. The facility's Fall Prevention Program and Neurological Evaluation Policy require monitoring of a resident's status for 72 hours after a fall and performing neurological evaluations whenever there is a possibility of a head injury, change in mentation, or an unwitnessed fall. However, the medical record of the resident, who was admitted with diagnoses of COVID-19 and orthostatic hypotension, showed a lack of evidence of neurological monitoring per policy after multiple unwitnessed falls. The resident experienced four unwitnessed falls during their stay, with documentation indicating incomplete or incorrect neurological monitoring. For instance, after a fall on 9/24/24, the medical record lacked evidence of neurological monitoring. On 10/6/24, the neurological evaluations recorded the same vital signs repeatedly, and some evaluations were not completed. After a fall on 10/13/24, the resident was sent to the emergency department for a CT scan, but the medical record lacked evidence of neurological monitoring upon their return. The Director of Nursing confirmed the deficiencies in neurological monitoring and documentation during a review with the surveyor.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to provide evidence that Advance Directives were offered or reviewed with residents and/or their representatives, and that written information concerning the right to formulate an Advance Directive was provided. This deficiency was identified for 11 out of 14 residents reviewed, including Residents #8, #3, #35, #17, #18, #19, #37, #64, #226, and #230. The electronic and paper medical records for these residents lacked documentation of the facility's compliance with these requirements. Interviews with facility staff, including the Administrator, social worker, and Director of Nursing, confirmed the deficiency. The social worker acknowledged that while they ask about Advance Directives upon admission, they do not always document or follow up. The Director of Nursing admitted that if documentation is not found in the chart, it is considered non-existent, and mentioned that calls were made to families for missing documentation. This lack of documentation and follow-up indicates a systemic issue in ensuring residents' rights to formulate Advance Directives are upheld.
Failure to Document Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that two authorized individuals signed the Narcotic Bound Book Shift Count page, indicating that they counted all controlled substances at the change of shift for multiple shifts. This deficiency was identified in one of the four units reviewed for drug diversion, specifically the Sagamore Unit. The facility's policy on Controlled Substances requires a physical inventory of controlled medications by two licensed clinicians at each shift change, documented on an audit record. However, between 8/14/24 and 9/3/24, there was a lack of documented evidence that a shift change count was conducted by two qualified staff for 56 shifts. The issue came to light when a 30ml bottle of Ativan could not be located during a shift change on 8/16/24. Further review of the shift count log revealed that the status of the count was left blank for 42 of the 56 shifts. Interviews with the Director of Nursing (DON) and several nursing staff confirmed the lack of documentation and adherence to the correct change of shift count process. The DON acknowledged that it is a common issue to find missing signatures and incomplete entries in the narcotic count logs.
Failure to Securely Store Controlled Drugs
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs, specifically those listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. This deficiency was identified during an observation on September 3, 2024, when a surveyor noted that the locked refrigerator in the locked Medication Room did not have a separate, locked box attached for the storage of controlled substances. This observation was confirmed during an interview with the Director of Nursing, who stated that there had never been a separate locked box in that refrigerator. The issue came to light following a facility-reported incident on August 16, 2024, when a 30ml bottle of Ativan could not be located during a shift change at 16:00.
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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