Madigan Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Houlton, Maine.
- Location
- 93 Military Street, Houlton, Maine 04730
- CMS Provider Number
- 205083
- Inspections on file
- 17
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Madigan Estates during CMS and state inspections, most recent first.
A resident receiving palliative care was administered multiple doses of prn Haldol for agitation beyond the required 14-day limit, without a provider evaluation or documented clinical rationale for continued use. The order lacked a stop date, and the provider did not review the medication's use during subsequent visits, resulting in noncompliance with regulations for psychotropic medication management.
A resident's Significant Change MDS was incorrectly coded to indicate the absence of a Level II PASRR, despite documentation showing that a Level II PASRR had been completed. The DON confirmed the coding error during the survey.
A resident was admitted with a Foley catheter, but the baseline care plan developed within 48 hours did not include instructions for catheter care. The DON confirmed the omission during a surveyor interview.
A resident's care plan was not updated to include required PASRR Level II services after qualifying for them. The PASRR Level II documentation was eventually provided by the DON, but review confirmed the care plan lacked a care area for these services.
A resident who fell and hit their head did not receive the required neurological assessments as outlined in facility policy. Although the resident was sent to the hospital and evaluated, staff did not perform or document the post-fall neurological checks, nor did they obtain a provider order to discontinue them.
A resident was admitted with a Foley catheter in place, but there was no documented physician order for its use during the time it remained in place. This was confirmed by both record review and interview with the DON.
Surveyors identified that dented cans were available for use in dry storage, food items in the kitchen and back room coolers were not properly labeled or dated, and kitchen staff with facial hair were not wearing appropriate restraints while preparing food. These issues were confirmed by the Food Service Director.
A resident's medical record indicated the presence of a Power of Attorney (POA), but the actual POA paperwork was not found in the file. The DON confirmed during an interview that the POA document was not available, resulting in incomplete documentation for the resident.
A resident with an indwelling catheter was on Enhanced Barrier Precautions (EBP), requiring staff to use PPE such as gowns and gloves during high-contact care. A CNA was observed sitting on the resident's bed without the required PPE, despite facility policy and posted signage. Both the CNA and an RN confirmed awareness of the EBP requirements, but the protocol was not followed during the observed interaction.
A CNA did not complete the required 12 hours of annual in-service education, including dementia care, resident rights, and infection control training, as confirmed by a review of the employee's education record and an interview with facility management.
A resident experienced alleged physical and verbal abuse by a CNA, including rough handling and derogatory language, which was witnessed and reported internally to the DON. Despite facility policy requiring timely reporting of such allegations, the incident was not reported to the Division of Licensing and Certification as mandated.
A facility did not investigate an allegation of physical and verbal abuse involving a resident, where a CNA was reported by an LPN to have been rough and used profanity toward the resident. The facility could not provide evidence of an abuse investigation after the incident was reported to management.
A resident with mild dementia and reduced mobility was reportedly abused by a CNA during incontinence care, resulting in a skin tear. The resident claimed the CNA threw them against a wall, and expressed fear of the CNA. The CNA had a history of animosity towards residents and was previously in a stress management program. The incident was substantiated by facility records and staff interviews, confirming the facility's failure to protect the resident from abuse.
A resident with trouble chewing and poor dentition was not provided with the prescribed mechanical soft diet. Despite the physician's order, the resident received regular consistency meals, and dietary staff were unaware of the current diet order. Miscommunication and delays in updating diet orders contributed to the deficiency.
A resident with respiratory failure and other conditions was found using improperly set up respiratory care equipment. The oxygen tubing was not correctly attached to the humidifier bottle, and the charge nurse and MDS nurse confirmed the improper setup.
The facility failed to remove expired medications from treatment and medication carts, as well as storage rooms. Additionally, the facility did not monitor or document temperatures in a medication refrigerator storing insulin, as the temperature log was missing and not maintained.
The facility failed to ensure that clinical records were complete and accurate for two residents. One resident's record lacked evidence of verbal orders for discontinuing a Foley catheter and administering a potassium supplement. Another resident's record lacked evidence of a physician order to discontinue insulin. These deficiencies were confirmed during interviews and record reviews with the DON and Assistant DON.
A facility failed to notify the State Mental Health authority for PASRR of a newly added bipolar disorder diagnosis for a resident. The oversight was confirmed by a Licensed Social Worker during an interview with a surveyor.
The facility failed to ensure that food products were properly dated and labeled, and did not remove dented cans from circulation. A surveyor observed dented cans, undated packages of gravy mix and soup base, and improperly stored items in the dry storage, walk-in freezer, and refrigerator. These findings were confirmed with the Dietary Supervisor and Cook #1.
Failure to Adhere to 14-Day Limit for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit for as needed (prn) psychotropic medication use, specifically Haldol, for one resident receiving palliative care. The resident's physician order set included a prn Haldol order for agitation without a stop date or documented clinical rationale for continued use beyond the required timeframe. Review of the treatment administration record showed that after the 14-day limit had passed, the resident received 17 additional doses of prn Haldol without a provider evaluation or documentation supporting the ongoing need for the medication. An interview with the Nurse Manager/Supervisor confirmed the absence of required documentation and provider review regarding the continued administration of prn Haldol, and the provider's progress notes did not address the medication's use during a subsequent visit. The deficiency centers on the lack of timely provider evaluation and documentation for the continued use of a psychotropic medication beyond regulatory limits, as well as the administration of multiple doses after the required review period had expired.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) 3.0 for a resident who had undergone a Significant Change assessment. Record review showed that the resident had a Level I PASRR indicating the need for a face-to-face review, and a Level II PASRR was completed. However, the Significant Change MDS was incorrectly coded in Section A1500 to indicate that the resident did not have a Level II PASRR. This error was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS was inaccurately completed regarding the resident's PASRR status.
Baseline Care Plan Lacked Foley Catheter Instructions for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included necessary instructions for the care of a newly admitted resident with a Foley catheter. Clinical record review showed that the resident was admitted in April 2025 with a Foley catheter in place, but the baseline care plan did not address the catheter. During an interview, the Director of Nursing confirmed that the Foley catheter was not included in the baseline care plan, and this omission was verified by the surveyor.
Failure to Revise Care Plan After PASRR Level II Qualification
Penalty
Summary
The facility failed to revise the care plan for a resident after the individual qualified for Preadmission Screening and Resident Review (PASRR) Level II services. Record review showed that the resident's PASRR, dated 4/2/24, indicated a referral for a Level II face-to-face onsite assessment, but the document was not initially found. The Director of Nursing later provided the PASRR Level II document, dated 4/15/24. Upon review, it was confirmed that the resident's care plan did not include a care area addressing the PASRR Level II services, as required. This deficiency was identified for one of three residents reviewed for PASRR compliance.
Failure to Complete Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to follow its Neurological Post-fall Assessment Protocol for a resident who experienced a witnessed fall and struck their head on the edge of the bed. According to the facility's policy, staff are required to initiate and document neurological assessments at specific intervals following a head injury. However, after the incident, no neurological assessments were completed or documented for the resident, and there was no provider order to discontinue these assessments. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident was sent to the hospital due to suspected stroke-like symptoms and received a negative CT scan. Despite this, the facility did not obtain an order to discontinue the required neurological assessments, nor did they perform or document the assessments as outlined in their policy. The deficiency was identified through record review, policy review, and staff interviews.
Lack of Physician Order for Foley Catheter Use
Penalty
Summary
The facility failed to ensure that a physician order was present for the use of a Foley catheter for one resident. The clinical record review showed that the resident was admitted with a Foley catheter in place, but there was no documented physician order authorizing its use from admission through the date the catheter was removed. This lack of documentation was confirmed by both the record review and an interview with the Director of Nursing, who was unable to locate an order for the catheter during the specified period.
Deficiencies in Food Storage, Labeling, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. In the dry food storage area, several dented cans, including diced peaches, tomato soup, and apple filling, were found on the shelf and available for use. In the kitchen's reach-in cooler near the steam table, a steamtable pan covered in plastic wrap was not labeled or dated. Additionally, in the back storage room/break room area, four trays containing dishes of food out of their original containers were labeled only with the meal and date, but not with the contents of the individual dishes. Furthermore, two kitchen staff members with facial hair were observed in the food preparation area without facial hair restraints. These findings were confirmed with the Food Service Director at the time of observation.
Missing Power of Attorney Documentation in Resident Record
Penalty
Summary
The facility failed to maintain a complete medical record for one resident by not having the Power of Attorney (POA) documentation on file. During a review of the resident's clinical record, it was noted in the electronic profile that the resident had a POA, but the actual POA paperwork could not be located. In an interview, the Director of Nursing confirmed that the POA document was not available in the resident's file. This deficiency was identified through record review and staff interview, with the surveyor unable to find the required documentation to support the resident's advance directive status as indicated in the clinical record.
Failure to Follow Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain its Infection Control Program as required for residents on Enhanced Barrier Precautions (EBP). Specifically, a certified nursing assistant (CNA) was observed sitting on the bed of a resident who was on EBP due to having an indwelling catheter. The posted signage on the resident's room and the facility's policy both indicated that staff must wear personal protective equipment (PPE), including a gown and gloves, when providing care or having prolonged, high-contact with items in the resident's room, such as sitting on the bed. Despite these requirements, the CNA was not wearing the required PPE during the observed interaction. The resident's medical record confirmed the need for EBP due to the presence of a catheter. During interviews, both the CNA and a registered nurse (RN) acknowledged that the CNA was aware of the EBP requirements and the need for PPE when engaging in high-contact activities, such as sitting on the resident's bed. The RN also confirmed observing the CNA without PPE and discussed the incident with the CNA, who was unable to confirm if the linens had been recently changed. This sequence of events demonstrates a failure to adhere to established infection control protocols for residents on EBP.
Failure to Ensure Required CNA Annual In-Service and Dementia Training
Penalty
Summary
The facility failed to implement and maintain an effective training program for Certified Nursing Assistants (CNAs), as evidenced by a review of one CNA's employee education record. The CNA, hired in August 2021, did not have documentation of completing the required 12 hours of annual in-service education, including mandatory training in dementia care, resident rights, and infection control. This deficiency was confirmed during an interview with the Payroll and Resident Accounts Manager, where it was acknowledged that the CNA had not fulfilled the annual education requirements.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of physical and verbal abuse involving a resident to the Division of Licensing and Certification as required by federal regulations. According to the facility's Abuse Prevention Program policy, all allegations of abuse must be investigated and reported within specified timeframes. In this case, a Certified Nursing Assistant (CNA) was witnessed raising their voice, using derogatory language, and profanity toward a resident who was experiencing difficulty breathing and discomfort during care. A Licensed Practical Nurse (LPN) provided a written statement describing the CNA's rough handling and inappropriate comments toward the resident. Despite the incident being reported internally to the Director of Nursing (DON), the facility did not notify the Division of Licensing and Certification of the alleged abuse. Documentation reviewed included statements from staff, disciplinary actions taken against the CNA, and internal communications, all confirming the occurrence of the incident and the facility's awareness. However, the required external reporting to authorities was not completed, resulting in a deficiency related to timely reporting of suspected abuse.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of physical and verbal abuse involving Resident #13, as required by its Abuse Prevention Program policy and federal regulations. The incident involved a Certified Nursing Assistant (CNA2) who was reported by a Licensed Practical Nurse (LPN) to have been extremely rough with the resident, allegedly attempting to pull out the resident's catheter and using profanity in a derogatory manner. The allegation was reported to the Division of Licensing and Certification by Adult Protective Services. During the recertification survey and investigation, the facility was unable to provide evidence that an abuse investigation was conducted after the allegation was brought to their attention by staff.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with mild dementia and reduced mobility. The resident, who had intact cognition, reported that the CNA threw them against a wall during an altercation over incontinence care, resulting in a significant skin tear. The resident expressed fear of the CNA and relief upon learning that the CNA was no longer employed at the facility. The CNA had a history of expressing animosity towards residents and the facility, and had previously been placed on an Employee Assistance Program for stress management. The incident was corroborated by the facility's records and interviews with staff, including the Unit Manager and the Supervisor, who heard the altercation and observed the CNA's frustration. The CNA claimed the resident lost balance, causing the skin tear, but the Supervisor noted the CNA's derogatory remarks about the resident in a text message. The Director of Nursing confirmed that the evidence substantiated the abuse, highlighting the facility's failure to ensure the resident's safety and protection from abuse.
Failure to Follow Physician's Diet Order
Penalty
Summary
The facility failed to ensure that a physician order for a mechanical soft diet was followed for a resident with trouble chewing and poor dentition. On multiple occasions, the resident was served food that did not match the prescribed mechanical soft diet, including a lunch consisting of a pork chop, a baked potato with skin, and squash. The resident expressed difficulty chewing the food and requested a replacement meal. The clinical record indicated that the diet order for a mechanical soft diet was initiated almost a year prior, but the dietary staff were unaware of the current diet order, leading to the resident receiving an incorrect diet. Interviews with the dietary staff and the Dietary Supervisor revealed a lack of awareness and communication regarding the resident's current diet order. The cook and dietary staff believed the resident was on a regular diet, and the Dietary Supervisor confirmed that diet orders are managed by a staff member not in the kitchen. Additionally, if a diet order changes over the weekend, it could take up to two days for the change to be implemented. This miscommunication and delay in updating diet orders resulted in the resident not receiving the appropriate diet as prescribed by the physician.
Improper Setup of Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure respiratory care equipment was hooked up properly for a resident diagnosed with hypoxic and hypercapnic respiratory failure, cor pulmonale, sleep apnea, and Chronic Obstructive Pulmonary Disease. During an observation, the resident was found using oxygen at 2 liters/minute via nasal cannula, but the humidification bottle was not attached to the tubing. The next day, the resident was observed using a trilogy breathing apparatus with a full mask, but the oxygen tubing was incorrectly attached to the humidifier bottle, which was not connected to the concentrator. The charge nurse admitted to replacing the humidification bottle but did not attach it correctly, and the MDS nurse confirmed the improper setup.
Expired Medications and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications and topicals were removed from the supply available for use in multiple locations, including two treatment carts, one medication cart, and two medication storage rooms. Specific expired items observed included Medihoney Gel, Hydrophilic wound dressing, Aquaphor healing ointment, BioFreeze pain roll-on, Benadryl Gel, Echinacea, Bisacodyl suppositories, Preparation H suppositories, and Procrit. These findings were confirmed by the surveyor at the time of the observations, indicating a lapse in the facility's medication management protocols. Additionally, the facility failed to monitor and document the temperatures in a medication refrigerator where insulin was stored. The temperature log sheet for the medication refrigerator was missing, and staff were unable to provide a current log. The Director of Nursing confirmed that the temperature log was not maintained, and a staff member admitted that temperatures were not documented due to the absence of a new log sheet. The DON later revealed that the previous temperature log was soiled and destroyed, leading to its disposal without replacement.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, the clinical record lacked evidence of a verbal order being written and entered into the physician orders for the discontinuation of a Foley catheter and a bladder scan. Additionally, there was no written order for the administration of a potassium supplement to address a critical potassium lab level. These deficiencies were confirmed during interviews with the Director of Nursing (DON) and record reviews conducted by the surveyor. For another resident, the clinical record lacked evidence of a physician order being obtained to discontinue an insulin order. The resident had an order for insulin Glargine 20 units subcutaneous every morning but had not received any insulin since a specific date. Despite documentation that the nurse practitioner was made aware and a new order to discontinue the insulin was received, there was no evidence of this order being written. These findings were confirmed during an interview and record review with the DON and Assistant DON.
Failure to Notify PASRR of New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State Mental Health authority for Pre-Admission Screening and Resident Review (PASRR) of a newly added mental health disorder diagnosis for a resident. The resident was admitted with a PASRR Level I screening that did not include a diagnosis of bipolar disorder. Documentation later indicated that the resident had a diagnosis of bipolar disorder added to their diagnoses list, but there was no evidence that the State Mental Health authority for PASRR was notified of this new diagnosis. This oversight was confirmed by a Licensed Social Worker during an interview with a surveyor.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure that food products were properly dated and labeled, and did not remove dented cans from circulation on two separate days of the survey. On 3/18/24, a surveyor observed two dented cans of tapioca pudding, an open and undated package of Roast Pork Gravy mix, and an open and undated package of Imperial Cream Soup Base in the dry storage area. These findings were confirmed with the Dietary Supervisor. On 3/21/24, a surveyor observed an open and undated bag of crinkle cut fries in the walk-in freezer, an open, unlabeled, and undated package of unidentified meat, and an open and undated head of lettuce in the walk-in refrigerator. These findings were confirmed with Cook #1.
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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