Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mainegeneral Rehab & Long Term Care - Gray Birch during CMS and state inspections, most recent first.
Housekeeping and maintenance services were not adequately provided to keep common areas and resident rooms sanitary, orderly, and comfortable. Surveyors observed broken heater covers in a dining room with exposed sharp fins and piping, multiple privacy curtains on the Birches unit hanging down or missing hooks, dirty and stained shower and whirlpool areas, rusty ceiling grids, and chipped or missing paint and unfinished wall surfaces in several resident rooms on the Birches and Pines units. The Administrator, ES Supervisor, Plant Ops Supervisor, and a Maintenance staff member confirmed the findings.
Kitchen sanitation and food handling practices were deficient, with surveyors observing a heavily soiled water softening machine, dirty food disposal units, wet-stacked dishware, dirty floors, dusty vents and ceiling tiles, and food equipment with residue, grease, rust, or chipped paint. Foods were left uncovered or not labeled and dated, refrigerated and frozen items were not properly monitored, dish machine temp logs had multiple missing entries, an ice machine drain lacked an air gap, and a male kitchen worker with facial hair was not wearing facial hair protection.
The facility failed to post entrance signage alerting visitors and staff to an active Flu outbreak, even though the DON confirmed the outbreak was ongoing. Staff were also observed not following PPE requirements for residents on contact, droplet, and enhanced barrier precautions: a RN entered a contact precaution room without PPE, a CNA entered a droplet precaution room without PPE before delivering a meal tray, an LPN disconnected a J-tube feed without a mask, and another CNA doffed PPE in the hallway and handled a clean mask and meal cart without sanitizing hands. A resident with Influenza A and a resident with VRE were among those affected by the observed PPE failures.
A resident with an active PTSD diagnosis had an incomplete trauma-informed care plan that did not identify triggers or document what caused the PTSD. Record review showed the MDS coded PTSD as an active diagnosis, but the clinical record lacked information about possible re-traumatization events, and the SW confirmed the care plan did not include PTSD triggers.
Expired medications were found in a medication cart on Pine Unit. During an observation of cart #3, a surveyor found a resident's Capsaicin Cream 0.1% 2 oz and loperamide tablets past their use-by dates, and an RN confirmed the expired meds had not been removed from available supply.
Improper Disposal of Garbage and Refuse: During a kitchen tour, a surveyor observed a dumpster with the top left lid open and refuse exposed. The FSD later confirmed the dumpster lid was open, exposing the refuse.
Missing Controlled Substance Shift Count Signatures: The facility failed to ensure licensed med admin staff signed the shift count logbooks for Schedule II controlled substances and other meds with abuse/diversion risk at change of shift. Surveyors found multiple missing signatures across six medication cart control logs on Pine and Birches units, and the DON confirmed the findings.
The facility breached confidentiality by displaying residents' personal and medical information on monitors visible to others. Monitors showed names, therapy schedules, weighing devices, shower days, and meal times. Additionally, a resident with developmental disorder was interviewed for depression in a public hallway, compromising privacy.
The facility failed to develop comprehensive care plans for two residents, one with obstructive sleep apnea (OSA) and congestive heart failure (CHF), and another with post-traumatic stress disorder (PTSD). The care plan for the resident with OSA and CHF did not include necessary elements like oxygen use and weight monitoring. Similarly, the resident with PTSD lacked a care plan addressing their condition, including triggers and interventions. These deficiencies were confirmed by the DON during a surveyor's review.
The facility failed to maintain a sanitary environment for respiratory care, with improper storage and maintenance of oxygen equipment for several residents. Observations included oxygen tubing stored improperly and soiled concentrator filters. Additionally, incorrect oxygen flow settings and an empty portable oxygen tank were noted, leading to inadequate respiratory care.
A facility failed to ensure proper monitoring of a dialysis catheter site for a resident. The resident, admitted with a right chest dialysis catheter, lacked physician orders for monitoring the catheter dressing and daily documentation of such monitoring. The unit manager confirmed the absence of an order and instructions for emergencies related to the catheter site during surveyor interviews.
The facility failed to maintain resident dignity during meal service, as observed by surveyors. A resident was left watching others eat for extended periods during both lunch and breakfast, while staff served other tables. This delay in serving meals was confirmed by the Administrator, who acknowledged the lack of dignity in the meal service process.
A facility failed to notify the State mental health authority for PASRR re-evaluation after a resident was diagnosed with PTSD, Major depressive disorder, and Generalized anxiety disorder upon admission. Despite these diagnoses, the facility did not update the PASRR evaluation, and the resident began experiencing PTSD symptoms and was prescribed medication for anxiety and depression. The DON confirmed the oversight during an audit.
A facility failed to update the care plan for a resident with diabetes who uses a continuous glucose monitoring device. The resident's care plan, last revised months prior, lacked mention of the device and necessary safety instructions, despite physician orders specifying its use. This oversight was confirmed by the DON.
The facility failed to follow physician's orders for wound care and insulin administration for two residents. An LPN used faucet water instead of Vashe solution and applied clobetasol incorrectly for a resident with venous insufficiency. Another resident received incorrect insulin dosage, and there was no documentation of provider notification for high blood sugar levels.
The facility failed to maintain sanitary conditions and proper food storage practices, as observed during a survey. The kitchen floors were heavily soiled, and containers used for food preparation were improperly stored. The air gap for the kitchen sink violated plumbing codes, and the walk-in refrigerator and freezer contained open and undated food items. Dented cans were also found in dry storage. These issues were confirmed with the Food Service Director, indicating a potential risk to all residents.
An LPN failed to maintain proper infection control during a resident's wound care by using the same gloves for multiple tasks without hand hygiene, touching contaminated surfaces, and accessing personal items under her gown. This compromised the sterile environment necessary to prevent disease transmission.
The facility failed to offer pneumococcal vaccinations to two residents as per CDC guidelines. Despite the Infection Preventionist's assertion that the Medical Provider follows CDC recommendations, the necessary vaccination protocol was not followed for these residents.
The facility failed to accurately code the MDS 3.0 for two residents. One resident's discharge was incorrectly recorded as to a short-term hospital instead of the community. Another resident's PASARR indicated a need for Level II services, but the MDS was inaccurately coded to show otherwise. These errors were confirmed by the MDS coordinator.
A resident with a history of falls and cognitive intactness fell from bed and reported that a nurse used profanity and did not assess or provide care. The facility's policy requires RN assessment after falls, but no evidence of such assessment or provider notification was found. The resident's catheter was not reinserted until five hours later by another RN. A CNA confirmed the nurse's refusal to provide care, and the DON acknowledged the nurse's failure to complete necessary actions.
The facility failed to maintain complete and accurate clinical records for two residents. A resident with a history of falls did not receive a required post-fall assessment by an RN, and another resident did not have a provider's order for a respiratory panel or a referral to geriatrics despite cognitive concerns. Documentation of behaviors was also lacking.
Housekeeping and Maintenance Deficiencies in Common Areas and Resident Rooms
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on the Birches and Pines units and in a common area dining room. During an environmental tour with the Administrator, Environmental Services Supervisor, Plant Operations Supervisor, and a Maintenance Staff member, the surveyor observed broken apart metal heater covers on the base board heating unit in the dining room, exposing sharp fins and metal piping. On the Birches unit, multiple resident rooms had privacy curtains missing hooks, hanging down, and in disrepair, and several bathroom doorframes and walls had chipped or missing paint creating uncleanable surfaces. Additional observations included dirty or stained floors and toilet caulking in the shower room and whirlpool room, a hole in the shower wall, rusty suspended ceiling grids in the shower and tub rooms, and more privacy curtains in disrepair in numerous resident rooms. On the Pines unit, several resident rooms had chipped, peeling, scuffed, or unfinished wall surfaces in sleeping areas and bathrooms, including areas behind beds, behind televisions, and below a hand sanitizer, creating uncleanable surfaces. The Administrator, Environmental Services Supervisor, Plant Operations Supervisor, and Maintenance Staff member confirmed these findings during the interview.
Kitchen sanitation, food storage, temperature monitoring, and plumbing deficiencies
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner during survey observations. The water softening machine connected to the dish machine was heavily soiled with dirt and dried liquid residue, and two food disposal units in the dish room had dried food particles and dried liquid residue on them. Surveyors also observed wet-stacked plate warmer lids and clear plastic dessert cups with dried liquid residue and dried soap on a dish rack. The kitchen floor had dirt and trash around the edges and under equipment, and the dry storage room floor also had trash and dirt throughout the room. In addition, the hood system, stove, backsplash, ceiling lights, ceiling vent, and surrounding ceiling tiles were dusty or dirty, and the food mixer, cook stove, and common area kitchenette equipment were observed with dried food particles, dried liquid residue, grease, rust, or chipped/missing paint creating uncleanable surfaces. Food storage practices were also not followed as observed by surveyors. Two large bins of white powdery substances and one large bin of oatmeal were not labeled and dated, a metal container of noodles was left uncovered on a counter, and a previously opened package of cheese in the walk-in refrigerator was not dated. A previously opened package of pizza crusts was not labeled and dated. The walk-in freezer had large amounts of ice build-up on a box of pork, the ceiling, the floor, and the shelving. The facility’s Food Storage policy required foods to be covered, labeled, and dated, and required refrigerated and frozen foods to be checked routinely, but these conditions were observed during the kitchen tour. The facility also failed to monitor and document dish machine temperatures on multiple dates across October 2025 through January 2026, despite its policy requiring wash and rinse cycle temperatures to be recorded at each meal. Surveyors reviewed the Dish Machine Temperature Logs and found numerous missing entries for breakfast, lunch, and supper across several months. In addition, the drainpipes for the ice machine were pushed into the drainpipe next to the ice machine without an air gap, and surveyors noted this direct connection of wastewater and potable water did not meet the Maine State Plumbing Code requirement to prevent contamination. A male kitchen worker with facial hair was observed without facial hair protection, and the Food Service Director confirmed the observations and log review findings during interviews.
Failure to Post Outbreak Notice and Use PPE Correctly
Penalty
Summary
The facility failed to inform visitors and staff of an active Influenza outbreak. On 1/12/26 at 8:00 a.m., no signage was observed upon entering the facility regarding active Influenza cases. Later that morning, the DON stated the facility was currently in a Flu outbreak with 2 residents on Pines Unit and 1 resident on Birches Unit, and that the last positive Flu case was on 1/9/26. When asked whether signage should be posted at the entrance to alert visitors, the DON stated that it should be, and the surveyor showed that no such signage was present. The facility also failed to maintain proper PPE use during resident care and meal delivery. A RN was observed carrying a lunch tray into a contact precaution room, rearranging items in the room, and placing the tray on a side table without PPE. The RN then exited the room, used hand sanitizer, and went to the medication cart. When asked, the RN stated the resident was on contact precautions and that she normally gowns up when providing care, confirming she had not followed precautions before entering the room. A CNA was also observed entering a resident room on droplet precautions without PPE, then returning to the room after looking at the precaution sign and placing a lunch tray on the bedside table; the CNA stated she knew what PPE was needed. Additional observations showed PPE was not used correctly for other residents on transmission-based precautions. An LPN disconnected a resident from tube feeding while wearing only a gown and gloves, despite the DON confirming the facility’s expectation for jejunostomy tube feeds included a mask. For a resident with Influenza A on droplet precautions, a CNA exited the room wearing a mask, gown, and gloves, doffed PPE into an uncovered trash can in the hallway, removed a clean mask from a PPE bag on the neighboring room’s door without sanitizing hands, and then approached the meal cart. For a resident with VRE on contact precautions, a CNA removed the meal tray from the hall cart and entered the room without PPE to set up the tray, despite the posted sign indicating PPE was required for all resident and environment contact.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent. Based on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD) to determine what trigger(s) might cause re-traumatization for 1 of 1 resident reviewed with a current diagnosis of PTSD. Resident #9 was admitted in 2024 with a diagnosis that included PTSD. Review of the resident's active trauma informed care plan lacked evidence of the resident's triggers for the PTSD diagnosis. Review of the Quarterly MDS 3.0 created 10/9/25 showed Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate an active diagnosis of Post Traumatic Stress Syndrome (PTSD). The surveyor was unable to find information in the clinical record that indicated what the resident's PTSD was caused by or what events might cause re-traumatization. On 1/13/26 at 3:28 p.m., the social worker confirmed that the resident's care plan did not include PTSD triggers.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from available supply in 1 of 3 medication carts observed. During an observation of medication cart #3 on Pine Unit, the surveyor found Resident #9's Capsaicin Cream 0.1% 2 oz with a use-by date of 11/2025 and anti-diarrheal 2 mg Loperamide Hydrochloride tablets with a use-by date of 8/2025. In an interview shortly after the observation, RN #1 confirmed the expired medications had not been removed from available supply.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. During an initial kitchen tour, a surveyor observed a dumpster with the top left lid open, exposing refuse. The Food Service Director later confirmed that the dumpster lid had been observed open with refuse exposed.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure that licensed medication administration personnel signing on and off duty completed the shift count logbook for Scheduled II controlled substances and other medications with a risk of abuse or diversion at the change of shift. The deficiency was identified through record review and interview and involved 6 of 6 controlled log books reviewed for multiple shifts between 6/13/25 and 1/9/26. On 1/13/26, the surveyor observed missing signatures in the control logbooks for multiple medication carts on Pine and Birches units. Pine unit medication cart #1 had missing signatures on 10/8/25 at 10:00 p.m. and 10/9/25 at 6:00 a.m.; Pine unit medication cart #2 had missing signatures on 1/9/26 at 7:00 p.m., 1/1/26 at 7:00 a.m., 12/30/25 at 7:00 p.m., 12/21/25 at 7:00 p.m., and 11/26/25 at 7:00 a.m.; Birches unit medication cart #3 had missing signatures on 12/19/25 at 7:00 a.m., 9/26/25 at 7:00 a.m., 9/24/25 at 7:00 a.m., and 9/17/25 at 7:00 a.m.; Pine unit medication cart #4 had missing signatures on 12/30/25 at 7:00 p.m., 12/25/25 at 7:00 p.m., 7/28/25 at 7:00 a.m. and 7:00 p.m., and 6/13/25 at 7:00 p.m.; Birches unit medication cart #5 had missing signatures on 11/26/25 at 7:00 a.m., 9/14/25 at 7:00 a.m., and 6/17/25 at 7:00 a.m.; and Birches unit medication cart #6 had missing signatures on 1/8/26 at 7:00 a.m., 12/30/25 at 7:00 a.m., 12/19/25 at 11:00 p.m., and 12/19/25 at 7:00 p.m. The DON confirmed these findings during interview on 1/13/26.
Confidentiality Breach in Resident Information Display
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information by displaying sensitive details on monitors visible to other residents and visitors. During the survey, it was observed that monitors located near the nurse's stations on the Birch and Pine Units displayed residents' first names, initials of last names, room numbers, and bed locations. Additionally, these monitors showed the times residents were scheduled for various therapies, the type of device used for weighing, shower days, participation in walking programs, and meal times corresponding with group activities. This information was confirmed by the Director of Nursing during an interview. Furthermore, the facility did not protect the privacy of a resident with developmental disorder and severe intellectual disabilities. A surveyor observed the MDS Coordinator conducting a depression interview with the resident in a public hallway, compromising the resident's privacy. This was confirmed in an interview with the MDS Coordinator, who acknowledged that the interview was conducted in a public space.
Deficiencies in Care Planning for Residents with OSA, CHF, and PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the physical needs of a resident with obstructive sleep apnea (OSA) and congestive heart failure (CHF). The resident was admitted with these diagnoses, which required the use of 2 liters of oxygen at night and daily weight monitoring. However, the care plan did not include these critical elements, as confirmed by the Director of Nursing during a surveyor's review. Additionally, the facility did not ensure a care plan was developed for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's clinical record indicated a diagnosis of PTSD, with documented issues such as trauma, abuse, and nightmares. Despite this, there was no evidence of a care plan addressing PTSD, including problem areas, triggers, or interventions. The Director of Nursing acknowledged that the resident was missed during an audit of residents with PTSD.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by multiple observations of improper storage and maintenance of oxygen equipment for several residents. For instance, Resident #9's oxygen nasal cannula tubing was repeatedly observed stored improperly over the oxygen concentrator handle and wheelchair. Similarly, Resident #221's oxygen tubing was found wrapped and stored under the handle of the oxygen concentrator, and Resident #60's tubing was observed lying across the bed instead of being stored in the provided bags. These practices were contrary to the facility's policy, which requires proper storage of oxygen equipment to prevent contamination. Additionally, the facility did not adhere to its policy regarding the cleaning of oxygen concentrator filters. Resident #15's oxygen concentrator filter was heavily soiled, and the oxygen flow was set incorrectly, deviating from the prescribed 2 liters per minute during sleep. Furthermore, Resident #49 was connected to an empty portable oxygen tank, resulting in an oxygen saturation level of 88%, below the care plan's requirement of maintaining 92% or greater. These deficiencies were confirmed through observations and interviews with the Director of Nursing, indicating a failure to implement appropriate respiratory care as directed.
Failure to Monitor Dialysis Catheter Site
Penalty
Summary
The facility failed to ensure that the clinical record contained necessary information to meet professional standards of practice for monitoring a dialysis catheter site for a resident requiring dialysis services. The resident, who was admitted to the facility with a right chest dialysis catheter, had no physician orders for monitoring the catheter dressing or documentation of daily monitoring. During interviews, the Pines Unit Manager acknowledged the absence of an order for monitoring the catheter dressing and was unable to find instructions for handling emergencies related to the dialysis catheter site. This deficiency was identified during a surveyor's review of the resident's clinical record and subsequent interviews with the unit manager.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service, as observed by surveyors. During a lunch meal observation, a resident was left watching two other residents eat while staff served other tables, resulting in a delay of 14 minutes before the resident was served. A similar incident occurred during breakfast the following day, where the same resident was again left watching others eat for 10 minutes before being served. These observations were confirmed in an interview with the Administrator, who acknowledged that the residents were not served with dignity when meals were not provided to all residents at a table simultaneously.
Failure to Notify State Mental Health Authority for PASRR Re-evaluation
Penalty
Summary
The facility failed to notify the State mental health authority for Pre-Admission Screening and Resident Review (PASRR) after a resident was newly diagnosed with mental health conditions. The resident, identified as R56, was admitted with a PASRR evaluation from the hospital indicating no mental health diagnosis and no need for a PASRR level II. However, on the date of admission, the resident's clinical record included diagnoses of Post-traumatic stress disorder (PTSD), Major depressive disorder, and Generalized anxiety disorder. Despite these diagnoses, the facility did not send the updated information to the State mental health authority for re-evaluation. The resident began experiencing symptoms related to PTSD, including nightmares, and was prescribed medication for anxiety and depression in the months following admission. During an interview, the Director of Nursing confirmed that the facility had not sent the necessary information for re-evaluation and acknowledged that the resident was missed during an audit of residents with PTSD.
Failure to Update Diabetes Care Plan for Resident with Glucose Monitoring Device
Penalty
Summary
The facility failed to update the care plan for a resident with diabetes who uses a continuous glucose monitoring device. On August 5, 2024, an observation was made of the resident with a continuous glucose monitoring device attached to the back of their right arm. The physician's orders, dated January 22, 2024, specified the use of a FreeStyle Libre 2 Sensor kit to be changed every fourteen days, with instructions to check finger stick readings if they were below 70 or above 350, or if the patient exhibited symptoms of hypoglycemia. However, the resident's care plan for diabetes management, last revised on April 19, 2023, did not include any mention of the glucose monitoring device or related safety instructions and interventions. This deficiency was confirmed during an interview with the Director of Nursing on August 7, 2024.
Failure to Follow Physician's Orders for Wound Care and Insulin Administration
Penalty
Summary
The facility failed to adhere to physician's orders for wound management for a resident with venous insufficiency. During an observation, an LPN was seen using faucet water instead of the prescribed Vashe solution to cleanse the resident's legs. Additionally, the LPN applied clobetasol directly to the open wounds rather than to the legs as directed by the physician's orders. The LPN confirmed the deviation from the prescribed wound care protocol during an interview. In another instance, the facility did not follow physician's orders for insulin administration for a resident. The resident's blood sugar level was recorded at 330, but they were administered 10 units of insulin instead of the prescribed 8 units. Furthermore, there was a lack of documentation indicating that the medical provider was notified of several high blood sugar readings in July, which exceeded the threshold for provider notification. These findings were confirmed during an interview with the Nurse Manager.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey conducted over two days. On the first day, the kitchen floors were found to be heavily soiled with crumbs, grease, fruit, and other debris. A container of measuring cups used for food preparation was observed with the lid ajar and covered in crumbs, with visible food debris inside the cups. Additionally, a large bin containing oats was left partially open to the environment. The air gap for the left kitchen sink was less than the required one inch, violating the Maine State Plumbing Code. The walk-in refrigerator floor was also heavily soiled with food debris, including shredded chicken. In the dry food storage area, several cans were found with dents, compromising their integrity, and in the walk-in freezer, boxes of breaded chicken breasts and pork sausage patties were open and undated, exposing them to the environment. On the second day, similar issues persisted. The dry food storage area still contained dented cans of diced beets, and the walk-in refrigerator floor remained soiled with plastic tape, food debris, and a potato. The kitchen's air gaps for both the left sink and the steamer were still less than one inch. These observations were confirmed with the Food Service Director at the time of each inspection, indicating a failure to maintain sanitary conditions and proper food storage practices, which could potentially affect all residents in the facility.
Infection Control Deficiency in Wound Management
Penalty
Summary
The facility failed to maintain an effective Infection Control Program during wound management for a resident. During an observation, two surveyors noted that an LPN did not adhere to proper infection control protocols while performing a bilateral leg dressing change for the resident. The LPN was observed using the same pair of gloves for multiple tasks without performing hand hygiene in between. This included touching potentially contaminated surfaces, such as the curtain and personal belongings, and then proceeding to handle wound care materials and apply ointment directly to the resident's wounds. The LPN also failed to maintain a sterile environment by repeatedly reaching under her gown to access personal items, such as a marker and Q-tips, and using them without changing gloves or washing hands. Additionally, the LPN placed scissors into a basin containing the resident's personal belongings multiple times during the procedure. These actions were confirmed by the LPN during an interview, acknowledging the failure to provide an environment that prevents the development and transmission of disease and infection during the dressing change.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. Specifically, two residents, identified as R54 and R66, were not reviewed, offered, or administered the Prevnar 20 vaccine as recommended by the CDC. R54 and R66 were both admitted to the facility, but the necessary vaccination protocol was not followed for either resident. During an interview with a surveyor, the Infection Preventionist confirmed that the Medical Provider is responsible for following CDC vaccination recommendations, yet the required actions were not taken for these residents. This oversight was identified during a surveyor's review of records and interviews, highlighting a deficiency in the facility's vaccination procedures.
Inaccurate MDS Coding for Discharge and PASARR
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) 3.0 for two residents. For one resident, the clinical record indicated a discharge to the community, but the discharge MDS inaccurately stated the resident was discharged to a short-term general hospital. This discrepancy was confirmed by the MDS coordinator during an interview. For another resident, the Pre Admission Screening And Resident Review (PASARR) indicated a qualification for Level II services, but the Annual MDS was incorrectly coded to show that the resident did not have a Level II PASARR. This error was also confirmed by the MDS coordinator during an interview with a surveyor.
Failure to Provide Care and Assessment After Resident Fall
Penalty
Summary
The facility failed to provide an environment free of abuse and neglect for a resident who experienced a fall from bed. The resident, who was cognitively intact and had a history of paraplegia, neurogenic bladder, neuromuscular deficiency, and falls, reported that after the fall, a nurse used profanity and did not enter the room to assess or provide care. The facility's policy requires a registered nurse to assess residents after a fall, but there was no evidence that the nurse completed an assessment or notified a provider following the incident. Additionally, the resident's clinical record indicated an order to reinsert a catheter if dislodged, but this was not done until approximately five hours later by another nurse. A certified nursing assistant corroborated the resident's account, stating that the nurse swore at the resident and refused to provide care. The Director of Nursing confirmed that the nurse failed to complete the necessary assessment, notify the provider, or provide care after the resident's fall.
Incomplete Clinical Records and Missing Provider Orders
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For Resident #1, who was admitted with diagnoses including paraplegia and a history of falls, the facility did not complete a required post-fall assessment. An incident report indicated that the resident fell out of bed and was found on the floor by a CNA. Although the report noted that an assessment was done with no injuries, the clinical record lacked evidence of a complete assessment by an RN, as required by the facility's fall prevention policy. The Director of Nursing confirmed that the RN failed to perform the necessary assessment. For Resident #5, admitted for skilled services with diagnoses including anxiety and depression, the facility did not obtain a provider's order for a respiratory panel, nor did it document a referral to geriatrics despite concerns about cognitive dysfunction. The resident's clinical record showed a lack of documentation regarding behaviors and a missing order for a respiratory panel that was conducted without provider authorization. A Nurse Practitioner confirmed the absence of a geriatrics referral, and an RN confirmed the lack of documentation for the resident's behaviors.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Augusta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mainegeneral Rehab & Long Term Care - Glenridge | 1.8 mi | ★★★★★ | 13 | 0 |
| Augusta Center For Health & Rehabilitation, Llc | 2.3 mi | ★★★★★ | 12 | 0 |
| Maine Veterans Home - Augusta | 4.6 mi | ★★★★★ | 12 | 0 |
| Lakewood A Continuing Care Center | 17.5 mi | ★★★★★ | 24 | 0 |
| Oak Grove Center | 18.1 mi | ★★★★★ | 1 | 0 |
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