Maplecrest Rehab & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Maine.
- Location
- 174 Main St, Madison, Maine 04950
- CMS Provider Number
- 205128
- Inspections on file
- 21
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Maplecrest Rehab & Living Center during CMS and state inspections, most recent first.
The facility did not promptly report or thoroughly investigate multiple allegations of abuse involving a CNA inflicting pain, making inappropriate remarks, and engaging in improper physical contact with residents. Required notifications to the State Agency and timely submission of investigation results were not completed, and the facility's investigation lacked necessary documentation and interviews.
Surveyors identified that two residents with respiratory needs did not have care plans addressing the use of CPAP, nebulizers, or oxygen therapy as ordered or observed, and a resident at risk for falls had a fall mat in use that was not included in the care plan. These deficiencies were confirmed through record review, observation, and staff interviews.
A facility failed to honor a resident's bathing preferences after the resident, who is cognitively intact and has a self-care deficit due to MS, reported not being offered a shower since a leg fracture incident. Despite having orders allowing for hygiene with a knee brace, the clinical record showed no evidence of the resident being offered, provided, or refusing a shower.
A resident with Multiple Sclerosis experienced a fall from a Hoyer lift, resulting in a left knee fracture. Despite medical orders for managing the fracture, the care plan was not updated to include these instructions. The DON confirmed the omission during a surveyor interview.
The facility failed to update and implement care plans for two residents. One resident's care plan incorrectly included an intervention to cut food into small pieces, which was not needed. Another resident's care plan indicated the use of dentures, but the resident was not wearing them, and staff confirmed they had not been used for some time. The DON acknowledged the discrepancies and the need for updates.
The facility failed to provide six residents with written information about their right to accept or refuse medical treatment and/or formulate an advance directive upon admission. Interviews and record reviews confirmed the deficiency.
The facility failed to provide adequate housekeeping and maintenance services, resulting in peeling wallpaper, marred walls with chipped or missing paint, worn surfaces exposing untreated wood, and broken or cracked floor tiles. These deficiencies were observed in multiple units, a common area, and the laundry room, compromising the sanitary conditions required for a long-term care environment.
The facility failed to update and implement care plans for two residents, leading to deficiencies in enteral feeding and mobility. One resident experienced significant weight fluctuations without re-weighs, and another resident was not walked as per their care plan. The DON confirmed these deficiencies.
The facility failed to provide continuous resident-centered activities on weekends, as confirmed by resident interviews and activity logs. The Activity Director acknowledged the absence of scheduled weekend activities, and the DON was informed.
The facility failed to ensure a safe environment by having exposed electric wall heating units and unsecured Sani-Cloth Bleach Germicidal Disposable Wipes. Surveyors observed these hazards in the hallway, resident rooms, and the Embden Shower room. Both the Administrator and the Director of Nursing confirmed these were accident hazards, especially for vulnerable and independently ambulating residents.
The facility failed to complete annual performance reviews for three CNAs. CNA#7, CNA#8, and CNA#9 did not have performance evaluations completed for 2023 and 2024. The DON confirmed that staff had not received their annual reviews.
The facility failed to reconcile the narcotic book during shift change, leading to discrepancies in the controlled substance log. Additionally, the facility did not monitor and record refrigerator temperatures containing biologicals and vaccines as required, with staff members unclear about their responsibilities.
The facility failed to maintain kitchen cleanliness and proper temperature monitoring. Observations revealed soiled ceiling units, unlabeled food items, and a malfunctioning dish machine. Documentation for temperature monitoring was inconsistent and incomplete, as confirmed by the FSD and Nutritional Services Coordinator.
The facility failed to ensure that CNAs attended the required 12 hours of annual in-service education. CNA #7 had only 3.5 documented in-service hours, CNA #8 had 4 documented in-service hours, and CNA #9 had 3.5 documented in-service hours. The DON confirmed the deficiency.
The facility failed to assess a resident for self-administration of medications, resulting in medications being left at the bedside without proper evaluation and orders. Staff interviews revealed inconsistencies in handling the resident's medications, and the Director of Nursing Services confirmed the policy was not followed.
The facility failed to follow a resident's bathing schedule and ensure the resident's choice in care. A resident expressed frustration about not receiving weekly showers and preferred whirlpools twice a week for chronic pain relief. Records showed the resident only received showers on two occasions and bed baths on other days. The DON confirmed these findings, and the LPN, MDS Coordinator acknowledged the need to update the care plan and document refusals.
The facility failed to notify a resident's representative of an injury of unknown origin, contrary to its own Notification of Changes policy. Despite the resident having a family representative and an Advanced Directive, the Director of Nursing did not ensure the notification was made, and the state reportable incident form indicated 'N/A' for family/guardian notification.
The facility failed to maintain an Infection Control Program, with a CNA observed handling soiled linen without gloves and without bagging it, and improper storage of urinary devices in shared bathrooms. These practices were confirmed by the DON as not supporting good infection control standards.
The facility failed to ensure that mail was delivered to all residents on Saturdays. Three residents reported not receiving mail on Saturdays. The DON was unaware, and the Administrator found that Saturday mail delivery had been on hold for four years and requested its resumption.
The facility failed to notify the resident, family, and/or the resident's representative in writing of transfers/discharges to an acute care hospital for two residents. Documentation showed no evidence of written transfer/discharge notices provided, as confirmed by staff interviews.
The facility failed to issue bed hold notices, including daily bed hold costs, to two residents or their representatives when they were transferred to an acute care hospital. This was confirmed by the MDS Coordinator and the DON.
The facility failed to complete and transmit MDS assessments within the required timeframes for seven residents. The MDS coordinator confirmed that Annual, Quarterly, and Discharge MDS assessments were not completed and/or submitted timely, indicating a systemic issue.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse as required by its own policy and federal regulations. After a Certified Nursing Assistant (CNA) reported witnessing another CNA inflict pain on a resident while brushing hair, apply hair dye without consent, and make derogatory remarks, the facility did not immediately report these allegations to the State Agency. Additional incidents included improper transfer of a resident resulting in pain, inappropriate physical contact, and removal of a resident's personal property. The facility's investigation did not include timely or thorough documentation, interviews, or assessments as outlined in their policy. The review of the facility's actions revealed that the abuse allegations were not reported within the required 24-hour timeframe, and the results of the investigation were not submitted to the State Agency within 5 business days. The investigation lacked evidence of immediate reporting by the staff member who witnessed the incidents, and there was insufficient documentation of interviews with involved residents, staff, and witnesses. The Director of Nursing confirmed these findings during an interview.
Failure to Develop and Update Care Plans for Respiratory and Fall Risk Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the specific needs of residents in the areas of respiratory care and fall prevention. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, the medical record showed the use of a CPAP machine and nebulizers, but there was no evidence of a care plan covering these respiratory interventions. Another resident was observed using oxygen at varying flow rates, yet the care plan did not reflect the physician's order for oxygen therapy, nor did it document the resident's use of oxygen as observed by surveyors. Additionally, a resident with a history of dementia, vertigo, osteoporosis, anxiety, and previous falls with fracture was found to have a fall mat in use, but the care plan did not include this intervention. The absence of documentation for the fall mat as a preventive measure was confirmed by the Director of Nursing. These omissions indicate that the facility did not ensure care plans were updated to reflect current physician orders and observed interventions for residents with respiratory needs and fall risks.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing preferences, specifically in providing showers, for one of the sampled residents. The resident, who is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported not being offered a shower since sustaining a leg fracture from a fall involving a Hoyer lift. The resident's care plan indicated a self-care deficit related to Multiple Sclerosis (MS), requiring assistance with activities of daily living (ADLs). Despite having orders from an orthopedic provider allowing for hygiene with a knee brace, the clinical record lacked evidence of the resident being offered, provided, or refusing a shower after the incident.
Failure to Update Care Plan for Resident's Knee Fracture
Penalty
Summary
The facility failed to update a care plan to address the physical needs of a resident who had a fall resulting in a left knee fracture. The resident, who was admitted with a diagnosis of Multiple Sclerosis, experienced a fall from a Hoyer lift, leading to the fracture. Following the incident, medical orders were given to manage the fracture, including wearing a knee immobilizer, non-weight bearing on the left leg, and specific instructions for transfers and support while seated. However, a review of the resident's care plan revealed that it did not include any management strategies for the knee fracture or the use of the knee immobilizer. During an interview, the Director of Nursing acknowledged that the knee immobilizer should have been addressed in the care plan, confirming the deficiency identified by the surveyor.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were updated and implemented for two residents during a complaint investigation. Resident #1, who was admitted with a history of heart attack, cerebral infarction, hemiplegia, hemiparesis, dysphagia, and morbid obesity, had a care plan that included an intervention to cut food into small pieces. However, the active orders did not reflect this need, and the Director of Nursing (DON) confirmed that the care plan was outdated and should not have included this intervention. Resident #2, diagnosed with dementia and dysphagia, had a care plan indicating the use of upper dentures with assistance for cleaning and wearing them daily. During a lunch observation, it was noted that Resident #2 was not wearing dentures, and the Certified Nursing Assistant (CNA) confirmed that the resident does not wear them anymore. The DON acknowledged that Resident #2 had not been wearing dentures for some time and confirmed the need to update the care plan. The facility's policy requires comprehensive person-centered care plans with measurable objectives and timeframes, which were not adhered to in these cases.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents or their representatives with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for six residents. The facility's policy mandates that upon admission, residents should be informed and provided with information about advance directives. However, the clinical records for Residents #7, #23, #27, #39, #304, and #306 lacked evidence that this information was provided. Interviews with the residents and the Licensed Social Worker confirmed that the residents were not offered or did not recall being offered the opportunity to formulate an advance directive upon admission. Resident #7, who is cognitively intact, did not remember being asked or offered an advanced directive. Similarly, Resident #23, who has a cardiac pacemaker, and Resident #39, who is also cognitively intact, did not recall being asked about an advanced directive. Resident #27 and Resident #304, both of whom are cognitively impaired, also lacked evidence in their records of being offered an advanced directive. Resident #306, who is cognitively intact, confirmed not being asked or offered an advanced directive. The Licensed Social Worker and the Director of Nursing acknowledged the deficiency during interviews with the surveyors.
Facility Fails to Maintain Sanitary and Well-Maintained Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. During a tour conducted by a surveyor, the Administrator, the Maintenance Director, and the District Manager for Health Care Services, several deficiencies were observed across multiple units, a common area, and the laundry room. In the Lakewood unit, the wallpaper was peeling in one resident's room. In the [NAME] Chase unit, walls in two resident rooms were marred with chipped or missing paint, and one room had a worn bathroom handrail exposing untreated wood. The [NAME] unit had similar issues with chipped or missing paint on bathroom electric wall heating units in two resident rooms. The nurse's station had a missing or broken piece of laminate near the bottom corner facing the hallway. The laundry room had chipped or missing paint on the cement floor, approximately 10 broken or cracked floor tiles, and wooden shelving with chipped or missing paint under stored chemicals and behind washing machines, creating uncleanable surfaces. These observations were confirmed in an interview with the Administrator, the Maintenance Director, and the District Manager of Health Care Services. The deficiencies noted include peeling wallpaper, marred walls with chipped or missing paint, worn surfaces exposing untreated wood, and broken or cracked floor tiles, all of which contribute to an environment that is not safe, clean, comfortable, or homelike. The uncleanable surfaces identified in various areas of the facility compromise the sanitary conditions required for a long-term care environment.
Failure to Implement Care Plans for Enteral Feeding and Mobility
Penalty
Summary
The facility failed to update and implement care plans for two residents, leading to deficiencies in enteral feeding and mobility. Resident #37, diagnosed with amyotrophic lateral sclerosis and peripheral vascular disease, had a physician order to obtain weight twice weekly. However, the facility did not re-weigh the resident despite significant weight fluctuations, as required by the facility's policy. The Director of Nursing confirmed that the care plan for weights was not implemented as written, and the resident was not re-weighed according to the policy. Resident #41, who has ambulation deficits, reported not being walked daily as per their care plan. The care plan stated that the resident should ambulate at least 160 feet twice per day with specific interventions. However, documentation revealed that the resident was not walked on 25 days and was only walked once a day on 39 days within a 79-day period. The Director of Nursing and the facility's Operation Education Coordinator confirmed that the resident was not participating in the Walk to Dining program and had not been walked twice a day as per the individualized care plan.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide a continuous resident-centered activities program for three of four residents reviewed for activity participation. The facility's policy stated that an activities calendar should be posted monthly, including daily and weekend activities. However, a review of activity calendars from June 2023 through April 2024 showed no evidence of continuous activities on weekends. Resident Daily Activities Logs for March and April 2024 also lacked evidence of weekend activities being offered or refused. Interviews with residents indicated dissatisfaction with the lack of weekend activities, and the Activity Director confirmed the absence of scheduled activities on weekends. The Director of Nursing was informed of these findings.
Accident Hazards: Exposed Electric Heaters and Unsecured Chemicals
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards relating to electric wall heating units and unsecured chemicals. On multiple occasions, surveyors observed electric wall heating units with missing or partially detached front covers, exposing hot, sharp metal fins. These observations were made in the hallway across from the Administrator's office and in the bathrooms of two resident rooms. Both the Administrator and the Maintenance Director confirmed that these exposed heaters were accident hazards, especially given the presence of vulnerable and independently ambulating residents in the facility. Additionally, a surveyor observed a container of Sani-Cloth Bleach Germicidal Disposable Wipes left unsecured in the Embden Shower room, with the door to the room left open. The Safety Data Sheet for the wipes indicates that they pose significant health risks if inhaled, ingested, or come into contact with skin or eyes. The Director of Nursing confirmed that leaving the bleach wipes unsecured was an accident hazard, particularly in a facility with vulnerable and independently ambulating residents.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete performance reviews at least once every twelve months for three Certified Nursing Assistants (CNAs). CNA#7, hired on January 7, 2022, did not have a performance evaluation completed in 2023 and 2024. Similarly, CNA#8, hired on May 5, 2022, also lacked performance evaluations for 2023 and 2024. Additionally, CNA#9, hired on July 15, 2019, did not have performance evaluations completed for 2023 and 2024. During an interview on April 18, 2024, the Director of Nursing confirmed that staff had not received their annual reviews.
Failure to Reconcile Narcotic Book and Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to reconcile the narcotic book during shift change on one of its units, leading to discrepancies in the controlled substance log. During a review, it was found that the log index was missing entries for several pages, and some entries were incorrectly filled out. The issue was confirmed by a Certified Nursing Assistant/Medication Technician and a Licensed Practical Nurse, who acknowledged that new medications should be entered into the controlled substance log by two nurses and properly indexed. The Director of Nursing Service also confirmed that narcotics should be signed in, logged, and indexed immediately upon delivery from the pharmacy, which was not done in this case. Additionally, the facility failed to monitor and record refrigerator temperatures containing biologicals and vaccines as per their policy. The temperature logs for February, March, and April 2024 showed multiple instances where temperatures were not documented twice daily, as required. Interviews with various staff members revealed confusion about who was responsible for this task, with some assuming it was a night shift duty. The Registered Nurse Manager confirmed that refrigerator temperatures should be checked twice a day but was unaware of who was currently responsible for this task.
Facility Fails to Maintain Kitchen Sanitation and Proper Temperature Monitoring
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The ceiling air handling unit, ceiling tiles, ceiling lights, ceiling vents, and wall-mounted fans were found to be moderately soiled with dust and dirt. Additionally, the dish room had ceiling tiles with dried food particles and liquid residue, and the wall-mounted fan and ceiling vent were dusty and dirty. The reach-in refrigerator contained a package of whipped topping with no thaw date, and the dry storage room had unlabeled bags of crackers and noodles, as well as a chest freezer with an undated package of whipped topping. The facility's high-temperature dish machine was observed to be malfunctioning, as it could not reach the required 150 degrees Fahrenheit during the wash cycle. Despite knowing the temperature requirements, the morning dietary aide confirmed that the dish machine had been acting up and was still in use even though it did not consistently reach the proper wash temperatures. The Food Service Director (FSD) confirmed the dish machine's malfunction during an interview. Documentation for monitoring and recording temperatures of dishwashers, refrigerators, and freezers was found to be inconsistent and incomplete for January, February, March, and April 2024. The Daily High-Temp Dish Washing Log, Sink/Bucket Sanitizer logs, and Freezer and Refrigerator Temperature logs had numerous missing entries and instances of low wash temperatures. The FSD and Nutritional Services Coordinator confirmed these findings during an interview.
Failure to Ensure Required Annual In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse's Aides (CNAs) attended the required 12 hours of annual in-service education. This deficiency was identified through a review of employee education records and interviews. Specifically, CNA #7, hired on 1/7/22, had only 3.5 documented in-service hours from 1/7/22 through 4/18/24. CNA #8, hired on 5/5/22, had only 4 documented in-service hours between 5/22/22 through 4/18/24. CNA #9, hired on 7/15/19, had only 3.5 documented in-service hours from 7/15/19 through 4/18/24. The Director of Nursing confirmed that these CNAs had not completed the required 12 hours of yearly in-service education.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as required by their policy. Resident #20, who had a moderate cognitive impairment with a BIMS score of 12 out of 15, was observed with a medication cup containing nine different pills at their bedside. The resident indicated a preference to take their medications after breakfast, but there was no evidence in the clinical record that a self-administration assessment had been completed for this resident. Interviews with facility staff revealed inconsistencies in the handling of Resident #20's medications. A CNA mentioned that the resident likes to take their medications after breakfast, so they leave them at the bedside. However, an LPN and the Director of Nursing Services (DNS) confirmed that medications should not be left at the bedside and that an evaluation and order are required for a resident to self-administer medications. The DNS confirmed the findings, indicating a failure to follow the facility's policy on self-administration of medications.
Failure to Follow Resident's Bathing Schedule and Preferences
Penalty
Summary
The facility failed to follow a resident's schedule for bathing and to ensure that a resident has a choice about his/her care in the area of bathing. Resident #11 expressed frustration about not receiving showers on a weekly basis and preferred a whirlpool twice a week to help with chronic pain. A review of the facility's Whirlpool & Shower List and the resident's electronic bath record indicated that the resident only received showers on two occasions and bed baths on other days. The Director of Nurses confirmed these findings, and the LPN, MDS Coordinator acknowledged that the care plan should be updated to reflect the resident's preferences and that refusals should be documented and reported to the charge nurse.
Failure to Notify Resident Representative of Injury
Penalty
Summary
The facility failed to ensure the resident representative was notified of an injury of unknown origin and did not follow its own Notification of Changes policy and procedure. The policy, developed in September 2018, mandates that the nurse immediately notify the resident, the resident's physician, and the resident's representative in case of an accident involving the resident that results in injury. On 4/15/24, nursing documentation noted that a resident woke up with a large bruise under their left eye of unknown origin. Despite this, the resident's representative was not notified as required by the policy. The Director of Nursing (DON) was aware of the bruise but did not ensure the notification was made, and the state reportable incident form indicated 'N/A' for family/guardian notification. The resident's medical record indicated that they had a family representative and an Advanced Directive signed by the representative. Despite this, the DON initially claimed the resident had no family and later admitted that the representative never visits but would attempt to call them. The Licensed Social Worker confirmed that attempts to contact the representative had been made but only resulted in voice messages with no return calls. This failure to notify the resident's representative of the injury constitutes a deficiency in following the facility's own policies and procedures for notification of changes in the resident's condition.
Infection Control Deficiencies in Linen Handling and Urinary Device Storage
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to prevent cross-contamination and infection. On multiple occasions, a Certified Nursing Assistant (CNA) was observed handling soiled linen without wearing gloves and without bagging the linen as per the facility's Linen Handling Policy. Specifically, on the [NAME] unit, the CNA transported soiled linen from a resident's room to the soiled utility room unbagged and without gloves. This was confirmed by the CNA and later discussed with the Director of Nursing (DON). Additionally, on the Lakewood Unit, a urinal was observed hanging on the side of a trash can in a shared bathroom, and on the [NAME] Unit, an unlabeled bedpan and urinal were found stored on the floor beside the toilet in a shared bathroom. These observations were confirmed by the DON as not supporting good infection control practices. The deficiencies were observed over three days of the survey on two different units. The facility's failure to adhere to its own Linen Handling Policy and proper storage of urinary collection devices indicates a lapse in maintaining a safe and sanitary environment. The DON confirmed that these practices did not align with good infection control standards, highlighting a significant issue in the facility's infection prevention and control program.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that mail was delivered to all residents on Saturdays. During a group interview, three residents indicated that they do not receive mail on Saturdays. The Director of Nursing was unaware of this issue. The Administrator contacted the post office and discovered that Saturday mail delivery had been on hold for approximately four years and requested to have it resumed.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to notify the resident, family, and/or the resident's representative in writing of transfers/discharges to an acute care hospital for two residents. Documentation in Resident #8's clinical record indicated transfers to the hospital on 1/29/24 and 3/4/24, with no evidence of written transfer/discharge notices provided. This was confirmed by the Minimum Data Set Coordinator. Similarly, Resident #11's clinical record showed a transfer to the hospital on 4/1/24, with no written notice provided, as confirmed by the Director of Nurses.
Failure to Issue Bed Hold Notices
Penalty
Summary
The facility failed to issue a bed hold notice, which included the daily bed hold cost, to two residents or their representatives when they were transferred to an acute care hospital. Resident #8 was transferred on 1/29/24 and 3/4/24, and the clinical record lacked evidence of a written bed hold notice being provided. This was confirmed by the Minimum Data Set Coordinator on 4/18/24. Similarly, Resident #11 was transferred on 4/1/24, and the clinical record also lacked evidence of a written bed hold notice. This was confirmed by the Director of Nurses on 4/17/24.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit Minimum Data Sets (MDS) within the required timeframes for seven residents. Specifically, the facility did not complete and submit Annual, Quarterly, and Discharge MDS assessments within the 14-day period following the Assessment Reference Date (ARD) for residents #6, #8, #13, #25, #35, #44, and #318. The MDS coordinator confirmed that these assessments were not completed and/or submitted timely, as required by regulations. For instance, Resident #6's Annual MDS with an ARD of 3/11/24 was due by 3/25/24 and should have been submitted by 4/8/24, but it was not completed or submitted by 4/17/24. Similarly, Resident #8's Discharge MDS with an ARD of 3/3/24 was due by 3/17/24 and should have been submitted by 3/31/24, but it was not completed or submitted by 4/17/24. These delays were consistent across all seven residents reviewed, indicating a systemic issue in the timely completion and submission of MDS assessments.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
