Market Square Health Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in South Paris, Maine.
- Location
- 3 Market Square, South Paris, Maine 04281
- CMS Provider Number
- 205076
- Inspections on file
- 14
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Market Square Health Care Center, Llc during CMS and state inspections, most recent first.
The facility did not maintain required documentation and monitoring for its Legionella Water Management Program, omitting key appendices and failing to monitor specified equipment. Additionally, a CNA-M used reusable blood pressure cuffs and a stethoscope on a resident and did not sanitize the equipment before returning it to the medication cart, despite acknowledging the need for disinfection between uses.
Surveyors identified widespread deficiencies in housekeeping and maintenance, including soiled equipment, uncleanable surfaces, damaged privacy curtains, dirty caulking, and exposed heating elements. These issues were observed in multiple resident rooms and common areas, resulting in an environment that was not consistently safe, clean, or comfortable for residents.
The facility did not create or implement baseline care plans within 48 hours of admission for three residents, including two who were current smokers and one with a Stage 4 pressure ulcer. The care plans lacked necessary interventions for smoking and did not accurately reflect the use of positioning wedges for pressure ulcer management, as confirmed by staff interviews and record reviews.
Staff did not consistently sign the controlled substance logs at shift changes, resulting in missing incoming and outgoing signatures on multiple occasions. Despite receiving education on the importance of this process, staff admitted to not always ensuring proper documentation, and these findings were confirmed by the facility's quality improvement specialist.
Surveyors found that the kitchen and food storage areas were not maintained in a clean and sanitary manner, with dirty floors, soiled equipment, and expired or unlabeled food items present. The Food Service Director and an RN confirmed these findings, which were not in accordance with the facility's food storage policy.
Surveyors identified incomplete and inaccurate clinical documentation for two residents related to smoking status and contracts, as both initialed all options on their smoking agreements and had inconsistent or incomplete smoking assessments. Additionally, documentation for a resident with a wander guard device failed to specify its placement during multiple shifts, and medication records for another resident lacked clear rationale and evidence of required orders, including for oxygen use. These deficiencies were confirmed by staff interviews and record reviews.
A resident did not consistently receive scheduled showers according to their preferences, with staff substituting bed baths due to staffing issues and failing to document refusals or changes. The facility's records confirmed missed showers and lack of proper documentation.
A resident receiving both a diuretic and an anticoagulant for atrial fibrillation did not have updated goals or interventions in their care plan addressing the use of these medications. Review by surveyors and a Quality Improvement Specialist confirmed the omission, which was not in accordance with facility policy requiring person-centered care plans with measurable objectives.
A resident did not receive wound care in accordance with physician orders, as an LPN deviated from prescribed wound care procedures for multiple wound sites and performed a dressing change on a wound without a current order. The LPN confirmed not following the provider's instructions and the lack of an order for one wound site.
A resident with COPD had their nasal cannula tubing left unbagged and draped over an oxygen concentrator, with the prongs in direct contact with the device, instead of being stored in a plastic bag as required by physician orders and the care plan. Staff confirmed that the tubing should have been stored properly when not in use, but this was not followed.
Surveyors observed that a resident had multiple medications, including eye drops, nasal sprays, and a cup of Lactulose, left unsecured at the bedside and on furniture in their room. There were no physician orders or IDT assessments for these medications or for self-administration, and an LPN confirmed that medications should not be left at the bedside and was unaware of their presence.
A facility failed to update a resident's care plan to include goals and interventions for falls, despite multiple incidents. The facility's policy requires care plans to be updated with new interventions, but the resident's care plan lacked evidence of such updates. The Administrator and ADON confirmed the oversight during interviews.
The facility failed to maintain complete clinical records for two residents following falls. One resident's record lacked the Post Fall Observation Tool for several incidents and did not include required nursing notes for three shifts post-fall. Another resident's record also missed nursing notes after falls, despite a care plan addressing fall risks. The ADON confirmed these deficiencies during a review.
A facility failed to maintain an effective Infection Control Program for a resident. Observations revealed an unbagged bedpan on the bathroom floor, an unused catheter bag stored with food items, and a nebulizer improperly stored with personal items. The resident expressed distress over these unsanitary conditions, and a nurse confirmed the improper practices.
The facility failed to maintain adequate hot water temperatures for its laundry equipment, resulting in insufficient cleaning and disinfection of linens. Despite reports from staff and the laundry chemical supplier, the facility's hot water system remained set at 120°F, below the required levels for effective disinfection. This deficiency poses a potential risk of exposure to contaminants for residents and staff.
The facility failed to maintain a clean kitchen environment, with issues such as dusty air conditioning units, food debris, and a dirty dish air dry machine. Additionally, there were significant gaps in monitoring and documenting kitchen operations, including dish machine temperatures and sanitizer levels, as confirmed by the Administrator.
The facility failed to maintain the small and large steam tables in safe operating condition. The small steam table had a broken electrical plug and inconsistent heating, while the large steam table was missing its plug end. Both were still used to serve food. The RD/LD was unaware of these issues until informed by staff, confirming the equipment was not properly maintained.
Infection Control Program Deficiencies: Legionella Management and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically regarding the prevention and control of Legionella. The Legionella Water Management Program referenced control measures and monitoring procedures in Appendices A and C, but these appendices were missing from the program documentation. Additionally, the monitoring spreadsheet (Appendix B) did not include required monitoring or sampling for the ice machine and floor scrubbing machine, both of which were identified as equipment to be included in the preventative maintenance schedule. The Quality Improvement Specialist confirmed that the facility was not following its own Legionella Water Management policy, as there were no measures in place to control, assess, or monitor areas where Legionella and other waterborne pathogens could grow and spread, nor was there a diagram indicating where these measures should be applied. During direct observation, a CNA-M used reusable blood pressure cuffs and a stethoscope on a resident and then failed to sanitize the equipment before placing it back in the medication cart or hanging it on the cart. The CNA-M acknowledged that the equipment was for multi-patient use and admitted that it should have been sanitized before being stored or reused. These findings were discussed with the Regional Quality Improvement Specialist, confirming lapses in infection control practices related to equipment sanitation.
Failure to Maintain Sanitary and Comfortable Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies in housekeeping and maintenance services across all three units during an environmental tour with the Environmental Services Director and the Quality Improvement Specialist. Specific findings included an EZ sit-to-stand patient lift with food debris and dirt in the foot base area, resident rooms with chipped or missing paint, marred walls, and exposed heating elements due to missing heater covers. In one room, a grabber/reacher was coated with a thick brown substance, and another room was noted to be very cold and without heat due to a broken baseboard heater. Additional issues included a bedpan stored on a toilet and a foam pad left on a shower floor. Further observations revealed multiple rooms with entrance and bathroom doors that were gouged, marred, or had untreated putty, creating uncleanable surfaces. Several rooms had privacy curtains in disrepair, missing hooks, or hanging down, and caulking around toilets was dirty. Floors were soiled with dirt and debris, bathroom exhaust fans were dusty, and some bathroom walls were marked with black scuffs. In one instance, a urine hat was found on a bathroom floor. These findings were confirmed by the Environmental Services Director and the Quality Improvement Specialist during the tour.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by facility policy. For one resident who was a current smoker, the baseline care plan did not include any interventions or instructions related to smoking upon admission, despite documentation of the resident's smoking status. Another resident, also identified as a smoker and permitted to smoke unsupervised, did not have any smoking-related interventions or goals included in the care plan as of the time of review. These omissions were confirmed during interviews with the Quality Improvement Specialist. Additionally, a resident with a Stage 4 sacral pressure ulcer was observed being repositioned with multiple wedge pillows, as described by staff. However, the baseline care plan for this resident only referenced the use of bolstered pillows to the bilateral lower extremities and did not reflect the actual practice of using additional positioning wedges for turning and repositioning every two hours. Interviews with staff confirmed the use of more wedges than documented in the care plan. These findings indicate that the facility did not ensure baseline care plans were accurately developed and implemented within the required timeframe for these residents.
Failure to Document Controlled Substance Shift Counts
Penalty
Summary
The facility failed to ensure that two authorized staff members signed the Shift Count page to confirm the count of all controlled substances at each change of shift on both the East and [NAME] Units. Record reviews revealed multiple instances where either the outgoing or incoming signature, or both, were missing from the controlled substance logs on various dates and times. This included missing signatures on both the East Wing Med Cart and Treatment Cart, as well as the [NAME] Wing Controlled Substance Log. The absence of these signatures indicates that the required verification of controlled substances was not consistently performed at shift changes. Interviews with Certified Nursing Assistant-Medication Technicians and a Licensed Practical Nurse confirmed that staff had received education on the importance of signing the controlled substance log after each count and at every shift change. However, staff admitted to not always ensuring that both parties signed the log as required. The Quality Improvement Specialist also confirmed these findings during the survey.
Deficient Sanitation and Food Storage Practices in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen and food storage areas in a clean and sanitary condition. During a kitchen tour, the kitchen floor was found dirty with food debris and trash, and similar debris was noted under equipment and shelving. The dish room food disposal unit had dried food and liquid residue, and a wall-mounted fan was heavily soiled with dust. A plunger with dried food and liquid residue was found on the dish room floor. In the dry storage room, several boxes of Apple Juice Blend base and containers of Med Plus 2.0 Nutritional Drink were found past their best if used by dates, and multiple bags of cornflakes were not labeled. The walk-in refrigerator and freezer floors were dirty, missing paint or sealant, and contained unlabeled and undated food items such as hot dogs and buns. The storage room floor was also dirty and missing paint or sealant. Additionally, in a kitchenette refrigerator, expired Apple Juice Blend base and Med Plus 2.0 Nutritional Drink were found, along with an unmarked and undated container of cereal on top of the refrigerator. These findings were confirmed by the Food Service Director and a registered nurse during interviews. The facility's own food storage policy requires all foods to be covered, labeled, dated, and discarded if past their use by dates, which was not followed in these instances.
Incomplete and Inaccurate Clinical Documentation for Smoking, Medication, and Safety Devices
Penalty
Summary
The facility failed to ensure that clinical records for several residents contained complete and accurate documentation, specifically regarding smoking status, smoking contracts, medication orders, and monitoring of safety devices. For two residents who smoked, their clinical records and smoking contracts were not completed accurately. Both residents had initialed all options on the smoking contract, rather than selecting the appropriate choice, and the smoking status assessments were either incomplete or inconsistent with the residents' actual smoking behaviors. These discrepancies were confirmed during interviews with the residents and facility staff. Additionally, for one resident with an order for a wander guard device, the clinical record lacked documentation specifying the placement of the device during multiple shifts over several days. Nursing staff documented the presence of the wander guard but did not indicate its location on the resident, as required. This omission was acknowledged by the DON and Assistant DON during interviews. The review of medication orders for another resident revealed incomplete documentation regarding the rationale for certain medications, such as constipation and sleep medications, and a lack of evidence that an order was obtained for oxygen use, despite active orders for oxygen tubing changes. These documentation gaps were confirmed by the facility's Quality Improvement Specialist during record reviews and interviews.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate a resident's preferences for bathing, as evidenced by the resident not consistently receiving scheduled showers on Sundays and Wednesdays. The resident reported that, due to staffing issues, showers were often replaced with bed baths without their preference being honored. Review of the bathing documentation for February 2025 confirmed that the resident did not receive showers on several scheduled dates, and there was no documentation indicating that the resident refused showers or that bed baths were provided as a substitute. The Quality Improvement Specialist verified the lack of documentation and the deviation from the resident's established bathing schedule.
Failure to Update Care Plan for Diuretic and Anticoagulant Use
Penalty
Summary
The facility failed to update and implement measurable goals and interventions in the care plan for a resident who was prescribed both a diuretic (Lasix) and an anticoagulant (Eliquis) for atrial fibrillation. Record review showed that the resident had active medication orders for these drugs, but the most recent care plan update did not include any goals or interventions related to their use. During a care plan review with the Quality Improvement Specialist and surveyors, it was confirmed that the care plan lacked the required documentation for managing these medications, despite facility policy requiring person-centered care plans with measurable objectives and timeframes for all identified needs.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were followed for one resident. Clinical record review revealed specific physician orders for wound care on the right shoulder, anterior neck, and lateral neck, including detailed instructions for cleansing, application of skin prep, Kaltostat, Medihoney, and appropriate dressings. However, during direct observation, the LPN did not follow these orders as written. For the right shoulder, the LPN applied Medihoney before Kaltostat, then placed a saline-soaked gauze over the Kaltostat, which was not in accordance with the physician's instructions. For the anterior and lateral neck wounds, the LPN applied Medihoney to a Mepilix dressing and then applied it to the wound, which also deviated from the prescribed method. Additionally, there was no current physician order for wound management for the left shoulder wound, yet the LPN performed a dressing change on this site. During interview, the LPN confirmed the failure to follow the provider's orders for the right shoulder, anterior neck, and lateral neck wounds, as well as the absence of a wound order for the left shoulder. These actions resulted in the facility not providing treatment and care according to physician orders and the resident's care plan.
Failure to Maintain Sanitary Storage of Oxygen Tubing
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the development and transmission of infection related to respiratory care for a resident with chronic obstructive pulmonary disease (COPD). During observations on two separate occasions, the resident's nasal cannula tubing was found unbagged and draped over the oxygen concentrator, with the prongs in direct contact with the concentrator's surface. An empty plastic storage bag, intended for storing the tubing when not in use, was tied to the nightstand drawer handle instead of being used. The resident's clinical record included active orders to change the tubing weekly and to store unused oxygen tubing in a plastic bag, as well as a care plan reflecting these requirements. Interviews with a CNA and an LPN confirmed that the tubing should have been stored in the designated bag when not in use, but this was not done.
Failure to Secure and Document Medications at Bedside
Penalty
Summary
Surveyors found that the facility failed to properly store medications and treatments on two out of three days of the survey. Specifically, a resident was observed to have multiple medications, including thera tears lubricant eye drops, Top Care nasal spray (oxymetazoline hydrochloride), and fluticasone propionate nasal spray, at their bedside and on their over-the-bed table and TV stand. Additionally, a clear medication cup containing approximately 30ml of yellow liquid, identified as Lactulose, was also found on the resident's TV stand. These medications were not secured in locked compartments as required. Review of the resident's clinical record revealed there were no physician orders for the medications found at the bedside, nor was there an order for self-administration. The record also lacked evidence of an interdisciplinary team (IDT) assessment to determine if self-administration was safe, as required by facility policy. An LPN confirmed that medications should not be left at the bedside and was unaware that the resident had these medications in their room.
Failure to Update Care Plan for Falls
Penalty
Summary
The facility failed to update a resident's care plan to reflect current care needs in the area of falls. The facility's Falls Management Policy requires that residents' care plans be updated with all new interventions. However, a review of the clinical record for a resident revealed multiple falls on specific dates, yet the care plan, last updated on 11/12/24, did not include goals and interventions for falls. During interviews with surveyors, both the Administrator and the Assistant Director of Nursing confirmed that the care plan was not updated to include necessary interventions for falls, despite the expectation that it should be updated after each fall.
Incomplete Clinical Records for Residents After Falls
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 revealed multiple falls on specific dates, but the Post Fall Observation Tool was not completed for several of these incidents. Additionally, the clinical record lacked evidence of a nurse's note for each shift for three shifts following these falls, as required by the facility's Falls Management Policy. Another resident's care plan indicated a history of falls related to impaired mobility and other factors, with specific interventions outlined to prevent further incidents. However, the clinical record for this resident also lacked evidence of nursing notes being completed for each shift for three shifts after falls occurred. The Assistant Director of Nursing confirmed these deficiencies during a review of the clinical records with surveyors.
Infection Control Program Deficiency
Penalty
Summary
The facility failed to maintain an effective Infection Control Program for one of the sampled residents. Observations in the resident's room revealed several issues: an unbagged bedpan was found on the bathroom floor, an unused catheter bag dated two days prior was placed in a cardboard box containing the resident's pudding cups, and a nebulizer was left disassembled on the bedside table. Additionally, the nebulizer tubing was improperly stored in a wash basin with personal items like headbands and a hairbrush with a significant amount of hair. The resident expressed distress over the unsanitary conditions, particularly the catheter bag being stored with food items. A registered nurse confirmed these findings, acknowledging that bedpans should be bagged, catheter bags should not be mixed with personal items, and nebulizer tubing should be bagged when not in use.
Inadequate Hot Water Supply for Laundry
Penalty
Summary
The facility failed to maintain its laundry equipment according to the manufacturer's instructions, resulting in inadequate cleaning and disinfecting of linens. On the day of the survey, the hot water temperatures in the washing machines were significantly below the required levels for effective cleaning and disinfection. The Laundry/Housekeeping Supervisor confirmed that the hot water temperatures were insufficient, and logs from August 2024 showed consistently low temperatures, ranging from 64°F to 123°F, which did not meet the necessary standards for healthcare settings. Interviews with maintenance workers revealed that the facility's hot water system was set at 120°F, which was insufficient for the laundry's needs. The system could not be adjusted higher due to the risk of scalding in resident areas. A hot water booster, which could have addressed the issue, had been removed years prior and was never replaced. The maintenance workers confirmed that the current setup could not provide the necessary hot water temperatures for proper linen disinfection. The Quality Improvement Specialist and other staff members had reported the issue to corporate employees and the facility's administration, but no effective solution had been implemented. Documentation from the Patriot Company, which provided laundry chemicals, consistently noted the low water temperatures in their monthly reports. Despite these warnings, the facility did not take action to ensure the washing machines received adequate hot water, leading to a potential risk of exposure to contaminants for both residents and staff.
Deficiencies in Kitchen Sanitation and Monitoring
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a survey. The surveyor noted several areas of concern, including dusty and dirty wall-mounted air conditioning units, food debris and trash on the kitchen floor, a dirty plunger in the dish room, and a dusty dish air dry machine. Additionally, the grease trap was found to be rusty and dirty, and the dry storage room had a heavily soiled floor, a dusty wall vent, and a ceiling light with a cracked lens filled with dust and debris. The walk-in freezer had a significant ice buildup and was littered with trash and dirt, with a bag of cut green beans frozen into the ice. These observations were confirmed with the cook during the survey. The facility also failed to adequately monitor and document critical kitchen operations. The Daily High-Temp Ware Wash Checklist showed temperatures below manufacturer recommendations on multiple occasions, and there were numerous missing entries for dish machine temperatures. Similarly, the Sink/Bucket Sanitizer checklist and the Refrigerator/Freezer Temperature Log had extensive gaps in monitoring and documentation. These deficiencies were confirmed with the Administrator, indicating a systemic failure to adhere to established protocols for maintaining kitchen sanitation and equipment monitoring.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the small and large steam tables, in good repair and safe operating condition. During a kitchen tour, a surveyor observed that the small steam table had a broken electrical plug and was still in use, while the large steam table was missing its electrical plug end entirely. Both pieces of equipment were reportedly used to serve food to residents despite their malfunctioning state. The dietary aide and cook confirmed that the small steam table had inconsistent heating issues and that maintenance was aware of the problem but had not yet fixed it. The large steam table had been broken for two to three months, and the facility was in the process of acquiring a replacement. The Registered Dietitian/Licensed Dietitian (RD/LD) was unaware of the issues with the steam tables until informed by the kitchen staff. She confirmed that both steam tables were being used to keep food hot, despite not being maintained in a safe and proper working condition. The RD/LD acknowledged that the equipment had not been properly maintained, which was corroborated by the observations and interviews conducted by the surveyor. The facility's failure to ensure the safe operation of essential kitchen equipment was evident in the continued use of the malfunctioning steam tables.
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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