Marshall Health Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Machias, Maine.
- Location
- 16 Beal Street, Machias, Maine 04654
- CMS Provider Number
- 205109
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Marshall Health Care And Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairments and mental health diagnoses sustained a finger injury of unknown origin, which was not reported to the State Agency as required by facility policy. Staff and administration acknowledged the resident's unreliable recall and the uncertainty surrounding the cause of the injury, but the incident was not reported as an injury of unknown origin.
A resident with heart failure and severe cognitive impairment was not consistently monitored according to discharge orders, including failure to administer prescribed Lasix and obtain daily weights. The facility did not notify the provider of a significant weight gain or new symptoms, resulting in the resident's hospitalization for worsening congestive heart failure.
Two residents had incomplete physician orders, with multiple instances where orders were signed but not dated, and care plans were not fully reviewed. One resident's medication orders and instructions were missing dates, while another's discharge instructions and provider notes lacked evidence of medication continuation and monitoring. The DON and Unit/Nurse Manager confirmed these documentation deficiencies.
Two residents missed multiple doses of prescribed medications, including pain management and GERD treatments, due to the facility's inability to obtain the medications from the pharmacy or emergency supply. The DON confirmed that the medications were not available and that no emergency prescription or override code was provided, resulting in missed doses as documented in the EMAR.
Surveyors found that medications and vaccines were stored inappropriately in dormitory-style refrigerators with significant ice buildup, and an expired pneumonia vaccine was available for use. Temperature monitoring logs for medication and immunization refrigerators were incomplete, with multiple days missing documentation, as confirmed by the DON.
A CNA repositioned a resident by pulling on their pants, causing their incontinence brief to shift and bulge, rather than using a gait belt, compromising the resident's dignity. On a separate occasion, a resident was left sitting in a wheelchair in the dining room without being offered a seat or served breakfast until prompted by another resident, and was not given silverware until several minutes after being served. Both incidents were confirmed by staff and administration.
Surveyors observed multiple fluid spills in common areas and resident rooms, as well as excessively hot water temperatures in several locations. Staff failed to address or warn about the hazards, and maintenance on water temperature controls was overdue, resulting in unsafe conditions for residents.
The facility did not ensure that two CNAs completed required in-service trainings, including abuse prevention, resident rights, behavioral health, and annual competency training. The Business Office Manager confirmed that these trainings were not completed or documented.
A facility failed to update a care plan for a resident with bipolar disorder as required by PASRR level II determination. The care plan mentioned mental wellbeing but lacked specific interventions for psychiatrist medication management. This deficiency was confirmed during an interview with a Licensed Social Worker and a surveyor.
The facility failed to ensure timely physician visits for several residents, with delays ranging from 8 to 42 days beyond the required intervals. These deficiencies were confirmed through clinical record reviews and staff interviews, highlighting a pattern of overdue visits for multiple residents.
Surveyors identified deficiencies in food storage and equipment maintenance, including outdated food in the walk-in cooler, dirty dish storage cabinets, and non-compliant plumbing fixtures. The ice machine's air gap was improperly installed, and dust was found on kitchen equipment, indicating inadequate cleaning practices.
The facility did not ensure that residents were offered pneumococcal vaccinations as per CDC guidelines. Five residents did not receive the Prevnar 20 vaccine, and their vaccination records were not properly reviewed. The Unit Manager-Infection Preventionist and the DON were unaware of the CDC recommendations regarding the Prevnar 20 vaccination.
A facility failed to accurately code the Annual MDS for a resident, indicating they did not have a Level II PASRR, despite qualifying for such services. This error was confirmed during a record review and an interview with a Licensed Social Worker.
A facility failed to implement PASRR level II recommendations for a resident with bipolar disorder, which required ongoing psychiatric services for medication management. The LSW was unaware of the need for these services and could not find documentation that they had been offered or refused.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident with COPD, omitting necessary information on oxygen and nebulizer treatments. This deficiency was confirmed through interviews and record reviews.
The facility failed to implement a nutrition care plan for a resident experiencing weight loss and hunger, as dietary staff did not follow the prescribed large portion meals. Additionally, the facility did not develop a respiratory care plan for another resident using oxygen and nebulizer treatments, as required by their admission orders.
A resident experienced significant weight loss due to the facility's failure to follow physician orders and care plan. The resident was not provided with the prescribed Kennedy cup for beverages, and dietary supplements were inconsistently given. Staff, including CNAs and the cook, were unaware of the requirement for the Kennedy cup, leading to the resident missing necessary nutritional support.
The facility failed to provide appropriate respiratory care for two residents by not following physician orders for oxygen administration and not maintaining clean respiratory equipment. One resident was observed with an incorrect oxygen flow rate and undated nebulizer setups, while another had a dusty concentrator filter despite records indicating it was recently cleaned.
A facility failed to ensure timely physician review and signature of a resident's medication and treatment orders. The physician signed the admission orders, but subsequent orders were signed three days late on two occasions. This delay was confirmed by a surveyor during an interview with the Administrator.
The facility failed to ensure attending physicians made required visits and documented progress notes, and also failed to remove outdated food items timely, leading to recurrent deficiencies during a re-visit. These issues were discussed with the Administrator and DON.
The facility failed to provide written notification to a resident and their representative for two hospital transfers. Verbal notification was given, but there was no evidence of written notices. The Ombudsman was also not notified. The Licensed Social Worker admitted to not sending written notices, and the Administrator was unaware of the requirement.
The facility failed to protect residents by allowing an alleged perpetrator, a CNA, to work all scheduled shifts before the investigation was completed. Despite the policy requiring accused employees to be placed on leave, the CNA continued to work from 4/1/24 to 4/5/24. The investigation concluded on 4/10/24, but the CNA was not informed and continued working until 4/5/24.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Policy and Procedure. A resident with multiple diagnoses, including mental health issues, dementia, and cognitive impairments, reported to staff that they had injured their finger, stating it was due to a fall. However, the resident was unable to specify where or when the fall occurred, and staff noted that the resident was not a reliable historian and could have sustained the injury in various ways. Documentation in the clinical record and interviews with staff confirmed the resident's cognitive limitations and behavioral issues, which contributed to uncertainty about the cause of the injury. Despite the facility's policy requiring immediate reporting of suspected abuse, neglect, exploitation, misappropriation, or injury of unknown origin to the Administrator and State Agency, the incident was not reported. Both the Administrator and Assistant Director of Nursing acknowledged that the resident's recall was unreliable and that the injury was of unknown origin, confirming that it should have been reported according to policy and state law.
Failure to Follow Discharge Orders and Monitor Heart Failure Resident
Penalty
Summary
The facility failed to monitor and adequately treat a resident with a diagnosis of heart failure and severe cognitive impairment. Upon admission, the resident's hospital discharge instructions included orders to continue home Lasix (furosemide), monitor daily weights, and notify the provider of a weight gain or loss of 3 pounds on two consecutive days, as well as signs of increased difficulty breathing or swelling. The clinical record did not show evidence that the Lasix was continued as directed, nor that daily weights were consistently obtained. Specifically, there were multiple days where no weight was recorded, and the resident was not weighed for 19 out of 22 days during the review period. Despite clear orders, the facility did not document administration of furosemide or consistent monitoring of the resident's weight. The resident experienced a significant weight gain of 12 pounds and developed new onset non-pitting and later pitting edema in both feet, as well as other symptoms such as shortness of breath, wheezing, and a new heart murmur. There was no evidence that the provider was notified of the significant weight gain or the new symptoms as required by the discharge instructions and physician orders. Ultimately, the resident's condition worsened, resulting in hospitalization for treatment of diastolic congestive heart failure. Interviews with facility staff confirmed that the discharge instructions were not fully implemented, and that communication issues and incomplete transfer of medication orders contributed to the failure to provide appropriate care and monitoring for the resident.
Physician Orders Not Properly Dated or Reviewed
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total programs of care and that all orders were complete, signed, and dated as required. For one resident, multiple telephone orders over a six-month period were found to be incomplete, with the provider signing but not dating a total of 11 orders. These included medication orders such as loperamide and instructions for administering Resource juice. The Director of Nursing confirmed during record review that these deficiencies existed and that the orders were not properly dated by the provider. For another resident, discharge instructions and provider notes related to conditions such as left hip fracture, hypothyroidism, and diastolic congestive heart failure were signed by the provider but not dated. Additionally, the clinical record did not show evidence that prescribed medications, such as Lasix, were continued in the facility or that required daily weights were monitored. The Unit/Nurse Manager confirmed that the provider's medication list was auto-populated from the provider's office system, which did not always reflect the facility's records, and that the provider did not review the full plan of care or date the signed orders on admission.
Failure to Provide Timely Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed for two residents. One resident had an order for Tramadol HCl 50 mg every 4 hours for pain, but missed three doses due to the medication being unavailable. Documentation showed that the medication was not available from the pharmacy or the Pyxis emergency medication supply, and no emergency prescription was sent to facilitate access. The Director of Nursing confirmed that the pharmacy did not provide an override code for the Pyxis, and the facility did not use a local pharmacy to obtain the medication because the primary pharmacy had already scheduled delivery for later that day. Another resident had orders for Dexlansoprazole 60 mg and Pantoprazole 40 mg, both used to treat GERD. This resident missed a total of nine doses of Dexlansoprazole and six doses of Pantoprazole over several days due to the medications being on order or not available. The EMAR documented each missed dose, and the Director of Nursing confirmed the missed administrations. These failures resulted from the facility's inability to obtain and provide the necessary medications as ordered by the residents' physicians.
Improper Medication Storage and Inadequate Temperature Monitoring
Penalty
Summary
Surveyors observed that medications and vaccines were not stored properly in multiple medication storage refrigerators across three wings of the facility. On two separate wings, dormitory-style combination refrigerator/freezer units with significant ice buildup were used to store medications, which is inappropriate due to temperature fluctuations. In one of these refrigerators, an expired vial of Prevnar 20 pneumonia vaccine was found available for use, 43 days past its expiration date. Additionally, there was a lack of evidence that refrigerator temperatures were being monitored in the immunization refrigerator on the South Wing. Temperature logbooks for the medication and immunization refrigerators were reviewed and found to have missing documentation for several days in June 2025. Specifically, the South Wing medication refrigerator log was missing temperatures for 2 of 25 days, the South Wing immunization refrigerator log was missing temperatures for 21 of 25 days, and the West Wing medication refrigerator log was missing temperatures for 6 of 25 days. These findings were confirmed through interviews with the Unit/Nurse Manager/Infection Control Preventionist and the Director of Nursing.
Failure to Maintain Resident Dignity During Repositioning and Meal Service
Penalty
Summary
On 6/23/25, a certified nursing assistant (CNA) was observed repositioning a resident in a wheelchair by grabbing the waistband of the resident's pants and pulling them up, which caused the resident's incontinence brief to shift and bulge in the crotch area. The CNA acknowledged during an interview that this method was inappropriate and that a gait belt should have been used instead. This action failed to maintain the resident's dignity and respect during care. On 6/26/25, another resident was observed sitting in a wheelchair in the aisle between two tables during breakfast, watching other residents eat. The resident was not offered a seat at a table or served breakfast until another resident pointed out the situation to staff. When the resident was finally seated and served breakfast, they were not provided with silverware until several minutes later. These observations were confirmed by the facility administrator at the time.
Failure to Prevent Accident Hazards Due to Fluid Spills and Excessive Water Temperatures
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by multiple observations of fluid spills and excessively hot water temperatures. Over four consecutive days, surveyors observed fluid puddles and streaks in various areas, including the entry area of a dining room, a resident's room, and a hallway. In one instance, a staff member walked through a fluid spill in a resident's room without addressing the hazard, and no wet floor signs or staff were present to alert or clean up the spills in the hallway. These conditions were confirmed by staff members present at the time of observation. Additionally, surveyors identified hot water temperatures in several locations that exceeded safe limits, with readings ranging from 120.2 to 125.0 degrees Fahrenheit. The Maintenance Director confirmed that water temperatures are only checked weekly and that maintenance on the mixing valve was overdue. These findings were directly observed and confirmed with facility staff, indicating a failure to provide adequate supervision and hazard prevention in the resident environment.
Failure to Ensure Required CNA Training and Annual In-Services
Penalty
Summary
The facility failed to implement and maintain an effective training program for its Certified Nursing Assistants (CNAs). One CNA, hired on 6/24/24, did not have documentation of required in-service trainings on abuse, resident rights, and behavioral topics in her education record. The Business Office Manager confirmed that these trainings had not been completed. Another CNA, hired on 5/2/22, lacked evidence in her employee file of having received annual in-service trainings on communication, resident rights, behavioral health, dementia management, abuse prevention, or the required minimum of 12 hours per year to ensure continuing competency. The Business Office Manager confirmed that while this CNA had an annual evaluation, the annual trainings had not been completed.
Failure to Update Care Plan for Psychiatric Services
Penalty
Summary
The facility failed to update a care plan for a resident as required by the Preadmission Screening and Resident Review (PASRR) level II determination. The resident, identified as having a serious mental illness due to a diagnosis of bipolar disorder, required ongoing psychiatric services, including medication management by a psychiatrist. However, upon review of the resident's care plan, it was found that while the care plan mentioned mental wellbeing and PASRR Level II, it lacked specific interventions related to psychiatrist medication management. This deficiency was confirmed during an interview with a Licensed Social Worker and a surveyor.
Physician Visit Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that the attending physician made required visits at the mandated intervals for five of the eleven sampled residents. Resident #25 had a physician visit on February 23, 2024, with the next visit due by May 3, 2024, including a 10-day grace period. However, the visit was not completed until May 31, 2024, making it 28 days overdue. Similarly, Resident #31's physician visit was due by May 15, 2024, but was completed on May 23, 2024, 8 days overdue. These delays were confirmed during interviews with the RN, ICP/Unit Manager, and the Administrator. Resident #11's physician visits were also delayed, with a visit due by January 17, 2024, but not completed until February 28, 2024, 42 days overdue. The next visit was due by May 8, 2024, but was completed on May 24, 2024, 16 days overdue. Resident #40's first 30-day physician visit was completed on February 8, 2024, with the next due by April 18, 2024, but it was not completed until May 24, 2024, 36 days overdue. Resident #44 experienced similar delays, with visits consistently overdue by 16 to 42 days. These findings were confirmed through interviews with the Administrator, Director of Nursing, and other staff members.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies during a survey, primarily related to food storage and equipment maintenance. During an initial tour of the kitchen, surveyors observed outdated food items in the walk-in cooler, including cooked turkey bacon dated over a month prior and celery with brown, slimy stalks. These items were removed from stock upon observation. Additionally, a metal cabinet used for storing dishes was found to have dirty shelves, indicating a lack of cleanliness in food storage areas. Further inspection revealed issues with plumbing fixtures, specifically the air gap on the ice machine, which was not in compliance with the Maine State Plumbing Code. The air gap was improperly installed, failing to meet the required separation standards. Dust accumulation was also noted on the juice machine and the front of the ice maker, suggesting inadequate cleaning practices. These observations were confirmed through interviews with the Dietary Manager and Maintenance Director, highlighting lapses in maintaining professional standards for food safety and equipment cleanliness.
Failure to Administer Prevnar 20 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. Specifically, five out of six residents reviewed for immunizations did not receive the Prevnar 20 vaccine as recommended. The residents involved were admitted to the facility on various dates, and their vaccination records were either not reviewed, not offered, or did not include the Prevnar 20 vaccination. During an interview, the Unit Manager-Infection Preventionist and the Director of Nursing confirmed that they were not following CDC recommendations and were unaware of the need to review, offer, and administer the Prevnar 20 vaccination.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to ensure the accurate coding of the Annual Minimum Data Set (MDS) 3.0 for a resident, leading to a deficiency in the assessment process. Specifically, the MDS for a resident was inaccurately coded to indicate that the resident did not have a Level II Preadmission Screening and Resident Review (PASRR), despite the resident qualifying for Level II services as per the PASRR completed earlier. This discrepancy was identified during a review of the resident's clinical record, which showed that the PASRR was completed and indicated the need for Level II services. The inaccuracy was confirmed during an interview with a Licensed Social Worker, who acknowledged the error in the MDS coding.
Failure to Implement PASRR Recommendations for Psychiatric Services
Penalty
Summary
The facility failed to obtain and implement recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination for a resident diagnosed with bipolar disorder. The PASRR, dated 4/20/23, indicated that the resident met the State of Maine's definition for serious mental illness and required ongoing psychiatric services by a psychiatrist. These services were necessary to evaluate the response and effectiveness of psychotropic medications, modify medication orders, and assess the need for additional behavioral health services. However, during an interview, the Licensed Social Worker (LSW) admitted to not realizing that the PASRR recommended psychiatric services for medication management and acknowledged that there was a provider available to offer these services. The LSW also could not find documentation indicating that these services had been offered or refused.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, identified as Resident #195, who was reviewed for new admissions. This deficiency was identified through interviews and record reviews. The resident was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had admission orders for the use of oxygen and nebulizer treatments. However, the baseline care plan did not include necessary information regarding the use and care of these respiratory treatments. This omission was confirmed during an interview with the Director of Nursing by a surveyor.
Deficiencies in Nutrition and Respiratory Care Planning
Penalty
Summary
The facility failed to implement a care plan approach in the area of nutrition for a resident who reported needing help with meals and feeling hungry after eating. Despite a documented 8-pound weight loss over five months, the resident's care plan, initiated to address swallowing precautions, required dietary staff to provide pureed meals with large portions. However, the diet order slip used by the dietary staff did not include the large portions, indicating a failure to follow the care plan. Additionally, the facility did not develop a care plan for respiratory care for another resident who was observed using oxygen and had a nebulizer treatment setup in their room. The resident's clinical record showed admission orders for oxygen and nebulizer treatments, and the care area assessment was completed, making the care plan due. However, upon review, the care plan lacked evidence of interventions related to the resident's respiratory treatments, including the use of oxygen and nebulizer treatments.
Failure to Provide Prescribed Nutritional Support and Adaptive Equipment
Penalty
Summary
The facility failed to adhere to physician orders and the care plan for a resident experiencing weight loss. The resident's clinical records indicated a significant weight loss of 8.01% over a few months. The physician had ordered a specific diet that included Carnation Instant Breakfast mixed with a Thrive supplement to be provided with each meal, and the use of adaptive equipment, specifically a Kennedy cup, for beverages. However, observations revealed that the resident was not provided with the Kennedy cup as required, and the dietary supplements were not consistently given. During the survey, it was observed that the resident was using a regular cup instead of the prescribed Kennedy cup, and the staff, including the cook and CNAs, were unaware of the requirement for the Kennedy cup. Additionally, the resident missed receiving the CIB shake at lunch due to a mishap with the cup's plastic wrap. The Dietary Manager indicated that CNAs were responsible for transferring beverages to the Kennedy cups, but this was not being done, leading to the resident not receiving the necessary nutritional support as per the care plan.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. For one resident, the surveyor observed the resident wearing oxygen via nasal cannula with the concentrator set at 1.5 liters per minute (LPM), contrary to the physician's order of 2 LPM for shortness of breath or oxygen saturations below 90%. Additionally, the oxygen and nebulizer setups were not dated to indicate when they were last changed, and the concentrator filter was dusty. The resident reported having to request a change of the oxygen tubing due to inadequate airflow, and the nebulizer setup was only changed on the morning of the surveyor's observation. For another resident, the surveyor observed a dusty concentrator filter, despite the treatment administration record indicating that the filter was cleaned as per the weekly schedule. The amount of dust observed was inconsistent with the filter being cleaned six days prior. These observations indicate a failure to adhere to physician orders and maintain clean respiratory equipment, which are essential components of providing safe and appropriate respiratory care.
Physician Order Review Delays
Penalty
Summary
The facility failed to ensure that the physician reviewed a resident's total program of care in a timely manner, specifically regarding the signing of orders for medications and treatments. A newly admitted resident, identified as Resident #40, had their admission orders signed by the physician, which were valid for 30 days. However, subsequent physician orders required review and signature by specific dates, including a 10-day grace period. The orders due for review by March 16, 2024, were signed three days late on March 19, 2024. Similarly, the next set of orders due by April 28, 2024, were signed three days late on May 1, 2024. This delay in signing was confirmed by a surveyor during an interview with the facility's Administrator.
Recurrent Deficiencies in Physician Visits and Food Safety
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for deficiencies identified during the annual Long Term Care Recertification Survey. Specifically, the facility was cited for failing to ensure that attending physicians made required visits and wrote progress notes at the mandated intervals. This deficiency was initially identified during the survey dated 6/12/24, involving several residents whose attending physician progress notes were not updated or signed off as required. Despite the facility's efforts to address this issue, the deficiency was cited again during a re-visit on 8/13/24, indicating ongoing non-compliance with the required physician visit schedule and documentation. Additionally, the facility was cited for failing to remove fresh food items and outdated meat in a timely manner and for not ensuring that plumbing fixtures were properly installed to prevent backflow. This deficiency was also identified during the survey dated 6/12/24. Observations during the re-visit on 8/13/24 revealed that the facility continued to have issues with the timely removal of food items, leading to the recitation of the same deficiency. These findings were discussed with the Administrator and Director of Nursing during the re-visit.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the reasons for two hospital transfers. The resident was transferred to the hospital on two occasions, and while verbal notification was given to the resident's representative, there was no evidence of written notices being provided. Additionally, the facility did not notify the Ombudsman of these transfers. During interviews, the Licensed Social Worker admitted to not sending written notices or notifying the Ombudsman, and the Administrator was unaware of the requirement to provide written notices to resident representatives.
Failure to Remove Alleged Perpetrator During Investigation
Penalty
Summary
The facility failed to protect residents during an investigation by allowing the alleged perpetrator, a Certified Nurse Assistant (CNA), to work all scheduled shifts from 4/1/24 to 4/5/24 before the investigation was completed. The facility's policy, revised in 2/2023, mandates that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. Despite this policy, the CNA continued to work and provide resident care during the investigation period. The Administrator became aware of the abuse allegation on 4/1/24, and the CNA provided a written statement on 4/3/24. The investigation concluded on 4/10/24, but the CNA was not informed of the investigation and continued working until 4/5/24. This failure to follow policy was confirmed through a review of the working schedule and interviews with the CNA and other staff members.
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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