Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marshwood Center during CMS and state inspections, most recent first.
Failure to maintain clean and orderly conditions was identified across multiple units, with surveyors observing cracked and broken floor tiles, marred walls, stained ceiling tiles, dusty vents and fans, dirty bathroom floors and fixtures, damaged privacy curtains, rusted or chipped heating units, and other disrepair in resident rooms, hallways, dining areas, and bathrooms. The Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor confirmed the findings during the environmental tour.
Failure to Hold IDT Care Plan Meetings Within Required Timeframe: The facility failed to document IDT care plan meetings within 7 days of quarterly MDS assessments for 5 residents. Record review showed multiple quarterly MDSs with no evidence of timely IDT meetings, and staff interviews confirmed the missing documentation; the MDS Coordinator could not provide evidence that family or representatives requested meetings outside the required timeframe.
Kitchen Sanitation and Maintenance Deficiencies: During an initial kitchen tour, surveyors observed missing sheet rock on the wall behind the stove, food debris and trash on the kitchen floor, chipped and missing paint in the walk-in freezer, dusty air vents, and multiple stained ceiling tiles and ceiling grids above the stove. The Director of Operations for Dietary for Health Care Services confirmed the findings.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments: Multiple residents had missing MAR/TAR entries for ordered meds, treatments, assessments, and monitoring, including insulin and BG checks, wound and skin care, enteral feeding tasks, HOB elevation checks, psych med side-effect monitoring, and other ordered nursing interventions. The Market Clinical Advisor confirmed the missing documentation during interview.
Failure to Maintain Resident Dignity During Grooming: A cognitively intact resident with ADL assistance needs was observed on multiple occasions with long facial hair on the chin despite stating it bothered him/her and that help had been requested. The resident said he/she could shave but lacked a mirror, while CNA confirmed the resident had not been shaved and razors were not left in rooms.
Unsecured Chemical Storage in Spa Area: An unlocked and ajar closet door in the [NAME] unit spa allowed resident access to 5 gallons of Cid-A-L ? II disinfectant stored inside. The SDS stated the chemical should be kept out of reach of children and identified it as toxic, with potential for eye, skin, inhalation, and ingestion harm. The DON and surveyor observed the unsecured chemicals, and the DON confirmed they were not secured.
Unsanitary dumpster area: A surveyor observed food and trash on the ground around 3 of 3 dumpsters, and the DO of Dietary for Health Care confirmed the finding during an interview with two surveyors.
Failure to Follow Contact Precautions for C-diff: A resident with C-diff was on Contact Precautions, with PPE available and signage posted at the room entrance. Surveyors observed an LSW in the resident’s room without a gown or gloves, and the RN Mgr stated PPE was only needed if touching items before later correcting the staff member. The facility policy required PPE to be worn before or upon entry for residents on Transmission Based Precautions, including C-diff.
The facility failed to provide four residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. Clinical records lacked evidence of offering or assisting with advance directives, with one resident not receiving paperwork due to being on leave.
The facility failed to maintain a sanitary and comfortable environment across all units and the activity room. Observations included missing hooks and disrepair of privacy curtains, cracked heating unit grills, soiled bathroom floors, dirty caulking, and dirty ceilings. Linen closets contained trash and debris, and rooms had strong odors and visible dirt. These findings were confirmed by the Maintenance Director, DON, and Administrator.
The facility failed to secure chemicals, including Bleach Germicidal Wipes and an unlabeled bleach/water spray bottle, in unlocked shower rooms accessible to residents with dementia and other compromising conditions. This was confirmed by an LPN, the DON, and the Administrator.
The facility did not ensure sufficient direct care staff were scheduled to meet resident needs, particularly on weekends. A review of staffing reports revealed excessively low weekend staffing during a specific quarter, and facility personnel confirmed the shortfall. This deficiency potentially affects all residents needing assistance with ADLs.
The facility failed to ensure that 8 out of 25 licensed staff members, including LPNs and RNs, had current BLS certification as required by their job descriptions. This deficiency was identified through interviews and record reviews, and discussed with the DON.
The facility's kitchen was found to be unsanitary, with food and trash on the floor, leaking sinks, and equipment covered in residue. Additionally, the ice machine was not plumbed according to code, risking contamination. These issues were confirmed by the Food Service Director and other management staff.
The facility failed to meet the needs of two residents: one was unable to obtain Ginger Ale unless deemed medically necessary, and another, with a recent amputation, struggled with an inadequately sized bed, leading to a fall. Staff were unaware of these issues, indicating communication and assessment gaps.
A facility failed to refer a resident with Major Depressive Disorder and Suicidal Ideations for a PASRR Level II evaluation after their stay extended beyond 30 days. Initially, a PASRR Level I determination indicated no further evaluation was needed due to a 30-day waiver. However, the resident's stay became long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority for further assessment, as confirmed by the Licensed Social Worker.
A resident's eyeglasses were lost, and the facility failed to document the loss or assist in obtaining a replacement, despite the resident's cognitive intactness and reliance on glasses for watching TV. Interviews confirmed the oversight, and the facility did not follow its policy on personal property management.
The facility failed to maintain or improve ROM and mobility for two residents after discharge from therapies. One resident's restorative program was not documented or followed, leading to falls and a return to therapy. Another resident reported decreased strength due to lack of daily exercises. CNAs were unable to perform restorative tasks due to staffing issues, and the facility lacked a restorative nursing program.
The facility failed to maintain a sanitary environment for respiratory care, as two residents' respiratory equipment was improperly stored. Observations revealed that a resident's nebulizer tubing was on the bedside table, and another resident's oxygen tubing was under the oxygen concentrator handle, contrary to facility procedures. This was confirmed by the DON.
The facility did not have an Infection Preventionist present at two of the four quarterly QAA meetings. The absence was due to the departure of the Infection Preventionist in mid-October, and the position remained vacant until a new hire was finalized recently. This was confirmed by the Administrator and the Marketing Clinical Advisor.
The facility did not post daily nurse staffing information, including the resident census, for three survey days and failed to maintain these records for 18 months. The absence of the resident census was confirmed by the Scheduler/Payroll/HR personnel, who was unaware of the record-keeping requirement. This was corroborated by the RN Market Clinical Advisor.
The facility failed to maintain a sanitary and comfortable environment in three units. Observations included chipped and missing paint on wall heaters and door frames, rust creating uncleanable surfaces, marred walls, and dirty areas in resident rooms and bathrooms. These issues were confirmed by the DON during the survey.
The facility failed to ensure a safe environment for residents, with observations of a loose toilet, sharp splintered wood on doors, and a broken baseboard heater exposing sharp metal. These hazards were identified during a survey and discussed with the DON.
Failure to Maintain Clean and Safe Environmental Conditions
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on 6 of 7 units. During environmental tours with the Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor, surveyors observed multiple areas of disrepair and poor cleanliness, including cracked and broken floor tiles in dining areas and hallways, marred and chipped walls with exposed sheet rock, stained ceiling tiles, dusty or dirty vents and fans, dirty floors around toilets, and dirty or stained bathroom fixtures and surfaces. Several resident rooms also had damaged or missing privacy curtain hooks, dirty bedside tables, a soiled plunger on the bathroom floor, and call bell cords lying on the floor. Additional findings included rusted or chipped heating units, a heating unit pulled away from the wall, a rotted bathroom door frame with a hole in it, debris in a light fixture, and bathroom areas with stained caulking and dirty floors. Surveyors also observed black marks on bathroom walls, peeling paint, broken or hanging heater components, and a broken plastic wrap around the base of a toilet. The Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor confirmed the findings during the interview at the end of the tour.
Failure to Hold IDT Care Plan Meetings Within Required Timeframe
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT), including resident and/or representative participation to the extent possible, after each MDS assessment for 5 of 28 residents reviewed. The cited residents were #1, #8, #35, #60, and #63. Record review showed quarterly MDS assessments for these residents, but the clinical record lacked evidence that an IDT meeting was held within 7 days of the assessments. For Resident #1, a quarterly MDS dated 1/6/26 had no evidence of an IDT meeting within 7 days. For Resident #8, quarterly MDS assessments dated 12/16/25 and 3/12/26 had no evidence of IDT meetings within 7 days of either assessment. Resident #60 had quarterly MDS assessments dated 6/24/25 and 9/26/25 with no evidence of IDT meetings within 7 days, and Resident #63 had a quarterly MDS dated 5/20/25 with no evidence of an IDT meeting within 7 days. Resident #35 had a quarterly MDS dated 12/23/25 with no evidence of an IDT meeting within 7 days. During interviews, the LSW stated documentation should reflect what was decided for a meeting date and time, and that the LSW documents the actual care plan meeting while Nursing completes the care plan. The MDS Coordinator could not provide documentation showing that any family or representative requested a meeting outside the 7-day timeframe, and the Market Clinical Advisor confirmed the findings.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner during an initial kitchen tour with the Director of Operations for Dietary for Health Care Services. Surveyors observed a wall behind the stove with missing sheet rock, food debris and trash under tables and equipment on the kitchen floor, chipped and missing paint on the walk-in freezer floor creating an uncleanable surface, air conditioner vents covered with dust and dirt, and approximately 15 ceiling tiles and the ceiling grids above the stove stained yellowish and soiled with dust and dirt. The Director of Operations for Dietary for Health Care Services confirmed these findings during interview with the surveyors.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments
Penalty
Summary
The facility failed to ensure that Medication Administration Records (MARs) and Treatment Administration Records (TARs) were accurately completed for 7 of 28 residents reviewed. Record review and interviews showed multiple missing entries for ordered medications, treatments, monitoring tasks, and assessments across several residents, including insulin administration and blood glucose checks, wound and skin care, enteral feeding-related care, respiratory positioning checks, and other ordered observations. In each of the cited examples, the MAR/TAR lacked documented evidence that the ordered task was completed on the specified dates and shifts. For Resident #1, the clinical record showed an active sliding-scale Humalog order requiring finger-stick blood glucose checks before administration, but the MAR/TAR lacked evidence that blood sugars were checked and insulin was given on multiple dates in March. During an interview, the Market Clinical Advisor confirmed there was no evidence that the resident received the blood sugar checks or insulin for those dates. For Resident #3, the record contained multiple active orders, including Humalog, Lantus, Dulaglutide, Miconazole powder, wound monitoring, acetaminophen, lab work, head-of-bed elevation checks, psychotherapeutic side effect checks, Voltaren gel, and wander guard checks; the MAR/TAR lacked documentation for numerous missed entries across January and February 2026, and the Market Clinical Advisor confirmed the findings during interview. Additional residents had similar documentation gaps. Resident #8 had missing documentation for Risperidone administration, head-of-bed elevation checks, psychotherapeutic side effect checks, weekly weight, vital signs, clonidine patch placement, lab work, toe care, and wound care. Resident #14 had missing documentation for ammonium lactate application, head-of-bed elevation checks, nebulizer treatment, and IV observation. Resident #35 had missing documentation for BMP completion, psychotherapeutic side effect checks, wander guard placement checks, and TED hose care. Resident #60 had extensive missing documentation related to ice chips, skin cream, colostomy care and appliance changes, head-of-bed elevation, enteral feeding care, tube placement and flushing, suction canister disinfection, oral care, and psychotherapeutic side effect checks. Resident #63 also had missing documentation for lab work, head-of-bed elevation checks, psychotherapeutic side effect checks, levothyroxine administration, foot skin care, and Lantus administration. In each case, the Market Clinical Advisor confirmed the findings during interview.
Failure to Maintain Resident Dignity During Grooming
Penalty
Summary
The facility failed to protect and promote Resident #24’s dignity by not ensuring the resident’s facial hair was addressed despite the resident’s expressed concern and ability to participate in shaving. Resident #24 was admitted in February 2026 with diagnoses of right tibia and fibula fracture, had a BIMS score of 14 out of 15, and was documented in the care plan as needing assistance with grooming and personal hygiene. During observation on 3/16/26, the resident was seen sitting in a wheelchair with long white facial hair on the chin and stated that it bothered him/her, that help had been requested, and that the resident could shave but did not have a mirror in the room. On 3/17/26, the resident was again observed with the same long white facial hair on the chin and repeated that it was bothersome and that the facility must have razors because men were present in the facility. During interview, CNA #1 stated she had not shaved the resident and that razors would not be left in resident rooms. The DON later discussed that the resident could be shaved by staff or shave independently and that the facility would obtain a mirror and electric shaver.
Unsecured Chemical Storage in Spa Area
Penalty
Summary
The facility failed to ensure the resident environment remained free from accident hazards when a closet door in the [NAME] unit spa was observed unlocked and ajar, allowing resident access to the area. Inside the closet, surveyors found 5 gallons of Cid-A-L ? II, a disinfectant, virucide, and fungicide chemical. The Safety Data Sheet for the product stated it should be kept out of reach of children and described it as toxic, with risks including irreversible eye damage or burns, skin burns or irritation, drowsiness, nausea, loss of motor skills or disorientation from inhalation, and digestive tract burns if ingested. The Director of Nursing and the surveyor observed the unsecured chemicals, and the DON confirmed the chemicals were not secured, creating a hazardous and unsafe environment for residents who could access the area.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests. On 3/16/26 at 8:18 a.m., a surveyor observed food and trash on the ground around 3 of 3 dumpsters. Later that morning, at 8:48 a.m., two surveyors interviewed the Director of Operations for Dietary for Health Care, who confirmed the finding.
Failure to Follow Contact Precautions for C-diff
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment and help prevent the development and transmission of disease and infection related to the management of a resident with Clostridioides difficile (C-diff) infection. Resident #117 was admitted with a diagnosis of Clostridioides difficile, and the care plan for actual infection, initiated on 3/14/26, included Contact Precautions. On 3/16/26 at 10:33 a.m., the resident’s room had a posted Contact Precautions sign instructing staff to put on gloves and a gown before entering, and PPE supplies of gloves and gowns were available in a bin next to the door. The resident stated he/she was on contact precautions due to having C-diff and was on an antibiotic for a couple more days. On 3/16/26 at 11:11 a.m., two surveyors observed the Licensed Social Worker in the resident’s room sitting in the resident’s wheelchair without gloves or a gown. When the surveyor asked the RN Manager why the LSW was not wearing the required PPE, the RN Manager stated that PPE was only needed if touching items. The RN Manager then called the LSW out of the room and explained that she should be wearing gown and gloves while in the room. At 11:17 a.m., the LSW applied gown and gloves. The facility’s Transmission Based Precautions policy, revised 5/1/25, stated that PPE should be readily available near the entrance and that appropriate PPE should be donned before or upon entry for patients on Transmission Based Precautions, including Contact Precautions for pathogens such as Clostridioides difficile.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for four residents during a review of their clinical records. Specifically, the records for these residents lacked evidence that the facility had provided or obtained the necessary documentation concerning these rights. For one resident, the social worker confirmed that the clinical records did not include evidence of offering or assisting with an advance directive. Another resident did not receive the advance directive paperwork because they were out on leave, and the task was not completed. The absence of documentation for these residents indicates a failure to comply with the requirement to inform and document residents' rights to make decisions about their medical care.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across all seven units and the activity room. During an environmental tour conducted by two surveyors, accompanied by the Maintenance Director, the Director of Nursing, and the Administrator, numerous deficiencies were observed. These included missing hooks and disrepair of privacy curtains, cracked and broken heating unit grills, heavily soiled bathroom floors, dirty caulking around toilets, and dirty ceilings with holes. Additionally, there were issues with linen closets containing trash and debris, and various rooms had strong odors, fruit flies, and visible dirt and dust. Specific observations included a cracked plastic grill on a room heating unit, missing ceiling tiles, and a sit-to-stand patient lift with food and debris. The activity room doors had chipped paint and black marks, while the dining room window was fogged, and a table fan was dusty. The storage room and shower room also had issues with debris and black substances in the grout. These findings were confirmed in an interview with the Maintenance Director, the Director of Nursing, and the Administrator.
Improper Storage of Chemicals in Resident Areas
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards due to improper storage of chemicals. On two separate days of the survey, surveyors observed unsecured containers of Bleach Germicidal Wipes in unlocked shower rooms. These chemicals were accessible to residents, including those who were confused, compromised, and could move around the unit, even in wheelchairs. The presence of these unsecured chemicals was confirmed by both an LPN and the Director of Nursing, who acknowledged the potential risk posed to residents. Additionally, a surveyor found an unlabeled spray bottle marked as containing bleach and water, with an unknown bleach-to-water ratio, in a shower room. The Administrator confirmed that the bottle was not labeled appropriately and should have been secured behind a locked door. The unit housed residents with dementia and other compromising conditions, further emphasizing the risk of having unsecured and improperly labeled chemicals accessible to them.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed excessively low weekend staffing during the fourth quarter of 2024. On December 19, 2024, both the Director of Nursing and the Scheduler/Payroll/Human Resource personnel confirmed that the facility did not have enough staff to meet resident needs on weekends. This staffing shortfall has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Deficiency in Staff BLS Certification
Penalty
Summary
The facility failed to ensure that 8 out of 25 licensed staff members had current certification in Healthcare Basic Life Support (BLS) as required by the facility's job descriptions for Registered Nurses and Licensed Practical Nurses. This deficiency was identified through interviews and record reviews conducted by a surveyor. The surveyor found that the documentation provided by the facility did not include current BLS/CPR certification for these 8 staff members, which included both LPNs and RNs. The issue was discussed with the Director of Nursing during the survey process.
Kitchen Sanitation and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour conducted by two surveyors. The tour revealed several issues, including food and trash scattered on the floor and under equipment, a leaking dish room spray sink, and chipped paint on the food mixer. Additionally, five ceiling tiles above a food preparation area had dried liquid spatter, and a broken ceiling tile was found near the walk-in freezer. The food disposal unit, blender, and convection oven were all covered with dried food particles and residue. In the dry storage room, a 50-pound bag of sugar was left open and unsecured, and a large box of sandwich buns in the walk-in freezer had significant ice build-up. Furthermore, the facility failed to ensure that the kitchen ice machine was plumbed according to code requirements, which is necessary to prevent food contamination. This was a direct violation of the State of Maine Rules Chapter 226 and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d), which mandate that plumbing must be designed, installed, and maintained to prevent contamination of the water supply, food, and food utensils. These findings were confirmed in an interview with the Food Service Director, the Director of Operations, and the District Manager.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the beverage preferences of a resident, as evidenced by the restriction on Ginger Ale availability. During a resident council meeting, a resident expressed dissatisfaction with not being able to obtain Ginger Ale unless deemed medically necessary by a nurse. Staff members confirmed that they were instructed to only provide Ginger Ale to residents who were sick. However, the Food Service Director stated that residents could have Ginger Ale if their diet allowed it, indicating a communication breakdown between the kitchen staff and the nursing staff. Additionally, the facility did not adequately address the bed size needs of a resident with a recent right below-the-knee amputation. The resident, who is 6 feet 2 inches tall, reported falling out of bed while reaching for the call bell and expressed difficulty moving in the bed due to its size. Despite the resident's complaints and a documented fall, staff members, including the RN and Director of Nursing, were unaware of any issues with the bed size. The initial bed assessment upon admission did not note any problems, suggesting a lack of follow-up on the resident's changing needs.
Failure to Initiate PASRR Level II Evaluation for Long-Term Resident
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred for a Pre-Admission Screening & Resident Review Level II (PASRR) evaluation. The resident was admitted with a diagnosis of Major Depressive Disorder and Suicidal Ideations. Initially, a PASRR Level I determination letter indicated that no further evaluation was required due to a 30-day Time Limited Waiver. However, the resident's stay transitioned from short-term to long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority to assess the need for a Level II evaluation. This oversight was confirmed during an interview with the Licensed Social Worker, who acknowledged that the resident had been in the facility for more than 30 days without the necessary PASRR Level II evaluation being initiated.
Failure to Assist Resident in Obtaining Replacement Eyeglasses
Penalty
Summary
The facility failed to assist a resident in obtaining new eyeglasses after the original pair was lost, as per the facility's policy on personal property. The policy requires personnel to identify and record a patient's belongings upon admission and document any loss or breakage of personal items. However, the facility did not complete an inventory sheet or incident report for the missing glasses of a resident who was cognitively intact and relied on glasses to watch television. Interviews with the resident and staff confirmed that the glasses had been missing for several months, and no action was taken to replace them. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitive intactness, reported the loss of glasses, which were necessary for watching television. Despite the resident's report and the facility's policy, the staff did not document the loss or assist in obtaining a replacement. Interviews with the CNA and the Registered Nurse Manager revealed that the inventory sheet and incident report were not completed, and the Director of Nursing confirmed the oversight. This inaction led to the resident being unable to see the television clearly, impacting their quality of life.
Failure to Maintain Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to maintain or improve the range of motion (ROM) and mobility for two residents following their discharge from physical and occupational therapies. For one resident, a restorative nursing program was recommended to maintain physical abilities achieved during therapy, which included ambulation with a walker and a home exercise program. However, this program was not included in the resident's care plan, and there was no documentation to show that the program was followed. This resident experienced falls and was referred back to physical therapy, indicating a decline in their physical abilities. Another resident reported not being able to walk or perform exercises daily since ending therapy, leading to a perceived decline in strength. The restorative plan for this resident was also not included in their care plan, and there was no documentation of the program being followed. Interviews with CNAs revealed that they were unable to perform restorative tasks due to staffing issues, and a unit manager confirmed that the facility lacked a restorative nursing program. The facility's assessment indicated that it should provide mobility and fall prevention care, but this was not being implemented effectively.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by observations and interviews. The facility's procedure for oxygen nasal cannula, revised on 8/7/23, requires that cannulas be dated and stored in a treatment bag when not in use. However, observations on 12/16/24 and 12/17/24 revealed that Resident 98's nebulizer tubing was stored on the bedside table, and Resident 405's oxygen tubing was stored under the oxygen concentrator handle. These storage practices were confirmed by the Director of Nursing during an interview on 12/17/24.
Infection Preventionist Absence at QAA Meetings
Penalty
Summary
The facility failed to ensure that an Infection Preventionist attended two of the four quarterly Quality Assessment and Assurance (QAA) meetings, specifically those held on July 25 and October 31, 2024. A review of the QAA meeting attendance sheets confirmed the absence of the Infection Preventionist at these meetings. During an interview on December 18, 2024, the Administrator acknowledged the absence, stating that the Infection Preventionist left the facility in mid-October and had not been replaced until recently. This was corroborated by the Marketing Clinical Advisor later that day.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the resident census per shift, for three out of four survey days. Specifically, on 12/16/24, 12/17/24, and 12/18/24, a surveyor observed that the nurse staffing information posted at the main entrance did not include the resident census. Additionally, the facility did not maintain records of the posted daily nurse staffing data for a minimum of 18 months as required. During an interview on 12/18/24, the Scheduler/Payroll/HR personnel confirmed the absence of the resident census on the posted nurse staffing information and admitted to being unaware of the requirement to keep these records for at least 18 months. This was further confirmed by the Registered Nurse Market Clinical Advisor.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in three of its six units, as observed during a survey. On the Gilber Unit, several resident rooms were found with chipped or missing paint on wall heater units, which also had rust, creating uncleanable surfaces. The walls in these rooms and bathrooms were marred and marked, and one room had a privacy curtain with large dirty and stained areas. These findings were confirmed by the Director of Nursing during the survey. In the [NAME] Unit and [NAME] Unit, similar issues were observed. Multiple resident rooms had entrance and bathroom door frames with chipped or missing paint. The dining room heater also had chipped or missing paint, creating an uncleanable surface. Additionally, one room had a dirty floor around the base of the toilet. These deficiencies were discussed with the Director of Nursing by the surveyor, highlighting the facility's failure to provide adequate housekeeping and maintenance services.
Environmental Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment for residents, as observed during a survey on the [NAME] Unit. In one resident room, the bathroom toilet was found to be loose and not secured to the floor, posing a potential hazard. Additionally, the bathroom door had chipped, gouged, and splintered wood, which was sharp and could cause injury. In another resident room, a baseboard heater was broken apart, exposing sharp metal edges. Furthermore, the entrance door to this room also had chipped, gouged, and splintered wood, creating another sharp hazard. These deficiencies were discussed with the Director of Nursing during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lewiston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Russell Park Rehabilitation & Living Center | 1.8 mi | ★★★★★ | 0 | 0 |
| St Mary's D'youville Pavilion | 1.9 mi | ★★★★★ | 3 | 1 |
| Montello Manor | 2 mi | ★★★★★ | 2 | 0 |
| Odd Fellows Health Care Center | 4 mi | ★★★★★ | 10 | 0 |
| Clover Health Care | 4.4 mi | ★★★★★ | 7 | 1 |
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