Montello Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 540 College St, Lewiston, Maine 04240
- CMS Provider Number
- 205006
- Inspections on file
- 18
- Latest survey
- February 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Montello Manor during CMS and state inspections, most recent first.
The facility failed to ensure call bells were within reach for four residents, as observed over two days. A resident in a wheelchair and another in a broda chair had call bells placed out of reach, while two others had call bells either not visible or wrapped around the wall. Despite staff observations and adjustments, the issue persisted, with a CNA failing to address a call bell on the floor until another CNA intervened.
The facility failed to maintain a sanitary and comfortable environment in both the North and East Wings, as well as the Laundry Room. Observations included chipped paint, dirty surfaces, broken tiles, unsecured trash, and uncleanable surfaces. These deficiencies were confirmed by the Environmental Services Director.
The facility failed to update and implement comprehensive care plans for residents with specific needs. A resident's care plan lacked updates for COPD management, while another was left unsupervised during meals, contrary to care plan directives. Additionally, a resident used outdated oxygen tubing, and another could not reach the call bell, violating care plan interventions. These issues were confirmed with the administrator.
The facility failed to follow physician orders for three residents, resulting in deficiencies in urinary, dietary, and respiratory care. A resident's Foley catheter was not flushed as ordered, another resident was not supervised during meals as required, and a third resident's oxygen tubing was not changed according to schedule.
The facility failed to secure chemicals and remove metal brackets, creating hazards. Unsecured Ajax detergent bottles were found in shared bathrooms, posing risks as per the Safety Data Sheet. Additionally, metal brackets were observed on the floor in a resident-accessible area, confirmed by the Environmental Services Director.
The facility failed to maintain proper respiratory equipment care, as observed with unbagged and undated oxygen tubing and nasal cannulas for several residents. Equipment was improperly stored, with some items not changed weekly as required by the facility's policy. These deficiencies were confirmed by a surveyor and discussed with the administrator.
The facility's Quality Assurance Committee failed to ensure the effectiveness of corrective plans for deficiencies identified in a previous survey. The same issues were recited, including inadequate housekeeping, failure to issue necessary notices for transfers and bed holds, unsecured chemicals posing hazards, and failure to provide meals accommodating resident preferences.
The facility did not ensure that CNAs received the required 12 hours of annual in-service education, including dementia training, for five CNAs employed for over a year. Employee records lacked evidence of completing the necessary training hours for 2024, as confirmed by the Facility Administrator and surveyors.
The facility failed to ensure licensed staff were trained on the PCC system, leading to medication errors for two residents. One resident received incorrect doses of Bupropion, while another received Reglan beyond the prescribed duration. The DON admitted training varied, with some staff opting out, resulting in errors in medication order entry and administration.
The facility did not complete annual performance evaluations for CNAs employed for over a year, affecting five CNAs. This was confirmed during an interview with the Facility Administrator and surveyors.
Two residents experienced significant medication errors due to incorrect dosing and duration of medications. One resident received both Bupropion ER 300 mg and 450 mg daily for four days, leading to hospitalization with lactic acidemia and a UTI. Another resident received Reglan for six additional days beyond the prescribed duration due to a missing stop date in the electronic charting system. The DON acknowledged the errors, and the surveyor confirmed them with the Administrator.
A facility failed to accommodate a resident's dietary preferences and did not provide alternative meal options for those on minced and moist and puree diets. Despite being cleared for a mechanical soft diet, the resident was limited to two exceptions due to facility constraints. The resident, who is cognitively intact, was not offered a waiver to choose a different diet, and the facility's menu lacked variety, impacting dietary satisfaction.
A facility failed to maintain complete and accurate clinical records for a resident receiving respiratory care. Observations showed the resident using a nasal cannula with tubing dated incorrectly, and discrepancies were found in the documentation of tubing changes. The provider order required regular changes and cleaning, but records did not align with these instructions.
The facility did not ensure that the required members attended the QAA meetings, with the DON missing the February meeting and the Infection Preventionist absent from the June meeting. This was confirmed by the Administrator.
The facility failed to disinfect reusable equipment during medication administration for two residents and did not implement proper infection prevention measures for a room under contact precaution. A CNA-M did not sanitize a blood pressure cuff between uses, and a room with a resident who had Norovirus lacked a contact precaution sign, contrary to facility policy.
The facility failed to regularly inspect bed frames and mattresses, resulting in a deficiency where a resident's bed had a mattress 12 inches too short, creating a potential entrapment risk. This was confirmed by the Maintenance Director and discussed with the Administrator.
The facility failed to ensure that nursing staff maintained active licenses and certifications. The DON worked with an expired RN license for five days, while a CNA worked 20 shifts and another CNA worked approximately 32 hours weekly with expired certifications. These issues were confirmed through interviews with the DON and the Administrator.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call bells were within reach for four residents during the survey period. On multiple occasions, Resident #24 was observed sitting in a wheelchair beside the bed with the call bell hanging down at the head of the bed, making it inaccessible. Similarly, Resident #7 was seen in a broda chair with the call bell wrapped on the side rail at the head of the bed, and later placed on the bed behind the chair, both times out of reach. Resident #15 was observed in a broda chair with no visible call bell around, and Resident #188 was lying in bed with the call bell wrapped around the call box on the wall behind the bed. On the second day of the survey, further observations confirmed that Residents #7, #15, and #188 still had their call bells out of reach. A Licensed Practical Nurse (LPN) and surveyors noted the issue and adjusted the call bells to be within reach. However, later observations showed that Resident #7's call bell was again on the floor, and a certified nurse's aide (CNA) failed to address it while attending to the resident. It was only after another CNA entered the room that the call bell was handed to the resident, confirming the ongoing issue of call bells being inaccessible to residents.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in both the North and East Wings, as well as the Laundry Room. During an Environmental Tour, several deficiencies were observed. In the North Wing, issues included chipped and gouged paint on a wooden board and metal baseboard heating unit, a dirty wheelchair with a torn armrest, stained and broken floor tiles in a bathroom, and unsecured trash bags in the exit area vestibule. Additionally, a bedpan and wash basin were found on the floor next to a toilet in one of the resident rooms. In the East Wing, the cove base in a resident room was visibly soiled, and a ceiling vent in the hallway was dirty and dusty. There were also cracked and broken floor tiles in a bathroom and a large crack in the sheetrock wall by a window. The Laundry Room had a cement floor with chipped and missing paint, and a large folding table with chipped paint and duct tape on the edges, creating uncleanable surfaces. These findings were confirmed by the Environmental Services Director during an interview.
Failure to Implement and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with specific needs. Resident #8's care plan was not updated to include goals and interventions for managing Chronic Obstructive Pulmonary Disease (COPD) and the use of a nebulizer, despite having physician orders for Ipratropium-Albuterol Inhalation Solution. The administrator confirmed the care plan's lack of updates. Resident #7 was observed without access to a call bell and was left unsupervised while eating, contrary to the care plan's interventions for dementia-related self-care deficits and swallowing problems. The care plan specified the need for supervision during meals and the use of a small plastic spoon, which was not adhered to during the observations. Resident #10 was observed using oxygen tubing that had not been changed since 1/28/25, despite the care plan's directive to change the tubing weekly and as needed. Resident #24 was unable to reach the call bell due to its placement, which contradicted the care plan's intervention to ensure the call bell was within reach to prevent falls and encourage the resident to request assistance. These deficiencies were discussed with the administrator, highlighting the facility's failure to implement and update care plans to meet the residents' needs effectively.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in urinary care, activities of daily living, and respiratory care. For Resident #12, the clinical record showed a physician order to flush the resident's Foley catheter daily with 60 cc of normal saline for obstructive uropathy, but there was no evidence this was being done. The Administrator confirmed the order was not completed daily. Resident #7 had a provider order for a minced and moist diet with nectar consistency, to be fed by staff using a plastic spoon. However, the resident was observed eating breakfast independently with a metal spoon and without staff supervision. A CNA entered the room but did not assist with feeding. For Resident #10, the provider order required changing and dating the O2 and C-pap tubing and cleaning the concentrator filter every Monday night shift. Observations showed the resident using a nasal cannula with tubing dated from several weeks prior, indicating the order was not followed.
Unsecured Chemicals and Metal Brackets Pose Hazards
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, unsecured bottles of Ajax laundry detergent were observed on the back of toilets in shared resident bathrooms. These observations were confirmed by the Environmental Services Director. The Safety Data Sheet for the detergent indicates potential harm if ingested or if it comes into contact with eyes or skin, highlighting the risk posed by the unsecured chemicals. Additionally, on another day of the survey, metal brackets approximately two feet long were found on the floor in the North wing staff exit vestibule, creating an accident hazard. This area was accessible to residents, and the presence of the metal brackets was confirmed by the Environmental Services Director. These findings indicate a failure to maintain a safe environment for residents, as required by regulations.
Improper Respiratory Equipment Storage and Maintenance
Penalty
Summary
The facility failed to maintain a proper respiratory program to prevent the development and transmission of disease and infection related to respiratory equipment care for four residents over three days of survey. Observations revealed that Resident #19 had unbagged oxygen tubing and a nasal cannula hanging on an oxygen tank attached to their wheelchair, which was stored in the hallway outside their room. The tubing was not dated, indicating a lack of adherence to infection control protocols. Similarly, Resident #7's nebulizer machine was found with an unlabeled mask and tubing stored improperly on a dresser, with no evidence of orders for changing the nebulizer mask and tubing weekly. Further observations showed that Resident #10's oxygen nasal cannula tubing was labeled with an outdated date, and the tubing was draped over personal belongings instead of being properly stored. Resident #187's oxygen nasal cannula tubing was wrapped and stored under the oxygen concentrator handle, which was not in compliance with the facility's policy. The facility's policy, last revised in February 2022, requires oxygen cannula and tubing to be changed every seven days and stored in a plastic bag when not in use. The surveyor discussed these findings with the administrator, confirming the improper storage and availability for use of the respiratory equipment.
Recurrent Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction for deficiencies identified during the Annual Long Term Care Survey Process for Federal Recertification. The deficiencies, which were initially cited on 12/12/23, were recited during the survey on 2/20/25. These included F584 for inadequate housekeeping and maintenance services, F623 for not issuing a written transfer/discharge notice, F625 for not providing a written bed hold notice with cost of care, F689 for not securing chemicals to prevent accident hazards, and F806 for failing to provide food that accommodates resident preferences and a second-choice meal of similar nutritive value. During an interview on 2/20/25, these findings were discussed with the Administrator, highlighting the recurrence of the same issues previously identified.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, including mandatory dementia training, for five CNAs employed for more than one year. Specifically, the employee records for CNAs hired on various dates from 1991 to 2023 lacked evidence of completing the necessary training hours for the year 2024. This deficiency was confirmed during an interview with the Facility Administrator and two surveyors.
Medication Administration Errors Due to Inadequate Training on PCC System
Penalty
Summary
The facility failed to ensure that licensed staff were adequately trained and assessed for competency in using the electronic clinical documentation program, Point Click Care (PCC), leading to medication administration errors for two residents. Resident #1 was administered Bupropion ER 300 mg and 450 mg daily for four days, despite physician orders to discontinue the 450 mg dose and hold the 300 mg dose due to increased delusions and visual hallucinations. The error was attributed to incorrect entry of the physician's order into the PCC system. Resident #34 received Reglan 5 mg four times daily for 20 days, exceeding the physician's order of 14 days, due to the absence of a stop date in the PCC system. The Director of Nursing acknowledged that training on the PCC system varied among staff, with some opting out of training. The facility's policy requires medications to be administered according to orders, including verifying the right resident, medication, dosage, time, and method before administration. However, the surveyor confirmed that licensed staff were not consistently provided training on the PCC system.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) who have been employed for more than one year. This deficiency was identified for five CNAs, all of whom had been employed for over a year without receiving the required annual performance evaluation. Specifically, CNA #1, hired in 2018, CNA #2 and CNA #4, both hired in 2023, CNA #3, hired in 1991, and CNA #5, hired in 2017, all lacked evidence of a completed performance evaluation for the year 2024. This information was confirmed during an interview with the Facility Administrator and two surveyors.
Significant Medication Errors in Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For one resident, a medication error occurred involving the incorrect dosing of the antidepressant Wellbutrin (Bupropion). The resident received both Bupropion ER 300 mg and Bupropion ER 450 mg daily for four days, leading to increased delusions, visual hallucinations, nausea, and vomiting. The resident was evaluated by a provider, and orders were obtained to hold the medications. The resident was subsequently admitted to the hospital with a diagnosis of lactic acidemia with elevated anion gap and a UTI. Another resident received an incorrect duration of the medication Reglan. The physician's order was for Reglan 5 mg to be given four times a day for 14 days, but the resident received the medication for an additional six days due to the absence of a stop date in the electronic clinical charting software. The Director of Nursing acknowledged that the physician's order for Bupropion ER 450 mg was entered incorrectly into the system, and the staff did not review the medication order thoroughly. The surveyor confirmed these significant medication errors with the Administrator.
Failure to Accommodate Resident Dietary Preferences and Provide Alternatives
Penalty
Summary
The facility failed to provide food that accommodates resident preferences and did not offer a second-choice meal or alternative with similar nutritive value for a resident on a minced and moist diet. The resident, who is cognitively intact and responsible for their own decision-making, expressed dissatisfaction with the limited food options and the lack of alternatives. Despite being cleared by a speech therapist for a mechanical soft diet, the facility only allowed two exceptions to the minced and moist diet, citing complexity as a reason for not offering more options. The resident's medical records and care plan indicated that they could feed themselves with supervision for exception foods. However, the facility did not provide a waiver for the resident to choose a different diet, as outlined in the admission contract. The facility's dietary notes revealed that the resident's diet was downgraded from ground meat to minced and moist, and the resident was informed that they could only choose two safe food items. The facility also failed to provide alternative meal options for residents on minced and moist and puree diets, with repetitive menu items like oatmeal and eggs served daily. Interviews with the Director of Food and Dietary and the DON confirmed the lack of food waivers and the facility's reluctance to offer them due to previous Immediate Jeopardy concerns. The DON acknowledged the resident's autonomy in decision-making but did not provide the necessary supervision for consuming restricted foods. The facility's actions and inactions led to the deficiency, impacting the resident's dietary satisfaction and potentially affecting all residents on similar diets.
Incomplete and Inaccurate Documentation of Respiratory Care
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident receiving respiratory care. Observations on February 18, 2025, revealed that the resident was using a nasal cannula for oxygen administration with tubing dated January 28, 2025. A review of the resident's provider order from December 2, 2024, instructed nursing staff to change and date the oxygen and C-PAP tubing and clean the concentrator filter every night shift on Mondays. However, the medication administration record for January 2025 documented the nasal cannula tubing change on January 27, and the February 2025 record showed changes on February 3, 10, and 17. This discrepancy indicates incomplete and inaccurate documentation of the resident's respiratory care.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members attended the Quality Assessment and Assurance (QAA) meetings. Specifically, the Director of Nursing did not attend the QAA meeting held on February 20, 2024, and an Infection Preventionist was absent from the meeting on June 4, 2024. This was confirmed during an interview with the Administrator on February 20, 2025.
Inadequate Disinfection and Infection Control Measures
Penalty
Summary
The facility failed to properly disinfect reusable resident equipment during medication administration for two residents. On February 19, 2025, a Certified Nursing Assistant - Med Tech was observed taking blood pressure readings for two residents using a blood pressure cuff. After each use, the CNA-M did not sanitize the blood pressure cuff, contrary to the facility's policy which requires decontamination of reusable resident care equipment between residents. During an interview, the CNA-M acknowledged the oversight, stating that equipment should be cleaned with a sanitizing wipe between residents but admitted to forgetting to do so on that day. Additionally, the facility did not implement appropriate infection prevention measures for a room under contact precaution. On February 20, 2025, a surveyor, along with the Maintenance Director, observed that there was no contact precaution sign on the door of a room where a resident with Norovirus had been staying. The Maintenance Director confirmed that the room would not be cleaned until instructed by Nursing administration. The Infection Preventionist later confirmed that the room should remain on precautions with signs on the door, as the resident had been sent to the hospital and the 48-hour precaution period had not yet passed.
Failure to Inspect Bed Frames and Mattresses
Penalty
Summary
The facility failed to conduct regular inspections of bed frames and mattresses as part of a maintenance program, leading to a deficiency involving one of the 37 beds. Specifically, a surveyor observed that a resident's bed had a mattress approximately 12 inches too short for the bed frame, creating a large gap between the mattress and the footboard, which posed a potential entrapment risk. This observation was confirmed by the Maintenance Director during an interview. The deficiency was noted during multiple observations by surveyors on the same day, and the issue was discussed with the facility's Administrator.
Expired Licenses and Certifications Among Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff maintained an active license and/or certification in accordance with state laws, as evidenced by the review of employee personnel records and interviews. The Director of Nursing (DON), a Registered Nurse (RN), worked for five days with an expired license. Additionally, a Certified Nursing Assistant (CNA #2) worked 20 shifts with an expired certification, and another CNA (CNA #3) worked approximately 32 hours weekly with an expired certification. These deficiencies were confirmed through interviews with the DON and the facility Administrator.
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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