Orchard Park Rehab & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Maine.
- Location
- 107 Orchard Street, Farmington, Maine 04938
- CMS Provider Number
- 205168
- Inspections on file
- 19
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Orchard Park Rehab & Living Center during CMS and state inspections, most recent first.
Surveyors identified widespread environmental and housekeeping deficiencies across three units, the therapy room, a common area, and the laundry room. Cooking dishes were stored under a therapy room sink near the drainpipe. Multiple resident rooms had privacy curtains in disrepair, rusty and chipped baseboard heaters, damaged bathroom doors with exposed unsealed wood, and a rusty toilet water line escutcheon. Hallways on two units had numerous chipped and broken floor tiles, and a whirlpool room had damaged walls, ripped and missing linoleum, rusty ceiling components, and a dirty, stained, and cracked whirlpool tub with soiled jets and intake screen. Additional findings included a damaged bathroom ceiling tile around a sprinkler head, cracked floor tiles and chipped paint in a shower room, stained ceiling near a nurse’s station, a broken ramp handrail, and laundry equipment and carts held together with Velcro and duct tape. These conditions were confirmed by the DON, Maintenance Director, and Director of Environmental Services.
Two residents were transferred multiple times to acute care hospitals, including ED visits and an admission for an intestinal blockage, without documented written transfer/discharge notices or bed-hold notices, including cost of care, being provided to their legal representatives. Clinical records and nursing notes confirmed the transfers and hospital admissions, but lacked evidence of the required written notifications. The LSW later acknowledged that there was no documentation of these notices and indicated that one ED transfer was viewed as a scheduled appointment, and thus she believed notices were not required.
A resident was found seated in a wheelchair with a sheet tied around their waist and johnny pants applied backwards, both secured in double knots, to prevent access to their brief. These actions, performed by a CNA without inclusion in the care plan, were determined to be abuse and use of a restraint, violating the resident's rights to dignity and respect.
A resident was found with a sheet tied around their waist and johnny pants applied backwards, both double knotted, restricting their ability to access their brief. A CNA implemented these measures, which were not part of the care plan, to prevent the resident from removing their brief. The CNA had received training on abuse and restraints but did not recognize the actions as inappropriate. The facility determined these actions constituted abuse and the use of a restraint, violating the resident's rights.
A resident was found with a sheet tied around the waist and johnny pants applied backwards, both secured in double knots, restricting movement and access to personal care items. A CNA performed these actions without including them in the care plan, intending to prevent the resident from removing their brief. The facility's policy defines such practices as physical restraint, and the CNA had previously received training on restraint use and resident rights.
The facility did not implement a policy to ensure staff received education on the COVID-19 vaccine, including its benefits and risks. The Infection Preventionist confirmed the absence of such education since the previous year, and the new employee packet lacked COVID-19 information. Interviews with the Maintenance Director, an LPN, and a facility clerk revealed they had not received education on the COVID Spikevax in the past year.
The facility failed to maintain a safe and clean environment, with issues such as broken fixtures, inadequate water temperatures, and non-operational dryers. A resident's room had a persistent urine odor due to a leaking foley bag, and wash basins were improperly stored on the bathroom floor. These deficiencies were confirmed by facility staff.
The facility failed to implement baseline care plans within 48 hours of admission for four residents, as required by policy. A resident with COPD and respiratory failure lacked a care plan addressing respiratory needs, while another with sleep apnea had no interventions for respiratory care. A resident with dementia had no care plan for behavioral needs, and another with multiple chronic conditions had no baseline care plan initiated. These deficiencies were confirmed by staff interviews.
A resident with severe cognitive impairment reported an unwitnessed fall, but the facility failed to complete a fall incident report, post-fall observation tool, or continued monitoring as required by policy. The resident's medical record lacked evidence of necessary documentation and monitoring for further injuries or neurological changes.
The facility failed to secure hazardous chemicals in an unlocked utility room, posing a risk to vulnerable residents. Despite the presence of Safety Data Sheets outlining potential harm, chemicals like disinfectants and hand sanitizers were observed unsecured on multiple survey days. The Acting DON and Infection Preventionist confirmed the unsafe storage, acknowledging the risk to confused and compromised residents.
The facility failed to maintain sanitary conditions and follow provider orders for respiratory care for three residents. A resident's nebulizer was left unbagged, and their oxygen concentrator was set below the prescribed rate. Another resident received oxygen at a lower rate than ordered, and a third resident's CPAP mask was improperly stored. These issues were confirmed by facility staff during observations.
The facility's kitchen was found to be unsanitary, with dusty and dirty hood system filters, wall air conditioning units, and walls. The ceiling grid hangers were rusty and stained, the floor fan was dusty, and the grease trap lid had chipped paint, creating an uncleanable surface. These issues were confirmed by the Food Service Director.
The facility failed to implement its Antibiotic Stewardship Program, as outlined in its policy, which aims to improve antibiotic use and prevent resistance. The Infection Preventionist did not have a system to monitor antibiotic use effectively, and the facility's quarterly reports lacked evidence of a review of antibiotic use. This deficiency could affect all residents receiving antibiotics.
A resident with severe cognitive impairment and a history of fractures fell while using a walker. The facility delayed notifying the medical provider by 20 hours and failed to promptly inform the resident's representative. The incident report and nursing documentation lacked necessary details and notifications.
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living. A resident with severe cognitive impairment was not receiving proper mouth care, resulting in significant tartar buildup. Another resident was observed in dirty clothes, highlighting a failure to maintain personal hygiene and dignity. These issues were confirmed by staff and a Quality Improvement Specialist.
A resident with type 2 Diabetes Mellitus received Novolog insulin doses outside of physician orders, which specified administration only for blood sugar levels above 110. Despite this, nursing staff administered insulin on several occasions when the resident's blood sugar was below 110, contrary to the care plan aimed at preventing diabetes complications. This was confirmed by Quality Improvement Specialists.
The facility's Quality Assurance Committee failed to ensure the effectiveness of corrective actions for previously identified deficiencies. During a follow-up survey, deficiencies F684 and F757 were cited again. F684 involved a failure to document and monitor a resident after an unwitnessed fall, while F757 involved a failure to ensure a resident's drug regimen was free from unnecessary medications. These issues were confirmed with the President of Quality Improvement and Nursing Services and the DON.
An LPN failed to maintain sanitary conditions during a lunch meal on the Cortland Unit by not sanitizing hands between resident contacts. The LPN handled a lunch tray, removed trash with bare hands, and touched a resident and a side table without using hand sanitizer, despite passing a sanitizer station. The DON confirmed the expectation for hand sanitization before and after resident contact.
Environmental and Housekeeping Deficiencies Across Multiple Units and Service Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and comfortable environment across multiple units and service areas. Surveyors observed multiple cooking dishes stored under the therapy room sink next to and below the drainpipe; this was confirmed by a COTA and the DON. During an environmental tour, surveyors, accompanied by the Maintenance Director and Director of Environmental Services, identified resident rooms on Cortland and Northern Spy units with privacy curtains missing hooks, hanging down, and in disrepair. In one Cortland resident room, the bathroom baseboard heater and room baseboard heater had chipped/missing paint and rust, creating uncleanable surfaces; the bathroom door’s protective surface was pulled away on both sides, and the bottom of the door was chipped/gouged with exposed unsealed wood. The same bathroom contained a wash basin on the floor under the sink and a toilet water fill line with a rusty escutcheon. Additional environmental issues were found throughout the facility. On Cortland, the hallway floor had seven chipped/broken tiles, and the whirlpool room had walls with chipped/missing paint and damaged sheetrock, ripped/missing linoleum at the wall corner and sink cabinet, ripped/missing flooring around the floor drain, split seams in the middle of the floor, a rusty ceiling light and ceiling grid, and a whirlpool tub that was dirty, yellow-stained, cracked, with soiled and stained water intake screen and jets. On Northern Spy, one resident room had a bathroom ceiling tile around a sprinkler head that was bubbled and bent, and the hallway floor had 32 chipped/broken tiles. On the [NAME] unit, six cracked/broken floor tiles and a shower room with chipped and missing paint on the walls were observed. In common areas, the ceiling near the nurse’s station had large brown stains, and a ramp handrail going downstairs was broken. In the laundry room, the left clothes dryer had Velcro tape holding the bottom lint door and tape on the door glass, and a three-shelf laundry cart had ripped and hanging duct tape on the bottom shelf. The Maintenance Director and Director of Environmental Services confirmed these findings.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge and bed-hold notices, including cost of care information, to residents and/or their legal representatives when residents were transferred to an acute care hospital. For one resident admitted in January 2024, the clinical record showed that the resident was transported to an acute care hospital on a specified date, but there was no documentation that the resident or the resident’s representative received a written transfer/discharge notice or a written bed-hold notice for that transfer. For another resident admitted in October 2022, the clinical record showed multiple transfers to an acute care hospital on several dates, including an Emergency Department visit followed by an admission for an intestinal blockage. Nursing progress notes documented communication with a gastroenterologist, the decision by the team to send the resident to an alternate ED, and the subsequent hospital admission. Additional record review showed another hospital transfer and admission on a later date. However, the record lacked evidence that the resident’s representative received written transfer/discharge notices and written bed-hold notices for any of these transfers. During an interview, the LSW confirmed there was no evidence of such notices for the identified transfers and stated that one ED transfer was considered a scheduled appointment, and therefore she believed notices were not required.
Resident Restrained with Improper Use of Sheet and Clothing, Violating Dignity and Rights
Penalty
Summary
A deficiency occurred when a certified nurse's assistant (CNA) applied a sheet around a resident's waist and secured it in a double knot while the resident was seated in a wheelchair. Additionally, the CNA put johnny pants on the resident backwards, with the ties positioned in the back and also secured in a double knot. These actions were taken to prevent the resident from accessing and removing their brief, as the CNA could not locate a belt. The CNA confirmed that these interventions were not part of the resident's care plan and acknowledged having received prior training on abuse, neglect, restraints, and resident rights. The facility's internal investigation determined that the CNA's actions constituted abuse and the use of a restraint, as they restricted the resident's ability to access their brief and were not authorized in the care plan. The investigation also found that the resident's rights to dignity and respect were violated by being inappropriately tied with a sheet and having clothing applied in a manner that restrained movement. The CNA did not recognize these actions as inappropriate, despite previous training and orientation on proper care and resident rights.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, as well as wearing johnny pants that had been applied backwards with the ties positioned in the back and also double knotted. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident was known to shred and remove it. The CNA admitted to not being able to locate a belt and therefore used the sheet and johnny pants as alternatives. These interventions were not part of the resident's care plan. The CNA confirmed during an interview that they had received training on abuse, neglect, restraints, and resident rights, but did not recognize their actions as inappropriate or as a form of restraint. The facility's investigation determined that the use of the sheet and backwards johnny pants, both double knotted, constituted a restraint and violated the resident's rights, amounting to abuse. The facility's policy clearly prohibits such actions, defining them as unreasonable confinement and restraint, and requires that residents be free from abuse, neglect, and harm.
Resident Restrained with Improper Use of Sheet and Clothing
Penalty
Summary
A deficiency occurred when a resident was found seated in a wheelchair with a sheet tied around their waist and secured in a double knot, and wearing johnny pants applied backwards with the ties also secured in a double knot. These actions were performed by a Certified Nurse's Assistant (CNA) who stated that the interventions were intended to deter the resident from accessing and removing their brief, as the resident had a history of shredding and removing it. The CNA admitted to tying the sheet and securing the clothing in this manner because a belt was not available, and confirmed that these interventions were not part of the resident's care plan. The facility's restraint use policy prohibits the use of physical restraints for discipline or convenience and specifies that fastening fabric or clothing to restrict a resident's movement meets the definition of a physical restraint. The CNA acknowledged having received training on abuse, neglect, restraints, and resident rights, but did not recognize the actions as inappropriate. The facility's internal investigation determined that the resident's rights were violated, and the actions constituted both the use of a restraint and resident abuse.
Lack of COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to develop and implement a policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine or information on obtaining the vaccine. The Infection Control Immunizations policy and the Employee Immunization/Vaccination Requirements policy did not include procedures for staff education on the COVID-19 vaccine. During interviews, the Infection Preventionist confirmed that staff had not been provided education on the COVID-19 vaccine since the previous year, and there was no information about COVID-19 in the new employee packet. Additionally, the Maintenance Director, a Licensed Practical Nurse, and a facility clerk all reported not receiving education on the COVID Spikevax within the past year.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across multiple units and areas, as observed during an environmental tour. Deficiencies included missing ceiling tiles, broken and dirty fixtures, and inadequate water temperatures in resident rooms. The whirlpool room had torn flooring and damaged cabinets, while several resident rooms had issues with baseboard heaters, dirty floors, and broken fixtures. The laundry room was also found to be in disrepair, with two out of three dryers non-operational, one of which had been out of order for over two years. These issues were confirmed by the Administrator, Maintenance Director, and Housekeeping Account Manager. Additionally, a strong urine odor was detected in a resident's room, attributed to a frequently leaking foley bag that had potentially absorbed into the flooring. Despite daily cleaning efforts, the odor persisted. Furthermore, two wash basins were observed on the bathroom floor under the sink, indicating a lack of proper storage or maintenance. These findings were confirmed with the Director of Nursing, highlighting ongoing issues with facility maintenance and cleanliness.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, as required by their policy. Resident #180, who was admitted with chronic obstructive pulmonary disease (COPD) and respiratory failure, had active orders for Trelegy Ellipta and continuous oxygen therapy. However, the care plan initiated on 11/20/24 did not include goals and interventions for the resident's respiratory needs. Similarly, Resident #80, admitted with sleep apnea, had orders for CPAP and PRN oxygen, but the baseline care plan initiated on 11/22/24 lacked evidence of goals and interventions for respiratory needs. Interviews with the Infection Preventionist and Quality Improvement Specialist confirmed these deficiencies. Resident #23, admitted with dementia and behavioral disturbances, had a care plan initiated on 10/10/24 that did not address goals and interventions for dementia needs. Additionally, Resident #27, admitted with chronic heart failure, respiratory failure, hypertension, and COPD, did not have a baseline care plan initiated at all. These findings were confirmed through interviews with facility staff, including the President of Clinical Operations and the Quality Improvement Specialist, highlighting a systemic issue in the facility's adherence to its baseline care plan policy.
Failure to Monitor Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to adequately monitor a resident after an unwitnessed fall, which was identified as a deficiency during a review. According to the facility's Fall Management Policy, a fall incident report should be completed after any fall, whether witnessed or not, and a post-fall observation tool should be used to identify potential causes of the fall. Additionally, documentation must be completed in the nurse's notes on each shift for three shifts following the fall. However, for Resident #5, who self-reported a fall in the bathroom, there was no evidence of a fall incident report, post-fall observation tool, or continued monitoring for further injuries or neurological changes. Resident #5, who has a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment, reported the fall to the nursing staff. Despite the resident's report of mild pain in the left knee, the medical record lacked the required documentation and monitoring as per the facility's policies. The Quality Improvement Specialists confirmed the facility's failure to complete the necessary documentation and monitoring for the resident's unwitnessed fall.
Improper Storage of Chemicals in Unlocked Utility Room
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During the survey, it was observed that various chemical products, including Rapid Multi Surface Disinfectant Cleaner, Enzymatic Foul Odor Digester, Germs Be Gone Hand Sanitizer Gel, and GelRite Instant Hand Sanitizer, were stored in an unlocked soiled utility room. These chemicals have specific first aid measures outlined in their Safety Data Sheets, indicating potential harm if they come into contact with eyes, skin, or if ingested or inhaled. The presence of these unsecured chemicals posed a risk, especially considering the facility had residents who were confused, compromised, and vulnerable, as confirmed by the Acting Director of Nursing and Infection Preventionist. On two separate days of the survey, the surveyor observed the same issue of unsecured chemicals in the soiled utility room. The Acting Director of Nursing and Infection Preventionist acknowledged that the chemicals were not stored safely behind a locked door. Additionally, the Quality Improvement Specialist confirmed the findings during an interview. The repeated observation of unsecured chemicals over multiple days highlights a failure in maintaining a safe environment for residents, particularly those who may be at risk of accessing these hazardous substances.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to provider orders for respiratory care for three residents. Resident #180, diagnosed with COPD and respiratory failure, had a nebulizer left unbagged on the bedside table, contrary to facility policy requiring respiratory equipment to be stored in a clean bag. Additionally, Resident #180's oxygen concentrator was set at 1.5 liters per minute, despite an active order for 3 liters per minute. These observations were confirmed by the Acting Director of Nursing/Infection Preventionist and a Quality Improvement Specialist. Resident #14, with diagnoses including COPD and asthma, was observed receiving oxygen at 2.5 liters per minute, although the active order specified 3 liters per minute. Similarly, Resident #80, diagnosed with sleep apnea, had a CPAP face mask stored improperly in an open drawer instead of being bagged. These deficiencies were confirmed by the Acting Director of Nursing/Infection Preventionist during observations with surveyors.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour conducted with the Food Service Director. The inspection revealed several deficiencies, including dusty and dirty hood system filters, wall air conditioning units, and walls above and below these units. Additionally, the ceiling grid hangers were found to be rusty and stained a yellowish color throughout the kitchen. The floor fan was also noted to be dusty and dirty, and the grease trap lid had chipped or missing paint, creating an uncleanable surface. These findings were confirmed by the Food Service Director during the interview.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) as outlined in its policy, which aims to improve antibiotic use, reduce adverse events, prevent resistance, and lead to better outcomes for residents. The policy specifies that the Infection Preventionist is responsible for monitoring and supporting antibiotic activities, tracking antibiotic therapy, reviewing resistance patterns, and monitoring healthcare-acquired infections (HAIs) and multi-drug resistant organisms (MDROs). However, the facility did not have a system in place to monitor antibiotic use effectively, as evidenced by the lack of tracking systems to identify trends and antibiotic use, and the absence of a review of the monthly pharmacy antibiotic report by the Infection Preventionist. The facility's Quality Assurance & Performance Improvement Pharmacy quarterly reports for several quarters lacked a section on Antibiotic/Antimicrobial Stewardship Discussion, indicating that there was no evidence of a review of antibiotic use or the ASP during these meetings. Additionally, the Infection Preventionist and Acting Director of Nursing confirmed frequent urinary tract infections requiring antibiotics but admitted to not implementing any tracking systems for trends and antibiotic use. This deficiency has the potential to affect all residents receiving antibiotics, as the facility did not adhere to its policy and failed to monitor antibiotic use effectively.
Failure to Timely Notify Medical Provider and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a medical provider and the resident's representative following a significant incident involving a resident. The resident, who has a history of lumbar vertebra fracture and bone density disorder, and severe cognitive impairment, experienced a fall on 2/2/25 at 5:00 p.m. The medical provider was not notified until 20 hours later, on 2/3/25 at 1 p.m. The incident report lacked a detailed description, resident assessment, or notification to the resident's representative. Additionally, the nursing documentation completed on 2/3/25 at 4:06 p.m. confirmed the fall occurred in the dining room while the resident was using a walker, but it also failed to document any notification to the resident's representative. The Director of Nursing stated that the family was notified the day after the fall.
Deficiencies in Oral Hygiene and Personal Care for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate dental care and maintain personal hygiene for two residents with dementia, leading to deficiencies in their activities of daily living (ADL). Resident #10, who has a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, was observed with significant food and tartar buildup on their teeth. Despite the care plan indicating the need for extensive assistance with self-care, the resident was not receiving mouth care twice a day as required. Interviews with CNAs revealed that although mouth care was part of the daily routine, it was not consistently performed, and the resident's teeth were not brushed, only rinsed. This lack of proper oral hygiene was confirmed by a Quality Improvement Specialist who noted that the resident could brush their teeth independently with minimal setup assistance. Resident #7, also diagnosed with dementia and having a BIMS score of 3, was observed wearing clothes with dried food particles, indicating a failure to maintain personal hygiene and dignity. The care plan for Resident #7 also required extensive assistance with self-care. Despite this, the resident was left in dirty clothes after breakfast and before being put to bed, which was acknowledged as a dignity issue by both a CNA and the Quality Improvement Specialist. These observations highlight the facility's failure to ensure residents' basic hygiene needs were met, impacting their dignity and quality of care.
Insulin Administered Outside Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering doses of insulin outside of the physician's order parameters. Specifically, a resident with type 2 Diabetes Mellitus and Diabetic Polyneuropathy had a physician's order for Novolog Insulin to be administered only if blood sugar levels were above 110. However, the Electronic Medication Administration Record (EMAR) showed that nursing staff administered 6 units of Novolog insulin on multiple occasions in October, November, and December 2024, despite the resident's blood sugar levels being below 110 on those dates. This action was contrary to the physician's orders and the resident's nutrition care plan, which aimed to prevent complications related to diabetes by adhering to prescribed medications and treatments. The Quality Improvement Specialists confirmed these findings during an interview, noting the failure to follow physician orders and the care plan.
Recurrent Deficiencies in Resident Monitoring and Medication Management
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. Specifically, deficiencies F684 and F757 were cited again during a follow-up survey. F684 was cited due to the facility's failure to document and adequately monitor a resident after an unwitnessed fall. Additionally, F757 was cited for the facility's failure to ensure that a resident's drug regimen was free from unnecessary medications. These deficiencies were confirmed during an interview with the President of Quality Improvement and Nursing Services and the Director of Nursing.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions during a lunch meal on the Cortland Unit. An LPN was observed exiting a room with a lunch tray, removing trash from the tray with bare hands, and placing it on a kitchen utility cart. The LPN then walked past a hand sanitizer station without using it and entered another resident's room, where she placed her bare hands on a resident's shoulder and a side table. After exiting the room, the LPN proceeded to the lunch cart, opened it with her bare hand, and retrieved another lunch tray without sanitizing her hands between resident contacts. During an interview, the Acting Director of Nursing/Infection Preventionist confirmed that it was expected for staff to sanitize their hands before and after resident contact.
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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