Ross Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 758 Broadway, Bangor, Maine 04401
- CMS Provider Number
- 205064
- Inspections on file
- 21
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ross Manor during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders: one received antibiotic doses on consecutive days instead of every 48 hours, and another did not have a blood sugar recheck documented after receiving additional insulin as ordered by the provider.
A resident with physician orders for nightly CPAP therapy was unable to use their machine due to missing tubing, and the facility did not obtain the required part for an extended period. Documentation and staff interviews confirmed that the resident was not provided with the ordered respiratory care, resulting in multiple hospitalizations related to hypoxia before the missing equipment was finally acquired.
Surveyors found that two ice machines had improper air gaps on their drain lines, resulting in a direct connection between wastewater and potable water, in violation of state plumbing code. The deficiency was confirmed with the FSD over several days, while the vegetable sink had the correct air gap.
Surveyors observed multiple lapses in infection control, including soiled and unlabeled bed pans left exposed, blood and stool on commode seats, soiled linens on floors, a hole in a shower floor, improper glove use and hand hygiene by a CNA, opened dressing wrappers on blankets, and a Foley bag dragging on the floor. These deficiencies were confirmed by staff interviews and repeated over several days.
A resident admitted for skilled care did not have a baseline care plan developed and implemented within 48 hours of admission, as required. Instead, the care plan was not created until four days after admission, and this delay was confirmed by the ADON during a surveyor interview.
A resident requiring assistance with oral hygiene due to hemiplegia did not consistently receive help with denture care, as staff failed to soak or wash dentures at night and documentation showed oral hygiene was not completed after the evening meal on multiple days. The DON confirmed that evening shift staff often did not provide this care if it was already documented by a previous shift, leading to inconsistent oral hygiene support.
Two residents had incomplete or inaccurate clinical records: one had a CPAP device documented as applied on days when it was missing parts and could not be used, while another had medications listed in the MAR for diagnoses not present in the active diagnosis list, with provider notes indicating different reasons for the prescriptions.
A facility failed to inform a resident's representative of a change in discharge plans and an incident where the resident attempted to leave the facility. Additionally, the resident's provider was not informed of the resident's elopement risk. Interviews confirmed the lack of communication regarding these issues.
A resident with Alzheimer's and a history of wandering eloped from the facility despite being identified as a wandering risk. The resident had previously attempted to leave multiple times, and on the night of the incident, exited through a window and was found a mile away in freezing temperatures. The facility was aware of the resident's elopement risk but failed to provide adequate supervision.
A facility failed to maintain complete and accurate clinical records for a resident who exhibited exit-seeking behaviors on several occasions. The resident attempted to leave the facility multiple times, expressing a desire to go home, but these incidents were not documented in the clinical records. A review with the DON and a Unit Manager confirmed the absence of nurse's notes for each elopement attempt, indicating a deficiency in record-keeping.
A facility failed to ensure immediate reporting of an alleged physical abuse incident involving a resident. A CNA witnessed another CNA twisting a resident's arm, causing bruising, but delayed reporting the incident until the next day, allowing the alleged perpetrator to continue care. The facility's policy requires immediate reporting within two hours, which was not followed.
A resident was mistakenly given another resident's medications by a C.N.A.-M, leading to low blood pressure and a hospital transfer. The error occurred due to a misreading of names in the computer system and a lack of recognition of the resident, who was mildly cognitively impaired. The facility's policy for verifying resident identity was not adequately followed.
A facility failed to provide dignified feeding assistance to a resident. A CNA was observed feeding a resident while standing and facing away, engaging in conversation with another staff member. The CNA briefly looked at the resident only to place food in their mouth. This undignified behavior was confirmed by both the CNA and an RN.
A facility failed to have a legal guardian sign an Advance Beneficiary Notice for a resident with intellectual disability, who functions at a 5-year-old level. The resident, admitted with a bimalleolar fracture, signed the notice themselves, contrary to protocol. Staff acknowledged the error during a survey, confirming the notice should have been signed by the guardian.
The facility failed to ensure accurate advanced directives for two residents, resulting in discrepancies between electronic records and paper charts regarding code status. The electronic records indicated full code status, while the paper charts, signed by the residents or their power of attorney, indicated DNR status. The DON confirmed these discrepancies during a surveyor interview.
A facility failed to incorporate PASARR level II recommendations into the care plan of a resident with schizoaffective disorder, anxiety disorder, and major depressive disorder. The PASARR report recommended specialized psychiatric services and rehabilitative support, but the LSW admitted to being unfamiliar with these requirements and confirmed no actions were taken.
A facility failed to provide restorative nursing services to a resident as outlined in their care plan. The resident's plan included daily passive range of motion (PROM) exercises to maintain functional mobility, but the facility could not provide evidence that these exercises were performed on 34 out of 45 days. This deficiency was confirmed during an interview with the DON.
The facility failed to follow physician orders for insulin administration for two residents, resulting in incorrect dosages being given. One resident received incorrect doses of Insulin Aspart according to a sliding scale, while another received Insulin Lispro despite blood sugar levels not meeting the criteria for administration. These errors were confirmed during a review with the DON.
A resident with a bimalleolar fracture and intellectual disability was sent to a community appointment without required staff supervision due to a miscommunication. The resident, who needed 24/7 assistance for cognitive and safety awareness deficits, was transported alone by a wheelchair van service. The facility realized the error after receiving complaints, and a CNA was sent to accompany the resident.
A facility failed to ensure a physician reviewed and signed a resident's medication and treatment orders in a timely manner. The physician initially signed the orders, which were valid for 60 days, but did not review and sign the subsequent orders by the required date. As confirmed by the DON, the orders remained unsigned past the grace period.
A facility failed to follow its infection control practices during a pressure ulcer dressing change for a resident with a Stage 4 ulcer. The RN placed treatment supplies on a soiled overbed table without establishing a clean field, contrary to the facility's Wound Care Policy. The nurse confirmed the oversight during a discussion with the surveyor.
The facility did not transmit the MDS assessments for two residents to the State database within the required 14-day period after completion. The assessments, completed on the same day, lacked evidence of transmission until identified during a surveyor interview with the MDS RN, who then submitted them successfully.
The facility failed to respond to residents' requests for assistance in a timely manner, causing increased anxiety for one resident and mental anguish for another who wanted to voice concerns about their care before discharge. The facility's call bell log did not verify the incidents, and the Administrator and DON were unaware of the requests.
A resident was denied daily showers as ordered by their provider, leading to neglect of personal hygiene and the development of a rash. Staff were not properly instructed on how to provide the shower, and documentation showed inconsistencies. The Director of Nursing confirmed the resident did not receive the required showers.
A resident with severe postoperative pain and impaired mobility did not receive daily showers as ordered by the physician. Despite being cleared to shower and having specific wound care instructions, the resident did not receive any showers for over a week. Staff cited a lack of training as the reason for not providing the showers, and the Director of Nursing confirmed the deficiency.
Failure to Follow Physician Orders for Medication and Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents. For one resident, there was an order to administer Levofloxacin 750 mg by mouth every 48 hours, starting on 4/2/25 and ending on 4/22/25. However, the medication administration record showed that the resident received doses on consecutive days, 4/2/25 and 4/3/25, rather than every 48 hours as ordered. Interviews with two LPNs revealed that the facility's Pyxis system did not have the required dose, and they expected the medication to arrive the next morning, but the resident still received the medication two days in a row, not in accordance with the provider's order. For another resident, the treatment administration record indicated a blood sugar result of 422, which required 12 units of insulin and a call to the medical doctor per the sliding scale insulin protocol. The clinical record confirmed that the MD was called, and an additional order was given to administer 3 more units of insulin and to recheck blood sugar in 2 hours. However, there was no evidence in the clinical record that the blood sugar was rechecked as ordered.
Failure to Provide Physician-Ordered CPAP Therapy Due to Missing Equipment
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for a resident who required nightly use of a CPAP machine. Upon admission, the resident's CPAP machine was missing necessary tubing, and documentation showed that the resident was unable to use the device as ordered. Despite repeated documentation in nursing progress notes and the electronic treatment administration record indicating the absence of the required part, the facility did not obtain the missing tubing for an extended period. The resident experienced multiple hospitalizations during this time, with all admission orders continuing to specify the need for nightly CPAP use. Interviews with facility staff confirmed that efforts to obtain the missing tubing were delayed, and the resident was unable to use the CPAP as ordered from the time of admission until the part was finally acquired. The Assistant Director of Nursing acknowledged that the facility contacted previous providers and suppliers but did not secure the necessary equipment until 50 days after the resident's initial admission. During this period, the resident had four hospital admissions related to hypoxia, and the lack of timely action by the facility directly resulted in the resident not receiving prescribed respiratory therapy.
Improper Air Gap Installation on Ice Machine Drain Lines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper installation of plumbing fixtures to prevent backflow, as required by the Maine State Plumbing Code. Specifically, on multiple consecutive days, the drain lines of two ice machines—one in the hallway leading to the kitchen and one in the kitchen—were found to have improper air gaps, resulting in a direct connection between wastewater and potable water. This was in violation of state regulations, which require an air-gap separation of at least one inch. The deficiency was confirmed with the Food Service Director on each visit, and while the vegetable sink had the proper air gap, the ice machines continued to lack the required separation throughout the survey period. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on environmental observations and staff interviews.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program over a three-day period, as evidenced by multiple observations of unsanitary conditions and improper infection control practices. Surveyors observed dried blood and stool on a commode seat used as an elevated toilet seat in a shared bathroom, with additional dried blood droplets on the floor leading to the sink. Unlabeled and soiled bed pans were left exposed in shared bathrooms, and soiled linen bed chucks were found on the floors of resident rooms. A hole in the shower floor created an uncleanable surface, and blood was observed on a resident's bed frame. These findings were confirmed by interviews with nursing staff, who acknowledged that bed pans should be labeled, sanitized, and stored properly, and that soiled items should not be left exposed or on the floor. Further deficiencies included improper glove use and hand hygiene by a CNA, who handled clean resident clothing and personal items while still wearing soiled gloves after providing peri care. Opened dressing wrappers were found on a resident's blankets, and a resident was observed self-propelling in a wheelchair with a Foley bag dragging on the floor. These observations were confirmed by staff, including the DON, who acknowledged the presence of blood on equipment and uncleanable surfaces. The repeated nature of these findings over several days demonstrates a lack of adherence to established infection control protocols.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted for skilled care services. Clinical record review showed that the resident was readmitted to the facility on 2/27/25, but there was no evidence that a baseline care plan with the necessary instructions for minimum healthcare information was created until 3/3/25, which was four days after admission. This delay was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the baseline care plan was not initiated within the required 48-hour timeframe.
Failure to Consistently Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to consistently provide activities of daily living (ADL) care in the area of oral hygiene for a resident who required assistance due to hemiplegia affecting the left non-dominant side. The resident, who was cognitively intact, reported that staff did not soak or wash dentures at night, and observation confirmed the dentures were soiled with food debris. Review of the care plan indicated the resident needed limited to extensive assistance with personal hygiene, including oral care. Documentation showed that oral hygiene was not completed after the evening meal on 13 out of 31 days in March. During an interview, the DON acknowledged that evening shift staff would mark oral hygiene as 'Not Applicable' if it was already documented as completed by a previous shift, resulting in inconsistent provision of oral hygiene care after the evening meal.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for two residents. For one resident, there was a physician's order for nightly use of a CPAP device, but the Treatment Administration Record (TAR) showed the device was applied on several dates when, in fact, the CPAP was missing necessary parts and could not be used. Documentation in the clinical record confirmed the device was not functional until a missing part was received, yet staff had inaccurately documented its application prior to that date. For another resident, the Medication Administration Record (MAR) listed medications as being prescribed for Parkinson's disease and psychosis, but the resident's active diagnosis list did not include these conditions. Provider notes clarified that the medications were actually prescribed for drug-induced tremor and bipolar disorder. During a review with the Director of Nursing, it was confirmed that the MAR contained inaccurate information regarding the indications for the prescribed medications.
Failure to Notify Resident's Representative and Provider of Critical Changes
Penalty
Summary
The facility failed to notify the resident's representative of a change in the discharge plan for a resident who required 24-hour supervision. Initially, a plan was made for the resident to transfer to an assisted living memory care unit, but this transfer did not occur, and the representative was not informed of this change. Additionally, the facility did not notify the representative when the resident went outside the facility and attempted to climb over a railing, an incident that was documented in the nursing notes. Furthermore, the resident's medical provider, who had been involved in their care since admission, was not informed of the resident's elopement risk or the use of a wander guard. The provider only became aware of the resident's elopement risk after examining them following an elopement incident. Interviews with the facility's Administrator, Director of Nursing, and Unit Manager confirmed the lack of communication with the resident's representative and medical provider regarding these critical changes and incidents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and monitor a resident with a known risk for wandering, resulting in the resident eloping from the facility. The resident, who had a diagnosis of left frontal parietal subarachnoid hemorrhage and Alzheimer's disease, was identified as a wandering risk upon admission, and a wander guard was placed. Despite multiple instances of exit-seeking behavior observed by staff, the resident was not moved to a more secure unit as recommended. On several occasions, the resident attempted to leave the facility, and on one occasion, successfully exited through the front door before being redirected back inside. On the night of the incident, the resident was last seen in bed at 10:30 p.m. but was discovered missing an hour later. A search revealed that the resident had eloped through an open window, and the window screen was found on the ground outside. The resident was found approximately a mile away from the facility in 14-degree Fahrenheit weather, inadequately dressed for the conditions. Upon return, the resident's body temperature was recorded at 93.2 degrees, indicating hypothermia. The facility was aware of the resident's increased elopement risk but failed to take sufficient preventive measures to ensure the resident's safety.
Incomplete Clinical Records for Resident Elopement
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for elopement. The resident exhibited exit-seeking behaviors on multiple occasions, specifically on the afternoon of January 3, the morning of January 6, the morning of January 9, and the morning of January 15, when the resident packed belongings and expressed a desire to go home. On January 15, the resident attempted to leave through the 701 and 708 hallways, carrying a bag of clothing and stating the intention to go home. This incident was not documented in the clinical record. During a review of the resident's clinical records with the Director of Nursing and a Unit Manager, it was confirmed that the records lacked evidence of nurse's notes for each elopement or exit-seeking attempt. This omission was identified during an interview with the charge nurse and a subsequent review of the records, highlighting a deficiency in maintaining complete and accurate clinical documentation.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that staff reported an allegation of physical abuse immediately, as required by their policy. The incident involved a Certified Nursing Assistant (CNA #1) who allegedly grabbed a resident by the left thumb and twisted the resident's arm behind their neck, resulting in bruising. This incident was witnessed by another CNA (CNA #2) on the evening of November 11, 2024, but was not reported until the following afternoon, November 12, 2024. This delay allowed the alleged perpetrator to continue providing care to the resident during this period. The facility's policy, revised in February 2023, mandates that any suspicion of abuse must be reported immediately, defined as within two hours of the allegation. However, CNA #2 did not report the incident to the charge nurse or the administrator immediately, citing a belief that nothing would be done about it. This failure to report promptly was confirmed during an interview with the Director of Nursing (DON) and two surveyors, highlighting a breach in the facility's protocol for handling allegations of abuse.
Medication Administration Error Leads to Hospital Transfer
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, resulting in the resident being transferred to the Acute Care Emergency Department for evaluation and monitoring. During a morning medication pass, a Certified Nurse Assistant-Medication (C.N.A.-M) mistakenly administered medications intended for another resident to Resident #1 (R1). The medications included Aspirin, Cholestyramine, Clopidogrel Bisulfate, Isosorbide, Psyllium Husk Powder, Metoprolol Tartrate, and Tylenol. R1 was not allergic to these medications, but the error led to low blood pressure and a mild drop in hemoglobin and hematocrit levels. The error occurred because the C.N.A.-M misread the name in the computer system, confusing R1's name with that of Resident #2 (R2). The C.N.A.-M, who had recently returned to work after a two-month absence, did not recognize R1 and mistakenly thought R1 was R2. The C.N.A.-M asked R1 if their name was R2's last name, and R1, who was mildly cognitively impaired, confirmed. This led to the administration of the wrong medications. Upon realizing the mistake, the C.N.A.-M immediately notified a nurse, and R1 was assessed and sent to the Emergency Department. R1's clinical records indicated a history of hypertension, with a prescribed medication of Metoprolol Tartrate. The resident's Minimum Data Set showed a Brief Interview for Mental Status score indicating mild cognitive impairment. After receiving the wrong medications, R1 experienced low blood pressure and lightheadedness, prompting an emergency transfer to the hospital. The facility's Medication Administration Policy requires verification of the resident's identity, including checking photographs and medication labels, which was not adequately followed in this incident.
Removal Plan
- The Skilled Nurse Manager re-educated C.N.A.-M on the medication administration policy and procedure.
- Copies of the Medication Administration policy and procedure along with sign sheets were placed at the nurse's stations.
- All medication technicians and nurses that administer medications were mandated to review the policy and procedure and sign the sheet that they did the review.
- Audits of all the residents' MARs were completed to ensure they all had a picture.
- On-going audits are being done by the Director of Nursing and/or the Skilled Nurse Manager to ensure new residents have a picture taken and attached to their MAR.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that a resident requiring feeding assistance was treated in a dignified manner. During an observation, a Certified Nursing Assistant (CNA2) was seen feeding a resident (R28) while standing at the side of the table, facing away from the resident, and engaging in conversation with another staff member. CNA2 used a spoon to feed the resident, briefly looking at the resident only to place food in their mouth before continuing the conversation. This behavior was confirmed through interviews with both CNA2 and a Registered Nurse (RN2), who acknowledged that the feeding was not conducted in a dignified manner.
Failure to Obtain Legal Guardian's Signature on Beneficiary Notice
Penalty
Summary
The facility failed to ensure that an Advance Beneficiary Notice was reviewed and signed by the legal guardian of a resident with intellectual disability, who functions at a 5-year-old level. The resident, admitted with a bimalleolar fracture of the right ankle and identified as having a legal guardian responsible for medical and financial decisions, signed the notice themselves on 12/16/23. This oversight was identified during a record review and interviews conducted on 05/15/24. Both the Licensed Social Worker and the Program Director of Therapy acknowledged that the notice should have been signed by the legal guardian, not the resident, as the resident was not capable of understanding the document.
Discrepancies in Residents' Advanced Directives
Penalty
Summary
The facility failed to ensure the accuracy of residents' advanced directives regarding code status in their electronic records. For one resident, the electronic record indicated a full code status for CPR, while the paper chart, signed by the resident's power of attorney, indicated a do not resuscitate (DNR) status. Similarly, another resident's electronic record showed a full code status, but the paper chart, signed by the resident, indicated a DNR status. The Director of Nursing confirmed the discrepancies in both residents' records during an interview with a surveyor.
Failure to Implement PASARR Recommendations for Resident with Mental Illness
Penalty
Summary
The facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) level II determination into the assessment, care planning, and transitions of care for a resident diagnosed with schizoaffective disorder, anxiety disorder, and major depressive disorder. The PASARR evaluation report, dated March 7, 2024, identified the resident as having serious mental illness, leading to functional limitations in interpersonal functioning, concentration, or adaptation to change. The report recommended specialized services, including ongoing psychiatric services by a psychiatrist to evaluate and modify psychotropic medications, and rehabilitative services for socialization, family involvement, and supportive counseling. However, during an interview, the Licensed Social Worker (LSW) admitted to being unfamiliar with PASARR level II requirements related to psychiatry and confirmed that no actions had been taken to implement the recommendations.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide services to maintain and/or improve a resident's highest level of functional mobility, specifically for Resident #87. The care plan for this resident, dated 3/28/24, directed staff to establish a restorative nursing program, which included a Nursing Rehab/Functional Maintenance Plan for passive range of motion (PROM) exercises to the lower extremities for 15 minutes every day. However, the facility was unable to provide documented evidence that the resident received the prescribed PROM exercises on multiple dates, totaling 34 out of 45 days. This deficiency was confirmed during an interview with the Director of Nursing on 5/16/24.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of sliding scale insulin for two residents, leading to medication errors. For Resident #19, the clinical record indicated a physician order to check blood sugar levels four times a day and administer Insulin Aspart according to a sliding scale. However, the Medication Administration Record (MAR) for May 2024 showed multiple instances where the insulin dosage administered did not align with the prescribed sliding scale. On several occasions, Resident #19 received either an incorrect dosage or no insulin at all, despite blood sugar levels indicating otherwise. These discrepancies were confirmed during an interview with the Director of Nursing. Similarly, for Resident #51, the facility did not follow the physician's order for Insulin Lispro administration. The order specified that insulin should only be given for blood sugar readings greater than 300. However, documentation revealed that on one occasion, Resident #51 received 5 units of Lispro despite having a blood sugar level of 165, which did not warrant insulin administration according to the order. This finding was also confirmed during a review with the Director of Nursing.
Failure to Provide Supervision for Resident with Cognitive Deficits
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R147, who was sent to an appointment in the community without the required staff accompaniment. R147 had a bimalleolar fracture of the right ankle and an intellectual disability, necessitating 24/7 assistance for cognitive and safety awareness deficits. The resident's records indicated a legal guardian for decision-making and a physician's order that required a staff member to accompany R147 to a follow-up appointment. However, due to a miscommunication, the facility mistakenly believed that a member from R147's group home would accompany the resident, resulting in R147 being transported alone by a wheelchair van service. The oversight was discovered after the facility received complaints about the lack of supervision, prompting a Certified Nursing Assistant to accompany the resident belatedly.
Physician's Timely Review and Signature of Orders Lacking
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. Specifically, for Resident #13, the physician signed the initial Physician Orders (block orders) on February 16, 2024, which were valid for 60 days. The subsequent orders required review and the physician's signature by April 26, 2024, including a 10-day grace period. However, the medical record lacked evidence of the physician's review and signature on or around the required date. As of May 16, 2024, during an interview with the Director of Nursing, it was confirmed that the orders were late, and no updated orders had been reviewed and signed by the physician.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control practices as outlined in its Wound Care Policy and Procedure during a pressure ulcer dressing change for a resident with a Stage 4 pressure ulcer. The resident, who has a complex medical history including insulin-dependent diabetes, obesity, and kidney failure, was observed during a dressing change performed by a registered nurse. The physician's order for the resident's pressure ulcer treatment included specific steps such as cleansing with Normal Saline, applying Lotrisone cream, packing the wound with Aquacel with Silver, and covering it with Mepilex, to be changed daily and as needed. During the dressing change, the registered nurse used the resident's overbed table, which was cluttered with personal items and a wash basin with used bath water, to place treatment supplies. The nurse did not establish a clean field on the table as required by the facility's Wound Care Policy. Instead, sterile packages and the cap of the Normal Saline spray bottle were placed directly on the soiled table surface. This oversight was confirmed by the nurse during a discussion with the surveyor, acknowledging the failure to create a clean field before placing the treatment supplies.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit the Minimum Data Set 3.0 (MDS) assessments for two residents to the State MDS database within the required 14-day period following completion. Specifically, the annual MDS for one resident and the quarterly MDS for another resident were both completed on April 2, 2024, but there was no evidence in the clinical records that these assessments were transmitted to the State database. This deficiency was identified during a review of records and an interview with the MDS Registered Nurse (RN) on May 15, 2024. During the interview, the MDS RN submitted the assessments, and they were subsequently accepted by the State database.
Failure to Respond to Residents' Requests in a Timely Manner
Penalty
Summary
The facility failed to respond to residents' requests for assistance in a manner that maintained or enhanced their dignity. One resident reported that their call bell was not answered for 50 minutes when they needed assistance with pain, causing them increased anxiety. This resident also mentioned a previous instance where the call bell rang for 35 minutes before a family member had to find staff to assist. The facility's call bell log did not have records to verify these incidents, and the Director of Nursing acknowledged that mornings are very busy, which could have led to the delay in response time. Another resident requested to speak to the Administrator before discharge to voice concerns about their care, specifically regarding not receiving daily showers as ordered by their provider. The charge nurse did not assist the resident in meeting or speaking with the Administrator, citing the resident's use of foul language. The resident expressed that this caused them mental anguish and anger, as they felt their care was not taken seriously. The Administrator and the Director of Nursing were not aware of the resident's request to speak with them before leaving the facility.
Failure to Provide Daily Showers as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from neglect when the resident was denied daily showers as ordered by their provider from 2/24/24 to 3/4/24. The resident had a specific written order for daily showers with detailed instructions to ensure safety and proper care. However, the electronic treatment administration record (eTAR) showed inconsistencies in the documentation of the showers, with entries indicating refusal, completion, and holding of the showers. Interviews with staff revealed that they were not properly instructed or shown how to provide the shower to the resident, leading to the resident not receiving the required daily showers. The resident developed a rash in the groin area due to the neglect of personal hygiene. The Occupational Therapist (OT) confirmed that he did not assist the resident with an actual shower but only simulated the steps. A Certified Nurse's Assistant (CNA) admitted to not knowing how to handle the resident's shoulder brace and therefore did not provide the shower. The Director of Nursing confirmed that the resident had not received a shower during their stay once cleared by the provider. The resident and their son also confirmed that the resident did not receive the showers and that there was a discrepancy in the documentation. The clinical record for bathing lacked evidence that the resident received a shower during their stay at the facility.
Failure to Follow Physician Orders for Resident Showers
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident who was admitted with severe postoperative pain and impaired mobility due to a right shoulder rotator cuff tear and left quadriceps tendon repair. The resident was cleared by the provider to take daily showers with specific wound care instructions starting from 2/24/24. However, the clinical record review revealed that the resident did not receive any showers from 2/24/24 to 3/3/24, despite having a written order dated 2/29/24 for daily showers with detailed wound care procedures. During an interview with the surveyor, the resident confirmed that they had been asking for showers and had a physician's order for daily showers. The resident stated that staff informed them they were not able to provide showers due to a lack of training. The Director of Nursing confirmed that the resident had not received a shower during their stay once cleared by the provider. This failure to follow physician orders resulted in a deficiency in the care provided to the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
