Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ross Manor during CMS and state inspections, most recent first.
The facility failed to provide written information and follow-up about advance directives and the right to accept or refuse treatment for 3 residents. Records for two residents lacked evidence that they were given the required written information, and for another resident the chart showed an unsigned advance directive form with no documented follow-up by the SW or confirmation of a Living Will.
Medication refrigeration and storage lapses were identified when a treatment cart still contained insulin products for a discharged resident, and 2 medication refrigerators had missing or out-of-range temperature logs over multiple months. The cart review showed insulin Lispro, Novolin R, and Lantus remained available after discharge, and staff stated these meds should have been removed within a few days. Refrigerator logs for the unit showed repeated missed checks and frequent temperatures outside the required range, with the QIPM, Nurse Manager, and Maintenance Director confirming the issues.
The facility failed to store and serve food in accordance with food safety standards. Surveyors found multiple refrigerated and frozen food items that were not properly sealed, labeled, or dated, including items exposed to air and items with unclear or outdated dates. Temperature logs also showed repeated refrigerator temperatures above the required range, missing dish machine temperature entries, and no evidence that out-of-range readings were reported. During breakfast service, a Dietary Aide handled toast with gloved hands, wiped the same glove on a soiled apron, and did not change gloves.
The facility failed to maintain an Infection Control Program when dietary staff did not perform hand hygiene during a dining service observation and bedpans were found stored improperly in a shared bathroom. A dietary aide handled items for a resident after touching her glasses with gloved hands and another aide rubbed her eyes after removing gloves, then began putting on new gloves without sanitizing her hands. Surveyors also observed unlabeled, unbagged, and soiled bedpans placed on a shower chair, behind a grab bar, and on top of a plastic bag, with clean towels touching one of the bedpans.
A resident with ESRD and dependence on renal dialysis was receiving hemodialysis 3 times per week before admission, but the admission MDS was coded No for both Dialysis and Hemodialysis in Section O. A surveyor reviewed the discrepancy with the DON.
A resident had a PASARR that did not require a level II determination, but after a new diagnosis of Psychotic Disorder with Hallucinations, the record lacked evidence that the State mental health authority was notified for a new PASRR review. During interview, the Administrator confirmed the resident was not resubmitted for a PASRR determination to include the new diagnosis.
A resident admitted with ESRD and dependence on dialysis had a left arm AV fistula and was receiving hemodialysis 3 times per week before admission, but the baseline care plan did not include goals or interventions for the fistula within 48 hours. The surveyor reviewed the issue with the DON.
Respiratory equipment was not maintained for a resident receiving O2 via nasal cannula and concentrator. Staff observed the O2 tubing dated and the concentrator filter with caked-on debris, despite an order requiring weekly tubing changes and weekly cleaning of the concentrator and filter. An RN and the QIPM confirmed the expected weekly maintenance process.
Failure to Obtain Dental Services for a Resident With Broken Teeth: A resident reported 2 broken teeth, pain, tongue scraping, and difficulty eating, and a dental visit could not be completed because the resident’s chair would not fit through the door. The record showed repeated complaints, a referral to dentistry, and orders for Dentemp, but the resident stated the issue was never addressed and no follow-up dental appointment was scheduled. The unit secretary and DON confirmed the resident was aware of the problem but dental services were not obtained.
A resident with ESRD and dependence on HD had incomplete clinical documentation related to dialysis care. The chart lacked evidence of dialysis and left arm fistula monitoring orders for part of the stay, the TAR did not show fistula monitoring, and the record did not show completion of the required Pre/Post Dialysis Evaluation. An RN said she checked VS and access after dialysis but was unsure about the assessment, and the DON confirmed the dialysis-related orders were not re-entered after hospitalization.
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 Provide Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives were provided written information and follow-up regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive for 3 of 10 residents reviewed. The facility policy stated that, prior to or upon admission, the social services director or designee should inquire about existing advance directives, provide written information about the right to refuse or accept treatment and to formulate an advance directive, and document any offer of assistance and the resident’s decision to accept or decline assistance. Resident 98, admitted in December 2025, had no evidence in the clinical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. Resident 36, admitted in April 2026, also had no evidence in the record of such written information, and the Licensed Social Worker confirmed on 6/10/26 that an advance directive had not been located for this resident. Resident 6, admitted in April 2026, had no evidence that the facility followed up with the resident and/or resident representative regarding the right to accept or refuse treatment and/or formulate an advance directive; the resident representative’s 11/4/17 Ross Manor Advanced Directive was not signed by the resident or resident representative, and the Social Service Initial Evaluation noted there was no evidence of a Living Will. On 6/9/26, the Social Worker confirmed that follow-up had not been completed regarding the unsigned Ross Manor Advanced Directive.
Medication Refrigeration and Discharge Storage Lapses
Penalty
Summary
The facility failed to ensure medications and biologicals were stored at appropriate temperatures in 2 of 3 medication refrigerators reviewed, and failed to remove medications from a treatment cart after a resident discharge. On the [NAME] Treatment cart, a review with RN #2 found a multi-use vial of insulin Lispro, a Novolin R100 flex pen, and a multi-use vial of insulin Lantus still available for use for a resident who had been discharged from the facility. RN #2 stated the medications were supposed to be removed within 2 to 3 days of discharge. Review of the medication storage policy showed refrigerated medications were to be kept between 2 C and 8 C with temperature monitoring documented. Observation of the [NAME] Unit medication refrigerator found insulins Novolog, Lantus, and Lispro, along with Ativan, Tuberculin, and COVID vaccinations. Temperature logs for the [NAME] Unit refrigerator showed multiple missing temperature checks across March, April, May, and June 2026. The LTC Med Room refrigerator log showed repeated out-of-range temperatures, including 22 of 57 readings out of range in March, 49 of 60 in April, 41 of 62 in May, and 15 of 16 in June. The QIPM, Nurse Manager, and Maintenance Director confirmed the temperature concerns and stated the refrigerators were supposed to be rechecked and maintenance notified if temperatures were out of range, but no work orders had been received for the medication refrigerators.
Food Storage, Temperature Monitoring, and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure food was stored and served in accordance with professional standards for food service safety. During a kitchen tour, the Food Service Director observed multiple items in a reach-in refrigerator and a walk-in freezer that were not properly sealed, labeled, or dated. Items included sweet potatoes and cottage cheese labeled with May dates while the survey occurred in June, beef base and chicken base dated only with 5/5, open boxes of ground beef patties, donuts, peas, and green beans exposed to air in the freezer, and crab cakes that were only partially covered and labeled with a prep date of 6/5/26 and a use-by date of 6/6/26. The surveyor also found thickened orange juice cartons and thickened cranberry cocktail in another refrigerator with dates that did not clearly reflect when the items were opened, and the Food Service Director stated the items were supposed to have received, open, and discard dates. The facility also failed to monitor refrigerator and dish machine temperatures as required. Review of temperature logs showed multiple refrigerator temperatures above 41 degrees in March and April, missing entries for some refrigerator checks, and no evidence that out-of-range temperatures were reported to the Food Service Director or maintenance. The dish machine temperature log for May was missing temperatures for several meal periods. Facility policy required refrigerator temperatures to be checked twice daily and recorded, and required dish machine temperatures and sanitizer readings to be documented throughout the dishwashing process. During breakfast service observation, a Dietary Aide served food with gloved hands and repeatedly picked up toast and plated it, then wiped the same gloved hand on a soiled apron without changing gloves. The surveyor observed this behavior multiple times, and the Dietary Aide confirmed she had wiped her hand on her soiled apron after plating toast and did not change her gloves.
Infection Control Program Failure with Hand Hygiene and Bedpan Storage
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection. During a lunch dining observation in the Long-Term Care Dining Room, Dietary Aide #2 was observed removing and replacing her glasses multiple times with a gloved right hand, then handling a cup and pouring ginger ale for a resident without sanitizing her hands. When questioned, Dietary Aide #2 stated she did not think about sanitizing her hands after removing dirty gloves or applying clean gloves. Dietary Aide #1 stated she could not sanitize her hands after glove removal because wet hands would prevent her from putting on new gloves, and she reported wearing 3-4 pairs of gloves at a time so she could remove the top layer when soiled and have clean gloves underneath. During the same dining service observation, Dietary Aide #1 removed her gloves and rubbed her right eye, then her left eye, and then her right eye again without sanitizing her hands before removing a new pair of gloves from the box and beginning to apply them. In addition, observations of a shared bathroom revealed bedpans stored in an unlabeled, unbagged, and soiled condition, including one placed on top of a shower chair with clean bath towels touching or hanging inside it, another tucked behind the grab bar in the shower, and another lying on top of a clear plastic bag on a shower chair. A CNA stated bedpans are supposed to be labeled and bagged, and the DON stated bedpans should be stored in a clear plastic bag in the bathroom and labeled if the bathroom is shared.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Version 3.0 assessment was accurately coded for dialysis for Resident #3. The resident’s admission diagnoses included End Stage Renal Disease with dependence on renal dialysis, and the clinical record showed the resident had been receiving hemodialysis 3 times per week before admission to the facility. However, the admission MDS assessment completed on 5/7/26, Section O - Special Treatments, Procedures, and Programs, was coded as No for both Dialysis and Hemodialysis. A surveyor discussed this finding with the DON on 6/10/26 at 12:30 p.m.
Failure to Notify State Mental Health Authority After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that the State mental health authority for PASRR was notified after a resident was newly diagnosed with a mental disorder. Resident #55 had a PASARR completed on 8/14/25 that did not require a level II determination, but on 9/10/25 the resident was diagnosed with Psychotic Disorder with Hallucinations. The clinical record did not show that the resident was referred to the State mental health authority for a new PASARR determination after this diagnosis. During an interview on 6/10/26, the Administrator reviewed the record with a surveyor and confirmed that the resident was not resubmitted for a PASRR determination to include the new diagnosis.
Baseline Care Plan Missing AV Fistula Instructions
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #3, who was recently admitted with End Stage Renal Disease and dependence on renal dialysis. Record review showed that Resident #3 had a left arm arteriovenous (AV) fistula and had been receiving hemodialysis 3 times per week prior to admission, but the baseline care plan did not include goals or interventions for the AV fistula. During an interview on 6/10/26 at 12:30 p.m., the surveyor discussed this finding with the Director of Nursing.
Respiratory Equipment Not Maintained
Penalty
Summary
The facility failed to maintain respiratory equipment for Resident #41, who was observed in bed with nasal cannula tubing attached to an oxygen concentrator. During observations on 6/8/26 and again on 6/9/26, the oxygen tubing was dated 6/26 and the concentrator filter was observed to have caked-on buildup and debris. The resident’s order, with a start date of 10/26/25, directed staff to change the oxygen tubing weekly, label it with the date changed, clean the concentrator with sani cloth, and remove, rinse, dry, and replace the filter every Sunday night shift. The TAR for 6/2026 showed this task was completed on 6/7/26. During interview, RN #1 stated the concentrator filters are supposed to be removed and rinsed under water weekly during each tubing change and that if this had been done there would not be dust on it. The QIPM also stated the expectation was that nurses change the O2 tubing weekly and clean the concentrator and filter at that time.
Failure to Obtain Dental Services for Resident With Broken Teeth
Penalty
Summary
The facility failed to obtain dental services for a resident with two broken teeth. The resident reported breaking 2 teeth about 4 months earlier and stated that a dental appointment had been scheduled for 3/20/26, but the resident could not go because the chair would not fit through the door. At the time of the surveyor’s observation, a molar on the bottom left jaw was broken with half of the tooth missing and jagged edges, and a molar on the bottom right jaw was broken/chipped. The resident stated the broken teeth were painful and that soft foods were needed for eating. The clinical record showed repeated reports of the dental problem and ongoing complaints that the issue had not been addressed. Notes documented difficulty sleeping due to the tooth issue, intermittent poor appetite, tongue scraping from the broken teeth, and repeated requests for a dentist referral. A provider order for referral to a dentist was entered, and Dentemp was ordered for the broken tooth, with later notes indicating it could be kept at bedside. The record also showed repeated follow-up notes stating the resident’s tooth concern had not been addressed and that an attempted appointment could not be completed because the resident’s wheelchair would not fit through the door. During interviews, the unit secretary stated that when she receives a referral, she usually calls for an appointment and schedules follow-up, but dental referrals were different and she was in the process of making improvements. Review of active dental referrals did not include this resident, and the surveyor confirmed there was no scheduled follow-up to ensure dental services were received after the missed appointment. The DON reviewed the record with the surveyor and confirmed the facility was aware the resident had 2 broken teeth but failed to ensure dental services were obtained.
Incomplete dialysis documentation and missing fistula monitoring orders
Penalty
Summary
Clinical records for Resident #3 were not complete and did not contain accurate dialysis-related information. Resident #3 was admitted in April 2026 with diagnoses including End Stage Renal Disease and dependence on renal dialysis, and had been receiving hemodialysis 3 times per week before admission. The resident’s active physician orders included orders for a left arm fistula to be checked for thrill and bruit every shift, the fistula site to be checked for bleeding and signs or symptoms of infection every shift, and dialysis on Monday, Wednesday, and Friday. Review of the record showed no evidence of a physician order for dialysis or for monitoring the left arm fistula from the resident’s admission until the orders with a 6/1/26 start date. The May 2026 TAR also lacked evidence that the fistula was being monitored, and the clinical record lacked evidence that the Pre/Post Dialysis Evaluation assessment was completed. RN #4 stated that she checks the resident’s vital signs and access when the resident returns from dialysis but did not know whether the pre/post dialysis assessment should be completed. The DON stated that the resident had been hospitalized in May and that when the resident returned, dialysis-related orders were never re-entered, and confirmed that the record lacked evidence that the Pre/Post Dialysis assessments were being done.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bangor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stillwater Health Care | 1.1 mi | ★★★★★ | 12 | 0 |
| Westgate Center For Rehab & Alzheimers Care | 1.3 mi | ★★★★★ | 5 | 0 |
| Bangor Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 28 | 0 |
| Eastside Center For Health & Rehabilitation, Llc | 1.9 mi | ★★★★★ | 16 | 0 |
| Maine Veterans Home - Bangor | 2.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.