Russell Park Rehabilitation & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 158 Russell St, Lewiston, Maine 04240
- CMS Provider Number
- 205052
- Inspections on file
- 19
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Russell Park Rehabilitation & Living Center during CMS and state inspections, most recent first.
The facility did not ensure that two authorized staff signed the controlled substance shift count sheets at each shift change for multiple medication carts, resulting in incomplete records for the receipt and disposition of controlled drugs, as confirmed by the DON and facility policy.
Two residents who smoked were not assessed for their ability to smoke safely, as required by facility policy. One resident was found with cigarettes and a lighter at bedside and reported occasional staff supervision while smoking outside, but had no documented assessment or contract. Another resident, who smoked independently, also lacked a completed smoking assessment, despite having cigarettes in their possession. The DON confirmed that these assessments, which determine if residents can keep smoking materials at bedside, were not completed as required.
Surveyors found that several residents with respiratory conditions were using oxygen tubing and nebulizer equipment that was not changed or stored according to physician orders and facility policy. Staff documented tubing changes as completed, but observations showed outdated tubing in use and improper storage of respiratory equipment, indicating a failure to maintain a sanitary environment and follow prescribed care schedules.
Surveyors observed unsanitary conditions in the kitchen, including food debris, dirt, and spillage on floors and equipment, as well as soiled dish racks. Additionally, a Dietary Aid with facial hair was found not wearing a beard restraint as required by facility policy, only applying it after being prompted by surveyors.
A review of CNA education records and staff interviews confirmed that several CNAs did not receive the required 12 hours of annual in-service training, including dementia care, resident rights, and abuse/neglect prevention, as mandated for the year. Documentation for these trainings was not available for any of the CNAs reviewed.
Surveyors found multiple deficiencies in facility maintenance and housekeeping, including stained and dirty caulking around toilets, damaged shower curtains, chipped paint on doors and heaters, uncleanable surfaces due to duct tape and marred walls, and a resident's electric wheelchair with food debris. These issues were confirmed by the Environmental Services Director and Administrator.
Staff did not consistently monitor or document urinary output for two residents with indwelling catheters, despite care plans requiring this intervention. Both residents had medical conditions necessitating catheter use, and their care plans specified monitoring and documentation of urine output, which was not carried out as written.
Annual performance evaluations were not completed for five CNAs employed for over a year, as confirmed by the DON and a review of employee records. Documentation for the required 2024 evaluations was missing for all affected staff.
The facility did not provide sufficient documentation to justify the ongoing use of psychotropic medications for two residents. One resident continued to receive multiple psychotropic drugs after a fall without a documented risk-benefit assessment, while another had a PRN order for Lorazepam that exceeded the 14-day limit without clinical justification.
A resident with a physician's order for 7 units of Aspart insulin was instead given 12 units of Humalog insulin. The nurse on duty could not verify the amount administered, and the error was later confirmed by the DON. The resident expressed anxiety and requested additional blood glucose checks after being informed of the incident.
Surveyors found that an LPN failed to label and properly dispose of open biologicals, including an unlabeled Basaglar insulin pen and an Epinephrine injection, as required by manufacturer instructions. The issue was confirmed and discussed with the DON.
Surveyors and the FSD observed a heavily soiled garbage storage area with food and trash debris behind three dumpsters, confirming the area was not maintained in a sanitary condition.
The Quality Assurance Committee failed to ensure the effectiveness of a corrective plan for a previously cited deficiency regarding the maintenance of a sanitary environment to prevent disease and infection related to respiratory care, resulting in the same issue being cited again during a follow-up survey, as confirmed by the Administrator and DON.
A facility failed to maintain accurate clinical records for a resident with a stage 4 pressure ulcer, as repositioning was not consistently documented or performed. Interviews confirmed the lack of compliance with repositioning orders. Additionally, another resident was prescribed psychotropic medications without appropriate diagnoses, violating the facility's policy. The DON confirmed these deficiencies with surveyors.
The facility failed to implement infection control precautions for residents with indwelling catheters, leading to multiple infections. A resident with a neurogenic bladder and another with a history of urosepsis were not placed on Enhanced Barrier Precautions or contact precautions despite having ESBL diagnoses. Staff were unaware of the infection status and necessary precautions. The DON confirmed the oversight and acknowledged the need for precautions for all residents with catheters.
The facility failed to ensure call bell accessibility for two residents. Observations showed one resident's call bell was hanging from the wall and attached to a wiffleball at the end of the bed, while another's was tucked under them, both out of reach. CNAs noted that one resident rarely uses the call bell, relying on their roommate to use it instead, and acknowledged that staff should ensure call bells are accessible.
Failure to Maintain Accurate Controlled Substance Shift Counts
Penalty
Summary
The facility failed to maintain an adequate system for recording the receipt and disposition of all controlled drugs, resulting in insufficient detail to enable accurate reconciliation. During a review of three medication carts (Cart A, Cart B & C, and the Nurse Treatment cart), it was observed that the required signatures from two authorized medication administrators were missing from the Shift Count pages on multiple dates. The facility's policy requires that incoming and outgoing nurses count all Schedule 2 controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Count Sheet. However, on numerous occasions, the required documentation was not completed as indicated by the absence of signatures, despite the facility's practice of counting controlled substances approximately three times a day at shift changes. The Director of Nursing Services confirmed the findings, acknowledging that a significant number of required signatures were missing from the narcotic books. The deficiency was identified through record review, observation, and staff interview, and it was corroborated by the facility's own policy dated 8/1/24, which outlines the procedures for inventory control of controlled substances. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Complete Smoking Assessments and Contracts for Residents
Penalty
Summary
The facility failed to complete required smoking assessments and contracts for two residents who were identified as smokers. One resident, who had been smoking since admission approximately two weeks prior, was observed with cigarettes and a lighter at the bedside. The resident confirmed that staff occasionally accompanied them to the designated outdoor smoking area. Review of the medical record showed no evidence of a smoking assessment or a signed smoking contract upon admission or after the facility became aware of the resident's smoking. The Director of Nursing Services (DNS) confirmed that the assessment was not completed until after the surveyor's inquiry. Another resident, also identified as a smoker, was found with multiple boxes of cigarettes in their room, including one in their shirt pocket and two on the windowsill. The resident was reported by an LPN to go out alone to smoke. Review of this resident's clinical record, who was admitted several months prior, also lacked evidence of a completed smoking assessment. The DNS confirmed that no assessment had been completed for this resident, and acknowledged that the assessment determines whether residents may keep smoking materials at bedside or require them to be secured. The facility's policy requires a smoking assessment upon admission or when a resident begins smoking, and quarterly thereafter.
Failure to Maintain Sanitary Respiratory Care Equipment and Adhere to Change Schedules
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to physician orders and facility policy regarding respiratory care for five residents requiring oxygen therapy or nebulizer treatments. Multiple residents were observed using oxygen tubing and nasal cannulas that were not changed according to the prescribed weekly schedule, with tubing dated well beyond the required change interval. Documentation on the Treatment Administration Record (TAR) indicated that tubing changes were recorded as completed, but direct observation showed otherwise. Additionally, nebulizer equipment was improperly stored, with one resident's nebulizer mask and tubing left unlabeled and on a dresser, and another resident's oxygen cannula left wrapped around a cylinder caddy handle instead of being stored in a protective bag as required by policy. Residents involved had significant respiratory diagnoses, including acute and chronic respiratory failure, hypoxia, COPD, metastatic lung cancer, and end-stage emphysema, necessitating strict adherence to respiratory care protocols. Staff interviews revealed inconsistent understanding and application of the facility's policy, with some staff stating tubing was changed every two weeks despite orders and documentation indicating weekly changes. The facility's own policy required nasal cannulas to be changed every two weeks and stored in a plastic bag when not in use, and nebulizer parts to be cleaned and stored properly, but these procedures were not consistently followed.
Failure to Maintain Kitchen Sanitation and Staff Compliance with Beard Restraints
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, as evidenced by observations of food debris and trash on the kitchen floor, under equipment, and shelving. Additional findings included dirt and debris in the hood system, the fan in the walk-in refrigerator, and the fly zapper. The reach-in refrigerator, walk-in refrigerator, and walk-in freezer all had dirt, debris, and spillage on their floors. Plastic coverings on racks containing clean dishes were found to be in poor condition and soiled with dry liquid residue. These conditions were confirmed by the Food Service Director during the survey. Furthermore, a Dietary Aid with facial hair was observed not wearing a beard restraint while in the kitchen, contrary to facility policy, and only applied the restraint after surveyor intervention. The facility's policy requires all employees to wear appropriate hair restraints to prevent hair from contacting exposed food.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) employed for more than one year received the required 12 hours of annual in-service education, including training in dementia care, resident rights, and abuse/neglect prevention. A review of employee education records for five CNAs revealed a lack of documentation showing completion of these mandatory trainings for the year 2024. Each CNA's file was specifically noted to be missing evidence of the required education hours and content areas. Interviews with the Business Office Manager and the Director of Nursing Services confirmed that there was no documentation available to demonstrate that the five CNAs had received the necessary annual in-service training. The deficiency was identified through both record review and staff interviews, with no evidence provided to show compliance with the training requirements for the specified period.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
During an environmental services tour, multiple deficiencies were observed throughout the facility, indicating a failure to maintain a safe, clean, and homelike environment for residents. In the A Unit shower/spa room, the caulking around the base of the toilet was stained and dirty, all four shower curtains were stained or ripped, and both the heater unit and entrance door had chipped or missing paint, creating uncleanable surfaces. Several resident rooms in the A Unit had issues such as missing or damaged privacy curtain hooks, chipped or marred walls with black marks, stained or dirty caulking around toilets, discolored flooring, dusty bathroom exhaust fans, and doors with chipped or missing laminate. A wash basin was also found sitting on the floor under a sink in one room. In the B Unit, similar issues were noted, including stained and dirty caulking and flooring around toilets, duct tape stuck to the bathroom floor creating uncleanable surfaces, and a baseboard heater with separated metal parts. Additionally, a resident's electric wheelchair was found to be dirty and dusty, with food crumbs and debris present. The C Unit also had a resident room with a door that had chipped, gouged, and missing laminate. These findings were confirmed by the Environmental Services Director and the Administrator during the tour.
Failure to Implement Care Plan Interventions for Indwelling Catheters
Penalty
Summary
The facility failed to implement care plan interventions for two residents who required indwelling urinary catheters. Both residents had documented medical conditions—one with obstructive uropathy and neuromuscular dysfunction of the bladder, and the other with neurogenic bladder and a history of urinary tract infections—that necessitated the use of indwelling catheters. Their care plans specifically included interventions to record the amount, color, and characteristics of urine, and to monitor and document urinary output. Record reviews and interviews revealed that staff did not consistently monitor or document urinary output for either resident, as required by their care plans. Documentation from CNAs and the Nurse Treatment Administration Record lacked evidence of this monitoring. Interviews with the Administrator and the Director of Nursing Services confirmed that urinary output was not documented unless there was a physician's order, despite the care plan directives. This resulted in the facility not following the established care plans for these residents.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for Certified Nursing Assistants (CNAs) as required, with no evidence of evaluations being conducted for five CNAs who had been employed for more than one year. Employee records for each of these CNAs, hired between 2002 and 2023, did not contain documentation of an annual performance evaluation for the year 2024. This deficiency was confirmed during an interview with the Director of Nursing Services, who acknowledged that the annual evaluations had not been completed for these staff members. No information regarding the medical history or condition of residents was provided in relation to this deficiency.
Failure to Justify and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation to justify the continued use of psychotropic medications for two residents. For one resident admitted in September 2024, the consultant pharmacist identified several medications, including Risperidone, Lorazepam, Fluoxetine, and Trazodone, as potential contributors to a recent fall. The pharmacist recommended that the physician evaluate these medications for their role in the fall and document a risk versus benefit assessment if therapy was to continue. The physician initially responded with 'Thank you. No change.' and later, after further inquiry, noted that the medications were being titrated for dementia and for safety/dignity, but did not provide a specific assessment or justification as recommended. For another resident, there was a provider order for Lorazepam 0.5 mg orally as needed for anxiety disorder, with no stop date, exceeding the required 14-day limit for PRN psychotropic medications. As of the date of review, the medical record did not contain evidence of clinical rationale to continue the medication beyond 14 days. These findings were confirmed through record review and interviews with the Director of Nursing Services.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
A physician's order was in place for a resident to receive 7 units of Aspart insulin subcutaneously three times daily. On one occasion, the resident returned from dialysis and a blood glucose check was performed. The nurse on duty administered insulin but was unable to verify the amount given when questioned by the charge nurse and the resident. The resident reported being told by the charge nurse that the wrong amount was given, but neither the nurse on duty nor the resident could specify the exact dosage at that time. Further review and interview with the Director of Nursing Services confirmed that the resident was given 12 units of Humalog insulin instead of the ordered 7 units of Aspart insulin. The nurse on duty also informed the night charge nurse of the situation, and the resident expressed anxiety and requested additional blood glucose monitoring. The physician's order was not followed, resulting in the administration of the incorrect type and dosage of insulin.
Failure to Properly Label and Dispose of Open Biologicals
Penalty
Summary
Surveyors observed that the facility failed to properly label and dispose of open biologicals in accordance with manufacturer specifications during an inspection of one of three medication carts. Specifically, an opened and unlabeled Basaglar (insulin) Kwik Pen was found, which, according to the manufacturer's instructions, should be discarded 28 days after first use, but lacked a date indicating when it was opened. Additionally, an Epinephrine injection was present with a manufacturer expiration date of 4/2025, but it was either undated or expired. These findings were confirmed by the LPN present at the time of observation and subsequently discussed with the Director of Nursing Services. No information about the residents involved or their medical conditions was provided in the report.
Unsanitary Garbage Storage Area Observed
Penalty
Summary
Surveyors, accompanied by the Food Service Director, observed a heavily soiled garbage storage area containing three trash dumpsters. Food and trash debris were noted behind all three dumpsters. This unsanitary condition was directly observed and confirmed during the survey. No information regarding residents or their medical history was included in the report.
Repeat Deficiency in Sanitary Environment for Respiratory Care
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. Specifically, the federal citation F695, related to failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection associated with respiratory care, was cited again during a follow-up survey. This repeat deficiency was confirmed through record review and interviews with the Administrator and the Director of Nursing.
Deficiencies in Clinical Record Accuracy and Psychotropic Medication Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a stage 4 pressure ulcer. The resident was supposed to be repositioned every two hours as per the provider's orders, but the documentation from July 11 to August 13 lacked evidence of compliance. Interviews with the resident, a Licensed Practical Nurse (LPN), Certified Nursing Assistants (CNAs), and the Director of Nursing confirmed that the repositioning was not consistently documented or performed as ordered. The resident expressed that staff did not follow the repositioning schedule, and the LPN and CNAs indicated that the documentation was either assumed or incomplete. Additionally, the facility did not ensure that psychotropic medication orders for another resident included appropriate diagnoses. The resident was prescribed several psychotropic medications, including Sertraline, Lorazepam, and Trazodone, without corresponding diagnoses as required by the facility's Psychoactive Medication Use Policy. The Director of Nursing confirmed with surveyors that the medications lacked appropriate diagnoses, which was a violation of the facility's policy.
Failure to Implement Infection Control Precautions for Residents with Catheters
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for residents with indwelling medical devices, specifically foley catheters. Three residents were identified as not being placed on Enhanced Barrier Precautions (EBP) or contact precautions despite having conditions that warranted such measures. Resident #1, who was admitted with a neurogenic bladder requiring a foley catheter, was not placed on EBP upon admission and later developed urosepsis secondary to a urinary tract infection. Despite a diagnosis of Escherichia coli with extended spectrum beta-lactamase (ESBL) activity, there was no evidence of contact precautions being implemented. Staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), were unaware of the resident's infection status and the necessary precautions. Similarly, Resident #3, with a history of urosepsis and a urinary catheter, was not placed on EBP upon admission and was later diagnosed with ESBL without subsequent contact precautions. Staff interviews revealed a lack of awareness regarding the resident's infection status and the required precautions. Resident #2, also with an indwelling catheter, was observed without EBP despite having a recent order for antibiotics due to a urinary tract infection. The Director of Nursing (DON) confirmed that residents with catheters had multiple infections and were not placed on appropriate precautions, acknowledging a gap in following CDC guidelines.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to make reasonable accommodations to ensure the call system was within reach for two residents. Observations on August 13, 2024, revealed that the call bell for Resident #2 was hanging from the wall and attached to a wiffleball at the end of the bed, making it inaccessible. Similarly, the call bell for Resident #1 was found tucked under the resident, also out of reach. Interviews with Certified Nursing Assistants (CNAs) indicated that Resident #2 rarely uses the call bell, relying instead on their roommate, Resident #1, to use it on their behalf. CNA #2 acknowledged that all staff should ensure call bells are within reach for all residents.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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