St Mary's D'youville Pavilion
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 102 Campus Ave, Lewiston, Maine 04240
- CMS Provider Number
- 205053
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Mary's D'youville Pavilion during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain clean and sanitary conditions in two units and the laundry rooms, with dusty fans and air conditioning units, dirty air filters, marred hallway walls, broken or chipped baseboard heaters, privacy curtains in disrepair, and commode buckets left on bathroom floors. Facility leadership confirmed these findings during the environmental tour.
Surveyors observed multiple instances where respiratory care equipment, including oxygen tubing, nasal cannulas, and nebulizer components, were unlabeled, undated, and improperly stored in resident rooms. Staff interviews confirmed inconsistent practices and a lack of documentation for regular cleaning or replacement of this equipment, resulting in a failure to maintain a sanitary environment and prevent infection transmission.
Two residents requiring hemodialysis did not receive appropriate monitoring or care planning for their dialysis access sites. One resident with an AVF reported no assessment or monitoring by staff, and documentation lacked orders or interventions for site monitoring or emergency response. Another resident with a dialysis catheter stated staff did not check the site after dialysis, and the care plan did not address regular monitoring or emergency procedures. Nursing staff interviews confirmed a lack of routine assessment and absence of facility policy for dialysis care.
Two residents with active PTSD diagnoses did not have their trauma histories, triggers, or preventive interventions assessed or documented in their clinical records or care plans. Staff confirmed the absence of trauma-informed care planning and screenings for these residents.
A resident admitted with a right ankle fracture and requiring daily anticoagulant injections did not have a baseline care plan developed and implemented within 48 hours of admission. The medical record lacked the necessary instructions to ensure proper care for the resident's immediate needs.
A resident with CHF and respiratory illness was observed receiving oxygen at 3 LPM via nasal cannula, despite a provider order and care plan specifying 4 LPM to maintain target oxygen saturation levels. Multiple observations, record reviews, and staff interviews confirmed the discrepancy between the ordered and administered oxygen flow rates.
A resident who used tobacco products and had poor vision or blindness was found with a lighter in their room, and their smoking safety assessment was incomplete. The assessment noted the resident was unable to extinguish tobacco safely, but required clinical interventions and supervision were not documented or implemented. Staff interviews confirmed that residents were not observed while smoking, and the facility relied on education about its non-smoking policy rather than conducting proper safety assessments.
Two unlocked and unattended medication carts were found in a hallway across from the nurses station, with staff present nearby but not monitoring the carts. A surveyor was able to open and inspect the carts without staff intervention, and only after being notified did a nurse secure the carts. This allowed unauthorized access to medications.
The facility did not provide evidence that all required members attended two quarterly QAPI meetings, with the Medical Director missing from one meeting and the Administrator, DON, and Infection Preventionist absent from another, as confirmed by attendance records and staff interview.
A facility failed to implement an infection control program for a resident on contact precautions for ESBL. Two CNAs entered the resident's room wearing only masks, despite instructions to wear gowns, gloves, and goggles if necessary. The LPN intervened to correct the PPE use after a surveyor's observation. The resident's contact precaution status was confirmed by the RN, and the DON later educated the CNAs on PPE requirements.
The facility failed to provide adequate housekeeping and maintenance services, resulting in uncleanable surfaces, dusty and dirty fans, improperly stored commode buckets and bed pans, and heavily marked walls and doorframes. These deficiencies were confirmed by the Plant Operations Manager during an environmental tour.
The facility failed to develop or implement care plan interventions for six residents, leading to various deficiencies. These included missing safety measures for fall prevention, lack of required eye protection during care, unrecorded pressure-reducing devices, undocumented psychotropic medication plans, and incomplete hospice care plans. Staff misunderstandings about the inclusion of interventions in care plans contributed to these issues.
The facility failed to revise care plans for three residents to reflect their current needs, including Hospice services, suicidal ideation, and antidepressant medication. This was confirmed by various staff members.
The facility failed to follow a physician's order for obtaining daily weights for a resident with edema and did not make a referral to a specialist for a resident with depression as ordered. The deficiencies were confirmed through clinical record reviews and staff interviews.
The facility failed to maintain kitchen cleanliness and proper food handling. Observations included staff not wearing facial hair protection, dirty ceiling vents, wet stacked glasses, and improperly stored food items. During lunch service, a dietary aide/server did not follow proper hand hygiene, leading to potential cross-contamination. Additionally, the facility did not consistently monitor and document dish machine and refrigerator/freezer temperatures.
The facility failed to maintain and implement an infection control program for two residents with MRSA. One resident with respiratory MRSA did not consistently receive care with appropriate eye protection, and another resident with MRSA in the urine did not have consistent Transmission-Based Precautions in place. Staff provided conflicting information, and the facility did not adhere to its own Infection Prevention and Control Plan.
The facility failed to ensure a resident's advance directive regarding CPR was accurately documented. Despite the resident's request to change their Code Status to CPR, the clinical record still indicated No CPR, and the necessary documentation was missing. The facility did not follow its own policy for updating advance directives.
A facility failed to conduct a comprehensive MDS 3.0 assessment within 14 days after a resident began receiving hospice services. The resident's most recent assessment was completed before the initiation of hospice, and no new assessment was conducted within the required timeframe. This was confirmed by the DON.
The facility failed to develop and implement a baseline care plan within 48 hours for a new admission requiring TBP. A resident admitted with sepsis, acute kidney injury, and recurrent C-Diff did not have a care plan initiated for 63 days, despite physician orders for treatment. This deficiency was discussed with the Assistant Director of Nursing.
The facility failed to ensure that a pharmacist identified the lack of a psychiatric evaluation for a resident prescribed Sertraline for depression. Despite multiple medication reviews, the required evaluation was not completed, as confirmed by the RN Manager.
The facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for a resident. The resident had been receiving Quetiapine since November 2022, but there was no documentation of a GDR attempt or clinical contraindication between November 2022 and January 2024. This was discussed with the Assistant Director of Nursing.
The facility failed to maintain sanitary conditions in resident rooms and bathrooms and did not ensure proper food labeling in the kitchen. Despite a Plan of Correction, issues with storage of bed pans/commode buckets, dusty exhaust fans, and unlabeled food items persisted, leading to the recitation of deficiencies F584 and F812.
Failure to Maintain Cleanliness and Repair in Resident and Laundry Areas
Penalty
Summary
The facility failed to maintain adequate maintenance and housekeeping services necessary to ensure a safe, clean, and homelike environment for residents. During an environmental tour, surveyors observed multiple deficiencies across two of three units and the laundry rooms. In the laundry rooms, both clean and soiled linen areas had wall-mounted fans and air conditioning units that were dusty and dirty, and the ceiling air system had filters that were also dusty and dirty. On the 3rd and 4th floor units, hallway walls were marred with black marks, and several resident rooms had privacy curtains in disrepair, missing hooks, and hanging down. Multiple baseboard heating units in resident rooms were broken, chipped, or had missing paint and were marred with black marks. Additionally, some resident rooms had commode buckets left on the bathroom floor, including one that was unbagged. These findings were confirmed by the Administrator, QAPI Manager, and 3rd Floor Unit Manager during the tour.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment, as evidenced by multiple observations of unlabeled and undated oxygen tubing, nasal cannulas, and nebulizer components stored improperly in resident rooms. On several occasions, respiratory equipment such as nebulizer pipes, oxygen tubing, and masks were found either lying on bedside dressers, hanging off machines, or stored in drawers without proper labeling or dating. In some cases, the equipment was not in use for extended periods, and there was no documentation of regular cleaning or scheduled replacement. Residents reported infrequent use of the equipment, and staff interviews confirmed a lack of consistent procedures for changing and storing respiratory care items. Record reviews and staff interviews revealed that the facility did not document the weekly changing of oxygen tubing, nasal cannulas, or nebulizer masks in the Treatment Administration Record (TAR). The RN unit manager acknowledged the absence of documentation and stated that the facility was in a transition period due to the departure of the respiratory therapist, resulting in inconsistent practices. The lack of proper labeling, dating, and storage of respiratory care equipment was observed for multiple residents over several days, with no evidence of adherence to infection control protocols.
Failure to Monitor and Care Plan for Dialysis Access Sites
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for two residents requiring hemodialysis. One resident with an arteriovenous fistula (AVF) reported that staff had never assessed or monitored the AVF site, despite a history of bleeding episodes requiring hospitalization. The resident's medical record confirmed a diagnosis of end-stage renal disease with an AVF and orders for hemodialysis, but there were no documented orders or interventions for assessment or monitoring of the AVF site. The care plan lacked interventions for monitoring the AVF for bruit and thrill, as well as emergency interventions for bleeding, and there was no evidence of nursing care or assessment in the medication and treatment administration records. The Director of Nursing confirmed the absence of a policy or procedure for nursing care and monitoring of hemodialysis residents. A second resident with a dialysis catheter in the right upper chest area stated that staff only looked at the site on dialysis days and that the dialysis center staff managed the dressing. Upon return from dialysis, facility staff did not check the catheter site. The resident's care plan included some interventions for dialysis but did not address regular monitoring of the access site or specify emergency procedures for complications. The medication and treatment administration records also lacked documentation of monitoring for the dialysis access site. Interviews with nursing staff revealed that they did not routinely assess or monitor the dialysis access sites, either AVF or catheter, and were unaware of the need for such monitoring. The care plans for both residents did not include necessary information or interventions for monitoring the dialysis access sites or emergency procedures, and there was no facility policy or procedure in place to guide staff in providing appropriate care for residents receiving hemodialysis.
Failure to Assess and Care Plan for PTSD Triggers and Interventions
Penalty
Summary
The facility failed to properly assess and document trauma-related triggers and interventions for residents with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). For one resident, the clinical record did not contain information regarding the cause of PTSD, potential triggers for re-traumatization, or measures to avoid such triggers. Additionally, the resident's care plan lacked evidence of trauma-informed planning, including identified triggers and interventions to prevent re-traumatization. These findings were confirmed by the Administrator and the Director of Social Services during the survey. Similarly, another resident with an active PTSD diagnosis did not have documentation in the clinical record identifying the cause of PTSD, potential triggers, or preventive measures. The care plan only mentioned PTSD as a problem without including specific goals, triggers, or trauma interventions. The Unit Manager and a Licensed Social Worker confirmed that this resident had not received a psych/PTSD/trauma screening or assessment.
Failure to Develop 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 with a primary diagnosis of a fall resulting in a right ankle fracture and required daily Lovenox (anticoagulant) injections. As of March 26, 2025, the resident's medical record did not contain evidence of a baseline care plan that included the necessary instructions to provide minimum healthcare information for proper care in this area. This deficiency was identified through interview and record review and was discussed with the Director of Nursing.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order and care plan for oxygen therapy for one resident with a history of congestive heart failure and respiratory illness. Observations on multiple occasions showed the resident receiving oxygen at 3 liters per minute (LPM) via nasal cannula, while the provider's order and care plan specified oxygen at 4 LPM to maintain specific oxygen saturation levels. Nursing documentation also indicated the resident was on 3 LPM on several dates, and both the RN unit manager and surveyor confirmed the oxygen was set at 3 LPM during their review, despite the standing order for 4 LPM. This deficiency was identified through direct observation, record review, and staff interview, demonstrating a failure to provide care according to the physician's order and the resident's care plan.
Failure to Complete Smoking Safety Assessment for Resident
Penalty
Summary
A deficiency was identified when the facility failed to complete a smoking assessment of a resident's capabilities and deficits to determine safety. During an interview, a RN found a lighter in the resident's open nightstand drawer and explained that it was a hazard, stating the resident could only obtain the lighter before going out to smoke. The resident indicated plans to smoke after breakfast. Review of the resident's Smoking Safety Interaction form showed that the resident used tobacco products, had poor vision or blindness, and was unable to extinguish tobacco safely. However, the section of the form addressing clinical suggestions and interventions, such as applying a smoking apron, setting up a cigarette holder, staff assistance to extinguish cigarettes, referral to the interdisciplinary team, and ensuring eyeglasses are worn, was not completed. Further interviews with the RN unit manager revealed that the facility did not observe residents while smoking and relied on educating them about the non-smoking policy, despite acknowledging residents' rights to smoke in a designated area. The facility's policy encouraged residents not to smoke but recognized their right to do so safely. The Director of Nursing confirmed that there was a lack of a completed safety assessment regarding the resident's abilities and the need for supervision while smoking.
Unlocked Medication Carts Left Unattended in Hallway
Penalty
Summary
On 3/25/25 at 9:15 a.m., two unlocked medication carts were observed in the hallway across from the nurses station on the 3 [NAME] Unit. At the time of the observation, two staff members were located behind the nurses station and one staff member was seated at the nurses station. The surveyor was able to open both medication carts and go through each drawer without any staff intervening or responding. One of the identified nurses left the area, and only after the surveyor informed the remaining nurse about the unlocked carts did she get up and lock them, confirming the finding. This situation resulted in medications being accessible to residents and unauthorized persons, in violation of proper medication storage protocols.
QAPI Meeting Attendance Lacked Required Members
Penalty
Summary
The facility failed to provide evidence that the required members of the Quality Assessment and Assurance (QAA) group attended two of the four quarterly Quality Assurance and Performance Improvement (QAPI) meetings reviewed. Specifically, the attendance sheet for the April 2024 QAPI meeting did not show that the Medical Director was present. Additionally, the July 2024 QAPI meeting attendance sheet lacked documentation of attendance by the Administrator, Director of Nursing, and Infection Preventionist. These findings were confirmed through review of attendance records and an interview with the QAPI Manager.
Inadequate PPE Use for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain and implement an infection control program to prevent the transmission of disease and infection for a resident on contact precautions. A surveyor observed two Certified Nursing Assistants (CNAs) entering the room of a resident on contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) wearing only masks, despite a sign on the door instructing staff to wear gowns, gloves, and goggles if there is a high chance of liquid exposure. The CNAs were not wearing the required Personal Protective Equipment (PPE) for direct care, which was available in a yellow precaution bag outside the resident's door. Upon intervention by the surveyor, the Licensed Practical Nurse (LPN) instructed the CNAs to don the appropriate PPE. The Registered Nurse confirmed the resident's contact precaution status, and the Director of Nursing later educated the CNAs on PPE requirements.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. During an environmental tour, several deficiencies were observed in the laundry rooms and on the 3rd floor. In the soiled laundry linen room, a wall fan was found to be dusty and dirty, the cement floor had chipped and missing paint, and non-skid floor tape was missing pieces, creating uncleanable surfaces. The clean laundry linen room had three dusty and dirty wall fans, and the cement floor also had chipped and missing paint. Additionally, the laundry room had 30 broken or missing floor tiles, and the cement floor behind and under the washing machines had chipped and missing paint, creating uncleanable surfaces. On the 3rd floor east, the wheelchair scale had ripped and missing non-skid surface tape, making it uncleanable. On the 3rd floor west, two sit-to-stand patient lifts had missing and chipped paint and rusty areas in the foot base areas, creating uncleanable surfaces. Several resident rooms and common areas were also found to be in poor condition, with dusty and dirty exhaust fans, unmarked urinals, commode buckets, and bed pans stored improperly, and heavily marked walls and doorframes. The Plant Operations Manager confirmed these findings during the tour. Specific observations included a dusty and dirty wall fan in a resident room, debris in a shower light lens, and a large brown stain on a hallway ceiling tile. The bathroom in one resident room, shared by four residents, had an unmarked urinal hanging on the grab bar behind the toilet, and the bathroom exhaust fan was dusty and dirty. Another resident room's bathroom had two commode buckets sitting on the floor under the sink and a bed pan stored on the handrail by the toilet. Additionally, two hallway ceiling vents were found to be dusty and dirty. These deficiencies indicate a failure to maintain a safe, clean, comfortable, and homelike environment for the residents.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop or implement care plan interventions for six residents, leading to various deficiencies. For Resident #2, who has muscle weakness and a history of falls, the care plan required floor mats on both sides of the bed for fall safety. However, a surveyor observed the resident in bed without the floor mats, and a registered nurse confirmed the mats were not in place. Resident #20, diagnosed with quadriplegia and MRSA in the respiratory tract, had a care plan that required staff to wear eye protection during procedures with risk of splashes or droplet contamination. Despite this, two CNAs were observed providing care without eye protection, and the resident confirmed that staff mostly did not wear eye protection unless there was a COVID-19 case on the unit. The Director of Nursing confirmed the care plan was not followed for eye protection use. Resident #166 was observed on a pressure-reducing mattress, but the care plan did not include this intervention. The rehab unit manager mistakenly believed that interventions listed in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) were part of the care plan. Similarly, Resident #101 had orders for heel protectors and turning every two hours, which were documented in the MAR and TAR but not in the care plan. Resident #52, who was on the psychotropic medication Quetiapine Fumarate, lacked a comprehensive care plan addressing the use, goals, and interventions for the medication. Lastly, Resident #173, who was receiving hospice services, did not have a hospice care plan developed with goals and interventions for end-of-life care from the onset of hospice services until the resident's death. The Director of Nursing confirmed that a comprehensive assessment should have been completed within 14 days after the resident began hospice services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans to reflect the current needs of three residents. Resident #104, who was initiated on Hospice for terminal Parkinson's Disease, had a Significant Change in Status MDS assessment completed and IDT meetings held, but the care plan was not revised to reflect Hospice services. This was confirmed by the Assistant Director of Nursing. Resident #135 exhibited verbal outbursts and suicidal ideation, with progress notes indicating increased antidepressant and antipsychotic medication. However, the care plan was not updated to reflect these changes, as confirmed by the Licensed Social Worker and the Nurse Manager on the Memory Unit. Resident #144 had a physician order for an antidepressant medication, but the care plan was not revised to include this medication. This was confirmed by two MDS coordinators. The lack of timely care plan revisions for these residents indicates a failure to address their current medical and psychological needs adequately.
Failure to Follow Physician Orders for Daily Weights and Specialist Referral
Penalty
Summary
The facility failed to follow a physician's order for obtaining daily weights for a resident with edema. The clinical record review revealed that the resident's weights were not taken on multiple dates between 10/13/23 and 1/21/24, despite a physician's order dated 10/12/23 for daily morning weights. This was confirmed by the Assistant Director of Nursing during an interview on 1/24/24, who acknowledged that the weights had not been taken as ordered. Additionally, the facility failed to follow a physician's order for making a referral to a specialist for a resident with depression. The clinical record showed a physician's order dated 9/13/23 for a psychiatric evaluation, but there was no evidence that the appointment was made. A nurse's note from 9/20/23 indicated that the referral was pending due to a lack of recent notes addressing depression. This was confirmed by the Registered Nurse Minimum Data Set Coordinator and the RN Manager of 4 East unit during interviews on 1/24/24. The RN Manager stated that an SBAR was made in September, but no response was received from the doctor, and the order for the psychiatric evaluation was eventually discontinued on 1/24/24.
Facility Fails to Maintain Kitchen Cleanliness and Proper Food Handling
Penalty
Summary
The facility failed to maintain the kitchen in a clean manner, as observed on 1/22/24. Specifically, four male kitchen staff were not wearing facial hair protection, and there were dusty, dirty, and rusty ceiling vents above clean dish storage shelves. Additionally, 30 plastic glasses were wet stacked, and the auto bag machine had chipped paint and rust, creating an uncleanable surface. The dish room had stained ceiling tiles and dirty vents. Furthermore, several food items in Refrigerator/Cooler #3 and Freezer #3 were unlabeled, undated, and improperly stored, with some items showing large amounts of ice crystals. These findings were confirmed by the Food Service Director during the initial tour of the kitchen. During lunch service on the 3rd floor [NAME] dining room, a dietary aide/server was observed handling and serving food without a hair restraint. The aide also failed to change gloves or wash and sanitize hands between tasks, leading to potential cross-contamination. The aide touched various surfaces and food items with the same gloved hands, including a cleaning towel, cupboards, dishes, rolls, biscuits, bread, meat patties, peanut butter, a muffin, cheese slices, and a phone. The dietary aide/server confirmed that his procedure did not prevent possible cross-contamination of foods. The facility also failed to monitor and document dish machine and refrigerator/freezer temperatures consistently. The main kitchen dish machine wash and rinse temperatures were not monitored and documented on multiple dates in October, November, December 2023, and January 2024. Additionally, the dish machine temperatures were recorded below the required 180 degrees Fahrenheit on several occasions. The facility also failed to monitor and document refrigerator and freezer temperatures on numerous dates across different units and storage areas. These findings were confirmed by the Food Service Director during an interview on 1/23/24.
Failure to Implement Infection Control Program for MRSA
Penalty
Summary
The facility failed to maintain and implement an infection control program to prevent the transmission of Methicillin Resistant Staphylococcus Aureus (MRSA) for two residents. Resident #20, diagnosed with quadriplegia, tracheostomy, and chronic respiratory failure, had MRSA colonized in his/her sputum. Despite the care plan instructing staff to wear masks and face shields during procedures with risk of splashes or droplet contamination, two CNAs were observed providing care without eye protection. The RN Manager later confirmed the need for eye protection, but it was not consistently used, as evidenced by the resident's statement and observations made by the surveyors. Additionally, the resident had not been tested for MRSA in a year and a half, despite receiving regular antibiotic nebulizer treatments for respiratory MRSA. Another resident, #148, had MRSA in the urine and was readmitted to the facility with a hospital discharge diagnosis indicating the same. However, the required Transmission-Based Precautions (TBP) were not consistently in place. Surveyors observed that the TBP cart and signage were missing for several hours, and staff provided conflicting information about the presence and necessity of TBP. The RN Manager and other staff members were unsure about the implementation of TBP, leading to a lapse in infection control measures. The facility's Infection Prevention and Control Plan, revised in January 2024, mandates following the Centers for Disease Control and Prevention Guidelines for Transmission-Based Precautions. Despite this, the facility failed to ensure consistent use of PPE and TBP for residents diagnosed with MRSA, thereby not adhering to their own policies and potentially risking the transmission of infection among residents and staff.
Failure to Accurately Document Advance Directive
Penalty
Summary
The facility failed to ensure a resident's right to formulate an advance directive regarding CPR or Code Status was accurately reflected in the clinical record. Resident #108 had requested a change in their Code Status to CPR, but the clinical record still indicated No CPR. This discrepancy was discovered during an interview with a Unit Secretary, who recalled the resident's request but noted that the chart had not been updated. The Unit Manager confirmed that Resident #108 was capable of making their own decisions, and the resident reiterated their desire for CPR during an interview with the surveyor. However, the clinical record did not reflect this change, and the staff was unaware of the request. The facility's policy on Advanced Healthcare Directives requires that any revocation of an advance directive be documented in the medical record, including a detailed statement of the revocation and notification to the physician. Despite this policy, the medical record for Resident #108 lacked the necessary documentation to support the change in Code Status. The Administrator and Director of Nursing confirmed that the clinical record was inaccurate and that the facility had not followed its own policy for changing the Code Status.
Failure to Conduct Timely MDS 3.0 Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition and hospice services were initiated. The resident began receiving hospice services on 10/5/23, but the most recent comprehensive MDS 3.0 assessment was completed on 9/7/23, and no new comprehensive assessment was conducted within the required 14-day period. This deficiency was confirmed by the Director of Nursing on 1/26/24.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented within 48 hours for a new admission requiring Transmission Based Precautions (TBP). Resident #160 was admitted with diagnoses of sepsis, acute kidney injury, and recurrent Clostridioides Difficile (C-Diff), which necessitated contact precautions. Despite physician orders for Fidaxomicin to treat septicemia and later C-Diff, the clinical record lacked evidence of a baseline care plan within the required timeframe. The care plan for C-Diff was not initiated until 63 days after admission. This deficiency was discussed with the Assistant Director of Nursing by a surveyor.
Failure to Ensure Psychiatric Evaluation for Resident on Antidepressant
Penalty
Summary
The facility failed to ensure that the pharmacist provided services to identify that a physician's order for a psychiatric evaluation was completed for one resident reviewed for unnecessary medications. Specifically, a physician's order dated 9/13/23 for the resident to start Sertraline 50 milligrams daily for depression and to have a psychiatric evaluation for depression was not followed up. As of 1/23/24, the medical record lacked evidence of the psychiatric evaluation. The pharmacist reviewed the resident's medication regimen on four separate occasions between 9/29/23 and 12/26/23 but did not identify the missing psychiatric evaluation. This deficiency was confirmed with the Registered Nurse Manager on 1/24/24.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for one resident. The resident's Physician Order Sheet indicated that the resident had been receiving Quetiapine 25 mg every morning and Quetiapine 50 mg twice daily since November 26, 2022. Between November 26, 2022, and January 25, 2024, there was no documentation in the clinical record that a GDR was attempted or that a GDR was clinically contraindicated for the resident. This finding was discussed with the Assistant Director of Nursing on January 26, 2024, at 11:15 a.m.
Failure to Maintain Sanitary Conditions and Proper Food Labeling
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, as well as ensure foods were dated and/or labeled in a freezer and refrigerator. During the annual Long Term Care survey, deficiencies were cited at F584 for the facility's failure to maintain sanitary conditions in resident rooms and bathrooms, and at F812 for the failure to date and label food items in the kitchen. The Plan of Correction (POC) indicated that the facility would clean ceiling fans weekly, store bed pans/commodes appropriately, and ensure kitchen staff would date and label items in the refrigerator and freezer, with a completion date of 3/11/24. During a re-visit survey, it was found that the facility had not effectively implemented the POC. Resident bathrooms on the 3rd Floor [NAME] unit were still found to have issues with the storage of bed pans/commode buckets and dusty/dirty exhaust fans. Additionally, several rooms had unlabeled personal items and medicated powder stored around the sink. In the kitchen, freezer #3 and refrigerator/cooler #2 still contained unlabeled and undated food items. These ongoing issues led to the recitation of the same tags, F584 and F812, indicating that the POC was not effective in addressing the deficiencies.
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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