Woodlawn Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Skowhegan, Maine.
- Location
- 59 West Front Street, Skowhegan, Maine 04976
- CMS Provider Number
- 205154
- Inspections on file
- 25
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Woodlawn Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to protect confidential health information when a med cart was left unattended with an open laptop displaying a resident's eMAR, including name, photo, DOB, vital signs, and medication orders, along with a face-up paper listing several residents' names and medications. On the same unit, a clipboard was left face-up on the nurse's station counter with no staff present, showing multiple residents' names, room numbers, meal intakes, bathing information, and vital signs, leaving this PHI visible and accessible to residents and visitors.
Staff failed to promptly clean a spilled liquid on the floor in an ambulatory, legally blind resident’s room after being notified, leaving the resident to transfer and ambulate with a walker in the presence of the spill. In addition, a metal threshold plate at a main entrance used by residents was not properly secured, with loose edges and gaps causing it to shift under weight, following a complaint that the broken threshold impeded wheelchair exit.
Surveyors found an unattended med cart on a unit with a med cup containing red liquid (identified by a CNA-M as Robitussin prepared for a resident) and a cup holding used crushing sleeves with med residue on top of the cart, while a resident was nearby in the hallway. The CNA-M stated she had left the cart and acknowledged she should have secured the medication in a locked drawer. This situation did not follow the facility’s policy requiring all meds and biologicals to be stored in locked compartments and prohibiting unattended med carts when meds are potentially accessible.
A resident who was cognitively intact went approximately two weeks without a bowel movement despite the facility having standing bowel management orders and a bowel protocol that should begin after three days without a BM. Documentation showed the resident had escalating pain over multiple shifts, and staff interviews confirmed that the protocol called for progressive use of prune juice, Senna, Milk of Magnesia, suppositories, and Fleet enemas as needed. In this case, only limited interventions were documented over a prolonged period, the resident repeatedly reported pain and discomfort to staff, and when a suppository was finally given it was ineffective. The resident developed hypoactive bowel sounds and a firm, tender abdomen and had to be transferred to the ER, where constipation was resolved with an enema. The DON and administrator confirmed that the resident’s constipation was not appropriately managed according to the facility’s bowel protocol.
A resident returned from an ER visit for constipation with an order to have a follow-up sodium level drawn on a specific date after a moderately low sodium result. The facility did not obtain the ordered lab on that date, and there was no documentation in the clinical record of a reported subsequent conversation between the DON and the provider to reschedule the lab to the facility’s routine lab day. The DON acknowledged she could have drawn the lab herself but did not. The sodium level was not checked until several days later, when it was found to be critically low, leading to another ER transfer.
Surveyors found that emergency respiratory equipment, including an Ambu bag, resuscitation mask, and oxygen tubing, was stored in poor condition, with items being dirty, discolored, expired, or overdue for inspection. The DON confirmed that night shift staff were responsible for maintaining the emergency cart and acknowledged the deficiencies.
Surveyors found that a resident's room contained multiple electrical cords and cables crossing the floor, creating trip hazards due to insufficient electrical outlets for necessary appliances. Additionally, both the East and West units and the main lobby had issues such as dirty floors, damaged surfaces, and unclean equipment, all confirmed by the Maintenance Director.
Surveyors identified multiple deficiencies in food storage and sanitation, including expired thickened water available for use, improper labeling and dating of food items, chemical hoses hanging in the pot sink, and improper storage of bread products in the freezer. These issues were confirmed by the Food Service Director and DON.
The facility did not ensure sufficient direct care staff were scheduled and on duty to meet resident needs, particularly on weekends. A review of the Payroll Based Journal staffing report revealed low weekend staffing during the second quarter of 2024. The Administrator confirmed the lack of adequate staffing, potentially affecting all residents needing assistance with ADLs.
A facility failed to monitor and document behaviors to support the use of psychotropic medications for a resident with depression. The resident was prescribed Escitalopram oxalate, but there was no evidence of monitoring for side effects. A nurse confirmed the lack of monitoring, and the DON stated that documentation is only done by exception.
The facility failed to maintain an effective infection control program, as evidenced by a COVID-19 positive resident moving unmasked through the facility and the absence of Enhanced Barrier Precautions (EBP) for residents with MDRO and Foley catheters. The LPN responsible for infection prevention was unaware of tracking procedures, and necessary signage and PPE were missing until noted by surveyors.
The facility did not effectively implement its Antibiotic Stewardship Program, as evidenced by an increase in antibiotic prescriptions and a lack of monitoring and discussion in QAPI meetings. The LPN responsible for infection prevention was not fully trained and did not track infections or manage antibiotic orders. The QIM could not provide evidence of antibiotic stewardship practices, and the Administrator confirmed the absence of such discussions in QAPI meetings.
The facility appointed an LPN as the Infection Preventionist in October 2023 without ensuring the completion of necessary specialized training. The LPN began the IP training course in February 2024 and was only halfway through it at the time of the survey, with no prior training or guidance provided. This was confirmed by the Senior DON and the Regional Quality Improvement Manager.
The facility failed to provide two residents with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. A Social Worker confirmed that advance directive information was not offered to these residents, highlighting a lapse in the facility's admission process.
A resident with dementia was found with a bruise of unknown origin, which was not investigated or reported to the state agency in a timely manner. The injury was initially noted as a small spot and later developed into a larger bruise. A nurse assumed the incident had been reported by others and did not inform the DON, leading to a delay in reporting to the DLC.
A facility failed to update a care plan for a resident diagnosed with COVID-19, resulting in the resident leaving their room unmasked and passing others in the hallway. A CNA reported a lack of guidance on handling the resident's noncompliance with isolation precautions. The care plan lacked goals and interventions for managing the infection and noncompliance, contrary to the expectations of the Senior DON.
The facility failed to update care plans for a resident who tested positive for COVID-19, as there were no precaution signs or PPE outside the room, and the care plan was not updated after the resident was off precautions. Additionally, another resident's care plan lacked goals and interventions for a cardiac pacemaker, as the necessary details were not on file.
A resident received incorrect insulin doses due to the facility's failure to follow physician's orders. Insulin was administered despite blood sugar levels being below the threshold, and variable doses were not adjusted according to blood sugar readings, leading to multiple discrepancies.
A facility failed to administer tube feedings according to provider orders for a resident with cognitive impairment and a diagnosis of failure to thrive. The resident's nutritional supplement was not administered continuously as ordered, and the feeding bag was unlabeled and undated. A nurse confirmed the resident did not receive the full nutritional support.
A facility failed to maintain a sanitary environment for respiratory care for a resident with COPD and COVID-19. Observations revealed an oxygen concentrator and nebulizer with tubing not properly bagged or dated, despite not being used since mid-July. The facility administrator was unaware of the equipment's presence, highlighting a deficiency in maintaining a sanitary environment.
The facility did not post nurse staffing information in a prominent and visible location for residents and visitors. This was confirmed by the Administrator during an interview.
The facility failed to ensure a CNA received the required 12 hours of annual in-service education, specifically lacking training on abuse and resident rights. This was confirmed during a review of the CNA's education records and an interview with the Administrator.
A facility failed to ensure a resident's safety during a Hoyer lift transfer, leading to a fall and head injury. A CNA transferred the resident alone, against the policy requiring two CNAs, resulting in the resident slipping and hitting their head.
Failure to Protect Confidential Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information on the West Unit when staff left electronic and written records unattended and visible. A surveyor observed an unattended medication cart outside a resident room with an open laptop displaying the electronic Medication Administration Record (eMAR) for Resident #4, including the resident's name, photograph, date of birth, vital signs, and medication orders. A white sheet of paper on top of the same cart, left face-up, listed three residents' names along with a medication name and strength under each name. The cart and information were unattended until a CNA-M returned, at which time she acknowledged she should have closed the laptop and turned the resident information sheet upside down before leaving the cart. On the same unit, a surveyor later observed a clipboard left face-up on the nurse's station countertop with no staff nearby. The assignment sheet on the clipboard contained the names of 17 residents, their room numbers, meal intakes, and bathing information. A smaller attached sheet listed the names and vital signs of two residents. This information remained visible and accessible to residents and visitors. During interviews, the DON acknowledged the observations and stated that she had previously educated nursing staff not to leave the clipboard on the countertop.
Failure to Maintain Safe Resident Environment and Secure Entrance Threshold
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards when staff did not promptly clean a liquid spill in an ambulatory resident’s room. A resident with recent admission diagnoses including legal blindness and syncope and collapse reported spilling coffee on the floor next to the bed and stated that a staff member had been notified and said she would return to clean it up but had not done so. During an initial observation, the resident was lying in bed with liquid visible on the floor. A subsequent observation showed the resident had transferred independently and ambulated with a walker from the bed to a chair positioned next to the bed while the coffee spill remained on the floor. The facility also failed to ensure that a metal threshold plate at the main front entrance used by residents was properly secured, resulting in a tripping hazard. A complaint had been received stating that the threshold at the first entrance was broken and that a client could not exit with a wheelchair in an emergency situation. Upon observation with the Maintenance Director, the metal transition plate at the entrance threshold had outer edges that were not properly secured, creating gaps between the plate and the floor or ground and causing the plate to shift when weight was applied. The Maintenance Director confirmed that residents use this entrance to exit and enter the building with family or staff.
Unattended Medication Cart With Accessible Medications on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored properly and in accordance with its own Medication Labeling and Storage policy on the West unit. On 2/25/26 at 9:43 a.m., a surveyor observed an unattended medication cart located outside a resident room on the named unit. On top of the cart, there was a medication cup containing an unknown red liquid and a clear plastic cup containing plastic sleeves used for crushing medications, with visible medication residue inside the sleeves. The medication cart was unattended during this time. During the observation, Resident #3 was seen foot-propelling in his/her wheelchair in the hallway near the unattended medication cart. At 9:50 a.m., CNA-M #1 returned to the cart and, during an interview, stated that the plastic sleeves were trash containing residue from medications she had crushed for a resident and that the red liquid in the medication cup was Robitussin she had poured for a resident. CNA-M #1 acknowledged she should have placed the medication in a locked drawer before leaving the cart unattended. The facility’s written policy, revised 3/2025, requires all medications and biologicals to be stored in locked compartments and specifies that carts used to transport medications are not to be left unattended if open or otherwise potentially available to others.
Failure to Follow Bowel Management Protocol Leading to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its standing bowel management orders for a cognitively intact resident, resulting in unmanaged constipation over an extended period. The facility’s standing orders and bowel protocol allowed nursing staff to administer multiple PRN bowel medications, including Bisacodyl suppositories, MiraLAX, Senna, Milk of Magnesia, and Fleet enemas, beginning after three days without a bowel movement and progressing from least to more invasive interventions. Record review showed the resident had a bowel movement on 1/9/26, then went seven days without a bowel movement before receiving Senna on 1/16/26, and ultimately went 15 days without a bowel movement before a Bisacodyl suppository was given on 1/24/26. The suppository was documented as ineffective, and nursing notes on 1/24/26 described hypoactive bowel sounds and a firm, tender abdomen, at which point an order was obtained to transfer the resident to the ER. The resident reported remembering going two weeks without a bowel movement and experiencing severe pain, stating they had informed multiple staff members of their pain and discomfort. Review of the medication and treatment administration records for the period 1/10/26 through 1/24/26 showed documented pain on multiple shifts, with two occurrences on day shift and six on evening shift under pain monitoring. Interviews with an LPN, a medication tech, the DON, and the administrator confirmed that the facility’s bowel protocol was to start after three days without a bowel movement and to escalate from prune juice to Senna, Milk of Magnesia, suppository, and then Fleet enema as needed. The DON and administrator acknowledged that the resident’s constipation was not appropriately managed according to this protocol, and the resident ultimately required transfer to the ER, where the constipation was resolved with an enema before the resident returned to the facility.
Failure to Obtain Timely Sodium Lab Draw After ER Discharge
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident who required follow-up sodium testing after an emergency room (ER) visit for constipation. During the ER visit, the resident’s sodium level was found to be moderately low at 125, and the ER discharge summary directed that the sodium level be redrawn on 1/26/26. Review of the resident’s medical record showed no evidence that this lab draw occurred on the specified date. Instead, a nursing progress note dated 1/29/26 documented that the resident had a critical sodium level of 121, the on-call provider was notified, and the resident was transferred back to the ER. In an interview, the DON and Administrator reported that the DON spoke with the facility provider on 1/27/26 and that the sodium level was ordered to be drawn on 1/29/26, the facility’s regular lab day, but this conversation was not documented in the clinical record. The DON acknowledged that she could have drawn the lab herself when she became aware of the order but did not, and confirmed that the lab should have been drawn on 1/26/26 as directed by the ER provider. This sequence of events shows that the facility did not follow the ER provider’s order for a sodium redraw on the specified date, did not document the reported provider communication regarding rescheduling the lab, and did not take available steps to obtain the lab in a timely manner, resulting in the resident’s sodium level not being reassessed until it was critically low and necessitated another ER transfer.
Emergency Cart Respiratory Equipment Not Maintained in Clean, Ready-to-Use Condition
Penalty
Summary
During an observation of the facility's emergency cart with the DON, several deficiencies were identified regarding the maintenance and cleanliness of emergency respiratory equipment. The adult manual resuscitator (Ambu bag) was found stored in a torn, cloudy plastic bag, with its attached reservoir bag appearing worn, discolored, and consistent with prior use. The plastic resuscitation mask and oxygen tubing were discolored, yellow, and visibly dirty. Additionally, a package of oxygen tubing was found to be expired. The suction machine on the cart was dusty, and its inspection sticker showed that the last inspection was overdue. In an interview, the DON confirmed that night shift staff were responsible for maintaining the emergency cart and acknowledged the issues with the overdue inspection and the condition of the equipment.
Unsafe Environment Due to Trip Hazards and Poor Maintenance
Penalty
Summary
Surveyors observed that the facility failed to provide a safe and comfortable environment for a resident by allowing multiple electrical cords and cables to cross the floor in the resident's room, creating trip hazards. The bed cord, television cable, bed remote cable, and power cord for the bed were all found running along the floor at the foot of the bed. The resident, who ambulates in the room, unplugged the bed to use a fan due to insufficient electrical outlets for their appliances, which included a nebulizer, cell phone charger, oxygen concentrator, and fan. The LPN and Maintenance Director confirmed the lack of outlets and the presence of trip hazards, with the Maintenance Director stating that management declined to install additional outlets. During an environmental tour, surveyors found further deficiencies in housekeeping and maintenance on both the East and West units and in the main lobby. Observations included dirty floors around toilets, cracked and stained ceilings, chipped and gouged wooden windowsills and lobby walls with missing sealant exposing untreated wood, a sit-to-stand lift with dirt and food debris, a ceiling vent in disrepair, and a door with torn laminate creating an uncleanable surface. The Maintenance Director confirmed these findings during the tour.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies related to food storage and sanitation during two tours of the facility's kitchen and food service areas. On the first tour, a maintenance worker was seen in the kitchen without appropriate hair or face protection. The three-bay pot sink had two chemical hoses hanging into the sinks, and in the dry storage room, two containers of thickened water were found with best use dates that had already passed. In the walk-in refrigerator, a package of whipped topping was present without a thaw date, despite manufacturer instructions requiring use within two weeks of thawing. Additionally, in the walk-in freezer, a large open box of hamburger buns was stored directly on the floor, and a package of bread sticks was stored under the freezer compressor with visible ice buildup. On the following day, an open container of thickened water with an expired best use date was found on a beverage cart in a hallway, available for use. These findings were confirmed by the Food Service Director and the DON during interviews. The facility's own Food Storage policy required all foods to be covered, labeled, dated, and monitored for use by their expiration dates, which was not followed in these instances.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the second quarter of 2024. On August 28, 2024, at 6:15 p.m., the facility's Administrator confirmed the lack of adequate staffing to meet resident needs on weekends, which has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of psychotropic medications for a resident diagnosed with depression. The resident was prescribed Escitalopram oxalate 10 mg daily for depressed mood, starting on March 12, 2024. However, the clinical record lacked evidence of monitoring for side effects of this medication. During interviews, a registered nurse confirmed that the facility does not monitor for side effects of psychotropic medication, and the Senior Director of Nursing indicated that documentation for side effects is only done by exception in nursing notes.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. The first deficiency involved the management of a COVID-19 outbreak, where a resident who tested positive for COVID-19 was observed unmasked and moving through the facility, potentially exposing other residents. The Certified Nursing Assistant (CNA) did not offer the resident a mask, and the Licensed Practical Nurse (LPN) responsible for infection prevention was unaware of how to track or trace the source of the infection. Despite acknowledging the need for improvement, the Quality Improvement Manager downplayed the issue by stating the facility had a low infection rate. The second deficiency was related to the lack of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDRO) and those with Foley catheters. Over two days, surveyors noted the absence of signage and personal protective equipment (PPE) for residents requiring EBP. Documentation regarding the use of EBP was also missing. It was only after the surveyor's observation that EBP signage and PPE were placed outside the rooms of the affected residents, confirming the facility's failure to implement necessary precautions for infection control.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, which includes protocols for antibiotic use and a system to monitor such use. During the months of April to July 2024, there was a noticeable increase in the number of antibiotics prescribed, yet the facility's RX Quality Pharmacy Reports lacked evidence of antibiotic use or discussion. Interviews revealed that the Licensed Practical Nurse (LPN) responsible for infection prevention was not fully trained and did not know how to track infections or manage antibiotic orders. The LPN also did not receive or review quarterly antibiotic use reports from the pharmacy during Quality Assurance and Performance Improvement (QAPI) meetings. The facility's Quality Improvement Manager (QIM) claimed that McGuire's criteria for antibiotic stewardship were consistently used but could not provide supporting documentation or evidence of review during QAPI meetings. The QIM acknowledged the need for improvement in infection control but believed the facility had a low infection rate. The Administrator confirmed that the RX Quality Assurance Reports discussed in QAPI meetings did not include antibiotic stewardship, indicating a lack of focus on this critical aspect of infection control.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that their designated Infection Preventionist (IP) had completed the necessary specialized training before assuming the role. An LPN was appointed as the IP in October 2023 but did not begin the required IP training until February 2024. As of the time of the survey, the LPN was only halfway through the course and had not received any prior training or guidance on the responsibilities of the IP role. This lack of training and preparation was confirmed by both the Senior Director of Nursing Services and the Regional Quality Improvement Manager during interviews with surveyors.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for two residents during a review of their clinical records. Resident #20 was admitted on April 18, 2023, and Resident #31 was admitted on July 24, 2024. In both cases, there was no evidence in their clinical records that they were offered or refused the opportunity to formulate an advance directive upon admission. During an interview with a surveyor, the Social Worker confirmed that she had not asked or offered advance directive information to these residents upon their admission. This oversight indicates a failure in the facility's process to ensure residents are informed of their rights regarding advance directives.
Failure to Timely Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and report an injury of unknown origin for a resident with dementia in a timely manner. The incident involved a resident who was found with a bruise on the left temple area, initially noted as a small spot and later developing into a larger bruise. The resident, due to dementia, was unable to recall how the injury occurred. The initial report to the Division of Licensing and Certification (DLC) was made four days after the incident was first noted, indicating a delay in reporting. The nursing notes indicated that the bruising was observed on the resident's face, but the origins were unknown. A registered nurse mentioned that she was informed by certified nursing assistants that the bruising had occurred days before her notes, but she did not report it, assuming it had already been reported. The Director of Nursing was not informed of the incident until the report was made to the DLC. The lack of timely investigation and reporting of the injury was confirmed by the facility's administrator during an interview with a surveyor.
Failure to Update Care Plan for COVID-19 Positive Resident
Penalty
Summary
The facility failed to update and implement a care plan for a resident diagnosed with COVID-19, leading to a deficiency. The resident, admitted on an unspecified date, tested positive for COVID-19 and required quarantine isolation precautions. However, on a subsequent observation, the resident was seen self-propelling down a unit hallway without a mask, passing other residents and a staff member. A Certified Nursing Assistant reported that the resident frequently left their room and that no guidance had been provided on managing the resident's noncompliance with isolation precautions. A review of the resident's care plan, last updated before the positive COVID-19 test, showed no goals or interventions for managing the infection or the resident's noncompliance with isolation measures. The Senior Director of Nursing expressed that care plans should have been updated to reflect these needs.
Failure to Update Care Plans for Isolation Precautions and Pacemaker Management
Penalty
Summary
The facility failed to update and implement care plans for isolation precautions for a resident who tested positive for COVID-19. The resident was admitted and placed on isolation precautions after testing positive. However, observations revealed that there were no precaution signs or personal protective equipment outside the resident's room. Interviews with staff confirmed that the resident had been off quarantine precautions for some time, yet the care plan was not updated to reflect this change. The Senior Director of Nursing acknowledged that the care plan should have been updated once the resident was no longer on precautions. Additionally, the facility did not update or implement goals and interventions for a resident with a cardiac pacemaker. The resident was admitted with a pacemaker, but the care plan lacked necessary details such as the serial number or expiration date of the pacemaker. The Minimum Data Set Coordinator confirmed that they were unaware of the need to have this information on file, as the resident sees a cardiologist regularly. This oversight resulted in the absence of a comprehensive care plan for the resident's pacemaker management.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for administering insulin to a resident, leading to multiple instances of incorrect insulin administration. The resident, who was receiving insulin coverage, had specific orders to hold insulin if blood sugar levels were below 170. However, on several occasions, the resident received insulin despite blood sugar readings being below the threshold. For example, on three separate mornings, the resident's blood sugar was below 170, yet insulin was administered contrary to the physician's instructions. Additionally, there were discrepancies in the administration of variable doses of insulin based on blood sugar levels. The resident's blood sugar readings indicated a need for specific insulin dosages, but the administered doses did not align with the physician's orders. On one occasion, the resident received no insulin when 6 units were required, and on another, the resident received fewer units than prescribed. These errors were confirmed during an interview with the Quality Improvement Manager, highlighting a failure in following the prescribed treatment plan.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feedings according to provider orders for a resident who was observed for tube feeding. The resident, who was admitted with a diagnosis of failure to thrive, had a Basic Interview for Mental Status (BIMS) score indicating cognitive impairment. The resident's active orders included a specific nutritional supplement to be administered via enteral tube at a continuous rate for 16 hours, with scheduled water flushes before, during, and after feeding. However, during an observation, it was noted that the feeding machine was off, and the bag containing the nutritional supplement was unlabeled and undated. A registered nurse confirmed that the bag had been hung the previous day and that the resident did not receive the entire nutritional support as ordered.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as observed in the case of a resident diagnosed with chronic obstructive pulmonary disease and who tested positive for COVID-19. The resident's room contained an oxygen concentrator and a nebulizer machine with tubing that was not properly bagged or dated, despite the equipment not being used since July 13, 2024. This lack of proper storage and sanitation was noted during multiple observations on August 19, 20, and 21, 2024. The resident's clinical records indicated labored breathing and the use of oxygen to maintain adequate oxygen saturation levels. However, the registered nurse confirmed that the resident had not used the oxygen or nebulizer since mid-July. The facility administrator was unaware of why the equipment remained in the room, especially since the resident's COVID-19 case was mild and did not necessitate the use of such equipment. This oversight in maintaining a sanitary environment for respiratory care was identified as a deficiency by the surveyors.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information in a prominent place that was readily accessible and visible to all residents and visitors. This deficiency was observed on one of the three days of the survey, specifically on 8/26/24. During an interview on 8/27/24, the Administrator confirmed that the nurse staffing information was not posted in an area visible to residents and visitors on the previous day.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that a Certified Nurse's Aide (CNA) received the required 12 hours of annual in-service education. Specifically, CNA2, who was hired on April 11, 2023, did not receive in-service training on abuse or resident rights for the period from April 11, 2023, through April 11, 2024. This deficiency was identified during a review of CNA2's education records and confirmed in an interview with the Administrator on August 28, 2024, at 6:24 p.m. with two surveyors.
Failure to Follow Hoyer Lift Policy Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a resident's safety during a Hoyer lift transfer, resulting in harm to the resident. On 4/9/24, a Certified Nursing Assistant (CNA) attempted to transfer a resident alone using a Hoyer lift, contrary to the facility's policy requiring two CNAs for such transfers. During the transfer, the resident became restless and slipped out of the Hoyer pad, falling to the floor and hitting their head. The resident sustained a closed head injury and was diagnosed with swelling at the back of the head. The resident's care plan, dated 3/2/24, indicated the need for extensive assistance with transfers using a mechanical lift and two people, which was not followed in this instance. The facility's internal investigation and the Incident Report confirmed that the CNA was aware of the policy but proceeded without assistance due to the unavailability of another CNA. The Root Cause Analysis identified the failure to follow the lift policy as a contributing factor. Interviews with the CNA and the facility administrator corroborated these findings, highlighting the lapse in adhering to established safety protocols during the transfer process.
Removal Plan
- One on One training with CNA #1 on the Lifting Machine policy and procedure that indicates At least two nursing assistants are needed to safely move a resident with a mechanical lift.
- Mandatory re-education on Hoyer Safety with all nursing staff.
- Newly hired CNAs will demonstrate competency with Hoyer lift transfers.
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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