Ross Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 758 Broadway, Bangor, Maine 04401
- CMS Provider Number
- 205064
- Inspections on file
- 21
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ross Manor during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders: one received antibiotic doses on consecutive days instead of every 48 hours, and another did not have a blood sugar recheck documented after receiving additional insulin as ordered by the provider.
A resident with physician orders for nightly CPAP therapy was unable to use their machine due to missing tubing, and the facility did not obtain the required part for an extended period. Documentation and staff interviews confirmed that the resident was not provided with the ordered respiratory care, resulting in multiple hospitalizations related to hypoxia before the missing equipment was finally acquired.
Surveyors found that two ice machines had improper air gaps on their drain lines, resulting in a direct connection between wastewater and potable water, in violation of state plumbing code. The deficiency was confirmed with the FSD over several days, while the vegetable sink had the correct air gap.
Surveyors observed multiple lapses in infection control, including soiled and unlabeled bed pans left exposed, blood and stool on commode seats, soiled linens on floors, a hole in a shower floor, improper glove use and hand hygiene by a CNA, opened dressing wrappers on blankets, and a Foley bag dragging on the floor. These deficiencies were confirmed by staff interviews and repeated over several days.
A resident admitted for skilled care did not have a baseline care plan developed and implemented within 48 hours of admission, as required. Instead, the care plan was not created until four days after admission, and this delay was confirmed by the ADON during a surveyor interview.
A resident requiring assistance with oral hygiene due to hemiplegia did not consistently receive help with denture care, as staff failed to soak or wash dentures at night and documentation showed oral hygiene was not completed after the evening meal on multiple days. The DON confirmed that evening shift staff often did not provide this care if it was already documented by a previous shift, leading to inconsistent oral hygiene support.
Two residents had incomplete or inaccurate clinical records: one had a CPAP device documented as applied on days when it was missing parts and could not be used, while another had medications listed in the MAR for diagnoses not present in the active diagnosis list, with provider notes indicating different reasons for the prescriptions.
A facility failed to inform a resident's representative of a change in discharge plans and an incident where the resident attempted to leave the facility. Additionally, the resident's provider was not informed of the resident's elopement risk. Interviews confirmed the lack of communication regarding these issues.
A resident with Alzheimer's and a history of wandering eloped from the facility despite being identified as a wandering risk. The resident had previously attempted to leave multiple times, and on the night of the incident, exited through a window and was found a mile away in freezing temperatures. The facility was aware of the resident's elopement risk but failed to provide adequate supervision.
A facility failed to maintain complete and accurate clinical records for a resident who exhibited exit-seeking behaviors on several occasions. The resident attempted to leave the facility multiple times, expressing a desire to go home, but these incidents were not documented in the clinical records. A review with the DON and a Unit Manager confirmed the absence of nurse's notes for each elopement attempt, indicating a deficiency in record-keeping.
A facility failed to ensure immediate reporting of an alleged physical abuse incident involving a resident. A CNA witnessed another CNA twisting a resident's arm, causing bruising, but delayed reporting the incident until the next day, allowing the alleged perpetrator to continue care. The facility's policy requires immediate reporting within two hours, which was not followed.
A resident was mistakenly given another resident's medications by a C.N.A.-M, leading to low blood pressure and a hospital transfer. The error occurred due to a misreading of names in the computer system and a lack of recognition of the resident, who was mildly cognitively impaired. The facility's policy for verifying resident identity was not adequately followed.
A facility failed to provide dignified feeding assistance to a resident. A CNA was observed feeding a resident while standing and facing away, engaging in conversation with another staff member. The CNA briefly looked at the resident only to place food in their mouth. This undignified behavior was confirmed by both the CNA and an RN.
A facility failed to have a legal guardian sign an Advance Beneficiary Notice for a resident with intellectual disability, who functions at a 5-year-old level. The resident, admitted with a bimalleolar fracture, signed the notice themselves, contrary to protocol. Staff acknowledged the error during a survey, confirming the notice should have been signed by the guardian.
The facility failed to ensure accurate advanced directives for two residents, resulting in discrepancies between electronic records and paper charts regarding code status. The electronic records indicated full code status, while the paper charts, signed by the residents or their power of attorney, indicated DNR status. The DON confirmed these discrepancies during a surveyor interview.
A facility failed to incorporate PASARR level II recommendations into the care plan of a resident with schizoaffective disorder, anxiety disorder, and major depressive disorder. The PASARR report recommended specialized psychiatric services and rehabilitative support, but the LSW admitted to being unfamiliar with these requirements and confirmed no actions were taken.
A facility failed to provide restorative nursing services to a resident as outlined in their care plan. The resident's plan included daily passive range of motion (PROM) exercises to maintain functional mobility, but the facility could not provide evidence that these exercises were performed on 34 out of 45 days. This deficiency was confirmed during an interview with the DON.
The facility failed to follow physician orders for insulin administration for two residents, resulting in incorrect dosages being given. One resident received incorrect doses of Insulin Aspart according to a sliding scale, while another received Insulin Lispro despite blood sugar levels not meeting the criteria for administration. These errors were confirmed during a review with the DON.
A resident with a bimalleolar fracture and intellectual disability was sent to a community appointment without required staff supervision due to a miscommunication. The resident, who needed 24/7 assistance for cognitive and safety awareness deficits, was transported alone by a wheelchair van service. The facility realized the error after receiving complaints, and a CNA was sent to accompany the resident.
A facility failed to ensure a physician reviewed and signed a resident's medication and treatment orders in a timely manner. The physician initially signed the orders, which were valid for 60 days, but did not review and sign the subsequent orders by the required date. As confirmed by the DON, the orders remained unsigned past the grace period.
A facility failed to follow its infection control practices during a pressure ulcer dressing change for a resident with a Stage 4 ulcer. The RN placed treatment supplies on a soiled overbed table without establishing a clean field, contrary to the facility's Wound Care Policy. The nurse confirmed the oversight during a discussion with the surveyor.
The facility did not transmit the MDS assessments for two residents to the State database within the required 14-day period after completion. The assessments, completed on the same day, lacked evidence of transmission until identified during a surveyor interview with the MDS RN, who then submitted them successfully.
The facility failed to respond to residents' requests for assistance in a timely manner, causing increased anxiety for one resident and mental anguish for another who wanted to voice concerns about their care before discharge. The facility's call bell log did not verify the incidents, and the Administrator and DON were unaware of the requests.
A resident was denied daily showers as ordered by their provider, leading to neglect of personal hygiene and the development of a rash. Staff were not properly instructed on how to provide the shower, and documentation showed inconsistencies. The Director of Nursing confirmed the resident did not receive the required showers.
A resident with severe postoperative pain and impaired mobility did not receive daily showers as ordered by the physician. Despite being cleared to shower and having specific wound care instructions, the resident did not receive any showers for over a week. Staff cited a lack of training as the reason for not providing the showers, and the Director of Nursing confirmed the deficiency.
Failure to Follow Physician Orders for Medication and Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents. For one resident, there was an order to administer Levofloxacin 750 mg by mouth every 48 hours, starting on 4/2/25 and ending on 4/22/25. However, the medication administration record showed that the resident received doses on consecutive days, 4/2/25 and 4/3/25, rather than every 48 hours as ordered. Interviews with two LPNs revealed that the facility's Pyxis system did not have the required dose, and they expected the medication to arrive the next morning, but the resident still received the medication two days in a row, not in accordance with the provider's order. For another resident, the treatment administration record indicated a blood sugar result of 422, which required 12 units of insulin and a call to the medical doctor per the sliding scale insulin protocol. The clinical record confirmed that the MD was called, and an additional order was given to administer 3 more units of insulin and to recheck blood sugar in 2 hours. However, there was no evidence in the clinical record that the blood sugar was rechecked as ordered.
Failure to Provide Physician-Ordered CPAP Therapy Due to Missing Equipment
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for a resident who required nightly use of a CPAP machine. Upon admission, the resident's CPAP machine was missing necessary tubing, and documentation showed that the resident was unable to use the device as ordered. Despite repeated documentation in nursing progress notes and the electronic treatment administration record indicating the absence of the required part, the facility did not obtain the missing tubing for an extended period. The resident experienced multiple hospitalizations during this time, with all admission orders continuing to specify the need for nightly CPAP use. Interviews with facility staff confirmed that efforts to obtain the missing tubing were delayed, and the resident was unable to use the CPAP as ordered from the time of admission until the part was finally acquired. The Assistant Director of Nursing acknowledged that the facility contacted previous providers and suppliers but did not secure the necessary equipment until 50 days after the resident's initial admission. During this period, the resident had four hospital admissions related to hypoxia, and the lack of timely action by the facility directly resulted in the resident not receiving prescribed respiratory therapy.
Improper Air Gap Installation on Ice Machine Drain Lines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper installation of plumbing fixtures to prevent backflow, as required by the Maine State Plumbing Code. Specifically, on multiple consecutive days, the drain lines of two ice machines—one in the hallway leading to the kitchen and one in the kitchen—were found to have improper air gaps, resulting in a direct connection between wastewater and potable water. This was in violation of state regulations, which require an air-gap separation of at least one inch. The deficiency was confirmed with the Food Service Director on each visit, and while the vegetable sink had the proper air gap, the ice machines continued to lack the required separation throughout the survey period. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on environmental observations and staff interviews.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program over a three-day period, as evidenced by multiple observations of unsanitary conditions and improper infection control practices. Surveyors observed dried blood and stool on a commode seat used as an elevated toilet seat in a shared bathroom, with additional dried blood droplets on the floor leading to the sink. Unlabeled and soiled bed pans were left exposed in shared bathrooms, and soiled linen bed chucks were found on the floors of resident rooms. A hole in the shower floor created an uncleanable surface, and blood was observed on a resident's bed frame. These findings were confirmed by interviews with nursing staff, who acknowledged that bed pans should be labeled, sanitized, and stored properly, and that soiled items should not be left exposed or on the floor. Further deficiencies included improper glove use and hand hygiene by a CNA, who handled clean resident clothing and personal items while still wearing soiled gloves after providing peri care. Opened dressing wrappers were found on a resident's blankets, and a resident was observed self-propelling in a wheelchair with a Foley bag dragging on the floor. These observations were confirmed by staff, including the DON, who acknowledged the presence of blood on equipment and uncleanable surfaces. The repeated nature of these findings over several days demonstrates a lack of adherence to established infection control protocols.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted for skilled care services. Clinical record review showed that the resident was readmitted to the facility on 2/27/25, but there was no evidence that a baseline care plan with the necessary instructions for minimum healthcare information was created until 3/3/25, which was four days after admission. This delay was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the baseline care plan was not initiated within the required 48-hour timeframe.
Failure to Consistently Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to consistently provide activities of daily living (ADL) care in the area of oral hygiene for a resident who required assistance due to hemiplegia affecting the left non-dominant side. The resident, who was cognitively intact, reported that staff did not soak or wash dentures at night, and observation confirmed the dentures were soiled with food debris. Review of the care plan indicated the resident needed limited to extensive assistance with personal hygiene, including oral care. Documentation showed that oral hygiene was not completed after the evening meal on 13 out of 31 days in March. During an interview, the DON acknowledged that evening shift staff would mark oral hygiene as 'Not Applicable' if it was already documented as completed by a previous shift, resulting in inconsistent provision of oral hygiene care after the evening meal.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for two residents. For one resident, there was a physician's order for nightly use of a CPAP device, but the Treatment Administration Record (TAR) showed the device was applied on several dates when, in fact, the CPAP was missing necessary parts and could not be used. Documentation in the clinical record confirmed the device was not functional until a missing part was received, yet staff had inaccurately documented its application prior to that date. For another resident, the Medication Administration Record (MAR) listed medications as being prescribed for Parkinson's disease and psychosis, but the resident's active diagnosis list did not include these conditions. Provider notes clarified that the medications were actually prescribed for drug-induced tremor and bipolar disorder. During a review with the Director of Nursing, it was confirmed that the MAR contained inaccurate information regarding the indications for the prescribed medications.
Failure to Notify Resident's Representative and Provider of Critical Changes
Penalty
Summary
The facility failed to notify the resident's representative of a change in the discharge plan for a resident who required 24-hour supervision. Initially, a plan was made for the resident to transfer to an assisted living memory care unit, but this transfer did not occur, and the representative was not informed of this change. Additionally, the facility did not notify the representative when the resident went outside the facility and attempted to climb over a railing, an incident that was documented in the nursing notes. Furthermore, the resident's medical provider, who had been involved in their care since admission, was not informed of the resident's elopement risk or the use of a wander guard. The provider only became aware of the resident's elopement risk after examining them following an elopement incident. Interviews with the facility's Administrator, Director of Nursing, and Unit Manager confirmed the lack of communication with the resident's representative and medical provider regarding these critical changes and incidents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and monitor a resident with a known risk for wandering, resulting in the resident eloping from the facility. The resident, who had a diagnosis of left frontal parietal subarachnoid hemorrhage and Alzheimer's disease, was identified as a wandering risk upon admission, and a wander guard was placed. Despite multiple instances of exit-seeking behavior observed by staff, the resident was not moved to a more secure unit as recommended. On several occasions, the resident attempted to leave the facility, and on one occasion, successfully exited through the front door before being redirected back inside. On the night of the incident, the resident was last seen in bed at 10:30 p.m. but was discovered missing an hour later. A search revealed that the resident had eloped through an open window, and the window screen was found on the ground outside. The resident was found approximately a mile away from the facility in 14-degree Fahrenheit weather, inadequately dressed for the conditions. Upon return, the resident's body temperature was recorded at 93.2 degrees, indicating hypothermia. The facility was aware of the resident's increased elopement risk but failed to take sufficient preventive measures to ensure the resident's safety.
Incomplete Clinical Records for Resident Elopement
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for elopement. The resident exhibited exit-seeking behaviors on multiple occasions, specifically on the afternoon of January 3, the morning of January 6, the morning of January 9, and the morning of January 15, when the resident packed belongings and expressed a desire to go home. On January 15, the resident attempted to leave through the 701 and 708 hallways, carrying a bag of clothing and stating the intention to go home. This incident was not documented in the clinical record. During a review of the resident's clinical records with the Director of Nursing and a Unit Manager, it was confirmed that the records lacked evidence of nurse's notes for each elopement or exit-seeking attempt. This omission was identified during an interview with the charge nurse and a subsequent review of the records, highlighting a deficiency in maintaining complete and accurate clinical documentation.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that staff reported an allegation of physical abuse immediately, as required by their policy. The incident involved a Certified Nursing Assistant (CNA #1) who allegedly grabbed a resident by the left thumb and twisted the resident's arm behind their neck, resulting in bruising. This incident was witnessed by another CNA (CNA #2) on the evening of November 11, 2024, but was not reported until the following afternoon, November 12, 2024. This delay allowed the alleged perpetrator to continue providing care to the resident during this period. The facility's policy, revised in February 2023, mandates that any suspicion of abuse must be reported immediately, defined as within two hours of the allegation. However, CNA #2 did not report the incident to the charge nurse or the administrator immediately, citing a belief that nothing would be done about it. This failure to report promptly was confirmed during an interview with the Director of Nursing (DON) and two surveyors, highlighting a breach in the facility's protocol for handling allegations of abuse.
Medication Administration Error Leads to Hospital Transfer
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, resulting in the resident being transferred to the Acute Care Emergency Department for evaluation and monitoring. During a morning medication pass, a Certified Nurse Assistant-Medication (C.N.A.-M) mistakenly administered medications intended for another resident to Resident #1 (R1). The medications included Aspirin, Cholestyramine, Clopidogrel Bisulfate, Isosorbide, Psyllium Husk Powder, Metoprolol Tartrate, and Tylenol. R1 was not allergic to these medications, but the error led to low blood pressure and a mild drop in hemoglobin and hematocrit levels. The error occurred because the C.N.A.-M misread the name in the computer system, confusing R1's name with that of Resident #2 (R2). The C.N.A.-M, who had recently returned to work after a two-month absence, did not recognize R1 and mistakenly thought R1 was R2. The C.N.A.-M asked R1 if their name was R2's last name, and R1, who was mildly cognitively impaired, confirmed. This led to the administration of the wrong medications. Upon realizing the mistake, the C.N.A.-M immediately notified a nurse, and R1 was assessed and sent to the Emergency Department. R1's clinical records indicated a history of hypertension, with a prescribed medication of Metoprolol Tartrate. The resident's Minimum Data Set showed a Brief Interview for Mental Status score indicating mild cognitive impairment. After receiving the wrong medications, R1 experienced low blood pressure and lightheadedness, prompting an emergency transfer to the hospital. The facility's Medication Administration Policy requires verification of the resident's identity, including checking photographs and medication labels, which was not adequately followed in this incident.
Removal Plan
- The Skilled Nurse Manager re-educated C.N.A.-M on the medication administration policy and procedure.
- Copies of the Medication Administration policy and procedure along with sign sheets were placed at the nurse's stations.
- All medication technicians and nurses that administer medications were mandated to review the policy and procedure and sign the sheet that they did the review.
- Audits of all the residents' MARs were completed to ensure they all had a picture.
- On-going audits are being done by the Director of Nursing and/or the Skilled Nurse Manager to ensure new residents have a picture taken and attached to their MAR.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that a resident requiring feeding assistance was treated in a dignified manner. During an observation, a Certified Nursing Assistant (CNA2) was seen feeding a resident (R28) while standing at the side of the table, facing away from the resident, and engaging in conversation with another staff member. CNA2 used a spoon to feed the resident, briefly looking at the resident only to place food in their mouth before continuing the conversation. This behavior was confirmed through interviews with both CNA2 and a Registered Nurse (RN2), who acknowledged that the feeding was not conducted in a dignified manner.
Failure to Obtain Legal Guardian's Signature on Beneficiary Notice
Penalty
Summary
The facility failed to ensure that an Advance Beneficiary Notice was reviewed and signed by the legal guardian of a resident with intellectual disability, who functions at a 5-year-old level. The resident, admitted with a bimalleolar fracture of the right ankle and identified as having a legal guardian responsible for medical and financial decisions, signed the notice themselves on 12/16/23. This oversight was identified during a record review and interviews conducted on 05/15/24. Both the Licensed Social Worker and the Program Director of Therapy acknowledged that the notice should have been signed by the legal guardian, not the resident, as the resident was not capable of understanding the document.
Discrepancies in Residents' Advanced Directives
Penalty
Summary
The facility failed to ensure the accuracy of residents' advanced directives regarding code status in their electronic records. For one resident, the electronic record indicated a full code status for CPR, while the paper chart, signed by the resident's power of attorney, indicated a do not resuscitate (DNR) status. Similarly, another resident's electronic record showed a full code status, but the paper chart, signed by the resident, indicated a DNR status. The Director of Nursing confirmed the discrepancies in both residents' records during an interview with a surveyor.
Failure to Implement PASARR Recommendations for Resident with Mental Illness
Penalty
Summary
The facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) level II determination into the assessment, care planning, and transitions of care for a resident diagnosed with schizoaffective disorder, anxiety disorder, and major depressive disorder. The PASARR evaluation report, dated March 7, 2024, identified the resident as having serious mental illness, leading to functional limitations in interpersonal functioning, concentration, or adaptation to change. The report recommended specialized services, including ongoing psychiatric services by a psychiatrist to evaluate and modify psychotropic medications, and rehabilitative services for socialization, family involvement, and supportive counseling. However, during an interview, the Licensed Social Worker (LSW) admitted to being unfamiliar with PASARR level II requirements related to psychiatry and confirmed that no actions had been taken to implement the recommendations.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide services to maintain and/or improve a resident's highest level of functional mobility, specifically for Resident #87. The care plan for this resident, dated 3/28/24, directed staff to establish a restorative nursing program, which included a Nursing Rehab/Functional Maintenance Plan for passive range of motion (PROM) exercises to the lower extremities for 15 minutes every day. However, the facility was unable to provide documented evidence that the resident received the prescribed PROM exercises on multiple dates, totaling 34 out of 45 days. This deficiency was confirmed during an interview with the Director of Nursing on 5/16/24.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of sliding scale insulin for two residents, leading to medication errors. For Resident #19, the clinical record indicated a physician order to check blood sugar levels four times a day and administer Insulin Aspart according to a sliding scale. However, the Medication Administration Record (MAR) for May 2024 showed multiple instances where the insulin dosage administered did not align with the prescribed sliding scale. On several occasions, Resident #19 received either an incorrect dosage or no insulin at all, despite blood sugar levels indicating otherwise. These discrepancies were confirmed during an interview with the Director of Nursing. Similarly, for Resident #51, the facility did not follow the physician's order for Insulin Lispro administration. The order specified that insulin should only be given for blood sugar readings greater than 300. However, documentation revealed that on one occasion, Resident #51 received 5 units of Lispro despite having a blood sugar level of 165, which did not warrant insulin administration according to the order. This finding was also confirmed during a review with the Director of Nursing.
Failure to Provide Supervision for Resident with Cognitive Deficits
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R147, who was sent to an appointment in the community without the required staff accompaniment. R147 had a bimalleolar fracture of the right ankle and an intellectual disability, necessitating 24/7 assistance for cognitive and safety awareness deficits. The resident's records indicated a legal guardian for decision-making and a physician's order that required a staff member to accompany R147 to a follow-up appointment. However, due to a miscommunication, the facility mistakenly believed that a member from R147's group home would accompany the resident, resulting in R147 being transported alone by a wheelchair van service. The oversight was discovered after the facility received complaints about the lack of supervision, prompting a Certified Nursing Assistant to accompany the resident belatedly.
Physician's Timely Review and Signature of Orders Lacking
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. Specifically, for Resident #13, the physician signed the initial Physician Orders (block orders) on February 16, 2024, which were valid for 60 days. The subsequent orders required review and the physician's signature by April 26, 2024, including a 10-day grace period. However, the medical record lacked evidence of the physician's review and signature on or around the required date. As of May 16, 2024, during an interview with the Director of Nursing, it was confirmed that the orders were late, and no updated orders had been reviewed and signed by the physician.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control practices as outlined in its Wound Care Policy and Procedure during a pressure ulcer dressing change for a resident with a Stage 4 pressure ulcer. The resident, who has a complex medical history including insulin-dependent diabetes, obesity, and kidney failure, was observed during a dressing change performed by a registered nurse. The physician's order for the resident's pressure ulcer treatment included specific steps such as cleansing with Normal Saline, applying Lotrisone cream, packing the wound with Aquacel with Silver, and covering it with Mepilex, to be changed daily and as needed. During the dressing change, the registered nurse used the resident's overbed table, which was cluttered with personal items and a wash basin with used bath water, to place treatment supplies. The nurse did not establish a clean field on the table as required by the facility's Wound Care Policy. Instead, sterile packages and the cap of the Normal Saline spray bottle were placed directly on the soiled table surface. This oversight was confirmed by the nurse during a discussion with the surveyor, acknowledging the failure to create a clean field before placing the treatment supplies.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit the Minimum Data Set 3.0 (MDS) assessments for two residents to the State MDS database within the required 14-day period following completion. Specifically, the annual MDS for one resident and the quarterly MDS for another resident were both completed on April 2, 2024, but there was no evidence in the clinical records that these assessments were transmitted to the State database. This deficiency was identified during a review of records and an interview with the MDS Registered Nurse (RN) on May 15, 2024. During the interview, the MDS RN submitted the assessments, and they were subsequently accepted by the State database.
Failure to Respond to Residents' Requests in a Timely Manner
Penalty
Summary
The facility failed to respond to residents' requests for assistance in a manner that maintained or enhanced their dignity. One resident reported that their call bell was not answered for 50 minutes when they needed assistance with pain, causing them increased anxiety. This resident also mentioned a previous instance where the call bell rang for 35 minutes before a family member had to find staff to assist. The facility's call bell log did not have records to verify these incidents, and the Director of Nursing acknowledged that mornings are very busy, which could have led to the delay in response time. Another resident requested to speak to the Administrator before discharge to voice concerns about their care, specifically regarding not receiving daily showers as ordered by their provider. The charge nurse did not assist the resident in meeting or speaking with the Administrator, citing the resident's use of foul language. The resident expressed that this caused them mental anguish and anger, as they felt their care was not taken seriously. The Administrator and the Director of Nursing were not aware of the resident's request to speak with them before leaving the facility.
Failure to Provide Daily Showers as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from neglect when the resident was denied daily showers as ordered by their provider from 2/24/24 to 3/4/24. The resident had a specific written order for daily showers with detailed instructions to ensure safety and proper care. However, the electronic treatment administration record (eTAR) showed inconsistencies in the documentation of the showers, with entries indicating refusal, completion, and holding of the showers. Interviews with staff revealed that they were not properly instructed or shown how to provide the shower to the resident, leading to the resident not receiving the required daily showers. The resident developed a rash in the groin area due to the neglect of personal hygiene. The Occupational Therapist (OT) confirmed that he did not assist the resident with an actual shower but only simulated the steps. A Certified Nurse's Assistant (CNA) admitted to not knowing how to handle the resident's shoulder brace and therefore did not provide the shower. The Director of Nursing confirmed that the resident had not received a shower during their stay once cleared by the provider. The resident and their son also confirmed that the resident did not receive the showers and that there was a discrepancy in the documentation. The clinical record for bathing lacked evidence that the resident received a shower during their stay at the facility.
Failure to Follow Physician Orders for Resident Showers
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident who was admitted with severe postoperative pain and impaired mobility due to a right shoulder rotator cuff tear and left quadriceps tendon repair. The resident was cleared by the provider to take daily showers with specific wound care instructions starting from 2/24/24. However, the clinical record review revealed that the resident did not receive any showers from 2/24/24 to 3/3/24, despite having a written order dated 2/29/24 for daily showers with detailed wound care procedures. During an interview with the surveyor, the resident confirmed that they had been asking for showers and had a physician's order for daily showers. The resident stated that staff informed them they were not able to provide showers due to a lack of training. The Director of Nursing confirmed that the resident had not received a shower during their stay once cleared by the provider. This failure to follow physician orders resulted in a deficiency in the care provided to the resident.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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