Marshwood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 33 Roger Street, Lewiston, Maine 04240
- CMS Provider Number
- 205072
- Inspections on file
- 21
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Marshwood Center during CMS and state inspections, most recent first.
Failure to maintain clean and orderly conditions was identified across multiple units, with surveyors observing cracked and broken floor tiles, marred walls, stained ceiling tiles, dusty vents and fans, dirty bathroom floors and fixtures, damaged privacy curtains, rusted or chipped heating units, and other disrepair in resident rooms, hallways, dining areas, and bathrooms. The Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor confirmed the findings during the environmental tour.
Failure to Hold IDT Care Plan Meetings Within Required Timeframe: The facility failed to document IDT care plan meetings within 7 days of quarterly MDS assessments for 5 residents. Record review showed multiple quarterly MDSs with no evidence of timely IDT meetings, and staff interviews confirmed the missing documentation; the MDS Coordinator could not provide evidence that family or representatives requested meetings outside the required timeframe.
Kitchen Sanitation and Maintenance Deficiencies: During an initial kitchen tour, surveyors observed missing sheet rock on the wall behind the stove, food debris and trash on the kitchen floor, chipped and missing paint in the walk-in freezer, dusty air vents, and multiple stained ceiling tiles and ceiling grids above the stove. The Director of Operations for Dietary for Health Care Services confirmed the findings.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments: Multiple residents had missing MAR/TAR entries for ordered meds, treatments, assessments, and monitoring, including insulin and BG checks, wound and skin care, enteral feeding tasks, HOB elevation checks, psych med side-effect monitoring, and other ordered nursing interventions. The Market Clinical Advisor confirmed the missing documentation during interview.
Failure to Maintain Resident Dignity During Grooming: A cognitively intact resident with ADL assistance needs was observed on multiple occasions with long facial hair on the chin despite stating it bothered him/her and that help had been requested. The resident said he/she could shave but lacked a mirror, while CNA confirmed the resident had not been shaved and razors were not left in rooms.
Unsecured Chemical Storage in Spa Area: An unlocked and ajar closet door in the [NAME] unit spa allowed resident access to 5 gallons of Cid-A-L ? II disinfectant stored inside. The SDS stated the chemical should be kept out of reach of children and identified it as toxic, with potential for eye, skin, inhalation, and ingestion harm. The DON and surveyor observed the unsecured chemicals, and the DON confirmed they were not secured.
Unsanitary dumpster area: A surveyor observed food and trash on the ground around 3 of 3 dumpsters, and the DO of Dietary for Health Care confirmed the finding during an interview with two surveyors.
Failure to Follow Contact Precautions for C-diff: A resident with C-diff was on Contact Precautions, with PPE available and signage posted at the room entrance. Surveyors observed an LSW in the resident’s room without a gown or gloves, and the RN Mgr stated PPE was only needed if touching items before later correcting the staff member. The facility policy required PPE to be worn before or upon entry for residents on Transmission Based Precautions, including C-diff.
The facility failed to provide four residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. Clinical records lacked evidence of offering or assisting with advance directives, with one resident not receiving paperwork due to being on leave.
The facility failed to maintain a sanitary and comfortable environment across all units and the activity room. Observations included missing hooks and disrepair of privacy curtains, cracked heating unit grills, soiled bathroom floors, dirty caulking, and dirty ceilings. Linen closets contained trash and debris, and rooms had strong odors and visible dirt. These findings were confirmed by the Maintenance Director, DON, and Administrator.
The facility failed to secure chemicals, including Bleach Germicidal Wipes and an unlabeled bleach/water spray bottle, in unlocked shower rooms accessible to residents with dementia and other compromising conditions. This was confirmed by an LPN, the DON, and the Administrator.
The facility did not ensure sufficient direct care staff were scheduled to meet resident needs, particularly on weekends. A review of staffing reports revealed excessively low weekend staffing during a specific quarter, and facility personnel confirmed the shortfall. This deficiency potentially affects all residents needing assistance with ADLs.
The facility failed to ensure that 8 out of 25 licensed staff members, including LPNs and RNs, had current BLS certification as required by their job descriptions. This deficiency was identified through interviews and record reviews, and discussed with the DON.
The facility's kitchen was found to be unsanitary, with food and trash on the floor, leaking sinks, and equipment covered in residue. Additionally, the ice machine was not plumbed according to code, risking contamination. These issues were confirmed by the Food Service Director and other management staff.
The facility failed to meet the needs of two residents: one was unable to obtain Ginger Ale unless deemed medically necessary, and another, with a recent amputation, struggled with an inadequately sized bed, leading to a fall. Staff were unaware of these issues, indicating communication and assessment gaps.
A facility failed to refer a resident with Major Depressive Disorder and Suicidal Ideations for a PASRR Level II evaluation after their stay extended beyond 30 days. Initially, a PASRR Level I determination indicated no further evaluation was needed due to a 30-day waiver. However, the resident's stay became long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority for further assessment, as confirmed by the Licensed Social Worker.
A resident's eyeglasses were lost, and the facility failed to document the loss or assist in obtaining a replacement, despite the resident's cognitive intactness and reliance on glasses for watching TV. Interviews confirmed the oversight, and the facility did not follow its policy on personal property management.
The facility failed to maintain or improve ROM and mobility for two residents after discharge from therapies. One resident's restorative program was not documented or followed, leading to falls and a return to therapy. Another resident reported decreased strength due to lack of daily exercises. CNAs were unable to perform restorative tasks due to staffing issues, and the facility lacked a restorative nursing program.
The facility failed to maintain a sanitary environment for respiratory care, as two residents' respiratory equipment was improperly stored. Observations revealed that a resident's nebulizer tubing was on the bedside table, and another resident's oxygen tubing was under the oxygen concentrator handle, contrary to facility procedures. This was confirmed by the DON.
The facility did not have an Infection Preventionist present at two of the four quarterly QAA meetings. The absence was due to the departure of the Infection Preventionist in mid-October, and the position remained vacant until a new hire was finalized recently. This was confirmed by the Administrator and the Marketing Clinical Advisor.
The facility did not post daily nurse staffing information, including the resident census, for three survey days and failed to maintain these records for 18 months. The absence of the resident census was confirmed by the Scheduler/Payroll/HR personnel, who was unaware of the record-keeping requirement. This was corroborated by the RN Market Clinical Advisor.
The facility failed to maintain a sanitary and comfortable environment in three units. Observations included chipped and missing paint on wall heaters and door frames, rust creating uncleanable surfaces, marred walls, and dirty areas in resident rooms and bathrooms. These issues were confirmed by the DON during the survey.
The facility failed to ensure a safe environment for residents, with observations of a loose toilet, sharp splintered wood on doors, and a broken baseboard heater exposing sharp metal. These hazards were identified during a survey and discussed with the DON.
Failure to Maintain Clean and Safe Environmental Conditions
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on 6 of 7 units. During environmental tours with the Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor, surveyors observed multiple areas of disrepair and poor cleanliness, including cracked and broken floor tiles in dining areas and hallways, marred and chipped walls with exposed sheet rock, stained ceiling tiles, dusty or dirty vents and fans, dirty floors around toilets, and dirty or stained bathroom fixtures and surfaces. Several resident rooms also had damaged or missing privacy curtain hooks, dirty bedside tables, a soiled plunger on the bathroom floor, and call bell cords lying on the floor. Additional findings included rusted or chipped heating units, a heating unit pulled away from the wall, a rotted bathroom door frame with a hole in it, debris in a light fixture, and bathroom areas with stained caulking and dirty floors. Surveyors also observed black marks on bathroom walls, peeling paint, broken or hanging heater components, and a broken plastic wrap around the base of a toilet. The Administrator, DON, Maintenance Director, Maintenance Assistant, and Housekeeping Supervisor confirmed the findings during the interview at the end of the tour.
Failure to Hold IDT Care Plan Meetings Within Required Timeframe
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT), including resident and/or representative participation to the extent possible, after each MDS assessment for 5 of 28 residents reviewed. The cited residents were #1, #8, #35, #60, and #63. Record review showed quarterly MDS assessments for these residents, but the clinical record lacked evidence that an IDT meeting was held within 7 days of the assessments. For Resident #1, a quarterly MDS dated 1/6/26 had no evidence of an IDT meeting within 7 days. For Resident #8, quarterly MDS assessments dated 12/16/25 and 3/12/26 had no evidence of IDT meetings within 7 days of either assessment. Resident #60 had quarterly MDS assessments dated 6/24/25 and 9/26/25 with no evidence of IDT meetings within 7 days, and Resident #63 had a quarterly MDS dated 5/20/25 with no evidence of an IDT meeting within 7 days. Resident #35 had a quarterly MDS dated 12/23/25 with no evidence of an IDT meeting within 7 days. During interviews, the LSW stated documentation should reflect what was decided for a meeting date and time, and that the LSW documents the actual care plan meeting while Nursing completes the care plan. The MDS Coordinator could not provide documentation showing that any family or representative requested a meeting outside the 7-day timeframe, and the Market Clinical Advisor confirmed the findings.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner during an initial kitchen tour with the Director of Operations for Dietary for Health Care Services. Surveyors observed a wall behind the stove with missing sheet rock, food debris and trash under tables and equipment on the kitchen floor, chipped and missing paint on the walk-in freezer floor creating an uncleanable surface, air conditioner vents covered with dust and dirt, and approximately 15 ceiling tiles and the ceiling grids above the stove stained yellowish and soiled with dust and dirt. The Director of Operations for Dietary for Health Care Services confirmed these findings during interview with the surveyors.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments
Penalty
Summary
The facility failed to ensure that Medication Administration Records (MARs) and Treatment Administration Records (TARs) were accurately completed for 7 of 28 residents reviewed. Record review and interviews showed multiple missing entries for ordered medications, treatments, monitoring tasks, and assessments across several residents, including insulin administration and blood glucose checks, wound and skin care, enteral feeding-related care, respiratory positioning checks, and other ordered observations. In each of the cited examples, the MAR/TAR lacked documented evidence that the ordered task was completed on the specified dates and shifts. For Resident #1, the clinical record showed an active sliding-scale Humalog order requiring finger-stick blood glucose checks before administration, but the MAR/TAR lacked evidence that blood sugars were checked and insulin was given on multiple dates in March. During an interview, the Market Clinical Advisor confirmed there was no evidence that the resident received the blood sugar checks or insulin for those dates. For Resident #3, the record contained multiple active orders, including Humalog, Lantus, Dulaglutide, Miconazole powder, wound monitoring, acetaminophen, lab work, head-of-bed elevation checks, psychotherapeutic side effect checks, Voltaren gel, and wander guard checks; the MAR/TAR lacked documentation for numerous missed entries across January and February 2026, and the Market Clinical Advisor confirmed the findings during interview. Additional residents had similar documentation gaps. Resident #8 had missing documentation for Risperidone administration, head-of-bed elevation checks, psychotherapeutic side effect checks, weekly weight, vital signs, clonidine patch placement, lab work, toe care, and wound care. Resident #14 had missing documentation for ammonium lactate application, head-of-bed elevation checks, nebulizer treatment, and IV observation. Resident #35 had missing documentation for BMP completion, psychotherapeutic side effect checks, wander guard placement checks, and TED hose care. Resident #60 had extensive missing documentation related to ice chips, skin cream, colostomy care and appliance changes, head-of-bed elevation, enteral feeding care, tube placement and flushing, suction canister disinfection, oral care, and psychotherapeutic side effect checks. Resident #63 also had missing documentation for lab work, head-of-bed elevation checks, psychotherapeutic side effect checks, levothyroxine administration, foot skin care, and Lantus administration. In each case, the Market Clinical Advisor confirmed the findings during interview.
Failure to Maintain Resident Dignity During Grooming
Penalty
Summary
The facility failed to protect and promote Resident #24’s dignity by not ensuring the resident’s facial hair was addressed despite the resident’s expressed concern and ability to participate in shaving. Resident #24 was admitted in February 2026 with diagnoses of right tibia and fibula fracture, had a BIMS score of 14 out of 15, and was documented in the care plan as needing assistance with grooming and personal hygiene. During observation on 3/16/26, the resident was seen sitting in a wheelchair with long white facial hair on the chin and stated that it bothered him/her, that help had been requested, and that the resident could shave but did not have a mirror in the room. On 3/17/26, the resident was again observed with the same long white facial hair on the chin and repeated that it was bothersome and that the facility must have razors because men were present in the facility. During interview, CNA #1 stated she had not shaved the resident and that razors would not be left in resident rooms. The DON later discussed that the resident could be shaved by staff or shave independently and that the facility would obtain a mirror and electric shaver.
Unsecured Chemical Storage in Spa Area
Penalty
Summary
The facility failed to ensure the resident environment remained free from accident hazards when a closet door in the [NAME] unit spa was observed unlocked and ajar, allowing resident access to the area. Inside the closet, surveyors found 5 gallons of Cid-A-L ? II, a disinfectant, virucide, and fungicide chemical. The Safety Data Sheet for the product stated it should be kept out of reach of children and described it as toxic, with risks including irreversible eye damage or burns, skin burns or irritation, drowsiness, nausea, loss of motor skills or disorientation from inhalation, and digestive tract burns if ingested. The Director of Nursing and the surveyor observed the unsecured chemicals, and the DON confirmed the chemicals were not secured, creating a hazardous and unsafe environment for residents who could access the area.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests. On 3/16/26 at 8:18 a.m., a surveyor observed food and trash on the ground around 3 of 3 dumpsters. Later that morning, at 8:48 a.m., two surveyors interviewed the Director of Operations for Dietary for Health Care, who confirmed the finding.
Failure to Follow Contact Precautions for C-diff
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment and help prevent the development and transmission of disease and infection related to the management of a resident with Clostridioides difficile (C-diff) infection. Resident #117 was admitted with a diagnosis of Clostridioides difficile, and the care plan for actual infection, initiated on 3/14/26, included Contact Precautions. On 3/16/26 at 10:33 a.m., the resident’s room had a posted Contact Precautions sign instructing staff to put on gloves and a gown before entering, and PPE supplies of gloves and gowns were available in a bin next to the door. The resident stated he/she was on contact precautions due to having C-diff and was on an antibiotic for a couple more days. On 3/16/26 at 11:11 a.m., two surveyors observed the Licensed Social Worker in the resident’s room sitting in the resident’s wheelchair without gloves or a gown. When the surveyor asked the RN Manager why the LSW was not wearing the required PPE, the RN Manager stated that PPE was only needed if touching items. The RN Manager then called the LSW out of the room and explained that she should be wearing gown and gloves while in the room. At 11:17 a.m., the LSW applied gown and gloves. The facility’s Transmission Based Precautions policy, revised 5/1/25, stated that PPE should be readily available near the entrance and that appropriate PPE should be donned before or upon entry for patients on Transmission Based Precautions, including Contact Precautions for pathogens such as Clostridioides difficile.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for four residents during a review of their clinical records. Specifically, the records for these residents lacked evidence that the facility had provided or obtained the necessary documentation concerning these rights. For one resident, the social worker confirmed that the clinical records did not include evidence of offering or assisting with an advance directive. Another resident did not receive the advance directive paperwork because they were out on leave, and the task was not completed. The absence of documentation for these residents indicates a failure to comply with the requirement to inform and document residents' rights to make decisions about their medical care.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across all seven units and the activity room. During an environmental tour conducted by two surveyors, accompanied by the Maintenance Director, the Director of Nursing, and the Administrator, numerous deficiencies were observed. These included missing hooks and disrepair of privacy curtains, cracked and broken heating unit grills, heavily soiled bathroom floors, dirty caulking around toilets, and dirty ceilings with holes. Additionally, there were issues with linen closets containing trash and debris, and various rooms had strong odors, fruit flies, and visible dirt and dust. Specific observations included a cracked plastic grill on a room heating unit, missing ceiling tiles, and a sit-to-stand patient lift with food and debris. The activity room doors had chipped paint and black marks, while the dining room window was fogged, and a table fan was dusty. The storage room and shower room also had issues with debris and black substances in the grout. These findings were confirmed in an interview with the Maintenance Director, the Director of Nursing, and the Administrator.
Improper Storage of Chemicals in Resident Areas
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards due to improper storage of chemicals. On two separate days of the survey, surveyors observed unsecured containers of Bleach Germicidal Wipes in unlocked shower rooms. These chemicals were accessible to residents, including those who were confused, compromised, and could move around the unit, even in wheelchairs. The presence of these unsecured chemicals was confirmed by both an LPN and the Director of Nursing, who acknowledged the potential risk posed to residents. Additionally, a surveyor found an unlabeled spray bottle marked as containing bleach and water, with an unknown bleach-to-water ratio, in a shower room. The Administrator confirmed that the bottle was not labeled appropriately and should have been secured behind a locked door. The unit housed residents with dementia and other compromising conditions, further emphasizing the risk of having unsecured and improperly labeled chemicals accessible to them.
Insufficient Weekend Staffing in Facility
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 excessively low weekend staffing during the fourth quarter of 2024. On December 19, 2024, both the Director of Nursing and the Scheduler/Payroll/Human Resource personnel confirmed that the facility did not have enough staff to meet resident needs on weekends. This staffing shortfall has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Deficiency in Staff BLS Certification
Penalty
Summary
The facility failed to ensure that 8 out of 25 licensed staff members had current certification in Healthcare Basic Life Support (BLS) as required by the facility's job descriptions for Registered Nurses and Licensed Practical Nurses. This deficiency was identified through interviews and record reviews conducted by a surveyor. The surveyor found that the documentation provided by the facility did not include current BLS/CPR certification for these 8 staff members, which included both LPNs and RNs. The issue was discussed with the Director of Nursing during the survey process.
Kitchen Sanitation and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour conducted by two surveyors. The tour revealed several issues, including food and trash scattered on the floor and under equipment, a leaking dish room spray sink, and chipped paint on the food mixer. Additionally, five ceiling tiles above a food preparation area had dried liquid spatter, and a broken ceiling tile was found near the walk-in freezer. The food disposal unit, blender, and convection oven were all covered with dried food particles and residue. In the dry storage room, a 50-pound bag of sugar was left open and unsecured, and a large box of sandwich buns in the walk-in freezer had significant ice build-up. Furthermore, the facility failed to ensure that the kitchen ice machine was plumbed according to code requirements, which is necessary to prevent food contamination. This was a direct violation of the State of Maine Rules Chapter 226 and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d), which mandate that plumbing must be designed, installed, and maintained to prevent contamination of the water supply, food, and food utensils. These findings were confirmed in an interview with the Food Service Director, the Director of Operations, and the District Manager.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the beverage preferences of a resident, as evidenced by the restriction on Ginger Ale availability. During a resident council meeting, a resident expressed dissatisfaction with not being able to obtain Ginger Ale unless deemed medically necessary by a nurse. Staff members confirmed that they were instructed to only provide Ginger Ale to residents who were sick. However, the Food Service Director stated that residents could have Ginger Ale if their diet allowed it, indicating a communication breakdown between the kitchen staff and the nursing staff. Additionally, the facility did not adequately address the bed size needs of a resident with a recent right below-the-knee amputation. The resident, who is 6 feet 2 inches tall, reported falling out of bed while reaching for the call bell and expressed difficulty moving in the bed due to its size. Despite the resident's complaints and a documented fall, staff members, including the RN and Director of Nursing, were unaware of any issues with the bed size. The initial bed assessment upon admission did not note any problems, suggesting a lack of follow-up on the resident's changing needs.
Failure to Initiate PASRR Level II Evaluation for Long-Term Resident
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred for a Pre-Admission Screening & Resident Review Level II (PASRR) evaluation. The resident was admitted with a diagnosis of Major Depressive Disorder and Suicidal Ideations. Initially, a PASRR Level I determination letter indicated that no further evaluation was required due to a 30-day Time Limited Waiver. However, the resident's stay transitioned from short-term to long-term, and the facility did not forward the PASRR Level I to the State Mental Health Authority to assess the need for a Level II evaluation. This oversight was confirmed during an interview with the Licensed Social Worker, who acknowledged that the resident had been in the facility for more than 30 days without the necessary PASRR Level II evaluation being initiated.
Failure to Assist Resident in Obtaining Replacement Eyeglasses
Penalty
Summary
The facility failed to assist a resident in obtaining new eyeglasses after the original pair was lost, as per the facility's policy on personal property. The policy requires personnel to identify and record a patient's belongings upon admission and document any loss or breakage of personal items. However, the facility did not complete an inventory sheet or incident report for the missing glasses of a resident who was cognitively intact and relied on glasses to watch television. Interviews with the resident and staff confirmed that the glasses had been missing for several months, and no action was taken to replace them. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitive intactness, reported the loss of glasses, which were necessary for watching television. Despite the resident's report and the facility's policy, the staff did not document the loss or assist in obtaining a replacement. Interviews with the CNA and the Registered Nurse Manager revealed that the inventory sheet and incident report were not completed, and the Director of Nursing confirmed the oversight. This inaction led to the resident being unable to see the television clearly, impacting their quality of life.
Failure to Maintain Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to maintain or improve the range of motion (ROM) and mobility for two residents following their discharge from physical and occupational therapies. For one resident, a restorative nursing program was recommended to maintain physical abilities achieved during therapy, which included ambulation with a walker and a home exercise program. However, this program was not included in the resident's care plan, and there was no documentation to show that the program was followed. This resident experienced falls and was referred back to physical therapy, indicating a decline in their physical abilities. Another resident reported not being able to walk or perform exercises daily since ending therapy, leading to a perceived decline in strength. The restorative plan for this resident was also not included in their care plan, and there was no documentation of the program being followed. Interviews with CNAs revealed that they were unable to perform restorative tasks due to staffing issues, and a unit manager confirmed that the facility lacked a restorative nursing program. The facility's assessment indicated that it should provide mobility and fall prevention care, but this was not being implemented effectively.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by observations and interviews. The facility's procedure for oxygen nasal cannula, revised on 8/7/23, requires that cannulas be dated and stored in a treatment bag when not in use. However, observations on 12/16/24 and 12/17/24 revealed that Resident 98's nebulizer tubing was stored on the bedside table, and Resident 405's oxygen tubing was stored under the oxygen concentrator handle. These storage practices were confirmed by the Director of Nursing during an interview on 12/17/24.
Infection Preventionist Absence at QAA Meetings
Penalty
Summary
The facility failed to ensure that an Infection Preventionist attended two of the four quarterly Quality Assessment and Assurance (QAA) meetings, specifically those held on July 25 and October 31, 2024. A review of the QAA meeting attendance sheets confirmed the absence of the Infection Preventionist at these meetings. During an interview on December 18, 2024, the Administrator acknowledged the absence, stating that the Infection Preventionist left the facility in mid-October and had not been replaced until recently. This was corroborated by the Marketing Clinical Advisor later that day.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the resident census per shift, for three out of four survey days. Specifically, on 12/16/24, 12/17/24, and 12/18/24, a surveyor observed that the nurse staffing information posted at the main entrance did not include the resident census. Additionally, the facility did not maintain records of the posted daily nurse staffing data for a minimum of 18 months as required. During an interview on 12/18/24, the Scheduler/Payroll/HR personnel confirmed the absence of the resident census on the posted nurse staffing information and admitted to being unaware of the requirement to keep these records for at least 18 months. This was further confirmed by the Registered Nurse Market Clinical Advisor.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in three of its six units, as observed during a survey. On the Gilber Unit, several resident rooms were found with chipped or missing paint on wall heater units, which also had rust, creating uncleanable surfaces. The walls in these rooms and bathrooms were marred and marked, and one room had a privacy curtain with large dirty and stained areas. These findings were confirmed by the Director of Nursing during the survey. In the [NAME] Unit and [NAME] Unit, similar issues were observed. Multiple resident rooms had entrance and bathroom door frames with chipped or missing paint. The dining room heater also had chipped or missing paint, creating an uncleanable surface. Additionally, one room had a dirty floor around the base of the toilet. These deficiencies were discussed with the Director of Nursing by the surveyor, highlighting the facility's failure to provide adequate housekeeping and maintenance services.
Environmental Hazards in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment for residents, as observed during a survey on the [NAME] Unit. In one resident room, the bathroom toilet was found to be loose and not secured to the floor, posing a potential hazard. Additionally, the bathroom door had chipped, gouged, and splintered wood, which was sharp and could cause injury. In another resident room, a baseboard heater was broken apart, exposing sharp metal edges. Furthermore, the entrance door to this room also had chipped, gouged, and splintered wood, creating another sharp hazard. These deficiencies were discussed with the Director of Nursing during the survey.
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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