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