Inspection Report
Complaint Investigation
Census: 74
Capacity: 80
Deficiencies: 1
Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with licensing requirements, specifically regarding the use of the Maine Background Check Center for personnel background checks.
Findings
The facility failed to utilize the Maine Background Check Center to obtain a comprehensive background check report for one employee, as required by state regulations. This was confirmed through record review, interviews, and verification with the Background Check Center.
Complaint Details
The complaint investigation found that Employee #1’s personnel record lacked evidence of a background check conducted through the Maine Background Check Center. Follow-up communications confirmed no application had been submitted for this employee.
Deficiencies (1)
| Description |
|---|
| Failed to utilize the Maine Background Check Center to obtain a comprehensive background check report for Employee #1. |
Report Facts
Census: 74
Total Capacity: 80
Inspection Report
Complaint Investigation
Census: 74
Capacity: 80
Deficiencies: 2
Mar 20, 2025
Visit Reason
The visit was conducted as a complaint investigation regarding medication administration and record-keeping practices at Birchwoods at Canco Senior Living.
Findings
The investigation found that one resident did not receive medications as ordered due to insurance authorization issues, and the facility failed to record incident reports for medication errors in the resident's record as required.
Complaint Details
The complaint investigation was substantiated by findings that Resident #1 did not receive prescribed medications due to insurance issues and that medication errors were not properly documented in incident reports until after the investigation.
Severity Breakdown
Class II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer medications as ordered by the licensed practitioner, including Xarelto and Metoprolol Tartrate. | — |
| Failure to record incident reports for medication errors in the resident's record. | Class II |
Report Facts
Census: 74
Total Capacity: 80
Medication omission days: 10
Medication omission doses: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Stewart | Administrator | Signed incident report for medication error dated 3/20/2025 |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 3
Jan 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to properly dispose of medications, including Schedule II controlled substances, within required timeframes following the death of consumers.
Findings
The facility failed to dispose of discontinued and expired medications, including Schedule II controlled substances, within 30 calendar days following the death of residents. Additionally, the facility did not maintain required weekly inventory counts for Schedule II medications and lacked proper documentation of medication disposal with required witness signatures.
Complaint Details
The complaint investigation was triggered by concerns about improper medication disposal and inventory management. The investigation substantiated that the facility failed to dispose of medications timely after resident deaths and did not maintain required inventory records or proper disposal documentation.
Severity Breakdown
Class II: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to dispose of medications within thirty calendar days following the death of a consumer (Resident #4). | — |
| Failure to maintain weekly inventory counts in the bound book for Schedule II controlled substances for two residents (Resident #1 and Resident #4). | Class II |
| Failure to dispose of Schedule II controlled substances as required, including lack of proper disposal documentation with two authorized signatures (Resident #1). | Class II |
Report Facts
Census: 80
Total Capacity: 80
Date of Resident #4 death: Nov 8, 2024
Date of Resident #1 death: Dec 30, 2024
Medication last administered to Resident #4: Nov 8, 2024
Medication last administered to Resident #1: Dec 30, 2024
Remaining Morphine for Resident #1: 29.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Poulin | Administrator | Named as administrator of the facility |
| Nurse #1 | Interviewed regarding medication disposal and inventory practices; confirmed failures in disposal and inventory documentation |
Inspection Report
Biennial Survey
Census: 80
Capacity: 80
Deficiencies: 4
Oct 9, 2024
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing assisted living programs, including licensing, consumer rights, medication administration, and progress notes.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to have signed standard contracts for new admissions, lack of current written consents to release information for several consumers, failure to obtain timely signed written orders for telephone medication orders, and incomplete monthly progress notes for several consumers.
Severity Breakdown
Class IV: 1
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to sign a standard contract with each consumer or authorized representative for new admissions (Consumer #4). | — |
| Failed to have written consents to release information upon admission or renew them every thirty months for four consumers (Consumers #2, #3, #4, and #5). | Class IV |
| Failed to obtain a written dated order signed by a licensed practitioner within five working days of a telephone order accepted by a registered nurse (Consumer #4). | Class III |
| Failed to have signed and dated progress notes completed monthly on implementation of the service plan or significant changes for three consumers (Consumers #1, #2, and #3). | — |
Report Facts
Consumers reviewed: 5
Months missing progress notes: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Poulin | Administrator | Interviewed and confirmed findings related to contracts, consents, and progress notes. |
| Resident Care Coordinator | Interviewed and confirmed findings related to contracts, consents, and medication orders. | |
| Registered Nurse (RN) | Confirmed failure to obtain signed written order following telephone medication order. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 80
Deficiencies: 2
May 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to protect a consumer from exploitation and issues with the functional assessment process.
Findings
The facility failed to protect one consumer from financial exploitation involving missing cash and did not include a review of the consumer's need for assistance with Instrumental Activities of Daily Living (IADLs) in the functional assessment.
Complaint Details
The complaint investigation found substantiated evidence that the facility failed to protect Consumer #1 from exploitation involving approximately $2400 in cash that went missing from the facility safe. The facility also lacked policies related to consumer funds.
Severity Breakdown
Class IV: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect one consumer from exploitation involving missing cash. | Class IV |
| Failed to include a review of the consumer’s need for assistance with IADLs in the functional assessment. | — |
Report Facts
Cash amount: 2400
Census: 87
Total Capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Poulin | Administrator | Interviewed during the investigation and confirmed details about the missing cash and assessment issues. |
Inspection Report
Capacity: 80
Deficiencies: 0
Jan 10, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for an Assisted Living Program, related to a case investigation AHP-2023-35680.
Findings
Birchwoods at Canco Senior Living is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Assisted Living Programs, Part of 10-144, Chapter 113.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 80
Deficiencies: 0
Nov 21, 2023
Visit Reason
The visit was conducted as a complaint investigation identified as 2023-AHP-35555 for Birchwoods at Canco Senior Living.
Findings
Birchwoods at Canco Senior Living was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Assisted Living Programs, Part of 10-144, Chapter 113.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 80
Deficiencies: 8
May 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review medication administration practices at Birchwoods at Canco Senior Living.
Findings
The Administrator failed to ensure safe and acceptable medication administration procedures for one resident, with multiple documented medication errors including incorrect dosing intervals, administration after discontinuation orders, and unavailable medications.
Complaint Details
Complaint investigation 2023-AHP-33256 focused on medication administration errors for Resident #1, substantiated by multiple documentation and administration discrepancies.
Deficiencies (8)
| Description |
|---|
| Lorazepam was administered twice within less than 2 hours, contrary to the ordered every 6 hours as needed schedule. |
| Risperidone was administered after a discontinue order was signed. |
| Atorvastatin Calcium doses were not consistently documented and exceptions were noted without proper recording. |
| Cran-Max Sup-STR 500MG Capsule was frequently documented as 'Medication not available' without a discontinue order. |
| D-mannose oral powder was administered as capsules at a different dose than ordered. |
| Melatonin doses were documented as exceptions due to medication unavailability. |
| Olanzapine was administered after discontinuation and had multiple exceptions noted for medication unavailability or refusal. |
| Flonase Allergy Relief Nasal Suspension was not documented as administered but had a signed discontinue order. |
Report Facts
Census: 65
Total Capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Poulin | Administrator | Named as facility administrator in relation to medication administration oversight |
| Director of Nursing | Interviewed regarding medication availability and documentation |
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