Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Maine average
Maine average: 5.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: Dec 19, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements across multiple areas including resident rights, environment, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident preferences, incomplete advance directive documentation, inadequate housekeeping and maintenance, failure to refer residents for required mental health evaluations, lack of assistance with personal property replacement, failure to maintain residents' physical abilities post-therapy, unsafe chemical storage, unsanitary respiratory care equipment, insufficient staffing levels, lack of current BLS certification for some licensed staff, failure to post and maintain nurse staffing information properly, unsanitary kitchen conditions, and absence of an Infection Preventionist at some Quality Assessment and Assurance meetings.
Deficiencies (13)
F 0558: Facility failed to meet reasonable needs of residents regarding beverage choices and bed size for 2 residents.
F 0578: Facility failed to ensure resident or representative written information on rights to accept or refuse treatment and advance directives for 4 residents.
F 0584: Facility failed to provide adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment on all units and activity room.
F 0645: Facility failed to refer a resident with a specialized mental health diagnosis for required PASRR Level II evaluation after stay exceeded 30 days.
F 0685: Facility failed to complete personal property list and assist a resident in obtaining new glasses after loss.
F 0688: Facility failed to maintain residents' range of motion and mobility post-therapy due to lack of restorative nursing program and staffing.
F 0689: Facility failed to ensure chemicals were properly secured and labeled to prevent accident hazards on multiple observations.
F 0695: Facility failed to maintain sanitary environment for respiratory care equipment for 2 residents.
F 0725: Facility failed to ensure sufficient direct care staff were scheduled and on duty to meet resident needs, especially on weekends.
F 0726: Facility failed to ensure 8 of 25 licensed staff had current BLS certification as required.
F 0732: Facility failed to post nurse staffing information daily including resident census and failed to maintain records for 18 months.
F 0812: Facility failed to maintain kitchen in a clean and sanitary manner and failed to ensure proper food storage and ice machine plumbing to prevent contamination.
F 0868: Facility failed to ensure Infection Preventionist attended 2 of 4 quarterly Quality Assessment and Assurance meetings.
Report Facts
Residents screened for accommodation of needs: 16
Residents reviewed for advance directives: 10
Licensed staff reviewed for BLS certification: 25
Excessively low weekend staffing period: 4
Residents reviewed for respiratory care: 2
Residents reviewed for maintenance of physical abilities: 11
Quarterly QAA meetings reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed unsecured chemical storage |
| Director of Nursing | Interviewed regarding bed size issue, chemical storage, staffing, BLS certification, respiratory care | |
| Food Service Director | Confirmed beverage choice policy and kitchen sanitation findings | |
| Director of Operations | Confirmed beverage choice policy and kitchen sanitation findings | |
| Licensed Social Worker | Confirmed lack of advance directive documentation and PASRR referral | |
| Scheduler/Payroll/HR personnel | Confirmed insufficient weekend staffing and failure to maintain nurse staffing records | |
| Administrator | Confirmed chemical storage, nurse staffing records, and Infection Preventionist attendance | |
| Registered Nurse Manager | Confirmed inventory and incident report procedures for lost personal property |
Inspection Report
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to maintaining a safe, clean, and hazard-free environment in the nursing home.
Findings
The facility failed to maintain housekeeping and maintenance services adequately, resulting in chipped and missing paint, rusted heater units, dirty privacy curtains, and sharp hazards such as broken baseboard heaters and splintered doors in multiple resident rooms across several units. These issues posed minimal harm or potential for actual harm to residents.
Deficiencies (2)
F 0584: The facility failed to maintain a safe, clean, and homelike environment, with chipped/missing paint, rusted heater units, marred walls, and dirty privacy curtains observed in multiple resident rooms across three units.
F 0689: The facility failed to ensure the environment was free from accident hazards, with a loose toilet, chipped/gouged and splintered bathroom doors, broken baseboard heater creating sharp metal, and splintered entrance doors observed in resident rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed findings and discussed deficiencies with surveyor |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to facility maintenance, resident care, safety, staffing, food handling, and sanitation.
Findings
The facility was found to have multiple deficiencies including inadequate housekeeping and maintenance, improper oxygen administration, missing safety clips on patient lifts, failure to post nurse staffing information timely, unsanitary kitchen conditions, unlabeled food items, and improper garbage storage.
Deficiencies (6)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with multiple issues such as soiled resident chairs, damaged walls, missing floor tiles, dirty air handling units, and broken privacy curtains across several units.
F 0684: Oxygen was not administered according to physician's orders for 1 of 3 sampled residents; Resident 69's oxygen flowmeter was set at 5 LPM instead of the ordered 2 LPM as needed.
F 0689: Two EZ sit-to-stand patient lifts were missing safety clips on the lift/swing arms, creating accident hazards.
F 0732: The facility failed to post current daily nurse staffing information for three consecutive days (9/16/23 to 9/18/23).
F 0812: The kitchen was not maintained in a clean and sanitary manner with issues including broken ceiling light covers, dusty hood exhaust filters, dirty food mixer, soiled cook stove, rusted grease trap cover, unlabeled food items, and staff without facial hair protection.
F 0814: Garbage storage areas were not maintained in a sanitary condition; two dumpsters had open doors exposing trash and trash was scattered around the dumpsters.
Report Facts
Date survey completed: Sep 21, 2023
Oxygen flow rate: 5
Oxygen flow rate ordered: 2
Days nurse staffing not posted: 3
Number of ceiling tiles dirty/broken/stained: 10
Number of dumpsters with open doors: 2
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Nov 4, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify resident representatives of significant medical condition changes, inadequate maintenance and cleanliness, failure to provide timely transfer/discharge notices, incomplete bed hold notices, failure to follow physician orders, medication irregularities, and unsanitary kitchen conditions.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify resident representatives of significant medical condition changes, inadequate maintenance and cleanliness, failure to provide timely transfer and bed hold notices, failure to follow physician orders, medication irregularities, unsanitary kitchen conditions, and incomplete clinical documentation.
Findings
The facility was found deficient in notifying a resident's representative of a significant change in medical condition, maintaining a safe and clean environment, providing timely transfer and bed hold notices, following physician orders for treatments and medications, responding to pharmacist recommendations, maintaining kitchen sanitation, and ensuring complete and accurate clinical documentation.
Deficiencies (9)
F 0580: The facility failed to notify a resident's representative of a significant change in the resident's medical condition related to C-Diff infection until after the fact.
F 0584: The facility failed to maintain a safe, clean, and homelike environment with multiple issues including dirty floors, stained ceiling tiles, uncleanable surfaces, and damaged equipment across several units.
F 0623: The facility failed to provide written notification to a resident and/or representative of a hospital transfer for 1 of 4 sampled residents.
F 0625: The facility failed to issue complete bed hold notices to residents or their representatives for 2 of 4 sampled residents transferred to the hospital.
F 0684: The facility failed to follow physician orders for PICC line care for 1 resident, with treatments not performed as ordered.
F 0686: The facility failed to provide pressure ulcer care as ordered for 1 of 3 residents, with dressing changes documented only once daily instead of twice.
F 0756: The facility failed to respond timely to a pharmacist's recommendation to discontinue a high-risk psychotropic medication for 1 of 5 residents.
F 0812: The facility failed to maintain kitchen sanitation, with dirty ceiling vents, tiles, floor fan, unlabeled fluids, improperly stored flammable cooking spray, and food debris on equipment.
F 0842: The facility failed to maintain complete and accurate clinical documentation for 3 of 36 sampled residents, including missing medication administration, wound care, vital signs, and feeding documentation.
Report Facts
Residents reviewed: 36
Residents reviewed for unnecessary medications: 5
Residents reviewed for pressure ulcers: 3
Residents sampled for transfer/discharge notice: 4
Residents sampled for bed hold notice: 4
Days medication not administered: 2
Days wound care not documented twice daily: 74
Days missing clinical documentation: 20
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