CUMMINGS HEALTH CARE FACILITY

5 CROCKER STREET, HOWLAND, ME 04448 (207) 732-4121
For profit - Corporation 34 Beds Independent Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
31/100
#48 of 77 in ME
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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Cummings Health Care Facility has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. They rank #48 out of 77 nursing homes in Maine, placing them in the bottom half of facilities in the state, and #8 out of 11 in Penobscot County, meaning there are only three local options that perform worse. Although the facility has seen an improvement in issues reported, going from 14 in 2024 to 8 in 2025, it still has serious deficits, including staffing rated at only 2 out of 5 stars and $23,345 in fines, which is higher than 94% of Maine facilities, pointing to repeated compliance problems. Specific incidents of concern include a resident who wandered away from the facility and suffered injuries due to inadequate supervision, as well as a failure to use a two-person lift during a transfer, resulting in a fall and serious injuries for another resident. While the turnover rate for staff is a positive 0%, indicating stability, the overall conditions at Cummings Health Care Facility raise significant red flags for families considering this option.

Trust Score
F
31/100
In Maine
#48/77
Bottom 38%
Safety Record
High Risk
Review needed
Inspections
Getting Better
14 → 8 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
⚠ Watch
$23,345 in fines. Higher than 78% of Maine facilities, suggesting repeated compliance issues.
Skilled Nurses
✓ Good
Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for Maine. RNs are trained to catch health problems early.
Violations
⚠ Watch
35 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 8 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below Maine average (3.0)

Below average - review inspection findings carefully

Federal Fines: $23,345

Below median ($33,413)

Minor penalties assessed

The Ugly 35 deficiencies on record

1 life-threatening 1 actual harm
Jun 2025 8 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observations and interviews, the facility failed to promote care for residents in a manner that maintains the resident's dignity and respect during resident observations on 2 of 3 days of sur...

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Based on observations and interviews, the facility failed to promote care for residents in a manner that maintains the resident's dignity and respect during resident observations on 2 of 3 days of survey (6/9/25 and 6/10/25) (Resident #27 [R27], and R12). Findings: 1. On 6/9/25 at approximately 1:30 p.m., staff were observed assisting R27 who is dependent on staff for all Activities of Daily Living tasks, with personal incontinence care. It was observed from the hallway by a surveyor that R27 was being asked to roll on their side for the staff to perform incontinence care. At this time the surveyor observed the privacy curtain was closed but the window curtains were open, and the window was facing the parking lot, potentially exposing R27. On 6/9/25 at 1:35 p.m. the surveyor asked the charge nurse to observe the task being conducted with R27. At this time the Surveyor confirmed the window curtain was not closed and R27 was exposed to the parking lot while receiving incontinence care. The charge nurse closed the window curtains at this time and informed staff to ensure resident privacy is maintained. On 6/11/25 at 9:34 a.m. during an interview with R27, he/she stated that the curtains being opened during his/her care the other day didn't bother him/her but they do prefer to have them closed during their care. 2. On 6/10/25 at 10:56 a.m. a surveyor overhead Certified Nursing Assistant #1 (CNA1) speaking to R12, and heard R12 say, please, then CNA1 was observed pushing R12 in his/her wheelchair toward his/her room, R12 was overheard saying, all I said was I had to go to the bathroom. On 6/10/25 at 10:58 a.m. in an interview with CNA1, a surveyor asked CNA1 to clarify what she said to R12, the surveyor asked if CNA1 asked R12 to say please before she would take him/her to the bathroom. The CNA1 stated she, asked [him/her] to say please. We just took [him/her], asked to go to the bathroom again, two person assist, I said okay, say please, because he gets very verbal, swearing. The surveyor confirmed with the CNA1 at this time that R12 was not treated with dignity and respect when she required R12 to say please before she would assist him/her. On 6/10/25 at 12:15 p.m. in an interview with the Administrator and Director of Nursing, a surveyor confirmed R12 was not treated with dignity and respect when CNA1 asked R12 to say please before she would assist him/her.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Based on facility policy review, record review, and interview, the facility failed to ensure that the resident and/or resident representative received assistance/follow up assistance to complete the w...

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Based on facility policy review, record review, and interview, the facility failed to ensure that the resident and/or resident representative received assistance/follow up assistance to complete the written information provided concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 1 of 16 residents reviewed for advanced directives. (Resident #22 [R22]). Finding: Review of facility policy Advanced Directives under the Optional Section: We will assist you to make an Advanced Directive . and by answering your questions about the forms. These services are available from the Social Service Director. On 6/11/25, a review of R22's electronic medical record was completed. The medical record lacked evidence that the facility offered assistance or followed up with the resident and/or resident representative concerning the right to accept or refuse medical or surgical treatment and to ensure the completion of the resident's advanced directive wishes.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the facility failed to ensure that a resident's physician was notified of a significant health change/abnormal lab result with a dieticians recommendation for 1 ...

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Based on record review and interviews, the facility failed to ensure that a resident's physician was notified of a significant health change/abnormal lab result with a dieticians recommendation for 1 of 1 resident reviewed (Resident #23 [R23]). Finding: On 6/9/25 at 1:44 p.m. R23's clinical record was reviewed, a nutrition/dietary note documented that R23 has a low albumin level with a suggestion/recommendation for 2 scoops of protein powder to be added to a beverage or soft vegetable such as mashed potato daily. Further review of R23's clinical record indicated that on 3/19/25 the facility wrote a communication to the provider with the problem listed as Albumin 3.0 and asked if they could get a diagnosis for protein/calorie malnutrition. On 3/19/25 R23 had the new diagnosis of protein/calorie malnutrition and was added to his/her diagnosis list. On 6/10/25 at 3:08 p.m. during an interview with a surveyor, the Director of Nursing (DON) stated that if the dietician made a recommendation/suggestion we would write it on a communication form for the provider and get an order. She stated that the dietician was reviewing the labs from March, 3/3/25, and she wrote a note in R23's clinical record. The dietician then gave the DON a handwritten note (DON showed the surveyor the note that was written for multiple residents with the suggestion/recommendation for 2 scoops of protein powder for R23. The DON stated that she is not sure how the suggestions/recommendations got missed but she has called the provider to let her know and they will start the order for the protein powder tomorrow. The surveyor confirmed this finding during this interview.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on clinical record reviews and interviews, the facility failed to follow physician orders for 1 of 16 residents reviewed. (Resident #30 [R30]). Finding: On 6/10/25 at 11:44 a.m., during a clini...

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Based on clinical record reviews and interviews, the facility failed to follow physician orders for 1 of 16 residents reviewed. (Resident #30 [R30]). Finding: On 6/10/25 at 11:44 a.m., during a clinical record review for R30 there is documentation that shows he/she had an order dated 5/29/25 for Boost (supplement) twice a day between meals with a diagnosis of protein, calorie malnutrition. The clinical record lacks evidence that R30 has received this supplement. During this clinical record review a physician progress note dated 6/2/25 that documents that R30 also has protein-calorie malnutrition with albumin of 2.6, decreased from 2.9 in February. Boost nutritional supplements twice daily was added to her regimen to increase caloric intake. The provider was not aware that R30 was not receiving the Boost supplement as ordered. A physician progress note dated 6/9/25 addresses R30's protein-calorie malnutrition and documents the Continuing nutritional supplement twice daily. Consider adding lactase enzyme before meals if there is any discomfort following meals. At this time R30 still had not been receiving the supplement as ordered. On 6/10/25 at 2:00 p.m. during an interview with the Director of Nursing, she stated she was not sure how this order got missed. The surveyor at this time confirmed that R30 was not receiving a supplement as ordered to treat his/her protein-calorie malnutrition.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed o...

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Based on record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders in a timely manner for 2 of 6 residents reviewed for unnecessary medications (Residents #14 [R14], and R23). Findings: 1. On 6/10/25, R14's clinical record was reviewed. A review of the physician visits and medication orders indicated that on 2/10/25, the first required 30-day physician visit (for a newly admitted resident) was completed and R14's admission orders were signed. On 2/24/25, the physician made a visit and medication orders signed. On 3/26/25, the second required 30-day physician visit (for a newly admitted resident) was completed and the medication orders signed. On 4/26/25, the third required 30-day physician visit was completed, but there was no evidence that the medication orders were signed at that visit. On 6/11/25 at 8:15 a.m., during an interview with the surveyor, the Director of Nursing (DON) confirmed that on 4/26/25 the physician made the last of the three 30-day required visits for new admissions, but did not sign the medication orders for that visit. 2. On 6/10/25, R23's clinical record was reviewed. A review of the physician visits and medication orders indicated that the last orders signed are dated 3/26/25 and were good for 60 days. On 6/2/25 R23 had a physician visit completed, but there was no evidence that the medication orders were signed at that visit. With the last orders signed on 3/26/25 they were due to be reviewed and renewed no later than 6/4/25which includes the 10-day grace period and as of 6/10/25 they were not signed and were 6 days late. On 6/10/25 at 2:43 p.m. during an interview with a surveyor, the DON stated that she had noticed today that R23's orders were not signed during the last physician visit. So, she called the physician and told her they needed to be signed that day. At this time the surveyor confirmed that R23's physician orders were not signed and were 6 days late.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to incorporate in a care plan the collaboration and responsibilities shared by the facility and Hospice for 1 of 2 Hospice residents reviewed ...

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Based on record review and interview, the facility failed to incorporate in a care plan the collaboration and responsibilities shared by the facility and Hospice for 1 of 2 Hospice residents reviewed (Resident #5 [R5]). Finding: On 6/10/25, a review of R5's clinical record was completed. Documentation in R5's clinical record indicated R5 is receiving Hospice services. Documentation in R5's care plan had a problem for terminal cancer and the name of the Hospice organization. There was no evidence of goals or interventions that indicated the collaboration of care between the facility and Hospice and there was no evidence of interventions that identified and directed the care between the two. On 6/10/25 at 2:00 p.m., in an interview with the surveyor, the Director of Nursing confirmed that Hospice responsibilities was not integrated in with facility care plan.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Based on interviews, the facility failed to ensure the Food Service Supervisor (FSS) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents (32...

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Based on interviews, the facility failed to ensure the Food Service Supervisor (FSS) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents (32 residents). Finding: On 6/9/25 at 10:45 a.m., during an interview with a surveyor, the FSS stated that she has been in this role for about one year. She stated that she does not have the qualifications for the job and that she is currently not enrolled in any qualifying course or a Managerial Servsafe course. She then stated the facility's dietician is on a consultant basis and comes in monthly. On 6/11/25 at 2:00 p.m., during an interview with the Administrator, the surveyor confirmed that the facility has failed to have a qualified Food Service Supervisor and uses a consultant dietician who is not employed by the facility in a full-time position.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

Based on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll dat...

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Based on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 2 2025 (January 1 - March 31, 2025). This has the potential to affect all residents (32 Residents). Findings: Interview with the Administrator on 6/9/25 at 10:30 a.m. revealed that he/she is the responsible person for the submission to CMS of staffing information based on payroll data. A document titled PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) 1705D FY (Fiscal Year) Quarter 2 2025 (January 1 -March 31) states that the facility Failed to Submit Data for the Quarter was triggered. Triggered' was defined as no data submitted for quarter. A facility document titled Daily Census, printed 6/9/25, documented there were 32 residents living in the facility. On 6/9/25 at 10:15 a.m. in an interview with a surveyor, the Administrator stated there were 32 residents living in the facility. On 6/11/25 at 1:51 p.m. in an interview with a surveyor, the Administrator revealed the expectation is that the facility submit to CMS the staffing information based on payroll data, the deadline was 5/15/25, and that they submitted the data on 5/15/25 missing the deadline for the last quarter by one day due to a change in staff.
Jul 2024 13 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition, when hospice services were discontinued for 1 of 1 sampled residents (Resident #5 [R5]). Finding: On 7/15/23, during a review of R5's clinical record, a surveyor could not find evidence that R5 was receiving hospice services even though the most recent MDS, dated [DATE], indicated under section O110-K1 that R5 was. On 7/15/24 at 1:17 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated that R5 ended hospice services on 6/3/24. The surveyor asked both the DON and MDS Coordinator if a significant change MDS was completed when hospice services ended and both replied no. The surveyor confirmed that when a resident comes off of hospice a significant change MDS needed to be done.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the facility failed to follow their fall protocol for neurological assessments and failed to follow physician orders for 1 of 1 residents reviewed for hospitaliz...

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Based on record review and interviews, the facility failed to follow their fall protocol for neurological assessments and failed to follow physician orders for 1 of 1 residents reviewed for hospitalization (Resident #22 [R22]). Finding: The facility's policy, Falls Protocol, undated, indicated that staff were to initiate Neuro Checks if a resident sustained a head injury and/or had an unattended fall and directed the licensed nurse to complete a Neurological Evaluation. The Neurological Assessment flowsheet directed staff to complete these every 15 minutes times (x) 4, 30 minutes x 4, 2 hours x 4, and every 4 hours x 4. On 7/16/24, R22's clinical record was reviewed and indicated that R22 had a fall on 6/8/24 at 7:30 a.m., bumped his/her head, and was sent to the hospital later in the day. A review of the Neurological Assessment flowsheet completed for R22 indicated that the assessments were not completed for the 9:45 a.m. and 10:15 a.m. assessment times, but were completed after those times up to 2:15 p.m., thereafter the resident was at the hospital. On 7/16/24 at 11:39 a.m., during an interview with a surveyor, Licensed Practical Nurse #1 (LPN1) stated she missed those assessments because she thought someone else was going to get them. R22's clinical record also included a physician order, dated 6/28/24, for Metoprolol (blood pressure medication) with parameters that directed staff to call the Medical Provider if R22's systolic blood pressure (SBP) was greater than 170. On 7/6/24 for the morning reading, the SBP was documented at 181 and on 7/15/24 for the morning reading, the SBP was documented at 267. The clinical record lacked evidence of the Medical Provider being called. On 7/16/24 at 11:21 a.m. during an interview with the Minimum Data Set (MDS) Coordinator and the Director of Nursing, a surveyor confirmed this finding. They were unable to find evidence that indicted the Medical Provider was notified each time.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on monthly schedule reviews and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 6 days of 2 months review...

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Based on monthly schedule reviews and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 6 days of 2 months reviewed for staffing (January and February 2024). Findings: On 7/17/24 at 8:20 a.m., a surveyor, Office Manager and Administrator, reviewed the schedules for January and February 2024. The following were confirmed: 1. For January, on 1/9/24, 1/11/24 and 1/29/24, the facility failed to ensure that an RN was working for 8 consecutive hours. 2. For February, on 2/9/24, 2/10/24 and 2/22/24, the facility failed to ensure that an RN was working for 8 consecutive hours.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on review of Employee Job Performance Evaluations and interview, the facility failed to complete an annual performance evaluation at least every 12 months, for 2 of 5 sampled Certified Nursing A...

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Based on review of Employee Job Performance Evaluations and interview, the facility failed to complete an annual performance evaluation at least every 12 months, for 2 of 5 sampled Certified Nursing Assistants (C.N.A.) employed greater than 1 year (Certified Nurse Assistant #2 [C.N.A.2] and Certified Nurse Assistant-Medications [C.N.A.-M]). Findings: On 7/17/24 at 10:00 a.m., a surveyor and Administrator reviewed C.N.A.2 and C.N.A.-M's employee files with the following confirmed: 1. C.N.A.2 was hired on 5/9/2018. The annual evaluation was due by 5/9/2024. There was no evidence that the evaluation had been completed as of 7/17/2024. 2. C.N.A.-M was hired on 8/17/2009. The annual evaluation was due by 5/9/2023. There was no evidence that the evaluation had been completed as of 7/17/2024.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for one trash dumpster for 1 of 3 days ...

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Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for one trash dumpster for 1 of 3 days of survey (7/17/24). Finding: On 7/17/24 at 7:40 a.m., a surveyor observed a trash dumpster with the top right lid open with two black bags on top of the dumpster exposing trash. On 7/17/24 at 7:44 a.m., in an interview and observation of the trash dumpster with the Administrator, a surveyor confirmed the above finding.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated 2023-2024 Coronavirus (COVID-19) vaccine for 1 of 5 residents reviewed (Resident #28 [R28]). Finding: On 7/16/24 at 9:02 a.m., clinical record review indicated R28 was admitted on [DATE] and is currently [AGE] years old. R28's last documented COVID-19 vaccination was on 4/28/22. There was no evidence R28 had received, been offered, or refused the COVID-19 vaccination. On 7/16/24 at 1:45 p.m., review of the Influenza, Pneumococcal, and COVID-19 Immunization Policy indicated each resident is offered a COVID-19 immunization unless the immunization is medically contraindicated, or the resident has already been immunized. On 7/16/24 at 1:36 p.m., in an interview with a surveyor, the Director of Nursing (DON) stated she uses the CDC website as a resource. Review of the CDC website, Stay Up to Date with COVID-19 Vaccines | CDC, indicated that CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19 and that people aged 65 years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose, and that you are up to date when you have received 2 updated 2023-2024 COVID-19 vaccine doses. On 7/17/24 at 8:23 a.m., in an interview with the DON, a surveyor confirmed the COVID-19 vaccine was not offered to R28.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations and interview, the facility failed to store food in a sanitary manner on 1 of 3 survey days, and the facility failed to keep accurate and complete temperature logs of the walk-in...

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Based on observations and interview, the facility failed to store food in a sanitary manner on 1 of 3 survey days, and the facility failed to keep accurate and complete temperature logs of the walk-in refrigerator, walk-in freezer, and refrigerator/freezer in the kitchen (7/15/24). Findings: On 7/15/24 from 10:35 a.m. through 11:10 a.m. during the initial observation of the kitchen with the Food Safety Supervisor (FSS), it was observed: 1. Thirty chocolate Hormel Magic dessert cups and thirty-five vanilla Hormel Magic dessert cups in the freezer portion of the refrigerator/freezer had a thick buildup of ice crystals around them, and one chocolate Hormel Magic dessert cup was open. Approximately half of the dessert cups were affected by the thick buildup of ice crystals. 2. Two large bins/containers of white dry substances (flour and sugar per interview during observation with the FSS) not labeled or dated in kitchen to the left of the oven. 3. One bag of confectioner sugar open and not dated, and one large open box of chocolate chips in an open bag inside the box, not sealed, and not dated in the dry goods storage room. 4. Walk-in freezer temperatures were missing from the temperature log sheet posted on the walk-in freezer for 7/13/24, 7/14/24, and 7/15/24. 5. Walk-in refrigerator temperatures were missing from the temperature log sheet posted on the walk-in refrigerator for 7/13/24, 7/14/24, and 7/15/24. 6. Refrigerator/freezer temperatures were missing from the temperature log sheet posted on the refrigerator/freezer for 7/13/24, 7/14/24, and 7/15/24. In an interview with the FSS at time of observation, a surveyor confirmed the above findings. The FSS states the temperatures were last done on 7/12/24, and it is supposed to be done by the cook.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on record review and interviews, the facility failed to develop a water management program to prevent the growth and spread of legionella and other water-borne pathogens, and the facility failed...

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Based on record review and interviews, the facility failed to develop a water management program to prevent the growth and spread of legionella and other water-borne pathogens, and the facility failed to develop policy and procedures for enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms. Findings: 1. On 7/16/24 at 1:36 p.m., a surveyor and the facility's Director of Nursing (DON) reviewed the facility's infection control policies. The DON stated there is not a policy for enhanced barrier precautions. The surveyor confirmed at this time that the facility did not have policy and procedures for enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms 2. On 7/16/24 at 1:36 p.m., in an interview with a surveyor, the DON stated not knowing of a water management policy for legionella and directed the surveyor to the Administrator. On 7/17/24 at 8:27 a.m., in an interview with a surveyor, the Maintenance Technician stated he did not know of a program that identifies where standing water would be and referred to the Administrator. On 7/17/24 at 8:49 a.m., in an interview with the Administrator, the surveyor confirmed the facility has not completed a risk assessment to determine potential areas of microbial growth, and there is not a policy or procedure for Legionella and other water-borne pathogens.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview, the facility failed to offer Pneumococcal Vaccinations (Prevnar 2...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview, the facility failed to offer Pneumococcal Vaccinations (Prevnar 20) to 3 of 5 residents reviewed (Resident #10 [R10], R28, and R32). Findings: On 7/16/24 at 9:02 a.m., clinical record review indicated: 1. R10 was admitted on [DATE]. There was no evidence R10 had received, been offered, or refused the Prevnar 20 vaccination. 2. R28 was admitted on [DATE]. There was no evidence R28 had received, been offered, or refused the Prevnar 20 vaccination. 3. R32 was admitted on [DATE]. There was no evidence R32 had received, been offered, or refused the Prevnar 20 vaccination. On 7/16/24 at 1:45 p.m., review of the Influenza, Pneumococcal, and COVID-19 Immunization Policy indicated, each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. On 7/17/24 at 8:23 a.m., in an interview with the DON, a surveyor confirmed the Prevnar 20 vaccine was not offered to R10, R28, and R32.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

Based on employee file reviews and interviews, the facility failed to ensure that a Certified Nursing Assistant (C.N.A.) received at a minimum 12 hours of annual in-service training that included abus...

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Based on employee file reviews and interviews, the facility failed to ensure that a Certified Nursing Assistant (C.N.A.) received at a minimum 12 hours of annual in-service training that included abuse prevention, resident rights and dementia for 1 of 5 Certified Nursing Assistants (C.N.A.s) reviewed (Certified Nurse Assistant #1 [C.N.A.1]). Finding: On 7/17/24 at 9:45 a.m., a surveyor, the Office Manager and Administrator reviewed C.N.A.1's employee file for in-service training during C.N.A.1's annual evaluation period from 2/21/23 to 2/21/24. There was no evidence that C.N.A.1 completed abuse training, resident rights or dementia in-servicing for her annual evaluation period. The Office Manager and Administrator confirmed this finding at the time of review.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0568 (Tag F0568)

Minor procedural issue · This affected multiple residents

Based on interviews and record reviews, the facility failed to ensure quarterly statements were provided to the Resident or Resident representative for 1 of 1 Resident with a trust account (Resident #...

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Based on interviews and record reviews, the facility failed to ensure quarterly statements were provided to the Resident or Resident representative for 1 of 1 Resident with a trust account (Resident #8 [R8]). In addition, the facility failed to ensure quarterly statements were provided to all Residents or Resident representatives with trust accounts. Finding: On 7/15/24 at 12:25 p.m. during a resident interview, R8 stated that he/she did not recall receiving any quarterly statements with an accounting of his/her resident trust account. On 7/17/24 at 8:41 a.m. during an interview with a surveyor, the Accountant stated they were unable to find documentation to support that R8 was sent his/her quarterly statements and that quarterly statements are not sent out to Residents unless a statement is sent with a cost of care statement or their trust account drops to a negative balance. A surveyor confirmed, at this time, with the Accountant that R8 did not receive any quarterly statements, and that quarterly statements are not sent out to Residents or Resident representatives.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected multiple residents

Based on observations and interview, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the fa...

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Based on observations and interview, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility in 2 of 2 survey folders (located in the dining room and entrance foyer). Findings: On 7/16/24 at 8:15 a.m., a surveyor observed the survey folder located in the dining room, located on a rack on the wall. This folder included the State Survey results, with the most recent results from a survey dated 2/11/20, although the State Agency had completed multiple surveys after that date. On 7/16/24 at 8:20 a.m., during an interview with a surveyor, the Administrator stated there were two survey folders, one in the dining room and one in the entrance foyer area for family members, The Administrator and surveyor observed both survey folders with the most recent survey in the entrance foyer folder was 5/11/23, although the State Agency had completed an additional survey after that date on 3/5/24; the Administrator and surveyor also observed the folder in the dining room with the most recent survey dated 2/11/20. During these observations, the surveyor confirmed that both survey folders did not contain the most recent surveys in them.
MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Annual Minimum Data Set (MDS) 3.0 was coded accurat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Annual Minimum Data Set (MDS) 3.0 was coded accurately on two annual MDS assessments to indicate that a resident had a State Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 sampled residents reviewed for PASRR (Resident #21 [R21]). Finding: On 7/15/24, R21's clinical record was reviewed and included a PASSR, dated 3/4/20, that indicated that R21 qualified for Level II services. Review of R21's annual MDS, dated [DATE], Section: A1500 was coded to indicate that R21 did not have a Level II PASRR and had been coded incorrectly starting with the 8/12/22 annual MDS. On 7/16/24 at 10:12 a.m., during an interview with a surveyor, the MDS Coordinator stated that R21 did have a Level II PASRR and that the MDS was coded inaccurately. The surveyor confirmed this finding during this interview.
Mar 2024 1 deficiency 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide necessary assistance to prevent accidents by failing to en...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide necessary assistance to prevent accidents by failing to ensure that a two-person mechanical lift assist was provided during transfer for 1 of 1 resident (Resident#1 [R1]) reviewed for an incident with injury. This fall resulted in R1 falling during an improper transfer from bed to shower chair and R1 sustaining a fractured left arm and left ankle. Findings: On 3/5/24, R1's clinical record was reviewed. The record indicated R1 was diagnosed with dementia, weakness, neuropathy, limited mobility, and other morbidities. On 12/7/23 at 1:30 p.m., a nurse note indicated: C.N.A.1 had another staff member tell writer (Registered Nurse [RN]) to come to residents' room immediately. Resident was laying supine on floor by his/her bed, C.N.A.1 stated that one corner of the Hoyer sling came undone and resident fell to the floor hitting his/her left shoulder and leg. Resident complained of severe left leg/shoulder pain. On 12/12/23, the Nurse Practitioner documented in her progress note that R1 fell on [DATE] and came back from the Emergency Department (ED) on 12/7/23 with a fractured left humerus(upper arm bone). R1 continued to complain of pain in left leg. On 12/11/23, an x-ray was done and a fractured left ankle was discovered. R1's care plan for December 2023 and current care plan, under the problem of Activity of Daily Living/self performance deficit (initiated 2020) indicated, Resident requires total assist with Hoyer lift by two staff with transfers. A review of the facility Employee Safety policy and procedure, dated 12/7/23, under Employee Instructions: Two staff members must assist at all times during the movement of residents, including using lifting devices and equipment. On 3/5/24 at 10:15 a.m., interview with Registered Nurse (RN). RN stated the following, I was Charge Nurse that morning. C.N.A.2 came and got me and said R1 had fallen out of the Hoyer lift. I got to the room and R1 was lying on his/her left side across the legs of the Hoyer lift. R1 was in a lot of pain. The Emergency Medical Technicians (EMT's) arrived but couldn't move him/her due to pain. They waited for a Paramedic to get here, and the Paramedic gave him/her morphine for pain, then transported. C.N.A.1 transferred R1 by herself and she shouldn't have done that. There were other staff here that could have helped her. On 3/5/24 at 10:40 a.m., interview with Certified Nurse Assistant (C.N.A.1). C.N.A.1 stated the following, I know I shouldn't have transferred her by myself. The other girls were busy and my Charge Nurse said R1 had to have a shower. I could have waited for someone to help me, but my Charge Nurse wanted her to have a shower. I got her on the Hoyer pad and started to lift R1 up. I was guiding his/her feet over the bed to get to the shower chair and down R1 went. On 3/5/24 at 10:55 a.m., interview with Certified Nurse Assistant (C.N.A.2). C.N.A.2 stated the following, I have never Hoyered a resident by myself. The policy says two people and that is how I do it. C.N.A.1 called for me to get the nurse the day R1 fell out of the Hoyer. C.N.A.1 transferred R1 by herself. As a result of this isolated incident, the following corrective actions were initiated between 12/7/23 and 12/12/23: On 12/7/23 (day of incident), the Administrator and Maintenance Supervisor removed the Hoyer lift used in the incident from use and assessed for any malfunction with the lift and parts. Non were found. In addition, the Hoyer lift sling used in the incident was removed from service and all other Hoyer slings were assessed for any damage. On 12/7/23 at 2:45 p.m., at shift change the Administrator demonstrated to the nursing staff the proper way to use the Hoyer lift. On 12/8/23, the Administrator provided nursing staff with the facility Hoyer lift policy and procedure and a test that they were mandated to complete. On this date, the Administrator demonstrated to the nursing staff the proper way to use the Hoyer lift. On 12/12/23, the Administrator provided nursing staff, that had not attended any previous training, with the facility's Hoyer transfer policy and procedure and test. The Administrator demonstrated to the nursing staff the proper way to use the Hoyer lift. On 3/5/24 at 9:50 a.m., in an interview with the DON, she stated that all the C.N.A.'s and nurses reviewed the Hoyer lift transfer policy and took a written test. She stated that after C.N.A.1 was trained, she was observed/audited doing Hoyer transfers and other staff were randomly audited as well.
May 2023 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 2 Units. (A-Unit and B-Unit) for 1 of 1 environmental tours. In addition, the facility failed to maintain a sanitary and clean nebulizer machine for 1 of 1 resident nebulizer machines observed (Resident #5). On 5/11/23 at 9:45 a.m., a surveyor did an environmental tour with the facility Administrator in which the following were observed: A-Unit room [ROOM NUMBER]: Bed-1's resident fan that blows on the resident's bed is heavily soiled with clumps of dust. room [ROOM NUMBER]: To the left of Bed-1, the floor is stained with a rust colored substance. The tiles under the sink are separated creating an uncleanable surface. room [ROOM NUMBER]: Bed-1, To the left of the room sink, the molding is chipped. To the right of the bathroom door, the cove base is missing. B-Unit room [ROOM NUMBER]: Above the room sink, a ceiling tile is stained. Bed-2's bedside table corners are chipped creating uncleanable surfaces. room [ROOM NUMBER]: Resident #5's nebulizer machine is soiled with dirt and debris. This was confirmed with the surveyor by the Assistant Director of Nursing on 5/11/23 at 12:09 p.m.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

2. Resident #32's clinical record was reviewed and included a physician order, dated 5/8/23 7:00 a.m., for the medication Ertapenem Sodium (an antibiotic medication to treat serious infections) Inject...

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2. Resident #32's clinical record was reviewed and included a physician order, dated 5/8/23 7:00 a.m., for the medication Ertapenem Sodium (an antibiotic medication to treat serious infections) Injection Solution Reconstituted 1 GM (gram) Inject 1 gram intramuscularly (in the muscle) one time a day for infection for 4 days mix with 1% lidocaine (a numbing medication) 3.2 cc (cubic centimeters), per Medical Doctor. - start date- 5/8/23 7:00 a.m., Resident #32's Treatment Administration Record (TAR) was reviewed and lacked evidence that the ordered medication Ertapenem Sodium was given on 5/8/23. On 5/8/23 at 10:39 a.m., a progress note titled, orders - Administration Note stated, have not received. Review of Resident #32's hospital discharge medication list dated 5/7/23 at 10:46 p.m. was documented that a prescription Ertapenem 1 GM injection powder for solution, 1 grams intramuscular Q24HR (every 24 hours), mix with 3.2 cc 1% lido (lidocaine), was sent to Omnicare of Maine. On 5/10/23 at 3:58 p.m. during an interview with the DON, a surveyor confirmed this finding. 3. Resident #32's clinical record was reviewed and included a physician order, dated 5/9/23 for Dificid (an antibiotic medication to treat infection) Oral Tablet 200mg (generic: Fidaxomicin) Give 1 tablet by mouth two times a day for cdiff (clostridium difficile) for 3 days per medical doctor. Resident #32's TAR was reviewed and lacked evidence that the ordered medication Dificid was given on 5/9/23. On 5/9/23 at 19:17 (7:17 p.m.) a progress note titled, orders - Administration Note stated, drug NA (not available) from PHX (pharmacy). Review of Resident #32's hospital discharge medication list dated 5/7/23 at 10:46 p.m. was documented that a prescription Dificid 200MG oral tablet (Generic: Fidaxomicin), 1 tablet by mouth twice a day with instructions x 3 days, was sent to Omnicare of Maine. The provider progress note dated 5/9/23 at 3:50 p.m. stated that Resident #32 is taking Ertapenem and Fidaxomicin. The progress note does not address that the provider is aware that Resident #32 has not received either antibiotic as ordered since returning to the facility after hospital discharge. On 5/10/23 at 3:58 p.m. during an interview with the DON, a surveyor confirmed this finding. The DON stated she was not working on 5/8/23, and she will contact the provider regarding missing doses of the antibiotics, Ertapenem and Fidaxomicin. Based on observation, record reviews, and interviews the facility failed to ensure that physician orders were followed for 1 of 5 resident's (Resident #15) observed during medication administration, and 1 of 5 resident's reviewed for unnecessary medications (Resident #32). 1. On 5/8/23 at 6:21 p.m., during a medication administration observation for Resident #15, who had an order for Metoprolol 50 milligrams (mg) twice a day with directions to hold if pulse is below 60. The Certified Nursing Assistant Medication aide (CNA-M) prepared his/her medications for administration. The CNA-M went into the resident's room and administered the Metoprolol 50 mg without taking Resident #15's pulse. The surveyor questioned the CNA-M about not taking the pulse before administering the Metoprolol and he stated that the order had been discontinued. The surveyor and the CNA-M reviewed the orders on the Electronic Medication Administration Record (E-MAR) and the directions to hold if pulse is below 60 showed as an active order. On 5/8/23 at 6:47 p.m., the surveyor asked the Charge Nurse if Resident #15 had an active order for Metoprolol with directions to hold if pulse is below 60. The Charge Nurse and the surveyor reviewed Resident #15's physician orders and it was noted that the directions to hold the medication Metoprolol if pulse was below 60 was still an active order. During the interview with the Charge Nurse the surveyor confirmed the above finding.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to label whipped topping with a thaw date on 1 of 4 days of survey (5/9/23), in addition the facility failed to label and date food in the resid...

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Based on observation and interview, the facility failed to label whipped topping with a thaw date on 1 of 4 days of survey (5/9/23), in addition the facility failed to label and date food in the resident's refrigerator located in the kitchenette on 1 of 4 days of survey (5/9/23). Findings: 1. On 5/9/23 at 8:21 a.m., during the initial tour of the kitchen, the surveyor found in the walk-in refrigerator 3 packages of thawed whipped topping with no thaw date. The storage instructions on the packages are that the item has a 2-week (14 day) shelf life once thawed. There is no evidence of when these whipped toppings were thawed. On 5/9/23 at 9:00 a.m., the surveyor confirmed this finding with the Food Service Manager. 2. On 5/9/23 at 9:30 a.m., during an observation of the residents kitchenette, the surveyor found 2 containers in the refrigerator that were unlabeled (name and date). On 5/9/23 at 9:41 a.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that the containers were not labeled with a name and date. The DON asked staff members if they knew what the items were and who they belonged to. The staff stated they had been in there before the weekend and they did not know who they belonged to or what they were.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to inform a resident or their representative, of a treatment that would be held due to unavailability for 1 of 1 resident reviewed. (Resident ...

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Based on record review and interview, the facility failed to inform a resident or their representative, of a treatment that would be held due to unavailability for 1 of 1 resident reviewed. (Resident #12). Finding: On 5/10/23 during a clinical record review for Resident #12, it was observed that he/she has an order for Imatinib Mesylate 400 milligrams (mg) give 1 tablet by mouth one time a day (at breakfast) for Chronic Myeloid Leukemia. This medication is used to manage and treat chronic myelogenous leukemia. Resident #12's clinical record indicated that he/she last received this medication on 2/3/23. On 2/4/23, his/her clinical record reflects that the order for Imatinib was documented as not being available and Resident #12 did not receive that dose. On 2/6/23, the facility was made aware that this medication is not covered by his/her insurance and the pharmacy was not able to send the medication to the facility. Resident #12's clinical record in the section labeled Progress notes (nursing notes), documents that on 2/13/23, the facility made the resident and his/her Power of Attorney (POA) aware that the medication Imatinib was not covered by his/her insurance and what the weekly cost of the medication would be. The clinical record indicated that the resident and his/her POA were made aware 10 days after the medication became unavailable. On 2/13/23, the POA requested that the facility make the oncologist aware of Resident #12 not receiving this medication as ordered. During further review of the clinical record, the record indicated that the medication was held from 2/4/23 to 3/25/23, for a total of 50 days/doses that were held. On 5/10/23 at 3:04 p.m., during an interview with Director of Nursing, the surveyor confirmed that the resident and his/her POA were not made aware of this significant medication not being available until 10 days (10 missed doses) after his/her last dose. And 7 days after the facility was made aware that his/her insurance would not cover the cost of this medication.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

Based on record review and interview the facility failed to notify a Practitioner and an Oncologist of resident changes in medications not being received due to unavailability for 1 of 1 resident revi...

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Based on record review and interview the facility failed to notify a Practitioner and an Oncologist of resident changes in medications not being received due to unavailability for 1 of 1 resident reviewed (Resident #12) Findings: On 5/10/23 during a clinical record review for Resident #12, it was observed that he/she has an order for Imatinib Mesylate 400 milligrams (mg) give 1 tablet by mouth one time a day (at breakfast) for Chronic Myeloid Leukemia. This medication is used to manage and treat chronic myelogenous leukemia. During a clinical record review, the electronic medication administration records for February and March indicated that the medication was held from 2/4/23 to 3/25/23, for a total of 50 days/doses The clinical record shows that on 2/14/23, the Practitioner was made aware of the medication not being available due to not being covered by insurance and wrote an order will hold until available. The Practitioner was made aware 11 days after his/her last dose was received. During further review of Resident #12's clinical record, it showed evidence that on 2/21/23 at 12:04 p.m., the oncology office was made aware of Resident #12 not receiving the medication Imatinib; 18 days after the last dose received. On 5/11/23 at 9:45 a.m., during an interview with the Director of Nursing, the surveyor confirmed that Resident #12's Practitioner was not made aware until 2/14/23, when they obtained an order to hold the medication until available, 11 days after the last dose was received and his/her Oncologist was not informed until 2/21/23; 18 days after the last dose was received
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

2. Review of facility protocol for C-diff stated, Protocol for C-diff - 6. Housekeeping is notified of infected resident and a system is to be set up to ensure that the resident's room is decontaminat...

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2. Review of facility protocol for C-diff stated, Protocol for C-diff - 6. Housekeeping is notified of infected resident and a system is to be set up to ensure that the resident's room is decontaminated with bleach. 3. On 5/10/23 at 12:35 p.m., a review of the facility's Protocol for C-diff disinfection was discussed with the DON/IP. The DON/IP confirmed that Resident #32's room was not cleaned with bleach, the appropriate cleaner for C-diff according to the facilities cleaning policy after contact precautions for Resident #32 for C-diff were removed on 5/9/23 at 8:29 a.m. Based on record review, review of the facility's Infection Prevention and Control Policy (IPCP) and interviews, the facility failed to conduct an annual overall review of the facility's Infection Prevention and Control Policy for 1 of 1 IPCP review. In addition, the facility failed to follow it's cleaning policy for a resident diagnosed with Clostridium difficile (C-diff) (a bacterium that causes an infection in the large intestines) for 1 of 1 resident reviewed with C-diff (Resident #32). Findings: 1. On 5/10/23 at 10:03 a.m., a review of the facility's Infection Prevention and Control Program was discussed with the Director of Nursing/ Infection Preventionist (DON/IP). The DON/IP confirmed that the Infection Prevention and Control Program has not been reviewed yearly.
MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

Based on observations and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and ...

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Based on observations and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care for 3 of 4 survey days, and the facility failed to keep a copy of the posted daily nurse staffing information for 18 months. (5/8/23, 5/9/23, and 5/10/23) Findings: 1. On 5/8/23 at 6:15 p.m., a surveyor observed that the nurse staffing information located at the nurses station was posted on an erasable white board. The nurse staffing information posted did not include the name of the facility, the total number of hours and the actual hours worked for registered and unlicensed nursing staff responsible for direct resident care for 5/8/23. 2. On 5/9/23 at 8:22 a.m., a surveyor observed that the nurse staffing information located at the nurses station was posted on an erasable white board. The nurse staffing information posted did not include the name of the facility, the total number of hours and the actual hours worked for registered and unlicensed nursing staff responsible for direct resident care for 5/9/23. 3. On 5/10/23 at 10:22 a.m., a surveyor observed that the nurse staffing information located at the nurses station was posted on an erasable white board. The nurse staffing information posted did not include the name of the facility, the total number of hours and the actual hours worked for registered and unlicensed nursing staff responsible for direct resident care for 5/10/23. 4. On 5/10/23 10:22 a.m., a surveyor requested to review previous posted nursing staffing information sheets, it was revealed, at this time, that the Director of Nursing (DON) has not been keeping the previous daily nurse staffing information. In an interview with a surveyor, the DON stated that she was unaware that they needed to be kept for a minimum of 18 months. A surveyor confirmed the finding at this time. On 5/10/23 at 10:22 a.m., in an interview with the Director of Nursing (DON) stated that she does not keep a copy of the posted list.
Dec 2022 3 deficiencies 1 IJ
CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the Emergency Medical Services Patient Care Report, the facility failed to supe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the Emergency Medical Services Patient Care Report, the facility failed to supervise and monitor 1 of 2 (Resident #1) wandering resident resulting in the resident eloping from the facility; wandered a mile away from the facility, going over a bridge and being found in a traffic rotary. Because of the facility's failure, the resident eloped; during this elopement the resident had a fall and sustained a head abrasion, cuts, and bruises. Finding: On 11/15/22, a review of Resident #1's clinical record was completed. Resident #1 was admitted in September 2022 with a diagnosis of Dementia with behaviors. A Wandering Risk Assessment was completed the day after admission and indicated Resident #1 was a moderate risk for wandering. On 9/11/22, staff observed Resident #1 exit through the front door (door did alarm) and resident re-directed back into facility without incident. On 11/3/22, staff observed Resident #1 exit through the front door (door did alarm) and resident re-directed back into facility without incident. On 11/8/22 at approximately 10:30 a.m., staff observed Resident #1 exit through the B-Wing side door (door did alarm) and resident re-directed back into facility without incident. On 11/8/22 in the afternoon, Resident #1 eloped. Documentation on the facility's elopement investigation indicated that on 11/8/22 at 1:15 p.m., Resident #1 was observed at the nurse's station. At 1:45 p.m., a daughter came to visit and was unable to locate Resident #1. A facility wide search was conducted, and the resident was not located. At 1:49 p.m., an off-facility search was initiated. At 2:05 p.m., a member of the local ambulance crew notified the facility that Resident #1 was located at the traffic rotary and transported to an acute care facility from that location. On 11/14/22 at 10:02 a.m., in an interview with Resident #1's Daughter #1, she related that when she saw Resident #1 in the emergency room, he/she was more confused than usual and had an abrasion on his/her head and bruises on both legs. On 11/14/22 at 11:12 a.m., in an interview with hospital Licensed Social Worker, she stated the resident eloped approximately a mile away from the building. At some point during the elopement the resident fell and sustained an abrasion on her head, cuts, and bruises on her legs. On 11/15/22 at 12:23 p.m., in an interview with the Charge Nurse-Registered Nurse #1 (RN #1), she stated that on the morning of 11/8/22, Resident #1 had been telling staff that he/she was going home. RN #1 stated staff were made aware to monitor Resident #1 closely. RN #1 stated it was a busy day, the Physician was in, and a birthday party was going on in the Long-Term Care (LTC) dining room. RN #1 stated that around 1:00 p.m., Certified Nursing Assistant #1 (C.N.A. #1) served Resident #1 lunch in his/her room. RN #1 stated the resident was at the nurse's station at 1:15 p.m. RN #1 stated all staff were monitoring her. RN #1 stated she felt Resident #1 went thought the LTC/Residential Care (RC) adjoining door and left the building from the RC front door. She stated there were no staff assisting the RC residents over, they are independent and didn't require assistance. Most aides were assisting residents at the party in the dining room. RN #1 stated Resident #1 must have slipped by the RC residents and left through the RC front door. RN #1 stated after 1:15 p.m., staff were unaware of Resident #1's whereabouts until 2:05 p.m. when she heard from a local ambulance crew member that the resident was located a mile from the facility. RN#1 added that she and Resident #1's Physician had discussed the residents care that morning and medication changes were made and a new Wandering Risk Assessment indicated Resident #1 had gone from a moderate risk for wandering to a high risk for wandering. On 11/15/22 at 1:33 p.m., in an interview with Housekeeper #1. She stated that she was aware of Resident #1 wanting to go home on [DATE]. She stated she was the staff person that observed the resident leave the building in the morning and she re-directed the resident back into the facility. She stated the door alarm did go off. She stated all staff were made aware that Resident #1 was talking about leaving. The Housekeeper stated she was unsure how Resident #1 got out of the building that afternoon but thought maybe through the door that adjoins RC. Documentation on the Emergency Medical Service (EMS) Patient Care Report, dated 11/8/22 at 1:49 p.m., indicated a passerby reported to the EMS that an elderly woman (Resident #1) was seen walking in the traffic rotary and appeared to be confused. Initially it was reported by someone who stopped into the station. Paramedic #1 went out via private vehicle to look for reported patient (Resident #1). Paramedic #1 found patient walking around the rotary in the middle of the road. Paramedic #1 then requested EMS response due to patient being confused. Patient alert to his/her name but does not know where he/she is. Patient had dried blood above his/her right eye and just below his/her right eye. Patient denies pain to his/her head, neck and back. On 11/15/22 at 1:45 p.m., in an interview with the Administrator, he stated all the facility doors have working alarms. Two of these doors have keypads and require a code to open. The one keypad door located in the rear of the building also has an alarm. He stated there is one door that adjoins the LTC building with the RC building. He stated the adjoining door has a keypad on the LTC side and cannot be opened from the LTC side without a code, however, the RC side of the door has no keypad and no alarm and can be opened on the RC side at any time. He stated the RC residents have always been able to freely come over to the LTC side to join in activities and visit. He stated most likely Resident #1 exited through the adjoining door because on the afternoon of 11/8/22, the LTC side was having a birthday party and many RC residents were coming over to join in. Resident #1 could have walked by the RC residents who were holding the door open for each other as they entered LTC. The Administrator stated there has never been an issue prior to this. This was the first time a LTC resident exited the building from the RC side. The Administrator confirmed that no staff were at the adjoining door at the time Resident #1 eloped through. Based on the above information, Immediate Jeopardy (IJ) was called on 11/29/22 for the facility's failure to ensure that a resident who was known for wandering and exit seeking was monitored and supervised. The facility's failure to provide these services constituted and immediate jeopardy situation. Please see F-0000 Initial Comments related to the IJ removal plan. Review of the facility policy titled Procedure/Protocol for Resident Elopement states .When a resident is noticed to be randomly moving about with purpose and a staff person is concerned that the resident may go outside the building unsafely, staff should do the following; 1. Report any concerns immediately to the Charge Nurse/Director of Nursing. Charge Nurse will; 1. Implement Elopement Care Plan 2. Put wrist or personal alarm on resident 3. Complete Elopement Assessment Form If a resident has eloped staff will follow procedure for missing resident
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to provide in writing a discharge notice including notice of appeal rights after refusing to take back a resident from the hospital emergency ...

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Based on record review and interview, the facility failed to provide in writing a discharge notice including notice of appeal rights after refusing to take back a resident from the hospital emergency department/hospital for 1 of 1 resident reviewed (Resident #1). Finding: On 11/14/22 at 10:02 a.m., in an interview with Resident #1's daughter #1/Power of Attorney (POA), she stated that on 11/8/22 at approximately 1:45 p.m., Resident #1 eloped from the facility and ended up in a hospital emergency department. While in the emergency department, another daughter#2/POA was notified by the facility Social Worker that Resident #1 was not allowed to return to the facility because they couldn't keep her safe. Daughter #1 stated that no one in her family received a written discharge notice with appeal rights. On 11/15/22, a review of Resident #1's clinical record was completed. There was no documentation describing what resident needs could not be met; what attempts the facility had made to meet those needs and why the resident was not allowed to return to the facility. There was no documentation as to what safety measures had been put in place prior the the facility initiated discharge and no documented evidence that a written discharge notice with appeal rights was provided in writing to the Resident Representatives and the Long term Care Ombudsman. On 11/8/22 at 8:45 a.m., in an interview with the surveyor, the Administrator confirmed that he did not provide Resident #1's Representatives or the Ombudsman with a written facility initiated discharge notice and appeal rights.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to develop a person-centered care plan based on the Care Area Assessment (CAA) for the behavior of wandering for 1 of 2 resident reviewed for ...

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Based on record review and interview, the facility failed to develop a person-centered care plan based on the Care Area Assessment (CAA) for the behavior of wandering for 1 of 2 resident reviewed for behaviors/wandering (Resident #1). Finding: On 11/15/22, a review of Resident #1's admission Minimum Data Set (MDS) 3.0 assessment, dated 7/29/22 was completed. The 9/20/22 MDS 3.0 was coded in Section E: E0900 - #2 that wandering occurred 4-6 days. The Care Area Assessment (CAAs) for Behaviors was triggered to proceed to care plan for the behavior of wandering. There was no care plan for wandering found in Resident #9's clinical record. On 11/15/22 at 11:44 a.m., in an interview with the Administrator, he confirmed that a care plan for Resident #1's wandering had not been developed.
Nov 2022 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record reviews, the facility failed to promptly notify the resident's physician after an injury of unknown origin was found (dark purple bruising with swelling from eyebrow to jaw line on lef...

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Based on record reviews, the facility failed to promptly notify the resident's physician after an injury of unknown origin was found (dark purple bruising with swelling from eyebrow to jaw line on left side of face) for 1 of 1 sampled resident (#1). Finding: On 9/15/22 Resident #1's was found on the blue unit, his/her face was black and blue and swollen on the left side. Resident denied falling and incident report documents that he/she would not be able to get up on his/her own as they need assistance to get up. The incident report documents that the Director of Nursing and residents daughter was made aware. On page 3 of the facility's reportable incident form has the question Was the Physician notified? the No box is marked indicating physician was not notified. The nursing note dated 9/15/22 for 10:00 p.m. documents that the bruising on the left side of his/her face extends from the eyebrow down to the chin. The residents daughter was notified, and the Director of Nursing was called. There is no evidence that the residents physician was made aware of this incident or bruising. On 11/30/22 at 5:32 p.m., the surveyor confirmed with the Administrator the incident report and the nursing notes do no provide evidence that the physician was made aware of the injury or of the facial bruising.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review the facility failed to ensure the facility's investigation for an injury of unknown origin was sent to the State Agency within 5 working days of the incident for 1 of 1 resident...

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Based on record review the facility failed to ensure the facility's investigation for an injury of unknown origin was sent to the State Agency within 5 working days of the incident for 1 of 1 resident reviewed for Injury of Unknown Origin. (Resident #1) Finding: A review of the facility's Reporting Resident Abuse policy, revised on 4/25/2016 which includes violations involving mistreatment, neglect, injuries of unknown origin and/or misappropriation of residents property under In-House investigation states the results of the investigation are reported to the State Agency within 5 working days of the incident, On 9/15/22., the facility initially reported to the State Agency an injury of unknown origin report. On 11/29/22, the facility was not able to verify nor provide evidence that an investigation was completed, and a 5-day report was sent to the State Agency on this incident. On 11/29/22 at approximately 4:00 p.m. the surveyor confirmed with the Assistant Director of Nursing the facility could not find the completed investigation and could not find a 5-day report of the incident.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record reviews and interview, the facility failed to follow physician orders for 1 of 4 sampled Residents (#1) . Finding: On 11/29/22 during a record reviews Resident #1 had a written physic...

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Based on record reviews and interview, the facility failed to follow physician orders for 1 of 4 sampled Residents (#1) . Finding: On 11/29/22 during a record reviews Resident #1 had a written physician with a noted date of 9/28/22 to discontinue Amoxicillin, add Augmentin 500/125 1 tablet by mouth twice a day for urinary tract infection until 10/5/22. A Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP) 1 week after antibiotic completed on the next lab draw day.There is no evidence in the clinical record that the CBC and BMP were collected. On 11/29/22 at 4:00 p.m. the surveyor confirmed during an interview with the Assistant Director of Nursing that the labs were not done for Resident #1 as ordered by the physician.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
  • • 35 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $23,345 in fines. Higher than 94% of Maine facilities, suggesting repeated compliance issues.
  • • Grade F (31/100). Below average facility with significant concerns.
Bottom line: Trust Score of 31/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Cummings Health Care Facility's CMS Rating?

CMS assigns CUMMINGS HEALTH CARE FACILITY an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Maine, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Cummings Health Care Facility Staffed?

CMS rates CUMMINGS HEALTH CARE FACILITY's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.

What Have Inspectors Found at Cummings Health Care Facility?

State health inspectors documented 35 deficiencies at CUMMINGS HEALTH CARE FACILITY during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 29 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Cummings Health Care Facility?

CUMMINGS HEALTH CARE FACILITY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 34 certified beds and approximately 31 residents (about 91% occupancy), it is a smaller facility located in HOWLAND, Maine.

How Does Cummings Health Care Facility Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, CUMMINGS HEALTH CARE FACILITY's overall rating (2 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Cummings Health Care Facility?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Cummings Health Care Facility Safe?

Based on CMS inspection data, CUMMINGS HEALTH CARE FACILITY has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Maine. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Cummings Health Care Facility Stick Around?

CUMMINGS HEALTH CARE FACILITY has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Cummings Health Care Facility Ever Fined?

CUMMINGS HEALTH CARE FACILITY has been fined $23,345 across 2 penalty actions. This is below the Maine average of $33,312. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Cummings Health Care Facility on Any Federal Watch List?

CUMMINGS HEALTH CARE FACILITY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

CUMMINGS HEALTH CARE FACILITY

5 CROCKER STREET, HOWLAND, ME 04448 | (207) 732-4121

F
Trust Grade (31/100)
2.0
CMS Rating
35
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 1 Immediate Jeopardy citation
  • 2-star rating
  • 35 deficiencies

Ask about: Inspection Response, Rn Coverage

nursinghomedata.org | Data: CMS November 2025