Aroostook Health Center

Based on record reviews and interview, the facility failed to implement a Comprehensive Care Plan that addressed the physical needs of 1 of 3 residents reviewed for Nutrition (Resident # 39 [R39]).On 12/15/25 at 9:28 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 8:37 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 12:07 p.m., a surveyor observed R39 in bed, eating lunch independently and unmonitored.On 12/16/25, record review indicated the following:-Review of provider orders indicated an active order dated 11/09/25, [Out of Bed (OOB)] for all meals with meals for choking risk, and a diet order dated 11/13/25, Regular texture, . OOB for all meals, Extra gravies for hydration and nutrition.-Review of the list of Residents for [Feeding Assistance (FA)], included R39. -Review of R39's Care Plan indicated a focus, I have a nutritional problem [related to (r/t)] my cognition, and [R39] has nutritional problem or potential nutritional problem: Underweight related to likely inadequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a care plan was updated to reflect a resident's current needs for 1 of 2 residents reviewed for pressure ulcers (Resident [R1]). Finding: On 12/15/25 at 9:35 a.m., during an interview with a surveyor, R1 stated that staff were treating a sore on his/her tail end. R1's clinical record was reviewed and indicated a quarterly Minimum Data Set (MDS), dated [DATE], was coded under Section M210B to reflect that R1 had one stage II pressure ulcer. On 12/15/25, during a clinical record review, a surveyor was unable to find a FOCUS for a current pressure ulcer or enhanced barrier precautions (FOCUS or interventions), but the current physician orders contained active orders for a treatment for a pressure injury and enhanced barrier precautions. On 12/16/2025 at 12:30 p.m., during an interview with the Director of Nursing (DON), a surveyor reviewed R1's care plan and noted that a care area for the pressure ulcer was updated yesterday (12/15/25) from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to follow up on pharmacist recommendations and failed to keep all copies of Medication Reviews in the resident's clinical record for 1 of 5 residents reviewed for unnecessary medications (Resident #5, [R5]).Finding:On 12/17/25 at 11:00 a.m. during a review of R5's clinical record there was no evidence the facility followed up on pharmacist medication regimen recommendations. In R5's clinical record there was a note from the pharmacist that a review was done and to see recommendations. The clinical record lacked copies of these recommendations. During an interview and review of R5's clinical record with the Director of Nursing, she stated the pharmacist told her they failed to send all reviews for November At this time it was discovered that the October review was not in R5's clinical record and the recommendation was not reviewed and was not signed by the provider.The above finding was confirmed by the surveyor at the time of this interview.

Based on record review and interview, the facility failed to ensure residents were free from an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications [Resident #7 (R7)].On 12/17/25, a surveyor reviewed R7's clinical record. Review of active provider orders indicated:-An active order dated 6/25/25, LORazepam Tablet 0.5 [milligram (MG)] Give 0.5 mg by mouth one time a day for anxiety,-An active order dated 6/25/25, LORazepam Tablet 0.5 MG by 0.25 mg by mouth two times a day for anxiety, and-An active order dated 12/4/25, LORazepam Oral Tablet 0.5 (Lorazepam) Give 0.5 mg by mouth one time a day for anxiety. On 12/17/2025 at 9:13 a.m., during an interview with a surveyor and the Director of Nursing (DON), R7's clinical record was reviewed. The DON stated the Lorazepam had a duplicate order, the order for Lorazepam 0.5 mg one time per day dated 6/25/25 should have been discontinued on 12/4/25 when the new order was placed. Review of the Medication Administration Record indicated R7 received an additional dose of Lorazepam related to the duplicate order on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not removing expired products from the available for use supply, ensuring refrigerators had thermometers for routine monitoring, and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 3 days of survey (12/16/25). On 12/16/2025 at 11:51 a.m., during an observation of the Assisted Dining Room kitchenette, 2 surveyors observed and confirmed the following with the Minimum Data Set (MDS) nurse:- 2 surveyors and the MDS nurse were unable to locate a thermometer in the refrigerator or freezer for routine monitoring.-The ice machine filter was observed to be heavily soiled with dust/debris. On 12/16/2025 at 12:07 p.m., during an observation of the Skilled Kitchenette, a surveyor observed and confirmed with the Director of Nursing (DON):-The refrigerator did not have a thermometer for routine monitoring.-1 open bottle, 60 fluid ounces Ocean Spray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and interview the facility failed to ensure that the Water Management Plan was fully developed/implemented to prevent the growth and spread of legionella and other water-borne pathogens, and failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to urinary catheter drainage bags for 2 of 3 residents reviewed with a foley catheter (Resident #38[R38], and [R4]). Findings: 1. On 10/16/24, the surveyor was provided with the facility's new Water Management Plan,, dated 9/19/23, for Northern Light Health Continuing Care. The surveyor reviewed this plan and requested documentation that indicated what areas were to be monitored where potential Legionella bacteria could grow, how the areas were monitored, and last time the facility had the water tested. On 10/17/24, the surveyor was provided with an updated Water Management Plan, dated 9/18/24, for Northern Light Health Continuing Care which included photographs of areas that were to be monitored where potential Legionella…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure that the kitchen equipment/dishware were stored in a sanitary manner by having mixing bowls and a colander wet stacked for 1 of 3 days of survey (10/15/24) and they failed to ensure that the correct 3 step process to manually wash, rinse and sanitize dishware was done correctly by failing to have sufficient concentration of the sanitizing solution in their 3 bay sink used to manually wash their dishware for 2 of 3 days of survey (10/15/24 and 10/16/24). In addition the facility failed to ensure that food was removed from use by the expiration date for 1 of 3 days (10/15/24). Findings: On 10/15/24 at 9:15 a.m., during the initial tour of the kitchen, a surveyor observed water drops dripping from a mixing bowl. Upon further observation it was observed by the surveyor and the Kitchen Lead that 4-mixing bowls and a colander were wet stacked on the shelf above the food preparation area. This finding was confirmed by the surveyor with the Kitchen Lead at the time of the observation. On 10/15/24 at 10:00 a.m. an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record reviews, and interview, the facility failed to notify the physician when residents were eligbile to receive the PCV20 (a vaccine that protects against Pneumococcal bacteria) and ensure residents were offered Pneumococcal vaccinations upon admission, annually, or in accordance with the Centers for Disease and Prevention Control (CDC) recommendations, for 3 of 5 residents reviewed for immunizations (Resident #19 [R19], R33, and R14). Findings: The facility's policy, Immunization Screening for Pneumococcal, Influenza and/or COVID-19 Vaccination for Adult Patients, last revised 5/2/2023, indicated: Under the section: Screening for Influenza and Pneumococcal Immunization - Long Term Care patients will be screened upon admission and annually thereafter. Under the section: Criteria for Eligibility, Pneumococcal Vaccine - Centers for Disease Control (CDC) criteria, the policy indicated that Northern Light Health offers PCV20 when either PCV15 or PCV20 is indicated and shared…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, a facility staff failed to speak to residents in a manner that maintains and promotes each resident's dignity and respect for 1 of 3 days of survey (10/15/24). Findings: On 10/15/24 at 2:00 p.m., a surveyor observed Certified Nursing Assistant #1 (CNA1) having a back-and-forth argument with Resident #1 (R1) during Bingo. CNA1 then turned her head away from R1 and continued to call Bingo letters/numbers to the residents playing Bingo while ignoring R1 while he/she was attempting to talk to CNA1. Another resident asked a question of CNA1, and CNA1 said, have some patience please [R15]. CNA1 was observed by a surveyor to be irritated and was speaking in a sharp voice to R15. On 10/15/24 at 2:18 p.m. in an interview with the Director of Nursing, a surveyor confirmed that R1 and R15 were not spoken to in a dignified manner when CNA1 argued with R1, ignored R1, and spoke sharply to R15.

Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), including a current diagnosis, and was updated for 1 of 1 resident reviewed (Resident #29 [R29]). Finding: On 10/15/24, during review of R29's clinical record, contained a PASRR Level I Screen dated 4/25/24 has a letter attached that he/she does not have a reason for a level II assessment. The PASRR Level I Screen in the diagnosis section did not include a current diagnosis of Post Traumatic Stress Disorder (PTSD). R29's current diagnosis list included a diagnosis of PTSD. The resident record lacked evidence that the PASRR Level I Screen was updated and resubmitted to include his/her diagnosis of PTSD and was not forwarded to the State-designated authority to determine if a Level II assessment was needed. On 10/16/24 at 2:45 p.m., during an interview with the Director of Nursing, a review of R29's PASRR was done and a surveyor confirmed that his/her diagnosis of PTSD was not included on the PASRR for a level II determination.

Based on record review and interviews, the facility failed to update a care plan to reflect a resident's current needs for 1 of 2 residents reviewed for falls (Resident #19 [R19]). Findings: 1. On 10/15/24, R19's clinical record was reviewed. R19's current care plan last revised on 10/9/24, included a problem area of osteoporosis that was developed on 3/4/24, with an intervention Resident/Family/Caregiver teaching - Fall Prevention: Hold railing when using stairs. If unsteady on feet, use cane, walker, or have someone help you walk. Keep away from icy streets, sidewalks, wet/ waxed floors. Keep inside well lit at night. Remove things that could make you trip i.e. loose rugs or electrical cords. Wear low-heeled soft-soled shoes. Wear padded hip protectors to prevent hip fractures. On 10/16/24 at 12:05 p.m., during an interview with a surveyor, Certified Nursing Assistant # 1 stated that R19 does not wear hip protectors. On 10/16/24 at 12:39 p.m., during an interview with a surveyor, Clinical Supervisor (CS) stated that R19 does not wear hip protectors. CS and the surveyor reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess a residents current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 2 sampled resident's reviewed with a current diagnosis of PTSD (Resident #16 [R16]). Finding: R16 was admitted to the facility on [DATE] to include a diagnosis of PTSD. On 10/17/24, a review of R16's clinical record, in the Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate R16 has an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what R16's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. On 10/17/24 at 11:13 a.m., in an interview with a surveyor, the Clinical Supervisor stated she did not find a care plan (goal and trauma interventions) for PTSD other than it being mentioned as one of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure opened insulin and opened/activated inhaler was labeled with an open date in 1 of 3 medication/treatment carts (South wing). Findings: On 10/15/24 at 10:26 a.m., a surveyor and a Licensed Practical Nurse (LPN) observed an opened Basaglar Kwik Pen (Lantus, insulin) for Resident #6 [R6] that was in the South wing medication cart that did not have an open or discard date (Lantus is good for 28 days once opened and at room temperature). On 10/15/24 at 10:30 a.m., a surveyor and LPN observed an opened Spiriva Respimat inhaler for R32 that was in the South wing medication cart that did not have an open or discard date (Spiriva Respimat inhaler, is good for 3 months after first use or when the locking mechanism is engaged, whichever comes first). On 10/15/24 at 10:54 a.m. , in an interview with LPN, a surveyor confirmed that the Basaglar Kwik Pen Lantus and the Spiriva Respimat inhaler were not labeled with an open or discard date. On 10/15/24 at 10:55 a.m., in an interview with the Clinical Supervisor, a surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and interviews, the facility failed to ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the electronic record for (Resident #26 [R26] and [R295]) Findings: 1. On [DATE] at 1:40 p.m., a surveyor observed R26's medical chart read DNAR [Do Not Attempt Resuscitation]/Full Treatment on the spine. The record contained 2 POLST forms. Both POLST forms have the word Void written across the front and back. Review of R26's electronic medical record indicated a code status of DNAR /Full treatment (Do not provide CPR). The record also indicated Special Instructions: . FULL CODE (Provide CPR). On [DATE] at 1:45 p.m., in an interview with a surveyor, the Registered Nurse (RN2) stated the code status of DNAR/Full Treatment means the resident would accept antibiotics and intravenous fluids but not CPR. On [DATE] at 1:48 p.m., in an interview with the surveyor, the Clinical Supervisor stated the code status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews the facility failed to provide residents with oral care for 3 of 6 residents observed. Findings: On 10/3/24 during a complaint investigation, facility tour and anonymous resident interviews a surveyor observed and was told by residents that the facility is not offering or providing oral care daily. On 10/3/24 at 10:30 a.m. during an interview/observation with a resident who will remain anonymous it was observed that his/her dentures were not clean. They appeared to be caked with a white unknown substance the resident stated that the only concern he/she has it that they do not brush his/her teeth. He/she has false teeth and stated that every few days they may come in and take them to brush them, a lot of the girls don't like to touch false teeth they say if they take them, it will make them throw up and I can't do it myself, my hands will not hold them, and I don't want to drop them and break them. I would like them to be brushed every day the food gets stuck under my dentures and the taste in my mouth isn't always that good when they aren't'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident [R] 5). Finding: On 9/20/23, R5's clinical record was reviewed and it was noted that the resident was on an anti-psychotic medication, Olanzapine, with the last increase 9/26/20. R5's current care plan contained an intervention that was last revised on 8/27/19, to complete Abnormal Involuntary Movement Scale (AIMS) testing per facility policy. The last AIMS test completed for R5 was done on 12/28/19. On 9/20/23 at 12:23 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated that she spoke with pharmacy and the reason the pharmacist did not pick up the missing AIMS assessment was because the pharmacist was not checking for it. The DON stated that the AIMS test is supposed to be done every 6 months.

Based on record review and interview, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS), used to monitor for potentially irreversible side effects of anti-psychotic medications, was completed every 6 months for 1 of 5 sampled residents reviewed for unnecessary medications (Resident [R] 5). Finding: On 9/20/23, R5's clinical record was reviewed and it was noted that the resident was on an anti-psychotic medication, Olanzapine, with the last increase 9/26/20. R5's current care plan contained an intervention that was last revised on 8/27/19, to complete AIMS testing per facility policy. The last AIMS test completed for R5 was done on 12/28/19. On 9/20/23 at 11:16 a.m., during an interview with a surveyor, the Minimum Data Set (MDS) Lead stated that there is no policy for the AIMS testing but that it should be done every 3 to 6 months. The surveyor confirmed that the AIMS test was not completed for R5.

Based on observations, record reviews, and interviews, the facility failed to ensure paid feeding assistants are assisting only those residents without complicated feeding problems and who have been selected as eligible to receive these services from a paid feeding assistant for 2 of 3 breakfast meal observations (9/19/23 and 9/20/23). Finding: During entrance conference on the evening of 9/18/23 that was completed with the Administrator/Director of Nursing, a surveyor requested information on paid Feeding Assistants (FA) and a list of residents the FA could assist. On 9/19/23, this information was provided by the Administrator and reviewed by a surveyor. The surveyor also reviewed Resident (R) #23's clinical record which included diagnoses of Dysphagia, unspecified and Dysphagia following Cerebral Infarction (stroke) and observed that R23 had a Dysphagia (difficulty swallowing) evaluation completed 6/1/23 due to worsening symptoms. On 9/19/23 at approximately 8:50 a.m., a surveyor observed a staff member assisting R23 with eating while in the resident's room. On 9/19/23 at 9:40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide Resident #13 (R13) with oral care on 2 of 3 morning observations. (9/19/23 and 9/21/23) Findings: On 9/19/23 at 08:13 a.m. during dining room observations R13 was brought to the dining room for breakfast. When surveyor attempted to interview resident, it was observed that his/her mouth care had not been completed. His/her mouth was noted to be covered in a sticky substance, his/her his lips were coated with a dried substance, and he/she was having a difficult time to talk (his/her tongue and lips sticking together). As surveyor was talking with R13 a staff person asked if him/her if they were thirsty. R13 stated he/she was very thirsty, and staff provided him/her a glass of water. A surveyor confirmed with staff that R13's mouth care had not been completed that morning prior to breakfast. The staff person then took the resident to their room to perform mouth care. When R13 came back to dining room he/she was then able to talk to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that a physician order was followed for 1 of 5 residents reviewed for unnecessary medications (Resident #5 [R5]). Finding: On 9/20/23, R5's clinical record was reviewed. The most recent order entered into the electronic clinical record for Trazodone was for 50 mg which was started on 3/23/23. On 8/22/23, the Physician signed a Pharmacist Consultant to Physician report that directed staff to trial Trazodone (anti-depressant) at 25 milligrams (mg) from the current 50 mg by checking the box Yes - Approve implementation of recommendation. Nursing please follow through. On 9/20/23 at 10:59 a.m., during an interview with the Minimum Data Set (MDS) Lead, the surveyor confirmed that this order was not implemented as ordered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide services to maintain and/or improve residents highest level of mobility. The facility failed to provide Restorative services as outlined in the resident's restorative care plan and [NAME] for 1 of 2 sampled residents (Resident #3[R3]). Finding: On 9/19/23 at 8:43 a.m., during a resident interview, R3 stated that he/she has asked to ambulate and is supposed to walk everyday but when he/she asked they told him/her they didn't have time. During review of R3's restorative care plan with a revision date of 8/23/23, it has a focus area which documents I need to work with restorative nursing to help maintain strength, mobility and Range of Motion the goal is documented as I walk with restorative nursing to maintain the ability to ambulate 5-10 feet, 1 to 6 times a week. The intervention is documented as Ambulate with restorative nursing 5 to 20 feet with a 4 wheeled walker and follow me with a wheelchair. Review of R3's visual/bedside [NAME] report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.