Aroostook Health Center

Inspectors wroteBased on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 2 of 3 days of survey (12/15/25 and 12/16/25). On 12/15/2025 at 11:35 a.m., during an observation of the dining room meal service, 2 surveyors observed staff serve meals to residents. R2, R4, and R5 were observed sitting at 3 separate tables shared with other residents. At 11:46 a.m., all residents had been served a meal, except for R2, R4, and R5. At 11:47 a.m., during an interview with 2 surveyors, the Nurse Manager stated their trays come on another cart and they never know who is going to eat in the dining room. At 11:54 a.m., all residents were observed to have their meals. This finding was observed and confirmed with the Unit Manager at the time of the observation, and again during the exit conference. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 2 of 3 residents reviewed for advanced directives (Resident #1 [R1] and R3).

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and in a homelike environment on 3 of 3 days of survey (12/15/25, 12/16/25 and 12/17/25).

Inspectors wroteBased on record reviews, facility policy review, and interviews, the facility failed to issue a written transfer/bed hold notice to a resident and their legal representative for a facility-initiated transfer/discharge for 2 of 4 sampled residents transferred/discharged to an acute care facility (Residents #1 [R1] and R33). In addition, the facility failed to notify (at least monthly) the Ombudsman office of transfer/discharges that have occurred since September 2025.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that physician orders were followed for 2 of 3 residents reviewed for nutrition (Resident #14 [R14] and R39). On 12/16/25, R14's clinical record was reviewed and indicated the following:-Review of the Provider Orders included and active order dated 12/18/24, [Esophagogastroduodenoscopy (EGD)] to rule out possible gastric ulcer when [appointment (apt)] available.-On 12/17/24, a Provider's progress note indicated, [R14] requested to be seen today secondary to epigastric abdominal pain. [R14] reports several weeks of epigastric abdominal pain with excessive burping and decreased appetite with early [feeling of being full after eating (satiety)]. [R14] has a history of gastric ulcers and is concerned this has returned. [R14's] last upper endoscopy. showed several nonbleeding gastric ulcers. [...]

Inspectors wroteBased on employee record reviews, and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 4 of 5 sampled staff (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, and CNA4).

Inspectors wroteBased on observation, and interviews the facility failed to ensure expired medications were removed from the supply available for use in 1 of 3 medication storage rooms, and 1 of 2 medication storage refrigerators (Main medication storage room, and Main medication storage refrigerator), and the facility failed to monitor medication storage refrigerator temperatures to ensure proper refrigerator temperatures were maintained for medications, immunizations, and biological storage requiring refrigeration for 2 of 2 medication storage refrigerators (Main medication room-main medication storage refrigerator, and Station 1 medication room-Station 1 immunization storage refrigerator).

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections in the area of Enhanced Barrier Precautions (EBP), changing soiled gloves during/after patient care, and linen handling for 2 of 3 days of survey (12/16/25 and 12/17/25).

Inspectors wroteBased on facility policy review, antibiotic stewardship spreadsheet reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 3 months reviewed (October and November). This has the potential to affect all residents receiving an antibiotic.

Inspectors wroteBased on interviews and record review, the facility failed to designate a qualified staff member to function as the Infection Preventionist who was responsible for the facility's Infection Control Program and worked at least part time in the role since 10/8/25. This has the potential to affect all residents in the facility.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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]).

Inspectors wroteBased 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]).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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]).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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]).

Inspectors wroteBased 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]).

Inspectors wroteBased 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]).

Inspectors wroteBased 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).

Inspectors wroteBased 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])

Inspectors wroteBased on observations and interviews the facility failed to provide residents with oral care for 3 of 6 residents observed.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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]).

Inspectors wroteBased 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]).