Ross Manor

Inspectors wroteBased on facility policy review, record reviews, and interviews, the facility failed to ensure that resident(s) and/or resident representative(s) were provided with written information and/or follow-up, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate for 3 of 10 residents reviewed for advanced directives (Resident 98 [R98], R36, and R6).

Inspectors wroteBased on facility policy, record review, observations, and interviews, the facility failed to adequately ensure medications and biologics were stored at appropriate temperatures in 2 of 3 refrigerators observed for 4 of 4 months of medication refrigerator logs reviewed ([NAME] Unit and [NAME] Unit). Additionally, the facility failed to ensure medications were removed from medication cart after discharge for 1 of 7 carts reviewed ([NAME] Unit).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety by failing to ensure foods were sealed, labeled, and dated in 2 reach-in refrigerators and a walk-in freezer for 1 of 2 kitchen tours and by failing to ensure staff perform hand hygiene during a breakfast service observation on 1 of 3 days of survey (6/10/26). Additionally, the facility failed to monitor refrigerator and dish machine temperatures for 3 of 4 months reviewed (March, April, and May).

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of bedpans on 2 of 3 days of survey (6/8/26, 6/9/26) and hand hygiene during a dining observation.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded in the area of dialysis for 1 of 2 sampled residents reviewed for dialysis (Resident #3).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 2 sampled residents reviewed for PASRR (Resident #55 [R55]).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 5 residents reviewed for baseline care plans (Resident #3).

Inspectors wroteBased on observations and interviews, the facility failed to maintain respiratory equipment for 1 of 2 residents reviewed for respiratory (Resident [R] #41).

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 3 resident reviewed for dental services (Resident #78 [R78]).

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 sampled residents reviewed for dialysis (Resident #3).

Inspectors wroteBased on clinical record reviews and interviews, the facility failed to follow physician orders for 2 of 19 residents reviewed. (Resident #64 [R64] and R90).

Inspectors wroteBased on clinical record reviews, and interviews, the facility failed to provide physician ordered respiratory services for 1 of 1 resident (Resident [R2]) reviewed with a continuous positive airway pressure (CPAP) machine when the facility failed to obtain missing tubing for R2's machine.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 kitchen equipment that require a 1 air gap on 4 of 4 days of survey.

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 for 3 of 4 days of survey (4/14/25, 4/15/25, and 4/16/25).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 sampled residents admitted for skilled care services (Resident #2[R2]).

Inspectors wroteBased on interview, observation, and record review, the facility failed to consistently provide Activities of Daily Living (ADL) care in the area of oral hygiene for 1 of 1 residents reviewed for dental care [Resident #58 (R58)].

Inspectors wroteBased on record review and interviews, the facility failed to ensure there was a physician ordered renewal for an as needed (PRN) psychotropic medication without a stop date, making it available for administration for 1 of 19 residents reviewed (Resident #6 [R6]).

Inspectors wroteBased on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 19 sampled residents (Resident #2 [R2], and [R1]).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the resident's representative was notified of a change in the resident's discharge plan, failed to notify the representative of the resident going outside the facility and failed to notify the medical provider of resident's elopement risk and exit seeking behaviors for 1 of 1 sampled resident (Resident #1)

Inspectors wroteBased on record reviews and interviews, the facility failed to supervise and monitor 1 of 1 (Resident #1) wandering resident resulting in the resident eloping from the facility; wandered a mile away from the facility in 14-degree Fahrenheit weather, and being found near the Convenient MD building.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 resident reviewed for elopement. (Residents #1).

Inspectors wroteBased on interviews, policy review, and record review, the facility failed to ensure staff reported an allegation of physical abuse immediately for 1 of 1 residents reviewed during a complaint investigation. (Resident #1[R1])

Inspectors wroteBased on review of the facility internal investigation, clinical record review, facility Medication Administration Policy and Procedure, and interviews, the facility failed to protect a resident from receiving another residents medications resulting in the resident being transferred to the Acute Care Emergency Department (ED) for evaluation and monitoring of low blood pressure and a drop in hemoglobin and hematocrit for 1 of 1 resident reviewed (Resident #1 [R1]).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a resident requiring feeding assistance was done in a dignified manner for 1 of 2 residents observed requiring feeding assistance (Resident #28 [R28]).

Inspectors wroteBased on record review and interviews, the facility failed to review an Advance Beneficiary Notice with a resident's legal guardian for 1 of 4 residents reviewed for beneficiary notices (Resident #147 [R147]). This had the potential to prevent R147's right to appeal discharge.

Inspectors wroteBased on record reviews and interview, 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 2 of 6 residents reviewed for advanced directives (Resident #53 [R53] and Resident #68 [R68]).

Inspectors wroteBased on record review and interview, the facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 1 sampled resident (Resident #77 [R77]).

Inspectors wroteBased on record review and interviews, the facility failed to provide services to maintain and/or improve residents' highest level of functional mobility. The facility failed to provide Resident Restorative Nursing as outlined in care plan for 1 of 1 sampled resident (Resident #87 [R87]).

Inspectors wroteBased on record reviews and interviews the facility failed to ensure physicians orders were followed for the use of sliding scale insulin order for 1 of 5 residents reviewed for unnecessary medications. (Resident#19 [R19], Resident #51 [R51]).

Inspectors wroteBased on record review and interviews, the facility failed to provide supervision for resident safety when they sent a resident out to an appointment in the community independently for 1 of 1 residents reviewed (Resident # 147 [R147]).

Inspectors wroteBased 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 (block orders) in a timely manner for 1 of 6 sampled residents (Residents #13 [R13]).

Inspectors wroteBased on record review, Wound Care Policy and Procedure review, observation and interview, the facility failed to ensure that the infection control practices according to the facility's Wound Policy and Procedure during a pressure ulcer dressing change was followed for 1 of 2 sampled residents with a Stage 3 or higher pressure ulcer (Resident #83 [R83]).

Inspectors wroteBased on record reviews and interview, the facility failed to transmit a quarterly and annual Minimum Data Set 3.0 (MDS) electronically to the State MDS database within 14 days of completion for 2 of 2 sampled residents reviewed for Resident Assessment (Resident#3 [R3], Resident#4 [R4]).

Inspectors wroteBased on record review and interviews the facility failed to respond to residents request for assistance in a manner that maintained or enhanced their dignity by not answering the call bells in a timely manner. In addition, the facility failed to respond to a residents request for assistance in speaking to the Administrator to voice grievance with respect to his/her treatment/care for 2 of 5 residents interviewed. (Resident #3, [R3}, and R2)

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that a resident receiving care was free from neglect when the resident was denied a daily shower as ordered by their provider from 2/24/24 to 3/4/24. (Resident #2 [R2])

Inspectors wroteBased on record reviews, and interviews the facility failed to ensure that physician orders were followed for 1 of 5 residents reviewed (Resident #2 [R2]