Clover Health Care

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

them, he then changed his direction towards them. [a staff member stayed close by to redirect, but far enough to give space] At one point the resident was able to grab this writers hand and squeeze hard enough for a pop to be heard. Resident stated, I should hit you, but I won't.11/14/25 11:30 a.m., Resident sent to [acute care hospital #2] via ambulance for aggressive behavior towards staff.11/23/25 09:46 am Health Status Note called [acute care hospital #2) to see status of patient. RN told me .that he has a very flat affect that he is very somnolent. There have been no aggressive behavior or IM meds in 5 days, IV fluids for hydration Medications continue with no changes. [He/she] is taking medications whole with ice cream or pudding. Review of ED Physician Note dated 11/14/25 at 11:34 a.m., states BIBA (brought in by ambulance) for agitation, violent behavior, dementia hx, assaulted CNA coming from clover seen at [acute care hospital #1 this am for same x2, behavior health screen, Clover states cannot return.Review of ED Physician Note dated 11/14/25 at 14:49 p.m. states: .The patient does not appear to suffer from any acute comorbidities and has already had multiple evaluations in the past 24 hours, and it appears that [his/her] nursing home facility is seeking placement at a different facility that is more equipped for geriatric psychiatric patients. While I feel this would be beneficial for the patient, there is no acute indication for admission to the hospital to seek admission to such facility. And the nursing home that [he/she] is currently residing in is an appropriate place for him to await transfer to a geriatric psychiatric facility.Review of ED Physician Note dated 11/15/25 at 3:47 a.m., Apparently after case management was consulted earlier today to arrange for discharge, [his/her] current living facility was not comfortable or confident in managing his condition and was requesting the patient be placed in another facility that could better manage h[his/her] outburst of aggression.there is no medical indication for inpatient admission to the hospital.Review of ED Physician Note dated 11/17/25 at 9:57 a.m., states . no inpatient hospitalization at

this time is indicated.Review of ED Physician Note-Addendum. dated 11/18/25 at 15:41: leadership would like to hold [him/her] in the ED for another 24 hour period. Still trying to get a plan in place with [facility] as

they are not willing to create a safe d/c [discharge] plan at this time.Resident #1 was admitted to [acute care hospital #2] on 11/18/25 at 15:54.During an interview on 11/24/25 at 10:45 a.m., with acute care hospital staff, Senior [NAME] President of Operations (SVPO) stated that Resident #1 did not meet the requirements for hospital level of care, and the facility has been refusing to taking [him/her] back. SVPO states that the facility has the same resources for psychiatric evaluations as the hospital does and there is no medical reason for Resident #1 to not return to the facility.Review of Transfer and Discharge Policy dated 10/18/25 states In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for the transfer or discharge will be provided by a physician.During an interview on 12/24/25 at 3:10 p.m., facility Administrator stated that the facility has not refused to take Resident #1 back, but they wanted to ensure an appropriate safety plan was in place for staff and residents for [his/her] return. The Administrator was unable to provide this writer with written physician documentation indicating resident's clinical or behavioral status endangers the safety or health of individuals in the facility.Resident #1 was transferred back to the facility on [DATE REDACTED] after an 11 day hospital stay.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clover Health Care

440 Minot Ave Auburn, ME 04210

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Based on record reviews, interviews, and facility policy, the facility failed to ensure physician orders for an as needed (PRN) anti-psychotic contained a duration/stop date and failed to ensure the physician evaluated a resident and wrote a new physician order to renew the PRN anti-psychotic medication every 14 days, for 1 of 3 residents reviewed during a complaint investigation (Resident #1).Findings:Review of policy Psychotropic Medication Usage. dated 8/19/24 states .PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents the findings. When entering a PRN order for a psychotropic medication, the licensed nurse should indicate in the ‘Scheduling section for the order a completion date of 14 days and check the box that a re-assessment is due. Review of Resident #1's active order dated 10/31/25 for antipsychotic Risperidone Oral Tablet 0.5 mg by mouth PRN (as needed) every 4 hours for dementia with behavioral disturbance: agitation. At least 4 hours apart and a max of 2 a day. End date: indefinite.During an interview with Administrator and DON on 11/24/25 at 2:39 p.m. the DON confirmed this finding.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clover Health Care

440 Minot Ave Auburn, ME 04210

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

confirmed Resident #1 showed no evidence on MAR/TAR the he/she was being monitored for behaviors.3

Review of Resident #2's clinical record revealed the following:-Order with start date 2/21/24 for antidepressant Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth one time a day for insomnia.-Order with start date 10/17/25 for anti-depressant Trazodone HCL Tablet 50 MG. Give 0.5 tablet by mouth in the morning for agitation. Give one hour before care.-Order with start date 11/15/25 for opioid Tramadol HCL Oral Tablet 25 MG (Tramadol HCL). Give 25 MG by mouth one time a day for pain. Review of Resident #2's clinical record lacked evidence that written consent was obtained for the use of the above medications. During an interview on 11/24/25 at 3:40 p.m., the Director of Nursing (DON) stated that she normally contacts the resident representative over the phone to get consent for psychotropic/pain medications and at some point, in time if/when they come in, they sign them. At this time DON confirmed

the consents were not done in writing.

Event ID:

Facility ID:

If continuation sheet