Orono Commons Rehab (SFF) Abuse and Neglect Lawyers

Orono Commons RehabBoth the State of Maine and the Centers for Medicare and Medicaid Services (CMS) conduct routine investigations, inspections, and surveys of every nursing facility statewide. The surveyors’ efforts help to identify serious violations and deficiencies that require immediate correction to protect every resident’s health and well-being.

In the most egregious cases, the nursing home regulators will designate the Center as a Special Focus Facility (SFF) and require the Home to undergo additional surveys and inspections. Also, the facility is added to the national Medicare watch list that identifies all facilities nationwide that provide substandard nursing care and hygiene assistance.

In 2017, nursing home regulators designated Orono Commons Rehab as a Special Focus Facility. The Center will likely remain on the Medicare watch list for many years to come until surveyors and investigators are satisfied that any needed improvement and revised policies and procedures helped to improve every resident’s quality of life. Some of the concerns, violations, and deficiencies involving this facility are detailed below.

Orono Commons Rehab

This facility is a ‘for profit’ 80-certified-bed Long Term Care Center providing cares and services to residents of Orono and Penobscot County, Maine. The Home is located at:

117 Bennoch Rd
Orono, ME 04473
(207) 866-4914

In addition to providing around-the-clock skilled nursing care, the Genesis-affiliated facility also offers:

  • Physical, occupational and speech therapies
  • Complex wound care
  • Intervenous (IV) therapy
  • Ostomy care
  • Pain management
  • Hypodermoclysis (interstitial/subcutaneous infusion) care
  • Diabetes management


In the last three years, Orono Commons Rehab received an imposed $3349 fine on March 22, 2017, from state and federal nursing home regulators. During that same time, there were ten formally filed complaints and four facility-reported issues that all resulted in citations.

Current Nursing Home Resident Safety Concerns

Families can visit the Medicare.gov website to obtain a complete list of all dangerous hazards, filed complaints, safety concerns, health violations, opened investigations, and incident inquiries in nursing homes nationwide. The regularly updated information can be used to make a well-informed decision on which long-term care facilities in the community provide the highest level of care.

Currently, Orono Commons Rehab maintains an overall one out of five stars compared to all nursing homes in the US. This ranking includes one out of five stars for health inspections, three out of five stars for staffing issues, and three stars for quality measures. Some violations, concerns, and deficiencies involving this facility include:

  • Failure to Develop, Implement and Enforce Policies and Forbid Mistreatment, Neglect or Abuse of Residents
  • In a summary statement of deficiencies dated February 22, 2017, the state investigator noted the facility’s failure “to administer pain medications as ordered.” The deficiency resulted in “the resident experiencing increased pain and discomfort at a level of 9 out of 10 on the pain scale.” The surveyor reviewed a resident’s January 23, 2017, Admission Paperwork indicating that the resident “was admitted to the facility at approximately 6:30 PM for skilled services [after leaving the hospital with] a total knee replacement, six days prior.”

    The hospital discharge summary indicated that the resident “had increased pain and swelling in the left knee and calf.” The hospital doctor’s “treatment plan was for the resident to be sent to Orono Commons Rehab for pain control and rehab services.” The Treatment plan outlined numerous medications to be given on a schedule including every five hours and every 12 hours.

    However, a review of the resident’s Clinical Record an Electronic Medication Administration the Administration Record and the facility’s Nurse's Notes “lacked evidence that [the resident] received the schedule pain medication… as ordered.” The surveyor interviewed the resident on the afternoon of February 21, 2017, at 4:35 PM. The resident stated that “they did receive pain medication at approximately 2:00 AM on January 24, 2017, which was five hours after the scheduled time, which caused [the resident] to have increased pain and discomfort.”

    A review of the resident’s Clinical Record, Electronic Medical Administration Record and the Nurses Note “lacked evidence that [the resident] received any as needed pain medications until 1:41 AM on January 24, 2017.” This deficiency “ resulted in [the resident] requesting to be released Against Medical Advice (AMA) due to the facility failing to treat [their] pain in a timely manner.” The Charge Nurse – License Practical Nurse confirmed these findings on February 23, 2017, at 9:58 AM and with the Director Nursing at 2:20 PM” the same day.

  • Failure to Provide an Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated February 22, 2017, the state investigator noted the facility’s failure “to follow its own policies for documentation and investigating three fall accidents/incidents” involving one resident.” The incident involved the documented evidence stated above of the resident falling out of [their] wheelchair.

  • Failure to Ensure That the Nursing Staff Followed Physician’s Orders Involving X-Rays
  • In a summary statement of deficiencies dated February 22, 2017, the state investigator noted the facility’s failure “to ensure that a chest x-ray was completed as ordered by the physician for [one resident].” The surveyor reviewed the resident’s “clinical record that contained a physician’s orders dated November 23, 2016, for a chest x-ray to rule out pneumonia due to an elevated white blood cell count on a recent blood test.”

    The surveyor noted that the “clinical record lacked evidence that this had been completed.” As a part of the investigation, the surveyor interviewed the Director of Nursing on February 22, 2017 (two months after the physician ordered the x-ray) who “confirmed that the chest x-ray had not been completed.”

  • Failure to Immediately Notify the Resident’s Doctor or Family Member of a Change in the Resident’s Condition
  • In a summary statement of deficiencies dated February 22, 2017, the state investigator noted the facility’s failure “to notify the physician of increased temperature, [and a failure] to notify the physician and family member of fall accidents/incidents.” The surveyor also noted the facility’s failure “to notify family member medication errors for [two residents at the facility].”

    An interview conducted with the Director of Nursing at 2:55 PM on February 22, 2017, confirmed: “that there is no documentation indicating that the physician was notified [on the resident’s] increased temperature.” A review of the resident’s Progress Notes for November 26, 2016, noting a Change of Condition Note revealed that the resident “was leaning over to pick up a piece of paper and slipped out of the wheelchair while in their room.” The resident’s Progress Notes “revealed that was no injury noted and that staff monitored [the resident] for the next 72 hours.”

    A review of the resident’s Clinical Record and Progress Notes dated December 12, 2016, contained documentation that the resident “had a temperature of 101.2 degrees axilla [temperature taken under the armpit].” However, there was a lack of documentation in the resident’s Progress Notes for February 22, 2017 “indicating the physician was notified of the resident’s increased temperature.

    The state investigator interviewed a Licensed Practical Nurse (LPN) at noon on February 21, 2017, who stated “that it is the responsibility of the Charge Nurse to notify the Nurse Manager or Director of Nursing of incidents. We inform the Director of Nursing of all situations and [get their] directions on what to do next.” The LPN also indicated that “the Charge Nurse is responsible for filling out the incident report on the Risk Management System. If an incident happens on the weekend, we have a sheet that we go by that outline step-by-step on what to do.”

    In a separate summary statement of deficiencies dated April 18, 2017, the state surveyor noted the facility’s failure “to ensure that [a resident’s] physician was notified of changes in condition.” These changes in condition included “severe pain, discomfort, and mental status changes” involving incidents where “a biliary drain tube treatment [had been] performed incorrectly.”

    The surveyor’s findings included evidence that a resident “had a biliary drain which is a tube to drain bile from [their] liver. The tube protrudes from the resident’s abdomen area, and the tube is connected to the bile connection bag.”

    The Director of Nursing was interviewed on the morning of April 18, 2017, stated that on March 27, 2017, a Licensed Practical Nurse (LPN) “performed the biliary to flush and emptied the drain bag. The next morning on March 28, 2017, at 6:30 AM, a Registered Nurse went to perform the biliary drain treatment and discovered that [the LPN] left the stopcock closed and fluid was leaking out around the tube and was going into the resident’s abdomen. There was zero drainage in the drainage bag.”

    When the error was discovered, the Registered Nurse “administered Tylenol per physician’s orders [but] did not write a Nurses Note regarding this incident and did not notify the physician.” Again, at 2:30 PM on March 28. 2017, a different Registered Nurse “went to perform might biliary drain treatment is discovered that the “first Registered Nurse] left the stopcock in the closed position. There was 20 mL of fluid in the drainage bag.” At that time, the second Register Nurse “told the surveyor that the resident new [their own] name but was drowsy and did not open [their] eyes.”

    The Director stated to the surveyor that the resident’s “physician was notified of the first incident on March 29, 2017, at 2:30 PM, more than 24 hours after the second incident was discovered.” The second Registered Nurse stated to the surveyor in an interview that “she did not notify [the resident’s] physician regarding her discovery of the stopcock being closed and that the resident had a change in mental status.”

  • Failure to Provide Necessary Care and Services to the Resident to Ensure the Highest Well-Being Is Maintained
  • In a summary statement of deficiencies dated June 12, 2017, the state surveyor noted the facility’s failure “to ensure the clinical records of [four residents] reviewed for bathing/shower and a range of motion was complete, accurate and consistent with the resident Plan of Care.” In one incident, a review of the resident’s Shower Schedule indicated the resident “was scheduled to receive a shower on Mondays.”

    However, documentation revealed that the resident “did not receive a shower or bath from May 8, 2017, until June 1, 2017.” The state investigator interviewed the resident who indicated that they “would like to have a shower but had not been offered one.”

    In a separate incident with another resident, the facility’s Shower Schedule indicated that that resident “was scheduled to receive a shower on Wednesday evenings.” However, documentation indicated that the resident “did not receive a shower or bath from May 11, 2017, through May 24, 2017, and in June, the resident received a bath on Saturday, June 3, 2017, only.” The surveyor interviewed that resident who indicated that “they would like to have a shower but had not been offered one.” A third separate incident involved another resident who “received one shower on Sunday, April 9, 2017, and had not received a shower again until Monday, May 15, 2017.”

    In a separate incident involving a resident’s scheduled range of motion therapy, the resident’s Care Plan dated May 15, 2017 “directed the staff to provide a range of motion [therapy] to the resident’s bilateral legs due to functional decline.” However, “there is no documentation of the resident’s records to indicate staff provided any range of motion [therapy] to the resident’s legs between June 1, 2017, June 12, 2017.” The facility’s Nurse Manager confirmed that “there was no evidence that range of motion [therapy] was provided to [the resident].”

Abuse in a Nursing Home? You Might Have a Case for Compensation

If your loved one was the victim of abuse, mistreatment or neglect while a patient at Orono Commons Rehab, hiring a personal injury attorney could be a wise decision. Contact us today! With legal representation, your lawyer working on your behalf can file the appropriate documents in the correct County Courthouse before Maine’s statute of limitations expires. Your lawyer can build a case, present evidence at trial, and negotiate an out of court settlement to ensure your family receives the financial compensation they deserve.

Hiring an attorney is an easy solution for you resolving your case. You are not required to make any upfront payment to receive immediate legal services. The fees owed to the law firm are paid only after your lawyers have successfully resolved your nursing home abuse case.


Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric