Mid Coast Senior Health Center

Based on observations, interview and record review, the facility failed to follow their policies ensuring staff wear required hair restraints, maintain the industrial mixer in a clean and sanitary condition and ensure food was not expired, outdated, unlabeled, or moldy for 1 of 3 kitchen tours observed. In addition, the facility failed to ensure the dishwashing machine maintained the proper temperature range necessary for effective cleaning and sanitizing for 7 of 7 temperature logs reviewed. These failures had the potential to affect all residents who consume facility prepared food. The facilities policy Infection Prevention - Kitchen requires that all Food Service staff comply with that all dishwashing staff comply with personal hygiene requirements, including wearing a hair and beard restraint and that all kitchen equipment including mixers be maintained in a clean and sanitary condition.On 8/4/25 from 9:30 a.m. to 10:30 a.m., during a kitchen tour with the Food Service Director, the following findings were observed: A male dishwasher with facial hair and no hair restraint. Dried…

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, record reviews and interviews, the facility failed to ensure a resident's right to be free from physical restraint for 1of 4 residents observed wearing wheelchair seatbelts. In addition, the facility failed to follow its own policy titled Physical Restraints/Side Rails in the area of physical restraints. (Resident #22)On 8/5/25 a surveyor reviewed the facility policy titled Physical Restraints/Side Rails last reviewed/revised 9/2020 which stated: A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed intentionally by the resident in the same manner as it was applied by staffUnder Section IV Procedure:1. An RN will complete a nursing assessment which includes resident behavior patterns, diagnoses that explain behaviors, resident safety needs and medications.2. The provider must be included in all discussions regarding the potential use of restraints.3. Only an RN or provider are…

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, review of Safety Data Sheets (SDS) and interviews, the facility failed to ensure that the residents environment remained free from hazards with regards to chemicals for 3 of 3 survey days.A surveyor reviewed the Safety Data Sheets (SDS) for the following chemicals and found the GHS (Global Harmonized System) information for Hazard class and category. A Category 1 in this system indicates the highest level of hazard for that category. SDS for Might Bowl 64GHS US Classification: Serious eye Damage/eye irritation Category 1, Skin sensitization, category 1 SDS for GC2030 GHS US Classification: Skin corrosion/irritation Category 1A, Serious eye damage/eye irritation Category 1, Skin sensitization, Category 1 SDS for Professional LYSOL toilet bowl cleaner - Complete clean powerGHS US Classification: Corrosive to metals - Category 1, Acute Toxicity (oral) Category 4, Skin Corrosion Category 1, Serious Eye Damage - Category 1.On 8/4/25 at 10:37 a.m. A surveyor observed the spa room and the shower room on Mere Point Unit and found an unlocked cupboard in the spa room…

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, record reviews and interviews the facility failed to update and/or implement goals and interventions for 2 of 14 care plans reviewed. (Resident's #12 and #29). Findings: Review of facility policy Comprehensive Resident Care Plan undated states It is the policy of Mid Coast Senior Health Center to develop, implement and evaluate a comprehensive care plan for each resident based on a comprehensive assessment of the residents needs . will be developed for each resident to include measurable objectives and timetables based on the Resident Assessment Protocols triggered by the MDS and other assessments . will reflect intermediate steps for each objective if identification of those steps will enhance the resident's ability to meet his/her objectives .will be developed 7 days after the completion of the comprehensive assessment by the interdisciplinary team will be reviewed and updated periodically and as the resident's condition dictates . 1. Resident #12 was admitted on [DATE] and has…

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 the kitchen was maintained in a clean and sanitary manner for the floor stand mixer, floor stand fan, and the small countertop mixer. Freezer #7 contained unlabeled and undated items for 2 of 2 observations. Additionally, the dry storage room floor was not maintained in clean and sanitary manner, there is no temperature log for the dish machine, and the Mere Point Unit Freezer contained the ice scoop in with the ice for 1 of 3 days of survey. Findings: On 6/10/24 at 8:10 a.m., during the initial tour of the kitchen with the cook and again on 6/12/24 at 8:00 a.m., during a kitchen tour with the Director of Facilities Operations, the following findings were observed and confirmed: 1- Observed that the facility lacks a log for the dish machine. The cook stated, we are supposed to have a log for that, but I do not know where it is. In an interview, the Kitchen Coordinator and a Diet Aide, that run the dish machine, both stated in the instructions for running the dish machine that they must observe the temperature gauge…

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 and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to urinary collection devices for 3 of 3 days of survey on 2 of 3 units (100 and 200 Units). Findings: Observations of 100 Unit revealed the following: -On 6/10/24 at 9:48 a.m., and 6/11/24 at 7:25 a.m., observations of room [ROOM NUMBER] bathroom revealed uncovered commode bucket on floor, available for use. -On 6/10/24 at 9:25 a.m., observation of room [ROOM NUMBER] bathroom revealed uncovered commode bucket on the floor with bed pan stored inside, available for use. Observations of 200 unit revealed the following: -On 6/11/24 at 8:14 a.m. and 3:09 p.m., and on 6/12/24 at 8:04 a.m., observations of room [ROOM NUMBER] bathroom revealed an uncovered commode bucket on bathroom floor, available for use. - On 6/11/24 at 8:21 a.m., and 3:13 p.m., observations of room [ROOM NUMBER] bathroom…

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 and interview the facility failed to provide maintenance services necessary to maintain a sanitary and comfortable interior on 2 of 3 units observed (100 and 200 units). Findings: During a facility tour on 6/12/24 between 8:31 a.m. and 8:55 a.m , the Director of Operations confirmed the following: 100 Unit the following was observed: -room [ROOM NUMBER] the bathroom had dead bugs/debis in the light fixture -room [ROOM NUMBER] entrance was missing the threshold -room [ROOM NUMBER] had approximately 4 feet section of baseborad trim missing left of the window 200 Unit the following was observed: -room [ROOM NUMBER] the sink was dripping and plugged up causeing pooling water in the sink. -room [ROOM NUMBER] the sink had a steady leak.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record reviews and interview the facility failed to provide a written Notice of Transfer or Discharge to resident and/or resident representatives for 1 of 6 residents reviewed for hospitalization (Resident #28). In addition, the facility failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfers for 2 of 6 residents reviewed for hospitalizations (Resident's #28 and #2). Findings: Review of facility policy Transfer and Discharge Policy undated, states .Notice of discharge shall be provided to the resident and resident representative: when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer shall be provided to the resident and resident representative as soon as practicable, A list of resident who transferred out for the facility is provided to the state ombudsman on a monthly basis . 1. Resident #28 was admitted on [DATE] with diagnoses to include stage 3 chronic kidney disease. On 6/11/24 Resident #28…

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, record review and interview, the facility failed to issue a bed hold notice which included the daily cost of care, to a resident, known family member or legal representative for 1 of 6 sampled residents who had been transferred to the hospital (Residents #28). Finding: Review of facility policy Resident Bed Hold Policy for Hospitalizations undated, states Prior to and upon a transfer, written information will be given to the residents and/or the resident representatives that explains in detail: the rights and limitations of the resident regarding bed-holds, The reserve bed payment policy as indicated by the state plan, the facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid residents). Resident #28 was admitted on [DATE] with diagnoses to include stage 3 chronic kidney disease. On 6/11/24 Resident #28 was transferred to an acute care hospital for evaluation and was subsequently admitted . Review of Resident…

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 interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 4 of 14 residents that were reviewed for new admissions. (#190, #196, #2 and #28) Findings: 1. Resident #190 was admitted to the facility on [DATE]. The hospital discharge summary included information that the resident was admitted with diagnosis of COVID-19, Atrial flutter requiring anticoagulant medication and a Coronary Artery Bypass Graft (CABG) on 5/24/24 which required Epicardial pacing wires. The discharge instructions stated, Epicardial pacing wires: prepped and cut on day of discharge. Instructions: you had temporary epicardial pacing wires placed during surgery and utilized in the post-operative period. These rest on the surface of your heart and allowed us to temporarily control your heart rate. These wires exited the skin just…

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, and document review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the wall mounted fan over the dish area, standing fan just outside the dish area, and ceiling. Additionally, the walk-in freezer floor was not maintained in clean and sanitary manner, and the reach-in refrigerator had uncovered, undated, and unlabeled food; the reach-in freezer had open bags of food; and all temperature logs were lacking complete documentation of temperature tracking, all of which has the ability to affect all residents in the facility. Findings: On 1/30/2024 at 8:05a.m. during a tour of the kitchen with morning cook the following was observed: 1. Two fans, one above the dish area and the other outside the dish area heavily soiled with dirt and debris. 2. Uncovered, unlabeled, and undated food in the reach-in refrigerator. 3. Open bag of frozen food in the reach-in freezer. 4. Moderate to heavy amounts of dirt and hanging from ceiling above clean dish area. 5. All current temperature logs lacking documentation for 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.