Waterville Center For Health And Rehab

Based on interviews and record reviews, the facility failed to review and revise the care plans by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 33 residents reviewed for care planning (Resident #125 [R125], R2, R45, R57, and R1).Findings: 1. Review of R125's clinical record revealed an MDS admission Assessment was completed on 11/8/24. Further review of R125’s clinical record indicated an Interdisciplinary Team (IDT) meeting was held 11/25/24 and lacked evidence that an IDT meeting was held within 7 days following the assessment. On 8/28/25 at 12:22 p.m. during an interview, the above finding was discussed with the Social Services Director. 2. Review of R2’s clinical record revealed the quarterly MDS was completed on 5/29/25. Further review of R2’s clinical record indicated, the Interdisciplinary Team meeting (IDT) was held on 6/15/25 (19 days after MDS completion). 3. Review of R45’s clinical record revealed the quarterly MDS was completed on…

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 facility policy review, record review, and interview the facility failed to document and adequately assess and monitor a resident after an unwitnessed fall for 1 of 5 residents reviewed for unnecessary medications (Resident #48 [R48]).Finding: Review of the policy, Fall Prevention and Response Policy, revised 7/14/25, states, .Immediate Response.Head-to-toe nursing assessment.vitals.anticoagulant use, anticoagulant last dose.Neurological Monitoring Protocol.Unwitnessed fall OR suspected head impact OR ON anticoagulant.Frequency & duration of neuro check.Q [every] 15 min [minutes] x 1h [hour], Q 30 min x 1 h, Q1 h x 4h, Q4 h x 24 h, Q8 h until 72 h total.Record completion of each neuro check in flowsheet. Resident #48 has diagnoses to include long term use of anticoagulant (blood thinner) and falls. Review of R48's clinical record revealed he/she sustained an unwitnessed fall on 6/3/25. Review of R48's Change in Condition Evaluation, dated 6/3/25 and SBAR [Situation, Background, Assessment, Response] nursing progress note, dated 6/3/25, lacked evidence that vital signs were…

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 record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #45 [R45]).Findings:Review of facility policy Medication Regiment Review (MRR) dated 6/5/24 states .Facility should encourage physician/prescriber or other responsible parties receiving the MMR and the director of nursing to act upon the recommendations contained in the MRR for those that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. The attending physician should document in the residents health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Facility should alert the Medical Director where MRRs are not…

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 record review and interview, the facility failed to monitor for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident [R] 86).Finding:R86 has diagnoses to include depression.R86's care plan states, .uses psychotropic medications r/t [related to] Behavior management: for dx [diagnosis] of Depression.will be/remain free of drug related complications.Monitor/document for side effects and effectiveness . Monitor/record/report to MD [Medical Doctor] prn [as needed] side effects.Review of R86's clinical record revealed the following active physician orders:Order for Sertraline HCl Oral Tablet 50 MG [milligram] Give 1 tablet by mouth 1 time a day for Depression.Order for Venlafaxine HCl ER [extended release] Oral Tablet.75MG.Give 1 tablet by mouth one time a day for Depression.Further review of R86's clinical record lacked evidence he/she was monitored for side effects of the above medications.On 8/28/25 at 10:13 a.m., during an interview, the Director of Nursing (DON) reviewed R86's entire clinical record and confirmed R86…

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, interviews and record reviews, 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 a urinary catheter drainage bag for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #66 [R66]). Additionally, the facility failed to ensure proper notification was given to resident representatives during 1 of 1 Covid-19 outbreak in the facility.Findings: 1. R66 has diagnoses to include obstructive uropathy (a blockage in urine flow), indwelling suprapubic urinary catheter, and chronic urinary tract infection. Review of R66's care plan states, .has Suprapubic Catheter for OBSTRUCTIVE AND REFLUX UROPATHY and I get chronic urinary tract infections . On 8/25/25 at 12:38 p.m., R66 was observed foot-propelling in his/her wheelchair from the Memory Unit dining room to the day room area, and his/her urinary catheter drainage bag was hanging under the wheelchair, with the catheter tubing and drainage bag dragging on…

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 record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed during an investigation of a facility-reported incident. (Resident #1) Findings: Resident #1 was admitted on [DATE] and had diagnoses to include venous stasis ulcers and deep vein thrombosis (DVT). Review of Resident #1's Care plan, initiated on 12/19/24, states, .history of Deep Vein Thrombosis r/t [related to] Immobility .at risk of developing another DVT . Inspect legs and feet for Skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish red, warm along the course of the vein (superficial) . Review of Resident #1's active physician orders, dated January 2025, lacked evidence that Resident #1 was being monitored for signs and symptoms related to a DVT. Review of Resident #1's daily skilled assessments dated 1/12/25, 1/16/25, and 1/17/25 lacked evidence that a cardiovascular assessment was completed, and…

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 record review and interviews the facility failed to provide/obtain Resident and/or Resident's Representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an Advance Directive for 8 of 8 Resident's reviewed for Advance Directives (Resident #26 [R26], R46, R251, R252, R43, R4, R64, and R34). Findings: Review of facility policy Advance Directive undated states, .As part of the admission process, [Facility] Social Service Department shall ask and document in the resident's medical record whether the resident has executed an Advance Directive (i.e., Living Will or Durable Healthcare Power of Attorney), if so, the social worker shall obtain a copy and place it in the resident's current medical record. In the absence of an Advance Directive, the social worker shall provide to the Resident and/or the admitting party written information about Maine's Advance Directive laws, the right to refuse or accept medical care, sample forms, and this policy.…

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 adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 4 units (Mountain Top Unit and Harbor Unit) for 3 of 3 facility tours (9/9/24, 9/10/24 and 9/12/24). Findings: 1. On 9/9/24, the following observations were made and confirmations received at time of observation: > On 9/9/24 at 12:52 p.m., in the Cranberry dining room on the Mountain Top Unit, a surveyor observed a pile of wet towels under the ice machine, the flooring had stripped away and the cabinet laminate had peeled back. Mildew was visible on the wall and the floor. At this time, in an interview, Certified Nursing Assistant #2 (CNA2) observed and confirmed the findings. > On 9/9/24 at 12:12 p.m., in the Blueberry dining room on the Mountain Top Unit, a surveyor observed fruit flies over the stove and around the sink. At this time, in an interview, Registered Nurse #2 (RN2) observed and confirmed…

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 provide a sanitary environment to ensure that respiratory equipment was clean to help prevent the development and transmission of disease and infection related to nebulizer and oxygen tubing for 3 of 3 residents reviewed for respiratory care (Resident #251 [R251], R3, and R47). Findings: Review of facility policy Nebulizer Cleaning dated 7/1/21 states ., store the nebulizer in a zip lock plastic bag . 1. Observations of R251 on 9/9/24 at 11:45 a.m., and 9/10/24 at 8:08 a.m., a nebulizer was observed on bedside table with tubing connected to mask lying on top of table not labeled or bagged. Observation of oxygen concentrator on opposite side of room with nasal cannula/tubing connected and observed lying on floor, undated and unbagged. Review of R251's active orders dated September 2024 lacked evidence of an order for oxygen or nebulizer use. During an interview on 9/09/24 at 11:49 a.m. with a surveyor, Registered Nurse (RN) #1 indicated R251 does not use a nebulizer or oxygen. During an observation of R251 on 9/10/24 at…

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 interviews, record review, and staffing schedule review, the facility failed to ensure sufficient staff were scheduled and on duty to meet the needs of resident's (Resident #25 [R25], R64, and R18) with the potential to affect all resident's. Findings: On 9/09/24 at 12:52 p.m., in an interview with a surveyor, Certified Nursing Assistant #2 (CNA2) stated, it's hard to provide care timely, lately it's me; a nurse will have 2 floors, and a med tech (Certified Medication Assistant - Medications [CNA-M]). On 9/10/24 at 7:30 a.m., in an interview with a surveyor, R25 states they had not received a bath 3 times in a row in the past month because staff wouldn't provide it. Record review of R25's Care Plan indicates, [R25] requires extensive assist for toileting and personal hygiene, and physical assist with bathing and patient to have a shower twice a week and prn [as needed]. On 9/10/24 at 10:45 a.m., in an interview with a surveyor, RN1 states there is a delay in care due to staffing. Resident's still get what they need but they may be sitting in incontinence for too long before…

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 record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts on 2 of 3 units observed for medication storage (Cove and Harbor). Findings: 1. Review of bound controlled medication book labeled Harbor Log #119 lacked evidence that controlled medication counts were conducted by the oncoming nurse on 8/17/24 at 18:20 (6:20 p.m.). Further review of controlled medication book lacked evidence that controlled medication counts were conducted by the outgoing nurse on 8/17/24 at 5:40 a.m., 8/18/24 at 6:00 a.m., and on 8/28/24 at 6:00 a.m. During an interview on 9/10/24 at 6:30 a.m. with a surveyor, Certified Nursing Assistant- Medications #1 (CNA-M1) confirmed above findings. 2. Review of bound controlled medication book labeled Cove #21 lacked evidence that controlled medication counts were conducted by the oncoming nurse on…

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, interviews, record reviews, and policy review, the facility failed to adequately date and properly dispose of biological's according to manufacturer specifications and expired medications on 1 of 1 unit (Cove). In addition, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 2 of 2 medication rooms observed (Cove and Harbor). Furthermore, the facility failed to ensure proper vaccine storage temperatures for 1 of 1 unit (Cove) and failed to monitor and record medication refrigerator temperatures for 3 of 4 medication refrigerators observed (Cove and Harbor). Findings: 1. Review of facility policy Storage and Expiration Dating of Medications and Biological's dated 12/1/07 states .Facility should ensure that medications and biological's that (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines . Medications with a manufactured expiration date expressed with month and year will expire on the last day of the month .Facility…

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, interviews, Resident Council Meeting Minutes and lunch meal test trays, the facility failed to serve hot foods hot, and cold foods cold for 2 of 4 lunch meals (lunch 9/9/24, and lunch 9/10/24) tested for appetizing temperatures (Resident #4 [R4], R5, R16, R34, R47, and R59). Findings: 1. On 9/09/24 at 11:13 a.m., in an interview with a surveyor, R59 states, The food is lukewarm most of the time. 2. On 9/09/24 at 11:50 a.m., in an interview with a surveyor, R47 states, The vegetables are soft and squishy. 3. On 9/9/24 at 11:55 a.m., a surveyor received a test tray from the Harbor Unit with Hot Potato salad, [NAME] Beans and a Hamburger. The temperature of the Hot Potato salad was 95.3 degrees Fahrenheit (F). The temperature of the [NAME] Beans was 95 degrees F. The temperature of the Hamburger was 99.6 degrees F. The hot foods on the test tray were found not to be palatable at those temperatures by the surveyor. 4. On 9/09/24 at 1:59 p.m., in an interview with a surveyor, R4 states, The food that comes is always cold and has to be reheated. It is never hot and…

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, interviews, facility logs and the facility's Dish Machine Temperatures policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall mounted fan, food disposals, the dishwasher, the standing floor mixer, ceiling air vents, ceiling tiles, and the walk-in freezer; failed to ensure hair protection was worn by staff; failed to ensure foods were dated/labeled appropriately; failed to ensure kitchen sanitizer was monitored and failed to ensure that kitchen and unit refrigerator/freezer and dishwasher temperatures were monitored appropriately for 1 of 1 kitchen tours (9/9/24) and 2 of 2 kitchen observations (9/9/24 and 9/10/24). This has the potential to affect all residents that eat food prepared by kitchen staff. Findings: Review of the facility's Dish Machine Temperatures policy revised 1/24 noted: Dish machine wash and rinse water should be maintained at temperatures that meet guidelines established by the Food and Drug administration. State or local regulations will apply if stricter. Note: The range for optimal…

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 the cumulative effect of deficiencies cited during the recertification survey from 9/9/24 through 9/17/24, the facility failed to ensure the facility was Administered in a manner that enabled residents to attain or maintain their highest practicable well-being as evidenced by Federal findings listed under §483.10 - Resident Rights (F567, F578, F584); § 483.12 - Freedom from Abuse, Neglect, and Exploitation (F604, F607, F609, and F610); §483.15 - Admission, Transfer, and Discharge (F623, and F625); §483.20 - Resident Assessments (F645); §483.24 - Quality of Life (F675); §483.25 - Quality of Care (F684, F695); §483.35 - Nursing Services (F725, and F730); §483.45 - Pharmacy Services (F755, and F761); §483.60 - Food and Nutrition Services (F804, F810, and F812); §483.70 - Administration (F842); §483.80 - Infection Control (F880, and F883); §483.90 - Physical Environment (F908); and §483.95 - Training Requirements (F940, F942, F943, F944, F946, F947, and F949). These failures to ensure a process was in place to monitor staff development and resident care resulted in the facility…

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 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 enhanced barrier precautions (EBP's) pertaining to Residents (Resident #70 [R70], R87, and R84) with a wound(s) for 2 of 5 days of survey (9/9/24, and 9/10/24). Findings: On 9/9/24, from 10:30 a.m. to 3:45 p.m., a surveyor observed no signage or personal protective equipment (PPE) other than gloves for R70's room who has a wound and is on EBP's. On 9/10/24, from 7:30 a.m. to 3:45 p.m., a surveyor observed no signage or PPE other than gloves for R70's room who has a wound and is on EBP's. On 9/9/24, from 10:30 a.m. to 3:45 p.m., a surveyor observed no signage or PPE other than gloves for R87's room, who has a wound and is on EBP's. On 9/10/24, from 7:30 a.m. to 3:45 p.m., a surveyor observed no signage or PPE other than gloves for R87's room who has a wound and is on EBP's. On 9/9/24, from 10:30 a.m. to 3:45 p.m., a surveyor observed no signage or PPE…

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 record review, and interview, the facility failed to ensure Residents were offered pneumococcal vaccinations in accordance with their policy and the Centers for Disease Control and Prevention (CDC) recommendations for 5 of 5 residents reviewed for immunizations (Resident [R] 87, R90, R29, R1, and R70). Findings: Review of the facility Pneumococcal Vaccine Policy Statement, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated., and 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. R87's admission date to the facility was on 1219/23. During review of immunization records, a surveyor could not locate evidence…

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, interviews, the facility's Dish Machine Temperatures, and a food equipment service company work log, the facility failed to ensure that the kitchen high temperature dish machine was maintained in good repair and in safe operating condition for 1 of 1 dish machine observations (9/9/24) and failed to ensure proper cleaning and sanitizing of dishes for 1 of 1 kitchen tours (9/9/24). Findings: Review of the facility's Dish Machine Temperatures policy revised 1/24 noted: Dish machine wash and rinse water should be maintained at temperatures that meet guidelines established by the Food and Drug administration. State or local regulations will apply if stricter. Note: The range for optimal cleaning performance of the Diversey dish detergent is 150° Fahrenheit (F) to 165°F. Supervisor: If documentation of temperatures and test strips/max temperatures results has been assigned to a food and nutrition associate, confirm that it is completed at each meal period. Director: In the event of inappropriate…

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 interviews and record review, the facility failed to provide a resident access to personal funds (Resident #47 [R47]). Finding: On 9/9/24 at 11:41 a.m., in an interview with a surveyor, R47 stated, I didn't get the $40.00 for the last 2 months. I was fighting about that this morning. Corporate took it all instead of giving it to me. They said they need to find out why. Review of R47's financial statements indicated the facility's cost of care deduction for R47 was $1,251.00 per month, which left $40.00 dollars in an account for personal use. The facility deducted $1,291.00 for cost of care on 8/2/24 and 9/3/24 with out explanation for the increased charge. On 9/12/24 at 7:50 a.m., in an interview with a surveyor, the Nursing and Operations Assistant stated she became aware of this when R47's guardian came to do some shopping for R47 but there was not enough money in the account; an email was sent on 9/9/24 regarding this error, and compensation had to wait until a reply was received from the Corporate office. At this time a surveyor confirmed that a resident did not have…

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 employee record review, facility policy review, and interview, the facility failed to implement its own Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition policy to ensure Maine background checks were completed for new employees before they were permitted to work for 2 of 12 sampled employees (Certified Nursing Assistant #5 [CNA5] and Registered Nurse #1 [RN1]). Findings: The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition Policy Date: 7/1/2021 and Revised: April 21, 2023, indicates under A. Screening . 1. At a minimum this Community will do the following prior to hiring a new colleague: a. Criminal background checks are conducted per state/federal law/regulation and per [Facility] guidelines. 1. On 9/13/24, a review of CNA5's employee file indicated the date of hire as 6/12/23. CNA5's Maine background check was completed on 7/30/23 (48 days after date of hire and working). 2. On 9/13/24, a review of RN1's employee file indicated the date of hire as 11/6/23. RN1's Maine background check was completed…

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 record reviews, and interviews, the facility failed to issue a written transfer/discharge notice to a Resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 Resident's reviewed for hospitalization (Resident #68 [R68], and R48). Findings: 1. R68 was admitted on [DATE] and has diagnoses to include dementia, dysphagia and atrial fibrillation. Review of R68's clinical record revealed on 9/5/24 he/she was transferred to an acute care hospital and subsequently admitted to the hospital. Further review of R68's clinical record lacked evidence that the Resident and/or Resident Representative was provided a written transfer/discharge notice. During a review of R68's clinical record on 9/11/24 at 1:40 p.m. with a surveyor, the Administrator confirmed the clinical record lacked evidence that a transfer notice was provided in writing to the Resident and/or Resident Representative. 2. R48 was admitted on [DATE] and has diagnoses to include Escherichia coli, dysphagia, hemiplegia…

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 record review and interview, the facility failed to issue written bed hold notices to include cost of care to the Resident and/or legal representative for 2 of 3 sampled Resident's reviewed for transfer to an acute care hospital (Residents #68 [R68], and R48). Findings: 1. R68 was admitted on [DATE] and has diagnoses to include dementia, dysphagia and atrial fibrillation. Review of R68's clinical record revealed on 9/5/24 he/she was transferred to an acute care hospital and subsequently admitted to the hospital. Review of R68's clinical record lacked evidence that the Resident and/or Resident Representative was provided a written bed hold notice upon this transfer. During a review of R68's clinical record on 9/11/24 at 1:40 p.m. in an interview with a surveyor, the Administrator confirmed the clinical record lacked evidence that a written bed hold notice was provided in writing to Resident and/or Resident Representative. 2. R48 was admitted on [DATE] and has diagnoses to include Escherichia coli,…

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 record reviews and interviews, the facility failed to ensure residents with a specialized mental health diagnosis had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review (PASRR) evaluation and determination for 3 of 3 residents reviewed for PASRR evaluation (Resident #90 [R90], R25, and R11). Findings: 1. Clinical record review indicates R90 was re-admitted to the facility on [DATE], diagnoses to include bipolar disorder, anxiety disorder, and depression. Review of R90's PASRR Level I dated 5/31/24 indicates R90 had a Convalescence Categorical exemption (a time-limited 30-day exemption). R90's clinical record lacks evidence that the resident had been re-evaluated for a PASRR Level II determination after the Convalescent period ended. On 9/12/24 at 4:40 p.m., in an interview with the Administrator, a surveyor confirmed R90 had not been re-evaluated for a PASRR Level II determination after the Convalescent period ended.

Based on record reviews, and interview the facility failed to ensure that physician orders were updated and/or followed for 1 of 5 Resident's reviewed for unnecessary medications. (Resident #29 [R29]). Findings: On 9/12/24 during R29's clinical record review, R29 had a new physician order filed in the paper record and scanned into the electronic record dated 9/4/24 to, 1) discontinue acetaminophen 650 mg (milligram [m.g]) 3 times daily, 2) Begin acetaminophen 1 g (gram) (1000 m.g equals 1 g) 3 times daily for chronic pain, 3) physical therapy evaluation and treatment for decreased mobility with the patient goal of regaining independence in bed mobility, and 4) occupational therapy evaluation and treatment for decreased mobility with the patient goal of regaining independence in bed mobility. Review of R29's clinical record lacked evidence that R29's acetaminophen order, physical therapy order, and occupational therapy order dated 9/4/24 was reviewed and/or updated by a provider. On 9/12/24 at 9:28 a.m. in an interview with a surveyor, Registered Nurse #4 (RN4), Charge Nurse on…

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 performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #2 [CNA2]). Findings: 1. CNA2 was hired on 7/1/21. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. On 9/13/24 at 1:00 p.m., in an interview with a surveyor, the Administrator confirmed that CNA2 had not received annual performance evaluations in 2023 and 2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to provide adaptive built-up utensils and Kennedy cups for 1 of 5 residents reviewed for nutrition (Resident #11 [R11]). Findings: Clinical record review indicates R11 was admitted on [DATE], diagnoses to include generalized muscle weakness, dysphagia (difficulty swallowing), and protein-calorie malnutrition. R11's Care Plan initiated on 7/9/24 states, [R11] has or may have a nutritional problem, the interventions for this include Adaptive equipment at meals: Kennedy cup, rimmed plate, built-up utensils. The Dietary Communication Slip dated 11/26 states Please issue weighted utensil. On 9/09/24 at 12:58 p.m., a surveyor observed R11 eating lunch in bed. The meal ticket on the tray indicates use of a Kennedy cup, and built-up utensils. R11's meal tray did not include a Kennedy cup or built-up utensils. On 9/10/24 at 8:30 a.m., a surveyor observed R11's breakfast tray did not include a Kennedy cup or built-up utensils. On 9/11/24 at 12:09…

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 record reviews, and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 20 residents reviewed for documentation (Resident #46 [R46], R3, and R47). Findings: R46 was admitted on [DATE] and has diagnoses to include diabetes mellitus II, chronic obstructive pulmonary disease (COPD), hypertension, vision loss, depression, chronic pain, and end stage renal failure - dialysis dependent. Review of R46's clinical record revealed active orders dated September 2024 and revealed the following: -Order with start date of 12/6/23 for Bupropion HCl ER (XL) Oral Tablet Extended Release 24 Hour (Bupropion HCl). Give 150 mg (milligram) by mouth one time a day for depression 150 mg. -Order with start date of 7/12/24 for Famotidine Oral Tablet 10 mg. Give 1 tablet by mouth one time a day every [Mon, Wed, Fri, Sun] for GERD (gastroesophageal reflux disease). -Order with start date of 2/15/24 for Apixaban Oral Tablet 5 MG (Apixaban). Give 1 tablet by mouth…

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 employee files review and interview, the facility failed to develop and implement an education program that included training on Resident Rights for 1 of 5 Certified Nursing Assistant's (CNA) reviewed (CNA4). Findings: CNA4 was hired on 6/27/22. A review of CNA4's education records revealed she has not received yearly education for Resident Rights since 6/27/22. On 9/13/24 at 2:10 p.m. in an interview with a surveyor, the Human Resource Director confirmed that CNA4 had not received the above In-service training in 2023 and 2024.

Based on review of Certified Nursing Assistant's (CNA) in-service training and interview, the facility failed to ensure that 1 of 1 CNA completed yearly training for Abuse, Neglect, Exploitation and Misappropriation of Property (CNA1). Finding: A review of the Facility Assessment for 2024-2025 revealed Required in-service training for new aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. CNA4 was hired on 6/27/22. A review of CNA4's education records revealed she has not received yearly education for Abuse, Neglect, Exploitation and Misappropriation of Property since hired. On 9/13/24 at 2:10 p.m. in an interview with a surveyor, the Human Resource Director confirmed that CNA4 had not received the above in-service training in 2023 and 2024.

Based on record review and interview, the facility failed to ensure staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 1 of 5 employee files reviewed (Certified Nursing Assistant #4 [CNA4]). Finding: CNA4 was hired on 6/27/22. A review of CNA4's education records lacked evidence she received annual mandatory training regarding the facilities QAPI program. On 9/13/24 at 2:10 p.m. in an interview with a surveyor, the Human Resource Director confirmed the CNA4 had not received the above in-service training in 2023 and 2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, review of the facility's Anti-psychotropic Medication Use Policy, and interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test for 1 of 5 residents reviewed for unnecessary medications (Resident # 70). Finding: A review of the facility's policy titled Abnormal Involuntary Movement Scale (AIMS), dated 7/1/2021, states The AIMS test is completed on admission, or with initiation of an anti-psychotic medication. The AIMS test is to be completed at least every 180 days (every six months) and/or when requested by the physician. The AIMS test is administered to residents who take anti-psychotics on a regularly scheduled basis or more than ten times per month. A review of Resident #70's clinical record revealed that since the resident's admission on [DATE], he/she has been on the anti-psychotic medication Quetiapine 25 mg (milligrams) twice a day; every day for agitation and anxiety. There was no evidence in Resident #70's clinical record that an AIMS test…

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.