Every finding on record at Aroostook Health Center

Based on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 2 of 3 days of survey (12/15/25 and 12/16/25).On 12/15/2025 at 11:35 a.m., during an observation of the dining room meal service, 2 surveyors observed staff serve meals to residents. R2, R4, and R5 were observed sitting at 3 separate tables shared with other residents. At 11:46 a.m., all residents had been served a meal, except for R2, R4, and R5. At 11:47 a.m., during an interview with 2 surveyors, the Nurse Manager stated their trays come on another cart and they never know who is going to eat in the dining room. At 11:54 a.m., all residents were observed to have their meals. This finding was observed and confirmed with the Unit Manager at the time of the observation, and again during the exit conference.On 12/16/25 at approximately 8:15 a.m., during observation of the breakfast meal service, a surveyor observed that R18 was at a table without a meal, and R18's tablemates had their meals. A surveyor observed R21 sitting at another table and was waiting for his/her breakfast tray. A surveyor observed that staff were not leaving the dining room to get the meal trays. During an interview with a surveyor, staff stated the meals would either be in the kitchen or on another meal cart. This finding was observed and confirmed with staff at the time of the observation, and again during the exit conference.

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 2 of 3 residents reviewed for advanced directives (Resident #1 [R1] and R3).Findings: 1. On 12/15/25, R1's clinical record was reviewed and indicated that R1 was admitted to the facility March 2024. On 12/16/25 at 12:30 p.m., during an interview with a surveyor, the Social Worker stated on (or about) 10/2/25, all residents received a document, Acknowledgement of Important Information and Policies and that under the section for Advanced Directives - it was checked that I DO have an Advanced Directive and have provided the facility with a copy of the document. The Social Worker stated that there was no copy of an Advanced Directive in the clinical record found from March 2024 to now and he was unsure if this was incorrectly documented. He has reached out to R1's family member to find out if one exists or to obtain a copy. On 12/16/25 at 2:30 p.m., during an interview with a surveyor, Nursing Supervisor (NS) stated that she reviewed the document with R1 on 10/2/25. NS stated that she did not follow up with R1's family or check in R1's clinical record to see if R1 had an Advanced Directive, indicating that R1 just stated that he/she had one. On 12/17/25 at 10:07 a.m., during an interview with a surveyor, the Social Worker stated that no additional information had been found on whether or not R1 was offered an Advanced Directive. 2. On 12/15/25, R3's clinical record was reviewed and indicated R3 was admitted to the facility October 2024. On 12/15/25 at 1:29 p.m., during an interview with the Social Worker, a surveyor inquired if R3 had an Advanced Directive or evidence that R3 was offered one. On 12/16/2025 at 9:48 a.m., during an interview with a surveyor, the Social Worker stated that he could not find evidence that Advance Directives were offered or declined by resident/resident representative. On 12/16/25 at 12:30 p.m., during an interview with a surveyor, the Social Worker stated on (or about) 10/2/25, all residents received a document, Acknowledgement of Important Information and Policies and that under the section for Advanced Directives - it was checked that I DO have an Advanced Directive and have provided the facility with a copy of the document. The Social Worker stated that there was no copy of an Advanced Directive found in the clinical record from October 2024 to now and was unsure if this was incorrectly documented. He has reached out to R3's family member to find out if one exists or to obtain a copy. On 12/17/25, at 10:07 a.m., during an interview with a surveyor, the Social Worker stated that no additional information has been found on whether or not R3 was offered an Advanced Directive. On 12/17/25 at 10:15 a.m., during an interview with a surveyor, the Director of Nursing stated that staff needs education on what an Advanced Directive is as some think that is the same as a Physicians Orders for Life Sustaining Treatment (POLST).

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and in a homelike environment on 3 of 3 days of survey (12/15/25, 12/16/25 and 12/17/25).Findings:On 12/15/25 at 8:45 a.m. upon entrance to the facility for their annual recertification, 3 surveyors observed the environment in a non-homelike environment with emergency light fixtures, call lights not being attached to the walls leaving visible wires. The thermostat near the front room did not have a cover on it. The wallpaper was removed leaving primed and unpainted surfaces throughout the hallways of the facility. In the charting area near station 1 nursing station the light switch did not have a cover. As the surveyors walked down the hallway it was observed that other areas did not have finished surfaces. The floors in the residents rooms were observed to have a build up of dirt and grime visible from the hallway.During resident interviews throughout this survey other areas of concern were noted with walls being dirty and marred. (see tour findings below for specific locations)On 12/15/2025 at 11:35 a.m., 2 surveyors observed 3 ceiling fans (not in use) in the dining. It was observed that the first fan closest to the doorway had moderately warped fan blades, The second fan had some warped fan blades. With the third ceiling fan not having any warped blades.On 12/15/25 at 2:23 p.m. the floor drain cover in the middle of the hallway near the conference room had cracked, broken and heavily soiled tiles around it creating an uncleanable surface with a potential to be a tripping hazard,On 12/15/25 at 2:50 p.m. the floor drain cover near the station 1 nurses station had cracked, broken and soiled tiles around it creating an uncleanable surface.On 12/16/2025 at 1:35 p.m. a surveyor observed and confirmed the warped fan blades in the dining room with the Director of Nursing.On 12/17/2025 at 1:37 p.m. the surveyor toured the facility with the Administrator and the Corporate Health Operations Consultant the following findings were observed and confirmed by the surveyor. In the hallways there are unpainted and exposed drywall paste making it uncleanable and unhomelike,In room [ROOM NUMBER] the wall near the bed was marred and stained with a white unknown substance. In room [ROOM NUMBER] the wall by bed 1 is marred and stained. In room [ROOM NUMBER] the wall is marred and stained. It was discussed with the Administrator and the Corporate Health Operations Consultant for the facility to look at all walls in the residents rooms for similar conditions.In room [ROOM NUMBER] the thermostat cover was missing and the over bed table for bed 1 was observed to have chipped edges creating an uncleanable surfaceOn bed 2 the over bed table had a corner that was chipped and uncleanable. In the hallway on station 3 and station 1 there were phone boxes that were not framed leaving exposed sheetrock edges creating an uncleanable surface.In the dining room area, the 2 ceiling fans with warped fan blades were shown to the Administrator and the Corporate Health Operations Consultant.The observations made upon entrance on 12/15/25 and during the facility tour were discussed with the Administrator and the Corporate Health Operations Consultant, the surveyor confirmed the above findings at that time.

Based on record reviews, facility policy review, and interviews, the facility failed to issue a written transfer/bed hold notice to a resident and their legal representative for a facility-initiated transfer/discharge for 2 of 4 sampled residents transferred/discharged to an acute care facility (Residents #1 [R1] and R33). In addition, the facility failed to notify (at least monthly) the Ombudsman office of transfer/discharges that have occurred since September 2025. Findings: The facility policy, Bed Holds and Returns, revised 3/2025, indicated that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: - notice 1: well in advance of any transfer (in the admission packet); and - notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours. 1. On 12/15/25, R1's clinical record was reviewed and indicated that on 11/4/25, R1 was transferred and admitted to the hospital. The bed hold notice, dated 11/4/25, included both the transfer/discharge reason and bed hold notice was completed. The notice only indicated that it was given to R1 'verbally and there was no documentation to indicate a written copy was provided to R1. On 12/16/2025 at 10:00 a.m., during an interview with the Business Office Manager (BOM), a surveyor confirmed this finding. 2. On 12/15/25, R33's clinical record was reviewed and indicated that on 11/23/25, R33 was transferred and admitted to the hospital. The bed hold notice, dated 11/23/25, included both the transfer/discharge reason and bed hold notice was completed. On 12/16/25 at 2:11 p.m., the BOM stated that she emailed a copy to the Resident Representative, but the notice and clinical record lacked evidence that a copy was provided to R33. On 12/16/2025 at 2:28 p.m., during an interview with a surveyor, Nursing Supervisor stated that she completed the bed hold/transfer notice but cannot say that a copy was given to R33. During these interviews, a surveyor confirmed that a written copy of this notice was not provided to both the Resident and Resident Representative. 3. On 12/16/25 at 10:00 a.m., during an interview with a surveyor, the BOM stated that she notifies the Ombudsman office quarterly and not monthly of transfer/discharges with the last listing sent for transfer/discharges through September.

Based on record review and interviews, the facility failed to ensure that physician orders were followed for 2 of 3 residents reviewed for nutrition (Resident #14 [R14] and R39).On 12/16/25, R14's clinical record was reviewed and indicated the following:-Review of the Provider Orders included and active order dated 12/18/24, [Esophagogastroduodenoscopy (EGD)] to rule out possible gastric ulcer when [appointment (apt)] available.-On 12/17/24, a Provider's progress note indicated, [R14] requested to be seen today secondary to epigastric abdominal pain. [R14] reports several weeks of epigastric abdominal pain with excessive burping and decreased appetite with early [feeling of being full after eating (satiety)]. [R14] has a history of gastric ulcers and is concerned this has returned. [R14's] last upper endoscopy. showed several nonbleeding gastric ulcers. Given this history and [R14's] complaint of early satiety with abdominal pain, we will repeat an upper endoscopy. Referral to General Surgery will be placed. The provider also ordered a new medication for symptom control.-On 12/17/24 at 7:31 p.m., a nursing note indicated, [Doctor] was in to see [R14] today for an acute visit. Resident is [complaint of (c/o)] upper gastric pain and thinks [he/she] might have an ulcer. [Doctor] ordered an EGD to be done soon to check for ulcers. Orders placed in [Point Click Care (PCC)].-On 12/18/24 at 6:15 p.m., an Administration note indicated, EGD one time only for Stomach ulcer for 5 Days No apt dates scheduled at this time.-On 12/31/24, a Provider's progress note indicated, 8. Chronic gastroesophageal reflux disease with history of gastric ulcer: . [R14] is awaiting general surgery consultation for possible repeat EGD.-On 12/31/24 at 5:37 p.m., a nursing note indicated, [Doctor] was in to see resident for [his/her] 60 day progress note. We are still waiting on General Surgery for [his/her] Scope.-On 3/4/25, a Provider's progress note indicated, 8. Chronic gastroesophageal reflux disease with history of gastric ulcer: . we are going to look into why [R14] still has not had any consultation with General Surgery.-On 3/5/25 at 10:29 a.m., a nursing note stated, Medical rounds completed with [Doctor of Medicine (MD)]- requested [follow-up (f/u)] on surgical consult for [complaint of (c/o)] stomach pain (ulcer) Will speak with Unit secretary in regards to.-On 5/6/25, a Provider's progress note indicated, 8. Chronic gastroesophageal reflux disease with history of gastric ulcer: . Nursing staff are again going to look into [R14's] general surgery referral, given [his/her] abdominal pain with history of gastric ulcer.The clinical record lacks evidence that R14's referral was sent to General Surgery, and/or that R14 was seen by General Surgery for consultation (1 year delay).On 12/16/25 at 1:35 p.m., during an interview with a surveyor, the Scheduler stated she was unable to find an apt for the EGD. The Scheduler stated nursing had not brought that to her. The Scheduler stated she would check the chart for that order. At 2:55 p.m., during an interview, the Schedule confirmed with the surveyor that she was unable to find any evidence that the EGD was scheduled for R14.2. On 12/15/25 at 9:28 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 8:37 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 12:07 p.m., a surveyor observed R39 in bed, eating lunch independently and unmonitored.On 12/16/25, review of R39's provider orders indicated an active order dated 11/09/25, [Out of Bed (OOB)] for all meals with meals for choking risk, and a diet order dated 11/13/25, Regular texture, . OOB for all meals, Extra gravies for hydration and nutrition. The clinical record lacked evidence that R39 refused to get Out of Bed for meals.On 12/16/25 at 12:21 p.m., during an interview with a surveyor and the Nurse Manager, R39's clinical record was reviewed. At this time a surveyor confirmed R39 is at risk for choking with meals, has not been Out of Bed for all meals, or monitored with meals as directed by the provider orders and Care Plan (See F656).

Based on employee record reviews, and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 4 of 5 sampled staff (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, and CNA4). Findings: 1. CNA1 was hired on 4/14/24. The last performance evaluation was completed for 4/14/24 - 9/30/24. The facility was unable to provide evidence that an annual performance evaluation was completed between 10/1/24 - 9/30/25. 2. CNA2 was hired on 6/18/23. The last performance evaluation was completed for 10/1/23 - 9/30/24. The facility was unable to provide evidence that an annual performance evaluation was completed between 10/1/24 - 9/30/25. 3. CNA3 was hired on 4/14/24. The last performance evaluation was completed for 4/14/24 - 9/30/24. The facility was unable to provide evidence that an annual performance evaluation was completed between 10/1/24 - 9/30/25. 4. CNA4 was hired on 8/18/24. The last performance evaluation was completed for 8/18/24 - 11/15/24. The facility was unable to provide evidence that an annual performance evaluation was completed between 11/16/24 - 11/15/25. On 12/17/25 at 12:07 p.m., in an interview with the Director of Nursing, a surveyor confirmed that there is no evidence that performance evaluations were completed within 12 months for CNA1, CNA2, CNA3, and CNA4.

Based on observation, and interviews the facility failed to ensure expired medications were removed from the supply available for use in 1 of 3 medication storage rooms, and 1 of 2 medication storage refrigerators (Main medication storage room, and Main medication storage refrigerator), and the facility failed to monitor medication storage refrigerator temperatures to ensure proper refrigerator temperatures were maintained for medications, immunizations, and biological storage requiring refrigeration for 2 of 2 medication storage refrigerators (Main medication room-main medication storage refrigerator, and Station 1 medication room-Station 1 immunization storage refrigerator). Findings:1. On 12/16/25 at 10:10 a.m., during observations and review of the Main medication storage room with a Certified Nursing Assistant-Medications [CNA-M1], a surveyor observed and confirmed the following expired medications in the Main medication storage room and Main medication storage refrigerator available for use.-one container of Hemorrhoidal Hygiene Pads, with an expiration date of 9/2025.-one bottle of Geri Care, Milk of Magnesium, with an expiration date of 10/2025.-two Humira 40 mg/0.8 ml pens both with expiration dates of 10/17/25 in the main medication storage refrigerator.2. On 12/16/25 at 11:22 a.m., a surveyor and Director of Nursing (DON) observed in Main medication storage room, Main medication storage refrigerator containing medications requiring refrigeration and observed in Station 1 medication storage room, Station 1 medication storage refrigerator containing immunizations requiring refrigeration. The facility lacked evidence of a temperature log sheet, and the DON stated that she has been taking the temperatures but has not for a while, she could not find the temperature log sheets and confirmed that temperatures have not been monitored.On 12/16/25 at 11:22 a.m., in an interview with the DON, a surveyor confirmed there was no evidence of documentation for monitoring medication storage refrigerator temperatures, and the refrigerators were not being monitored for safe temperatures.

Based 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 in the area of Enhanced Barrier Precautions (EBP), changing soiled gloves during/after patient care, and linen handling for 2 of 3 days of survey (12/16/25 and 12/17/25).Findings: The facility policy, Enhanced Barrier Precautions, revised 3/2025, indicated that Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug organisms (MDROs) to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: -dressing; -bathing/showering; -transferring; -providing hygiene; -changing linens; -changing briefs or assisting with toileting; -device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc); and -wound care (any skin opening requiring a dressing). The facility's policy, Laundry and Bedding, Soiled, revised 3/2025, indicates the following: -Contaminated laundry is bagged or contained at the point of collection and -Leak-resistant containers or bags are used for linens or textiles contaminated with blood or body substances. 1. On 12/15/25, a surveyor reviewed Resident #38 (R38)'s clinical record and noted that the resident was on EBP. R38's care plan included a FOCUS of I am on enhanced barrier precautions .and direct care staff are to utilize gowns and gloves for all personal care, all added on 10/20/25. On 12/16/2025 at 9:05 a.m., a surveyor observed R38's room door closed. A surveyor knocked on the door, and a voice was heard from inside the room, stating patient care. Certified Nursing Assistant #5 (CNA5) knocked on R38's door and went into room. Upon exiting the room, a surveyor asked CNA5 who was in the room and if they were wearing a gown. CNA5 stated that CNA1 was in the room washing the resident up and was not wearing a gown. On 12/16/2025 at 9:17 a.m., during an interview with a surveyor, CNA1 stated that she was not aware that R38 was on EBP and stated that she was washing R38 up and she was not wearing a gown. 2. On 12/16/25 at 10:48 a.m., a surveyor observed Licensed Practical Nurse #1 (LPN1) prepare for a dressing change on R1's coccyx area. At the start of the procedure, LPN1 discovered that R1 needed a brief change and exited the room to get help. At 11:00 a.m., CNA2 and LPN1 returned. R1's soiled (feces) brief was removed and LPN1 cleaned R1's bottom area as R1 was positioned on his/her left side. The [NAME] (absorbent incontinence bed protector pad) was then changed as it was soiled. LPN1 placed a clean brief under R1 and touched his/her leg while rolling R1 from his/her side to the back, onto the clean brief and fastened it, still wearing the same soiled gloves that were worn during the brief change R1. After the brief was changed, LPN1 changed her gown and gloves and continued with the dressing change by cleaning the coccyx wound with saline wipes, a skin prep wipe, applied triad cream, and placed an abdominal pad under R1's coccyx area before fastening R1's brief. LPN1 then rearranged R1's bed sheet over him/her, touched the bedside table, and pulled the privacy curtain open, still wearing the same soiled gloves that were used during the dressing change. On 12/16/25 at 11:26 a.m., during an interview with LPN1, the surveyor confirmed that gloves were not removed after being soiled, before touching other items. 3. On 12/16/25 at 11:10 a.m., the surveyor observed CNA2 leaving the resident's room, carrying the soiled [NAME] down the hallway, not bagged. On 12/16/25 at 11:23 a.m., during an interview with CNA2, the surveyor confirmed that soiled [NAME] was carried down the hallway not bagged. 4. On 12/17/25 at 10:56 a.m., the surveyor observed 2 staff assisting R41 to the bathroom. While the 2 staff were assisting R41 it was noted that he/she was on Enhanced Barrier Precautions (EBP) and the staff were observed with donned gloves but did not have gowns that were required for his/her EBP. Clinical record review identified that R41 has an open wound with a Methicillin-resistant-staphylococcus aureus (MRSA) culture, this open wound area was not covered with a dressing. Review of R41's care plan addresses the MRSA in the wound and for staff to use EBP (gown and gloves) for high contact care activities in addition to standard precautions for multi-drug resistant organisms (MDRO). At the time of this observation the surveyor confirmed this finding with the staff who were assisting R41.

Based on facility policy review, antibiotic stewardship spreadsheet reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 3 months reviewed (October and November). This has the potential to affect all residents receiving an antibiotic.Finding:The facility policy, Antibiotic Stewardship - Review and Surveillance of Antibiotic use and Outcomes, revised 3/2025, indicated that antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. - The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide-antibiotic stewardship.- As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. -All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include resident name and medical number, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. On 12/17/2025 at 1:20 p.m., during the Antibiotic Stewardship review, the Director of Nursing and a surveyor reviewed September's antibiotic surveillance tracking form which was the last month of surveillance tracking form was completed. The surveyor confirmed October and November's Antibiotic Stewardship surveillance spreadsheets were not completed for review.

Based on interviews and record review, the facility failed to designate a qualified staff member to function as the Infection Preventionist who was responsible for the facility's Infection Control Program and worked at least part time in the role since 10/8/25. This has the potential to affect all residents in the facility.Finding: On 12/15/25 at 9:00 a.m., during an interview with 2 surveyors, the Director of Nursing (DON) stated that the Infection Preventionist (IP) position was an open position. On 12/17/2025 at 12:27 p.m., during an interview with a surveyor, the DON stated that she worked in the role of the DON fulltime. The previous IP left on 10/8/25 and that currently, she was the only staff member that had completed the proper IP training that was working in the facility. On 12/17/25 at 1:20 p.m., the Antibiotic Stewardship spreadsheet documentation was reviewed. This had not been updated since the previous IP left, with September being the last completed month documented. On 12/18/25 at 11:09 a.m., during an interview with a surveyor, the Administrator stated that part time hours were considered working 20 hours a week. During these interviews, a surveyor confirmed that the facility did not have a qualified IP currently working a minimum of 20 hours a week in the IP position and that even though the position was an open position, the IP role was not being completed.

Based on record reviews and interview, the facility failed to implement a Comprehensive Care Plan that addressed the physical needs of 1 of 3 residents reviewed for Nutrition (Resident # 39 [R39]).On 12/15/25 at 9:28 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 8:37 a.m., a surveyor observed R39 in bed, eating breakfast independently and unmonitored.On 12/16/25 at 12:07 p.m., a surveyor observed R39 in bed, eating lunch independently and unmonitored.On 12/16/25, record review indicated the following:-Review of provider orders indicated an active order dated 11/09/25, [Out of Bed (OOB)] for all meals with meals for choking risk, and a diet order dated 11/13/25, Regular texture, . OOB for all meals, Extra gravies for hydration and nutrition.-Review of the list of Residents for [Feeding Assistance (FA)], included R39. -Review of R39's Care Plan indicated a focus, I have a nutritional problem [related to (r/t)] my cognition, and [R39] has nutritional problem or potential nutritional problem: Underweight related to likely inadequate energy intake as evidenced by [Body Mass Index (BMI)] 17.3. Interventions for these focus areas include the following:- Monitor/document/report [as needed (PRN)] any [signs/symptoms (s/sx)] of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals.- encourage meals in the dining for socialization and supervision- Provide and serve diet as ordered. This intervention is listed twice in the Care Plan Interventions/Tasks.- [Regular (Reg)]/[High (Hi)] protein/Hi Calorie diet, . OOB for meals, Extra gravies for hydration and nutrition.On 12/16/25 at 12:21 p.m., during an interview with a surveyor and the Nurse Manager, R39's clinical record was reviewed. At this time a surveyor confirmed R39 is at risk for choking with meals and has not been Out of Bed for all meals or monitored with meals as directed by the provider orders and Care Plan.

Based on record reviews and interviews, the facility failed to ensure a care plan was updated to reflect a resident's current needs for 1 of 2 residents reviewed for pressure ulcers (Resident [R1]). Finding: On 12/15/25 at 9:35 a.m., during an interview with a surveyor, R1 stated that staff were treating a sore on his/her tail end. R1's clinical record was reviewed and indicated a quarterly Minimum Data Set (MDS), dated [DATE], was coded under Section M210B to reflect that R1 had one stage II pressure ulcer. On 12/15/25, during a clinical record review, a surveyor was unable to find a FOCUS for a current pressure ulcer or enhanced barrier precautions (FOCUS or interventions), but the current physician orders contained active orders for a treatment for a pressure injury and enhanced barrier precautions. On 12/16/2025 at 12:30 p.m., during an interview with the Director of Nursing (DON), a surveyor reviewed R1's care plan and noted that a care area for the pressure ulcer was updated yesterday (12/15/25) from healed to currently have a stage II but the care plan still lacked a FOCUS and/or interventions for enhanced barrier precautions.

Based on record review and interview, the facility failed to follow up on pharmacist recommendations and failed to keep all copies of Medication Reviews in the resident's clinical record for 1 of 5 residents reviewed for unnecessary medications (Resident #5, [R5]).Finding:On 12/17/25 at 11:00 a.m. during a review of R5's clinical record there was no evidence the facility followed up on pharmacist medication regimen recommendations. In R5's clinical record there was a note from the pharmacist that a review was done and to see recommendations. The clinical record lacked copies of these recommendations. During an interview and review of R5's clinical record with the Director of Nursing, she stated the pharmacist told her they failed to send all reviews for November At this time it was discovered that the October review was not in R5's clinical record and the recommendation was not reviewed and was not signed by the provider.The above finding was confirmed by the surveyor at the time of this interview.

Based on record review and interview, the facility failed to ensure residents were free from an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications [Resident #7 (R7)].On 12/17/25, a surveyor reviewed R7's clinical record. Review of active provider orders indicated:-An active order dated 6/25/25, LORazepam Tablet 0.5 [milligram (MG)] Give 0.5 mg by mouth one time a day for anxiety,-An active order dated 6/25/25, LORazepam Tablet 0.5 MG by 0.25 mg by mouth two times a day for anxiety, and-An active order dated 12/4/25, LORazepam Oral Tablet 0.5 (Lorazepam) Give 0.5 mg by mouth one time a day for anxiety. On 12/17/2025 at 9:13 a.m., during an interview with a surveyor and the Director of Nursing (DON), R7's clinical record was reviewed. The DON stated the Lorazepam had a duplicate order, the order for Lorazepam 0.5 mg one time per day dated 6/25/25 should have been discontinued on 12/4/25 when the new order was placed. Review of the Medication Administration Record indicated R7 received an additional dose of Lorazepam related to the duplicate order on 12/7/25 and 12/14/25. At this time the surveyor confirmed the above finding with the DON.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not removing expired products from the available for use supply, ensuring refrigerators had thermometers for routine monitoring, and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 3 days of survey (12/16/25). On 12/16/2025 at 11:51 a.m., during an observation of the Assisted Dining Room kitchenette, 2 surveyors observed and confirmed the following with the Minimum Data Set (MDS) nurse:- 2 surveyors and the MDS nurse were unable to locate a thermometer in the refrigerator or freezer for routine monitoring.-The ice machine filter was observed to be heavily soiled with dust/debris. On 12/16/2025 at 12:07 p.m., during an observation of the Skilled Kitchenette, a surveyor observed and confirmed with the Director of Nursing (DON):-The refrigerator did not have a thermometer for routine monitoring.-1 open bottle, 60 fluid ounces Ocean Spray Orange Juice, on the shelf and available for use, with an open date of 11/19/25. The label states, use within 2 weeks of opening (13 days past expiration).-1 open bottle 64 fluid ounces Clamato, labeled with an open date of 9/29/25, not labeled with an expiration date.-The surveyor and the DON were unable to find a thermometer in the refrigerator and/or freezer for routine temperature monitoring.-The ice machine drainage pipe did not have a 1 air gap to prevent backflow.

Based on observations, record review, and interview the facility failed to ensure that the Water Management Plan was fully developed/implemented to prevent the growth and spread of legionella and other water-borne pathogens, and failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to urinary catheter drainage bags for 2 of 3 residents reviewed with a foley catheter (Resident #38[R38], and [R4]). Findings: 1. On 10/16/24, the surveyor was provided with the facility's new Water Management Plan,, dated 9/19/23, for Northern Light Health Continuing Care. The surveyor reviewed this plan and requested documentation that indicated what areas were to be monitored where potential Legionella bacteria could grow, how the areas were monitored, and last time the facility had the water tested . On 10/17/24, the surveyor was provided with an updated Water Management Plan, dated 9/18/24, for Northern Light Health Continuing Care which included photographs of areas that were to be monitored where potential Legionella bacteria could grow. The Water Management Plan (WMP) indicated the following under Overview: Processes - The procedures (control measures) are outlined in the Control Measures section. The person responsible for verifying the implementation of the control measures are also listed in that section; and Risk Assessment and Management Strategy directed the facility to assess risk by identifying and describing all water systems on the property and that present a significant risk of Legionella growth and transmission, establish control locations (determine points and processing steps at which control measures can and should be applied (see Risk Assessment per Hazard Analysis). The facility should implement control measures to check for, minimize, and/or mitigate conditions favorable for growth or transmission of Legionella and listed for each control measure are a monitoring procedure, control limit, and corrective action (see control measures). The facility should verify implementation - control measures must be documented and the documentation must be reviewed on a schedule to verify implementation and to validate effectiveness of the WMP. The WMP indicated the following under Confirmation (Verification and Validation): Verification - For this water management plan to be most effective in preventing disease, it must be fully implemented. The persons responsible for verifying implementation of control measures, and the verification frequency, are listed within each control measure; and Validation - The effectiveness of the WMP will be validated by routinely testing certain building water systems by a laboratory and to test domestic water systems and other drinking water for Legionella at least four times yearly initially and then more frequently if indicated. The policy included a Risk Assessment Per Hazard Analysis which identified areas that should be a control location and reasoning but what control measure was needed was not identified. The policy did not have a Control Measures section which identified the monitoring procedure, control limit, and corrective action. The facility had no written documentation of areas checked to ensure control measures were within normal limits or evidence that the program was reviewed to verify and validate effectiveness of the program. The last time the facility had the water tested for Legionella was June 2023. On 10/18/24 at 11:38 a.m., the facility provided information that the last completed water test submitted by the facility for a Legionella test was resulted on 6/19/23. The facility discovered that the contract had been canceled and a new contract was made on yesterday (10/17/24). At 11:51 a.m., the Administrator stated that Nursing Home Maintenance has been doing a daily temperature check in different areas, and he does a daily running/flushing of water to make sure the S traps fresh have water in them, but there is no documentation. 49635 2. Review of the Prevention of Catheter-associated Urinary Tract Infections Policy revised on 9/27/24, states Purpose To outline the minimum standards of care based on evidenced-based methods to prevent Catheter Associated Urinary Tract Infections (CAUTI), under the Techniques for [indwelling urinary catheter] maintenance it states, urine collection containers shall not be allowed to rest on the floor or a grossly contaminated surface. On 10/15/24 at 9:10 a.m., a surveyor observed R38's urinary catheter drainage bag resting on floor. On 10/16/24 at 11:38 a.m., a surveyor observed R38's urinary catheter drainage bag resting on floor. On 10/17/24 at 10:52 a.m., during an interview with the Director of Nursing and the Administrator, a surveyor confirmed R38's urinary catheter drainage bag was not maintained in a manner that would prevent catheter associated urinary tract infections. 32540 On 10/17/24 at 11:00 a.m., a surveyor observed R4's urinary catheter drainage bag resting on the floor. On 10/17/24 at 11:10 a.m. a surveyor confirmed with the charge nurse RN1. R4's catheter drainage bag was not covered and on the floor.

Based on observations and interviews, the facility failed to ensure that the kitchen equipment/dishware were stored in a sanitary manner by having mixing bowls and a colander wet stacked for 1 of 3 days of survey ([DATE]) and they failed to ensure that the correct 3 step process to manually wash, rinse and sanitize dishware was done correctly by failing to have sufficient concentration of the sanitizing solution in their 3 bay sink used to manually wash their dishware for 2 of 3 days of survey ([DATE] and [DATE]). In addition the facility failed to ensure that food was removed from use by the expiration date for 1 of 3 days ([DATE]). Findings: On [DATE] at 9:15 a.m., during the initial tour of the kitchen, a surveyor observed water drops dripping from a mixing bowl. Upon further observation it was observed by the surveyor and the Kitchen Lead that 4-mixing bowls and a colander were wet stacked on the shelf above the food preparation area. This finding was confirmed by the surveyor with the Kitchen Lead at the time of the observation. On [DATE] at 10:00 a.m. an observation of a dietary staff manually washing dishware in the 3 bay sink area was made. The surveyor asked if they could test the sanitizing section, and the dietary staff redirected the request to the Kitchen Lead. There was a poster on the wall directing staff how to complete the test and what the sanitizing level should be. The instructions direct staff to hold the test strip in the sanitizing section for 10 seconds and directed them to compare the color of the strip to the chart on the test strip bottle. The correct range should be 272 and turn the test strip into a teal color. When the Kitchen Lead person removed the test strip from the sanitizer the strip color was not teal but a light blue indicating the sanitizer was not at the correct concentration, the light blue indicated the level was at 170 and not the desired 272. The Kitchen Lead explained that the sanitizer comes from an automatic dispenser and Eco Lab manages that system. The facility called Eco Lab to have them come evaluate the system. In the meantime, the Kitchen Lead stated they will use their high temp ware washer to clean and sanitize all dishware. The logbook for the 3 Bay Sink was reviewed, all days were marked as ok, and the test strips were tapped on the pages. All strips were not in the correct levels all showing a light blue at 170 PPM. The test strips being used expired since February 2023. On [DATE] at 2:15 p.m., The Eco Lab manager arrived, the surveyor, the Food Service Supervisor and the Kitchen Lead entered the kitchen. The sanitizing sink was filled and tested with a new bottle of test strips. The test was done 3 times by the Eco Lab manager, all were not at the correct levels. The Eco Lab manager stated that putting the test strips in the binder would fade over time to the wrong color. Eco lab manager found the automatic dispenser had the wrong pump being used and the aspirator had a crack causing the inaccurate sanitizer levels being dispensed. The parts were replaced and the correct sanitizer levels were dispensed. On [DATE] at 2:45 p.m. 2 surveyors confirmed all kitchen findings with the Food Service Supervisor. 35904 On [DATE] at 10:52 a.m., during an observation of 1 of 3 medication carts (South Unit), a surveyor observed, on the medication cart, 1 open/covered container of chocolate pudding with a date written on the lid of [DATE]. The LPN states she is not sure how long the pudding is good for and a few residents, including R41 received the chocolate pudding with his/her medications this morning. In an interview with the LPN at this time, a surveyor confirmed that the chocolate pudding was given beyond the expiration date. On [DATE] at 10:30 a.m., in an interview with a surveyor, the Food Service Supervisor stated pudding made for use with medications are good for 5 days, and the date made is on the container. The chocolate pudding was given 3 days beyond expiration date.

Based on facility policy review, record reviews, and interview, the facility failed to notify the physician when residents were eligbile to receive the PCV20 (a vaccine that protects against Pneumococcal bacteria) and ensure residents were offered Pneumococcal vaccinations upon admission, annually, or in accordance with the Centers for Disease and Prevention Control (CDC) recommendations, for 3 of 5 residents reviewed for immunizations (Resident #19 [R19], R33, and R14). Findings: The facility's policy, Immunization Screening for Pneumococcal, Influenza and/or COVID-19 Vaccination for Adult Patients, last revised 5/2/2023, indicated: Under the section: Screening for Influenza and Pneumococcal Immunization - Long Term Care patients will be screened upon admission and annually thereafter. Under the section: Criteria for Eligibility, Pneumococcal Vaccine - Centers for Disease Control (CDC) criteria, the policy indicated that Northern Light Health offers PCV20 when either PCV15 or PCV20 is indicated and shared clinical decision-making will be utilized when indicated per provider discretion and that the timing of the vaccination is based on the person's Pneumococcal vaccine history, medical history and age. CDC guidance using the PneumoRecs VaxAdvisor website or application is recommended to determine this timing and the type of vaccine the person should receive. 1. On 10/15/24, R19's clinical record was reviewed and indicated that R19 was admitted to the facility on [DATE] and R19's last Pneumococcal vaccine was documented as received in 2015. The PneumoRecs VaxAdmisor website indicated that based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last Pneumococcal vaccine dose. 2. On 10/15/24, R33's clinical record was reviewed and indicated that R33 was admitted to the facility on [DATE] and R33's last Pneumococcal vaccine was documented as received in 2016. The PneumoRecs VaxAdmisor website indicated that based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last Pneumococcal vaccine dose. 3. On 10/15/24, R14's clinical record was reviewed and indicated that R14 was admitted to the facility on [DATE]. The PneumoRecs VaxAdmisor website indicated to give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23 (Pneumococcal vaccine) which was documented as given on 5/22/2014. On 10/17/24 at 10:54 a.m., during an interview with a surveyor, the Director of Nursing (DON) stated that there is no shared evidence to indicate the provider was notified that R19 and R33 could receive the vaccine, to determine whether to offer it. The DON also stated that for R14, the consent for the vaccine was just sent to family last month and not at the time of admission.

Based on observation and interviews, a facility staff failed to speak to residents in a manner that maintains and promotes each resident's dignity and respect for 1 of 3 days of survey (10/15/24). Findings: On 10/15/24 at 2:00 p.m., a surveyor observed Certified Nursing Assistant #1 (CNA1) having a back-and-forth argument with Resident #1 (R1) during Bingo. CNA1 then turned her head away from R1 and continued to call Bingo letters/numbers to the residents playing Bingo while ignoring R1 while he/she was attempting to talk to CNA1. Another resident asked a question of CNA1, and CNA1 said, have some patience please [R15]. CNA1 was observed by a surveyor to be irritated and was speaking in a sharp voice to R15. On 10/15/24 at 2:18 p.m. in an interview with the Director of Nursing, a surveyor confirmed that R1 and R15 were not spoken to in a dignified manner when CNA1 argued with R1, ignored R1, and spoke sharply to R15.

Based on record review and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR), including a current diagnosis, and was updated for 1 of 1 resident reviewed (Resident #29 [R29]). Finding: On 10/15/24, during review of R29's clinical record, contained a PASRR Level I Screen dated 4/25/24 has a letter attached that he/she does not have a reason for a level II assessment. The PASRR Level I Screen in the diagnosis section did not include a current diagnosis of Post Traumatic Stress Disorder (PTSD). R29's current diagnosis list included a diagnosis of PTSD. The resident record lacked evidence that the PASRR Level I Screen was updated and resubmitted to include his/her diagnosis of PTSD and was not forwarded to the State-designated authority to determine if a Level II assessment was needed. On 10/16/24 at 2:45 p.m., during an interview with the Director of Nursing, a review of R29's PASRR was done and a surveyor confirmed that his/her diagnosis of PTSD was not included on the PASRR for a level II determination.