Every finding on record at High View Rehabilitation and Living Center

Based on interviews and personnel file reviews, the facility failed to ensure the Dietary Supervisors met the qualifications required to be a Food Service Director or Supervisor. This has the potential to affect all the residents. Finding: On 6/15/26 at 10:05 a.m., during an interview with the acting Dietary Supervisor, she stated that she has been in this role for approximately two weeks. She stated she does not currently have a Serve Safe Certificate from the State of Maine. She is not enrolled in a dietetic technician program and is not certified as a dietary manager. She was hired on 6/1/26 as the Dietary Supervisor. On 6/16/26 at approximately 3:00 p.m. during an interview with the Administrator, the surveyor confirmed that the facility does not have a qualified Dietary Supervisor. She stated they were given permission last week to enroll in the Serve Safe manager program but had not yet enrolled. On 6/17/26 at approximately 1:00 p.m. during a review of the personnel files with the office staff for the current and previous Dietary Supervisors the following was confirmed the last qualified Dietary Supervisor left employment on 6/6/25. The facility does not have a full-time dietician they use a consultant dietician who is not a full-time employee.

Based on interviews, the facility failed to employ a qualified Activity Director (AD) to manage resident centered activities for all residents (33 residents).On 6/17/26 at 12:30 p.m., during an interview with a surveyor, the Administrator stated that the initial Activities Director's last day was 3/6/26. The Administrator confirmed with the surveyor that the staff member that filled the role on 3/8/26 was not qualified for the position and was terminated on 6/8/26. At this time the surveyor confirmed the facility does not currently have a qualified Activities Director, and that the previous staff member had not completed the State-approved program and was not qualified to be the AD.

Based on record review and interviews, the facility failed to inform a Resident in advance, of treatment risks and benefits, options, and alternatives related to the use of psychotropic medications (prescription drugs that alter brain chemistry, affecting mood, perception, thoughts, or behavior) for 1 of 5 sampled residents reviewed (Resident #23 [R23]).Finding:On 6/17/26, R23's clinical record was reviewed and indicated that R23 had orders for the following psychotropic medications to treat anxiety and major depression:-Amitriptyline (antidepressant that works by increasing the levels of the neurotransmitters serotonin and norepinephrine in the brain, which helps regulate mood, reduce pain signals, and promote sleep).-Diazepam (antianxiety that works by calming the central nervous system).-Duloxetine (used to treat depression, anxiety, fibromyalgia, and chronic nerve or muscle pain. It works by increasing serotonin and norepinephrine in the brain to help elevate mood and block pain signals).- Mirtazapine (antidepressant used to treat major depressive disorder and is frequently prescribed off-label for insomnia and to stimulate appetite).The clinical record lacked evidence that the resident was informed in advance of treatment risks and benefits, options, and alternatives prior to the use of psychotropic medications.On 6/17/26 at 1:51 p.m., during an interview with a surveyor and the Director of Nursing (DON), R23s clinical record was reviewed. At this time, a surveyor confirmed the clinical record lacked evidence that R23 was informed in advance of treatment the risks and benefits, options, and alternatives prior to the use of psychotropic medications.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, comfortable, and homelike environment for 3 of 3 days of survey (6/15/26, 6/16/26, and 6/17/26).Finding:1. On 6/15/26 at 1:49 p.m., during an interview with a surveyor, Resident #6 (R6) stated that when he/she used the bathroom, he/she had urine run down their leg because of the gap between the raised seat and the toilet. At this time the surveyor observed R6's private bathroom. The toilet was observed to be installed facing a wall. A commode seat without a bucket was positioned perpendicular to the toilet creating a large gap between the toilet and seat. Excrement splatter was observed around the rim of the toilet.On 6/17/26 at 10:07 a.m., during an interview with a surveyor and the Maintenance Director, R6's bathroom was observed with the toilet facing the wall and the raised toilet seat / commode seat positioned perpendicular to the toilet. At this time, the surveyor confirmed the toilet is not homelike and does not allow the resident to use the toilet in a dignified and sanitary manner.

Based on record review and interviews, the facility failed to ensure that the Resident Representative (RR) received a written copy of the bed hold and transfer notice for 2 of 2 transfers and admissions to the hospital (3/23/26 and 4/20/26) for Resident #17 (R17),Findings: On 6/16/25, R17's clinical record was reviewed and noted the following: 1, R17 was admitted to the hospital on [DATE] and returned to the facility on 3/25/26.2. R17 was admitted to the hospital on [DATE] and returned to the facility on 4/24/26. The clinical record included a Social Services note, dated 2/3/26, that indicated that R17 had a family member that decided to be the Resident Representative (person to make decisions on R17's behalf) after an Adult Protective Services case was opened. Review of the clinical record indicated R17 received a bed hold and transfer notice for both of these discharge/transfers but there was no evidence that the RR received a written copy of the written bed hold and transfer notice for either of these admissions to the hospital. On 6/17/26 at 11:25 a.m., during an interview with a surveyor, the Administrator stated that the RR was not provided a written copy of the notices.

Based on clinical record reviews and interview, the facility failed to follow physician orders for 1 of 2 residents reviewed for constipation (Resident #6 [R6]).Findings:1. On 6/17/26, R6's clinical record was reviewed and indicated the following:- Review of R6's Bowel Elimination Record indicated R6 did not have a bowel movement from 5/22/26 through 5/26/26 (5 days total). Additionally, R6 did not have a bowel movement from 6/2/26 through 6/5/26 (4 days total).- Review of R6's standing orders stated, Constipation (Acute):1. Two days without a bowel movement:a. If resident has an as needed laxative ordered, use that order as directedb. Milk of Magnesia 30 [milliliters (cc)] by mouth [one dose (x1 dose)]2. Three days without a bowel movement:a. Dulcolax 5 [milligram (mg)] tab-Give 2 tabs = 10mg by mouth x1 dose OR Dulcolax 10mg suppository insert 1 suppository rectally x1 dose.b. If Dulcolax tab or suppository not effective within 8 hours, repeat dose x13. Four days without a bowel movement:a. Contact [the doctor (MD) or Family Nurse Practitioner (FNP)]-Review of the Medication Administration Record for the month of May indicated that on 5/24/26 (day 3 without a bowel movement) R6 received a 15-milliliter dose of Milk of Magnesia for constipation (1 day late and only 1/2 the dose indicated on the standing order).-Review of the Medication Administration Record for the month of June indicated that on 6/4/26 (day 3 without a bowel movement), R6 received a 30-milliliter dose of Milk of Magnesia (1 day late). On 6/5/26 (day 4 without a bowel movement), R6 received a 10-milligram dose of Dulcolax (1 day late).The clinical record lacked evidence that standing order interventions were provided as ordered. Additionally, the clinical record lacked evidence that the provider was notified when R6 went 4 or more days, without a bowel movement, as ordered.On 6/17/26 at 1:51 p.m., during an interview, a surveyor and the Director of Nursing (DON) R6's clinical record was reviewed for bowel elimination. At this time the surveyor confirmed the clinical record lacked evidence that the provider was not notified of 4 or more days without a bowel movement and that interventions were not provided per the provider's standing orders.

Based on interviews, observation, and record review, the facility failed to ensure transportation was provided timely for a wound care clinic appointment for 1 of 1 resident reviewed for leg and foot wound care (Resident #2 [R2]). Findings: On 6/16/26 at 10:56 a.m. in an interview and observation with a surveyor, R2 stated that he/she goes to a wound clinic for wound care for his/her lower legs and feet every week and is not sure if there is transportation available to go tomorrow (6/17/26) and is concerned about this. The surveyor observed R2's left and right lower legs and feet wrapped with cling wrap/bandages. Review of R1's clinical record, hospital discharge instructions on 4/3/26 states, you were hospitalized for an infection of the left lower extremity. More than likely, one of the chronic ulcers that you have become infected. Review of R1's Wound Outpatient note on 6/10/26 15:41(3:41 p.m.) states, Wound Outpatient Note: wound location - Bilateral lower legs/feet (multiple sites), left outer midfoot, right inner heel, right outer ankle. Follow up appointment scheduled for: Wednesday June 17, 2026, 10:30 a.m. Writer gave Highview driver the follow up appointment card and MD order sheet. R1 has been seen weekly for wound care since April, 2026. Review of Physician Order dated 5/12/26 states, Right lower leg ulcer: (1) Cleanse with wound wash (2) Dry well (3) Apply mupirocin ointment to scab (4) Cover with dry dressing two times a day, discontinue 5/12/26 9:38 a.m. Discontinue Date/Reason Resident having wound clinic dressing changes weekly., and Left lower leg - Cleanse area, hydrofera blue (cut to fit), ABD pads, wrap with cling- change daily and as needed. Every day shift. Discontinue 5/12/26 9:36 a.m. discontinue date/reason: resident having wound clinic dressing changes weekly. On 6/16/26 at 1:45 p.m. in an interview with the Director of Nursing [DON], a surveyor confirmed that the facility could not provide transportation to R1's wound clinic appointment on 6/17/26 and could not provide transportation to R1's wound clinic appointment rescheduled for 6/16/26. The DON contacted the wound clinic today, and a new appointment was scheduled 6/22/26, 5 days past the weekly scheduled wound care appointment.

Based on record reviews and interviews, the facility failed to ensure that a Resident Profile (Facesheet) contained accurate and complete information regarding a responsible party for 1 of 5 residents reviewed for Advance Directives (Resident #17 [R17]). Finding: On 6/16/26, a surveyor reviewed R17's clinical record and was unable to locate an Advance Directives. On 6/17/26 at 9:20 a.m., during an interview with a surveyor, the Administrator stated that R17 was not capable of completing an Advance Directive and provided a Social Service note, dated 2/3/26, that Adult Protective Services had been involved in a case concerning R17 but closed it because R17 had a family member that agreed to be the person that would make decisions on R17's behalf. On 6/18/26 at approximately 2:45 p.m., during an interview with the Administrator, the surveyor confirmed that R17's resident profile indicated that R17 was responsible for self and had not been updated to reflect that R17 has a responsible party.

Based on record review and interview, the facility failed to complete and transmit a discharge Minimum Data Set 3.0 (MDS) electronically to the State MDS database for 1 of 1 sampled resident transferred to another long-term care facility. As of 6/16/26, this MDS was due to be completed and transmitted by 5/14/26, now 33 days late. On 6/15/26, R7's clinical record was reviewed and indicated that on 4/21/26, R7 was discharged to another long-term care facility, and a recapitulation of stay was in the clinical record. There was no evidence in the clinical record that the discharge MDS had been completed within 14 days from discharge and transmitted to the State MDS database within 14 days after completion. On 6/16/26 at 2:56 p.m., during an interview with the Minimum Data Set (MDS) Coordinator, a surveyor confirmed this finding.

Based on observations and interview, the facility failed to post the daily nurse staffing information in a prominent place, readily accessible and visible to all residents for 2 of 3 days of survey (6/15/26 and 6/16/26). Findings:1. On 6/15/26 at 12:32 p.m., a surveyor observed the daily staff report attached to a magazine rack that was partially shielded by the weekly menu which was also attached to the magazine rack; both of these documents were hanging sideways from the rack. In order to read this report, a person would need to turn the page upright which would move the menu during this process. 2. On 6/16/2026 at 2:33 p.m., the Nurse Manager (NM) and surveyor a surveyor observed the daily staff report (dated for yesterday) attached to a magazine rack that was partially shielded by the weekly menu which was also attached to the magazine rack; both of these documents were hanging sideways from the rack. In order to read this report, a person would need to turn the page upright which would move the menu during this process. This observation of placement and report date was confirmed at this time with the NM who stated that she forgot to post the report for today.

Based on personnel file reviews 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 3 of 3 personnel files reviewed that had been employed greater than 1 year (Certified Nursing Assistant #1 (CNA1, CNA2, and CNA3).Findings:On 6/16/26, a surveyor reviewed the following Certified Nursing Assistant (CNA) personnel files and was unable to find evidence QAPI training had been provided: 1. CNA1 was hired on 5/8/24, the employee training record lacked evidence of QAPI training. 2. CNA2 was hired on 8/1/23, the employee training record lacked evidence of QAPI training. 3. CNA3 was hired on 1/11/23, the employee training record lacked evidence of QAPI training. On 6/17/26 at 11:25 a.m., during an interview with a surveyor, the Administrator stated that QAPI training had only been provided to new hire employees during orientation that were hired after 3/18/26 and had not been provided to employees hired prior to that date.

Based on observations, review of facility's Bed Safety policy, clinical record reviews, and interviews, the facility failed to identify hazards in a resident's environment and implement interventions to prevent avoidable accidents/injuries. This failure resulted in Resident #3 (R3) obtaining a skin tear when hitting his/her right arm on the exposed, uncovered, square tubing on the bed frame that the mattress was not wide enough to cover, and failure to identify exposed areas of a bed frame that created a risk of entrapment for Resident #26 (R26). This created an Immediate Jeopardy (IJ) situation for all 35 residents. Findings: On 3/31/25, the facility census was 35; all 35 resident bed frames have a mattress, and 2 quarter size bed rails attached to the bed frames. On 3/31/25, the facility's Bed Safety policy, undated, was reviewed. The policy indicated the following: -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the Federal and Drug Administration (FDA) (See Bionix Bed System Measurement Device Instructions and www.Bionix.com). -Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard etc.); and - Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness, etc.). -The maintenance department or designee shall provide a copy of inspections to the Administrator and report results to the Quality Assurance (QA) Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. -The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. -The Administrator shall ensure that reports are made to the Food and Drug Administration (FDA) or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment document, published by the FDA on March 10, 2006, the FDA is recommending a dimensional limit of less than 120 millimeters (4 3/4 inches) for the area between the inside surface of the (bed) rail and the compressed mattress. 1. On 3/31/25 at 10:58 a.m., a surveyor observed a skin tear on R3's right arm. R3 stated that he/she fell on Saturday (3/29) and hit their arm on the bed frame as R3 pointed to an area of the bed frame; the surveyor observed that R3's mattress did not cover the bed frame, exposing a mechanical hinge, a screw, and sharp metal edges where plastic caps were missing. Review of R3's clinical record indicated that R3 self-reported to nursing that he/she had fallen in his/her room and hit the bed frame. On 3/31/25 at 11:44 a.m., a surveyor and the Director of Nursing (DON) observed R3's skin tear and the area of the bedframe that R3 hit their arm on. R3 stated to the DON that the bed frame was harder than his/her arm. The DON stated to R3 that someone would be in to clean up the injury and started treatment for R3's skin tear. On 3/31/25 at 1:10 p.m., the Maintenance/Housekeeping/Laundry Supervisor stated that the Administrator brought down a tool (Bionix Bed System Measurement Device) from the third floor, but he doesn't know how to use it or what the proper measurements are supposed to be (between mattress and bed side rail). The surveyor shared photos of R3 and R29's bed frames and mattresses with the Maintenance/Housekeeping/Laundry Supervisor at this time and confirmed the mattresses did not fit the bed frames. On 3/31/25 at 1:18 p.m., during an interview with the DON, a surveyor confirmed that R3's mattress does not fit the bed frame which allowed R3's arm to strike the square tubing on the bed frame that was not covered. On 3/31/25 at 2:19 p.m., two surveyors observed Maintenance/Housekeeping/Laundry Supervisor in the process of changing R3's bedframe. He stated it was one of the last beds in the facility this way and that the mattress was a 36 inch mattress on a 39 inch bed frame. On 4/2/25, R3's clinical record was reviewed; on 4/1/25 at 4:57 p.m., it was documented that R3's right forearm skin tear dressing was changed. There was serous drainage and during the wound dressing change, R3 reported pain 3/10. At 7:20 p.m., the skin tear measurements were documented as follows: the top measures 1.2 centimeters (cm) length (L) x 0.8 cm width (W), the middle skin tear measured 1.5 cm L x 0.7 cm W, and the bottom skin tear measured 0.5 cm L x 0.5 cm W and was superficial. The length of all 3 areas together measured 4 cm L x 0.8 cm W. 49635 2. On 3/31/25 at 11:32 a.m., 2 surveyors observed R26 lying in bed leaning toward his/her left side. The mattress did not appear to be compatible with the bed frame as several inches of bed frame was observed exposed on both sides of the mattress creating multiple areas for possible entrapment of body parts (See F909 for details). The bed rail at the height of the resident's head measured 10 inches from the mattress, this had the potential to cause death as a result of entrapment of body parts (See F700 for details). On 4/1/25 at 8:30 a.m., during an interview with 2 surveyors and the Maintenance/Housekeeping/Laundry Supervisor, R26's bed frame was observed to be wider than the mattress by a couple inches (improved compared to observation on 3/31/25). The Maintenance/Housekeeping/Laundry Supervisor stated he had narrowed the width of the bed frame this morning, and staff independently adjust bed equipment, and he doesn't know why. On 4/1/25 at 9:05 a.m., during an interview with a surveyor, the Administrator stated night staff have made changes such as switching out a resident's bed mattress without letting administrative staff know of the changes. At this time the surveyor confirmed that staff did not identify the risk for accidents / injuries associated with exposed bed frames around resident mattresses. The immediate jeopardy that began on 3/31/25 when the facility failed to identify hazards in a resident environment and implement interventions to prevent injury including the risk of death by entrapment of body parts. The Administrator was notified of the immediate jeopardy at 12:25 p.m. on 4/1/25. Please See F-000 Initial Comments related to the IJ removal plan.

Based on observation, interview, and record review, the facility failed to ensure a resident's bed dimensions were appropriate for a resident resulting in a 10 inch gap between the mattress and the bed rail. This failure created the potential for bodily injury including death by entrapment of body parts, for 1 of 35 residents [Resident #26 (R26]. In addition to the resident in immediate jeopardy, the facility's failure to regularly inspect and monitor bed rails resulted in the potential for harm for 35 out of 35 residents with bed rails. Finding: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment document, published by the FDA on March 10, 2006, the FDA is recommending a dimensional limit of less than 120 millimeters (4 3/4 inches) for the area between the inside surface of the (bed) rail and the compressed mattress. According to the clinical record, R26 is diagnosed with HEMIPLEGIA AND HEMIPARESIS (paralysis or severe loss of motor function on one side of the body) affecting the resident's left side, and osteoporosis (condition where bones become weak and brittle increasing the risk of fractures). The care plan indicates The resident has limited physical mobility [related to (r/t)] Stroke, and The resident is at risk for falls r/t Hemiparesis, Confusion Unaware of safety needs. Care plan interventions indicate that R26 is on fall precautions, requires fall mats on the floor beside the bed, R26 will use the bed rails for independent bed mobility, and R26 is dependent on 2 staff for turning and repositioning in bed. On 3/31/25 at 11:32 a.m., 2 surveyors observed R26 lying in bed leaning toward his/her left side. The mattress was observed to be smaller than the bed frame. The resident's left bed rail measured 10 inches from the mattress at resident's head level. The mattress was off set, creating a wedge shaped gap with the opening wider toward the top of the mattress. On 3/31/25 at 1:10 p.m., during an interview with a surveyor, the Maintenance/Housekeeping/Laundry Supervisor stated the facility has a tool to measure the bed rail gaps, but he does not know how to use it, or what the proper measurements are supposed to be (between mattress and bed side rail). At this time, the surveyor confirmed the mattresses did not fit the bed frame creating the potential for entrapment of body parts. The immediate jeopardy that began on 3/31/25 when the facility failed to ensure a resident's bed dimensions were appropriate for a resident resulting in a 10 inch gap between the mattress and the bed rail creating the potential for entrapment of body parts including the risk of death. The Administrator was notified of the immediate jeopardy at 12:25 p.m. on 4/1/25. Please See F-000 Initial Comments related to the IJ removal plan.

Based on observation, interview, and record review, the facility failed to identify the existing risk for entrapment of body parts through bed inspections, this failure created the potential for severe bodily injury including death by entrapment of body parts, for 3 of 35 residents [Resident #26 (R26), (R3) and (R13)]. In addition to the resident in immediate jeopardy, the facility's failure to implement an effective inspection of all resident bed equipment (bed frames, mattresses, and bed rails) to ensure that bed mattresses fit the bed frames to prevent entrapment of body parts, this has the potential to effect 35 out of 35 residents with bed rails. Findings: On 3/31/25, the facility's Bed Safety policy, undated, was reviewed. The policy indicated, to prevent deaths/injuries, maintenance staff would inspect all beds and related equipment to identify risks and problems including potential entrapment of body parts using the Bionix Bed System Measurement Device (Please see F689). 1. According to the clinical record, R26 is diagnosed with HEMIPLEGIA AND HEMIPARESIS (paralysis or severe loss of motor function on one side of the body) affecting the resident's left side, and osteoporosis (condition where bones become weak and brittle increasing the risk of fractures). The care plan indicates The resident has limited physical mobility [related to (r/t)] Stroke, and The resident is at risk for falls r/t Hemiparesis, Confusion Unaware of safety needs. Care plan interventions indicate that R26 is on fall precautions, requires fall mats on the floor beside the bed, R26 will use the bed rails for independent bed mobility, and R26 is dependent on 2 staff for turning and repositioning in bed. On 3/31/25 at 11:32 a.m., 2 surveyors observed R26 lying in bed leaning toward his/her left side. The mattress did not appear to be compatible with the bed frame. The bed frame had exposed square holes measuring 4 inches by 5 inches along the lower end of the bed frame on both sides of the mattress creating the risk for entrapment of body parts. On R26's left side at his/her waist level, the bed frame had rectangular openings creating risk for entrapment of body parts. The bed rail at the height of the resident's head measured 10 inches from the mattress, creating the risk of entrapment of body parts (See F700 details). 2. On 3/31/25 at 11:22 a.m., 2 surveyors observed a skin tear on R3's right upper forearm. R3's mattress observed to be smaller than the bed frame, exposing a mechanical hinge, a screw, and sharp metal edges where plastic caps are missing. At 2:19 p.m., the Maintenance/Housekeeping/Laundry Supervisor stated the mattress does not fit the frame, the mattress is 36 inches, and the frame is 39 inches (See F689 for details). 3. On 3/31/25 at 2:00 p.m., a surveyor observed R13's mattress length was not compatible with the length of the bed frame creating a 3 inch gap between the end of the mattress and the foot board (See F558 for details). On 3/31/25 at 1:10 p.m., during an interview with a surveyor, the Maintenance/Housekeeping/Laundry Supervisor stated the facility has a tool to measure the bed rail gaps, but he does not know how to use it, or what the proper measurements are supposed to be (between mattress and bed side rail). He stated bed inspections were recently completed but he was not sure what the inspection included. On 4/1/25 at 7:15 a.m., during an interview with a surveyor, the Administrator stated the recent bed inspections only evaluated the electrical mechanics of resident beds. At this time a surveyor confirmed that bed inspections did not evaluate bed mattress and bed frame compatibility or identify areas of possible entrapment. The immediate jeopardy that began on 3/31/25 when the facility failed to implement an effective inspection of all resident bed equipment or identify the existing risk for entrapment of body parts. The Administrator was notified of the immediate jeopardy at 12:25 p.m. on 4/1/25. Please See F-000 Initial Comments related to the IJ removal plan.

Based on observations and interviews, the facility failed to maintain the building in good repair for 4 of 4 days of survey (3/31/25, 4/1/25, 4/2/25, and 4/3/25). Findings: On 3/31/25 at 11:22 a.m., a surveyor observed chipped paint around the room [ROOM NUMBER] placard, and the wall next to the nurse station door had a large un-painted area around a camera installation. On 4/1/25 at 8:08 a.m., during an interview with a surveyor and the Administrator, Resident #26's (R26) bathroom was observed. The bathroom had a large trash bag taped to the ceiling directing a steady leak of water into a trash barrel. Paint chips and insulation debris was observed in the standing water of the trash barrel. The Administrator stated it has been like that over the winter and will not be repaired until it is warmer outside. The Maintenance, Housekeeping, and Laundry Supervisor was able to redirect all the water into R26's bathroom (R26 does not use the bathroom). On 4/2/25 at 7:30 a.m., a surveyor observed the ceiling outside room [ROOM NUMBER] to be discolored, and large pieces of peeling paint were observed hanging down and an out of order sign was observed on the bathroom door in room [ROOM NUMBER]. At 7:51 a.m., during an interview with 2 surveyors, the Maintenance, Housekeeping, and Laundry Supervisor stated the resident in room [ROOM NUMBER] does not use the toilet, and the toilet has been out of order for 2 weeks due to a leaking seal. On 4/3/25 at 9:00 a.m., during a facility tour with a surveyor and the Maintenance, Housekeeping, and Laundry Supervisor, the following were observed and confirmed: -the transition strip, connecting the hall to the sitting area created uncleanable surfaces at the wall, and had accumulations of dirt /debris along the strip border; -the wall next to the nurse station door had a large un-painted area around a camera installation; -the wall around the room number placard for room [ROOM NUMBER] had chipped paint; -the ceiling outside of room [ROOM NUMBER] is discolored, and peeling paint observed hanging from the ceiling; -the resident bathroom in room [ROOM NUMBER] is out of order due to a leaking toilet; -the closet door of room [ROOM NUMBER] is displaced from the track, the track support is broken. The closet ceiling in room [ROOM NUMBER] is discolored with peeling paint. Paint chips observed on the resident's clothing below the ceiling damage; and -the resident bathroom in room [ROOM NUMBER] is observed with trash bag funnel taped to ceiling draining water into the trash barrel below. Paint chips and insulation debris observed in the standing water of the collection barrel.

Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean manner on 4 of 4 days of survey ([DATE], [DATE], [DATE], and [DATE]), the facility failed to label thawed nutritional shakes with a thaw date on 1 of 4 days of survey. ([DATE]), the facility failed to discard expired foods on 1 of 4 days of survey ([DATE]), the facility failed to label, and date opened foods for 1 of 4 days of survey ([DATE]). In addition, the facility failed to consistently monitor and document food temperatures for proper cooked temperatures and proper serving temperatures for 94 of 99 meals reviewed. (Food Temperature Log sheets for March and 2 days in April) Findings: On [DATE] at 10:50 a.m., during the initial tour of the kitchen a surveyor observed the following areas that were not clean: Under the dish storage rack there was a seam in the linoleum flooring that was raised and had dirt buildup. Under the stove there was a seam in the linoleum flooring that was raised and had dirt buildup. The wall behind the stove was observed to have food splatter and around the pipes on the back wall was a build up of dirt and grime. The wall behind the meat slicers was observed to have food splatter. The warewasher room (dishwasher room) on the clean side, the flooring was raised and had dirt build up, the tiles on the dirty side were soiled and had dirt build up in the grout lines. In the reach in cooler there were ,d+[DATE] fluid ounce thawed cartons of Mighty Shakes with directions to store frozen, thaw at or below 40 degrees Fahrenheit and use thawed produce within 14 days. There was a ,d+[DATE] gallon of fat free milk with an expiration date of [DATE] that was available for use. In the walk-in refrigerator there were 5 containers of Yoplait plain yogurt 2 pounds each with a best by date of [DATE]. There were 3 containers of Ricotta Cheese 48 ounce each with a best by date of [DATE]. On the second shelf there was a steamtable pan that contained thawed meat wrapped in plastic with a label identifying the meat as Roast Beef with a use by label of [DATE]. (Food Service Supervisor (FSS) opened the plastic wrap, and the inner label identified the meat as a Pot Roast.) In the dry food storage area, there was an unopened bag with a label of 4 Season with a use by date of [DATE] (per interview with the FSS this would be the date it should have been discarded). There were 12 bags of unlabeled/unidentified crumbs with no expiration date, there were 11 assorted bags of cereal that were not labeled or had expiration dates. On a serving cart, on the second shelf, was a bin containing 8 unlabeled bags of cereals with no expiration dates, and 3 opened bags with no labels or expiration dates. On [DATE] at 11:30 a.m. during an interview with the FSS the surveyor confirmed the above findings. On [DATE] at 11:00 a.m. during a meal prep and meal service observation the surveyor observed the FSS taking the cooked temperatures of the lunch meal. The surveyor asked the FSS for the facilities food temperature logs for previous meals. Upon reviewing the facilities food temperature logs for the month of March, the facility failed to consistently record cooked temperatures and serving temperatures for 94 out of 99 meals. The surveyor confirmed this finding during an interview with the FSS at 2:40 p.m.

Based on facility policy review and interviews, the facility failed to notify the Centers for Disease Control and Prevention (CDC) of an outbreak of Norovirus in the facility. In addition, based on review of the facility's Legionella Water Management Program and interview, the facility failed to fully develop and implement a water management program to monitor for and prevent the growth and spread of Legionella and other water-borne pathogens. Findings: The facility's policy, Reporting Communicable Diseases, revised 3/20/25, indicated that the Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases. The Maine CDC Notifiable diseases and Conditions List, dated 2/17/21, indicated that any cluster/outbreak of illness with potential public health significance needs to be reported. 1. On 3/31/25 at 10:15 a.m., the Administrator stated that the facility is experiencing what was thought to be an outbreak of Norovirus. On 3/31/25 at 3:59 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated the CDC had not been notified of the outbreak. She also stated that they have not tested residents for Norovirus but five (5) residents have symptoms of nausea, vomiting, and diarrhea. On 4/1/25, the DON provided a statement that she had contacted the CDC and that she was advised that they are not required to test symptomatic individuals for Norovirus and to continue precautions per guidance. A line list of affected residents will be sent to the CDC when the outbreak is completed and that an outbreak of unknown etiology is reportable (to the CDC). On 4/2/25 at 2:10 p.m., during an interview with a surveyor, the Nurse Manager-Infection Preventionist stated she was away part of last week and that the DON filled her in on the communication with the CDC. 2. On 4/3/25, a review of the facility's Legionella Water Management Program was completed by the surveyor with the Administrator and Maintenance/Housekeeping/Laundry Supervisor. The program lacked evidence of testing protocols and acceptable ranges for control measures, documentation of the results of testing, and what corrective actions would be taken if control limits are not maintained. The program also lacked evidence of validating the effectiveness of the program by testing the water for Legionella/water pathogens.

Based on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Pneumococcal vaccination to 3 of 5 residents (Resident #3 [R3], R22, and R29). Findings: The facility's policy, Pneumococcal Vaccine, revised 3/2025, indicated prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessments of Pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Administration of the Pneumococcal vaccines are made in accordance with current CDC recommendations at the time of the vaccination. On 4/3/25 at 9:10 a.m., during an interview with a surveyor, the Nurse Manager-Infection Preventionist stated she was unable to find information to indicate that R3, R22, and R29 were offered the most recent Pneumococcal vaccination, and that the facility does use the PneumoRecs VaxAdvisor: Vaccine Provider App | CDC tool to determine Pneumococcal vaccination recommendations. The following were confirmed at this time: 1. The documentation in R3's clinical record indicated that R3 received the Pneumococcal Conjugate Vaccine (PCV) 13 in 2019. The CDC recommendation was to give one dose of PCV20 or PCV21 at least 1 year after PCV13. 2. The documentation in R22's clinical record indicated that R22 received the PCV13 in 2015 and the Pneumococcal Polysaccharide Vaccine (PPV) 23 in 2011. The CDC recommendation was 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. The documentation in R29's clinical record indicated that R29 received the PCV13 in 2016 and the PPV23 in 2007. The CDC recommendation was 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

Based on interviews and observations, the facility failed to meet the reasonable needs of residents in the area of bed size for 1 of 35 residents reviewed for accommodation of needs (Resident #13 [R13]) Finding: On 3/31/25 at 2:00 p.m., a surveyor spoke to R13, he/she stated that his/her bed is too short for them and was told by the facility they would get a bed to fit him/her. R13 stated that it has not happened. Observation of the bed shows there is a 3-inch gap from the end of the mattress to the footboard with a rolled-up blanket to fill the gap. R13 is over 6 feet tall and the mattress on the bed is not long enough leaving a gap at the foot of the mattress where his/her feet hang over the edge of the mattress. On 3/31/25 at 2:19 p.m., a surveyor confirmed this finding during an interview with the Maintenance/Housekeeping/Laundry Supervisor and was told the facility has ordered R13 a longer mattress on this date.

Based on clinical record review and interviews, the facility failed to ensure physician orders were followed for 1 of 5 residents reviewed for unnecessary medications (Resident #27, [R27]). Finding: On 4/2/25 during a review of R27's clinical record, a telephone order on 3/21/25 at 17:57 (5:57 p.m.) stated, Eliquis (a blood thinner) oral tablet 2.5 m.g (milligram) give 1 tablet by mouth two times a day related to non-ST elevation MI (myocardial infarction [heart attack]) HOLD 3/22/25 06:00 a.m. - 3/24/25 14:00 (2:00 p.m.), Hold Date / Reason: procedure for wart removal on 3/24/25. Review of R27's medication administration record dated March 2025 stated, on 3/23/25 at 20:00 (8:00 p.m.) H (Hold). On 4/3/25 at 10:38 a.m. in an interview with a surveyor, the Director of Nursing (DON) stated that the Registered Nurse (RN) gave Eliquis to R27 on the evening of 3/23/25 when it should have been held, and the RN only noticed the hold order when she went to chart medication given. A review of Resident/Facility Notification Form to the provider on 3/24/25 stated, Resident's (R27's) Eliquis was on hold for 3/24/25 appointment to remove lesion. Med tech did not notice the hold on this med, and it was given. On 4/3/25 at 10:39 a.m., during an interview with a surveyor, the DON confirmed that Eliquis was given to R27 on the evening of 3/23/25 when the medication was supposed to be held. The failure to follow the providers orders to hold Eliquis for R27 prior to a medical procedure resulted in the cancellation and rescheduling of the medical procedure and necessity to hold the Eliquis a second time prior to a medical procedure.

Based on record review and interviews, the facility failed to ensure that one person assist was provided during activities of daily living (ADL's) for 1 of 2 sampled residents (Resident #3), reviewed for falls. The failure to have supervision (one person assist) as directed by the care plan, and the Minimum Data Set (MDS) 3.0, resulted in an avoidable accident; Resident #3 falling during evening ADL's, required transfer to the emergency room , sustained an abrasion and hematoma to the right hip causing an increase in pain and limited mobility. Findings: Review of Resident #3's Resident Incident Report, High View Manor dated 12/5/22 at 2:05 a.m., indicated that on 12/5/22 at 7:00 p.m., Resident was found on the floor by his/her bed laying on his/her right side. Resident stated he/she had finished washing himself/herself and fell to the floor hitting his/her back on the wastepaper basket, but did not hit his/her head. Resident complaining of severe pain to rt (right) hip area. Resident sent to ER (emergency room ) for evaluation. Resident has a bruise/abrasion to his/her right mid lower back. Review of Resident #3's Care Plan 8/17/22, indicated under Problem Onset: Inability to bathe independently, Approaches: Assist me with my bathing, dressing, grooming and personal hygiene. Review of Resident #3's MDS 3.0 Item Listing-Version 1.17.2 effective 10/1/20, quarterly review dated 11/8/22 under section G. Functional Status, 1. ADL Self-Performance, is coded 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support, and 2. ADL Support Provided, is coded 2. One person physical assist. Section G. Functional Status for G. Dressing, and J. Personal hygiene for Resident #3 for self-performance is coded 3. extensive assistance, and for support is coded 2. one person physical assist. Review of Departmental Notes on 8/18/22 3:21 p.m., by the MDS Coordinator, indicated, under Category: Care Plan Notes, Resident voiced during IDT that he/she feels he/she is more tired after completing his/her ADL's and he/she would like to have more help to complete them. Staff will be made aware of resident's increased need for assistance. Review of Resident #3's ADL Assistance and Support documentation of 12/5/22 was documented by CNA #3 and indicated that Bathing, Eve, was 0/1 (0 = Independent - no help or staff oversight at any time, and 1 = Setup help only). The Resident is an extensive, one person physical assist for this task. Review of physician clinic note dated 12/13/22 at 10:13 a.m., follow up pain. suffered a fall on 12/5/22 and was evaluated to the emergency room . He/she was noted to have possible hairline fractures of the hip. He/she was returned to the nursing home with Tylenol and Tramadol. Patient continued to have pain, was resent to the emergency roiagnom on [DATE]. He/she did undergo an MRI which did not show any fracture. Tramadol was scheduled. Tylenol continued. He/she continues to have pain to his/her right flank area whenever he/she is moved. He/she is working with physical therapy in bed. He/she has not gotten out of bed. he/she does have a hematoma noted to his/her right flank area. There is some ecchymosis. Seems to be dissipating At this time, he/she is not getting out of bed due to pain to his/her right flank area. Assessment/plan: 1. Right hip pain. On 12/19/22 at 2:06 p.m. in an interview with a surveyor, CNA #4, works during the evening, stated, regarding Resident #3 We help with lower half. We set up with bin, he/she was very independent. CNA #4 was not aware that Resident #3 was supposed to have one person physical assistance. On 12/20/22 at 9:08 a.m. in an interview with a surveyor, CNA #2, works during the day, and stated, regarding Resident #3, during the day we wash upper body and supervise him/her the entire time. On 12/20/22 at 9:10 a.m. in an interview with a surveyor, CNA #1, works during the day, stated, regarding Resident #3, during the day we wash upper body and supervise. If he/she would attempt to do himself/herself, we would assist. On 12/20/22 at 2:43 p.m. in an interview with a surveyor, CNA #6, works during the evening, stated, regarding Resident #3, we set him/her up with a wash basin, and left. We would leave, leave him/her to sit down, upper half only, then he/she rings and will stand him/her up to help him/her. Now we help with everything. CNA #6 was not aware that Resident #3 was supposed to have one person physical assistance. On 12/20/22 at 2:56 p.m. in an interview with a surveyor, CNA #5, works during the evening, stated, regarding Resident #3, he/she (thought Resident #3) was an independent before, he/she was self-sufficient, setup for PJ's, and take away, etc., now (after fall) extensive, go in setup and wash in chair, help take clothes off, get dressed. CNA #5 was not aware that Resident #3 was supposed to have one person physical assistance at time of fall. On 12/21/22 at 2:43 p.m. in an interview with a surveyor, CNA #3, works during the evening, stated, regarding Resident #3, that she was assigned to this resident on 12/6/22, the evening he/she had a fall. CNA #3 stated that Resident #3 is so independent, I set him/her up to wash himself/herself, and I had gone to go help someone else. CNA #3 stated Resident #3 was doing it himself/herself, referring to evening ADL's. CNA #3 was not aware that Resident #3 required one person physical assistance as stated in his/her care plan. On 12/20/22 at 2:50 p.m. in an interview with the Director of Nursing (DON), a surveyor confirmed that the care plan for Resident #3 stated he/she needed assistance with bathing, dressing, grooming and personal hygiene. The failure to have one staff member present during care for Resident #3 resulted in the resident falling and sustaining injuries. The evening shift staff interviewed were unaware that Resident #3 required one person physical assist.