Every finding on record at Maine Veterans Home - Augusta

Based on record review and interviews, the facility failed to ensure that a resident's physician and representative were notified immediately of a significant change in the resident's medical condition and failed to follow its own policy and procedure for Notification of Change in Resident Condition or Treatment plan for 2 of 5 residents reviewed for significant changes. (Resident's #47 and #110).The facilities Notification of Change in Resident Condition or Treatment Plan policy dated 8/20/24 states under Family Notification.The resident's representative will be notified if the resident chooses and/or: there is a change in the resident's physical, mental or psychosocial status. The resident is involved in an accident or occurrence. Except in medical emergencies, representative notifications will be made within 24 hours. 1 Resident #110 had diagnoses to include dementia and chronic kidney disease. Review of Resident #110's progress note dated 6/19/25 at 05:15 states Observed on floor, un-witnessed in residents room attempting to self-transfer. Further review of Resident #110's clinical record lacked evidence the Residents record lacked evidence the resident representative or provider was notified of this fall. During an interview on 10/2/25 at 2:00 p.m., Medical Doctor (MD) stated that she did not believe she was notified of Resident #110's fall that she can recall. During an interview 10/2/25 at 1:00 p.m., the Director of Nursing (DON) confirmed the resident representative was not notified of residents fall on 6/19/25 but believes the provider was notified in writing and is trying to locate the note. DON failed to provide this information by the end of survey. 2. Review of resident #47's medical record contained the following nursing documentation: Nursing note dated 4/29/25 at 7:58 p.m., states observed sitting on bathroom floor - able to use call bell, call bell in reach . Family: needs to be called, will let day shift know in the morning. Nursing note dated 5/14/25 at 8:35 p.m., states observed on floor- gripper socks on, using bedside table as walker.Family: will alert next shift family needs notified. Nursing note dated 6/13/25 at 3:32 pm. states observed on floor, un-witnessed, attempting to self transfer. Resident stated (he/she) was attempting to get something out of (his/her) closet and slipped and fell on (his/her) bottom, Staff found (him/her) seated on the floor next to (his/her) bed.Family: not notified. Further review of Resident #47's medical record lacked evidence of the family being notified of the above 3 falls. On 10/2/25 at 11:46 a.m., during an interview, the Freedom Bay Registered Nurse Manager was unable to find documentation where the family was notified of the above falls.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 4 wings (Freedom Bay (FB) and Eagle's Landing (EL) and a common area for 3 of 3 facility tours.Findings: 1. On 9/30/25 at 9:13 a.m., on EL-[NAME] outside of Resident rooms [ROOM NUMBERS], a surveyor observed a cushion of the couch was ripped creating an uncleanable surface. At this time, in an interview with a surveyor, the Facility Manager confirmed the finding.2. On 10/01/2025 at 12:55 p.m., on EL - Delta in resident room [ROOM NUMBER], a surveyor observed a floor mat that was dirty, had stains and had ripped material along the side edges. At this time, in an interview with a surveyor, RN #1 confirmed the finding. 3. On 10/2/25 from 8:15 am to 9:00a.m., a surveyor conducted an Environmental Tour with the Facilities Manager in which the following findings were observed:Freedom Bay -Alpha- Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty.- Resident Rooms 3 - The caulking around the base of the toilet was dirty.- Resident Rooms 4 - The caulking around the base of the toilet was dirty.- Resident Rooms 8 - The caulking around the base of the toilet was dirty.- Resident #24's Broda chair ripped/torn on back left side of chair.- The common area bathroom, next to the Belgrade Room, had dirty caulking around the toilet. The small floor grate in front of the toilet had dirt build up in it. The counter top was faded/stained behind the sink. - Delta -2 restroom-caulking dirty around toilet. On 10/2/25 at 9:00a.m., in an interview with a surveyor, the Facilities Manager confirmed the findings.

Based on observations, interviews, and review of the facility's Food Storage and Protection policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall fan, a food disposal unit, and the floor; and failed to ensure foods were labeled in the walk-in refrigerators, the walk-in freezer and the dry storage area for 2 of 2 observations on 1 of 4 days of survey (9/29/25). In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 1 kitchen tours (9/29/25).Findings:The facility's Food Storage and Protection policy/procedure noted: Policy: Food shall be stored, prepared, served, transported and distributed with protection from potential contamination including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs, and sneezes, flooding, drainage, leakage, and condensation. All foods removed from the original package or container shall be stored in a clean and sanitized container and labeled and dated. Leftovers must be labeled with the date the item was produced. and the name of the product before being put in storage.This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one-inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils.1. Initial Kitchen Tour on 9/29/25 From 8:45 a.m. to 9:15 a.m., in a tour with a surveyor, the facility Food Service Director observed the following findings:- The dish room wall fan was dusty/dirty. - The food disposal unit had dried food particles and dried liquid residue on it.- The floor had food and debris on the floor under the equipment and the stoves. - The reach-in freezer had three and one-half large bags of breaded patties, 10 large bags of French fries, and 7 large bags of waffle fries that were not labeled.- The walk-in freezer had 2 larges bags of breaded patties, 6 large bags of tater tots and 4 bags of sub rolls that were not labeled. - The dry storage room had 3 large bags of cereal that were not labeled. - A surveyor food preparation sink, next to the ice machine, had no required air gap installed.On 9/29/25 at 9:15 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings. 2. On 9/29/2025 at 10:48 a.m., a surveyor observed the Freedom Bay Unit reach-in freezer which contained one large bag of bread, one large bag of breaded patties and two individual pie crusts that were not labeled.On 9/29/25 at 10:50 a.m., in an interview with a surveyor, a kitchen staff member confirmed the findings.

Based on medical record review and interview the facility failed to ensure that a resident's drug regimen was free from unnecessary medication by prescribing an antipsychotic medication (a drugs that treats symptoms that happen with schizophrenia and other conditions that involve psychosis) without adequate indications for 1 of 5 reviewed for unnecessary medications (#107).Finding:Resident #107's current electronic medical record contained a Physician order dated 5/5/25 for Olanzapine (antipsychotic medication used to treat mental health conditions such as schizophrenia and bipolar disorder) 5 milligrams daily at hour of sleep for the indicated use (diagnosis) of encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition).On 10/1/25 at 12:02 p.m., during an interview, the Registered Nurse Manager of Freedom Bay Delta House stated the diagnosis of encephalopathy was incorrect and the provider is updating the diagnosis. At 12:19 p.m., the physician order for Olanzapine had a diagnosis of behavioral disorders associated with dementia paranoia and delusions.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of hearing aids for 1 of 1 sampled resident reviewed for communication difficulty and/or sensory problems. (Resident #3) (R3)Findings:Review of facility policy Care Area Assessments and Plan of Care dated 6/3/25 states .residents will have an individualized interdisciplinary Plan of Care that identifies the care and services necessary to maintain the highest practicable physical, mental and psycho-social well-being ensuring resident wishes for treatment and care are well defined and honored.Resident #3 was admitted to the facility in August 2025. Review of Resident #3's Comprehensive Minimum Data Set (MDS) dated [DATE] noted in section B-Hearing that R3 had and used a hearing aid. R3's current care plan, updated 9/2/25, lacked evidence that a hearing aid care plan was developed/initiated for R3.On 10/2/25 at 9:55 a.m., in an interview with a surveyor, RN #2 stated that she thought R3 had only one hearing aid but not sure and was not sure what ear it was in.On 10/2/25 at 9:55 a.m., a surveyor observed R3 sitting at a dining room table eating breakfast. The resident had a hearing aide in his/her left ear. On 10/2/25 at 10:13 a.m., in an interview with a surveyor, the Director of Nursing (DON) stated that R3 can't manage the hearing aid by himself/herself and would need staff assistance to help use it. On 10/02/2025 at 10:50 a.m., in an interview with 3 surveyors present, the Liberty Island Unit Manager confirmed that the resident's hearing aid and use/ storage had not been care planned for.

Based on record review and interview, the facility failed to assess and monitor a resident after unwitnessed falls and failed to follow their own Neurological Assessments policy and procedure by obtaining neurological assessments after the unwitnessed falls for 1 of 5 residents reviewed for falls. (Resident #47).FindingsThe facilities Neurological Assessments policy dated 5/8/24 states, A neurological assessment will be completed and documented in ECS after any incident or fall in which a head injury is suspected. In the case of an unwitnessed fall, the resident will be considered to have hit their head unless he/she can reliably state he/she did not. Assessments will be completed every 15 minutes for the first hour after the fall; every 30 minutes for the subsequent 4 hours; every shift for the next 72 hours.Review of resident #47's medical record contained the following nursing documentation:A nurses note dated 5/14/25 at 8:35 p.m., states, observed on floor- gripper socks on, using bedside table as walker. Neurochecks (neurological assessments) initiated as per facility policy. Review of the neurological assessments revealed only one of the 15 minute checks was completed on 5/14/25 at 8:50 p.m., and no evidence of the 30 minute checks being completed. The next documented neurological assessment was on 5/15/25 at 2:02 a.m. A nurses noted dated 5/26/25 at 5:05 pm states, observed on floor, unwitnessed. Resident states, [He/she] was trying to go to a different chair. Neuros initiated. Review of the neurological assessments lacked evidence of the 15 minute and 30 minute neurological assessments were completed with the next documented neurological assessment on 5/27/25 at 3:40 a.m.On 10/02/25 at 11:46 a.m., during an interview, the Freedom Bay Registered Nurse Manager stated confirmed the neurological assessments were not completed for the falls on 5/14/25 and 5/26/25

Based on facility policy review, 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 9 of 13 residents reviewed for advanced directives. (Resident [R] , R70, R78, , R12, R5, R42, R101, R61, R80 and R94). Findings: Review of facility policy Advanced Directives, DNR (Do Not Resusitate) Orders and Health Care Decision Making undated states Provide to all residents at the time of their admission, and subsequently upon request, written information concerning their rights under Maine Law to make decisions concerning their health care, including the right to accept or refuse medical treatment, .the right to execute advance directives concerning their health care decisions, and the right to designate a representative to exercise the rights of the resident .MVH (Maine Veterans Home) staff shall, at the time of residents admission: Document whether or not the resident has executed an advance directive; document the type of advance directive the resident has .Request a copy of the advance directive for inclusion in the resident' medical record; Document the name, address, telephone number and legal status of any person designated by the resident as the resident's authorized decision maker, such as a healthcare power of attorney agent, agent under the mental health treatment declaration, guardian, or healthcare surrogate; In the event that the resident is incapacitated at the time of admission or at the start of care and is unable to receive information or articulate whether he or she was executed an advance directive, MVH staff shall give the advance directive information required under this Policy to the residents authorized representative or a family member .MVH staff shall ensure that the above information is documented on the Advance Directive Documentation Form and placed in a prominent part of the resident's current medical record . 1. R70 was admitted to the facility on [DATE]. A review of Resident #70's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical/ surgical treatment and/or formulate an advance directive or appoint a surrogate. 2. R78 was admitted to the facility on [DATE]. A review of Resident #78's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical/ surgical treatment and/or formulate an advance directive or appoint a surrogate. During an interview on 10/22/24 at 11:12 a.m., Social Worker (SW) indicated that residents/representatives should be asked for Advanced Directives (AD) upon admission, and if they have one its scanned into the electronic medical record (EMR). If a resident doesn't have one, they are offered the information/help to fill one out, if they refuse or are offered, it is all supposed to be documented in the EMR. During a follow up interview on 10/22/24 at 1:28 p.m., SW confirmed he reviewed residents clinical records, did not show evidence they were asked or offered opportunity to fill out an advanced directive. During an interview on 10/23/24 at 1:56 p.m., a surveyor and Clinical director and DON (Director of Nursing) confirmed not all residents/representatives were asked/offered opportunity to fill out an advanced directives upon admission 17282 3. R12 was admitted to the facility on [DATE]. Review of R12's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview with a surveyor on 10/23/24 at 2:00 p.m., the Licensed Social Worker confirmed he reviewed R12's clinical record did not show evidence they were asked or offered an Advanced Directive. 32540 4. R5 was admitted to the facility on [DATE]. A review of R5's clinical record lacked evidence that the facility provided resident and/or resident's representative with written information concerning the right to accept or refuse medical/ surgical treatment and/or formulate an advance directive or appoint a surrogate. 5. R42 was admitted to the facility on [DATE]. A review of R42's clinical record lacked evidence that the facility provided resident and/or resident's representative with written information concerning the right to accept or refuse medical/ surgical treatment and/or formulate an advance directive or appoint a surrogate. 6. R101 was admitted to the facility on [DATE]. A review of R101's clinical record lacked evidence that the facility provided resident and/or resident's representative with written information concerning the right to accept or refuse medical/ surgical treatment and/or formulate an advance directive or appoint a surrogate. On 10/23/24 at 1:56 p.m. during an interview, the Clinical Director and DON confirmed that not all residents/representatives were asked/offered opportunity to fill out an advanced directives upon admission 37440 7. R61 was admitted to the facility on [DATE]. Review of R61's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 8. R80 was admitted to the facility on [DATE]. Review of R80's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 9. R94 was admitted to the facility on [DATE]. Review of R94's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 10/23/24 at 1:56 p.m. during an interview, the Clinical Director and DON confirmed not all residents/representatives were asked/offered opportunity to fill out an advanced directives upon admission.

Based on observations, interviews, and facility policy, the facility failed to follow professional standards of practice with usage of Personal Protective Equipment (PPE) and to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene during a medication pass on 1 of 3 days of survey. In addition, the facility failed to post enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters, and multi drug resistant organisms [MDRO] for 3 of 3 days of survey (10/21/24, 10/22/24 and 10/23/24) (Resident #34 [R34]). Findings: 1.Review of facility policy Medication Administration-General Guidelines dated 10/17 states Handwashing and Hand Sanitization: the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass, prior to handling medication, after coming into direct contact with a resident, .Hand sanitization is done with an approved hand sanitizer.; between hand washings, when returning to the medication care or preparation area . If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel [and examination gloves work] prior to handling tablets . During an observation of medication pass on Freedom Bay unit on 10/22/24 between 7:49 a.m., and 8:23 a.m., the following was observed: At 7:49 a.m., Certified Nursing Assistant Medication Technician (CNA-M) was observed in room [ROOM NUMBER] administering a medication underneath the tongue of a resident with an oral syringe with an ungloved right hand. A laptop was observed on the counter. CNA-M was then observed leaving room [ROOM NUMBER], with the empty syringe walking by hand sanitizer located on the wall next to exit door, left the room and proceeded to walk to the end of the hall and into the medication room where another hand sanitizer was located on top of the shelf by the door. CNA-M then picked up a clear plastic cup with her left hand, and while still holding empty syringe in her right hand walked back down the hall and around the corner to the kitchenette. CNA-M then placed the plastic cup on the counter with her left hand, opened the refrigerator door with her right hand containing the empty syringe and removed a bottle of cranberry juice with her left hand. She then moved the empty syringe from her right hand to her left hand and used her right hand to pick up the juice and poured it into the plastic cup and put the juice back in the refrigerator. CNA-M then picked up the plastic cup with her right hand, empty syringe in her left and proceeded to walk back into room [ROOM NUMBER] and assisted resident to drink the juice. CNA-M then took the empty plastic cup in her right hand and the empty syringe in her left hand and again walked past the hand sanitizer on the wall by the exit door and proceeded to walk to the end of the hall and back to the medication room, where she disposed of the syringe, threw the plastic cup in the trash and began to wash her hands. CNM-M then returned to room [ROOM NUMBER] and retrieved her laptop from the counter by the door. At 8:03 a.m., 2 surveyors observed CNA-M in common area where Resident #41, (who resided in room [ROOM NUMBER]) was sitting and asked him/her if he/she was ready for morning medications. CNA-M was then observed placing the lap top she just obtained from room [ROOM NUMBER] and placed it on the counter in room [ROOM NUMBER]. At this time, a surveyor attempted to obtain hand sanitizer from the dispenser located on the wall by the door entrance, but it was empty. A surveyor then said out loud that the sanitizer was empty. CNA-M began to open the medication cupboard and started removing pills from prepared pill packs and placed them in a medicine cup without using hand hygiene prior. CNA-M then dropped a pill on the counter, reached over and removed a glove from a glove box located on the counter, donned (put on), picked up the pill and placed it in the medication cup. She then doffed (removed) the glove and threw it in the trash can located next to the counter, then reached over to the hand sanitizer located on the wall next to the door and rubbed her hands together. The surveyor again indicated the hand sanitizer was empty. CNA-M said That's ok. At this time CNA-M's phone rang, she put her right hand in her pocket and retrieved the phone answered it and returned it to her pocket. She then picked up the medication cup with her right hand, and the laptop with her left and left the room, walked up the hall to the medication room and retrieved a plastic cup, tucked the laptop under her left arm and came back down the hall to the kitchenette and placed the laptop and medication cup on the counter next to the refrigerator. CNA-M then opened the refrigerator with her right hand, removed cranberry juice, and poured it in the plastic cup. She then replaced the juice in refrigerator, picked up the juice in her left hand covering the top lip of the cup, picked up the cup of juice with her right and walked around the corner toward Resident #41. At this time a surveyor asked what her intent was at this point, CNA-M indicated she was going to give resident his/her medications. A surveyor expressed their concerns regarding hand hygiene, as she did not use hand hygiene prior to preparing medication, did not practice hand hygiene prior to doffing gloves, and pretended to use hand sanitizer after doffing gloves, answered the phone, and her hands were touching the lip of the medication cup. CNA-M stated, You're absolutely right She then walked around the corner, down the hall and to the medication area, put the pills and cup of juice on the counter, washed her hands, picked up the pills and juice back up and returned to give the resident his/her medications. She then picked up the laptop, walked out of room and went directly into room [ROOM NUMBER]. At 8:23 a.m., CNA-M was observed entering room [ROOM NUMBER] and placed the laptop on the counter just inside the door. CNA-M opened medication cabinet and began to remove medications from bottles and pill packets. CNA-M then removed 2 gloves from the box on the counter and donned them without using hand sanitizer and started to pull apart capsules to remove the medications and pored them inside a medication cup. At this time a surveyor asked what the policy was for doffing and donning gloves. CNA-M stated she was not sure and would have to ask her supervisor and continued to pull apart the remaining capsules. She then doffed the gloves and used hand sanitizer. At this time 2 surveyors confirmed with CNA-M that she did not use and sanitizer prior to preparing the medications or donning gloves. At this time 2 surveyors confirmed with CNA-M she did not use hand sanitizer prior to donning gloves. During an interview with 2 surveyors on 10/22/24 at 8:33 a.m., Cares Demetia Specialist (CNS) confirmed the expectation is that staff use hand sanitizer before and after the use of gloves, before and after entering the rooms and before and after preparing and administering medications. 37440 2. In reviewing the facility policy on infections regarding transmission based precautions, the following was noted: methods of implementing and control, page 17 of the facilities infection control policy-the CDC has provided guidance for enhanced barrier precautions, which falls between standard and contact precautions, and requires gown and glove use for certain residents during specific high contact resident care activities that have been found to increase risk for multi drug resistant organism(MDRO) transmission. Enhanced barrier precautions-definition: Barrier Precautions expands the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Examples of high contact resident care activities requiring gown and glove use for enhanced barrier precautions 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, wound care: any skin opening requiring a dressing. Implementation: when implementing contact precautions or enhanced barrier precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: post clear signage on the door or wall outside of the resident's room indicating the type of precautions and required PPE (e.g., gown and gloves). For enhanced barrier precautions, signage should also clearly indicate the high contact resident care activities that require the use of gown and gloves. R34 was admitted on [DATE] with diagnoses including multiple drug resistant organism (MDRO)and a Urinary tract Infection. Regarding continence, the resident has an ileostomy. R34's Minimum Data Set(MDS) dated [DATE] noted the following: Bed mobility - 02,substantial/maximal assistance/03, supervision or touching assistance; Locomotion with wheelchair- 02, substantial/maximal assistance; Dressing - 01, dependent, Eating - 05, set up and clean up assistance; Toileting - 02, substantial/maximal assistance; Personal Hygiene - 04, supervision or touching assistance; Bathing-03, partial/moderate assistance and Continence - Ostomy. On 10/21/24 at 1:30 p.m., a surveyor observed Liberty Island resident room [ROOM NUMBER] entrance lacked signage indicating to visitors, staff and residents the type of precautions needed to enter the room. On 10/22/24 at 2:35 p.m., a surveyor observed Liberty Island resident room [ROOM NUMBER] entrance lacked signage indicating to visitors, staff and residents the type of precautions needed to enter the room. On 10/22/24 at 02:30 p.m., in an interview, Certified Nursing Assistant (CNA) #1 stated that the R34 was on contact precautions. She stated and confirmed that there was no signage at the room entrance indicating to visitors, staff and residents the type of precautions needed to enter the room because a nurse manager told her one was not needed. On 10/22/24 at 02:44 p.m., in an interview, Liberty Island Nurse Manager confirmed that the resident was on contact precaution and that there was no signage at the room entrance indicating to visitors, staff and residents the type of precautions needed to enter the room. On 10/22/24 at 02:55 p.m., in an interview with the Director of Nursing, a surveyor discussed that R34 was on contact precautions and that there was no signage at the room entrance indicating to visitors, staff and residents the type of precautions needed to enter the room. On 10/23/24 at 8:07 a.m., a surveyor observed Liberty Island resident room [ROOM NUMBER] entrance lacked signage indicating to visitors, staff and residents the type of precautions needed to enter the room. On 10/23/24 at 12:30 p.m., in an interview with a surveyor, the Liberty Island Nurse Manager and the Administrator confirmed that there was no signage at the room entrance indicating to visitors, staff and residents the type of precautions needed to enter the room.

Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 1 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (Resident [R]56). Findings: R56, who remained in the facility, had a SNFABN which indicated his/her last day of Skilled services was on 7/16/24. R56 was not provided the SNFABN until 7/16/25, the day the services ended. During an interview on 10/22/24 at 11:11 a.m., Social Worker confirmed R56 was not provided a SNFABN notice at least 2 days prior to last covered day.

Based on record review, interviews, and facility policy, the facility failed to update goals and interventions on the resident's current comprehensive care plan for the areas of mood/behavior for 1 of 1 residents reviewed for behaviors (Resident #9[R9]). Findings: Review of facility policy Care Area Assessments and Plan of Care dated 5/24/24 states .residents will have and individualized interdisciplinary Plan of Care that identifies the care and services necessary to maintain the highest practicable physical, mental and psychosocial well-being ensuring resident wishes for treatment and care are well defined and honored. 1. R9 was admitted on [DATE] and has diagnoses to include senile dementia, epilepsy with behaviors, delusional disorder, adjustment disorder, and depression. Review of R9's care plan updated 7/14/24 states Behavior: Potential for disruptive behavior identified wanderer. Related to dementia schizoaffective disorder with highs and lows of behaviors and paranoia manifested by hitting, pushing, punching staff, pacing exit seeking. wandering. agitation, refusing care, pushing over furniture, physically threatening others, paranoia, less trusting of some staff. APPROACH: perform behavioral check sheet assessment every hour, check sheet is located in residents room follow medication combination orders listed on sheet . Observations of R9's room on 10/21/24 at 2:14 p.m., and 10/23/24 at 8:10 a.m., No behavior monitoring sheets were observed in room. During an interview on 10/23/24 at 12:30 p.m., Unit Manager Freedom Bay (UM1) confirmed R9 had not been receiving hourly behavioral checks and were changed to every shift in September, and his/her care plan had not been updated to reflect their current behavior monitoring. 37440

Based on record reviews, facility policy review, and interview, the facility failed to ensure a resident's preferred code status was accurate in the clinical record for 1 of 3 newly admitted residents admitted in December 2022 reviewed (Resident #64). Findings: The facility's policy, Cardiopulmonary Resuscitation, last reviewed April 8, 2022, indicated the purpose of this policy is to establish clear procedures in response to a resident's cardiac or respiratory arrest as outlined in the Resident's Advanced Directives. This policy indicated: 5.1 Resuscitation wishes will be discussed with the resident and/or their responsible party and their decisions documented in ECS (name of electronic software system). 5.2 Assistance will be offered as appropriate in completing an Advance Directive. A completed copy will be kept in the resident's medical record. On 1/25/23, Resident #64's clinical record was reviewed which indicated the resident was admitted in December of 2022. The clinical record contained a Physician Progress Note, dated 12/23/22, that indicated the patient reports he/she has a Do Not Resuscitate (DNR) in place but I (physician) do not have records of this. Will need to confirm with his Power of Attorney (POA) if this is accurate. The surveyor was unable to find an Advance Directive, an active code status in the physician orders, or a Physicians Orders for Life Sustaining Treatment (POLST) form in the clinical record. On 1/25/23 at 3:58 p.m., the Liberty Island ([NAME]) Unit Manager (UM) and surveyor reviewed Resident #64's clinical record regarding the resident's code status and the 12/23/22 Physician Progress Note. The LIUM went to see Resident #64 and asked him/her what code status he/she would like and to which the resident told the LIUM that he/she wanted to be a full code and do not intubate (DNI). The surveyor observed the LIUM leaving a note for the physician regarding this. On 1/26/23, the surveyor reviewed Resident #64's clinical record and noted that a code status was added in the physician orders for a Full Code/DNI on 1/26/23 at 8:30 a.m.

Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 2 of 2 sampled residents with the diagnosis of Post Traumatic Stress Disorder (PTSD)(Resident #57 and #71). Findings: 1. On 1/25/23, Resident #57's clinical record was reviewed and indicated the resident was admitted in March of 2022. The diagnosis list included a diagnosis that was added on 6/21/22 for PTSD. The surveyor was unable to find any information in the clinical record regarding this diagnosis. Review of Resident #57's quarterly MDS, dated [DATE], included on Section: I Active Diagnoses (in the last 7 days) of PTSD (I6100) and depression (I5800). On 1/25/23 at 9:48 a.m., during an interview with a surveyor, Registered Nurse (RN) #1 stated that she would see if there was an assessment regarding Resident #57's PTSD; the Social Services Manager stated that there wasn't a care plan for the PTSD because it is not a known problem and the Resident was able to make his/her needs known and has not identified a problem/triggers at this given time. At 11:15 a.m., during an interview with a surveyor, Registered Nurse (RN) #1 stated she would try to find out where the diagnosis was coming from; RN #1 returned with the Eagles Landing (EL) UM who stated she called the medical provider and discussed Resident #57's diagnosis of PTSD. The diagnosis was added when medical records from another facility were received (3 months after admission), but Resident #57 was only being treated for depression currently. ELUM received an order to discontinue the PTSD diagnosis from the physician because it was not active. On 1/26/23 at 8:17 a.m., the diagnosis of PTSD was discontinued from the diagnosis list with an effective date of 1/25/23. 42531 2. Resident #71 was admitted to the facility in August of 2022, with diagnoses to include PTSD and depression. Review of Resident #71's quarterly Minimum Data Set (MDS) dated [DATE], revealed: Section: I Active Diagnoses: PTSD. Review of Resident #71's care plan initiated on 8/10/22, recently updated 11/15/22 lacked evidence that goals and interventions were put into place for this diagnosis. During an interview 1/26/23 at 1:56 p.m., Freedom Bay Unit Manager (UM) confirmed Resident #71 was admitted with PTSD diagnosis but has never shown any signs of it since admission and they consider it an old diagnosis. During an interview on 1/26/23 at 3:24 p.m., MDS Coordinator indicated that she enters information into the resident's MDS's by obtaining information from diagnoses list, provider notes, hospital discharge documents and medical records during the 7 days look back period. During an interview on 1/26/23 at approximately 3:45 p.m., the above was discussed with the Director of Clinical Services (DCS).

Based on interview, review of facility policy, and CDC guidelines the facility failed to ensure that all visitors were screened in accordance with facility policy and CDC (Centers for Disease Control) recommendation for screening during the Coronavirus Disease 2019 (COVID-19) Pandemic for 1 of 1 visitor. Finding: On 8/26/2020 the Division of Licensing and Certification received an anonymous report that an alleged COVID-19 positive visitor entered the facility boiler room on 8/20/20, and had close contact with several staff persons for more than 15 minutes. The visitor gained entrance to the boiler room by being admitted by a member of the maintenance staff. On 8/26/2020 at 12:45 p.m., during a tour of the boiler room with the Administrator, revealed that there are doors in the boiler room that lead directly outside to the back parking lot. The surveyor confirmed, with the Administrator at this time, that there was no screening station at the boiler room outside door. The United States Centers for Disease Control and Prevention (US CDC)'s Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/2020, indicated all facilities screen everyone (patients, HCP (Health Care Personnel), visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control and actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature 100.0°F or subjective fever. Facility Policy and Procedure/ Policy Number: EM11, Topic: Coronavirus Disease 2019 (COVID-19) revised on 7/1/2020 states 5.4.5.2 MVH (Maine Veterans' Homes) will monitor/screen for the development of COVID-19 among visitors in the facility. Also, 5.4.5.3 MVH shall follow recommended CDC and CMS criteria and protocol for when visitors will be limited or restricted from the facility. Additionally, 5.4.5.3.3 MVH shall follow CDC and CMS criteria and protocol when visitor restrictions are implemented. On 8/26/2020 at 1:25 p.m., an interview with Maintenance Staff #1 revealed that, while he was in the boiler room, he had opened the boiler room outside door to the back parking lot when he heard a knock. The visitor was known to the maintenance staff and that he let the visitor into the boiler room. The visitor stayed only 5 to 10 minutes in the boiler room and then left the facility. The visitor never entered any other part of the facility. When asked by the surveyor if the visitor was screened, he stated, No, we (the facility) don't screen visitors at the outside boiler room door, only at the front entrance of the facility, I am aware of the policy and procedure regarding screening visitors. I just wasn't thinking and was shocked when I saw him. On 8/26/2020 at 1:38 p.m., during an interview with Maintenance Staff #3 he stated he was in the boiler room at the time that the visitor was let in by Maintenance Staff #1. All persons were about 5 to 6 feet from each other and all staff persons had on face masks. The visitor was only in the boiler room for 5 to 10 minutes and then went outside. The visitor never entered any other part of the facility. When asked by the surveyor if the visitor was screened, he stated, No, visitors are screened only at the front entrance. On 8/26/20 at 2:49 p.m., during an interview with the Visitor he confirmed that he did come to the facility. No one was in the back parking lot by the outside boiler room door so he knocked on the outside boiler room door. Maintenance Worker #1 opened the door and let him in. He went into the boiler room and was in there for 10 to 15 minutes. All staff persons in the boiler room had on face masks and all stayed a good distance apart. Another Maintenance Worker #4 came into the boiler room and at that time, the Visitor was asked to leave and went outside. When asked by the surveyor if he was screened prior to entering the boiler room, the Visitor stated, No, I was not screened by anyone. On 8/26/2020 at 10:30 a.m., during and interview with the Director of Nursing(DON) she stated she found out about the incident on 8/25/2020. A visitor was let into the boiler room, from an outside boiler room door, by a facility employee. It was the DON's understanding that all staff persons involved wore face masks, social distanced and that the visitor was only in the boiler room for a few minutes. The surveyor asked the DON if visitors are let into the building at locations other than the front entrance? The DON stated, No. Our policy is to have all visitors screened at the front entrance. Our employee failed to follow the recommended CDC and CMS guidelines we use for visitors entering the facility. No screening was done. The Infection Prevention and Control Policies and Procedures were not followed. It was a breach of our Infection Prevention and Control policy. On 8/26/2020 at approximately 10:48 a.m., the surveyor confirmed in an interview with the DON the finding of a breach of the facility's infection control practices by not screening a visitor that was let into the facility. On 8/26/2020 at 10:50 a.m., during an interview with the Administrator he stated he received details of the incident on Friday 8/21/2020. A visitor was let into the boiler room at the back of the building on the morning of 8/20/2020 by one of the maintenance staff. It was the Administrator's understanding that all staff persons involved wore face masks, social distanced and that the visitor was only in the boiler room for a few minutes. The surveyor asked the Administrator if visitors are let into the building at locations other than the front entrance? The Administrator stated, No, our policy is to have all visitors screened at the front entrance. We do not screen visitors at the outside boiler room door. The maintenance worker who let the visitor in the boiler room was not following facility policy and procedure. Our policies and procedures for COVID-19 Infection Control practices come from the CDC and CMS guidelines. This was a breach of the facility's infection control practices. On 8/26/2020 at approximately 11:15 a.m., the surveyor confirmed in an interview with the Administrator the finding of a breach of the facility's Infection control practices by not screening a visitor that was let into the facility.

Based on observation, record review, and interview the facility failed to ensure a current physician order [REDACTED]. Findings: 1. Review of Resident #6's clinical record, indicated an admission on 12/17/19, and a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].>On 12/19/19 at 11:20 a.m., in an interview with the surveyor, Resident #6 stated he/she wears oxygen at 2 liters during the night. The surveyor observed an oxygen concentrator and a nasal cannula and tubing at the bedside. On 12/19/19 at 3:30 p.m., in an interview with the surveyor, a Registered Nurse (RN) was asked if Resident #6 used oxygen. The RN stated the resident uses it at night and prn (as needed). The surveyor asked if the resident had used oxygen the night before and at what amount. The RN stated 2 liters and yes, as far as I know. On 12/19/19 at 3:40 p.m., in an interview with Nurse Manager, the surveyor discussed the observation and interview with Resident #6, indicating oxygen was in use and a concentrator was present. The Nurse Manager reviewed the (Medication and Treatment Administration Records) MAR/TARs and physician orders [REDACTED]. 2. Review of Resident #7's clinical record, indicated an admission on 12/7/19, and a [DIAGNOSES REDACTED]. Physician block orders, signed 12/9/19, indicated an order for [REDACTED]. The provider response, signed on 12/16/19, stated schedule twice daily (BID) and every 6 hours as needed. See order. On 12/19/19 at 3:40 p.m., in an interview with the surveyor, the Nurse Manager reviewed the note to the provider regarding Resident #7. The nurse manager reviewed the clinical record and noted the current order, dated 12/12/19, instructed to administer [MEDICATION NAME] 5 mg, dose: 0.5 tablet/2.5 mg by mouth every 4 hours as needed. The most recent physician's orders [REDACTED]. The Nurse Manager confirmed the order signed by the physician on 12/16/19 had been omitted, and that Resident #7 was not receiving the medication as intended. On 12/19/19 at 4:00 p.m., during the exit interview, the surveyor confirmed the lack of a physician order [REDACTED].

Based on observation and interviews, the facility failed to provide locomotion assistance to 1 of 26 investigated residents (#32) in a dignified manner during 1 of 4 survey days. Finding: On 4/2/19 at 12:57 p.m., a surveyor noted Resident #32, with a [DIAGNOSES REDACTED]. A Certified Nursing Assistant (CNA) provided the resident assistance with lunch. At the completion of lunch, the CNA encouraged the resident to elevate his/her feet to assist in propelling out of the dining room. The resident did not readily elevate his/her feet. A CNA-Medications (CNA-M) came to assist by encouraging Resident #32 to elevate his/her feet. The resident yelled out hey during the attempts to maintain the resident's feet in an elevated position. After approximately 3 minutes, when the resident would not maintain his/her feet in an elevated position, the CNA-M turned the wheelchair around and pulled Resident #32 backwards out of the dining room and down the hall. At 1:06 p.m., in an interview with the surveyor, the CNA-M stated the resident makes a game out of it and will laugh about it. The CNA-M then confirmed the resident was not laughing. On 4/2/19 at 1:19 p.m., during an interview with the Director of Nursing Services, the surveyor described the observation and confirmed that Resident #32's dignity was not maintained when propelled backwards from the dining room and down the hall.

Based on record review and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR), which reflected current [DIAGNOSES REDACTED].#1 & #52). Findings: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#1's medical record contained a PASRR Level I Screen dated 09/08/17. The PASRR Level I Screen indicated in section 6.1, that the resident did not have a [DIAGNOSES REDACTED]. The resident record lacked evidence that the PASRR Level I Screen was forwarded to the State-designated authority to determine if a Level II assessment was needed. Resident #1's medical record contained a history and physical dated 09/25/17 indicating that the resident had a [DIAGNOSES REDACTED]. As of 02/27/17 his/her medical record lacked evidence that a PASRR Level I screen was updated to reflect the resident's current [DIAGNOSES REDACTED]. 2. Resident #52 was admitted to the facility on [DATE]. Resident #52's medical record contained a PASRR Level I Screen dated 03/18/14. The PASRR indicated that the resident did not have a [DIAGNOSES REDACTED].#52's medical record contained physician's orders [REDACTED]. Resident #52's medial record also contained a physician's progress note dated 10/17/17 indicating that the resident had a [DIAGNOSES REDACTED]. On 02/27/18 at 3:43 p.m., a surveyor confirmed the finding in an interview with the Social Services Director and Administrator.

Based on record review and interview, the facility failed to ensure a care plan was updated in the area of impaired swallowing for 1 of 1 sampled residents reviewed for nutrition (#82). Finding: In review of Resident #80's medical record, the Speech Therapy (ST) Swallow Initial assessment dated [DATE] indicated that the resident is at risk for aspiration. Recommendations: Mechanical soft diet with thin liquids. Out of bed to eat, upright at 90 degrees. Small bites/sips one at a time, alternate liquids with solids. Supervision with all PO intake. Resident #80's current care plan dated 01/22/18, indicated the following interventions: Mechanical soft diet with thin liquids. Out of bed to eat. Upright at 90 degrees. Small bites/sips one at a time, alternate liquids with solids. Supervision with all by mouth (PO) intake. Frequency: three times per day. A Certified Nurses Aid (CNA) Assignment Card lists Care area and Approach: Impaired swallowing, Mechanical soft diet with thin liquids. Out of bed to eat. Upright at 90 degrees. Small bites/sips one at a time, alternate liquids with solids. Supervision with all by mouth (PO) intake. On 02/28/18 at 12:20 p.m., a surveyor observed a Certified Nurses Aid (CNA) enter Resident #80's room with the resident's lunch on a bedside table. The CNA assisted the resident with setting up his/her meal and left the room. Observation of the resident from 12:20 p.m. to 12:40 p.m. Resident #80 was observed in his/her room eating lunch unsupervised. On 03/01/18 at 12:45 p.m. a surveyor confirmed the finding in an interview with the Nurse Manager.

Based on observation and interview, the facility failed to ensure that the residents environment remains free from hazards with regards to unsecured insulin needle during 1 of 4 days of survey (#92). Finding: On 02/27/18 at approximately 08:10 a.m., the surveyor observed the Registered Nurse (RN) place an open and filled insulin needle on top of the medication cart and walk away leaving the needle unattended for approximately one minute. At this time, a surveyor confirmed the finding with the RN, he/she acknowledged the unsafe technique.

Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications for 1 insulin pen available for use, in 1 of 2 medication rooms observed. Finding: On 02/27/18 at 9:34 a.m., in Company C's medication storage room, a surveyor observed Resident #63's [MEDICATION NAME] pen (insulin) open, with approximately 120 units remaining, not labeled with an open and/or discard date. Manufacturer specifications on the insulin pen indicate to Discard unused portion after 28 days. In review of the residents medical record, a Physicians order dated for 12/21/17 indicated [MEDICATION NAME] 10 units to be given subcutaneously daily at hour of sleep. At this time a surveyor confirmed the finding with the Registered Nurse, who confirmed resident is receiving the medication and that the insulin pen should have been labeled when opened.

Based on observations, interview the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to urinary catheter drainage bags for 3 of 4 days of survey. Finding: -On 02/26/18 at 1:49 p.m., two surveyors observed Resident #73's urinary catheter drainage bag dragging on the floor, under his/her wheelchair, while ambulating in the hallway across from the dining area on Company B unit. -On 02/27/18 at 12:35 p.m., a surveyor observed Resident #73's urinary catheter drainage bag dragging on the floor, under his/her wheelchair, while ambulating in the main entrance lobby of the facility. -On 02/28/18 at 10:25 a.m., two surveyors and the Director of Nursing observed Resident #73's uncovered urinary catheter drainage bag dragging on the floor, while being transported by wheelchair from the bathing area on Company B unit to his/her room. On 02/28/18 at 10:25 a.m., two surveyors confirmed the finding in an interview with the Director of Nursing.