Every finding on record at Mainegeneral Rehab & Long Term Care - Gray Birch

Based on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 of 3 residents reviewed during a complaint investigation (Resident #2).Observations of Resident #2 on 6/30/26 at 9:42 a.m., 11:32 a.m., 12:45 p.m., and 2:16 p.m., a urinary catheter was observed hanging from bedframe visible from door containing a yellow liquid. During an interview on 6/30/26 at 11:32 a.m., Resident #2 stated it bothers him/her that the foley can be seen from the door. During an observation of Resident #2 on 6/30/26 11/45 a.m., Licensed Practical Nurse (LPN)1 states that the foleys the facility uses have the cover attached and normally they are changed out on admission. At this time LPN1 observed Resident #2 and noted the foley is visible from the door and is not covered. Charge nurse stated that it's had to have been that way for a while because that's a hospital foley and not theirs and he/she has been back since last weekend (6/26/26) but should have been changed out, and at the very least covered.During an interview on 6/30/26 at 2:36 p.m., the above concern was discussed with Administrator .

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 2 units (Birches and Pines) and for a common area dining room for 1 of 1 facility tour (1/14/26). Findings:On 1/14/26 from 9:00 a.m. to 9:30 a.m., a surveyor did an Environmental Tour with the Administrator, the Environmental Services Supervisor, the Plant Operations Supervisor and a Maintenance Staff member in which the following findings were observed: Dining Room:- The base board heating unit, in a common area dining room, had broken apart metal heater covers that were broken apart exposing sharp fins and metal piping. Birches Unit- Resident room [ROOM NUMBER] - The privacy curtains were missing hooks, hanging down and in disrepair. The bathroom doorframes had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The walls by bed 2 had marred/chipped/missing paint. The bathroom doorframes and the walls by the sink had chipped/missing paint creating uncleanable surfaces. - Resident rooms 1, 2, 4, 5, 6, 10, 11, 14, 15, 18, 19, 20, and 21 had privacy curtains that had missing hooks, were hanging down and were in disrepair. - Birches shower room: The floor and the caulking around the base of the toilet were dirty/stained. The bottom right side of the shower wall had a hole in it. The suspended ceiling grid, above the window, was rusty.- The whirlpool room had a dirty floor and caulking around the base of the toilet.- Tub room [ROOM NUMBER] had rusty ceiling grids by the ceiling light and by the shower. Pines Unit- Resident room [ROOM NUMBER]A - The walls behind head of bed and below a hand sanitizer had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER]A - The walls behind head of the bed 2 and where the television is mounted had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER]A - The walls in the bathroom had chipped/peeling paint creating uncleanable surfaces.- Resident room [ROOM NUMBER]A: The walls behind the bed had scuffed/chipped paint creating uncleanable surfaces.- room [ROOM NUMBER]B: The wall behind the television was spackled and unfinished creating an uncleanable surface. On 1/14/26 at 9:30 a.m., in an interview with a surveyor, the Administrator, the Environmental Services Supervisor, the Plant Operations Supervisor, and a Maintenance Staff member confirmed the findings.

Based on observations, interviews, the facility's Dish Machine Temperature Logs, the facility's Refrigerator/Freezer Temperature Logs, and the facility's the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a water softening machine, food disposal units, floors, ceiling tiles, and ceiling lights; failed to ensure foods were covered/sealed and/or dated and labeled; failed to ensure dishes weren't wet stacked; failed to ensure refrigerators/freezers and dish washing machines temperatures were monitored/documented; and failed to ensure facial hair protection was used by staff with facial hair. Additionally, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (1/12/26 and 1/13/26).Findings:The direct connection of wastewater and potable water is 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.The facility's Dish Machine Temperature Log policy/procedure noted:Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. The facility's Food Storage policy/procedure noted:Policy: .Food will be stored, at appropriate and by methods designed to prevent contamination or cross contamination. Procedure: 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers od storage bags must be legible and accurately labeled and dated. 13. Refrigerated food storage: b. Thermometers should be checked at least two times a day. f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods(including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 14. Frozen Foods: b. Freezer temperature should be checked at least two times each day. c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. The facility's General Food Preparation and Handling policy/procedure noted:Procedure: 1. The kitchen will be kept neat and orderly. a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. 5. Equipment a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. 1. On 1/12/26 from 8:20 a.m. to 9:30 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director in which the following findings were observed:- The water softening machine, hooked to the dish washing machine, was heavily soiled with dirt and had dried liquid residue on it. - There were two food disposal units, in the dish room, that had dried food particles and dried liquid residue on them.- There were eighteen plate warmer lids, in the dish room, that had been wet stacked on a table and there were twenty-five clear plastic dessert cups that had dried liquid residue and dried soap on them that were on a dish rack. - The kitchen floor had dirt and trash on it around the edges and under the equipment. - There was a male kitchen worker, with facial hair, that was not wearing facial hair protection.- The ceiling light, in the dish room, had dried liquid residue on it. - There were two large bins of white powdery substances and one large bin with oatmeal in it that were not labeled and dated. - There was a metal container of noodles left uncovered on a counter.- The floor, under the shelf holding the large food bins, had an approximately two feet by two feet metal cover that had chipped/missing paint creating an uncleanable surface. - The food mixer had chipped/missing paint on the mix arm and the base. - The hood system, above the stove, was dusty/dirty. - The cook stove had dried liquid residue and dried food particles on it and the backsplash. - There were two ceiling lights that were dusty/dirty.- There was a ceiling vent and eight surrounding ceiling tiles, above a food preparation area, that were dusty/dirty. - The dry storage room floor was dirty and had trash on it around the entire room. The ceiling vent was dusty/dirty. - The walk-in refrigerator had a previously opened package of cheese that was not dated.- The walk-in freezer had large amounts of ice build-up on a box of pork, the ceiling, the floor and the shelving. Additionally, there was a previously opened package of pizza crusts that were not labeled and dated. - The utility closet had a cement floor that had chipped/missing paint creating an uncleanable surface. - The drainpipes for the ice machine were pushed into the drainpipe located next to the ice machine. The drain lines did not have an air gap as required. On 1/12/26 at 9:30 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings. 2. On 1/12/26 at 12:25 p.m., two surveyors observed the following findings in the common area kitchenette:- The hood system, over the stove/grill, was dirty and greasy.- The stove/grill had dried food particles and dried liquid residue on the top and sides of it. - The bottom shelf of the metal table, under the stove/grill, was dirty and rusty. - There was a wall air vent, behind the metal table holding the stove/grill, that was heavily soiled with dust/dirt. On 1/12/26 at 12:30 p.m., in an interview with two surveyors present, the Food Service Director confirmed the findings. 3. On 1/13/26 at 2:30 p.m., a surveyor reviewed refrigerator/freezer temperatures and the dish machine wash/rinse temperatures and found multiple dates not monitored/documented for October, November and December 2025 and for January 2026. Dish Machine Temperature Logs: Dates not Monitored/Documented.October 2025: Wash - 30th for lunch and supper, 31st for supper Rinse -30th for lunch and supper November 2025:Wash and Rinse - 3rd for supper, 5th for lunch, 17th and 18th for supper, 19th and 20th for lunch and supper, 21st for supper, 24th for supper, 28th for supper, 30th-for lunch and supper. December 2025:Wash and Rinse - 1st and 2nd for breakfast and lunch, 7th for supper, 9th for breakfast and lunch, 12th for supper, 19th and 20th for supper, 27th at supper, 30th for lunch, 31st for breakfast and lunch. January 2026: Wash and Rinse - 1st- 5th for breakfast, lunch and supper. 6th for lunch. On 1/13/26 at 2:40 p.m., in an interview with the Food Service Director, the surveyor confirmed the above findings.

Based on observations, interviews and record reviews, the facility failed to inform visitors and staff of an Influenza outbreak. Furthermore, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) for 2 of the 3 days of survey.Findings: 1. On 1/12/26 at 8:00 a.m., no signage was noted upon entering the facility regarding active Influenza cases in the building. On 8/12/26 at 8:39 a.m., in an interview with 3 surveyors present, the Director of Nursing informed the surveyors that they are currently in a Flu outbreak, with 2 residents on Pines Unit and 1 resident on Birches Unit. She discussed that the last positive case of the Flu was on 1/9/26. At this time, the surveyor asked if signage should be posted upon entrance to the facility alerting visitors of the Flu outbreak. The DON stated there should be. At this time the surveyor showed the DON that there is no signage upon entering the facility to alert visitors. 2. On 1/12/26 at 11:46 a.m., 2 surveyors observed RN #1 (Registered Nurse) carrying a lunch tray into a contact precaution room, rearranging items in the resident's room, and placing the lunch tray down on the side table without Personal Protective Equipment (PPE). She was then observed exiting the room, applying hand sanitizer, and then going to the medication cart. At this time, a surveyor asked RN # if the resident was on any precautions, RN # stated they are on contact precautions. When the surveyor asked why she did not follow precautions upon entering the room, she stated she normally gowns up when providing care. At this time RN # confirms she did not follow the precautions prior to entering the resident's room. On 1/12/26 at 11:49 a.m., 2 surveyors observed a CNA (Certified Nursing Assistant) carrying a lunch tray, entering a resident room without PPE, stepping out of the resident's room, looking at the droplet precaution sign, then walking fully into the resident's room and placing the lunch tray on the resident's bedside table. When a surveyor asked CNA # what PPE was supposed to be worn upon entering this resident's room, the CNA was able to tell the surveyors what PPE was needed. On 1/12/26 at 2:38 p.m., in an interview with the DON a surveyor confirmed the lack of PPE usage. 3. On 1/14/26 at 8:51 a.m., a surveyor observed LPN #1 (Licensed Practical Nurse) disconnect Resident #7 from his/her tube feed. The surveyor observed the LPN#1 wear a gown and gloves only and questioned LPN#1 why he/she did not wear a mask for the task and they did not respond. On 1/14/26 at 9:22 a.m., in an interview with a surveyor, the DON stated that staff follows the EBP (Enhanced Barrier Precaution) policy when preforming tube feed tasks. The facilities EBP states under Procedure for the use of eye protection, the first bullet, Masks and eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields shall be worn together whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated and eye nose, or mouth contamination can be expected. On 1/14/26 at 9:14 a.m., in an interview with a surveyor, the DON confirmed that the facility's PPE expectation for Jejunostomy tube feeds is to wear a mask and that the LPN should have worn a mask along with the gown and gloves. 4. A review of Resident #9's clinical record revealed that he/she was recently diagnosed with Influenza A and is on Droplet Transmission Based Precautions (TBP). On 1/12/26 at 12:23 p.m., a surveyor observed a Droplet Precautions sign hanging on the outer door frame of Resident #9's room. At this time, Certified Nursing Assistant (CNA) #2 exited Resident #9's room wearing a mask, gown, and gloves. CNA #2 stepped into the hallway and proceeded to doff (take off) her PPE and discard it into an uncovered trash can located in the hall outside of the room. The surveyor observed the sleeves of the discarded gown hanging over the outside of the trash can. Without sanitizing her hands, CNA#2 then removed a clean mask from the PPE bag hanging on the front of the door of the room next to Resident #9's room and donned (put on) the mask. CNA #2 then approached the meal cart in the hall containing the residents' lunch trays and began to place her hand on the cart. At this time, the surveyor intervened, and CNA #2 stated that she usually doffs PPE in the room and sanitizes her hands after but that she forgot and then proceeded to sanitize her hands. 5. A review of Resident #19's clinical record revealed that he/she has a diagnosis of Vancomycin Resistant Enterococcus (VRE) and indicated that he/she is on Contact TBP. On 1/12/26 at 10:33 a.m., a surveyor observed a Contact Precautions sign hanging on the outer door frame of Resident #19's room. The sign indicated PPE was to be worn for all resident contact and contact with the resident's environment. On 1/12/26 at approximately 10:40 a.m. during an interview, Registered Nurse (RN) #5 stated that all staff should wear a gown and gloves PPE for any contact with Resident #19 and his/her environment because he/she is on Contact precautions. On 1/12/26 at 12:38 p.m. during an observation of the lunch meal delivery service, CNA #3 removed Resident #19's meal tray from a cart located in the hall and without donning PPE, entered Resident #19's room and set up his/her meal tray on his/her over-the-bed table. CNA #3 then exited the room and sanitized her hands. During an interview at this time, CNA #3 stated that she does not wear PPE to deliver meal trays to residents on Contact precautions. The surveyor pointed out the Contact precautions sign to CNA #3 and that it indicated PPE for all resident/resident environment contact. CNA #3 then stated she would have to check with the nurse to verify if she should wear PPE. On 1/12/26 at 12:48 p.m. the above findings were discussed during an interview with the Unit Manager. At this time, the Unit Manager stated that for residents on EBP, trash cans are located inside the resident's room, but for residents on TBP, larger trash cans are needed and that the large trash cans do not fit in the resident rooms, so they are placed in the hallway. The Unit Manager then confirmed that staff should be doffing their PPE inside the resident's room and then placing the PPE in the trash can located in the hall.

Based on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 resident reviewed with a current diagnosis of PTSD (Resident #9).Finding:Resident #9 was admitted in 2024 with a diagnosis to include post-traumatic stress disorder.Review of Resident #9's active trauma informed care plan lacked evidence of his/her triggers for the resident's PTSD diagnoses.Review of Resident #9's Quarterly Minimum Data Set (MDS) 3.0 created 10/9/25, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #9 had an active diagnosis for Post Traumatic Stress Syndrome (PTSD). The surveyor was unable to find information in the clinical record that indicated what Resident #9's PTSD was caused by or what events might cause re-traumatization.On 1/13/26 at 3:28 p.m., In a interview with the social worker, the surveyor confirmed that Resident #9s care plan did not include PTSD triggers.

Based on observation and interview, the facility failed to ensure expired medications were removed from available supply in 1 of 3 medications carts observed. Findings:On 1/13/26 at 10:47 a.m. on Pine Unit during an observation of medication cart #3 the surveyor found Resident #9's Capsaicin Cream 0.1% 2oz with a use by date of 11/2025, and anti-Diarrheal 2 milligram, Loperamide Hydrochloride tablets with a use by date of 8/2025. On 1/13/26 at 10:50 a.m. in an interview with Registered Nurse #1, the surveyor confirmed the expired medications were not removed from available supply.

Based on observation and interview, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. (1/12/26). Findings: On 1/12/26 between 8:20 a.m. to 9:30 a.m. during an initial kitchen tour, a surveyor observed a dumpster with the top left lid open exposing refuse. On 1/12/26 at 9:30 a.m., in an interview with the Food Service Director, the surveyor confirmed that the dumpster lid was observed open exposing refuse.

Based on record review and interview, the facility failed to ensure that the licensed medication administration personnel coming on duty and going off duty signed the shift count logbook indicating that they counted all Scheduled II controlled substances and other medications with a risk of abuse or diversion at the change of shirt for 6 of 6 controlled log books reviewed for several shifts between 6/13/25 and 1/9/26.Findings:On 1/13/26 at 7:51 a.m. the surveyor observed Pine unit medication cart #1's control logbook with several missing signatures on the following dates and times: 10/8/25 at 10:00 p.m., and 10/9/25 6:00 a.m.On 1/13/26 at 10:25 a.m. the surveyor observed Pine unit medication cart #2's control logbook with several missing signatures on the following dates and times: 1/9/26 at 7:00 p.m., 1/1/26 at 7:00 a.m., 12/30/25 at 7:00 p.m., 12/21/25 at 7:00 p.m., and 11/26/25 at 7:00 a.m.On 1/13/26 at 10:40 a.m. the surveyor observed Birches unit medication cart #3's control logbook with several missing signatures on the following dates and times: 12/19/25 at 7:00 a.m., 9/26/25 7:00 a.m., 9/24/25 7:00 a.m., and 9/17/25 at 7:00 a.m.On 1/13/26 at 11:20 a.m. the surveyor observed Pine unit medication cart #4's control logbook with several missing signatures on the following dates and times: 12/30/25 at 7:00 p.m., 12/25/25 at 7:00 p.m., 7/28/25 at 7:00 a.m. and 7:00 p.m., and 6/13/25 at 7:00 p.m.On 1/13/26 at 11:20 a.m. the surveyor observed Birches unit medication cart #5's control logbook with several missing signatures on the following dates and times: 11/26/25 at 7:00 a.m., 9/14/25 at 7:00 a.m., and 6/17/25 at 7:00 a.m.On 1/13/26 at 11:56 a.m. the surveyor observed Birches unit medication cart #6's control logbook with several missing signatures on the following dates and times: 1/8/26 at 7:00 a.m., 12/30/25 at 7:00 a.m., 12/19/25 at 11:00 p.m., and 12/19/25 at 7:00 p.m.On 1/13/26 at 12:36 p.m. in an interview with a surveyor the Director of Nursing confirmed the above findings.

Based on observations and interviews, the facility failed to ensure the confidentiality of protected resident health information by displaying on monitors next to a resident's name and room number identification, what therapeutic needs they required, time of a meal corresponding with a group activity, what device was required to obtain the resident's weight, walking program, and shower day for 2 of 3 days of survey. In addition, the facility failed to protect and promote a resident's privacy and confidentiality for 1 of 1 residents reviewed for privacy (Resident #54 [R54]). Findings: 1. On 8/5/24 at noon, during an initial tour, it was observed that on the corridor walls, outside the resident's room, on the Birch Unit and the Pine Unit, the resident's full name, room number and bed location ('A' means bed by door of room/'B' means bed by window of room) is posted. On 8/5/24 between noon and 1:00 p.m., the surveyors observed a large monitor on the wall across from the Birch Unit nurse's station and a large monitor on the wall near the Pine Unit nurse's station that could be seen by other residents, and visitors. In bright colors, the monitors displayed the residents first name, first initial of last name, room number and bed location. Next to the resident's name indicated the time the resident was going to receive Occupational Therapy, Physical Therapy, or Speech Therapy. Also displayed is the type of device the resident would be weighed on (floor scale or chair scale) and what day they received a shower. Also displayed is who is on a walking program and what time a resident will be eating-corresponding with a group. On the bottom left hand side of the monitor is a key indicating information in a color code. On 8/6/24 at approximately 10:00 a.m., in an interview with the Director of Nursing, she confirmed that this information was on monitors in the corridors and at 2:15 p.m., this finding was discussed with the Administrator. 49635 2. On 4/30/24, R54 was admitted with Developmental disorder of scholastic skills and severe intellectual disabilities. On 8/05/24 at 1:00 p.m., a surveyor observed the MDS Coordinator (MDS2) conduct an interview for depression with R54 in the hallway. On 8/05/24 at 1:03 p.m., in an interview MDS2, a surveyor confirmed that the depression interview was held in a public space and did not protect the resident's privacy.

Based on record reviews and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 1 of 5 residents reviewed for Respiratory (Resident #15 [R15]) and failed to ensure that a care plan was developed in the area of Post Traumatic Stress Disorder (PTSD) for 1 of 1 residents reviewed for PTSD (R56). Findings: 1. On 8/7/24, clinical record review indicated R15 was admitted on [DATE]. Admitting diagnoses included Obstructive Sleep Apnea (OSA) and Congestive Heart Failure (CHF). Orders for these diagnoses include the use of 2 liters of oxygen at night and daily weight monitoring. On 8/7/24 at 11:02 a.m., the surveyor confirmed with the Director of Nursing that the Care Plan does not address R15's use of oxygen, or the diagnoses of OSA or CHF. 33242 2. On 8/6/24, a surveyor reviewed R56's clinical record which included a diagnosis of Post-traumatic stress disorder (PTSD) with a start date of 11/5/21, which was the admitted for R56. A physician progress note with the topic of PTSD, dated 12/14/21, talked about trauma, abuse, and that R56 was having nightmares. There was no evidence of a problem area of PTSD or triggers and interventions that addressed R56's PTSD in the current care plan. On 8/07/24 at 2:12 p.m., during an interview with the Director of Nursing (DON), a surveyor confirmed this finding. The DON stated that the facility had just done an audit of residents with PTSD and R56 must have been missed.

Based on observations, record reviews, facility policy, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 6 residents reviewed for respiratory care (Resident #9 [R9]), Resident #60 [R60], Resident #221 [R221]), Resident #15 [R15], Resident #49 [R49]). Findings: The facilities policy on Obtaining and Use of Oxygen Devises, last revised on 7/23/24. Under section 4 procedures, subsection C Cleaning/changing of oxygen equipment states the particle filter on the concentrators should be removed and cleaned weekly. 1. On 8/5/24 at 3:56 p.m., observation of R9's oxygen (O2) nasal cannula tubing stored over the O2 concentrator handle. On 8/6/24 at 8:00 a.m., and on 8/7/24 at 7:12 a.m., additional observation of R9's O2 nasal cannula tubing wrapped up and hanging over the cylinder on the back of his/her wheelchair. 37648 2. On 8/5/24 at 12:41 p.m., observation of R221's O2 nasal cannula tubing wrapped up and stored under the handle of the oxygen concentrator. On 8/6/24 at 7:43 a.m., and 8/7/24 at 7:11 a.m., additional observations of his/her O2 nasal cannula tubing wrapped and hanging over oxygen concentrator. On 8/7/24 at 7:20 a.m., both the surveyor and Director of Nursing observed the above finding. 3. On 8/5/24 at 12:32 p.m., observation of R60's O2 tubing wrapped up and stored under the handle of the concentrator and on 8/6/24 at 7:35 a.m., additional observation of the oxygen nasal cannula being stored by lying across his/her bed. On 8/7/24 at 10:35 a.m., during an interview, the DON stated the O2 tubings are expected to be stored in the provided bags for when the tubing is not in use. 49635 4. On 8/5/24 at 1:31 p.m., a surveyor observed R15's oxygen concentrator filter to be heavily soiled. On 8/7/24 at 11:13 a.m., a surveyor and the Director of Nursing (DON) observed R15's concentrator to be set to 3 liters of oxygen flow and the filter was heavily soiled. Review of the clinical record indicated the oxygen is to be used during hours of sleep at 2 liters per minute. The surveyor confirmed these findings at the time of the observations with the DON. 5. On 8/6/24 at 12:19 p.m., a surveyor observed R49 connected to a portable oxygen tank set to 3 liters of oxygen flow; the tank was observed to be empty. R49's oxygen saturation was observed to be 88% on room air. At 2:36 p.m., review of the care plan indicated, To ease breathing, oxygen is used at 2 liters via nasal cannula, to maintain an oxygen saturation of 92% or greater. On 8/7/24 at 1:27 p.m., in an interview with the DON, a surveyor confirmed respiratory care was not implemented as directed.

Based on interviews and record review, the facility failed to ensure that the clinical record contained information necessary to meet the professional standards of practice for monitoring a dialysis catheter site for 1 of 1 residents reviewed for dialysis (Resident #56 [R56]). Finding: On 8/6/24, R56's clinical record was reviewed it stated R56 was admitted to the facility on [DATE]. The clinical record indicated that R56 had received dialysis prior to admission and currently was using a right chest dialysis catheter for treatments. The surveyor was unable to find in the physician orders, an order to monitor the dressing that covered the right chest dialysis catheter or daily documentation that it was being monitored. On 8/06/24 at 02:35 p.m., during an interview with a surveyor, the Pines Unit Manager stated that they monitor the clear dressing that covers the catheter site, but not sure if there was an order to do so. The surveyor also asked about instructions on what to do in case of an emergency related to R56's dialysis catheter site as the surveyor could not find instructions in the physician orders or the care plan. The Pines Unit Manager stated she would check on it. On 8/7/24 at 8:09 a.m., during an interview with a surveyor, the Pines Unit Manager stated she was unable to find an order for the monitoring of the catheter dressing or what to do in case of an emergency related to R56's dialysis catheter site at the time of yesterday's interview with the surveyor.

Based on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 2 of 3 meals observed. (Resident #21 [R21], R11, and R7). Findings: 1. On 8/05/24 from 12:00 through 12:45 p.m., during observation of lunch meal pass, a surveyor observed R21, R11 and R7 sitting at the same table. At 12:10 p.m., Staff served R21 and R7. R11 was observed watching R21 and R7 eat, while staff served other tables. At 12:24 p.m., R11 was served lunch. 2. On 8/6/24 from 8:20 a.m. through 8:30 a.m. during observation of breakfast meal pass, R21, R11, and R7 were observed sitting at the same table. At 8:20 a.m. staff served breakfast to R21 and R7. R11 was observed watching R21 and R7 eat, while staff served other tables. At 8:30 a.m., R11 was served breakfast. On 8/06/24 at 2:13 p.m., in an interview with the Administrator, a surveyor confirmed residents were not served with dignity when meals were not served to all residents at a table at the same time. 51331

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-Admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 3 sampled residents reviewed for PASRR (Resident #56 [R56]). Finding: On 8/6/24, a surveyor reviewed R56's clinical record which included a PASRR evaluation completed by the hospital, dated 11/5/21, that indicated no PASRR level II was required and there was no mental health diagnosis. A review of R56's diagnosis list included in the clinical record: Post-traumatic stress disorder (PTSD) , Major depressive disorder, and Generalized anxiety disorder, all added to the clinical record on 11/5/21, the date of admission. A physician progress note with the topic of PTSD, dated 12/14/21, talked about trauma, abuse, and that R56 was having nightmares. On 1/24/22, R56 started medication for anxiety and on 3/17/22, R56 started medication for depression. On 8/07/24 at 2:12 p.m., during an interview with the Director of Nursing (DON), a surveyor confirmed that information for R56 was not sent to the State mental health authority for re-evaluation since the original PASRR did not include the mental health diagnosis on the original submission and R56 had started to have symptoms related to the diagnosis of PTSD. The DON stated that the facility had just done an audit of residents with PTSD and R56 must have been missed.

Based on observations, record review and interview the facility failed to update a care plan in the area of Diabetes for 1 of 1 sampled resident who utilizes a continuous glucose monitoring device. (Resident #20 [R#20]) Finding: On 8/5/24 at 3:28 p.m., observation of R20 with a continuous glucose monitoring device attached to back of his/her right arm. Review of physician orders dated 1/22/24, states, FreeStyle Libre 2 Sensor kit (1) KIT Subcutaneous Every Fourteen Days Starting 1/26/24 .Notes: Change per package instructions. Check finger stick if reading is <70 or >350 or if pt is having symptoms of hypoglycemia Dx type 2 dm on insulin. R20's care plan for Diabetes Management, last revised on 4/19/23 lacks evidence of a glucose monitoring device and/or safety instructions/interventions. On 8/7/24 at 11:20 a.m., during an interview, the Director of Nursing confirmed the care plan did not contain the continued glucose monitoring device and/or safety interventions.

Based on record review, observations and interviews, the facility failed to ensure that physician's orders were followed for 1 of 2 sampled residents for wound management (Resident #12 [R12]) and 1 of 5 residents reviewed for unnecessary medications. (Resident #47 [R47]) Findings: 1. On 8/5/24, R12's clinical record was reviewed and included a physician order for wound care instructing nursing to Cleanse legs with Vashe - apply clobetasol to legs- cover open areas with xeroform, then Abd pads and the hold in place with netting. DX: venous insufficiency (chronic) (peripheral). On 8/5/24 from 12:49 p.m. through 1:36 p.m., 2 surveyors observed the Licensed Practical Nurse (LPN #1) perform R12's bilateral leg dressing changes. The LPN #1 wet a facecloth with faucet water and cleansed R12's legs and then applied clobetasol to the open wounds. On 8/5/24 at 1:36 p.m., the LPN #1 confirmed she did not follow the physician orders by using water to clean R12's legs and should have applied clobetasol to the legs not the open wounds. 33242 2. On 8/7/24, R47's clinical record was review and included a physician order, dated 6/4/24, to administer Novolog Insulin based on blood sugar results as follows: Instructions: 0-150: 0 units 151-200: 2 units, 201-250: 4 units, 251-300: 6 units, 301-350: 8 units, 351-400: 10 units, equal to or greater than 401: 12, units Alert provider if BG is less than 70 or greater than 400. On 8/2/24, R47's blood sugar results was 330. Documentation indicated that R47 received 10 units and should have received 8 units. R47's clinical record was further reviewed for physician notification for high blood sugars for July 2024, for the 7:30 a.m. blood sugar results with the following documented but lacked evidence that the Medical Provider was notified: On 7/18/24, the blood sugar was not documented but R47 received 12 units which indicated that the blood sugar was grater than 401; On 7/20/24, the blood sugar was 531; On 7/23/24, the blood sugar was 531; On 7/24/24, the blood sugar was 411; On 7/25/24, the blood sugar was 421; and On 7/30/24, the blood sugar was 418. On 8/7/24 at 11:38 a.m., during an interview with the Pines Nurse Manager, a surveyor confirmed these findings.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes and food in a sanitary manner, not maintaining a clean kitchen floor, and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (8/5/24 and 8/6/24). This has the potential to effect all residents. Findings: On 8/05/24 at 11:10 a.m., during the initial kitchen tour, a surveyor observed with the Food Service Director (FSD), the floors to be heavily soiled with crumbs, grease, fruit, and unidentifiable debris. A container full of measuring cups used for food preparation was observed with the lid ajar and covered in crumbs. The measuring cups within the container had visible food debris inside them. A large bin containing oats was observed with the lid partially open to the environment. The air gap for the left kitchen sink was less than 1 inch, 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). Observation of the walk-in refrigerator revealed the floor was heavily soiled with food debris including shredded pieces of chicken. Observation of dry food storage revealed on the shelf and available for use: 3 cans - 6 pounds (lbs) 10 ounces (oz) [NAME] Creek Diced Beets, 1 had a dented in side, 2 had dented bottom seals. 1 can - 6lbs 12 0z Magellan Pineapple Slices with a dented top seal. 2 cans - 7lbs [NAME] Creek Banana Pudding both dented on the top seal. Observation of the walk-in freezer revealed on the shelf and available for use: 1 box - 10.25lbs [NAME] Breaded chicken breasts open and undated, open to the environment. 1 box - 10lbs Pork Sausage 2oz patties (fully cooked heat & serve), open to the environment. These findings were observed and confirmed with the FSD at the time of the observation. On 8/6/24 at 9:57a.m., observation of the dry food storage revealed on the shelf and available for use, 2 cans of 6lbs 10oz [NAME] Creek Diced Beets, both dented on the bottom seal. Observation of the walk-in refrigerator revealed soiled flooring including plastic tape, food debris and a potato on the floor. Observation of the kitchen revealed the air gap for the left kitchen sink and the air gap for the steamer were less than 1. These findings were observed and confirmed with the FSD at the time of the observation.

Based on observations, interviews, and record reviews the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to wound management for 1 of 2 residents sampled for wound care. (Resident #12 [R12]). Finding: On 8/5/24 from 12:49 p.m. through 1:36 p.m. 2 surveyors observed the Licensed Practical Nurse (LPN 1) perform R12's bilateral leg dressing change. During the observation the following was observed: LPN1 gowned and gloved, entered the room and closed curtain with her gloved hand. With the same gloved hands, she began removing the xeroform from the wound bed, removed her gloves then exited the room and returned with a handful of facecloths. Next, she donned a new gown and gloves and cleansed both legs using the face cloths with faucet water. With the same gloved hands, she applied clobetasol ointment to several wounds using her gloved fingers. She then stopped, removed gown and gloves, performed hand hygiene and exited the room returning with Q-tips. She washed her hands and applied new gown and gloves. The following care was all completed with the same gloved hands and without performing hand hygiene. With her gloved hand she tucked her hair behind her ear, lifted up her gown and removed the packages of Q-tips from her scrub pocket. She opened the Q-tips and continued to apply the ointment to the wound beds. Then she again lifted her gown and removed more Q-tips from her scrub pocket and continued to apply the ointment. She then took a package of xeroform off the windowsill, reached under her gown again to her name badge which had an attached black marker and dated the package of xeroform. She then obtained scissors off the windowsill and cut a piece of the xeroform off, placing each piece of xeroform on an open wound beds, during this process she placed the scissors into the basin filled with the residents personal belongings 6 times. Next, she obtained the abdominal pads off the windowsill, opened and placed them on the legs, again reached under her gown to obtain the marker and dated the ABD pads. Finally, she applied the netting to bilateral legs, all with the same gloved hands and without performing hand hygiene. On 8/5/24 at 1:36 p.m., during an interview, LPN1 confirmed she failed to provide an environment to prevent development and transmission of disease and infection during the dressing change. On 8/6/24 at 9:38 a.m., the above concerns were discussed with the Director of Nursing.

Based on record reviews and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 2 of 5 residents reviewed for immunizations (Resident #54 [R54] and R66). Findings: 1. R54 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. 2. R66 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. On 8/7/24 1:22 p.m., during an interview with a surveyor, the Infection Preventionist stated that the Medical Provider follows the CDC recommendations for vaccinations. The surveyor confirmed these findings.

Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately for 1 of 1 resident reviewed for discharged to the community (Resident #68 [R68]) and 1 of 3 residents reviewed for Pre Admission Screening And Resident Review (PASARR) (Resident #47 [R47]). Findings: 1. On 8/7/24, R68's clinical record was reviewed for discharge. Medical record indicated R68 was discharged to the community on 5/8/24. Review of the discharge MDS dated [DATE], section 2A105 states R68 was discharged to short term general hospital. On 8/7/24 at 10:35 a.m. during an interview, the MDS coordinator confirmed the MDS was coded inaccurately for discharge. 33242 2. On 8/5/24, R47's clinical record was reviewed. On 4/8/24, R47's PASSAR was completed and indicated that R47 qualified for Level II services. Review of R47's Annual MDS, dated [DATE], Section: A1500 was coded to indicate that R47 did not have a Level II PASSAR. On 8/7/24 at 9:27 a.m., during an interview with a surveyor, the MDS coordinator stated the MDS was coded inaccurately. The surveyor confirmed this finding during this interview.

Based on clinical record review, interviews, observation, and review of facility policy, the facility failed to ensure that the resident's environment was free of accident/ hazards relating to a food allergy. As a result of this failure, a resident experienced an anaphylactic reaction, requiring administration of epinephrine and emergency transport to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident #32). Findings: A review of Resident #32's clinical record was conducted. Resident #32 was originally admitted to the facility in early June of 2022, with a documented allergy to onions. A dietary order dated 6/8/22 states Food Allergy(s): onions and a care plan initiated on 6/8/22 which states Goal: [Resident #32] will tolerate prescribed food/liquid texture diet, Interventions: Dislikes (list): Allergy to onions. Review of a clinical note, dated 11/11/22, states .1745-Dietary informed this staff member that resident has soup with onions in it. (pearl) Resident is allergic. Met resident in the hall who states [he/she] feels bad but is vague and unable to explain. Resp uneven and unlabored. Resident was assisted back to [his/her] room and placed in bed .provider agreed not to administer epi pen at this time, okay to give Benadryl 23 mg x1 . Review of a clinical note, dated 11/20/22, states Dietary down to unit with [CNA] and stated that resident had onions in [his/her] beef tips. Resident ate approx. 25% of the meal. Resident states [he/she's] fine, originally refused to have vitals taken. No Resp distress noted, no need for EPI pen. Call placed with [Provider] who okayed a 25 mg Benadryl XL. Review of a clinical note, dated 1/18/23, states at 12:20 p.m., this RN notified that resident consumed at lunch -onions in the meat sauce .resident by nurse's station, speech started to become more garbled and redness to face, sweating, lungs diminished, poor airway exchange, 911 called, given PRN epi pen at 12:28 . Review of the acute care hospital Emergency Report, dated 1/18/23 states .reported history of allergy to onions .after receiving IV diphenhydramine and IM epi-pen for developing symptoms suspicious for allergy. [He/She] reportedly had some tomato sauce that contained onions unknowingly and afterward developed erthroderma [red skin], diaphoresis, dyspnea all improved after IM epi . Diagnosis: anaphylaxis. During an interview on 5/23/23 at 12:01 p.m., Director of Support Services (DSS) indicated that the facility Cooks were the primary focus for the education provided on 2/14/23 because they are the ones that prepare all the food for service. DSS further indicated that kitchen staff don't always have time outs [dietary staff huddle prior to delivering meals to floor to discuss what is being served, what is in the food, who has allergies and what alternatives they are getting] as they should prior to serving. DSS further indicated that the dietary staff that received the food shipments is responsible to label any food items that contained onions with a green sticker and that all foods containing onions have a green sticker. DDS indicated that he was not aware of the incidents on 11/11/22 or 11/21/22, so there were no measures put into place as far as he knows. At this time DSS confirmed above findings. During an interview on 5/23/23 at 12:32 p.m., Cook #1 indicated that she was aware that Resident #32 had an onion allergy, and she did not take the time to look at the tomato/meat sauce label as she normally would. Cook #1 further indicated that after she served the meal, she observed Resident #32 eating the tomato/meat sauce and she immediately went to the nurse and informed them of what had happened. During an interview on 5/24/23 at 7:00 a.m. Resident #32 confirmed that [he/she] has had an allergy to onions since the age of 3. [He/she] further indicates inability to have raw or cooked onions, and [he/she] can't touch or eat them. On 2/12/23 the facility completed a Root Cause Analysis related to the 1/18/23 event a review of that analysis states Date of Event: 1/18/23; Root Cause Analysis Event: Received onions with known allergy .Further review revealed 11/11/22: Received onions in soup, 11/21/22: Received onions on [his/her] beef tips [he/she] had 25% of meal when CNA [certified nursing assistant] caught it. Benadryl given. 1/18/23 received onions in spaghetti sauce: canned sauce. Had resp distress, redness, sweating. [He/she] received Epi pen and went to [acute care hospital]. Below are some of the changes that we have made since this occurred: -Menu slips have been colored coded to help flag allergens, diets, and constancy's -Green labels have been added to all canned items that contain onions .At the beginning of each meal service, cooks and aids need to do a time out. Review the allergies and what the resident with these allergies can or cannot have .review allergies at the daily huddle . Review of Onion Allergy Event Inservice dated 2/14/23 states .All long-term care staff have to take these allergies very seriously. We have seen an increase in allergies over the years and I need each kitchen staff member to do the following: -Read all labels, with the particular resident any items that contains onions including onion powder cannot be served to [him/her]. During an observation of the dry storage room on 5/23/23 at approximately 12:32 p.m. two surveyors, Director of Support Services (DSS), and cook observed multiple soup cans and approximately 4 bags of stuffing that also contained onions that were not labeled with a green sticker. At this time SSD indicated that at the time he was so concerned with the initial cause of Resident #32's reaction [tomato sauce] he did not think to check all the other food items in the storage room. Review of facility policy Food Allergies undated states Individuals with food allergies will be provided with safe foods and fluids, and appropriate substitutions to maintain health. On 5/23/23 at 4:04 p.m., the surveyor confirmed in an interview with the Administrator and the Director of Nursing, Resident #32 was served meals containing onions, and the dry storage room contained food items which did not identify (with the green label) that the items contained onions. 48648

Based on observations, interviews and review of the Hot Water Testing, log the facility failed to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit in 4 of 40 resident rooms, and in two tub rooms. The failure of the facility to lower hot water temperatures when the log for September 26, 2016 indicated temperatures exceeding 120 degrees Fahrenheit in the Pines tub room, created the potential for resident's to be burned by the domestic hot water. Findings: 1. On 9/26/16 at 12:30 p.m., the surveyor measured and observed hot water temperature of 122 degrees Fahrenheit in Resident Room #N1 on the Pines Unit. 2. On 9/26/16 at 12:35 p.m., the surveyor measured and observed hot water temperature of 125 degrees Fahrenheit in Resident Room #N5 on the Pines Unit. 3. On 9/26/16 at 12:36 p.m., the surveyor measured and observed hot water temperature of 127 degrees Fahrenheit in Resident Room #N6 on the Pines Unit. 4. On 9/26/16 at 12:39 p.m., the surveyor measured and observed hot water temperature of 126 degrees Fahrenheit in Resident Room #N10 on the Pines Unit. 5. On 9/26/16 at 12:41 p.m., the surveyor measured and observed hot water temperature of 141 degrees Fahrenheit in Tub Room #1 of the Pines Unit. On 9/26/16 at 12:43 p.m, in an interview with the Administrator, he indicated that he was not aware that the facility's hot water temperature was over 120 degrees Fahrenheit. The administrator also indicated that he was not aware that the facility's Hot Water Testing log indicated that the water temperature in the Pines Tub room was 128 degrees Fahrenheit. 7. On 9/26/16 at 12:46 p.m., the surveyor along with the facility Administrator, measured and observed hot water temperature of 148 in Tub Room #1 of the Pines Unit. 8. On 9/26/16 at 12:48 p.m., the surveyor along with the facility Administrator, measured and observed hot water temperature of 149 in Tub Room #2 of the Pines Unit. On 9/26/16 at 2:10 p.m., In an interview with a surveyor, maintenance staff indicated that he took the temperature of the Tub Room #1 at 6:15 a.m. on 9/26/16 and confirmed the temperature was 128 degrees Fahrenheit. He further indicated that at that time he adjusted the temperature down, and had not checked the water temperature again, nor was staff alerted to the high hot water temperature until the surveyors brought it to the facility's attention.