Every finding on record at Mid Coast Senior Health Center

Based on observations, interview and record review, the facility failed to follow their policies ensuring staff wear required hair restraints, maintain the industrial mixer in a clean and sanitary condition and ensure food was not expired, outdated, unlabeled, or moldy for 1 of 3 kitchen tours observed. In addition, the facility failed to ensure the dishwashing machine maintained the proper temperature range necessary for effective cleaning and sanitizing for 7 of 7 temperature logs reviewed. These failures had the potential to affect all residents who consume facility prepared food. The facilities policy Infection Prevention - Kitchen requires that all Food Service staff comply with that all dishwashing staff comply with personal hygiene requirements, including wearing a hair and beard restraint and that all kitchen equipment including mixers be maintained in a clean and sanitary condition.On 8/4/25 from 9:30 a.m. to 10:30 a.m., during a kitchen tour with the Food Service Director, the following findings were observed: A male dishwasher with facial hair and no hair restraint. Dried flour residue was observed on the underside of the industrial mixer head.The facilities Food and Nutrition Services Policy - Food Storage states that food shall be labeled, dated, and stored in a manner to prevent spoilage contamination and the use of expired products.During the kitchen tour the following expired, outdated or improperly stored foods were observed in the refrigerator and walk-in cooler:1 gallon Monarch blue cheese salad dressing (open, no date, expired)1 6-pound Monarch sliced strawberries, dated 7-26, use by 8-21 gallon Ken's Dijon Honey Mustard Dressing (opened, no open date)1 9-pound 6-ounce Monarch Large Maraschino Cherries (no open date)1 5-pound Glenview Farms sour cream (Open, moldy, no date)1 16-ounce container of Ridgecrest Lobster Base (open, no date)1 3.5-liter container of orange juice (container had a hole)1 4-pound container of hummus (Open, no date, moldy)1 5-pound ham roast, dated 7-23, use by 8-34 moldy cantaloupes1 10-pound plastic container of [NAME] Potato salad (open, no date)1 open 16-ounce package of Elios Pita Pocket bread, originally containing eight pita pockets, with three pita pockets remaining had visible mold inside the packaging. The facility's Dish Machine Temperature Logs for January 2025 to July 2025 revealed multiple dates and periods where temperatures did not reach the required minimum of 165 F for the wash cycle and the final rinse/sanitizing cycle did not meet the minimum required temperature of 180 F.January 2025:Wash cycle temperatures below 165 at Breakfast - 1, 2, 4, 6, 9, 13, 28; Lunch - 1, 26 and 28; Dinner - 1, 2, 3, 4, 9, 21, 22, 25, 31.Rinse/Sanitizing cycle temperatures below 180 F at Breakfast - 16, 28 - Lunch - 23, 24 and 25.February 2025:Wash cycle temperatures below 165 F at Breakfast - 1; Lunch - 14, 18, 22 and 23; Dinner - 1, 2, 4, 5, 6, 8, 17, 23, 24, 25, 26, 27 and 28.Rinse/Sanitizing cycle temperatures below 180 F at Lunch - 8 and 16; Dinner - 4, 5 and 26 - 28.April 2025:Wash cycle temperatures below 165 F at Breakfast - 24 - 27; Lunch - 1, 5, 6, 10, 17, 18, 21, 24 -28 and 30; Dinner - 1, 2, 4, 5, 8-20, 23-31.Rinse/Sanitizing cycle temperatures below 180 F at Lunch - 3-7, 9, 14, 17, 21-28 - Dinner - 3-6, 8, 9, 11-18, 20, 22-31.May 2025Rinse/Sanitizing cycle temperatures below 180 F at Breakfast - 1-31; Lunch - 1-31; Dinner - 1-31.June 2025:Wash cycle temperatures below 165 F at Breakfast - 1, 2, 8-10, 12, 27, 28 and 30 Lunch - 1-6, 22, 23, 27-30 Dinner - 1-26 and 28-30.July 2025:Wash cycle temperatures below 165 F at Breakfast -3, 6 -11, 14 - 25, 28, 29 Lunch - 6-12, 18, 23, 25, 26 Dinner - 3, 7 - 28.On 8/6/25 at 11:03 a.m. the Food Service Director confirmed that Dish machine temperatures were not consistently meeting required ranges and acknowledged that the logs showed out of range readings in January 2025 through July 2025 temperature logs.

Based on observations, review of Safety Data Sheets (SDS) and interviews, the facility failed to ensure that the residents environment remained free from hazards with regards to chemicals for 3 of 3 survey days.A surveyor reviewed the Safety Data Sheets (SDS) for the following chemicals and found the GHS (Global Harmonized System) information for Hazard class and category. A Category 1 in this system indicates the highest level of hazard for that category. SDS for Might Bowl 64GHS US Classification: Serious eye Damage/eye irritation Category 1, Skin sensitization, category 1 SDS for GC2030 GHS US Classification: Skin corrosion/irritation Category 1A, Serious eye damage/eye irritation Category 1, Skin sensitization, Category 1 SDS for Professional LYSOL toilet bowl cleaner - Complete clean powerGHS US Classification: Corrosive to metals - Category 1, Acute Toxicity (oral) Category 4, Skin Corrosion Category 1, Serious Eye Damage - Category 1.On 8/4/25 at 10:37 a.m. A surveyor observed the spa room and the shower room on Mere Point Unit and found an unlocked cupboard in the spa room with a spray bottle containing liquid labeled Syntec Ready to Use GC2030. A surveyor also observed an unlocked cupboard in the shower room on Mere Point Unit with 2 spray bottles containing liquid with the following labels: Syntec Ready to use GC2030 and Syntec Ready to use Might Bowl 66. On 8/4/25 at 10:40 a.m. a surveyor showed the Administrator the unlocked cupboard in the shower room and stated concerns for the accessibility of the chemicals in this cupboard and the cupboard in the spa room. The Administrator confirmed that there were residents on the unit with cognitive deficits who were mobile, and the chemicals should be secured.On 8/4/25 at 12:30 a surveyor was told by the Director of Facilities that the shower cabinet was now secured. On 8/5/25 at 10:40 a.m. a surveyor observed the spa room and shower room on Mere Point Unit and found a cabinet in the spa room was unlocked and a spray bottle containing liquid labeled Syntec Ready to Use GC2030 was still accessible to residents. The cabinet in the shower room now had a magnetic removable knob that would lock and unlock the cabinet door. The door was found unlocked with 2 spray bottles containing liquid labeled Syntec ready to use GC2030 and Syntec Ready to use Mighty Bowl 66. In addition, a surveyor observed an unlocked linen closet in the Mere Point Unit with a bottle of Lysol Toilet Bowl Cleaner on the top shelf, accessible to residents who are ambulatory.On 8/06/2025 at 07:52 a.m. a surveyor observed an open door to the spa room and found an unlocked cabinet with a spray bottle containing liquid labeled Syntec Ready to Use GC2030. On 8/6/25 at 11:40 a.m. a surveyor met with the Administrator about the findings.

Based on observations, record reviews and interviews, the facility failed to ensure a resident's right to be free from physical restraint for 1of 4 residents observed wearing wheelchair seatbelts. In addition, the facility failed to follow its own policy titled Physical Restraints/Side Rails in the area of physical restraints. (Resident #22)On 8/5/25 a surveyor reviewed the facility policy titled Physical Restraints/Side Rails last reviewed/revised 9/2020 which stated: A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed intentionally by the resident in the same manner as it was applied by staffUnder Section IV Procedure:1. An RN will complete a nursing assessment which includes resident behavior patterns, diagnoses that explain behaviors, resident safety needs and medications.2. The provider must be included in all discussions regarding the potential use of restraints.3. Only an RN or provider are authorized to apply restraints.4. Any restraint must be ordered by the provider. Note that the provider alone cannot warrant the use of the restraint without supporting clinical documentation that includes:a. Identification of the medical symptom(s) being treated and the specific type of restraint.b. Thoughtful individualized care planning by interdisciplinary team.c. Evidence that the use of the physical restraint is for the least amount of time possible.d. Evidence that interventions, including less restrictive alternatives, were attempted but were ineffective;e. Education and notification to the resident/representative of potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use;f. The length of time the restraint is anticipated to be used to treat the medical symptom,g. Where and how the restraint is to be applied and used,h. The time and frequency the restraint should be released and,i. Who may determine when the medical symptom has resolved in order to discontinue use of the restraint;j. The type of specific direct monitoring and supervision provided during the use of the restraint, including documentation of the monitoring;k. The identification of how the resident may request staff assistance and how needs will be met during the use of the restraint, such as for re-positioning, hydration, meals, using the bathroom and hygiene;l. The resident's record includes ongoing re-evaluation for the need for a restraint and is effective in treating the medical symptom; andm. The development and implementation of interventions to prevent and address any risks related to the use of the restraint.On 8/5/25 a surveyor reviewed Resident #22's Minimum Data Set assessment (MDS) dated [DATE] that documented an admission to facility on 4/8/25 with a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. On 8/5/25 a surveyor reviewed a Physical Therapy (PT) assessment dated [DATE] under Standardized Assessments, Not appropriate for Standardized Assessments (provide reason) patient unable to follow instructions. On 8/5/25 at 2:11 p.m. surveyors observed Resident #22 in the common area sitting in a wheelchair against the wall. The wheelchair brakes were engaged, and Resident #22 was wearing a seatbelt. Resident #22 was observed straining against the seatbelt, attempting to stand up and move his/her wheelchair. Resident #22 was gesturing repeatedly and saying I want to go there. Resident #22 was in distress as demonstrated by his/her restless body movements, vocalizations and facial expressions. Activity Staff were present in the common room assisting other residents.On 8/5/25 at 2:13 p.m. surveyors approached Resident #22 and asked if he/she was able to unlatch the seatbelt. The resident continued to gesture and point and say he/she wanted to go there. No action was made by the resident that indicated he/she understood they were wearing a seatbelt or were able to unlatch it. A surveyor then asked Resident #22 if they were able to unlock the wheelchair brakes. Resident #22 made no action that indicated understanding of the brakes or how to unlock them. It was determined that Resident #22 was being restrained by the seatbelt and brakes on the wheelchair. Surveyors asked nearby staff to retrieve Resident #22's nurse.The facility Director of Quality and Compliance and RN #1 arrived and were asked by surveyor if Resident #22 could independently remove the seatbelt or brakes. RN#1 stated yes but was unable to get Resident #22 to demonstrate this. Staff then immediately assisted the resident out of the chair and took Resident #22 for a walk.On 8/5/25 at 2:22 p.m. a surveyor interviewed the Director of Quality and Compliance and RN #1 and learned that the resident had been using a seatbelt since last week because he/she walked constantly and it was felt he/she needed to rest. When a resident wears a seatbelt in their wheelchair, they are reassessed every Friday for the ability to release themselves, but Resident #22 had not been reassessed because it hadn't been a week yet. RN #1 stated that Occupational Therapy (OT) did the initial safety assessment and put the seatbelt on the chair. They had not been following a restraint protocol because they said the resident could unlatch the seatbelt independently. Documentation failed to show any assessments, monitoring or follow-up assessments were done. I asked if he/she could cognitively understand the seatbelt and brakes and was told yes. I asked if the resident's cognitive status had changed from last week until now. They stated no, he was about the same. The Director of Quality and Compliance and RN #1 did acknowledge that Resident #22 was unable to cognitively manage the seatbelt and brakes at this time and was restrained.On 8/5/25 a surveyor reviewed Resident #22's Electronic Medical Record (EMR) and found it failed to show any nursing documentation about Resident #22 was wearing a seatbelt or that any of the steps listed above in the facility's policy Physical Restraints/Side Rails under Section IV: Procedures was completed. The EMR failed to document when the seatbelt was put on or the medical reason it was being used. Resident #22's care plan failed to include a focus, goal or intervention for the seatbelt. On 8/6/25 at 8:30 a.m. a surveyor observed Resident #22 independently ambulating in the hallway with a walker.On 8/6/25 at 9:40 a.m. a surveyor interviewed OT #1 who confirmed he/she put the seatbelt on Resident #22's wheelchair and learned that an assessment to ensure Resident #22 could physically and cognitively unlatch and latch a seatbelt had not been completed yet and was therefore not available. On 8/6/25 at 9:30 a.m. a surveyor met with the administrator, the director of nursing and the Director of Quality and Compliance about the findings.

Based on record review and interviews the facility failed to maintain an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This could affect all residents receiving antibiotics. Findings: Review of facility policy Antibiotic Stewardship dated 4/15/24 states Purpose: to monitor the use of antibiotics in our residents. Promotes the judicious use of antimicrobials in order to optimize the treatment of infections, reduce the risk of adverse events to patients/resident, and minimize the development of antibiotic-resistant organisms .conduct surveillance and collect data on pathogens related to antibiotic. On 6/12/24 at 1:04 p.m., during an interview, the Admissions Coordinator, Registered Nurse Care Manger, and Infection Preventionist, confirmed the facility does not track antibiotic use.

Based on observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to urinary collection devices for 3 of 3 days of survey on 2 of 3 units (100 and 200 Units). Findings: Observations of 100 Unit revealed the following: -On 6/10/24 at 9:48 a.m., and 6/11/24 at 7:25 a.m., observations of room [ROOM NUMBER] bathroom revealed uncovered commode bucket on floor, available for use. -On 6/10/24 at 9:25 a.m., observation of room [ROOM NUMBER] bathroom revealed uncovered commode bucket on the floor with bed pan stored inside, available for use. Observations of 200 unit revealed the following: -On 6/11/24 at 8:14 a.m. and 3:09 p.m., and on 6/12/24 at 8:04 a.m., observations of room [ROOM NUMBER] bathroom revealed an uncovered commode bucket on bathroom floor, available for use. - On 6/11/24 at 8:21 a.m., and 3:13 p.m., observations of room [ROOM NUMBER] bathroom revealed an uncovered commode bucket on floor, available for use. -On 6/12/24 at 8:16 a.m. 2 surveyors observed room [ROOM NUMBER] bathroom containing uncovered commode bucket on floor and urinal drainage bag hanging over the hand railing containing approximately 250 ccs yellow liquid. During a facility tour on 6/12/24 at 9:00 a.m., the above findings were confirmed with the Director of Operations.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the floor stand mixer, floor stand fan, and the small countertop mixer. Freezer #7 contained unlabeled and undated items for 2 of 2 observations. Additionally, the dry storage room floor was not maintained in clean and sanitary manner, there is no temperature log for the dish machine, and the Mere Point Unit Freezer contained the ice scoop in with the ice for 1 of 3 days of survey. Findings: On 6/10/24 at 8:10 a.m., during the initial tour of the kitchen with the cook and again on 6/12/24 at 8:00 a.m., during a kitchen tour with the Director of Facilities Operations, the following findings were observed and confirmed: 1- Observed that the facility lacks a log for the dish machine. The cook stated, we are supposed to have a log for that, but I do not know where it is. In an interview, the Kitchen Coordinator and a Diet Aide, that run the dish machine, both stated in the instructions for running the dish machine that they must observe the temperature gauge and see that it rises to the correct temperature. 2- Observation of the dry storage room to have food on the floor i.e. packets of peanut butter, crackers and an energy bar. 3- Observation of the large floor mounted mixer to have stuck on dried food on mixer. At this time, the cook stated that she had not used the machine for 2 days. 4- Observation of the floor mounted fan to have a light to moderate covering of dirt like debris on fan with some long strands of dust like debris blowing in the air. 5- Observation of the small countertop mixer with dried food/debris on the side and the stand. No staff member could say when that machine was last used. 6- Observation of Kitchen Freezer #7 containing a package of Frozen French Fries with no label or date, an open bag of Hash browns with no date, and two packages of log shaped food with no label and no date. On 6/12/24 at 8:35 a.m. in the Mere Point Unit Kitchen, during observation of breakfast, surveyor noted the ice scoop in the ice bin of the freezer compartment of fridge. At this time, the kitchen staff member confirmed the ice scoop should not be stored in the ice bin.

Based on facility policy, record reviews and interviews the facility failed to update and/or implement goals and interventions for 2 of 14 care plans reviewed. (Resident's #12 and #29). Findings: Review of facility policy Comprehensive Resident Care Plan undated states It is the policy of Mid Coast Senior Health Center to develop, implement and evaluate a comprehensive care plan for each resident based on a comprehensive assessment of the residents needs . will be developed for each resident to include measurable objectives and timetables based on the Resident Assessment Protocols triggered by the MDS and other assessments . will reflect intermediate steps for each objective if identification of those steps will enhance the resident's ability to meet his/her objectives .will be developed 7 days after the completion of the comprehensive assessment by the interdisciplinary team will be reviewed and updated periodically and as the resident's condition dictates . 1. Resident #12 was admitted on [DATE] and has diagnoses to include chronic kidney disease stage 2, congestive heart failure [CHF], Diabetes Mellitus II[DMII], right leg above knee amputation and atrial fibrillation. Review of Resident #12's clinical record revealed his/her last quarterly Minimum Data Set [MDS] was completed on 3/7/24. The most recently signed provider orders dated 4/26/24 revealed the flowing: -Order with start date of 1/18/23 for Blood glucose checks fasting and pm qid [4 times daily]- call provider if BG above 400. -Order with start date of 5/17/23 for insulin Aspart 100 unit/ml solution injection sub-q 8units tid [three times daily] for DMII. -Order with start date of 10/1/22 for insulin Aspart 100 unit/ml solution sub q tid per sliding scale 0730/730 am 1130/1130 am, 1630/430pm sliding scale: 70-150=0 units, 151-199=1 units 200-249=2 units, 250-299=3 units 300-349= 4 units, 350-399=5 units >400 call MD/provider for DMII. -Order with a start date of 1/21/23 for apixaban 5mg tablet by mouth 1 tab bid for DVT [deep vein thrombosis] prophylaxis -Order with start date of 3/22/24 for torsemide 20 mg tablet by mouth .2 tablet/40mg 8am for CHF. -Order with start date of 4/4/24 for ipratropium-albuterol 0.5mg/3ml -2.5 mg/3ml solution inhalation 1 vail tid prn for dyspnea. Review of Resident #12's care plan updated 5/31/24 lacked evidence of goals and interventions for the above diagnoses. On 6/11/24 at 12:21 p.m. during a review of Resident #12's care plan, the Director of Nursing confirmed the above finding. 44049 2. On 6/10/24 at 9:47 a.m., in an interview with the Resident #29's representative, [he/she] stated, The doctor has told me how to massage [his/her] leg because now that [he/she] is on Hospice they may not cover continued Physical Therapy (PT) for [him/her]. On 6/11/24 at 12:15 p.m. in an interview with the charge nurse, she confirmed that the edema is not in the care plan stating, that she has documentation in the resident's clinical record that shows on 6/5/24, 6/6/24, and 6/8/24 she elevated the resident's legs higher than the resident's heart to attempt to reduce the edema in the resident's left leg . I am not sure why it is not on the care plan.

Based on facility policy, record review and interview, the facility failed to issue a bed hold notice which included the daily cost of care, to a resident, known family member or legal representative for 1 of 6 sampled residents who had been transferred to the hospital (Residents #28). Finding: Review of facility policy Resident Bed Hold Policy for hospitalization s undated, states Prior to and upon a transfer, written information will be given to the residents and/or the resident representatives that explains in detail: the rights and limitations of the resident regarding bed-holds, The reserve bed payment policy as indicated by the state plan, the facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid residents). Resident #28 was admitted on [DATE] with diagnoses to include stage 3 chronic kidney disease. On 6/11/24 Resident #28 was transferred to an acute care hospital for evaluation and was subsequently admitted . Review of Resident #28's clinical record lacked evidence that a written notice bed hold was provided to the resident and/or resident representative. On 6/11/24 at 11:44 a.m., during an interview, the Director of Nursing confirmed above findings.

Based on observation and interview the facility failed to provide maintenance services necessary to maintain a sanitary and comfortable interior on 2 of 3 units observed (100 and 200 units). Findings: During a facility tour on 6/12/24 between 8:31 a.m. and 8:55 a.m , the Director of Operations confirmed the following: 100 Unit the following was observed: -room [ROOM NUMBER] the bathroom had dead bugs/debis in the light fixture -room [ROOM NUMBER] entrance was missing the threshold -room [ROOM NUMBER] had approximately 4 feet section of baseborad trim missing left of the window 200 Unit the following was observed: -room [ROOM NUMBER] the sink was dripping and plugged up causeing pooling water in the sink. -room [ROOM NUMBER] the sink had a steady leak.

Based on facility policy, record reviews and interview the facility failed to provide a written Notice of Transfer or Discharge to resident and/or resident representatives for 1 of 6 residents reviewed for hospitalization (Resident #28). In addition, the facility failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfers for 2 of 6 residents reviewed for hospitalization s (Resident's #28 and #2). Findings: Review of facility policy Transfer and Discharge Policy undated, states .Notice of discharge shall be provided to the resident and resident representative: when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer shall be provided to the resident and resident representative as soon as practicable, A list of resident who transferred out for the facility is provided to the state ombudsman on a monthly basis . 1. Resident #28 was admitted on [DATE] with diagnoses to include stage 3 chronic kidney disease. On 6/11/24 Resident #28 was transferred to an acute care hospital for evaluation and was subsequently admitted . Review of Resident #28's clinical record lacked evidence that a written notice of transfer/discharge was provided to the resident and/or resident representative. Further review lacked evidence the facility provided notice of this discharge to Office of the State Long-Term Care Ombudsman. 2. Resident #2 was admitted to facility on 5/9/24 with diagnoses to include acute respiratory failure with hypoxia, chronic systolic heart failure, and atrial fibrillation. On 6/1/24 Resident #2 was transferred to an acute care hospital and subsequently admitted . Review of Resident #2's clinical record lacked evidence that a written notice of transfer/discharge was provided to Office of the State Long-Term Care Ombudsman. On 6/11/24 at 11:43 a.m., during an interview, the Director of Nursing confirmed above findings.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 4 of 14 residents that were reviewed for new admissions. (#190, #196, #2 and #28) Findings: 1. Resident #190 was admitted to the facility on [DATE]. The hospital discharge summary included information that the resident was admitted with diagnosis of COVID-19, Atrial flutter requiring anticoagulant medication and a Coronary Artery Bypass Graft (CABG) on 5/24/24 which required Epicardial pacing wires. The discharge instructions stated, Epicardial pacing wires: prepped and cut on day of discharge. Instructions: you had temporary epicardial pacing wires placed during surgery and utilized in the post-operative period. These rest on the surface of your heart and allowed us to temporarily control your heart rate. These wires exited the skin just below your ribcage and were cut at the time of discharge. These wires should no longer be visible . Do NOT pull these wires. Incision: Keep your incision dry. No bathing, whirlpool tub, or swimming for 3 weeks. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #190's immediate health and safety needs for the above concerns. 2. Resident #196 was admitted to the facility on [DATE]. The hospital discharge summary included information that the resident was admitted with diagnosis of left hip prosthetic joint infection requiring intravenous antibiotics via a peripherally inserted central catheter line. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #160's immediate health and safety needs for the above concerns. On 6/12/24 at approx. 10:55 a.m., during an interview, the above was discussed with the Registered Nurse Admission Coordinator. 42531 3. Resident #2 was admitted to facility on 5/9/24 with diagnoses to include acute respiratory failure with hypoxia, type 2 diabetes mellitus, chronic systolic heart failure, atrial fibrillation, and malnutrition. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #2's immediate health and safety needs for the above concerns. 4. Resident #28 was admitted on [DATE] with diagnoses to include chronic kidney disease stage 3, benign prostatic hyperplasia with lower urinary tract symptoms and history of multiple urinary tract infections requiring use of prophylactic antibiotics. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #28's immediate health and safety needs for the above concerns. On 6/11/24 at approximately 11:21 a.m., during and interview, the above was discussed with Director of Nursing

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to end of Skilled services for 1 of 3 residents whose Medicare Part A Skilled services were discontinued (Residents #26). In addition, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form 10055, which included appeal rights and liability of payment was provided at least two days prior to a resident's last covered day for 2 of 3 residents whose Medicare Part A services were discontinued and remained in the facility (#26 and #32). Findings: 1. Resident #26's NOMNC indicated that the resident's Medicare Part A services would end on 1/25/24 and was signed by residents Guardian on 1/24/24, one day prior to end of skilled services. The medical record lacked evidence that Resident #28's legal guardian was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. 2. Resident #32's Medicare Part A coverage for skilled services ended on 5/16/24. The medical record lacked evidence that Resident #32 or his/her legal representative was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. On 6/11/24 at 11:43 a.m., during an interview, the Director of Quality and Compliance confirmed the above.

Based on observations and interviews, and document review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the wall mounted fan over the dish area, standing fan just outside the dish area, and ceiling. Additionally, the walk-in freezer floor was not maintained in clean and sanitary manner, and the reach-in refrigerator had uncovered, undated, and unlabeled food; the reach-in freezer had open bags of food; and all temperature logs were lacking complete documentation of temperature tracking, all of which has the ability to affect all residents in the facility. Findings: On 1/30/2024 at 8:05a.m. during a tour of the kitchen with morning cook the following was observed: 1. Two fans, one above the dish area and the other outside the dish area heavily soiled with dirt and debris. 2. Uncovered, unlabeled, and undated food in the reach-in refrigerator. 3. Open bag of frozen food in the reach-in freezer. 4. Moderate to heavy amounts of dirt and hanging from ceiling above clean dish area. 5. All current temperature logs lacking documentation for the last two days. On 1/30/2024, at 8:25a.m. observation of the Mere Point Unit kitchen, it was found to be lacking documentation of monitoring the unit refrigerator and freezer for 6 of 30 days. On 1/30/2024, during review of past temperature monitoring logs, the following was found: September 2023 -Sandwich Unit, Main Kitchen (ID#15) lacking documentation for 17 of 30 days. -Walk-in Freezer, Main Kitchen (ID#1) lacking documentation for 17 of 30 days. -Walk-in Refrigerator, Main Kitchen (ID#2) lacking documentation for 18 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#3) lacking documentation for 18 of 30 days. -Single Door Refrigerator, Main Kitchen (ID#5) lacking documentation for 17 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#6) lacking documentation for 17 of 30 days. -2-Door Freezer, Main Kitchen (ID#7) lacking documentation for 17 of 30 days. October 2023 -Sandwich Unit, Main Kitchen (ID#15) page missing (31 of 31 days) -Single Door Refrigerator, Main Kitchen (ID#5) lacking documentation for 14 of 31 days. -2-Door Refrigerator, Main Kitchen (ID#6) lacking documentation for 14 of 31 days. -2-Door Freezer, Main Kitchen (ID#7) lacking documentation for 4 of 31 days. November 2023 -Sandwich Unit, Main Kitchen (ID#15) lacking documentation for 12 of 30 days. -Walk-in Freezer, Main Kitchen (ID#1) lacking documentation for 2 of 30 days. -Walk-in Refrigerator, Main Kitchen (ID#2) lacking documentation for 2 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#3) lacking documentation for 2 of 30 days. Single Door Refrigerator, Main Kitchen (ID#5) lacking documentation for 2 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#6) lacking documentation for 2 of 30 days. -2-Door Freezer, Main Kitchen (ID#7) lacking documentation for 7 of 30 days. December 2023 -The facility was unable to find any documentation of any equipment for the month of December, but the manager stated that he knows they were being done. January 2024 -Sandwich Unit, Main Kitchen (ID#15) no page for this unit was found -Walk-in Freezer, Main Kitchen (ID#1) lacking documentation for 2 of 30 days. -Walk-in Refrigerator, Main Kitchen (ID#2) lacking documentation for 2 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#3) lacking documentation for 2 of 30 days. -Ice Cream Chest, Main Kitchen (ID#4) lacking documentation for 2 of 30 days -Single Door Refrigerator, Main Kitchen (ID#5) lacking documentation for 2 of 30 days. -2-Door Refrigerator, Main Kitchen (ID#6) lacking documentation for 2 of 30 days. -2-Door Freezer, Main Kitchen (ID#7) lacking documentation for 2 of 30 days. On 1/30/2024 at 8:45a.m. by request of the Administrator, there was a second visit to the kitchen so that she could see the issues. When that visit was complete the above findings were confirmed with the Dietary Manager, the Director of Facilities and the Administrator.

Based on observations and interview facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 3 days of the survey. And failed to ensure dented soup cans were taken out of circulation for use for 1of 1 kitchen tour. Finding: On 3/13/23, at 9:10 a.m. - During the initial tour of the kitchen with the lead cook, the following was observed and confirmed: three stained ceiling tiles in the entry just above the dessert table, and the wall mounted fan just inside the entry was covered with a moderate amount of dust and debris. On 3/15/23 at 7:45 a.m. - During the return observation of kitchen, the following was observed: side intake vent of the ice machine covered with a heavy amount of dust and debris, and two large cans of tomato soup that were dented, stored in area that indicated the tomato soup was available for use. On 3/15/23 at 8:10 a.m., in an interview with the Lead Cook the surveyor confirmed the observation of dust and debris on the side intake vent of the ice machine, and dented tomato soup cans remained stored in an area that indicated the soup was available for use.

Based on record review, and interview, the facility failed to follow its own fall policy in completing a neurological assessment for 1 of 1 resident reviewed for an unwitnessed fall (#1). Finding: During a review of the medical record, on Friday, 4/29/22 at approximately 10:15 a.m., Resident #1 was found on the floor. The nursing assessment showed Resident #1 to have abrasions on his/her forehead with superficial bleeding. The wound was cleaned and bandaged, and ice was applied. The resident's [family member] was notified of the incident. Resident #1 was admitted to the facility in late December of 2021 with diagnosis of vertebral artery dissection, essential (primary) hypertension, basal cell carcinoma of skin of other parts of face, mild impairment of uncertain or unknown etiology. Resident #1 was admitted to the facility from independent living for skilled therapy services to address recurrent falls and weakness. A review of the Physical Therapy discharge summary of Wednesday, 3/9/22, stated the resident had progressed to ambulating with supervision during gait with assistive device (rolling walker). On Monday, 5/2/22 the Medical Director made the decision to send Resident #1 to the emergency room after he/she was complaining of increased pain and stiffness in his/her neck. On Tuesday, 5/3/22 a CAT scan revealed that Resident #1 had a C2 fracture and was transferred to Maine Medical Center. On Thursday, 5/12/22, Resident #1 returned to the facility with an Aspen Collar in place. Resident was on cervical precautions and was scheduled for Physical Therapy. The facility's Fall Protocol, dated August 2021 indicates after all falls nurse must complete and document an initial assessment and document vital signs at these intervals: 15 minutes times 4; every 30 minutes times 2; every hour times 2; once per shift for 72 hours. A fall that is unwitnessed, or in which the head is struck, requires the addition of neurological checks at the same intervals as above: orientation to person, place and time, strength of extremities, eye and pupil response. Any change in resident condition requires a a phone call to the primary care physician (e.g. facial droop, behavior changes, or weakness on one side). There was no documentation in the clinical record of Resident #1 that neurological checks had been initiated and monitored in accordance with the facility's policy after the fall that occurred on 4/29/22. On 3/16/23 at approximately 11:50 a.m., during an interview with the Administrator, the surveyor confirmed there was no evidence of neurological checks conducted and monitored in accordance with the facility's policy after Resident #1's unwitnessed fall in April of 2022. As a result of the the facility investigation into the unwitnessed fall, the following corrective actions were initiated; -Mandatory Nurse Staff Meetings were scheduled immediately, and took place on both 5/5/22 and 5/6/22 to review policies and procedures as follows: -Education and review of Fall Protocol including notification of physician required neurological checks was conducted. -Education and review of the importance of good shift to shift communication. -Education and review of the importance of doing a fall assessment and documenting interventions on the care plan. -Discussion of all falls will take place within the past 24 hours and to be discussed at Leader Huddle every morning to ensure that the fall protocol is being followed and necessary action steps are taken. -Mandatory Staff Education was provided and completed on 5/6/22. Attendance sign-in sheets completed. Training and education is ongoing. -Root Cause Analysis was completed.

Based on immunization record review, review of the facility's immunization policy, and interviews, the facility failed to implement its Pneumococcal and COVID Vaccination Policy for 3 of 5 residents whose immunization records were reviewed (#1, #25, #28). Findings: The facility's Pneumococcal and COVID Vaccination Policy, with a revision date of 5/21, indicated in section I. Policy, Patients and residents on the skilled and long-term care communities will be assessed for appropriate administration of pneumococcal vaccines. Section III, Purpose, To offer patients/residents with vaccination PCV 13 (Pneumococcal Conjugate), PPSV23 (Pneumococcal [MEDICATION(S)]), and COVID-19 vaccine, according to CMS regulations and Centers for Disease Control (CDC) guidelines. Section IV. Procedure, A. Pneumococcal Vaccines: 4. Long-term care residents will be assessed for prior PCV13 (Pneumococcal Conjugate) vaccination and offered the PCV13 vaccine if appropriate. The CDC Vaccine Information Statement (VIS) for the Pneumococcal Conjugate Vaccine (PCV13), brand name Prevnar, dated 10/30/19, indicated, This vaccine may be given to adults [AGE] years or older based on discussions between the patient and health care provider. -On review of Resident #1's clinical record, the surveyor noted in the Electronic Charting System - Immunizations, [MEDICATION(S)] (PPSV23) - 2/21/12. The surveyor could not locate evidence indicating whether the PCV13 vaccine was offered. -On review of Resident #25's clinical record, the surveyor noted in the Electronic Charting System - Immunizations, [MEDICATION(S)] (PPSV23) - 10/15/10. The surveyor could not locate evidence indicating whether the PCV13 vaccine was offered. -On review of Resident #28's clinical record, the surveyor noted in the Electronic Charting System - Immunizations, [MEDICATION(S)] (PPSV23) - 4/11/18. The surveyor could not locate evidence indicating whether the PCV13 vaccine was offered. On 8/3/21 at 10:45 a.m., in an interview with the surveyor, the facility's Infection Preventionist, stated she is focusing on all residents receiving the [MEDICATION(S)] (PPSV23) vaccine first. On 8/4/21 at 11:50 a.m., in an interview, the Director of Nursing confirmed that Prevnar (PCV13) has not been routinely offered. The Director of nursing stated that in a previous discussion, the facility's leadership thought that providing [MEDICATION(S)] (PPSV23) would meet the requirements and streamline the process of providing immunizations.

Based on record review and interviews, the facility failed to assess and monitor a resident after a fall, and failed to follow their own Fall Protocol and Fall follow up worksheet by containing neurological assessments post a resident who obtains an unwitnessed fall for 1 of 2 sampled residents. (Resident #6). Findings: Facilities Fall protocol, created 3/2019, under the section Procedure indicated the Registered Nursing Staff will: #5 A fall that is unwitnessed, or in which the head is struck, requires the addition of neurological checks - orientation to person, place and time, strength of extremities, eye and pupil response. Facilities Fall follow up worksheet instructs nursing to obtain a set of vitals and neurological checks after an unwitnessed fall; every 15 minutes x4, then every 30 min x2, then every hour x2 and once per shift x72 hours. Resident #6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/21 during review of residents #6's medical record under nursing notes stated the following: - On 5/23/21 Resident #6 had an unwitnessed fall and was found on the floor. The initial neuro check: stated pupils equal, round and reactive to light, with the action to continue to observe. The medical record lacked evidence of further neurological assessments and/or fall follow up worksheet completion after this fall. - On 6/14/21 Resident #6 had an unwitnessed fall and was found on the floor. The record lacked evidence of any neurological assessments being completed after the fall. Review of the fall follow up worksheet contained only vitals. - On 6/17/21 Resident #6 had an unwitnessed fall and was found on the floor. The initial neuro check: stated pupils equal, round and reactive to light with the action to continue to observe. Review of the fall follow up worksheet contained a total of 2 neurological assessments completed and 4 sets of missing vitals. - On 7/10/21 Resident #6 had an unwitnessed fall which was self-reported by the resident. The medical record lacked evidence of further neurological assessments and/or fall follow up worksheet completion after this fall. - On 8/1/21 at 10:31 p.m., Resident #6 had an unwitnessed fall and was found on the floor. The initial neuro check: stated pupils equal, round and reactive to light, with the action to Orders received. Transfer to ER for further eval d/t pt is on [MEDICATION(S)]. He/she returned to the facility early that morning. The medical record lacked evidence of further neurological assessments and/or fall follow up worksheet completion after this fall. On 8/4/21 at 11:05 a.m., during an interview with the Director of Nursing she stated, after a resident has an unwitnessed fall, nursing is to obtain frequent neurological checks following the Fall follow up worksheet. At this time, the surveyor confirmed the lack of neurological checks for the above unwitnessed falls.

Based on interview and observation, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 2 kitchen tours on 1 of 4 days of survey. Findings: On 8/2/21 at 11:00 a.m., during a second tour of the kitchen, a surveyor observed the following: -The wall air conditioner was dirty/dusty. -Moderate dust/dirt on external pipes behind the ice machine and oven warmer. -Vent facing the hot food prep table with black debris. -Vent in ceiling near the 3-bay sink with moderate dust build-up. -Moderate dust build-up on pipes behind the fan near the dish wash room. -Heavily chipped paint on the pole between the two tables in the hot food prep area. -Heavy dust build-up on the sprinkler head above the hot food prep table. On 8/2/21 at approximately 11:30 a.m., the surveyor confirmed the above observations in an interview with the Food Services Director.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 3 medication carts (300's) inspected and 1 of 1 medication rooms for 1 of 4 days of survey. Findings: 1. On 8/2/21 at 11:15 a.m., during observation of unit 300's medication cart with the Certified Nurses Aid- Medication Technician (CNA-M), the surveyor observed the following expired medications available for use: - A bingo card of [MEDICATION(S)] 0.125 milligram (mg) tabs, 13 tabs remaining with expiration date of 3/17/21. - A bingo card of [MEDICATION(S)] 40mg tabs, 10 tabs remaining with expiration date of 11/18/20 At this time, the CNA-M confirmed the expired medications should have been removed for supply. 2. On 8/2/21 at 11:44 a.m., during observation of the medication room with the Registered Nurse (RN) Care Coordinator, the surveyor observed the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - 2 unopened bottles of [MEDICATION(S)], acetaminophen aspirin (NSAID) and [MEDICATION(S)] with expiration date of 6/21. - 1 unopened bottle of [MEDICATION(S)] 50 mg with expiration date of 7/21 At this time, the surveyor confirmed the expired medications stored in an area available for use, in an interview with the RN. On 8/2/21 at approx. 3:40 p.m., a surveyor confirmed expired medication remaining available for use in an interview with the Administrator.

Based on record review, observations and interview, the facility failed to ensure that a care plan was developed for the use of a wander/elopement alarm for 1 of 1 sampled resident reviewed for wandering. (#2) Finding: Resident wandering and Elopement Prevention Policy and Procedure, reviewed 12/2018. Section 4 under Assessment of Patients/Residents at Risk of Elopement indicated The patients/residents care plan will indicate they are at risk for elopement or other safety issues and Interventions to try to maintain safety will be included in the patients/residents care plan Resident #2's Minimum Data Set (MDS) 4.0 Quarterly assessment, dated 11/17/20 and 2/9/21 and the Annual MDS 4.0 Annual assessment dated [DATE], under section P0200 is checked to indicate Resident #2 has a wander/elopement alarm. Review of resident #2's wander/elopement assessment dated [DATE] indicated resident had no history of elopement, wander guard on for safety. Safety management interventions dated 8/18/20, 11/15/20, 2/9/21 and 4/29/21 state a wander/elopement alarm is used. On 8/2/21 at 11:04 a.m. and 2:04 p.m., Resident #2 was observed to have a wander guard bracelet on his/her right ankle and wandering independently, back and forth, throughout the Mere Point hallways. On 8/3/21 at 8:09 a.m. and 10:33 a.m., Resident #2 was observed wandering Mere Point hallways and dining room with a wander guard to his/her right ankle. From 4/28/20 through 8/4/2021 Residents #2's care plan lacked evidence of a wander/elopement risk and/or safety issues with intervention and goals. On 8/4/21 at 12:56 p.m., the above findings were confirmed with the Director of Nursing.