Every finding on record at Rumford Community Home

Based on interviews and record review, the facility failed to ensure the facility was Administered in a manner that enabled residents to attain or maintain their highest practicable well-being when facility was aware of Certified Nurses' Aides provided pressure ulcer wound care. In addition, the facility failed to follow their Root Cause Analysis Action plan for when untrained CNA's provided CPR (Cardiopulmonary Resuscitation) to a resident. This has the ability to affect all 29 residents residing at the facility.Findings:1. On [DATE] the Division of Licensing and certification received an anonymous complaint stating a CNA was at the nurse's station on [DATE] discussing how he/she provided wound care on [DATE]. On [DATE] at 7:35 a.m., during an interview with anonymous CNA#1, he/she stated that on [DATE] a CNA discussed how they performed wound care the night before. Anonymous CNA#1 stated that the Director of Nurses (DON) was sitting at the nurse's station during this conversation and did not say anything.On [DATE] at 7:40 a.m., during an interview with anonymous CNA #2, he/she stated I have provided wound care to residents here at this facility. The CNA then stated he/she has reported this to the DON and the facility Administrator.On [DATE] at 2:00 p.m., in another interview with anonymous CNA #2 and 3 surveyors present, he/she states they have been providing wound care at this facility since 2023. He/she states he/she was doing wound care for the DON. During this interview he/she states I have gone to the DON and Administrator for wound care supplies.On [DATE] at 1:27 p.m., during an interview with the DON, Administrator, and 2 surveyors present, the Administrator stated that she remembers a CNA coming to her and informing her that they are being asked to perform wound care. The DON and Administrator informed the CNA that wound care is not in their scope of practice. When asked if they investigated the concern, the Administrator stated it was not looked into any further. When the surveyors asked how long ago this happened, the Administrator stated this occurred a few months ago (see F726).2. On [DATE] during interview, a surveyor was informed on [DATE] a resident became unresponsive and required CPR and AED (Automated External Defibrillator) use by 2 non-CPR certified CNA's. No licensed nurse assessed the resident or dictated the code. (See F726).A review of the facilities Root Cause Analysis (RCA) revealed an Action Plan that stated they will review code/CPR policy, Ensure all licensed staff have active CPR certificates, Consider getting as many other clinical staff certified as we only have 1 licensed nurse on during shifts, ensure AED is working, re-education staff on code/CPR responsibilities, and after re-education is completed complete mock codes as part of QAPI process. A review of facility emails between [DATE] and [DATE] indicated the facility was working on completing 2 CPR courses for clinical staff. Further review of facility records lacked evidence that this occurred.Facility records lacked evidence that mock codes were conducted per the facilities Action Plan.Facility records lacked evidence that the facility moved forward with this action plan.On [DATE] at 11:50 a.m., in an interview with the Facility Administrator and Director of Nursing, the above information was confirmed.

Based on record review, interviews, and facility policy, the facility failed to provide Pressure Ulcer wound care by competent staff when pressure ulcer dressing changes were completed by three Certified Nurses Aides(CNA's) for 2 of 8 residents with wounds. (Resident ID #3, #2) In addition, the facility failed to follow the facility CPR (Cardiopulmonary Resuscitation) policy and provided CPR along with AED (Automated External Defibrillator) use by 2 non-CPR certified CNA's to a resident who may not have required CPR. This has potential to cause harm to 1 of 6 residents residing in the facility who are full codes. (Resident #4). Findings:1. On [DATE] the Division of Licensing and Certification received an anonymous complaint stating on [DATE] a CNA was at the nurse's station discussing how he/she provided wound care for [Resident #3] on [DATE]. The anonymous complainant stated this is not in CNA's scope of practice.On [DATE] at 7:35 a.m., during an interview with anonymous CNA #1, stated that on [DATE], a CNA discussed how they performed wound care the night before. The anonymous staff stated that the Director of Nursing (DON) was sitting at the nurse's station during this conversation and did not say anything.On [DATE] at 7:40 a.m., during an interview with anonymous CNA #2, stated I have provided wound care to residents here at this facility. CNA #2, confirmed he/she provided wound care to [Resident #3] wounds on his/her coccyx and one on the leg. The CNA discussed how the wound on [Resident #3'] coccyx is black and the one on the leg is pretty deep, but it's not wide. The CNA then stated he/she cleans the wounds with saline and gauze and apply Mepilex to them. CNA #2 stated she gets the wound care supplies from the Registered Nurse (RN) #1 and stated the RN#1 often asks him/her to provide wound care to residents as the RN claims to not know how to do the wound care. CNA #2 , stated RN #1 has him/her do all of the treatments on residents. The CNA confirmed he/she has never been provided with training for wound care. The CNA adds he/she also preforms wound care on [Resident #2] coccyx pressure ulcer. CNA #2 stated care for Resident #2 consists of using saline wash, a blue bottle wash, applying a fiber glass substance, and then covering it with a band aid. During the interview, the CNA stated he/she has previously reported doing wound care to the Director of Nursing (DON) and the Facility Administrator.On [DATE] at 2:00 p.m., in a second interview with anonymous CNA #2 and 3 surveyors present, he/she states they have been providing wound care at this facility since 2023. He/she states they remember providing wound care to [Resident #5]. He/she states I was doing wound care for the DON. During this interview he/she states I have gone to the DON and Administrator for wound care supplies on Resident #5. He/she remembers Resident #5's wound care being very tedious.On [DATE] at 8:10 a.m., during an interview with anonymous CNA, who stated they know about CNA's going out of their scope of practice by providing wound care to residents. He/she stated the DON knows about this occurring. He/she states CNA's cannot be doing this stuff as it is out of their scope of practice.On [DATE] at 8:30 a.m., during an interview with anonymous CNA #1 who states he/she has gone out of his/her scope of practice often by providing wound care. Stating he/she will do Resident #2's dressing changes on his/her bottom by cleaning it, applying collagen to it, then applying a material to it, and then putting on a Mepilex dressing. When ask who directs him/her to provide wound care, he/she states RN #1 tells him/her to. He/she adds that they do this often and the nurses do not assess the wounds at that time.On [DATE] at 9:45 a.m., during an interview with anonymous CNA #3 who discussed that he/she is asked often to perform dressing changes to wounds.On [DATE] at 10:15 a.m., during an interview with Resident #2 (Brief Interview for Mental Status (BIMS) of 13, indicating cognitively intact) stated when RN #1 is on she does not know what to do wound care, so she has a CNA do my wound care.Resident #2's clinical record revealed the following:- wound assessment completed on [DATE] by a Nurse Practitioner, indicated that Resident #2 has a Stage 3 Pressure Ulcer to his/her right buttock and a Stage 3 Pressure Ulcer to his/her left buttock. Review of Resident #2's provider orders dated [DATE], Pressure ulcer wound care to left and right buttocks: cleanse with vache gauze (soak 3-5 minutes), apply calcium alginate. Cover all with silicone foam boarder dressing every day shift Tuesday, Thursday, Sunday, and as needed.- Previous wound order, dated [DATE], provider ordered Pressure ulcer wound care to right buttock (right buttocks)/sacral region: cleanse with vache gauze (soak 3-5 minutes), apply calcium alginate. Cover all with silicon foam boarder dressing every day shift and as needed, Order discontinued on [DATE].- wound order, dated [DATE] stated Pressure ulcer wound care to right buttock/sacral region: cleanse with vache gauze, apply collagen to wound beds, calcium alginate to deepest wound. Triad cream to entire area including new skin. Skin prep to peri wounds, cover all with foam boarder dressing everyday shift and as needed, Order discontinued on [DATE].During review of Resident #3's medical record the following was revealed; a nursing progress note dated [DATE], Posterior right knee wound appears larger. Wound bed open and bone visible. Had large amount of thick green drainage. Another nursing progress note dated, [DATE] Upon assessment unstageable pressure ulcer is present on the coccyx/sacrum. Surrounding skin to wound is purple-like-color- Kennedy ulcer presentation.measures 2 cm(centimeters)x3cmx0.2cm. A physician order dated [DATE] Unstageable pressure ulcer to coccyx: cleanse with NS (normal saline), apply Aquacel ag, skin prep peri wound, cover with boarder dressing change every Tuesday, Thursday, Sunday, and as needed. physician order dated [DATE] Cleanse open area to right knee with wound cleanser, pat dry, apply calcium alginate and cover with foam boarder change every Tuesday, Thursday, Sunday, and as needed.On [DATE] at 1:27 p.m., during an interview with the DON, Administrator, and 2 surveyors present, the above information was discussed and confirmed. At this time, the Administrator stated that she remembers a CNA coming to her and informing her that they are being asked to perform wound care. The DON and Administrator informed the CNA that wound care is not in their scope of practice. When asked if they investigated this, the Administrator stated it was not looked into any further. When the surveyors asked how long ago this happened, the Administrator stated this occurred a few months ago.Board of Nursing, Chapter 5, Regulations Relating to Training Program and Delegation by Registered Professional Nurses of Selected Nursing Tasks to Certified Task to Certified Nursing Assistants. Section 1,.A.1.No task shall be delegated that is not listed in the Skills Checklist of the Prescribed Generalist Curriculum for Nursing Assistant Training Programs. Chapter 5 Section1, A.3 - No task shall be delegated that is not listed in the Skills Checklist of the Prescribed Generalist Curriculum for Nursing Assistant Training Programs.State of Maine Certified Nursing Assistant Curriculum indicates what is allowed for Care of Patients Skin includes only, apply topical creams, lotions, ointments, apply band aid/4x4 gauze, and skin protectants.2. Resident #4 admitted to facility on [DATE]. Minimal Data Set(MDS) 3.0 admission Assessment, admission Reference Date (ARD) is [DATE]. Section I, I5400 coded yes for Seizure Disorder. Hospital Discharge Documentation, dated [DATE], states Code Status: Full code, history of epilepsy. Discharge diagnoses to include altered mental status, DKA (diabetic ketoacidosis) hypovolemia and UTI (urinary Tract infection) stage iii pressure ulcer left glute, stage II lumbar back, DMII. Atrial fibrillation Chronic, stable Pacemaker.On [DATE] at 7:40 a.m., during an interview with CNA #2, stated that a few months ago ([DATE]), a bladder scan was being conducted on Resident #4 by a Registered Nurse (RN). During the bladder scan, the CNA observed the resident having Seizure like activity and informed the RN, but nothing happened. The CNA stated that all staff left the resident's room (2 CNA's and a RN). Shortly after CNA #2 came into the room and observed resident unresponsive. He/she called out for help and a CNA and Certified Residential Medication Aid (CRMA) arrived. He/she stated they also facetimed (video chat app) a Medication Technician (MT), who was not in facility at the time, who told them to start compressions, so he/she started compressions while another CNA applied the AED. The AED advised a shock, so we shocked. CNA then resumed compressions. He/she stated that he/she was yelling at the MT to help me help me get through this. The CNA stated the RN never came down to assess the resident during this time.On [DATE] at 9:45 a.m., during an interview with CNA #3, who confirmed that earlier in the shift ([DATE]) the RN preformed a bladder scan on Resident #4, during the scan him/her and another CNA observed the resident having seizure like activity. He/she stated they informed the nurse and then left the room to pass meal trays. Shortly after, he/she heard another CNA yell for help. Upon arrival they checked for a pulse, didn't find one, the other CNA started compressions while he/she applied the AED. The AED advised a shock, so they shocked the resident and then the other CNA resumed compressions. He/she stated the AED did not advise another shock as the resident's pulse came back. At no point did the RN come down to assess the situation or the resident.On [DATE] at 9:40 a.m., during an interview with the Primary Physician and 3 surveyors present, he stated that he would expect the licensed professional to make a clinical evaluation and assess the residents need for CPR.On [DATE] at 1:00 p.m., during an interview with RN #2 and 2 surveyors, she stated that her and the CNA's went into Resident #4's room to change residents brief and obtain a bladder scan. During the bladder scan 2 CNAs informed her that the resident had seizure like activity, but the RN stated she did not witness it. She stated that the resident was alive when she left the room. RN #2 stated later that evening she heard someone yelling her name, saw a Med-tech run down the hall, and witnessed a CNA performing a sternal rub on Resident #4 while another CNA applied the AED. She then informed the CNAs to wait a minute as the resident was breathing and his/her eyes were fluttering. One CNA told another CNA to call 911. The CNA who called 911 yelled down the hall to her asking what he/she should say to dispatch. The RN then left the room and went to the nurses station to talk to 911 and get her stethoscope. Per the RN, by the time she got back to the room, the ambulance had arrived. The RN then called the family of Resident #4 where she was informed that the resident had a history of seizures. She stated she was not impressed as the residents history of seizures was not indicated in their chart. When the surveyor asked the RN why she left the room while CPR was occurring, the RN stated that they were not doing CPR, they were doing sternal rubs. The RN then stated she did not feel like CPR and AED was necessary from what she could see (eyes fluttering, resident turning his/her head, he/she had a pulse and a heartbeat). The RN stated it was possible she had a seizure, but did not think the resident coded.On [DATE] at 5:50 p.m., during an interview with the Emergency Medical Technician (EMT), who responded to the code on [DATE], stated upon arrival, no nurse was found. The EMT stated they were just dealing with the CNAs, who were very upset, but gave a competent report about the resident's history and the situation that occurred. The EMT adds that the nurse refused to come down and see the resident.A review of the facilities root cause analysis stated the following: -On [DATE] at approximately (approx.). 4:45 p.m., 2 CNA's noted possible seizure activity (Resident's head dropped backwards, eyes rolled to the back of head, and resident started shaking). CNA#1 alerted RN#2 who was in the room, but she did not assess the resident. They all left the room, leaving Resident #4 unattended. - At approx. 5:18 p.m., CNA #2 entered the room and observed Resident #4 blue and not breathing. CNA #1 initiated sternal rub, and there was no response or pulse noted. -CNA#2 called Med Tech (who was on lunch break in his/her car) via facetime for guidance and Med Tech said to get the AED (Automated External Defibrillator) and started driving back to the facility. -CNA#3 heard the call for help and came from another unit to help. CNA#3 went to get a CRMA from another unit. CNA #3 then obtained the AED and placed the pads on Resident #4. The AED advised a shock, which was initiated. CNA#3 noted Resident #4 started breathing and the color returned to his/her face. Approximately 5 minutes later RN (who had been at nurses station) and Med Tech (returned from break) entered the room together. There is no documentation as to where the AED pads were placed, as Resident #4 has an implanted pacemaker. -Emergency Medical Services (EMS) arrived at approximately 5:25 p.m.Review of witness statements dated [DATE] stated the following: -At approx. 5:18 p.m., CNA#2 went in room and noted Resident #4 was completely blue, CNA#2 yelled for the nurse (who was sitting at nurses' station) stating I need help with [Resident #4]. - CNA#2 rubbed his/her chest to try to get him/her to come too, while yelling out for help. CNA#3 came in, the room RN came to room looked at Resident #4 and walked out of the room to nurses station. -CNA#2 yelled is she a full code, RN yelled from nurses' station yes. -CNA#3 ran for AED, located in hallway by nurses' station where RN was sitting. CRMA came from another unit to help. - CNA#2 called Med Tech on telephone via facetime asking for guidance. Med Tech gave ok to initiate CPR. CNA #2 started CPR while CNA#3 placed AED pads, and a shock was indicated. CNA#2 continued CPR. - RN came down to the room at the same time the Med tech returned to the building. -EMS arrived at 5:28 p.m.Ambulance service notes dated, [DATE] at 5:28 p.m. state EMT's arrived after CPR finished. EMS noted that CNA #1 informed them the resident seized and became unresponsive, compressions were started and a shock was delivered. Due to staff being upset, EMT's were unable to gain information about the resident's baseline. The note included that the nurse called the residents' daughter, who informed them that the resident had a history of seizures. When EMT's asked the nurse why seizure disorder is not listed in the residents past medical history (from this facility), the nurse informed them that she did not know. Hospital Emergency Department provider notes, dated [DATE] indicated: Patient arrived via EMS, resident awake but in a post-ictal state (recovery period that occurs immediately after an epileptic seizure). EMS believes resident did not arrest but was post ictal from a seizure and the AED advised a shock due to movement that was confused for V-Tach.Hospital Discharge summary, dated [DATE], states [Resident #4] is thought to have seizure, but hard to say if resident in prolonged postictal state but due to being unresponsive, bystander CPR was preformed and a shock was administered. EMS questioned if seizure like activity was confused for V-Tach. No concerns for STEMI.A review of facility CPR certifications revealed that the RN#2, was the only staff on duty at that time who was CPR certified.Review of Automated External Defibrillator (AED) Use & Full code Policy undated states .The facility will maintain readiness to respond to cardiopulmonary emergencies by: Training staff in CRP/AED use .Recognize emergencies and activate Code Blue; Initiate CPR if trained. Licensed Nurses (RN/LPN) Lead code response until EMS arrival; confirmed code status; Direct ADE use and assign roles. Charge Nurse/Supervisor: Ensure emergency equipment readiness; coordinate post-event documentation and debrief.On [DATE] at 7:30 a.m., the above findings were discussed with the Facility Administrator.

Based on interview, record review, and facility policy, 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 1 of 4 residents reviewed for baseline care plans. (Resident #4).Findings: Review of policy Baseline Care Plan Policy and Procedure revised 3/17/23 noted: .The baseline care plan must (i) Be developed within 48 hours of a resident's admission ., (ii) include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a. initial goals based on admission orders, b. Physician orders-Code status, c. dietary orders, d. therapy service e. social service- discharge, f. PASRR recommendations (if applicable).Review of Resident #4's Hospital Discharge Documentation dated 4/13/26 states Code Status: Full code, History of epilepsy. Discharge diagnoses to include altered mental status, DKA (diabetic ketoacidosis) hypovolemia and Uti (urinary Tract infection) Stage iii pressure ulcer left glute, stage II lumbar back, DMII. Atrial fibrillation Chronic, stable Pacemaker.Resident #4, admitted in April of 2026, had a diagnosis to include Epilepsy. Review of Resident #4's baseline care plan dated 4/14/26 lacked evidence of goals and interventions in the area of Epilepsy.On 8/12/26 at 2:55 p.m., in an interview with three surveyors present, the Director of Nursing stated that Resident #4's base line care plan lacked evidence of goals and interventions in the area of Epilepsy.

Based on observations and interview, 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 (East and West) and the laundry room for 3 of 3 facility observations/tours. (4/21/26 and 4/22/26)Findings:1. On 4/21/26 at 10:27 a.m., a surveyor observed a specialized gel cushion stored on the floor by the window. At this time, in an interview with a surveyor, Certified Nursing Assistant (CNA #1) confirmed the finding.2. On 4/21/26 at 10:50 a.m., a surveyor observed a wash basin on the bathroom floor in Resident room [ROOM NUMBER]. At this time, in an interview with a surveyor, CNA #1 confirmed the finding.3. On 4/22/26 from 11:30 a.m. to 12:00 p.m., a surveyor conducted an Environmental Tour with the Maintenance Director in which the following findings were discussed and/or observed. East Unit:- Resident room [ROOM NUMBER] - A privacy curtain was missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER] - A privacy curtain was missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER] - The bathroom had a ceiling tile that had a large brow stain on it. The room wall, above the baseboard heater, had chipped/missing paint creating an uncleanable surface. - The dining room wall, to the right after entering the first door, had dried liquid residue on it. [NAME] Unit:- Resident room [ROOM NUMBER] - There was a wash basin and a clean brief lying on the closet floor.- Resident room [ROOM NUMBER] - A privacy curtain was missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER]- A resident dresser had worn/missing surface finish exposing untreated wood like material creating uncleanable surfaces. There the shared bathroom had a graduated cylinder on top of the toilet that was not labeled. - Resident room [ROOM NUMBER] - A resident dresser had worn/missing surface finish exposing untreated wood like material creating uncleanable surfaces. - Resident room [ROOM NUMBER] - There were two stained ceiling tiles in the room. - Resident room [ROOM NUMBER] - There was one stained ceiling tile in the middle of the room. - Whirlpool room - There were two broken ceiling tiles in the room. Laundry Room:- The cement floor behind the washing machines had chipped/missing paint creating an uncleanable surface. Additionally, the floor was covered with lint and trash. - A laundry cart had untreated wood holding the laundry bin to the wheeled unit creating an uncleanable surface.- There was an approximately five feet by five feet section of wall, to the left of the washing machines, that was missing sheetrock and exposing untreated wooden wall studs creating uncleanable surfaces. On 4/22/2026 at 12:00 p.m., in an interview with a surveyor, the Maintenance Director confirmed the discussed and observed findings.

Based on interviews and record reviews the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 7 of 14 residents whose care plans were reviewed (Resident #1, #5, #6, #7, #15, #27, #29). Findings: 1. Review of Resident #6's clinical record revealed an MDS Quarterly Assessment was completed on 4/13/26. Further review of Resident #6's clinical record revealed that an IDT meeting was held 4/9/26 (prior to completion of the assessment). 2. Review of Resident #29's clinical record revealed an MDS Quarterly Assessment was completed on 4/2/26. Further review of Resident #29's clinical record revealed that an IDT meeting was held 3/31/26 (prior to completion of the assessment). 3. Review of Resident #7's clinical record revealed an MDS Quarterly Assessment was completed on 3/3/26. Further review of Resident #7's clinical record revealed that an IDT meeting was held 2/26/26 (prior to completion of the assessment). 4. Review of Resident #1's clinical record revealed an MDS Quarterly Assessment was completed on 10/17/25. Further review of Resident #1's clinical record revealed that an IDT meeting was held 10/7/25(prior to completion of the assessment). Review of Resident #1's clinical record revealed an MDS Quarterly Assessment was completed on 1/2/26. Further review of Resident #1's clinical record revealed that an IDT meeting was held 1/27/26 which was not within 7 days of the above MDS assessment. 5. Resident #5's medical record contained a quarterly MDS dated [DATE] and an annual MDS dated [DATE]. The record lacked evidence of an IDT meeting being held within 7 days of the above MDS assessments. 6. Resident #15's medical record contained a quarterly MDS dated [DATE], 9/6/25, and an annual MDS dated [DATE]. The record lacked evidence of an IDT meeting being held within 7 days of the above MDS assessments. 7. Resident #27's medical record contained a quarterly MDS dated [DATE], 1/2/26, 10/1/25, and an annual MDS dated [DATE]. The record lacked evidence of an IDT meeting being held within 7 days of the above MDS assessments. On 4/22/25 at 9:25 a.m. during an interview with 4 surveyors the Director of Social Services stated, we have 14 days to have the IDT meeting, and two surveyors reviewed the federal regulation with her regarding the timing. On 4/22/25 at 9:45 a.m. during an interview with four surveyors The Director of Social Services presented an email from the administrator to him/her that states, I accessed the reg (regulation) through the State Operations Manual, Appendix PP. The Care Plan must be reviewed and revised by the IDT after each MDS and show evidence of resident and/or resident representative participation. I am looking through the SOM (State Operation Manual), and it only specifies that the initial IDT needs to be done within 7 days of completion of the MDS, so I think that following the 7-14 days mentioned by your SSD (Social Service Director) would be acceptable. Then the Director of Social Services stated they go by the ARD (assessment reference date) and not the completion date and confirmed the above findings with four surveyors.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 2 days of survey (4/22/26). Findings:Safety Data SheetsPure Bright Germicidal Ultra Bleach4. First Aid MeasuresEye Contact: Immediately flush with plenty of water. After initial flushing, remove any contact lenses and continue flushing for at least 15 minutes.Skin contact: Wash skin with soap and water.Inhalation: Remove to fresh air.Ingestion: Do not induce vomiting. Clean mouth with water and drink afterwards plenty of water. If symptoms persist, call a physician. Micro-Kill Q3 Concentrated Disinfectant, Cleaner & Deodorizer4. First Aid MeasuresInhalation: Remove person to fresh air and keep comfortable for breathing. If experiencing respiratory symptoms: Call a poison center or a doctor. Causes irritation of the respiratory tract. Dizziness. Headache. Skin contact: Take off immediately all contaminated clothing and wash it before reuse. Rinse skin with water/shower. If skin irritation occurs: Get medical advice/attention. Causes caustic burns/corrosion of the skin. Eye Contact: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a poison control center or doctor/physician. Causes serious eye damage. Corrosion of the eye tissue. Permanent eye damage. Ingestion: Rinse Mouth. Do not induce vomiting. Immediately call a poison control center or doctor/physician. Causes burns to the gastric/intestinal mucosa. Diarrhea. Nausea. Vomiting. Odor Control Spray4. First Aid MeasuresInhalation: If breathing is irregular or stopped, immediately seek medical assistance and start first aid actions. Provide fresh air. Skin Contact: Wash with plenty of soap and water. Eye Contact: Remove contact lenses, if present and easy to do. Continue rinsing. Irrigate copiously with clean, fresh water for at least 10 minutes, holding the eyelids apart. Ingestion: Rinse mouth with water (only if the person is conscious). Do not induce vomiting. Oxivir TB Wipes4. First Aid MeasuresEyes: Rinse with plenty of water. If irritation occurs and persists, get medical attention. Skin: No specific first aid measures are required. Inhalation: No specific first aid measures are requiredIngestion: If swallowed: call a poison center or doctor/physician if you feel unwell.On 4/22/26 at 10:41 a.m., two surveyors observed the clean side laundry room door to be ajar. The door was not shut and locked. The two surveyors entered the laundry room and found numerous hazardous chemicals in the room that would be accessible to residents that ambulate and roam in their wheelchairs. The chemicals found were as followed:- One gallon of Pure Bright Bleach( gallon container)- One 32 ounce spray bottle of Micro Kill Concentrated Disinfectant, Cleaner, and Deodorizer - Two 1.8 lb tubs of Diversey Oxivir Tb Wipes - One 8 oz spray bottle of Medline Simply Fresh Odor Eliminator. - One unlabeled spray bottle containing clear liquidDuring an interview with two surveyors present at this time, a laundry aide confirmed that the door does not always shut when leaving the room. On 4/22/26 at 11:00 a.m., in an interview with two surveyors present, the Administrator confirmed that the chemicals in laundry were not stored safely and appropriately to safe guard residents that are confused and ambulate and move about in their wheelchairs. The Administrator went on to say that the door should be shut and locked at all times.

Based on record review and interviews the facility failed to ensure annual performance reviews were completed at least once every 12 months for 3 of 5 Certified Nursing Assistants selected for reviews (CNA) (Staff #2, Staff #4 and Staff #5).Findings:1.Staff #2's was hired 11/1/16. Staff #2's personnel file lacked evidence that an annual performance evaluation was reviewed and signed by CNA #2 in 2024 and 2025.2. Staff #4 was hired 6/20/22. Staff #4's personal file lacked evidence that a performance evaluation was reviewed and signed in 2024 and 2025.3. Staff #5 was hired 12/10/97. Staff #5's personnel file lacked evidence that a performance evaluation was reviewed and signed in 2024 and 2025.During an interview with Director of Nursing and Administrator on 4/22/26 at 11:36 a.m., the DON confirmed that only 3 of the 5 annual reviews were signed by staff. Administrator states they are currently changing the process of annual evaluations because they are done online and they can't see when they are completed.During a follow up interview on 4/22/26 at 11:51 a.m. the Administrator stated it is the supervisor's responsibility to ensure the annual reviews are completed. states they are all completed at the same time.

Based on observations, interviews, and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood system, floors, a small reach-in standing freezer, a grease trap and a large walk-in freezer; and failed to ensure foods were labeled and dated in a walk-in freezer for 1 of 1 kitchen tour for 1 of 2 days of survey. (4/21/26)Findings:The facility's Food Storage policy, dated 2013 noted: Procedure-13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 14. Refrigerated Food Storage-f. All foods should be covered, labeled and dated .15. Frozen Foods-c. All foods should be covered, labeled and datedOn 4/21/26 from 9:00 a.m. to 9:30 a.m., a surveyor completed an initial kitchen tour with a cook in which the following findings were observed:- The cook stove hood system was dusty/dirty. - The small reach-in standing freezer had dried food particles and dried liquid residue on the unit shelving and door shelving. - There was trash and food debris around the entire kitchen floor, under the equipment and under the shelving. - The large walk-in freezer had nine packages of rolls and a tray of hamburger patties that that were not labeled and dated. Additionally, the floor was visibly dirty and had trash on it. - The dish room grease trap cover was rusty around the top edges creating an uncleanable surface. On 4/21/26 at 9:30 a.m., in an interview with a surveyor, the cook confirmed the findings. On 4/21/26 at 9:40 a.m., a surveyor discussed the findings with the Administrator.

Based on observations and interviews, the facility failed to promote care for resident in a manner that maintains the resident's dignity by allowing an uncovered colostomy bag to be seen by passersby for 1 of 2 residents (Resident #1) observed for dignity related to urinary/colostomy bags during 1 of 2 days of survey (4/21/26). Findings:On 4/21/26 at 10:30 a.m., a surveyor observed Resident #1's colostomy bag hanging on the side of the bed, containing brownish/reddish waste, visible from the hallway. At this time, in an interview with a surveyor, Resident #1 indicated he/she would like to have it covered and would be embarrassed if people could see it from the hallway. On 4/21/26 at 10:46 a.m., in an interview with a surveyor, Certified Nursing Assistant (CNA #1) confirmed that Resident #1's colostomy bag containing brownish/reddish waste was visible to passersby in the hallway.

Based on record review and interview the facility failed to notify a provider when a resident verbalized desire to self-harm for 1 of 14 residents reviewed during the survey process (Resident [R]#16).Findings: Resident #16 was admitted in 2019 and has diagnoses to include multiple sclerosis, and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) of 14 of 15 indicating he/she is cognitively intact. Review of Resident #16's clinical record revealed progress note dated 4/14/26 at 8:06 a.m. Behavior Note stating: 'Resident in the dining room for breakfast and was noted to be talking very loudly on the phone. [He/she] was yelling that [he/she] wanted to kill [himself/herself] and that [he/she] did not want to be in this facility anymore. When the cook asked [him/her] if [he/she] needed anything else before [he/she] left the dining room the resident responded, a gun. Per the CNA after this nurse left the dining room [he/she] continued to say[ he/she] wanted to kill [himself/herself] . Further review of R#16's clinical record lacked evidence the nurse notified provider/management was notified of [his/her] statement. During an interview on 4/22/26 at 8:00 a.m., Licensed Practical Nurse (LPN) stated that day Resident #16 was very angry speaking with someone on the phone. {He/she} was getting upset with the other residents in the room. [He/she] stated [he/she] wanted to kill [himself/herself]. [He/she] was removed from the situation and once he/she was in the TV room, he was de-escalated. He/she did not have a plan. It was very short-lived and didn't mention it again. He did say he didn't want to be here and i told him/her that the SW could help him find a new place if that's what he wanted to do. She did notify SW and DON in morning meeting at 8:30 but did not document it. States definitely informed SW and DON because it was part of the same conversation about him wanting to leave and it was all in the same note. During an interview on 4/22/26 at 8:10 a.m., Certified Nursing Assistant (CNA) stated she was made aware of Resident #16's self-harm statement when she arrived for report at 2:00 p.m., When this happens staff are made aware, and they make sure to check on the resident regularly. States he/she used to make the statement regularly a while ago when he/she was angry/mad but has not made the statement in a long time. During an interview on 4/22/26 at 9:01, in presence of three surveyors the Director of Nursing (DON) stated she remembered that day but does not recall nurse stating he/she wanted to harm himself like that. DON states Resident #16 used to make that statement a lot when [he/she] was mad/angry, but it's been a while.

Based on record review and interview the facility failed to update a care plan to include goals and interventions in the area of suicidal ideation for 1 of 14 sampled residents (Resident (R)#16).Findings: Resident #16 was admitted in 2019 and has diagnoses to include multiple sclerosis, and major depressive disorder.Review of Resident #16's clinical record revealed progress note dated 4/14/26 at 8:06 a.m. Behavior Note stating: 'Resident in the dining room for breakfast and was noted to be talking very loudly on the phone. [He/she] was yelling that [he/she] wanted to kill [himself/herself] and that [he/she] did not want to be in this facility anymore. When the cook asked [him/her] if [he/she] needed anything else before [he/she] left the dining room the resident responded, a gun. Per the CNA after this nurse left the dining room [he/she] continued to say[ he/she] wanted to kill [himself/herself] . Review of R#16's care plan reviewed 3/16/26 [R #16] has a behavior problem (occasionally refuses to eat, verbal outburst to staff, emotional distress by disease process r/t paraplegia, morbid obesity, secondary to progression of Multiple sclerosis goal: [R#16] will have fewer episodes of meal refusals, negative statements weekly by review date INTERVENTIONS: Intervene as necessary to protect the rights and safety of others. Approach. speak in a calm manner Divert attentions. Remove from situation and take to alternative location as needed. Monitor each shift for sad or angry affect and notify MD of any changes in behaviors. Further review of R#16's care plan lacked evidence that it contained goals and interventions in the area of suicidal Ideation.During an interview on 4/22/26 at 9:01 a.m., in presence of three surveyors the Director of Nursing (DON) states R#16 used to make self-harm statements in the past but had not made them for a while. At this time a surveyor reviewed R#16's care plan with DON who confirmed it does not contain goals and interventions in the area of suicidal ideation.

Based on observations and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters for 1 of 2 days of survey (4/21/26).Findings:On 4/21/26 at 8:30 a.m., three surveyors observed the top right lid of 1 of 2 dumpsters to be open exposing trash. On 4/21/26 at 8:35 a.m., in an interview with a surveyor, the Administrator confirmed the finding.

Based on record review and interviews, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). Finding:On 4/22/26, initial review of the facility's infection control policies lacked evidence that the facility had developed and implemented written policies and procedures for their IPCP in the areas of hand hygiene and standard and transmission-based precautions.On 4/22/26 at 12:40 p.m. the surveyor discussed the above concern during an interview with the Director of Nursing (DON). At this time, the DON was unable to provide the above policies to the surveyor and stated that she was not sure if the facility had these policies, but that she would look.On 4/22/26 at 1:33 p.m. the DON provided the requested policies, and surveyor review of the policies revealed the following:Facility policy, Hand Hygiene, dated 12/20/2017, last reviewed 7/22/24Facility policy, Standard Precautions Used for All Patients, dated 3/31/23, lacked evidence that the policy has been reviewed and/or revised.Facility policy, Droplet Precautions, dated 3/31/23, lacked evidence that the policy has been reviewed and/or revised.Facility policy, Precautions to Prevent Infection, last reviewed 6/2024.On 4/22/26 at 1:56 p.m., the surveyor discussed the finding during a follow-up interview with the DON, and at this time the DON confirmed that the facility had not conducted an annual review of its IPCP.

Based on record review, facility policies, review of a reportable incident form, and interviews the facility failed to ensure that a resident was free from injury when the facility staff failed to properly transfer a resident causing the resident to sustain a laceration on the nose and several lacerations with hematomas to the head for 1 of 13 residents requiring a mechanical lift for transfers. (Resident #1) Findings: On 5/5/25, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 5/4/25 at 1:50 p.m. Resident #1 was being transferred out of bed to a Broda chair using a mechanical lift (hoyer). The legs of the hoyer lift were not opened and the hoyer lift fell over sideways while the resident was in the sling. The resident fell to his/her left side onto the floor resulting in a laceration to the back of the head and the bridge of his/her nose. Review of nurses note dated 5/4/25 at 2:42 p.m., stated, This nurse was called to resident's room. Resident was laying on [his/her] left side on the floor and the staff was in the process of standing the hoyer lift back up. Per staff resident was being transferred into [his/her] broda chair. The legs of the hoyer were not open and the hoyer lift tipped over sideways with the resident in it. Resident noted to have a small laceration on the bridge of [his/her] nose. [He/she] also has a 8cm (centimeter) x 7cm [NAME] on the left side of [his/her] head. There is a 0.5cm laceration in the center of the [NAME]. Also noted is a 0.5cm laceration on the back of [his/her] head. Resident alert and answering questions appropriately. Offers no complaint of pain or discomfort. Able to move all extremities. Lacerations cleansed with wound cleanser and left open to air. Review of Physician order dated 5/5/25 stated, Hematoma to left side of head and posterior head: monitor q (every) shift, notify provider of any new or worsening sx (symptoms)- HA (headache), nausea, vomiting, confusion. Resident #1's care plan initiated on 8/16/23 stated, he/she has ADL self-care performance deficit related to Dementia and requires extensive assists with bathing, grooming, personal hygiene and bed mobility. Interventions include the resident requires total assist via hoyer lift with 2 staff. On 5/14/25 at 12:17 p.m., during an interview, the Certified Nurses Aid (CNA #5) stated she assisted 2 other CNA's and the Licensed Practical Nurse get Resident #1 off the floor using the hoyer lift and into his/her Broda chair. When she entered the room the hoyer lift was on its side and the legs were in the closed position stating, the first thing I said, oh the legs are closed, you're supposed to have them open. On 5/14/25 at 1:16 p.m., during an interview, the Licensed Practical Nurse (LPN) stated CNA #7, a witness, reported that the hoyer legs were closed during the transfer. On 5/15/25 at 1:21 p.m., during a telephone interview, CNA #7 confirmed she was assisting CNA #3 with the hoyer transfer for Resident #1 with CNA #3 operating the hoyer. CNA #7 stated, we were going to the chair that we had placed and when she went to try to open the legs, it was like a manual hoyer, you have to pull it, like physically to open the legs. So, basically when she went to go do that, it kind of made the balance off centered and that's when the hoyer fell. The surveyor asked if Resident #1 was lifted out of the bed and transferred over to the broda chair with the hoyer legs in the closed position. CNA #7 stated, it wasn't until we got to the chair that she was trying to open them. Mechanical lift Policy effective 4/2004, revision date 5/6/2025 states The base legs of the lift will be locked in the maximum open position. The base legs must be always locked for stability and resident safety when lifting and transferring a resident. On 5/14/25 at 2:45 p.m., the above was confirmed with the Administrator. As a result of the facility's investigation, the following corrective actions were initiated: Immediate education on mechanical lift safety to staff involved in the incident Hoyer lifts were inspected and removed from service if needed Resident #1's care plan was reviewed and revised on 5/9/25 Nursing staff completed education on mechanical lift safety including videos, in person training and tests New hoyer lifts were ordered Facility conducted an investigation with root cause analysis. Audits in place for hoyer use observations and results will be brought to QAPI.

Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 32 of 32 beds. This has the potential to affect the safety of all residents. Finding: On 2/10/25 at 11:30 a.m., a surveyor asked the Administrator for the bed gap measurements and side rail gap measurement documentation. A surveyor received and reviewed the documentation with the Administrator and she confirmed that the bed gap measurements and side rail gap measurements had not been completed since February 2023. On 2/10/25 at 12:05 a.m., a surveyor and the Director of Ancillary Services reviewed the bed gap measurements and side rail gap measurement documentation. At this time, in an interview, the Director of Ancillary Services confirmed that regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment and bed gap measurements and side rail gap measurements have not been completed since February 2023.

Based on interviews and record review, the facility failed to ensure resident preferences were followed for 2 of 3 residents reviewed for bathing ( Residents #23 #8). Findings: 1.Resident #23 and has a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating he/she is moderately cognitively impaired. Review of Resident #23's care plan revealed, . requires extensive assist by 1 staff with bathing BID [2 times a day] and as necessary .often refuses care reapproach and offer several times as needed . Review of East/West Bath Schedule, updated 1/25/25, revealed that Resident #23 is to receive a shower or bed bath on Thursday day shift. Review of Resident #23's clinical record lacked evidence that he/she was offered/refused a shower or bed bath on 10/10/24, 1/2/25, 1/9/25, 1/16/25, 1/30/25, and 2/6/25. During an interview on 2/5/25 at 11:33 a.m., Certified Nursing Assistant (CNA) #7 stated Resident #23 primarily receives bed baths but is showered occasionally and sometimes refuses to bathe, though not often. 2. Resident #8 has a BIMS of 15 out of 15, indicating he/she is cognitively intact. Review of Resident #8's Annual Minimum Data Set (MDS) dated [DATE], under Section F- Preferences for Customary Routine and Activities, Interview for Daily Preferences, revealed it is very important for Resident #8 to choose his/her bathing options. Review of Resident #8's care plan states, .self-care performance deficit r/t [related to] Activity Intolerance, Impaired balance . BATHING/SHOWERING .requires extensive assist by 1 staff for bathing daily and as necessary . Review of East/West Bath Schedule, updated 1/25/25, revealed that Resident #8 is to receive a shower on Thursday night shift. During an interview on 2/5/25 at 10:00 a.m., Resident #8 stated his/her shower day is Thursday and that he/she is supposed to get a shower but that staff does not want to give him/her one, so they provide a bed bath instead. During a follow-up interview on 2/7/25 at 11:09 a.m., Resident #8 stated that he/she wanted to get a shower last night, but staff did not offer a shower and instead gave him/her a bed bath. Review of Resident #8's Bathing Task, revealed he/she received a shower on 12/12/24. Further review lacked evidence he/she was offered/refused a shower or bed bath on 10/17/24, 10/24/24, 10/31/24, 11/7/24, 11/14/24, 11/21/24, 11/28/24, 12/5/24, 12/19/24, 12/26/24, 1/2/25, and 1/23/25. During an interview on 2/5/25 at 11:33 a.m., CNA #7 stated Resident #8's shower day is Thursday and that he/she requires a Hoyer lift to transfer to a shower chair and is dependent on assistance for bathing. During an interview in the presence of 2 surveyors on 2/7/25 at 11:37 a.m., the Director of Nursing (DON) stated that CNAs know a resident's bathing preference and schedule based on the Electronic Medical Record (EMR) and the bath/shower list in CNA binder at the nurses' desk. At this time, the DON stated it is her expectation that residents receive sponge baths daily and receive a weekly shower, whirlpool bath, or bed bath on their designated bath day. On 2/7/25 at 12:47 p.m., the DON reviewed the clinical records for Residents #8 and #23 and confirmed the above findings.

Based on observations and interview, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 2 units (East and West), a laundry cart, the conference room and the laundry room for 2 of 2 environmental tours (2/5/25 and 2/6/25). Findings: 1. On 2/05/25 at 10:30 a.m., a surveyor and the Administrator observed a laundry cart being used in the East Unit Hallway that had untreated wood holding the laundry bin to the wheeled unit. At this time, in an interview, the Administrator confirmed the wood was not treated and created uncleanable surfaces. 2. On 2/06/25 from 8:35 a.m. to 9:10 a.m., an environmental tour was conducted with the Director of Ancillary Services in which the following findings were observed: Conference Room - There were four(4) ceiling lights that had dirt/debris in them. East Unit - Resident room [ROOM NUMBER] - The baseboard heater was coming apart, hanging down and in a disrepair. The room entrance door had chipped/gouges on the face of the door and had rough edges creating an uncleanable surface. - The wheelchair storage closet, across from resident room [ROOM NUMBER], had chipped/missing paint and gouges on the door creating an uncleanable surface. - Resident room [ROOM NUMBER] - The room entrance door had chipped, gouged and missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The baseboard heater was broken apart, hanging down and in disrepair. The caulking around the base of the toilet was stained yellowish brown. - Resident room [ROOM NUMBER] - The baseboard heater has chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The baseboard heater in the bathroom has chipped/missing paint creating an uncleanable surface. The toilet seat was stained yellowish brown. - The base board heater in the dining room had chipped/missing paint creating an uncleanable surface. West Unit - Resident Rooms 7, 8, 10, 11, 12, 13,,15, 16 and 18 had room entrance doors that had chipped, gouged and missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The room entrance door had chipped, gouged and missing paint creating uncleanable surfaces. The walls had chipped/missing paint and there was a large area of spackled wall near the bathroom door. - The hallway base board heater, near the Rehab room, had chipped/missing paint creating an uncleanable surface. Laundry Room: - The ceiling above the 2 bay sink had a large brown stain on it. - The floor was dirty and stained brown throughout the laundry. On 2/06/25 at 9:10 a.m., in an interview, the Director of Ancillary Services confirmed the findings.

Based on observations and interviews, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 days of survey. (2/4/25, 2/5/25 and 2/10/25) Findings: 1. On 2/4/25 at 10:40 a.m., a surveyor observed Resident #13's oxygen concentrator tubing and nasal cannula was observed stored on top of resident's bureau on some of his/her personal belongings and not bagged. The resident stated to the surveyor that he/she only wears oxygen at night and it is stored during the day. 2. On 2/5/25 at 8:15 a.m., a surveyor observed Resident #13's oxygen concentrator tubing and nasal cannula was observed stored on top of her concentrator and not bagged. On 2/05/25 at 10:25 a.m., in an interview, the Administrator confirmed that the oxygen tubing and nasal canula should be stored in a bag and not just draped on the resident's belongings on the night stand or coiled up and stored on top of the O2 concentrator. At this time, the surveyor asked for the oxygen/respiratory policy and procedure for storing equipment in the resident. On 2/05/25 at 11:50 a.m., the Administrator reached out to the Regional Director of Clinical Operation-Maine for input and a policy on O2 storage and equipment storage. The Regional Director of Clinical Operation-Maine informed the Administrator that National Health Care Associates Inc. does not have a specific policy on that however, they store tubing in respiratory bags when they are not in use. The facility could not produce a policy and procedure on storing oxygen/respiratory equipment in the resident rooms. 3. On 2/10/25 at 9:25 a.m Resident #13's oxygen concentrator tubing and nasal cannula was observed lying on the floor next to the head of her bed and was not bagged. On 2/10/25 at 9:30 a.m., in an interview, LPN #1 confirmed that Resident #13's oxygen concentrator tubing and nasal cannula was lying on the floor next to the head of her bed and was not stored in a bag.

Based on observations, interviews, review of the Dish Machine Temperature Logs (dated 2013), and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling tiles, floors, and a wall mounted fan; failed to ensure foods were sealed, labeled and dated in a reach-in freezer and in a walk-in refrigerator; failed to ensure that the kitchen ice machine was plumbed in accordance with code requirements to prevent food contamination and failed to ensure that the dish machine was monitored for proper wash and rinse temperatures to ensure clean and sanitized utensils and dishes, all for 1 of 1 kitchen tour for 1 of 1 day of survey (2/4/25). Findings: 1. On 2/4/25 from 9:10 a.m. to 10:00 a.m., a surveyor conducted a kitchen tour with the Food Service Director in which the following findings were observed: - There were three ceiling tiles above a food preparation area that had brown stains on them. - There was trash and food debris on the floor under the equipment and around the edges of the floor. - The dish room had a wall mounted fan that was dusty/dirty and a base board heater that had chipped/missing paint creating an uncleanable surface. - There was an unlabeled and undated plastic container of cereal on a food preparation table. - There was a large bin of flour that was unlabeled and undated. - The walk-in refrigerator had one pie crust wrap that was unlabeled and undated. Also, there was a container of peeled eggs that was not securely shut/sealed and open to the air. - The walk-in freezer had one large package of meatballs, one package of stuffed shells, one package of chicken patties and two packages of pancakes that were unlabeled and undated. - The kitchen ice machine air gap was not plumbed in accordance with code requirements to prevent food contamination. The facility's Food Storage policy noted: Procedure: 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 14. Refrigerated food storage: F. All food should be covered, labeled and dated. 16. Frozen foods: All food should be covered, labeled and dated. This direct connection of waste water and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 2/4/25 at 10:00 a.m., in an interview, the Food Service Director (FSD) confirmed the findings. 2. Upon review of the Dish Machine Temperature Logs, the surveyor found the following missing dates of monitoring/documentation. November 2024: Breakfast - 2, 3, 8, 15, 16, 17 and 19. Lunch - 16, 18, 24, 27 and 28. Dinner - 22, 27 and 28. December 2024: Breakfast - 1, 6, 10, 19, 2 and 30. Lunch - 1, 5, 19, 20 and 25. January 2025: Breakfast - 7, 21, 30 and 31. Lunch - 5, 8, 12, 13, 14, 16, 22 and 23. Dinner - 1, 2, 3, 5, 8, 12-16, 21 and 22. The facility's Dish Machine Temperature Log noted: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. 3. Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. a. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. On 2/5/25 at 2:00 p.m., in an interview, the FSD confirmed there were missing dates of monitoring/documentation of the dish machine temperatures for November 2024, December 2024 and January 2025.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings On 2/6/25, a surveyor reviewed the following employee education files: 1. CNA #1 was hired 3/27/23. A review of CNA #1's education records revealed they had not received the required 12 hours of education/in-service training including Resident Rights, Dementia, Quality Assurance and Performance Improvement Program (QAPI), and Infection Control in 2024. 2. CNA #2 was hired 4/10/23. A review of CNA #2's education records revealed they had not received the required 12 hours of education/in-service training including Resident Rights, QAPI, and Infection Control in 2024. 3. CNA #3 was hired 1/8/24. A review of CNA #3's education records revealed they had not received the required 12 hours of education/in-service training including Dementia, QAPI, and Infection Control in 2024. 4. CNA #4 was hired 9/13/1994. A review of CNA #4's education records revealed they had not received the required 12 hours of education/in-service training including QAPI and Infection Control in 2024. 5. CNA #5 was hired 11/1/2016. A review of CNA #5's education records revealed they had not received the required 12 hours of education/in-service training including Resident Rights, QAPI and Infection Control in 2024. On 2/06/25 at 11:19 a.m., in an interview, the Administrator confirmed that all 5 CNAs had not received the required 12 hours, including certain mandatory education and in-service training in 2024.

Based on record reviews and interviews during the survey for immediate jeopardy and during the extended survey, the facility failed to provide interventions to prevent injuries as a result of a fall from the bed for 2 of 4 residents observed in bed (Residents #1 and #6.) This failure resulted in Resident #1 falling out of bed and sustaining life threatening injuries. In addition, the facility failed to properly implement safety devices for 3 of 4 residents observed in bed (Residents #1, #9 and #10.) Findings: 1. Resident #1's "Fall Risk Screen" assessment score was a 22 on 05/25/11, a score of 17 on 07/05/11 and again on 07/12/11. On 07/12/11, Resident #1 had a score of 19. This screen indicated that anything above a score of 10 represented a high risk for falls. Resident #1's current care plan indicated that the facility had put in place a "Tag" alarm to be used at all times. Resident #1's clinical record indicated that from 02/10/11 through 06/27/11 the resident had several falls out of his/her wheel chair resulting in injuries to his/her hands and head. The facility used a "Tag" alarm when the resident was in a wheel chair and in bed, but there were no other interventions in place to prevent injuries from a fall from the resident's bed. According to the resident's nurse's note, dated 05/30/11, during the night shift, Resident #1 was frequently trying to climb out of bed. On 05/31/11, during the night shift, the nurse's note indicated that Resident #1 was trying to climb out of bed. On 06/08/11, the resident's nurse's note indicated that Resident #1 had been crawling out of bed from 11:00 p.m. through to 3:00 a.m. On 06/27/11, shift not indicated, Resident #1 had been found "writhing in bed" and observed nearly out of bed several times. Besides the "Tag" alarm, there was no indication that any other bed safety interventions were put in place. On 07/17/11 at 3:00 p.m., Resident #1's nurse's note indicated that Resident #1 was found lying on the floor next to his/her bed with a moderate amount of blood under his/her head. The "Tag" alarm was lying on the floor next to the resident and the alarm had not been activated. Resident #1 was transferred to an acute care facility where it was determined the the resident had sustained a subdural hematoma with hemorrhage, fractures of the left orbital bones and evidence of a fracture of the left maxillary antrum. On 07/29/11 at 12:00 p.m., in an interview with the surveyor, an evening Charge Nurse stated that she was aware that Resident #1 had made several attempts to get out of bed. She stated to the surveyor that Resident #1 would try to swing his/her legs over the side of the bed and would "shimmy down" to the end of the bed. On 07/29/11 at approximately 1:15 p.m., in an interview with the surveyor, the MDS Coordinator stated that if a resident falls from a wheel chair, then nursing would decide what safety interventions to put in place. The facility most often would place a "Tag" alarm on the wheel chair. She also stated that if a resident fell out of bed, then nursing would discuss the fall and decide what safety interventions to put in place. On 07/29/11 at 2:45 p.m., in an interview with the surveyor, an evening Certified Nursing Assistant (C.N.A. #1) stated that "Tag" alarms could not be properly fastened to the beds so she often had to just lay the alarm next to the resident in bed. The C.N.A. #1 stated she had told two Charge Nurses that the "Tag" alarms could not be properly attached to the bed, but she had never received a response and the situation was never corrected. On 07/29/11 at 3:15 p.m., the surveyor discussed the findings with the Administrator. After Resident #1's fall on 07/17/11, Resident #1 was returned to the facility on [DATE], from an acute care facility as a Hospice patient. The prognosis was poor and according to the resident's hospital discharge summary, Resident #1 was probably terminal; if not from the subdural hematoma, then from his/her advanced and progressive dementia. 2. Resident #6's "Fall Risk Screen" assessment score has been a 24 from 05/01/11 to the last screen done on 07/14/11. The screen indicated that anything above a score of 10 represented a high risk for falls. The resident's current care plan indicated the resident was to have a "Tag" alarm on when in bed or a wheel chair. Resident #6's clinical record indicated the resident had sustained multiple falls from his/her wheel chair and from bed. On 08/01/11 at 11:40 a.m., two surveyors observed that the resident remained in a regular bed versus a low bed and without any protective mats on the floor next to the bed to prevent injuries as a result of a fall from the bed. The surveyors discussed this finding with the facility's Nurse Consultant, on 08/01/11 at 12:30 p.m. 3. Resident #9's admission "Fall Risk Screen" dated 07/12/11, indicated the resident was at high risk for falls. The resident's care plan was updated on 07/29/11 to indicate the resident was to have a "Tag" alarm. Resident #9's clinical record indicated the resident had sustained a right hip fracture from a fall prior to admission to the facility. On 08/01/11 at approximately 11:00 a.m., two surveyors observed the resident lying in bed with the "Tag" alarm string attached to the resident's clothing. The alarm was in the bed next to the resident unattached to any surface so that the alarm would not be activated if the resident attempted to exit the bed unassisted. The surveyors discussed this finding with the facility's Nurse Consultant, on 08/01/11 at 12:30 p.m. 4. Resident #10's clinical record contained a "Fall Risk Screen" dated 06/22/11, which indicated the resident was at high risk for falls. A nurse's note indicated that on 07/22/11 the resident was found on the floor next to his/her bed sitting on a mat. The resident's care plan under the problem of high risk for injury and frequent falls indicated the resident was to have a "Tag" alarm on at all times. On 08/01/11 at approximately 11:00 a.m., two surveyors observed the resident lying in bed with the "Tag" alarm string attached to the resident's clothing. The alarm was in the bed next to the resident unattached to any surface so that the alarm would not be activated if the resident attempted to exit the bed unassisted. The surveyors discussed this finding with the facility's Nurse Consultant, on 08/01/11 at 12:30 p.m.