Every finding on record at Westgate Center for Rehab & Alzheimers Care

Based on observations and interviews, the facility failed to adequately provide housekeeping services necessary to maintain an environment free from offensive odors for 3 of 3 days of survey (5/11/26 through 5/13/26) on the locked Acadia Unit.Findings:On 5/11/26 at 11 a.m. and 12:56 p.m., upon entering the locked dementia/Alzheimer's Acadia Unit, a strong, foul urine odor was observed and it lingered throughout the unit.On 5/12/26 at 7:30 a.m., 11:55 a.m. and 2:00 p.m., upon entering the Acadia Unit, a strong foul urine odor was observed and it lingered throughout the unit. On 5/13/26 at 9 a.m., and 1p.m., upon entering the Acadia Unit, a strong foul urine odor was observed and it lingered throughout the unit. On 5/13/26 at 1:10 p.m., in an interview with the Acadia Unit RN-Charge Nurse, she stated the Unit does have a strong odor. They open windows when they can; housekeeping cleans daily and they have air freshener sprays.On 5/13/26 at approximately 1:35 p.m., in an interview with the Director of Nursing Services, the surveyor discussed the above findings.

Based on record reviews and interviews, the facility failed to ensure a care plan was updated and implemented for 2 of 14 residents reviewed on survey (Resident #3 [R3] and R9). Findings: 1. On [DATE], R3's clinical record was reviewed and indicated the following: -On [DATE], a provider order indicated, Do Not Resuscitate [Do not perform Cardio-Pulmonary Resuscitation (CPR)]. Review of the Care Plan indicated a code status of Full Code (Perform CPR), dated [DATE]. -On [DATE], a provider order indicated, change code status to DNR only not CPR or DNI one time a day. Review of the Care plan indicated a code status of Full Code (Perform CPR), dated [DATE]. -On [DATE], a provider order indicated, NovoLOG FlexPen Subcutaneous Solution Peninjector 100 UNIT/[milliliter (ML)] (Insulin Aspart) Inject as per sliding scale: if 0 - 299 = 0; 300 - 500 = 5, subcutaneously before meals and at bedtime for [Diabetes Mellitus (DMII)]. The care plan does not address R3's insulin orders including goals and interventions for the monitoring and management of its use. -On [DATE], a provider order indicated, NovoLOG FlexPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Aspart) Inject 7 unit subcutaneously before meals for DMII. The care plan does not address R3's insulin orders including goals and interventions for the monitoring and management of its use. -On [DATE], a provider order indicated, Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 32 unit subcutaneously one time a day for DM II. The care plan does not address R3's insulin orders including goals and interventions for the monitoring and management of its use. -Review of R3's care plan included a focus, goals and interventions for deficient self-care related to a Urinary Tract Infection (UTI) with sepsis, and dependent on staff for meeting some physical needs [related to (r/t)] SEPSIS DUE TO ESCHERICHIA COLI [bacteria native to the intestinal tract (e.coli)]. The clinical record lacked evidence that R3 was receiving interventions for a urinary tract infection or sepsis after [DATE]. On [DATE] 9:40 a.m., during an interview with a surveyor and the Director of Nursing (DON), R3's clinical record was reviewed. The DON confirmed with the surveyor that R3's care plan was not updated with R3's current end of life goals, urinary status, or goals and interventions for the monitoring and management of insulin. 2. On [DATE] , R9's clinical record was reviewed and indicated that he/she was hospitalized and treated for constipation twice ([DATE] and [DATE]). Review of R9's care plan lacks evidence that his/her care plan was revised to include treatment of his/her constipation. On [DATE] at 9:54 a.m., during an interview with the Director of Nursing services the surveyor confirmed that R9's constipation was not addressed on his/her care plan and was not revised after the second hospitalization for the treatment of constipation.

Based on record reviews and interviews the facility failed to ensure a duplicate order was removed from an electronic Medication Administration Record which resulted in the resident receiving duplicate doses of the same medication for 1 of 5 residents reviewed for unnecessary medications (Resident #10 [R10])Finding:On 5/13/2026 at 12:59 p.m. during a clinical record review R10's signed physician orders dated 4/23/26 indicated that R10 had an order for Senna oral tablet 8.6 milligrams (mg) give 2 tablets by mouth two times a day for constipation hold for loose stools. Review of R10's electronic Medication administration record (MAR) shows that since 3/26/26 R10 has been receiving two separate doses of Senna. On 3/26/26 a second order was entered onto the MAR and R10 received Senna 8.6mg, 2 tablets at 8:00 p.m. and senna docusate sodium (senna-s) 8.6-50 mg 2 tablets at 8:00 p.m. From the date 3/27/26 to 5/13/26 R10 has received both medications twice daily.On 5/13/26 during an interview with the Assistant Director of nursing services (ADNS), she was not able to identify the reason the senna-s was on the MAR. the ADNS reviewed the signed physician orders and the MARs for March, April and May and at this time the surveyor confirmed that R10 had been receiving a second dose of senna (senna-s) twice a day since 3/26/26.

Based on record reviews and interview, the facility failed to ensure the attending Provider signed the medication Order Review History Report (Physician block orders) that is required during a visit at least every 60 days plus a 10 day grace period for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #40 [R40]Finding: 1. On 5/13/26, a review of R40's clinical record was completed. Documentation indicated a required regulatory visit was completed on 4/30/26. A provider progress note was completed on 4/30/26, but there was no evidence that the physician block orders were signed until a day later on 5/1/26. The facility was unable to provide evidence that the physician block orders were signed on the day of the required recertification visit. On 5/13/26 at approximately 1:35 p.m., the surveyor discussed and confirmed this finding with the Director of Nursing and the Regional Director of Clinical Operations.

Based on observations, record review and interviews, the facility failed to ensure that a resident record contained accurate, complete, and/or readily accessible information for 1 of 1 resident(s) reviewed hospice (Resident #45 [R45]).Findings:On 5/11/26, R45's clinical record was reviewed and indicated the following:-On 3/26/26, a health status note indicated R45 was discharged from hospice services.-On 4/1/26 at 1:15 p.m., a provider note stated, [R45], . now on hospice level care. Patient is seen today for weekly hospice visit. The clinical record lacked evidence that R45 was receiving hospice services at the time of the visit.-On 4/8/26 at 11:30 a.m., a provider note stated, [R45], . now on hospice level care. Patient is seen today for weekly hospice visit. The clinical record lacked evidence that R45 was receiving hospice services at the time of the visit.-On 4/15/26 at 11:45 a.m., a provider note stated, [R45], .now on hospice level care. Patient is seen today for weekly hospice visit. Patient has been on hospice since 4/10/2024. The clinical record lacked evidence that R45 was receiving hospice services at the time of the visit.-On 4/30/26 at 9:30 a.m., a provider note stated, The patient continues to receive hospice services with aide support and RN visits. The clinical record lacked evidence that R45 was receiving hospice services at the time of the visit.-On 5/7/26 at 1:15 p.m., a provider note stated, [R45], . now on hospice level care. Patient is seen today for weekly hospice visit. The clinical record lacked evidence that R45 was receiving hospice services at the time of the visit.On 5/13/26 at 9:56 a.m., during an interview with a surveyor, the Director of Nursing stated that R45 was discharged from hospice services and confirmed the statements in the provider notes were not accurate. At this time, a surveyor confirmed R45's clinical record had inaccurate documentation regarding hospice services.

Based on observations and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 3 units observed for pests (Cascade Unit). Finding: On 3/24/25 a surveyor observed small flies in the following locations: -At 10:20 a.m., a small fly was observed circling over the full recyclable containers bin in the kitchen. -At 10:59 a.m., a small fly was observed in the hall outside resident room [ROOM NUMBER]. -At 11:20 a.m., a small fly was observed on a resident's bedding in room [ROOM NUMBER] and another small fly was observed in the bathroom of room [ROOM NUMBER]. -At 11:35 a.m., a small fly was observed flying in resident room [ROOM NUMBER]. On 3/25/25 a surveyor observed small flies in the following locations: -At 9:28 a.m., a small fly was observed flying in resident room [ROOM NUMBER]. -At 11:30 a.m., a small fly was observed circling the trash in the dining room during the lunch service. -At 2:30 p.m., during an interview with the Food Services Supervisor (FSS), a swarm of small flies was observed in the kitchen by the dishwasher, flying around and landing on stacked ware-washer dish racks. The FSS stated this has been an ongoing problem. On 3/26/25 at 10:49 a.m., during an interview with the Maintenance Director and a surveyor, a swarm of small flies was observed by the dishwasher, flying around and landing on stacked ware-washer dish racks. The Maintenance Director stated Pest Control comes monthly. At this time the surveyor confirmed that the facility does not have an effective Pest Control Program.

Based on observations and interviews, the facility failed to protect a resident's right to a dignified existence and right of self-determination for a visitor for 1 of 1 resident's reviewed for Dignity (Resident # 10 [R10]). Finding: 1. On 3/25/25 at 9:10 a.m., a surveyor observed from the resident hallway, R10 lying in his/her bed. R10's pants were below his/her waste with an exposed brief. A wash basin was observed on the bedside table and R10 was talking with a Certified Nursing Assistant (CNA). After the surveyor knocked on the open door and introduced self, the CNA made 2 attempts to close the door and prevent communication with the resident. The resident provided consent for the surveyor to enter and observe care. On 3/26/25 at 12:00 p.m., during an interview with the Director of Nursing, the surveyor confirmed that R10's right to privacy and self-determination for a visitor was not protected. 2. On 3/25/25 at 9:18 a.m., during an interview with a surveyor and R10, CNA1 and CNA2 entered R10's room and explained to the surveyor that R10's family took the shoes home, that R10 cannot wear them until the wound on his/her heel resolves. At this time the surveyor requested this to be explained to the resident not the surveyor. Staff repeated the explanation to R10. R10 stated, I wish people would tell me instead of taking them without talking to me. After CNA1 and CNA2 left the room, R10 denied having a wound on his/her feet. R10 removed his/her slippers one at a time and stated, do you see anything? No wounds were observed on the heels at that time. On 3/26/25 at 8:26 a.m., during an interview with R10 and CNA3, R10 repeated concern for his/her missing shoes. R10 stated he/she did not believe they went home with family. CNA3 stated she would look into the missing shoes. At 9:21 a.m., CNA3 stated R10's shoes are in his/her dresser. R10's shoes were observed in the dresser drawer at that time. On 3/26/25 at 12:00 p.m., during an interview with the Director of Nursing, a surveyor confirmed that the R10 was not treated with dignity when staff talked about him/her instead of to R10 directly regarding the missing shoes.

Based on interviews and record review, the facility failed to implement a resident's care plan in the area a restorative walking program for 1 of 1 residents reviewed for activities of daily living (Resident #10 [R10]). Finding: On 3/25/25 at 9:35 a.m., during an interview with a surveyor, R10 stated he/she is losing his/her ability to walk. R10 stated, I don't think anyone walked with me after therapy [ended]. I think I am a blind spot. On 3/26/25 at 10:40 a.m., a surveyor observed R10 ambulating in the hallway with Physical Therapy (PT) staff. PT stated nursing notified her of a decline in function and R10 has had several falls prompting her to conduct today's evaluation. On 3/26/25, R10's clinical record was reviewed. The care plan identified R10 as having a functional mobility deficit, for which the intervention AMBULATION: [R10] will ambulate 50-75 feet with 2 wheel walker and extensive assist, as patient is able, last revised on 3/12/25. On 3/26/25 at 12:19 p.m., during an interview with a surveyor and the Director of Nursing (DON), R10's clinical records was reviewed. The DON stated R10 should ambulate with staff on day and evening shift. At this time the surveyor confirmed that the medical record lacked evidence that R10 was ambulated 50-75 feet twice daily as directed by the care plan.

Based on record reviews and interviews, the facility failed to complete neurological assessments for a resident who had a fall and hit their head, failed to follow their Bowel Regimen, and failed to follow physician orders for 3 of 18 residents reviewed (Resident #3 [R3], R48, and R6). Findings: 1. On 3/25/25 at 8:47 a.m., R3's clinical record was reviewed. On 3/20/25 at 12:37 p.m., a health status note from Third eye Health with a date of service of 6:04 a.m. it was documented that R3 being seen for an unwitnessed fall that occurred at 5:30 a.m. he/she was found on the floor in their room. R3 has a hematoma to the back of head to left side and reports head pain. Clinical record review shows documentation for Neuro checks that were initiated on 3/21/25 at 1:00 p.m. and lacked evidence that Neuro checks were completed as outlined in their Neurological Evaluation Policy. The facility's Neurological Evaluation Policy dated 4/23 and their neurological (neuro)/vital sign check sheet instructs staff that the licensed nurse performs neurological evaluations whenever there is the possibility of a head injury. On page 2 under number 3 the instructions for the timeframe for the neuro checks to be completed are: After the initial evaluation, the neuro checks are repeated every 15 minutes x 4 (1 hour, (hr.), every 30 minutes x 4 (2hrs), every 2 hours x 4 (8hrs), then every shift x 8 (64hrs) The columns on the form to be completed included nurse's initials, date, time, vital signs (temperature, pulse, respirations, blood pressure) and neurological check (pupils, level of consciousness, motor function, speech, and facial symmetry). On 3/26/25 at 11:47 a.m., during a clinical record review with the Regional Director of Clinical operations the surveyor confirmed that the clinical record lacked evidence that the facility followed their Neurological Evaluation Policy after R3 had a fall with a head injury. 2. The facility's Bowel Regimen dated 4/27/23 under the heading procedure number 2. instructs that the charge nurse will review the Bowel Movement (BM) Record for residents in need of the bowel regime and list residents who have not had sufficient BM'S within the last three days, prune Juice (warm/cold upon preference) 4 ounce (oz) and senna-s 8.6/50 milligram (mg) tab, give 2 tabs by mouth x 1 now (at the beginning of the 10th shift) 3. If insufficient BM after the prune juice the charge nurse will administer Dulcolax tablet 10 mg by mouth the following shift. On 3/24/25 at 11:43 a.m. during a clinical record review a health status note for an acute visit with date of service for 3/19/25 at 8:45 a.m. documented that R46 is being seen today for loose stools. Staff reported R46 was having large loose stools. R46 was also seen on 3/12/2025 for diarrhea. Bowel medications were adjusted and held due to loose stools. During this record review it is documented that on 3/19/25 at 7:46 a.m. R46 received the Dulcolax 5 mg, 2 tablets to equal 10mg for constipation and resulted in R46 having a large loose stool prior to being seen by the Provider. The Bowel elimination record review showed that R46 had 2 large bowel movements on 3/18/25, a large bowel movement on 3/17/25 and a large bowel movement and a medium bowel movement on 3/16/25 showing R46 was not constipated and did not need a laxative per their bowel regimen policy. R46 did not go for 3 days without a bowel movement and was seen by the Provider for diarrhea on 3/12/25. On 3/26/25 at 2:06 p.m. during the review of R46's bowel elimination record and during an interview with the charge Nurse RN#1, the surveyor confirmed that R46 should not have received the Dulcolax laxative as he/she had 2 large bowel movements on 3/18/25 and did not meet the criteria for using the bowel regimen. 33242 3. On 3/26/25, R6's clinical record was reviewed and included orders for Humalog (insulin) sliding scale to be administered at 5 units if blood sugar was 350 or greater (hold insulin if resident refuses meal) and for Hydralazine 10 milligram tablet to be administered if systolic blood pressure (SBP) was 160 or above. A review of R6's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for February 2025 was completed. On 2/19/25 at 1:00 p.m., R6's blood sugar was 406 but the documentation on the TAR indicated that the Humalog sliding scale insulin was not administered. On 2/2/25, R6's SBP was 121 but documentation on the MAR indicated Hydralazine was administered. A review of R6's TAR and MAR for March 2025 was completed. On 3/11/25 at 6:00 p.m., R6's blood sugar was 355 but the documentation on the TAR indicated that the Humalog sliding scale insulin was not administered. The medication Hydralazine was documented as administered when SBP was less than 160 as follows: 3/8/25 at 5:00 p.m. when SBP was 132, 3/9/25 at 8:00 a.m. when SBP was 133, 3/10/25 at 5:00 p.m. when SBP was 142, and 3/17/25 at 5:00 p.m. when SBP was 129. On 3/26/25 at 2:03 p.m., during an interview with the Director of Nursing, a surveyor confirmed these findings. The DON stated that the insulin should have been administered because documentation also indicated that R6 ate greater than 50% of his/her meal and the Hydralazine should not have been administered.

Based on observations and interviews, the facility failed to ensure that hot water temperatures in resident rooms and restroom did not exceed 120 degrees Fahrenheit (F) on 2 of 3 days of survey (3/24/25 and 3/25/25). Findings: 1. On 3/24/25 between 11:47 a.m. thru 12:36 p.m., surveyors observed the following hot water temperatures: In room [ROOM NUMBER] at 11:49 a.m., the hot water temperature was 121.7 degrees F and at 11:57 a.m. was 120.9 degrees F; In room [ROOM NUMBER] at 11:59 a.m., the hot water temperature was 121.1 F; In room [ROOM NUMBER] at 12:07 p.m., the hot water temperature was 124.1 F; In room [ROOM NUMBER] at 12:10 p.m., the hot water temperature was 125.0 F; In Cascade Unit Shower/Restroom at 12:25 p.m., the hot water temperature was 125.4 F; In room [ROOM NUMBER] at 12:27 p.m., the hot water temperature was 122.3 F; In room [ROOM NUMBER] at 12:28 p.m., the hot water temperature was 122.3 F; and In room [ROOM NUMBER] at 12:30 p.m., the hot water temperature was 120.5 F. On 3/24/25 at 12:50 p.m., the surveyor informed the Administrator that there was hot water greater than 120 degrees F. At 12:57 p.m., the surveyor notified the Maintenance Director of the surveyors findings of hot water. 2. On 3/25/25, in room [ROOM NUMBER] at 12:07 p.m., the hot water temperature was 120.7 F. On 3/26/25 at 7:30 a.m., the Administrator stated that additional water temperature adjustments were completed last night when Mechanical Services lowered the temperature less than 120 degrees. Documentation indicated the facility was monitoring hot water temperatures in resident rooms daily and the temperature log did not reflect temperatures above 120 degrees.

Based on performance evaluation reviews and interview, the facility failed to complete an annual performance evaluation at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #3 [CNA3]). Finding: CNA3 was hired on 12/20/2012. A review of CNA3's performance evaluation, dated 3/21/23 thru 12/10/24, indicated the evaluation was completed 8 months and 20 days past the 12 month evaluation period. On 3/26/25 at 8:00 a.m., in an interview with the surveyor, the Assistant Director of Nursing, confirmed that CNA3 receive her performance evaluation 8 months and 20 days late.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 2 of 3 days of survey (3/24/25, and 3/25/25). Findings: On 3/24/25 at 10:20 a.m., during the initial tour of the kitchen with the Food Service Supervisor (FSS), a surveyor observed in the walk in freezer, a package of [NAME]-O Turkey Breast and Thigh Roast on the shelf. Package observed to have frozen raw meat / juices attached to the side of the package and exposed to the environment. A surveyor confirmed this finding with the FSS at the time of the observation. On 3/25/25 at 11:51 a.m., during a kitchen observation, a surveyor observed [NAME] #1 serving plates and wearing a glove on the right hand only. The gloved hand handled serving spoons and bread to serve food onto dishes. [NAME] #1's bare left hand was observed to be in contact with the surface of the dishes while plating food. [NAME] #1 opened a new bag of bread, walked to the trash, lifted the trash with one hand while reaching the other hand in to throw away the bread bag. [NAME] #1 then donned a new glove and returned to the steam table to serve food. At this time the surveyor confirmed with [NAME] #1 that she had been in contact with the trash and returned to serve food without washing her hands. On 3/25/25 at 11:54 a.m., a surveyor observed [NAME] #2 remove his soiled gloves and throw them in the trash. [NAME] #2's bare hands were observed to be in contact with the trash at that time. [NAME] #2 picked up the thermometer and attempted to place it in the mashed potatoes. At this time the surveyor intervened and confirmed with [NAME] #2 he had been in contact with the trash, then the thermometer, without washing his hands. On 3/25/25 at 12:00 p.m., during an interview with a surveyor, [NAME] #2 stated they use the sanitizer bucket to clean the thermometer. The surveyor observed [NAME] #2 test the sanitizer bucket. The test strip result was 150 parts per million (ppm). [NAME] #2 stated the sanitizer bucket should contain a concentration of 200 ppm. A surveyor confirmed this finding with [NAME] #2 at the time of the observation.

Based on employee personnel files/in-service training reviews and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on resident rights by failing to ensure that 2 of 5 Certified Nurse Assistants (Certified Nurse Assistant #1 [CNA1] and CNA2) completed the required annual training. Findings: On 3/25/25, during a review of employee personnel files, the following was noted: 1. CNA1 was hired on 8/19/2020. CNA1's employee personnel file lacked evidence of mandatory resident rights education within the last twelve months. 2. CNA2 was hired on 5/27/2021. CNA2's employee personnel file lacked evidence of mandatory resident rights education within the last twelve months. On 3/26/25 at 8:00 a.m., in an interview with the surveyor, the Assistant Director of Nursing, confirmed that there was no evidence that CNA1 and CNA2, had received resident rights training.

Based on record reviews and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) 3.0 in a timely manner for 7 of 14 sampled residents (Resident [R] R3, R5, R8, R35, R7, R23, R10 ). Findings: 1. On 1/30/24, R3's clinical record was reviewed. R3's Quarterly MDS had an Assessment Reference Date (ARD) of 10/24/23 and was due to be completed by 11/7/23, which is the ARD plus 14 calendar days. R3's Quarterly MDS was completed on 11/27/23, 10 days late. 2. On 1/30/24, R5's clinical record was reviewed. R5's Quarterly MDS had an Assessment Reference Date (ARD) of 12/1/23 and was due to be completed by 12/15/23, which is the ARD plus 14 calendar days. R5's Quarterly MDS was completed on 12/25/23, 10 days late. 3. On 1/30/24, R8's clinical record was reviewed. R8's Quarterly MDS had an Assessment Reference Date (ARD) of 8/25/23 and was due to be completed by 9/8/23, which is the ARD plus 14 calendar days. R8's Quarterly MDS was completed on 9/13/23, 5 days late. 33242 4. On 1/30/24, R35's clinical record was reviewed. R35's Quarterly MDS had an Assessment Reference Date (ARD) of 11/22/23 and was due to be completed by 12/6/23, which is the ARD plus 14 calendar days. R35's Quarterly MDS was completed on 12/21/23, 15 days late. 5. On 1/31/24, a review of R7's clinical record was reviewed. R7's Quarterly MDS had an ARD of 12/4/23 and was due to be completed by 12/18/23, which is the ARD plus 14 calendar days. R7's Quarterly MDS was completed on 12/25/23, 7 days late. 6. On 1/31/24, a review of R23's clinical record was reviewed. R23's Quarterly MDS had an ARD of 10/27/23 and was due to be completed by 11/10/23, which is the ARD plus 14 calendar days. R23's Quarterly MDS was completed on 11/12/23, 2 days late. R23 had another Quarterly MDS with an ARD date of 11/20/23 and was due to be completed by 12/4/23, which is the ARD plus 14 calendar days. R23's Quarterly MDS was completed on 12/2123, 17 days late. 49635 7. On 1/30/24, R10's clinical record was reviewed. R10's Quarterly MDS had an Assessment Reference Date (ARD) of 10/17/23 and was due to be completed by 10/31/23, which is the ARD plus 14 calendar days. R10's Quarterly MDS was completed on 11/13/23, 13 days late. On 1/31/24 at 8:25 a.m., during an interview with the MDS Coordinator, two surveyors confirmed this finding when she stated she has been behind on finishing the MDS's in a timely manner.

Based on observations and interviews the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code on 1 of 3 survey days (1/29/24). In addition, the facility failed to ensure products in the reach-in refrigerator located in the kitchen were labeled on 2 of 3 days of survey (1/29/24, 1/30/24). Findings: 1. On 1/29/24, at 11:00 a.m., three surveyors observed there was an improper air gap provided on the drain lines of the ice machine located in the hallway leading to the kitchen. This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm). On 1/29/24 at 11:10 a.m., a surveyor confirmed this finding with the Food Service Director (FSD). 2. On 1/29/24 at 11:13 a.m., during the initial kitchen tour, a surveyor observed 2 trays of individual cups of a yellow/orange substance that were not labeled in the reach in refrigerator. The surveyor asked the FSD what was in the individual cups, the FSD identified the substance to be sugar free pudding used for medication passes. 3. On 1/30/24 at 11:25 a.m., during a second tour of the kitchen, the surveyor observed 2 trays of individual cups of a yellow/orange substance that were not labeled in the reach in refrigerator. The surveyor confirmed with the FSD at this time that the trays were not labeled.

Based on record review and interview, the facility failed to complete an Annual Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) in a timely manner for 2 of 14 sampled residents (Resident [R] 7, Resident [R] 6). Findings: 1. On 1/31/24, a review of R7's clinical record was reviewed. R7's Annual MDS with CAA had an Assessment Reference Date (ARD) of 9/3/23 and was due to be completed by 9/17/23, which is the ARD plus 14 calendar days. R7's Annual MDS was completed on 9/18/23, 1 day late. On 1/31/24 at 8:25 a.m., during an interview with a surveyor, the MDS Coordinator, stated she has been behind on finishing the MDS's in a timely manner. 49635 2. On 1/31/24, a review of R6's clinical record was reviewed. R6's Annual MDS with CAA had an ARD of 1/12/24, and was due to be completed by 1/26/24, which is the ARD plus 14 calendar days. R6's Annual MDS was completed on 1/30/24, 4 days late. On 1/31/24 at 8:25 a.m., during an interview with the MDS Coordinator, two surveyors confirmed this finding when she stated she has been behind on finishing the MDS's in a timely manner.

Based on record review and interview, the facility failed to complete a Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) for a significant change in status, in a timely manner for 1 of 14 sampled residents (Resident #9[R9]). Finding: On 1/31/24, R9's clinical record was reviewed. R9's significant change in status MDS with CAA had an Assessment Reference Date (ARD) of 12/05/23, which was due to be completed by 12/19/23 (which is the ARD plus 14 calendar days). R9's MDS with CAA was completed on 12/25/23, 6 days late. On 1/31/24 at 8:25 a.m., during an interview with the MDS Coordinator, two surveyors confirmed this finding when she stated she has been behind on finishing the MDS's in a timely manner.

Based on observations and interview, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 1 of 3 days of survey (1/31/24). Finding: On 1/31/24 at approximately 12:12 p.m., two surveyors observed the dumpster filled with garbage bags not allowing the covers to be closed. During this observation the two surveyors observed a full black garbage bag that was under the dumpster that was spilling some of the contents on the ground on the right side of the dumpster, behind the dumpster were two bags filled with garbage. On 1/31/24 at 12:14 p.m., the two surveyors confirmed with the Maintenance Supervisor, Food Service Director, Director of Nursing, Assistant Director of Nursing, and the Regional Director of clinical operations that the dumpster was full not allowing the covers to be closed and the garbage bags that were under and behind the dumpster.

Based on observations and interviews the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for 1 of 3 meal observations (10/24/22). Finding: On 10/24/22 on the Cascade Unit during the lunch meal observation between 11:20 a.m. and 11:55 a.m., it was observed that 6 residents were seated at a long table. These 6 residents needed assistance with their meals. All 6 residents had their meals placed on the table in front of them. At 11:25, 3 residents were being assisted with their meals while the other 3 residents sat there watching their tablemates being assisted with meals and beverages. At 11:50 a.m., a second surveyor asked the Director of Nursing (DON) why the 3 residents were not being assisted. The DON came into the Cascade dining room and instructed staff to assist the remaining 3 residents with their meals and staff questioned if they were able to assist 2 residents at a time during the meal service. The DON confirmed with the staff that they could assist 2 residents that were sitting side by side with their meal. At 11:57 a.m., 32 minutes after their tablemates were assisted. staff did begin to assist the other 3 residents. On 10/24/22 at 11:57 a.m., the two surveyors confirmed with the DON, the residents were not all assisted at the same time with their meals.

Based on observations, interviews and record review, the facilities interdisciplinary team failed to determine if it was clinically appropriate for a resident to keep a medication at bedside and self-administer medications for 1 of 16 Residents investigated during the investigation stage of the survey process (Resident #32). Finding: On 10/24/22 at approximately 2:00 p.m., during the initial interview with Resident #32, the resident told surveyor that he/she was applying the cream for his/her arthritis in their knees 3 times a day. Surveyor asked what type of cream they were using, resident stated it was in his/her top drawer and couldn't remember the name. Resident showed surveyor a tube of Bio freeze pain relieving gel that they have been using. During review of his/her clinical record, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the facilities interdisciplinary team determined it was clinically appropriate for Resident #32 to keep and self-administer the medicated gel. On 10/26/22 at 1:15 p.m., the surveyor asked the Director of Nursing (DON) what the facilities policy/process was for residents to self-administer medications. The DON stated the resident would need to be assessed to show they knew what the medication was and what it was being used for, they would also have to show they knew when it was due and could self-administer the medication properly. On 10/26/22 at 1:20 p.m., the surveyor and DON went down to resident room, the DON asked Resident #32 if she could look in resident top drawer. Resident gave permission and the DON found a tube of Bio freeze pain relieving gel and resident told her he/she had extra tubes as well. At that time, the surveyor confirmed with the DON that Resident #32 did not have a self-administrative assessment completed and did not have an order to keep the gel at bedside.