Every finding on record at Hospice of Southern Maine

Based on document review, observation, and interview, the agency failed to ensure that controls were working properly to regulate the temperature of the hot water in one (1) of eighteen (18) patient care rooms (Room #106 ). --- Finding:During a tour of the agencys inpatient care facility, ";Gosnell House", on 03/18/2025 at approximately 11:57 AM, a temperature reading was measured in room #106. The temperature of the water was measured at 126° F (degrees Fahrenheit). This reading was verified by the Clinical Nurse Manager. An interview with the Maintenance Supervisor at approximately 12:40 PM reported that patient water temperature should not exceed 120° F. At the time of the survey, there were no patients admitted to room #106. Additional rooms were checked, and all subsequent readings were below the 120° F reading. On 9/21/2021 at approximately 12:55 PM, the temperature was again measured in room #106. The temperature measured at that time was 118.4° F and was verified by the Maintenance Supervisor.

Based on observation, documentation review and interview, the hospice facility failed to provide permits issued from the State Fire Marshals Office in accordance with permits and plan review per Maine Statute Title 25 §2448. Findings: Based on observation and interview with the Resource Nurse, Property Manager, and Clinical Nurse Manager during the survey on 3.19.2025 between the hours of 0900 and 1500 it was identified: 1. It was observed during the survey there were renovations being made in the 100 and 300 wings of the facility, replacing open alcove areas into enclosed closet spaces. This will need plans review through the Fire Marshals Office to ensure that NFPA 101 Chapter 19 codes and requirements are met and followed. The surveyor confirmed this finding with the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of the observation.

Based on observation and interview, the Hospice facility failed to maintain the Exit Corridor required width and storing combustibles in 1 of 3 egress corridors per NFPA 101, Life Safety Code, 2012 Edition, Sections 18.2.1, 19.2.1, 7.1.10.1 Finding: On 03.19.2025, between 9:00 AM and 15:00 PM, a surveyor, with Resource Nurse present, observed the following: 1. In the 100 Wing of the facility storage units made of combustible materials were stored in the hallway near room 103 blocking clear access and potentially disrupting proper sprinkler flow if system was engaged. This is not in accordance with NFPA 101. The storage units were removed prior to leaving the facility. The surveyor confirmed this finding with Resource Nurse at the time of the observation.

Based on observation, document review, and interview, the facility failed to protect the commercial cooking operations by ensuring the entire exhaust system was inspected for grease buildup by a properly trained, qualified, and certified person in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition Sections 11.4 and 12.1.2.2, as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.2.5.1, and 9.2.3. This deficient practice could affect the kitchen area of the facility by having a commercial cooking assembly that is excessively laden with flammable grease and not properly in place under the extinguishing system. Findings: Observation, Interview, and Document Review during a facility tour with the Resource Nurse present on 03.19.2025 from 09:00 to 15:00 identified: 1.When commercial cooking appliances are on wheels, an approved method of marking the precise location for the appliance to be installed to ensure it is properly protected by the extinguishing system shall be applied. An approved method shall ensure that the appliance is returned to its position before cooking takes place. These findings were verified by the Resource Nurse at the time of observations and document review on 03.19.2025 from 09:00 to15:00.

Based on observation and interview, the hospice care facility failed to maintain the interior wall and ceiling finishes, including exposed interior surface per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.3.1, 19.3.3.2 Finding: On 03.19.2025, between 9:00 AM and 15:00 PM, a surveyor, with the Resource Nurse, Property Manager and Clinical Nurse Manager present on 03.19.2025 from 9:00 AM to 15:00 PM identified: 1. It was observed in the Electrical Room that there were multiple cables and conduit penetrating the walls with improper firestopping or smoke penetration protection and not in accordance with NFPA 101. This finding was verified by the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of interview and document review on 03.19.2025 from 9:00 AM to 15:00 PM.

Based on observation, documentation review and interview, the facility failed to ensure the escutcheons and cover plate were not properly installed per NFPA 25 5.2.1.1.6 requires escutcheons and cover plates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or cover plate if found missing during the inspection. Findings: Based on observation and interview with the Resource Nurse, Property Manager, and Clinical Nurse Manager during the survey on 3.19.2025 between the hours of 0900 and 1500 it was identified: 1. It was observed that the escutcheon plate in the soiled utility room was not properly installed or in place in accordance with NFPA 25. This was noted to the staff that a licensed sprinkler tech would need to repair this per Maine Law regarding the maintenance of sprinkler systems. The surveyor confirmed this finding with the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of the observation.

Based on observation, the Hospice facility failed to maintain the corridor doors to resist the passage of smoke to and from the corridor in 2 of 3 egress corridors as referenced by NFPA 101, Life Safety Code 2012 edition, Section 19.3.6.3 Findings: Observation and interview during a facility tour with the Resource Nurse and Clinical Nurse Manager present on 03.19.2025 from 09:00 AM to 15:00 PM identified: 1. Patient Room103 latch side has a 1/2-inch gap on the latch side of the door that allows light through and does not resist the passage of smoke. 2. Patient Room 105 latch side has a 1/2-inch gap on the latch side of the door that allows light through and does not resist the passage of smoke. 3. Patient Room 306 latch side has a 1/2-inch gap on the latch side of the door that allows light through and does not resist the passage of smoke. These findings were verified by the Resource Nurse and Clinical Nurse Manager at the time of interview and document review on 03.19.2025 from 09:00 AM to 15:00 PM.

Based on observation, documentation review and interview, the facility failed to ensure that the dryer exhaust ducts were constructed of rigid metallic material per NFPA 211 10.7.3.2 Findings: Based on observation and interview with the Resource Nurse and Clinical Nurse Manager during the survey on 3.19.2025 between the hours of 0900 am and 1500 pm it was identified: 1. The exhaust hose on two clothes dryer units in the 200 wing were not constructed of rigid materials listed or labeled for the occupancy and not in accordance with NFPA 211. The surveyor confirmed this finding with the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of the observation.

Based on observation, documentation review and interview, the hospice facility failed to provide a written smoking policy in accordance with NFPA 101, Life Safety Code, 2012 edition, Section 19.7.4 Finding: Observation, documentation review and interview during a facility tour on 03.19.2025, between 9:00 AM and 15:00 PM, a surveyor, with the Resource Nurse, Property Manager and Clinical Nurse Manager present on 03.19.2025 from 09:00 AM to 15:00 PM identified: 1. The facility was unable to provide written documentation of a smoking policy. This finding was verified by the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of interview and document review on 03.19.2025 from 09:00 AM to 15:00 PM.

Based on observation, documentation review and interview, the facility failed to ensure proper type and use of portable space heaters were in operation per NFPA 101 19.7.8 Findings: Based on observation and interview with the Resource Nurse, Property Manager and Clinical Nurse Manager during the survey on 3.19.2025 between the hours of 0900 and 1500 it was identified: 1. In the nurses station area 4 different space heating units were found under desks in workspaces. Units were not labeled with the heating element temperatures, and did not meet clearances need to comply with the UL listings and manufacturers recommendations. These portable space heaters were removed from the building prior to ending the survey. The surveyor confirmed this finding with the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of the observation.

Based on observation, and interview, and generator inspection documentation review during the facility tour, the hospice facility failed to maintain the Essential Electric System Generator per NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, sections 8.4.2, and NFPA 99, Healthcare Facilities Code, 2012 edition, section 6.4.4.1.1.3.This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location. Finding: Review of documentation and interview with the Resource Nurse, Property Manager and Clinical Nurse Manager present on 03.19.2025 between 9:00 AM and 15:00 PM identified the following deficiency: 1) The provided generator inspection reports did not show that the generators were tested under the 30% rated load or to the manufacturers recommend exhaust temperatures. This finding was verified by the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of observation on 03.19.2025 between 9:00 AM and 15:00 PM.

Based on observation, the hospice facility failed to ensure that Gas Equipment - ensure oxygen cylinders in the Oxygen Room were protected from being knocked over per NFPA 99 Section 11.6.2.3 Finding: On 03.19.2025, between 9:00 AM and 1500 PM, a surveyor, with the Resource Nurse, Property Manager and Clinical Nurse Manager present, observed the following: 1. It was observed that 4 E size oxygen cylinders in the Oxygen Room were not in a cradle or secured in a stand potentially allowing them to fall and be damaged and not in accordance with NFPA 99. The surveyor confirmed this finding with the Resource Nurse, Property Manager and Clinical Nurse Manager at the time of the observation.