cms_ME
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint ▼ | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3988 | 3988 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 246 | D | L1SY11 | Based on observation and interview, the facility failed to ensure that reasonable accommodations of individual needs and preferences, were provided for 1 of 29 sampled residents (#57). Finding: On 3/3/11 at 11:45 a.m., Resident #57 stated he/she was experiencing pain to a Certified Nurses Assistant (CNA). He relayed that he/she had been seated in his/her wheelchair all morning and was in pain. The resident requested to go to bed, three times, to the Certified Nurses Assistant (CNA). The surveyors witnessed the CNA refuse to assist the resident into bed, stating, "we are not allowed to put people to bed until after lunch." Interview with the CNA at 11:55 a.m. indicated, as a result of a meeting yesterday, the staff were not allowed to put residents in bed until after lunch. Interview with the Assistant Director of Nurses (ADON) at 12:00 p.m., indicated there was a meeting to address the "management of behaviors," as residents needing to go to bed "interrupted lunch service". The ADON corrected staff immediately stating resident needs must be met. | 2014-04-01 | ||
| 3989 | 3989 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 253 | D | L1SY11 | Based on observation and interview, there was a gap under a door to the outside in the kitchen. Finding: On 2/28/11 and 3/3/11, during kitchen observations, the surveyor observed that there were openings large enough to admit a mouse under the door from the outside into the kitchen. This created the potential for pests, including insects and mice, to enter areas of the kitchen. This finding was discussed with the Maintenance Director at 2:00 p.m. on 3/1/11, and the Dietary Manager on 3/3/11 at 11:30 a.m. | 2014-04-01 | ||
| 3990 | 3990 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 279 | E | L1SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and observations, the facility failed to develop a care plan to meet the needs of the resident for 2 of 29 sampled residents (Residents #58 and #73). Findings: 1. Resident #58 had nurses notes dated 12/28/10 through 1/22/11, that indicated a change in status. The resident was noted to have increased agitation, [MEDICAL CONDITION] and hallucinations. The care plan dated 6/24/10, and most recently reviewed on 3/1/11, did not identify mood and/or behaviors as a problem. The care plan was not developed to aid the resident with any interventions that could prevent/assist the resident with his/her [MEDICAL CONDITION]. In an interview with the Assistant Director of Nursing, on 3/2/11 at 3:00 p.m., she confirmed the care plan did not address his/her psychosocial needs. 2. Resident #73's physician's orders [REDACTED]. As of 3/2/11, the medical record lacked evidence that use of the antianxiety medication was included in the care plan. A surveyor discussed this finding in an interview with the Director of Nurses (DON), on 3/2/11 at 3:15 p.m. At this time, the DON confirmed the facility did not have a care plan in place for use of an antianxiety medicine. | 2014-04-01 | ||
| 3991 | 3991 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 368 | E | L1SY11 | Based on interviews, the facility failed to offer bedtime snacks to all residents. Findings: On 3/3/11 at 9:58 a.m., in an interview with the surveyor, the Dietary Manager confirmed there was a 15 hour interval between the evening and morning meals. Additionally, she stated bedtime snacks were offered to some residents, and documented on the Medication Administration Record (MAR); however bedtime snacks were not offered to all residents. The surveyor discussed this finding with the Administrator, on 3/3/11 at 2:30 p.m. | 2014-04-01 | ||
| 3992 | 3992 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 371 | D | L1SY11 | Based on observation and interview, the facility failed to ensure that a fan and radio used in the kitchen area were clean. Finding: On 2/28/11 and 3/3/11, the surveyor observed a soiled fan and radio stored on the top shelf of the clean dishes drying unit. The surveyor confirmed this finding in an interview, with the Cook and Dietary Manager, on 3/3/11 at 11:00 a.m. | 2014-04-01 | ||
| 3993 | 3993 | MONTELLO MANOR | 205006 | 540 COLLEGE ST | LEWISTON | ME | 4240 | 2011-03-03 | 431 | E | L1SY11 | Based on interview and record review, the facility failed to ensure all medications and biologicals were stored under proper temperature controls. Finding: On 3/2/11 at 1:30 p.m., during inspection of the medication room with a Licensed Practical Nurse (LPN) present, the surveyor requested to view the daily medication refrigerator temperature log. The LPN was unable to provide documentation of daily medication refrigerator temperatures and provided the surveyor with documentation of temperatures recorded only once per month. On 3/2/11 at 2:30 p.m., in an interview with the LPN, she acknowledged the importance of taking and recording medication refrigerator temperatures daily, since there were 2 vials of insulin stored in the refrigerator. | 2014-04-01 | ||
| 3994 | 3994 | TAMC - AHC | 205018 | PO BOX 410 | MARS HILL | ME | 4758 | 2010-09-24 | 441 | E | 9XNK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure isolation techniques were maintained to prevent the spread of Clostridium Difficile for 1 of 19 sampled residents (#66). Finding: Documentation on the "Narrative" section on a "Patient Care Monitoring 24 Hour Flowsheet," dated 9/7/10, indicated that Resident #66's stool was positive for Clostridium Difficile (C Diff). Documentation on a physician's "Progress Notes" form, dated 9/8/10, indicated that the resident's[DIAGNOSES REDACTED] toxin was a recurrence and indicated that the resident was starting on his/her second series of treatment with [MEDICATION NAME]. The facility placed the resident on contact precautions. On 9/21/10 at 9:45 AM, a surveyor observed a Registered Nurse (RN), wearing a blue plastic gown & clean gloves, set things up in the room. The RN raised the resident's bed, turned on the over bed light, touched linens, removed the resident's footie sock and then reached under the blue disposable gown into her uniform pocket to retrieve a pair of bandage scissors while still wearing the contaminated gloves. After finishing the dressing change and putting the bed back down, the RN moved to head of the resident's bed to turn off the over bed light. The large open area on the back of the blue plastic gown exposed her uniform. The RN brushed the exposed area of her uniform against th contaminated cubicle curtain. A surveyor discussed these findings in an interview with the RN at the time of the findings. In addition, a surveyor discussed the concern that the facility's blue disposable precaution gowns did not meet in the back and cover staff or visitors' backs, thus exposing everyone to contamination when working in the resident care environment with the facility's Infection Control Professional, on 9/23/10 at 9:15 AM. | 2014-04-01 | ||
| 3995 | 3995 | TAMC - AHC | 205018 | PO BOX 410 | MARS HILL | ME | 4758 | 2010-09-24 | 157 | D | 9XNK11 | Based on observations, record review and interview, the facility failed to ensure a physician and an interested family member were notified of bruising of unknown origin for 1 of 19 sampled residents (#29). Finding: On 9/20/10 at 3:15 PM, a surveyor observed bruising on the top of Resident #29's right hand and wrist. As of 9/23/10 at 3:29 PM, there was no evidence in the resident's medical record to indicate that the physician had been notified of the bruising, until after the surveyor discussed the bruising with the facility. On 9/23/10 at 3:29 PM, a surveyor discussed this finding with the Charge Nurse and on 9/24/10 at 8:26 AM, discussed this finding with the Acting Administrator. | 2014-04-01 | ||
| 3996 | 3996 | TAMC - AHC | 205018 | PO BOX 410 | MARS HILL | ME | 4758 | 2010-09-24 | 279 | D | 9XNK11 | Based on record review and interviews, the facility failed to develop a care plan to address knee pain for 1 of 19 sampled residents (#61). Finding: Resident #61's most recent "Comprehensive Pain Assessment," dated 7/29/10, indicated that the resident was not having pain. In an interview with the resident on 9/21/10 @ 8:39 am, the resident stated that he/she had pain in his/her knee. Nurses notes, dated 9/2/10, indicated that the resident had a dull ache/pain in his/her left knee. Nurses notes indicated that the resident had complained of left knee pain, on 9/3/10, 9/6/10, 9/10/10, 9/11/10, 9/13/10, 9/14/10, 9/16/10, 9/18/10, 9/21/10 and 9/22/10. Resident's "Medication Administration Record" (MAR) indicated that the resident received Tylenol 650 mg for left knee pain, 16 times from 9/10/10 to 9/20/10. Resident's "Pain Management Flow Record" indicated that the resident had verbally scored his/her pain level at a "0" from 9/1/10 to 9/11/10. Beginning 9/12/10 through 9/21/10, the resident verbally scored his/her pain level between 3-5 (mild to moderate pain) daily. As of 9/22/10, the facility failed to develop a care plan to address the resident's left knee pain. On 9/22/10 at 1:54 PM, a surveyor discussed this finding with the Charge Nurse. | 2014-04-01 | ||
| 3997 | 3997 | TAMC - AHC | 205018 | PO BOX 410 | MARS HILL | ME | 4758 | 2010-09-24 | 309 | D | 9XNK11 | Based on record reviews, observations and interviews, the facility failed to ensure assessments of the new onset of pain and bruising of unknown origin were completed for 2 of 19 sampled residents and failed to develop a care plan to address the new onset of pain for 1 of 19 sampled residents (#61 & #29). Findings: 1. Resident #61's "Comprehensive Pain Assessment," dated 7/29/10, indicated that the resident was not having pain. On 9/21/10 at 8:39 AM, in an interview with a surveyor, Resident #61 stated he/she had pain in his/her knee. Nurses notes, dated 9/2/10, indicated that the resident had complained of a dull ache/pain in his/her left knee. Nurses notes indicated that the resident had complained of left knee pain on 9/3/10, 9/6/10, 9/10/10, 9/11/10, 9/13/10, 9/14/10, 9/16/10, 9/18/10, 9/21/10 and 9/22/10. The resident's "Medication Administration Record" (MAR) indicated that the resident received Tylenol 650 mg for complaints of left knee pain, 16 times from 9/10/10 to 9/20/10. The resident's "Pain Management Flow Record" indicated that the resident verbally scored his/her pain level at a "0" between 9/1/10 to 9/11/10. From 9/12/10 through 9/21/10, the resident verbally scored his/her pain level between 3-5 (mild to moderate pain) daily. The resident's medical record lacked evidence that the facility completed an assessment of the resident's new on-set of pain and based on an assessment, developed a care plan to address the resident's knee pain. On 9/22/10 at 1:54 PM, a surveyor discussed this finding with the Charge Nurse. 2. On 9/20/10 at 3:15 PM, a surveyor observed that Resident #29 had bruising on the top of the resident's right hand and wrist. The resident's medical record lacked evidence that the facility had assessed the bruising on the resident's hand and wrist until after the surveyor discussed the bruising with the facility. On 9/23/10 at 3:30 PM, a surveyor discussed this finding with the Charge Nurse. On 9/24/10 at 8:26 PM, a surveyor discussed this finding with the Administrator. | 2014-04-01 | ||
| 3998 | 3998 | TAMC - AHC | 205018 | PO BOX 410 | MARS HILL | ME | 4758 | 2010-09-24 | 514 | B | 9XNK11 | Based on record review and interviews, the facility failed to ensure staff documented when completing moist heat treatments to 1 of 19 sampled resident's hand (#64). Finding: Resident #64's record contained a "Restorative Program," dated 5/27/10, that directed staff to apply moist heat to the resident's hand for 10 minutes and then to slowly and gently massage the resident's hand and wrist. The staff was to then complete passive range of motion (PROM) to the residents fingers and wrists two to three time a week. On 9/22/10 at 1:00 PM, in an interview with a surveyor, a Certified Nursing Assistant (CNA) stated that they were applying the moist heat and massaging the resident's wrist prior to completing PROM. The resident's "Treatment Administration Records" and/or CNAs documentation records lacked evidence that the application of moist heat to the resident's hand was being documented in June 2010, July 2010, August 2010 and September 2010, when the treatment was discontinued. On 9/24/10 at 11:00 AM, a surveyor discussed this finding with the Acting Administrator. | 2014-04-01 | ||
| 3999 | 3999 | ROSS MANOR | 205064 | 758 BROADWAY | BANGOR | ME | 4401 | 2011-01-18 | 431 | D | EOU111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a record for the accounting and disposition of a controlled substance for 1 of 4 sampled closed records reviewed (#1). Finding: Resident #1's clinical record was reviewed on 1/18/11 and indicated the resident had a physician's orders [REDACTED]. The clinical record indicated the resident had been discharged on [DATE] and had received 25 tablets of the Oxycodone. There was no "Controlled Substance Accountability Sheet" found to account for this medication and any tablets that were remaining at the time of discharge. This finding was discussed with the Administrator during an interview with the surveyor, on 1/18/11 at 12:10 p.m. | 2014-04-01 | ||
| 4000 | 4000 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 164 | B | YYXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the confidentiality of each residents' medical information during 2 of 4 survey days. Findings: 1. On 12/28/11 at 8:15 a.m. and at 8:40 a.m., on the Blue Point Unit, a surveyor observed the Registered Nurse leaving the medication cart with a portion of a resident's "Medication Administration Record" (MAR) exposed. The exposed portion of the MAR indicated [REDACTED]. 2. On 12/29/11, at 8:00 a.m., 8:30 a.m. and 10:20 a.m., on the Blue Point, Oak Hill and Pleasant Hill units, a surveyor observed the Registered Nurses leaving the medication cart with a portion of a resident's "Medication Administration Record" (MAR) exposed. The exposed portion of the MAR indicated [REDACTED]. In an interview on 12/29/11 at 10:20 a.m., the Registered Nurse confirmed residents privacy was compromised. | 2014-04-01 | ||
| 4001 | 4001 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 241 | E | YYXR11 | Based on observations and interviews, the facility failed to provide care to 3 of 29 sampled residents, in a manner to maintain the resident's dignity (#88, #26 and #71). Findings: 1. On 12/29/11 at 9:00 a.m., a surveyor observed Resident #88 in bed with his/her indwelling urinary catheter drainage bag uncovered and visible to other residents and visitors. In an interview with the Director of Nursing, on 12/29/11 at 3:15 p.m., she was made aware of this finding. 2. On 12/27/11 at 1:57 p.m., a surveyor observed Resident #26 in bed with an indwelling urinary catheter drainage bag uncovered and suspended from the bed visible to other residents and visitors. This finding was confirmed with the Certified Nursing Assistant (CNA) assigned to care for the resident at the time of the observation. 3. On 12/27/11 at 9:40 a.m., a surveyor observed Resident #71 participating in a group activity with his/her indwelling urinary catheter drainage bag resting on the floor under his/her wheelchair. On 12/28/11 at 1:52 p.m., a surveyor again observed Resident #71, wheeling him/herself by the nurse's station with his/her urine drainage bag and tubing dragging on the floor. In an interview with the Charge Nurse on 12/28/11 at 1:52 p.m., she acknowledged the resident's urine drainage bag should be kept off the floor. 4. On 12/29/11 at 9:02 a.m., a surveyor observed Resident #71 in bed eating breakfast with his/her urinary drainage bag and tubing suspended from the bed, uncovered and fully exposed to other residents and visitors. In an interview with a staff nurse, on 12/29/11 at 9:05 a.m., she acknowledged the resident's urinary drainage bag should be kept covered. | 2014-04-01 | ||
| 4002 | 4002 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 279 | D | YYXR11 | Based on record review and interview, the facility failed to develop a care plan to meet the psychosocial needs of the resident whose life style changed due to placement in long term care for 1 of 29 sampled residents (#124). Finding: Resident # 124 was admitted in September, 2011 for skilled services after an acute injury requiring hospitalization . It was determined by Long Term Care assessment, that the resident would remain at the facility long term. Nurses notes, dated 9/30/11, indicated the resident was informed he/she would be remaining at the facility . Review of social worker and nursing notes indicated the resident was confused; suffered from anxiety and was requesting to go home. The care plan, developed on 9/20/11 and updated on 12/6/11, did not identify the resident's psychosocial needs to assist him/her in adjustment to long term care placement. In an interview with the Social Worker on 12/29/11 at 9:30 a.m. , she confirmed the residents change in status was introduced during the residents rehabilitation stay. | 2014-04-01 | ||
| 4003 | 4003 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 282 | E | YYXR11 | Based on record reviews, observations and interviews, the care plan for 2 of 29 sampled residents was not followed in the area of placement of a urinary drainage bag. Findings: 1. The current comprehensive care plan for Resident #88, directed staff to ensure the urinary drainage bag was kept off the floor. On 12/27/11, during Stage 1 interview; on 12/29/11 at 9:00 a.m. and 12/29/11 at 1:15 p.m., the resident's uncovered urinary drainage bag was observed resting on the floor mat next to the bed. This finding was reviewed with the Director of Nursing, on 12/29/11 at 3:15 p.m. 2. On 12/27/11 at 9:40 a.m., a surveyor observed Resident #71, who was in a group activity, with his/her urinary drainage bag on the floor under his/her wheelchair. The resident's care plan, dated 11/26/11, directed staff to ensure the "urine collection bag to be kept off floor." On 12/28/11, at 1:52 p.m., a surveyor again observed Resident #71, who was wheeling him/herself by the nurse's station with his/her urinary drainage bag and tubing dragging on the floor. In an interview, on 12/28/11 at 1:52 p.m., the Charge Nurse acknowledged the resident's urinary drainage bag should be kept off the floor in accordance with the resident's care plan. | 2014-04-01 | ||
| 4004 | 4004 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 329 | D | YYXR11 | Based on record reviews and interviews, the facility failed to monitor for potential adverse interactions between 2 medications for 1 of 29 sampled residents (#26). Finding: Resident #26's clinical record for contained a facismille, dated 12/2/11, from the Consultant Pharmacist to the physician which advised that the use of the 12/2/11 ordered antibiotic, Linezolid, concurrently with a serotonergic medication could result in a severe drug to drug reaction. According to the Consultant Pharmacist recommendation, dated 12/2/11, the use of these medications together could result in rapid development of symptoms such as Hyperthermia, Hypertension, muscle twitching, rigidity, autonomic instability and mental status changes. In an interview with the facility's Medical Director on 12/29/11 at 3:55 p.m., he stated that the Consultant Pharmacist reports and facsimile's are meant for the physician and Nurse Practitioner and are not routinely shared or distributed to the nursing staff. On 12/8/11, the facility's Consultant Pharmacist report (which is contained in the clinical record), stated that monitoring was required for 2 weeks or 24 hours after completion of the Linezolid for emergent symptoms of central nervous system toxicity. The surveyor noted that the physician had seen the resident on 12/5/11 and 12/7/11 which were 2 of the 7 days the resident recieved these medications, but there was no evidence in the resident's clinical record to indicate that the resident was monitored for a rapid development of a severe reaction by the nursing staff. This finding was reviewed with the facility Medical Director on 12/29/11 at 3:55 p.m. | 2014-04-01 | ||
| 4005 | 4005 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 431 | D | YYXR11 | Based on observation and interview, the facility failed to ensure medications were secured to prevent access by wandering residents and passersby on 1 of 4 days of survey. Finding: On 12/28/11 at 8:20 a.m., the Registered Nurse left the medication cart unattended with Prednisone 20mg (4 tablets, 5mg each) on top of the medication cart. In an interview with the Registered Nurse at 8:25 a.m., she confirmed the medications should not have been left unattended. | 2014-04-01 | ||
| 4006 | 4006 | PINE POINT CENTER | 205070 | 67 PINE POINT RD | SCARBOROUGH | ME | 4074 | 2011-12-30 | 441 | D | YYXR11 | Based on observation and interview, staff failed to follow current infection control practices for 2 of 29 sampled residents, whose urinary drainage bags were observed in contact with the floor and floor mats. Findings: According to Lippincott Manual of Nursing Practice, Ninth Edition, which was identified by the Director of Nursing as the facility's manual for standards of practice, on page 785, maintaining a closed urinary drainage system, to prevent cross contamination, includes keeping the drainage bag off the floor. 1. On 12/27/11, during a Stage 1 interview with Resident #88, the surveyor observed the resident's uncovered urinary drainage bag lying on the floor mat next to the bed. On 12/29/11 at 9:00 a.m. and 1:15 p.m., the surveyor again observed the resident's uncovered urinary drainage bag lying on the floor mat next to the bed. This finding was reviewed with the Director of Nursing on 12/30/11 at 10:00 a.m. 2. On 12/27/11 at 9:40 a.m., the surveyor observed Resident #71, who was in a group with his/her urinary drainage bag on the floor under his/her wheelchair. On 12/28/11 at 1:52 p.m., the surveyor again observed Resident #71, wheeling him/herself by the nurse's station with his/her urinary drainage bag and tubing dragging on the floor. On 12/28/11 at 1:52 p.m., in an interview with the Charge Nurse, she acknowledged the resident's urinary drainage bag should be kept off the floor. | 2014-04-01 | ||
| 4007 | 4007 | BRENTWOOD CENTER FOR HEALTH & REHABILITATION, LLC | 205079 | 370 PORTLAND ST | YARMOUTH | ME | 4096 | 2011-03-24 | 520 | E | L2YB11 | Based on observation and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the annual survey on 1/25/10 through 2/1/10 and the follow up visit to the annual survey on 03/25/10 through 3/26/10, were effective. One of the same federal deficiencies, F514 (the facility must maintain clinical records that are complete and accurate) identified during the 1/25/10 through 2/1/10 and 3/25/10 through 3/26/10 surveys was again identified during this survey. Finding: At the annual survey on 1/25/10 through 2/1/10, and the follow up visit to the annual survey on 3/25/10 through 3/26/10, deficiencies were cited at F514 for an inaccurate medical record. During the annual survey on 3/21/11 through 3/24/11, it was determined that F514 would be cited again for the same issues. | 2014-04-01 | ||
| 4008 | 4008 | BRENTWOOD CENTER FOR HEALTH & REHABILITATION, LLC | 205079 | 370 PORTLAND ST | YARMOUTH | ME | 4096 | 2011-03-24 | 514 | D | L2YB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that the clinical records were complete and contained accurate documentation of a resident's laboratory orders for 1 of 29 sampled residents (#111). Finding: The clinical record, for Resident #111, contained a current physician's orders [REDACTED]. There was no evidence in the resident's clinical record to indicate that the lab had been obtained. In an interview with the Registered Nurse (RN) on duty on 3/23/11, the surveyor was informed that the PT/INR order was written on the wrong resident's recertification orders. This finding was reviewed with the Director of Nurses on 3/23/11, at 3:25 p.m. | 2014-04-01 | ||
| 4009 | 4009 | GREENWOOD CENTER | 205082 | 1142 MAIN ST | SANFORD | ME | 4073 | 2011-02-04 | 170 | C | N7G811 | Based on interview, the facility does not provide mail delivery on Saturdays. Finding: In an interview with the surveyor on 2/3/11 at 1:00 p.m., the former Resident Council President reported that mail was not delivered on Saturday. In an interview, with the Administrator on 2/3/11 at 3:00 p.m., he confirmed that the post office did not deliver the mail on Saturday, but held it at the post office until Monday when the business office was open. | 2014-04-01 | ||
| 4010 | 4010 | GREENWOOD CENTER | 205082 | 1142 MAIN ST | SANFORD | ME | 4073 | 2011-02-04 | 253 | E | N7G811 | Based on observation and interview, the facility failed to provide necessary maintenance services to maintain a sanitary, orderly and comfortable interior. Findings: 1. On 2/3/11 during the facility tour, a surveyor observed damaged walls in resident rooms around the soap dispensers. The damaged walls were observed in rooms 111, 114, 115, 117, 121, 122, 123, 124, 126, 128, 131, 132, 133, 137, 138, 211, 212, 213, 214, 215, 216, 217, 218, 221, 223, 224, 225, 227, 228, 233, 234, 236, and 238. 2. Also during the facility tour, a surveyor observed resident's clothes closets that were damaged. The closets were observed in rooms 111, 115, 116, 117, 121, 122, 123, 124, 126, 128, 132, 133, 134, 137, 138, 216, 218, 221, 224, 228, 236 and 238. 3. During the facility tour on 2/3/11, a surveyor also observed loose floor tiles in front of the sink in Resident room 122. 4. A surveyor also observed 2 Resident rooms doors that were damaged. These doors were the bathroom door in room 126 and the room door for room 231. 5. At 1:15 p.m. on 1/3/11 a surveyor observed that the arm covering on the geri-chair for Resident # 2 was torn. These findings were discussed with the Administrator at the time of the findings. | 2014-04-01 | ||
| 4011 | 4011 | GREENWOOD CENTER | 205082 | 1142 MAIN ST | SANFORD | ME | 4073 | 2011-02-04 | 325 | D | N7G811 | Based on observation and interview, the facility failed to ensure a resident receives a diet based on preferences to ensure adequate nutritional intake for 1 of 26 sampled residents (#4). Findings: Resident #4 had nurses notes dated 10/31/10 through 1/2/11 that indicated the residents declining status, refusal to eat and increased confusion. CNA "Nutritional Intake and Outputs" indicated the resident was consuming 20 percent of meals occasionally and refusing most. The "Documentation Record" documented the resident refused snack on all shifts. "Family Team Notes" dated 1/12/11 indicated that Hospice services were necessary and that the family suggested to increase the resident intake, he/she was to provided soup the resident "seems to enjoy" it and perhaps would encourage his/her intake. The family request was followed. Again, during Interdisciplinary Team Review on 2/2/11 the request was not considered. Interview with the Social Worker on 2/4/11 indicated the information was forwarded to the dietary staff but was not acted upon. | 2014-04-01 | ||
| 4012 | 4012 | GREENWOOD CENTER | 205082 | 1142 MAIN ST | SANFORD | ME | 4073 | 2011-02-04 | 334 | E | N7G811 | Based on record review and interview, the facility failed to offer influenza and pneumococcal immunizations and ensure that the medical record included documentation that the residents had recieved education on the risks and/or benefits of recieving the immunizations for 3 of 5 sampled residents (#120, #108, and #93) . Findings: 1. Resident #120 was admitted to the facility in 11/4/2010. There was no evidence in the resident's clinical record that the resident had received, or been offered, the influenza vaccine for the 2011 flu season. Additionally, there was no evidence in the resident's clinical record that education regarding the benefits and potential side effects of the vaccine had been provided to the resident/family. During an interview with the charge nurse on 2/3/11, she confirmed the immunization was not offered as the clinical record contained no documentation. 2. Resident #108 was admitted to the facility in 4/28/10. There was no evidence in the resident's clinical record that the resident had received or been offered the influenza vaccine for the 2011 flu season. Additionaly, there was no evidence in the resident's clinical record that education regarding the benefits and potential side effects of the vaccine had been provided to the resident/family. The surveyor discussed this finding in an interview with the Infection control nurse, on 2/3/11 at 12:20 p.m. who confirmed that the clinical record lacked the aforementioned documentation. 3. 1. Resident #93 was admitted to the facility in 5/4/10. There was no evidence in the resident's clinical record that the resident had received or been offered the influenza vaccine for the 2011 flu season. There was also no evidence in the resident's clinical record that education regarding the benefits and potential side effects of the vaccine had been provided to the resident/family. The surveyor discussed this finding in an interview with the Infection control nurse, on 2/3/11 at 12:20 p.m. who confirmed that the clinical record lacked the aforementioned docume… | 2014-04-01 | ||
| 4013 | 4013 | FREEPORT NURSING & REHAB CENTER | 205092 | 3 EAST ST | FREEPORT | ME | 4032 | 2011-01-11 | 250 | D | 1VFZ11 | Based on record reviews and interviews, the facility failed to ensure that medically-related social services were consistently provided for 1 of 27 sampled residents (Resident #18) in the areas of community discharge and care plan meeting involvement. Finding: In an interview with Resident #18 on 1/07/11 at 10:20 a.m. he/she expressed a strong desire to relocate to a facility up the coast and closer to the geographical area in which he/she lived and still has friends. Resident #18 also indicated that he/she was not aware of any scheduled meetings in which his/her care was discussed. The surveyor noted that there was no evidence to indicate that the resident was incapacitated and unable to participate in team meetings. Additionally, the Power of Attorney documented in the clinical record was for financial matters and not medical or care decisions. The surveyor discussed these findings on 1/10/11 at 2:20 p.m. in an interview with the Licensed Social Worker, who informed the surveyor that the resident's Power of Attorney did not think community discharge for this resident is appropriate, and was the person notified of the team meetings and not the resident. | 2014-04-01 | ||
| 4014 | 4014 | FREEPORT NURSING & REHAB CENTER | 205092 | 3 EAST ST | FREEPORT | ME | 4032 | 2011-01-11 | 279 | D | 1VFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's needs in coordination with hospice care for 1 of 27 sampled residents (#34). Finding: Resident #34 had a physician's orders [REDACTED]. The care plan updated on 1/3/10 contained no indication the resident was receiving hospice services or, interventions to coordinate care in order to meet the needs of the resident for end of life care. Interview with the nurse on 1/10/11 at 11:00 a.m. indicated she was not aware the resident was receiving hospice services. | 2014-04-01 | ||
| 4015 | 4015 | FREEPORT NURSING & REHAB CENTER | 205092 | 3 EAST ST | FREEPORT | ME | 4032 | 2011-01-11 | 280 | D | 1VFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure that care plans were updated to reflect the resident's current needs in the area of nutritional services and high risk for injury for 2 of 27 sampled residents (#45 and #38 ). Findings: 1. Resident #45, with a [DIAGNOSES REDACTED]. The resident's weight on admission was 145 pounds. Over the next quarter the resident lost 9.5 pounds and on 10/14/10 was weighed at 135.5 pounds. The Interdisciplinary Team Meeting,on 11/2/10, indicated the care plan was reviewed but did not identify the weight loss, or suggest interventions to prevent further weight loss. Interview with the care plan nurse on 1/7/10 at 10:00 a.m. confirmed that the resident's weight loss was "missed" while updating the care plan and was not addressed. 2. Resident #38's care plan, dated 9/7/10, and updated on 11/16/10, indicated the following intervention: "Be sure that resident can get to his/her grabber/gripper and remind resident to use it to reach for things." On 1/6/11, at 10:55 a.m., the surveyor observed the resident in his/her room with no grabber/gripper device in sight. In an interview with the resident's CNA on 1/7/11 at 10:55 a.m., the CNA stated that the resident had not used the device in a long time, but that they did use a Dycem pad on the resident's wheelchair to prevent the resident from sliding out of the wheelchair and falling. The surveyor discussed this finding in an interview with the MDS Coordinator/Care Plan Nurse, on 1/7/11 at 1:45 p.m., who was not aware the Grabber/Gripper device was no longer in use or that the staff was utilizing Dycem pads for fall prevention. | 2014-04-01 | ||
| 4016 | 4016 | FREEPORT NURSING & REHAB CENTER | 205092 | 3 EAST ST | FREEPORT | ME | 4032 | 2011-01-11 | 325 | E | 1VFZ12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide nutritional services to ensure that each resident maintained acceptable parameters of nutritional status based on body weight for 1 of 9 sampled residents (Resident #9). Findings: Resident #9, with a [DIAGNOSES REDACTED]. The resident's weight record indicated a weight of 215 lbs on 1/10/11. Documentation in the clinical record indicated that his/her weight was 209 lbs on 2/3/11, (a 6 lb. weight loss in 24 days). On 3/2/11, the resident's weight was documented as 219 lbs, (a 10 lb. weight gain in 27 days.) On 3/15/11 at 1:45 p.m., the weight fluctuations were discussed with the Director of Nursing and Administrator. The Director of Nursing reported that there was nothing in place to direct that weight fluctuations be questioned or reweighed. | 2014-04-01 | ||
| 4017 | 4017 | FREEPORT NURSING & REHAB CENTER | 205092 | 3 EAST ST | FREEPORT | ME | 4032 | 2011-01-11 | 456 | E | 1VFZ11 | Based on record review and interviews, the facility failed to ensure all patient care equipment was maintained and in safe operating condition. Finding: On 1/7/11 at 1:30 p.m., in an interview with the Nurse Manager, she informed the surveyor that the hoyer lift scale was not in operating condition through the summer of 2010; therefore weights were not obtained during this time for select residents. In an additional interview, on 1/10/11 at 11:55 a.m., the Dietician confirmed the hoyer lift scale was not in operating condition; therefore weights could not be assessed for select residents thus affecting nutritional assessments. | 2014-04-01 | ||
| 4018 | 4018 | RUMFORD COMMUNITY HOME | 205099 | 11 JOHN F KENNEDY LANE | RUMFORD | ME | 4276 | 2011-04-07 | 253 | D | LLBR11 | Based on observations and interview, the facility failed to ensure that resident equipment, bedside tables, baseboard heaters and flooring were in good repair. Findings: On 04/05/2011 at 3:00 p.m., a surveyor toured environment with the Administrator. Findings were confirmed at time of the observation with the Administrator. Findings: 1. East Wing: a. Across from the first wall fan, the cove base was pushed in creating an approximate 2 feet by 3/4 of an inch gap that was uncleanable. b. The base of the Sit-to-Stand Hoyer was heavily soiled with dust and dirt particles. c. Room E1, the baseboard heater cover on the outside wall was separated which exposed a sharp metal edge. d. Room E-2, the baseboard heater cover on the outside wall was separated which exposed a sharp metal edge. 2. West Wing: a. Room W-15, on the outside wall of the room, the middle baseboard connector cover was missing which exposed a sharp metal edge. b. Room W-16, on the outside wall of the room, the middle baseboard connector cover was missing which exposed a sharp metal edge. c. Room W-17, the veneer on the bedside table was pulled away leaving sharp edges. Four floor tiles behind the water closet were cracked and gouged creating an uncleanable surface. The outside wall frame was missing the top piece exposing the insulation that was between the wall and window casing. d. Room W-19, towards the bathroom, the end of the baseboard heater was missing an end cover which exposed sharp metal edges. e. Room W-21, on the outside wall of the room, the middle baseboard connector cover was missing which exposed a sharp metal edge. f. Room W-24, the outside wall frame was missing the top piece exposing the insulation that was between the wall and window casing. g. The West Wing Whirlpool, in front of the water closet there was a large piece of the linoleum flooring missing and in the middle of the floor was an approximate 2-3 foot gap in the linoleum that created an uncleanable surface. | 2014-04-01 | ||
| 4019 | 4019 | RUMFORD COMMUNITY HOME | 205099 | 11 JOHN F KENNEDY LANE | RUMFORD | ME | 4276 | 2011-04-07 | 329 | E | LLBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the clinical record for 1 of 23 Stage 2 sampled residents (Resident #27), lacked documentation to justify the continued use of an antipsychotic medication and failed to show evidence of an attempt at a gradual dose reduction after September 2008. Finding: Resident #27 had been receiving the antipsychotic medication, [MEDICATION NAME], since June 2007. The initial [DIAGNOSES REDACTED]. In February 2008 the dose of the [MEDICATION NAME] was reduced from 4 milligrams (mg) every evening to 2 mg every evening. According to documentation in the clinical record, a further attempt to discontinue the [MEDICATION NAME] failed in September 2008. The 12/28/10 annual Minimum Data Set (MDS) 3.0 identified the resident as exhibiting no mood issues and the only behavior identified was wandering. Again, the only behavior identified on the 03/22/11 MDS 3.0 was wandering. The 12/30/10 Care Area Assessment form indicated that behaviors triggered however, the decision was made not to proceed to care plan as the resident's wandering was not disruptive to other residents or activities. On 04/06/11 at 2:00 p.m. and 2:45 p.m., in interviews with the surveyor, four different Certified Nursing Assistants stated that Resident #27 was not combative or resistive to care and that the only behavior exhibited was wandering. There was no evidence found in the clinical record that a gradual dose reduction of the [MEDICATION NAME] was attempted after September 2008 and that there were adequate indications for the continued use of the antipsychotic. The surveyor discussed this finding with the Administrator, on 04/06/11 and with the Director of Nursing Services, on 04/07/11. | 2014-04-01 | ||
| 4020 | 4020 | KINDRED NURSING AND REHABILITATION-WESTGATE | 205105 | 750 UNION ST | BANGOR | ME | 4401 | 2011-01-24 | 282 | D | XSO611 | Based on record review and interview, the facility failed to provide interventions outlined in the resident's care plan for toileting for 1 of 1 sampled resident (Resident #1). Finding: Resident #1's current care plan indicated that the resident was to be toileted upon awakening in the a.m., after lunch and supper, at bedtime and when needed. On 01/24/2011 at 10:20 a.m., in an interview with the surveyor, C.N.A. #1 stated that on 01/05/2011, at approximately 5:30 p.m. (after supper). Resident #1 was not toileted and was subsequently incontinent of stool. Resident #1 had no skin problems and did not show signs of distress because of the staff's failure to implement the resident's toileting plan. The surveyor discussed this finding in an interview with the Director of Nursing Services, on 01/24/2011 at 10:55 a.m.. | 2014-04-01 | ||
| 4021 | 4021 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-01-26 | 282 | D | 8W0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident's care plan for food allergies [REDACTED].#1). Finding: Resident#1's current care plan indicated that the resident had many food allergies [REDACTED]. On 01/26/2011 at 1:15 p.m., in an interview, a C.N.A. stated to the surveyor that on 01/17/2011, she was assisting Resident #1 with eating his/her breakfast. The C.N.A. stated that she observed a banana on the resident's tray. The C.N.A. did not give the banana to the resident because she was told that Resident #1 was allergic to bananas. The dietary card has since been updated to show that Resident #1 was allergic to bananas. On 01/26/2011 at 2:00 p.m., the surveyor discussed this finding with the Director of Nursing Services. | 2014-04-01 | ||
| 4022 | 4022 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-03-31 | 279 | E | Q6OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure that care plans were developed in the identified areas of limited range of motion for 2 of 3 Stage 2 sampled residents with contractures ( #19 and #85). Findings: 1. Resident #19's significant change Minimum Data Set, dated dated [DATE], was coded to indicate the resident had functional limitation in range of motion of the lower extremity on one side. In addition, all of the resident's MDSs since 2009 had also been coded to indicate the resident had had functional limitation in range of motion of the lower extremity on one side. On 3/29/11, a surveyor observed that Resident #19 had a contracture of his/her left foot. The resident's current care plan for Activities of Daily Living function did not address the resident's left ankle contracture or identify approaches to maintain or improve range of motion. On 3/31/11 at 12:50 pm, a surveyor discussed this finding with the Deputy Director of Clinical Operations. 2. Resident #85's admission MDS, dated [DATE], was coded to indicate that the resident had limitations in range of motion in both legs and feet with full loss of voluntary motion and was coded to indicate the resident did not ambulate. The resident's most recent quarterly MDS, dated [DATE], was coded to indicate the resident had functional limitations in range of motion in both lower extremities. On 3/30/11 at 12:25 pm, the surveyor observed that the resident had contractures of both ankles. The resident's RAPS, dated 6/08/10, indicated that ADL function/Rehab Potential triggered and would be care planned related to [MEDICAL CONDITION] and lower extremity weakness-presently wheelchair bound. The resident's care plans for ADL function, dated 5/27/10 and 10/27/10, did not address the resident's ankle contracture or identify approaches to maintain or improve range of motion. On 3/30/11 at 2:00 pm, a surveyor discussed this finding with the Director of Nursing… | 2014-04-01 | ||
| 4023 | 4023 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-03-31 | 280 | E | Q6OV11 | Based on record review and interview, the facility failed to ensure that a care plan was updated to reflect the resident's current status in the area of weight loss for 1 of 32 Stage 2 sampled residents (#19). Finding: Documentation in Resident #19's clinical record indicated that, from 9/01/10 through 3/24/11, the resident lost 32 pounds, a weight loss of 11.64%. The resident's current nutrition care plan, dated 2/14/11 and updated on 3/30/11, indicated the resident had had a potential alteration in nutritional status. There was no evidence in the resident's care plan to indicate that the resident had experienced actual weight loss. A surveyor discussed this finding in an interview with the District Director Clinical Operations, on 3/31/11 at 8:30 am. | 2014-04-01 | ||
| 4024 | 4024 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-03-31 | 314 | D | Q6OV11 | Based on observations, record review and interviews, the facility failed to ensure that pressure ulcer treatment to prevent further breakdown and promote healing was provided to 1 of 2 Stage 2 sampled residents with pressure ulcers (# 81). Finding: Documentation on Resident # 81's "Weekly Pressure Ulcer Condition Report," dated 2/23/11, indicated that the resident had a Stage IV pressure ulcer on the lateral aspect of his/her right foot. The resident's "Treatment Record," dated February, 2011, indicated that the resident was to have heel lift boots on bilateral lower extremities at all times except when giving care. The resident's wound clinic order sheets, dated 3/15/11 and 3/29/11, indicated that direct pressure over the wound site was to be avoided and that weight was to be kept off the wound. On 3/30/11 at 2:45 pm, a surveyor observed the resident lying in bed on his/her right side with the resident's legs contracted. A dressing was in place on the lateral aspect of the resident's right foot which was in contact with the surface of the bed. The resident was not wearing the heel lift boots. On 3/31/11 at 1:45 pm, the surveyor discussed this finding with the Director of Nursing and the Deputy Director of Clinical Operations. | 2014-04-01 | ||
| 4025 | 4025 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-03-31 | 318 | E | Q6OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure that residents received treatment and services to prevent further decline in range of motion for 2 of 3 Stage 2 residents with limited range of motion ( #19 and 85). Findings: 1. Resident #19's significant change MDS, dated [DATE], was coded to indicate the resident had functional limitation in range of motion of the lower extremity on one side. In addition, all of the resident's MDSs since 2009 had also been coded to indicate the resident had a functional limitation in range of motion of the lower extremity on one side. On 3/29/11, a surveyor observed that Resident #19 had a contracture of his/her left foot. There was no evidence in the resident's clinical record to indicate the resident had received treatment and services to prevent further contractures of the left foot. On 3/31/11 at 12:50 pm, a surveyor discussed this finding with the Deputy Director of Clinical Operations. 2. Resident #85's admission MDS, dated [DATE], was coded to indicate that resident had limitation in range of motion in both legs and feet with full loss of voluntary motion and was coded to indicate the resident did not ambulate. The resident's most current quarterly MDS, dated [DATE], was coded to indicate the resident had functional limitations in range of motion in both lower extremities. On 3/30/11 at 12:25 pm, a surveyor observed that the resident had contractures of both ankles. The resident had a physician's orders [REDACTED]. There was no evidence in the resident's clinical record that a therapy evaluation had been completed or the resident had received treatment for [REDACTED]. On 3/30/11 at 2:00 pm, a surveyor discussed this finding with the Director of Nursing and the Deputy Director of Clinical Operations. Based on record review and interview, the facility failed to ensure that a Functional Maintenance Program was followed for 1 of 2 sampled residents with a Functional Main… | 2014-04-01 | ||
| 4026 | 4026 | EASTSIDE CENTER FOR HEALTH & REHABILITATION, LLC | 205106 | 516 MT HOPE AVENUE | BANGOR | ME | 4401 | 2011-03-31 | 492 | B | Q6OV11 | Based on interview, the facility was not in compliance with the State Regulations in regards to having a State Qualified Food Service Supervisor. The State of Maine Regulation 18.B.4 states: A Food Service Supervisor (Dietetic Service Supervisor) is a person who: a. Is a qualified dietician: or b. Is a graduate of a dietetic technician program, approved by the American Dietetic Association; or is a graduate of the Dietary Managers Association approved course and has passed the Certifying Board for Dietary Managers Association approved course and has passed the Certifying Board for dietary Managers credentialing exam; or c. Is a graduate of a State-approved course in food service supervision; or d. Has training and experience in food service supervision and management in a military service, equivalent to the requirements in (b) or (c) above. Finding: 1. As of 03/31/11, the Food Service Supervisor (FSS) did not meet the qualifications for the Food Service Supervisor. This was confirmed with the FSS in an interview, on 3/31/2011 at 10:43 am. The responsibilities for dietary services was being supervised by a Registered Dietician. Based on review of the nursing staff schedule and interview, the facility failed to meet the State minimum staff to resident ratio of 1 staff to 5 residents for 6 day shifts randomly chosen between 02/01/2011 through 02/13/2011. The State Regulation 9.A.4 states: The nursing staff-to-resident ratio is the number of nursing staff to the number of occupied beds. Nursing assistants in training shall not be counted in the ratios. The minimum nursing staff to resident ratio shall be: a. One-to-five on the day shift; b. One-to-ten on the evening shift; and c. One-to-fifteen on the night shift. Findings: 1. On 02/01/2011, the facility had a census of 62 residents, which required 13 nursing staff to be on duty on the day shift to meet the State minimum staff-to-resident ratio of one nursing staff member to every five residents. The nursing schedule given to the surveyor indicated that 12 nursing st… | 2014-04-01 | ||
| 4027 | 4027 | MARSHALL HEALTH CARE AND REHAB | 205109 | 16 BEAL STREET | MACHIAS | ME | 4654 | 2011-01-27 | 323 | E | UCLI12 | Based on observations and interviews, the facility failed to ensure that a large chipped area on a resident's footboard was repaired. Finding: On 01/27/2011 at 10:30 a.m., during a follow up survey, the surveyor observed that the resident's bed in Room #20 which previously had a large chipped area on the footboard that had created sharp, splintery areas was missing. The Maintenance Supervisor and the housekeeper stated that the bed had been moved to another room, but they were not sure what room. The bed was moved to Room 11. The surveyor observed that the large, chipped area on the footboard had not been repaired before the facility had another resident occupy the bed. This was discussed with the Maintenance Supervisor at the time of the observation and discussed with the Director of Nursing Services, on 01/27/2011 at 11:00 a.m. | 2014-04-01 | ||
| 4028 | 4028 | MARSHALL HEALTH CARE AND REHAB | 205109 | 16 BEAL STREET | MACHIAS | ME | 4654 | 2010-12-10 | 253 | E | UCLI11 | Based on observations and interviews, the facility failed to maintain door seals on three entry doors, cleanable surfaces around sinks and water closets and failed to prevent sharp edges on sink counters, resident fixtures and resident room doors. In addition, the facility failed to finish repairs on the walls in resident living areas. Findings: 1. On 12/8/10, two surveyors noted three of the facility's exit doors had a gap to the outside at the bottom center of the doors. The exit door next to kitchen and in the front entrance to the building had an approximately 1 and 1/2 inch wide by 1/2 inch in height gap in the center where the two doors meet and the exit door at the end of West wing had an approximately 1 and 1/2 inch wide by 1/4 inch in height gap to the outside. These gaps would create the potential for insects and/or rodents to enter the facility. The surveyor discussed this finding with the Administrator, on 12/12/10 at 1:30 p.m. During the facility environmental tour, the following were observed: Room #5: The bathroom floor tiles around the water closet were separated and a section of the cove base was separated from the wall leaving uncleanable surfaces. In addition, the laminate counter top in front of the hand sink was chipped creating sharp edges. South Wing Whirlpool room: The edges along the shower floor abutting the cove base was rusty creating an uncleanable surface. The caulking around the water closet was soiled and rusted. The laminate counter top in front of the hand sink was chipped creating sharp edges. Room #12: The caulking around the hand sink was missing creating an uncleanable surface. South Wing Day Room: The inside of the microwave was soiled with food particles. Room #14: Two bolt ends on one of the bathroom doors were sticking inward into the bathroom creating a potential safety hazard. The caulking around the hand sink was separated creating an uncleanable surface. Room #15: The laminate counter top in front of the hand sink was chipped creating sharp edges and the caulking arou… | 2014-04-01 | ||
| 4029 | 4029 | MARSHALL HEALTH CARE AND REHAB | 205109 | 16 BEAL STREET | MACHIAS | ME | 4654 | 2010-12-10 | 279 | B | UCLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the care plan for 1 of 1 (#30) residents, who was receiving the Medicare Hospice benefit, reflected the participation of Hospice services. Resident #30 had a physician's orders [REDACTED]. Resident #30 began receiving Hospice services on 11/18/2010. As of 12/10/2010, the resident's facility care plan did not identify the care and services that Hospice would provide to this resident. The surveyor discussed this finding in an interview with the Unit Manager, on 12/10/2010 at 8:40 am. | 2014-04-01 | ||
| 4030 | 4030 | MARSHALL HEALTH CARE AND REHAB | 205109 | 16 BEAL STREET | MACHIAS | ME | 4654 | 2010-12-10 | 371 | E | UCLI11 | Based on observations and interviews, the facility failed to maintain a sanitary environment in the kitchen by not having cleanable surfaces and equipment that was free from dust and debris. In addition, a gap in a kitchen window created the potential for insects to enter the facility. Findings: During a tour of the kitchen on 12/7/10 at 12:40 p.m. and 2:15 p.m. and on 12/8/10 at 8:10 a.m. and 1:30 p.m., a surveyor observed the following: 1. On the initial tour, the surveyor observed an Air Conditioning (AC) unit in the window over the cook's food prep area. There was no cover over the front of the unit and dust clumps were visible on a hose and in the unit. The AC unit set on unfinished boards on top of the window sill with a gap along the bottom left side of the unit open to the outside, creating the potential for insects to enter the facility. On 12/7/10, this finding was discussed with the Dietary Services Manager (DSM) who stated to the surveyor that the AC unit was broken and was on the list for maintenance to remove, but would check with them to see how far down on the list. On a tour of the kitchen at 2:15 p.m., the AC unit had been removed. 2. The facility's stove was heavily soiled on the sides and front with dust and debris, the pipes behind the stove, to the left of the stove and running up to the hood on the right side of the stove, were soiled with clumps of dust hanging off them. Clumps of dust and debris were under the knobs of the stove and on top of a panel along the bottom of the stove and inside the oven broil area. The gas flames under the rack were coated with hanging clumps of dust. The mat the stove was on was heavily soiled with debris and dust clumps were observed under stove. The surveyor discussed this finding during an interview with the Administrator, on 12/7/10 at 3:00 p.m. 3. The bottom of the food mixer was soiled with dried food particles, that were still present on 12/9/10 at 8:35 a.m., 2 days after it was originally observed and discussed with the facility staff. 4. The rolling… | 2014-04-01 | ||
| 4031 | 4031 | MARSHALL HEALTH CARE AND REHAB | 205109 | 16 BEAL STREET | MACHIAS | ME | 4654 | 2010-12-10 | 463 | E | UCLI11 | Based on observations and interviews, the facility failed to have a functional electronic nursing call system on the South Wing. Findings: 1. On 12/8/10, two surveyors checked a resident's call bell on the South wing. The surveyors found the call system to be inoperable. The Charge Nurse stated to the surveyors that none of the call bells worked on that wing and had been inoperable for "several weeks." The Charge Nurse stated that the residents who were able to ring for help, used a hand-held bell. 2. On 12/8/10 at 3:15 p.m., two surveyors heard a bell ringing in room 2. At approximately 3:17 p.m., 3 Certified Nursing Assistants (CNA) were observed walking down the hall, discussing as to the location of the ringing bell. One CNA stated she could not hear any bell. The other 2 CNA's stated they thought it was coming from room 2 and upon entering, found Resident #42 in the bathroom ringing his/her bell. 3. On 12/10/10 at 10:45 a.m., a Certified Nursing Assistant stated to the surveyor that some residents just ring the bell once and she would not be able to tell which room it was so she would walk up and down the hall checking to see which resident was ringing the bell. 4. On 12/10/10 10:10 a.m., the surveyor interviewed Resident #42 who stated the problem with the call bell not working had been going on for a month and he/she got tired ringing the bell. Resident #42 stated he/she does need help going to and from the bathroom as "I have a habit of falling." 5. On 12/10/10 10:10 a.m., Resident #63 stated to the surveyor that he/she had only been in the facility a short time but was tired of ringing the bell. The resident also stated at night, if the CNA's are at the other end of the building they can not hear it and he/she has had to wait up to an hour for a response. 6. In an interview with the Administrator on 12/9/2010, at 3:16 p.m., he stated to the surveyor that the electronic call system went down on 11/12/2010. The facility provided alert and oriented residents with hand held call bells and ensured identified … | 2014-04-01 | ||
| 4032 | 4032 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 201 | D | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to allow 1 of 1 residents (#63) to remain in the facility. Finding: On 1/13/11, the medical record for Resident #63 indicated that the resident was transfered to another facility after the resident's skilled nursing care was completed. Resident #63 was admitted from the hospital on [DATE]. The resident was previously a resident on Heritage Manor's Residential Care Unit. The discharge plan was for the resident to complete necessary therapy and return to the Residential Care Unit. Resident #63 did not make necessary progress to return safely to the Unit. On 10/22/10, the resident was discharged to a facility in Coopers Mills. In an interview with the charge nurse on 1/13/11, a surveyor was informed that the reason the resident was transferred to Coopers Mills was that the facility did not have an available bed. Also, on 1/13/11, a surveyor was informed by the facility's Social Service Director that the resident was discharged due to no available bed. The medical record contained a note by the Social Service Director on 10/8/10 that indicated that the resident's desire was to stay in Winthrop. A review of the resident's medical record indicated that the resident grew up in Winthrop, worked in Winthrop, attended church in Winthrop and had family in Winthrop. This finding was discussed with the Administrator at the time of the finding. | 2014-04-01 | ||
| 4033 | 4033 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 225 | E | ZOBY11 | Based on record reviews and interviews, the facility failed to ensure that 2 of 4 newly hired professionals was in good standing with his/her licensing authority. Findings: 1. On 1/14/11, during a review of 4 personnel records of licensed professionals, the personnel record for a Occupational Therapist (OT) lacked evidence that the OT's license was verified with the licensing board prior to the OT's hire date of 11/1/10. 2. On 1/14/11, during a review of 4 personnel records of licensed professionals, the personnel record for a Speech/Language Patholigist (SLP) lacked evidence that the SLP's license was verified with the licensing board prior of the SLP's hire date of 12/1/10. These findings were discussed with the Rehabilitation Manager at the time of the findings. | 2014-04-01 | ||
| 4034 | 4034 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 226 | E | ZOBY11 | Based on record reviews and interviews, the facility failed to ensure that 2 of 4 newly hired professionals was in good standing with his/her licensing authority. Findings: 1. On 1/14/11, during a review of 4 personnel records of licensed professionals, the personnel record for a Occupational Therapist (OT) lacked evidence that the OT's license was verified with the licensing board prior to the OT's hire date of 11/1/10. 2. On 1/14/11, during a review of 4 personnel records of licensed professionals, the personnel record for a Speech/Language Patholigist (SLP) lacked evidence that the SLP's license was verified with the licensing board prior of the SLP's hire date of 12/1/10. These findings were discussed with the Rehabilitation Manager at the time of the findings. | 2014-04-01 | ||
| 4035 | 4035 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 246 | D | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide reasonable accommodation of resident individual needs and preferences for 1 of 3 residents (#72). Finding; On 1/10/11 at 11:30 AM, a surveyor interviewed Resident #72. During the interview, Resident #72 indicated that he/she is unable to choose when to get up. The resident indicated "If you want to go to breakfast you have to get up and go." Resident #72 also indicated that he/she did not feel that staff take the time to listen and were not helpful when he/she requested to stay in his/her room for dinner. Resident #72 indicated to the surveyor that he/she was having pain and felt he/she was not able to get into the wheelchair and objected to going to dining room for dinner. Resident indicated, "In order to fulfill rules of the house, everyone goes to the dining room three meals a day." Resident #72 indicated that he/she saw no one and no one brought a meal to him/her in the evening he/she requested to stay in the room. Admission Nursing Screen, dated 1/5/11, indicated resident is alert/oriented. Resident has [DIAGNOSES REDACTED]. Nurses Notes dated 1/9/11 indicated that "OOB to w/c with 3 cushions/pillows. Refuses after 2-3 minute to be up. Returned to bed. Frequent request for pain med". On 1/12/11 at 11:34 AM, in an interview, the Administrator indicated that when residents first come to the facility during the first 72 hours, staff strongly recommend that residents go to the dining room for meals because they are not sure if there is a choking risk with the residents. On 1/12/11, in an interview with the Food Service Director(FSD) and Director of Nursing(DON), the FSD and DON confirmed the facility always encourage residents to go to dining room when first admitted because they do not know the residents, don't know if the residents have swallowing/chewing difficulties as they have not been screened yet. Staff want to make sure the residents are safe. A surveyor discussed… | 2014-04-01 | ||
| 4036 | 4036 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 253 | B | ZOBY11 | Based on observation and interview, the facility failed to maintain cleanable floor surfaces. Findings: 1. On 1/10/11 at 8:05 AM, a surveyor observed that floor tiles were cracked in room nine creating an uncleanable surface that is not easily sanitized. The surveyor discussed this finding in an interview with Director of Nurses at the time of the finding. 2. On 1/18/11 at 10:30 AM during environmental tour a surveyor found cracked tiles in rooms fourteen and sixteen. A surveyor discussed this finding at the time of the finding with the Maintenance Supervisor. | 2014-04-01 | ||
| 4037 | 4037 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 279 | E | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to document measurable objectives and resident specific interventions in the area of psychoactive medications for 2 of 3 residents sampled in the area of psychoactive medications (#7 & #28). Findings: 1. Documentation on a Resident #7's computer generated "Orders" form, signed by the physician on 11/23/10, indicated that the resident had been on 3 psychoactive medications: [MEDICATION NAME], an antidepressant medication; Ambien, a sedative, hypnotic medication; and [MEDICATION NAME], an antipsychotic medication since August 2010. In addition, documentation on the 11/23/10 "Orders" form indicated that the resident had been on a 4th psychoactive medication, [MEDICATION NAME], an anxiolytic medication, since October 2010. Documentation on the resident's current care plan, dated 8/22/10, indicated that the resident had a "Potential for ineffective coping" and referred to [MEDICAL CONDITION], history of hallucinations, anxiety, depression, [MEDICAL CONDITION] and history of suicidal ideation. The goal indicated that the resident would "demonstrate adjustment to new environment in 3 months." In addition the care plan directed the staff to "administer medications as ordered, observe for side effects and effectiveness of medications." There were no measurable goals, objectives or interventions specific to the resident, his/her psychoactive medications and his/her psychoemotional issues included on the resident's care plan. A surveyor discussed this finding in an interview with the Director of Nursing and Professional Services Consultant, on 1/19/11, at 2:45 PM. 2. Documentation on Resident #28's computer generated "Orders" form signed by the physician on 12/16/10, indicating the resident had been on psychoactive medications: [MEDICATION NAME] an anti-psychotic medication used for [MEDICAL CONDITION] since 11/11/10, Klonopin an anticonvulsant/benzodiazepine used for Anxiety since 1/4/11 and [… | 2014-04-01 | ||
| 4038 | 4038 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 280 | D | ZOBY11 | Based on observation, record review and interviews the facility failed to ensure care plans were updated in the area of falls for 1 of 1 residents (#28). Finding: Resident #28's record contained documentation in the "Interdisciplinary Progress Notes", dated 12/2/10 and 12/12/10, that the resident threw him/herself on the floor. There was no documentation to indicate he/she was seen doing this. During interviews with the nursing staff, there was only one time a staff person observed the resident throw him/herself on the floor, which was on 11/5/10. The resident current care plan, last updated on 11/15/10, lacked evidence of being updated to reflect falls on 12/2/10 and 12/12/10. On 1/18/11 at 3:00 PM, a surveyor discussed this finding in an interview with the Director of Nurses and Professional Service Consultant. | 2014-04-01 | ||
| 4039 | 4039 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 309 | E | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow Registered Dietician recommendations for a resident on [MEDICAL TREATMENT] for eight days (#33). Finding: Resident #33 was admitted on [DATE], with documentation on "Transfer Summary", dated 12/30/10, that indicated on transfer to have a Stage II and III on his/her buttocks. On admission the nursing staff assessed and documented on an "Admission Assessment Screen and Daily Pressure Ulcer Documentation" form dated 12/30/10, contained documentation of upper coccyx measures 0.7 x 1.3 x 0.4, middle coccyx 0.7 x 1.0 and posterior coccyx 0.6 x 0.9 with no documentation of units of measurements and the resident had a Stage II and III. As of 1/12/11 at 12:40 PM there was no evidence that a Registered Dietician had assessed the resident for estimated protein, calorie and fluid needs. On 1/13/11, at approximately 8:30 AM, the Food Service Supervisor (FSS) with the Director of Nurses (DON) presented a copy of The Registered Dietician's notes for 1/5/11 and 1/12/11, that contained recommendation for an estimated 70-90 grams/daily of protein, 2065 calories and 1475 cc/daily fluid needs. The FSS stated, as she was handing the RD notes dated 1/5/11 to a surveyor, it was in my basket." On 1/13/10 at 8:30 AM, this finding was discussed with the Food Service Supervisor and the Director of Nurses. | 2014-04-01 | ||
| 4040 | 4040 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 314 | E | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of record review and interviews the facility failed to follow standards of practice in the area of pressure ulcers for 2 of 2 residents (#33, # 57). Findings: 1. Resident #33 was admitted on [DATE], with documentation on "Transfer Summary" dated 12/30/10, that indicated on transfer to have a Stage II and III on his/her buttocks. On admission the nursing staff assessed and documented on an Admission Assessment Screen and Daily Pressure Ulcer Documentation" form dated 12/30/10, contained documentation of upper coccyx measures 0.7 x 1.3 x 0.4, middle coccyx 0.7 x 1.0 and posterior coccyx 0.6 x 0.9 with no documentation of units of measurements and the resident had a Stage II and III. As of 1/12/11 at 12:40 PM there was evidence that a Registered Dietician (RD) had assessed the resident for estimated protein - calorie- fluid needs. A surveyor discussed this with the Professional service Consultant. On 1/13/11 at approximately 8:30 AM, the Food Service Supervisor (FSS) with the Director of Nurses (DON) presented a copy of The Registered Dietician ' s notes for 1/5/11 and 1/12/11, that contained recommendation for estimated protein - calorie- fluid needs. The FSS stated as she was handing the RD notes dated 1/5/11 was in my basket. On 1/13/10 at 8:30 AM, this finding was discussed with the Food Service Supervisor and Director of Nurses 2. Documentation on Resident' #57's 7/19/10 "Discharge Summary" indicated that the resident's [DIAGNOSES REDACTED]." Documentation on the resident's "Daily Pressure Ulcer Documentation" forms indicated that the the resident's "unstaged" pressure ulcer on his/her coccyx was monitored on 7/21, 7/26, 8/2, 8/3 and 8/4. There was no documentation to indicate that the resident's pressure ulcer was monitored on 13 out of 18 days of his/her stay. In addition, there was no documentation in the resident's medical record to indicate that the resident's protein, calorie and fluid needs, in the presence of [MEDICAL CONDITIO… | 2014-04-01 | ||
| 4041 | 4041 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 371 | D | ZOBY11 | Based on observation and interviews, the facility failed to ensure food was served in a sanitary manor for 1 of 7 days. Findings: On 1/10/11 from 12:00 PM to 12:15 PM, observation of the noon meal service in the first dining. the following observations were made at the noon meal. Observed the server with his gloves on touch his cap with his right and left hand. Observed the server with same gloves take the steam table cord and plug it in. Observed him with same gloves open and close cupboard doors and then touch butter pats. Heard Administrator tell and point to server to wash his hands and apply new gloves. Observed after new gloves the server pushed eye glasses up on nose with gloved left hand. Observed the server use his right hand and push his cap back on his head. On 1/10/10 at 3:30 PM, a surveyor discussed these finding with the Director of Nurses, the Administrator and Professional Service Consultant. | 2014-04-01 | ||
| 4042 | 4042 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 441 | F | ZOBY11 | Based of observation, record reviews and interviews the facility failed to follow Federal Centers for Disease Control (CDC) recommendation to prevent the spread of Norovirus for 6 out of 12 residents. (#7, #34, #6, #28, #3, #47). Finding: Centers for Disease Control and Prevention (CDC) Appendix A - Type and Duration of Precaution Recommended for Selected Infections and Conditions; page 100; indicated for Norovirus "Use Contact Precautions for incontinent persons for the duration of the illness or to control institutional outbreaks." On 1/20/11 at 9:40 AM, in an interview with the Charge Nurse, she confirmed that 6 of 12 residents that were having Norovirus symptom were incontinent of stool. On 1/20/11 at 9:25 AM in an interview the Director of Nurses(DON), she indicated the facility was using standard precautions for the residents with the Norovirus symptoms. On 1/20/11, surveyors observed staff going into infected rooms donning only gloves. The survey team did not observe any staff using gowns when entering the rooms of the residents who had/or were suspected to have Norovirus and were incontinent of stool. A surveyor discussed this finding with the Director of Nurses, on 1/20/11 at 9:40 AM. | 2014-04-01 | ||
| 4043 | 4043 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 157 | F | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of record reviews and interviews, the facility failed to promply notify the resident's physician of a Registered Dietician recommendations (#33), for confirmed/suspected Norovirus (#46, #3, #9, #6, #28, #72) and a medication not administered (#28). Findings: 1. Documentation in Resident #33's "Transfer Summary," dated 12/30/10, indicated the resident had [MEDICAL CONDITION], on [MEDICAL TREATMENT], and a Stage II and III area on his/her buttocks. As of 1/13/11 at 8:30 AM, a surveyor was presented a copy of a Registered Dietician's recommendations, dated 1/5/11. There was no evidence in the resident's clinical record to indicate that the resident's physician was notified of the Registered Dietician's recommendation. A surveyor discussed this finding in an interview with Food Service Supervisor and Director of Nurses, on 1/13/11 at 8:30 AM. 2. Interdisciplinary Progress Notes, dated between 1/19/11 and 1/20/11, lacked documentation that the physician was notified promptly when 2 of 6 residents were confirmed with Norovirus. Documentation, dated 1/19/11, indicated that the six residents were having symptoms of the Norovirus and, as of 1/20/11, there was no evidence that the physician was notified. A surveyor discussed this finding in an interview with the Director of Nurses, on 1/20/11 at 9:45 AM. 3. Resident #28's record contained a "Routine MAR" for the month of October 2010 that indicated, on 10/14/10, the medication [MEDICATION NAME] 250 milligram had not been administered and/or circled as to why this medication for [MEDICAL CONDITION] had not been administered to the resident. In an interview with the Director of Nurses, on 1/19/11 at 3:30 PM, he stated, "I do not know why the medication was not given. There was no documentation in the resident's record to indicate the physician was notified the medication [MEDICATION NAME] had not been administered as ordered. | 2014-04-01 | ||
| 4044 | 4044 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 281 | D | ZOBY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to follow professional standards of practice in the area of care plans and medication administration to assure medications were given as ordered for 2 of 26 sampled residents (#57, #28). Findings: The "Fundamentals of Nursing The Art and Science of Nursing Care" 7 th Edition, by Lippincott, Williams, and Wilkins (Lippincott) includes information relative to the standards of nursing practice for care planning in Chapter 14: "Outcomes Identification and Planning." On page 268, in Chapter 14, Lippincott indicates, "Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. This comprehensive plan addresses each problem listed in the prioritized nursing [DIAGNOSES REDACTED]. Its chief purpose is to keep the plan up to date ... The nurse caring for the patient uses new data as they are collected and analyzed to make the plan more specific and accurate and therefore more effective." 1. Documentation on Resident' #57's 7/19/10 "Discharge Summary" indicated that the resident's [DIAGNOSES REDACTED]." Documentation in the resident's "Interdisciplinary Progress Notes" indicated that the resident was evaluated by and opened to hospice services on 7/30/10. There was no documentation on the resident's "Interim Care Plan" or on any of the attached facility "Protocols" indicating that the resident was open to hospice services and no notation of problems, goals or interventions specific to end of life care. A surveyor discussed this finding in an interview with the Director of Nursing and Professional Services Consultant, on 1/19/11, at 12:30 PM. 2. Resident #33's " Transfer Summary " contained documentation that the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. There was no documentation on the resident's "Interim Care Plan " dated 12/31/10, to indicate specific measurable goal, nor on the protocol form for "Skin Care Protocol At … | 2014-04-01 | ||
| 4045 | 4045 | HERITAGE REHAB & LIVING CTR | 205133 | 457 OLD LEWISTON RD | WINTHROP | ME | 4364 | 2011-01-20 | 323 | D | ZOBY11 | Based on observation and interviews the facility failed to ensure the environment maintained was free of potential hazards for 1 of 26 sampled residents (#34). Finding: On 1/12/11 at 8:33 AM, a surveyor observed the Registered Nurse (RN) prepared to administer Vancomycin 1 gram intravenously (IV) to Resident #34. The heparin lock was in the resident's right arm. The RN prepped the heparin lock with saline flush prior to hooking up the antibiotic. Following attachment of the IV tubing to the IVAC, the Registered Nurse stored a syringe with saline and a syringe with heparin under the handle of the IVAC prior to leaving the resident's room. On 1/12/11 at 8:38 AM, a surveyor discussed this finding with Director of Nurses and Professional Service Consultant. | 2014-04-01 | ||
| 4046 | 4046 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 156 | C | W8S211 | Based on observation and interview, the facility failed to post the required notices in an area accessable to residents. Finding: On 1/25/11 at 2:55 p.m.,during tour, the notices regarding applying for Medicare and Medicaid, where the survey results are found, the names, addresses, phone numbers and information relating to the Ombudsman, Abuse reporting, and Adult protective were not found posted in an area accessible to residents. This was confirmed with the surveyor by the Administrator and the Social Service department at the time. | 2014-04-01 | ||
| 4047 | 4047 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 167 | C | W8S211 | Based on observation and interview, the survey results were not readily available for the residents. Findings: On 1/25/11 at 12:20 p.m., during tour, the surveyor found the survey results in a white loose leaf notebook in the lobby without any labelling to indicate what it was. There was no posting to indicate to residents and visitors where the notebook was located. The surveyor pointed out the lack of accessibility of the survey results at the time of tour. | 2014-04-01 | ||
| 4048 | 4048 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 248 | D | W8S211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an ongoing program of activities to meet the resident's needs for 1 of 30 sampled residents (#169). Finding: Resident #169 was admitted [DATE] for palliative, end of life care. The initial assessment dated [DATE], done with the resident indicated he/she was not interested in participating in group activities however, he/she enjoyed musical activities and dance. Record review indicated the facility failed to provide an ongoing program of activities designed to meet his/her needs. Interview with the Activity Director, 1/27/11 at 11:30 a.m., indicated that based on the initial assessment, the determination was made that the resident did not need to be assessed further or care planned for activities because of his/her refusal to participate in groups. | 2014-04-01 | ||
| 4049 | 4049 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 279 | D | W8S211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the needs of the resident in the areas of activities, and [MEDICAL TREATMENT] for 2 of 30 sampled residents (#169, and #45). Findings: 1. Resident #169 was admitted [DATE] for palliative care, end of life care. The resident had a [DIAGNOSES REDACTED]. The initial activity assessment, dated 9/8/10, indicated he/she was not interested in participating in group activities however, enjoyed musical activities and dance. The care plan dated 12/16/11 did not identify the resident's activity needs as a potential problem,and there was no evidence that a care plan was developed for ongoing program designed to enhance his/her psychosocial needs. 2. The care plan for Resident #45 did not include the interventions needed to provide care for his/her [MEDICAL TREATMENT] catheter. The interventions such as monitor for bleeding/emergencies and [MEDICAL TREATMENT] catheter care were not included as recommended by the Vascular Access Center. This was discussed by the surveyor with the Director of Nursing on 1/27/11 at 1:45 p.m. | 2014-04-01 | ||
| 4050 | 4050 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 325 | D | W8S211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the nutritional needs and preferences were provided for 1 of 30 sampled residents (#148). Finding: Resident #148 had physician's orders [REDACTED]. Nutrition notes, dated 12/8/10, indicated the resident was suffering a decline in health status, his/her intake was declining, and required house supplements to ensure his/her caloric needs. Nursing "Monthly Summary" reports indicated the resident's meal intake was poor to fair. During an Interdisciplinary Team, on 12/1/10, the family requested the facility provide the resident with over easy eggs and strawberry mighty shakes, due to his/her preferences, in order to encourage more meal consumption. The resident's "Profile Detail" report indicated this request was not communicated to the kitchen staff. Interview with the dietician, on 1/25/11, confirmed that the families request was not initiated and that she "forgot" to follow through on the request. | 2014-04-01 | ||
| 4051 | 4051 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 329 | D | W8S211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to effectivly monitor the medication regimine for 1 of 30 sampled residents (#47 ). Finding: Resident #47 had a physician's orders [REDACTED]. The recapitualtion of oders for December signed by the physician directed to administer the medication after meals. The facilty failed to clarify the order as to when to administer the medication. The surveyor discussed this finding on 1/26/11 at 2:30 p.m. with the Registered Nurse (RN) and the Director of Nurses (DON) who stated that they would get it clarified. | 2014-04-01 | ||
| 4052 | 4052 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 428 | D | W8S211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the consultant pharmacist failed to identify irregularities in the medication regimen for 1 of 30 sampled residents (#47 ). Finding: Resident #47 had a physician's orders [REDACTED]. The recapitulation of orders for December signed by the physician directed to administer the medication after meals. The consultant pharmacist had reviewed the resident's medication regime on 11/19/10, 12/17/10, and 1/21/11 and failed to identify that the administration schedule was conflicting. In and interview,on 1/26/11 at 2:30 p.m., with the Registered Nurse (RN) the surveyor confirmed the contradiction of administration time. | 2014-04-01 | ||
| 4053 | 4053 | ST JOSEPH'S REHABILITATION AND RESIDENCE | 205134 | 1133 WASHINGTON | PORTLAND | ME | 4103 | 2011-01-28 | 431 | E | W8S211 | Based on observation, record review and interview the facility failed to adequately monitor temperatures to assure proper medication storage conditions in 2 of 3 medication storage refrigerators. Additionally, 1 drug item was not stored in a sanitary condition in 1 medication room. Evidence includes: Inspection of the A unit medication room on 1/26/11 @8:20 AM found the refrigerator temperature to be 40 F. Review of the refrigerator temperature log revealed the log contained only 5 entry's for the month of January. (Jan. 1-4, and Jan. 8). The log for December 2010 consisted of only 4 entry's. Previous months also had numerous omissions. The unit manager confirmed there was no other record of refrigerator temperatures and no way to assure adequate temperatures for medication storage on days when the temperatures were not recorded. Inspection of C unit Med Room at 9:00 AM found the refrigerator temperature at 36 F. Review of the refrigerator temperature logs revealed no temperature log for January 2011, 2 entry's for Dec. 2010, 8 entry's for Both November and October 2010. Additionally, inspection of the stock medication shelf found 1 bottle of Tussin DM cough syrup put on shelf covered with syrup residue. The unit Charge Nurse confirmed these findings at 9:10 AM on 1/26/10. | 2014-04-01 | ||
| 4054 | 4054 | KATAHDIN NURSING HOME | 205149 | 22 WALNUT STREET | MILLINOCKET | ME | 4462 | 2010-12-02 | 281 | B | 63WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately transcribe a medication order in accordance with acceptable standard of practice for 1 of 18 sampled residents (#5). Finding: Resident #5's clinical record contained a physician's orders [REDACTED]." The current 60 day "Doctor's Orders" sheet, dated 11/27/10, indicated the medication had been transcribed as being for "anxiety." The resident's "Medication Records" for October 2010, November 2010 and December 2010 indicated the resident was to receive the [MEDICATION NAME] "as needed." According to Lippincott, Williams and Wilkins' "Fundamentals of Nursing, The Art and Science of Nursing Care," Fifth Edition, page 716 notes that, "The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original order." The surveyor discussed this finding in an interview with the Director of Nursing, on 12/1/10 at 12:40 p.m. | 2014-04-01 | ||
| 4055 | 4055 | KATAHDIN NURSING HOME | 205149 | 22 WALNUT STREET | MILLINOCKET | ME | 4462 | 2010-12-02 | 329 | E | 63WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure physician's orders for psychoactive and pain medications included the parameters for their use, for 3 of 18 sampled residents (#5, #6, and #21). Findings: 1. Resident #5's clinical record contained a physician's order, dated 3/31/10, for the antianxiety medication [MEDICATION NAME] 0.5 mg to 1.0 mg to be given every 8 hours as needed for "severe anxiety." The clinical record did not identify parameters for when to use each dose of the antianxiety medication. The surveyor discussed this finding in an interview with the Director of Nursing, on 12/1/10 at 12:40 p.m. 2. Resident #6 has had a physician's order in place, since 6/11/10, for [MEDICATION NAME] 5/500 1-2 tablets by mouth every 4-6 hours as needed for pain. The physician's order did not include parameters to direct staff on when to administer 1 tablet versus two tablets. The surveyor reviewed this finding with the Director of Nursing, on 12/2/10 at 10:50 a.m. 3. Resident #21's clinical record included physician's orders for [MEDICATION NAME] 5/500 mg 1/2 to 1 tablet four times a day as needed for pain and Tylenol Extra Strength 2 tablets every eight hours as needed for pain or fever. The physician's orders did not identify parameters for which dose of the [MEDICATION NAME] was to be used and when each of the pain medications should be administered. This finding was discussed with the Director of Nursing during an interview with the surveyor on 12/2/10 at 10:35 a.m. Based on record review and interview, the facility failed to ensure that Tylenol was monitored to assure maximum dosages were not exceeded for 1 of 18 sampled residents (#21). Finding: Resident #21's clinical record contained a current physician's order for 1000 milligrams (mgs) of Tylenol three times a day. In addition, the resident had an as needed (prn) dose of 1000 mgs of Tylenol that could be given every eight hours. The physician's orders also contain… | 2014-04-01 | ||
| 4056 | 4056 | KATAHDIN NURSING HOME | 205149 | 22 WALNUT STREET | MILLINOCKET | ME | 4462 | 2010-12-02 | 428 | E | 63WU11 | Based on record reviews and interviews, the consultant pharmacist failed to identify and report irregularities in the medication regimes of 3 of 18 sampled residents (#5, #6 and #21). Findings: 1. Resident #5's clinical record contained a physician's order, dated 3/31/10, for the antianxiety medication Ativan 0.5 mg to 1.0 mg to be given every 8 hours as needed for "severe anxiety." The clinical record did not identify parameters for when to use each dose of the antianxiety medication. The Consultant Pharmacist's medication review notes, from 4/14/10 through 11/8/10, did not identify this irregularity. The surveyor discussed this finding in an interview with the Director of Nursing, on 12/1/10 at 12:40 p.m. 2. Resident #6 has had a physician's order in place, since 6/11/10, for Vicodin 5/500 1-2 tablets by mouth every 4-6 hours as needed for pain. The physician's order did not include parameters to direct staff on when to administer 1 tablet versus two tablets. The consultant pharmacist failed to identify and report this irregularity The surveyor reviewed this finding with the Director of Nursing, on 12/2/10 at 10:50 a.m. 3. Resident #21's clinical record included physician's orders for Vicodin 5/500 mg 1/2 to 1 tablet four times a day as needed for pain, and Tylenol Extra Strength 2 tablets every eight hours as needed for pain or fever. The physician's orders did not identify parameters for which dose of the Vicodin was to be used and when each of the pain medications should be administered. The consultant pharmacist failed to identify and report this irregularity. This finding was discussed with the Director of Nursing during an interview with the surveyor, on 12/2/10 at 10:35 a.m. 4. Resident #21's clinical record contained a current physician's order for 1000 milligrams (mgs) of Tylenol three times a day. In addition, the resident had an as needed (prn) dose of 1000 mgs of Tylenol that could be given every eight hours. The physician's orders also contained the pain medication Vicodin 5/500 mg, which contains … | 2014-04-01 | ||
| 4057 | 4057 | KATAHDIN NURSING HOME | 205149 | 22 WALNUT STREET | MILLINOCKET | ME | 4462 | 2010-12-02 | 431 | B | 63WU11 | Based on observation and interview, the facility failed to remove all expired medications and biologicals from potential use by residents. Finding: On 11/30/10 at 10:20 a.m., during observation of the medication room, the surveyor noted 9 vials of Pneumonia vaccine in the refrigerator, which had expired on 11/14/10. The shelves, used to store stock medications for resident use, contained 3 single use phosphate enemas, which had expired on 10/10; a bottle of Diphenhydramine Hydrochloride 25 mg tablets, opened and approximately half full, which had expired on 8/10; a tube of Hemorrhoid cream labeled for a resident's use, which had expired on 12/09; and a second tube of Hemorrhoid cream labeled for a different resident, which had expired on 6/09. The surveyor confirmed this finding with the Licensed Practical Nurse (LPN) at the time of the observation. These items were removed from storage and use by the LPN. | 2014-04-01 | ||
| 4058 | 4058 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 241 | B | 9QB011 | Based on observations and interview, the facility failed to ensure residents dignity was maintained by serving the resident's meals in disposable containers during 2 dining observations. Findings: 1. On 5/18/10, during observation of the breakfast meal in the Dining Room, 5 residents were observed eating cereal out of disposable containers and 4 residents were observed eating fruit out of disposable containers. On observation of resident meal service in residents' rooms, 2 residents were also observed eating cereal out of disposable containers and 1 resident was observed drinking apple juice out of a Styrofoam cup. 2. On 5/19/10, during observation of the breakfast meal in the Dining Room, 6 residents were observed eating fruit out of disposable containers. The surveyor discussed these findings in an interview with the Administrator, on 5/19/10 at 4:00 p.m. | 2014-04-01 | ||
| 4059 | 4059 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 252 | B | 9QB011 | Based on observation, the facility failed to provide a homelike atmosphere in the Dining Room during 1 dining observation. Finding: During the breakfast meal observation on 5/18/10, 14 residents were observed eating their meals off dinner-ware still left on serving trays in the Dining Room. The surveyor discussed this finding in an interview with the Administrator, on 5/19/10 at 4:00 p.m. | 2014-04-01 | ||
| 4060 | 4060 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 272 | E | 9QB011 | Based on record review and interview, the facility failed to ensure that an assessment was completed prior to the use of a seat belt for 1 of 2 sampled residents who used a seat belt (#6). In addition, the facility failed to ensure that pressure ulcer risk assessments were completed weekly, according to the facility policy for 1 of 2 sampled residents with pressure ulcers (#6). Findings: 1. Resident #6's current care plan, dated 4/12/10, indicated that a hook-loop alarm (Velcro seat belt) was to be applied when the resident was seated in his/her wheelchair. The resident was observed, on 5/18/10, 5/19/10 and 5/20/10, sitting in a wheelchair with a Velcro seat belt fastened around the resident's waist. There was no evidence in the resident's clinical record to indicate that an assessment had been completed, prior to the implementation of the seat belt, to determine if this device was a restraint for this resident. The surveyor discussed this finding in an interview with the Administrator and Director of Nursing, on 5/20/10 at 8:15 a.m. 2. The facility's current "Prevention, Identification and Care of Pressure Ulcer" policy and procedure, dated 11/02/09, indicated that all residents upon admission, readmission and weekly for the first 4 weeks after admission would be assessed for risk factors associated with the development of pressure ulcers utilizating the "Braden Scale." Resident #6 was due to have a risk assessment completed on 2/19/10 and 3/03/10 per the facility's policy. However, there was no evidence in the resident's clinical record to indicate these assessments were completed. The surveyor confirmed that the risk assessments were not completed as required by the facility's policy with the Administrator, on 5/20/10 at 3:55 pm. | 2014-04-01 | ||
| 4061 | 4061 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 280 | D | 9QB011 | Based on record reviews and interviews, the facility failed to ensure that care plans were updated to reflect the resident's current needs in the area of weight loss for 2 of 20 sampled residents (#6 and #21). Findings: 1. Documentation in Resident #6's clinical record indicated that the resident, from 3/08/10 through 3/22/10, lost 13 pounds. There was no evidence in the resident's care plan to indicate that the care plan had been updated to reflect the new weight loss. The surveyor discussed this finding in an interview with the Administrator, on 5/19/10 at 2:10 p.m. 2. Documentation in Resident #21's computerized " Weight Detail Report" indicated a weight of 110.2 for January 1, 2010 and a weight of 100.6 for February 5, 2010, a significant weight loss of greater than 9%. There was no evidence in the resident's care plan to indicated that the care plan had been updated to indicate the significant weight loss. The surveyor discussed this finidng with the Administrator and Director of Nursing on 5/21/2010 at 10:20 a.m. | 2014-04-01 | ||
| 4062 | 4062 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 309 | E | 9QB011 | Based on observation, record review and interview, the facility failed to ensure that residents received services to maintain their ability to ambulate for 1 of 20 sampled residents (#6). Finding: Documentation on Resident #6's physical therapy "Plan of Treatment," dated 2/22/10, indicated that the resident ambulated 25 feet on level surfaces, requiring minimal assistance with a rolling walker and tactile and verbal instructions/cues for safety. There was no documentation in the resident's clinical record or computerized "Compressed ADL Report" to indicate that the resident ambulated, in his/her room between 2/22/10 and 4/03/10 and no documentation in the resident's clinical record or computerized "Compressed ADL Report" to indicate that the resident ambulated in the hall between 2/22/10 and 4/26/10. There was no documentation in the resident's clinical record to indicate a reason the resident had not been ambulated by staff. The surveyor discussed this finding in an interview with the Administrator, on 5/20/10 at 3:10 p.m. | 2014-04-01 | ||
| 4063 | 4063 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 385 | D | 9QB011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that supplements to treat residents' weight loss were ordered by the physician for 2 of 20 sampled residents (#6 and #21). Findings: 1. Documentation in Resident #6's care plan indicated that the resident received Carnation Instant Breakfast with meals and with snacks. Documentation in the resident's computerized "Weights Detail Report" indicated that the resident had lost 13 pounds between 3/08/10 and 3/22/10. There was no physician's order for this treatment of [REDACTED]. 2. Documentation in Resident #21's computerized " Weight Detail Report" indicated a weight of 110.2 for January 1, 2010 and a weight of 100.6 for February 5, 2010, a significant weight loss of greater than 9%. On 5/20/2010, at 9:55 a.m., the Certified Dietary Supervisor told the surveyor that she had reviewed the weight loss and that the resident was receiving 6 Carnation Instant Breakfasts daily. There was no physician's order for this treatment of [REDACTED]. | 2014-04-01 | ||
| 4064 | 4064 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 367 | B | 9QB011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure that therapeutic diets were specified by the physician for 2 of 20 sampled residents (#8 and #21). Findings: Documentation in Resident #21's clinical record indicated a significant weight loss of greater than 9% between January 1, 2010 and February 5, 2010. In an interview with the Certified Dietary Manager on 5/20/10 at 9:55 a.m, she stated, to the surveyor, that 2 scoops of protein powder was added to each of Resident #21's meals . The addition of a protein powder would be considered a therapeutic diet and would require a physician's orders [REDACTED]. The surveyor discussed this finding in an interview with the Administrator and Director of Nursing, on 5/21/2010 at 10:20 a.m. Documentation in Resident #8's clinical record indicated that the resident had a surgical wound on his/her coccyx. In an interview with the Certified Dietary Supervisor on 5/20/2010 at 9:55 a.m., she stated to the surveyor, that protein powder was being added to the resident's diet. The addition of a protein powder, would be considered a therapeutic diet and would require a physician's orders [REDACTED]. | 2014-04-01 | ||
| 4065 | 4065 | MAINE VETERANS HOME - CARIBOU | 205151 | 163 VAN BUREN RD SUITE 2 | CARIBOU | ME | 4736 | 2010-05-21 | 157 | D | 9QB011 | Based on record reviews and interview, the facility failed to promptly notify the resident's physician after a significant weight change for 1 of 20 sampled residents (#21). Finding: Documentation in Resident #21's computerized "Weight Detail Report" indicated a weight of 110.2 for January 1, 2010 and a weight of 100.6 for February 5, 2010, a significant weight loss of greater than 9%. There was no evidence in the resident's clinical record to indicate that the facility notified the physician of the significant weight loss. The surveyor discussed this finding in an interview with the Administrator and Director of Nursing, on 5/21/2010 at 10:20 a.m. | 2014-04-01 | ||
| 4066 | 4066 | EVERGREEN MANOR | 205162 | 328 NORTH ST | SACO | ME | 4072 | 2010-12-02 | 280 | D | FNG611 | Based on record review and interview, the facility failed to revise the current care plan to reflect a resident's needs for 1 of 28 Stage 2 sampled residents (#67). Finding: Resident # 67 had a "Fall Risk Screen" on 8/18/10 and 11/16/10, with scores over 10, which indicated the resident was a "HIGH RISK" for falls. On 11/7/10, the resident fell and the facility instituted the use of a tab alarm. The current care plan was not revised to reflect the use of a tab alarm. In an interview with the Director of Nursing, on 12/1/10 at 10:15 a.m., she confirmed the care plan had not been updated to reflect the use of a tab alarm. | 2014-04-01 | ||
| 4067 | 4067 | EVERGREEN MANOR | 205162 | 328 NORTH ST | SACO | ME | 4072 | 2010-12-02 | 281 | D | FNG611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care, for 1 of 28 Stage 2 sampled residents (#15), with an indwelling catheter in accordance with the facility's "Indwelling Catheter Protocol." The facility's "Indwelling Catheter Protocol" included "Change catheter per physician order." Finding: 1. Resident #15 had a physician's order, dated 10/7/10, "Change Foley catheter monthly. Diagnosis: [REDACTED]." The clinical record contained documentation that, on 9/28/10, a Foley catheter size 18 French with a 30cc. balloon was inserted. There was no physician's order for the size change of the catheter. The clinical record contained documentation that, on 11/28/10, a #16 Foley catheter with a 30cc balloon was inserted. There was no physician's order for the change in the size of the Foley catheter and balloon. On 12/1/10 at 1:30 p.m., the surveyor discussed the finding with the Director of Nursing who was unable to supply additional information. | 2014-04-01 | ||
| 4068 | 4068 | EVERGREEN MANOR | 205162 | 328 NORTH ST | SACO | ME | 4072 | 2010-12-02 | 315 | D | FNG611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care relating to an indwelling catheter for 1 of 28 stage 2 sampled residents (#15) according to their "Indwelling Catheter Protocol." The facility's "Indwelling Catheter Protocol" included "Change catheter per physician order." Finding: 1. Resident #15 had a physician's order, dated 10/7/10, "Change Foley catheter monthly. Diagnosis: [REDACTED]." The clinical record contained documentation that, on 9/28/10, a Foley catheter size 18 French with a 30cc. balloon was inserted. There was no physician's order for the change in the size of the Foley catheter and balloon. The clinical record contained documentation that, on 11/28/10, a #16 French Foley catheter with a 30cc balloon was inserted. There was no physician's order for the change in the size of the Foley catheter and balloon. On 12/1/10 at 1:30 p.m., the surveyor discussed the finding with the Director of Nursing (DON) who was unable to supply physician's orders for the changes in sizes of the catheters. | 2014-04-01 | ||
| 4069 | 4069 | ODD FELLOWS & REBEKAHS' HOME OF MAINE | 205170 | 85 CARON LANE | AUBURN | ME | 4210 | 2010-08-25 | 279 | E | 45ZR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure that care plans were developed in the area of falls for 2 of 18 sampled residents (# 20 and # 26). Findings: 1. Resident #20's Admission Fall Risk Assessment, dated 2/15/10, was coded to indicate that the resident was a high risk for falls. Additionally, the comprehensive admission assessment for Resident #20 indicated that the resident had triggered for falls. The clinical recorded contained documentation which indicated that the resident had 2 falls each month in February, March, and May and one fall in June and August. A review of the facility's Fall Risk Assessment Policy indicated, "should the resident have 2 or more falls per month, or a consistent pattern of falls, then the resident will be provided with a tabs monitor and a care plan will be developed for mobility." The surveyor noted that despite being assessed as a high risk for falls and having had 2 falls in February 2010, a care plan which addressed this resident's fall risk was not developed until 8/17/10. The surveyor discussed this finding in an interview with the Director Of Nurses, on 8/25/10 at 2:45 p.m. 2. On 8/23/10 at 10:00 a.m., in an interview with the Assistant Director of Nursing (ADON), she informed the surveyor that resident # 26 fell on [DATE]. On 8/24/10 during a record review, resident # 26's chart contained a Fall Risk Assessment form, which revealed a fall on 5/10/10, and a fall risk assessment score of 12 on 5/26/10. In a previous fall risk assessment on 2/26/10, resident #26 scored a 10. The Fall Risk Assessment form states: 'If a resident scores a 10 or higher they are at risk for falls. Safety and environmental changes should be considered." On 8/24/10 at 2:00 p.m., in an interview with the ADON, she failed to provide evidence that a care plan item had been developed to address risk of falls for resident # 26. | 2014-04-01 | ||
| 4070 | 4070 | ODD FELLOWS & REBEKAHS' HOME OF MAINE | 205170 | 85 CARON LANE | AUBURN | ME | 4210 | 2010-08-25 | 371 | E | 45ZR11 | Based on observation, interview, and record review, the facility failed to ensure all food is stored at appropriate temperatures in two separate refrigerators. Finding: On 8/24/10 at 10:50 a.m., the surveyor requested to see a temperature log for two, stand-alone refrigerators, which contained dairy products, eggs, and produce. The Director of Food Services failed to provide documentation of refrigerator temperatures, and or a system to ensure food is stored at the proper temperatures. | 2014-04-01 | ||
| 4071 | 4071 | SUNRISE CARE FACILITY | 205172 | 11 OCEAN ST | JONESPORT | ME | 4649 | 2010-12-21 | 309 | D | MO6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a physician's order was followed for blood tests for 1 of 1 sampled residents (#1 ). The blood tests were to be drawn every six months. Finding: Resident #1 had a physician's order, dated 11/19/2010, for a BMP, CBC, LFT and [MEDICATION NAME] Acid level to be drawn every six months. Documentation in the resident's record, indicated that the only blood work obtained was drawn on 12/15/2010. The surveyor discussed this finding in an interview with the Director of Nursing Services and the Charge Nurse, on 12/21/2010 at 11:00 a.m.. | 2014-04-01 | ||
| 4072 | 4072 | FOREST HILL MANOR | 205176 | 25 BOLDUC AVE | FORT KENT | ME | 4743 | 2010-12-15 | 281 | D | J3KK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a medication was administered in accordance with acceptable current standards of practice as outlined in the facility's current Medication Administration Policy for 1 of 1 sampled resident (#1). Findings: Documentation in Resident #1's clinical record indicated the Resident returned from the hospital on [DATE] with a physician's orders [REDACTED]. The Bactrim was ordered to treat a Urinary Track Infection. The Resident's clinical record indicated that the Resident was allergic to Sulfa. The medication "Bactrim" contains sulfa. According to the documentation on the Medication Administration Record, [REDACTED]. No adverse effects were observed following the administration of the medication. The surveyor confirmed this finding during a telephone interview with the Director of Nursing, on 12/17/2010. On 12/21/2010 at 09:51 a.m., the Director of Nursing informed the surveyor that the facility's current policy on Medication Administration, was from the Pharmacy Services of Nursing Facilities, 2006 American Society of Consultant Pharmacists and MED-PASS, Inc. | 2014-04-01 | ||
| 4073 | 4073 | WINDWARD GARDENS | 205180 | 105 MECHANIC ST | CAMDEN | ME | 4843 | 2011-06-28 | 309 | E | IRB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to follow physician's orders for 2 of 29 residents (#66 and #96). Findings: 1. Documentation on Resident #66's June 2011 "Medication Record" (MAR) directed staff to administer the antihypertensive medication, [MEDICATION NAME] 40 milligrams (mg) 1/2 tablet or 20 mg, by mouth every day for treatment of [REDACTED]. Documentation on the back of the MAR indicated that the medication was unavailable and/or awaiting insurance approval. A surveyor discussed this finding in an interview with the Spring Gardens Manager, on 6/27/11, at 9:30 AM. 2. Documentation on Resident #96's June 2011 MAR directed staff to administer [MEDICATION NAME] four (4) mgs by mouth twice a day for dyspnea and pain. Documentation on the MAR indicated that the [MEDICATION NAME] was not administered to the resident from 6/18/11 through 6/22/11, except for two doses (6/20/11 and 6/22/11 at 8:00 a.m.). On 6/23/11 at 11:50 a.m., a Licensed Practical Nurse (LPN) and a surveyor observed, in the medications cart, a medication card of [MEDICATION NAME] for this resident. The label on this medication card indicated that the card had been sent from the pharmacy to the facility on [DATE], three days after the initial physician's order. In addition, the LPN and surveyor observed that only one dosage of the medication, not two dosages as indicated by the MAR, had been administered to the resident from this medication card. A surveyor discussed this finding in an interview with the Manager of Clinical Operations, on 6/23/11, at 2:00 PM. 3. Resident #96 had a physician's order, dated 6/10/11, for [MEDICATION NAME] by mouth daily until the resident's bowel movements were regular. Documentation on the resident's "ADL Flow Record - 3," between 6/10/11 through 6/23/11 at 7:00 AM, indicated that the resident had a bowel movement on 6/10/11, 6/12/11 and 6/16/11. There was no evidence on the MAR to indicate that this physician's order had… | 2014-04-01 | ||
| 4074 | 4074 | WINDWARD GARDENS | 205180 | 105 MECHANIC ST | CAMDEN | ME | 4843 | 2011-06-28 | 282 | E | IRB611 | Based on record review and interviews, the facility failed to ensure range of motion was provided twice a day in accordance with care plan interventions for 1 of 2 sampled residents at risk for limited range of motion (#4). Finding: Residents #4's care plan, revised on 6/9/11, directed staff to provide range of motion (ROM) to the resident's: fingers; wrist; knees and elbows, twice a day with 10 repetitions. The ROM care plan also directed staff to provide reminders, supervision or actual physical assistance to the resident to move his/her extremities and when conducting passive ROM, for staff to move the joint slowly and gently. On 6/27/11 at 11:00 AM, in an interview with a surveyor, Resident #4 stated that the staff "sometimes" do range of motion. On 6/28/11 at 10:45 AM, in an interview with a surveyor, the resident stated that when staff completed ROM they usually performed the ROM on his/her "whole arm". The resident stated that the staff did not complete range of motion twice a day and that he/she would like the staff to complete ROM on his/her legs. The resident's "Restorative Nursing Record," under the box labeled "passive ROM" to the resident's "fingers, hands, knees and wrist 2x daily with staff," for April 2011, "N/A" (the activity did not occur), was coded on 4/4/11, 4/5/11, 4/6/11 and 4/8/11 on the evening shift. This form was blank on the day shift for 4/25/11, 4/26/11, 4/28/11 and 4/30/11. This form was also blank on the evening shift for 4/3/11, 4/7/11 and 4/21/11. In May 2011, the "Restorative Nursing Record" for ROM was blank during the day shifts from 5/1/11 through 5/8/11, and on 5/27/11 and was also blank for the evening shifts from 5/1/11 through 5/7/11; on 5/9/11, 5/10/11, 5/12/11, 5/18/11 and 5/21/11. The May 2011 "Restorative Nursing Record" indicated no ROM was completed on 5/8/11 during the evening shift. The resident's June 2011 "Restorative Nursing Record" was blank on the day shifts for 6/5/11 and 6/23/11 and was blank on the evening shifts for 6/3/11 and 6/15/11. The June 2011 "Rest… | 2014-04-01 | ||
| 4075 | 4075 | WINDWARD GARDENS | 205180 | 105 MECHANIC ST | CAMDEN | ME | 4843 | 2011-06-28 | 318 | E | IRB611 | Based on record review and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 sampled residents with limited range of motion (#4). Finding: Resident #4's quarterly Minimum Data Set, Version 3.0 (MDS) assessment, dated 4/20/11, was coded under section O, to indicated the resident was receiving restorative nursing services with active and passive range of motion. Residents #4's care plan, revised on 6/9/11, directed staff to provide range of motion (ROM) to the resident's: fingers; wrist; knees and elbows, twice a day with 10 repetitions. The ROM care plan also directed staff to provide reminders, supervision or actual physical assistance to the resident to move his/her extremities and when conducting passive ROM, for staff to move the joint slowly and gently. On 6/27/11 at 11:00 AM, in an interview with a surveyor, Resident #4 stated that the staff "sometimes" do range of motion. On 6/28/11 at 10:45 AM, in an interview with a surveyor, the resident stated that when staff completed ROM they usually performed the ROM on his/her "whole arm". The resident stated that the staff did not complete range of motion twice a day and that he/she would like the staff to complete ROM on his/her legs. An electronic progress note, dated 5/25/11 at 04:43, indicated "passive range of motion" was provided to the resident's lower extremities by an aide, which the resident stated was "lovely". The resident's "Restorative Nursing Record," under the box labeled "passive ROM" to the resident's "fingers, hands, knees and wrist 2x daily with staff," for April 2011, "N/A" (the activity did not occur), was coded on 4/4/11, 4/5/11, 4/6/11 and 4/8/11 on the evening shift. This form was blank on the day shift for 4/25/11, 4/26/11, 4/28/11 and 4/30/11. This form was also blank on the evening shift for 4/3/11, 4/7/11 and 4/21/11. In May 2011, the "Restorative Nursing Record" for ROM was blank during the day shif… | 2014-04-01 | ||
| 4076 | 4076 | WINDWARD GARDENS | 205180 | 105 MECHANIC ST | CAMDEN | ME | 4843 | 2011-06-28 | 425 | E | IRB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain medications promptly from the pharmacy for 2 of 29 residents (#66 and #96) and to offer prescribed medications for 1 of 29 residents (#96). Findings: The facility's "Medication Shortages/Drugs Not Available" policy, revised 12/15/08, indicated that when medications were "not received or unavailable, the licensed nurse will immediately initiate action in cooperation with the attending physician and the pharmacy provider. All medication orders unavailable to the patient will be managed with urgency." 1. Documentation on Resident #66's June 2011 "Medication Record" (MAR) directed staff to administer the antihypertensive medication, Diovan 40 milligrams (mg) 1/2 tablet or 20 mg, by mouth every day for treatment of [REDACTED]. Documentation on the back of the MAR indicated that the medication was unavailable and/or awaiting insurance approval. A surveyor discussed this finding in an interview with the Spring Gardens Manager, on 6/27/11, at 9:30 AM. 2. Documentation on Resident #96's June 2011 MAR directed staff to administer Dexamethasone four (4) mgs by mouth twice a day for dyspnea and pain. Documentation on the MAR indicated that the Dexamethasone was not administered to the resident from 6/18/11 through 6/22/11, except for two doses (6/20/11 and 6/22/11 at 8:00 a.m.). On 6/23/11 at 11:50 a.m., a Licensed Practical Nurse (LPN) and a surveyor observed, in the medications cart, a medication card of Dexamethasone for this resident. The label on this medication card indicated that the card had been sent from the pharmacy to the facility on [DATE], three days after the initial physician's orders [REDACTED]. A surveyor discussed this finding in an interview with the Manager of Clinical Operations, on 6/23/11, at 2:00 PM. 3. Resident #96 had a physician's orders [REDACTED]. Documentation on the resident's "ADL Flow Record - 3," between 6/10/11 through 6/23/11 at 7:00 AM, indicated t… | 2014-04-01 | ||
| 4077 | 4077 | MOUNTAIN HEIGHTS HEALTH CARE | 205181 | 83 HOULTON ROAD | PATTEN | ME | 4765 | 2010-10-14 | 279 | D | 3ISI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that resident care plans had specific interventions for behaviors requiring the use of an antianxiety medication for 1 of 17 sampled residents (#18). Finding: Resident #18 had a physician's orders [REDACTED]. The resident's care plan for psychoactive medications did not indicate any non-pharmaceutical interventions to manage the resident's behaviors of irritability and being short tempered with others. On 10/13/10 at 3:15 p.m., the surveyor discussed this finding with the Director of Nursing. . | 2014-04-01 | ||
| 4078 | 4078 | MOUNTAIN HEIGHTS HEALTH CARE | 205181 | 83 HOULTON ROAD | PATTEN | ME | 4765 | 2010-10-14 | 329 | E | 3ISI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess a medication for adequate indications for its use for 1 of 17 sampled residents (#21). Finding: Resident #21 had a physician's orders [REDACTED]. A physician's note, dated 5/13/10, indicated that the resident had been staying up all night and sleeping all day, and that [MEDICATION NAME] had not been effective for sleep and he would order [MEDICATION NAME] instead. Documentation in the resident's nurse's notes, dated 5/13/10 and 5/22/10, indicated the resident was awake all night and then was very sleepy all day. There was no documentation in the resident's clinical record to indicate the resident had anxiety and that was the reason for the [MEDICAL CONDITION]. Documentation in the "Documentation Record" for CNA documentation, dated June, July, August and September, 2010 indicated the resident had occasional episodes of [MEDICAL CONDITION]. The resident's care plan for the use of the [MEDICATION NAME] did not indicate the resident was receiving the medication for [MEDICAL CONDITION] or address non drug interventions to be utilized to address the resident's [MEDICAL CONDITION]. On 10/14/10 at 12:30 p.m., the surveyor discussed with the Director of Nursing that there was no evidence in the clinical record of a medical reason for the use of the antianxiety medication [MEDICATION NAME], or to indicate that non drug interventions had been attempted in regards to the resident's problem of [MEDICAL CONDITION]. | 2014-04-01 | ||
| 4079 | 4079 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 156 | B | D5O711 | Based on record review and interview, the facility failed to issue the Notice of Medicare Provider Non-Coverage prior to the end of Skilled Services to 1 of 3 Stage 2 sampled residents (#3). Finding: On 2/02/11, the surveyor requested to see the Advance Beneficiary Notice (SNFABN) issued to Resident #3 when the resident was discharged from Skilled Care. The resident was discharged from Skilled Services 1/04/11. The resident did not sign the SNF ABN notice until 1/05/11, the day after services ended. The surveyor discussed this finding with the Social Worker, on 2/02/11 at 9:10 am. | 2014-04-01 | ||
| 4080 | 4080 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 281 | D | D5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide care to promote the healing of a resident's Stage 3 pressure ulcer in accordance with professional standards for 1 of 3 Stage 2 sampled residents with a pressure ulcer (#194). Finding: In accordance with acceptable standards of practice outlined in the U.S. Department of Human Services, Agency for Health Care Policy and Research "treatment of [REDACTED]. that will keep the ulcer bed continuously moist." Resident #194's clinical record contained a nurse's note, dated 1/30/11, which indicated the resident had a Stage 3 pressure ulcer on his/her coccyx that measured 0.2 cm by 0.3 cm in size with redness in the surrounding skin. The Registered Nurse (RN #1) noted no dressing was applied and the area was left "OTA" (open to air). On 1/31/11, a physician's orders [REDACTED]. The resident's treatment record for January 2011 indicated the dressing was to be applied on 1/31/11. There was no documentation to indicate that a dressing had been applied to the resident's pressure ulcer. On 2/01/11 at 10:30 a.m., the surveyor accompanied RN #2 and the Licensed Practical Nurse (LPN) to observe the resident's pressure ulcer. The surveyor observed the resident had a small open area in the region of the resident's gluteal fold which was measured by RN #2 as being 0.2 cm by 0.25 cm with a small area of slough in lower portion of the wound. There was no dressing covering the resident's wound. The LPN then cleaned the area and applied the [MEDICATION NAME] foam dressing. On 2/01/11 at 10:45 a.m. and 11:30 a.m., the surveyor discussed with the Director of Nursing that there was no documentation to indicate that a dressing was applied to the resident's Stage 3 pressure ulcer until 2/01/11. | 2014-04-01 | ||
| 4081 | 4081 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 282 | D | D5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide interventions as outlined in the resident's care plan for falls for 1 of 34 Stage 2 sampled residents (#35). Finding: Documentation in Resident #35's clinical record indicated the resident had a history of [REDACTED]. Documentation in the resident's nurse's notes indicated the resident had a fall on 1/06/11 when attempting to self transfer into bed from his/her wheelchair. Documentation in the nurse's note indicated there was no injury. On 2/01/11, the surveyor reviewed the resident's care plan and under the problem of falls, staff were directed that the resident was to wear a PCA (Personal Care Alarm) at all times and updated on 1/06/11 to include when the resident was in chairs. On 2/01/11 at 12:30 p.m., the surveyor observed the resident sitting in a wheelchair in the dining room without a Personal Care Alarm. On 2/01/11 at 2:10 p.m., the surveyor observed the resident sitting in his/her room in a wheelchair and no alarm was attached to the resident. On 2/02/11 at 8:15 a.m., the surveyor observed the resident sitting in a wheelchair in the restorative dining room and no alarm was attached to the resident. The resident never attempted to get out of his/her wheelchair during these observations. On 2/02/11 at 8:30 a.m., in an interview with the Certified Nursing Assistant (CNA), she stated to the surveyor that the resident did not wear any alarm and there was no alarm in his/her room. On 2/02/11 at 9:20 a.m., the surveyor discussed this finding with the Registered Nurse, who confirmed that the resident's care plan indicated he/she was to have a PCA on when in the chair. | 2014-04-01 | ||
| 4082 | 4082 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 314 | D | D5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide care to promote the healing of a resident's Stage 3 pressure ulcer for 1 of 3 Stage 2 sampled residents with pressure ulcers (#194). Finding: Resident #194's clinical record contained an admission nurse's note, dated 1/26/11, which indicated the resident had an excoriation around his/her rectum and inner gluteal folds bilaterally, otherwise the skin was intact. There was no further documentation by the Licensed Nurse related to the resident's excoriated skin until 1/30/11 when the Registered Nurse (RN #1) noted the resident had a Stage 3 pressure ulcer on his/her coccyx that measured 0.2 cm by 0.3 cm in size with redness in the surrounding skin. RN #1 noted that no dressing was applied and the area was left "OTA" (open to air). The resident's physician's orders [REDACTED]." On 2/01/11, the surveyor reviewed the facility's wound care protocol and the protocol indicated that for a Stage 3 pressure ulcer treatment options would be for Calcium Alginate or Hydrogel dressing. In accordance with acceptable standards of practice outlined in the U.S. Department of Human Services, Agency for Health Care Policy and Research "treatment of [REDACTED]. that will keep the ulcer bed continuously moist." On 1/31/11, a physician's orders [REDACTED]. The resident's treatment record for January 2011, indicated the dressing was to be applied on 1/31/11. There was no documentation to indicate that this dressing was done. On 2/01/11 at 10:30 a.m., the surveyor accompanied RN #2 and the Licensed Practical Nurse (LPN) to observe the resident's pressure ulcer. The surveyor observed the resident had a small open area in the region of the resident's gluteal fold which RN #2 measured 0.2 cm by 0.25 cm with a small area of slough in the lower portion of the wound. There was no dressing covering the resident's wound. RN #2 stated she would document the pressure ulcer as unstageable due to the presence of… | 2014-04-01 | ||
| 4083 | 4083 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 332 | E | D5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that the medication error rate was less than five percent. A total of 98 medications were observed administered and 16 errors were identified. These 16 errors constituted a 16 percent medication error rate. Findings: 1. Resident #44's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#44 received his/her medications at 8:38 a.m., one hour and thirty eight minutes later. In addition, the Calcium and Vitamin D were to be administered with food. At the time of administration at 8:36 a.m., Resident #44 had finished eating breakfast. 2. Resident #107's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. Resident #29's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In addition, the resident was to receive [MEDICATION NAME] Plus. The Registered Nurse who was administering the medications dispensed regular [MEDICATION NAME] to the resident. 4. Resident #150's clinical record contained a physician's orders [REDACTED]. On 1/31/11 at 8:30 a.m., during observation of the morning medication administration, the surveyor observed the Certified Nursing Assistant (CNA-M) pour the medication [MEDICATION NAME] 17.5 mg to administer to Resident #150. The surveyor observed that the resident's medication record indicated the [MEDICATION NAME] was to be given at bedtime. The surveyor brought this to the attention of the CNA-M before she administered the medication. The surveyor discussed this finding with the CNA-M at time of the observation and with the Unit Manager on 2/1/11. On 02/02/2011 at 1:00 p.m., the surveyor discussed these findings with the Director of Nursing Services. | 2014-04-01 | ||
| 4084 | 4084 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 364 | E | D5O711 | Based on observations and information gathered during resident interviews, the facility failed to serve all foods that were intended to be served hot or cold at the appropriate temperatures for 2 of 2 breakfast test trays. Findings: 1. On 01/31/2011 at 10:00 a.m., in a confidential interview with the surveyor , the resident stated that hot foods were not always served hot. The resident stated that the breakfast meal was most often served cold. 2. On 01/30/2011 at 1:30 p.m., in a confidential interview with the surveyor, the resident stated that the food did not taste good. 3. On 01/30/2011 at 2:46 p.m., in a confidential interview with the surveyor, the resident stated that he/she had been served cold eggs at breakfast and cold roasted potatoes at supper time. He/she stated that other foods were served cold but he/she could not think what they were. On 02/01/2011 at 7:40 a.m., two surveyors received the requested sample trays, one regular consistency food and the other pureed food. The meal consisted of an egg, oatmeal, a muffin, a banana, orange juice and milk. The temperature of the regular and pureed foods were noted as follows: 1. Regular consistency food: Fried egg was 111.2 degrees Fahrenheit (F) with the taste sensation of luke warm. Oatmeal was 126.7 degrees F with the taste sensation of warm. Orange juice was 53.6 degrees F with the taste sensation of luke warm. 2. The pureed consistency food: Scrambled egg was 108.3 degrees F with the taste sensation of cool. Oatmeal was 118 degrees with the taste sensation of luke warm. Orange juice was 52.9 degrees F with the taste sensation of warm. On 02/01/2011, the surveyors discussed these findings with the Food Service Supervisor and the Dietary Consultant at the time of the observation. | 2014-04-01 | ||
| 4085 | 4085 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 371 | D | D5O711 | Based on observations and interviews, the facility failed to ensure that kitchen equipment and food storage areas were maintained in a clean and sanitary manner. Findings: 1. On 1/30/11 at 9:45 a.m., during a tour of the kitchen, the surveyor made the following observations: a. A fan was heavily soiled with dust on the front and sides and blowing towards clean pots and pans; b. A 1 inch by 4 inch hole in the bottom portion of the wall under a counter area behind the grease trap and the floor in the area around the grease trap was covered with debris. c. In the dry storage room, the surveyor observed the ceiling next to the wall had three 1 inch holes and the ceiling around a conduit had 1 inch by 4 inch and 1/2 inch by 16 inch size holes open to the area above the ceiling. The surveyor discussed this finding with the Dietary Technician at the time of the observations. 2. On 1/31/11 at 9:20 a.m., during a tour of the kitchen, the surveyor observed that the floor area next to the wall, under the three wash sinks, was soiled with debris and dust was observed along the top of the pipes which were underneath the three wash sinks. The surveyor discussed this finding with the Dietary Service Manager at the time of the observation. | 2014-04-01 | ||
| 4086 | 4086 | MAINE VETERANS HOME - BANGOR | 205185 | 44 HOGAN RD | BANGOR | ME | 4401 | 2011-02-03 | 431 | D | D5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure an expired medication was removed from the supply available for use and that a multi-dose vial of insulin was dated when opened. Findings: 1. On [DATE] at 10:20 a.m., the surveyor observed an unopened bottle of Glucosamine Chondroitin with an expiration date of ,[DATE] in the stock supply of the medication room on Unit D. The Nurse Manager immediately removed the medication from the medication room. 2. On [DATE] at 10:35 a.m., the surveyor observed, in the C Unit refrigerator, an opened multi-dose vial of Novolin ,[DATE] Insulin, with a pharmacy sent date of ,[DATE], which was not dated when opened. The facility's policy for "Vials and Ampules of Injectable Medications," indicated that the date opened and the initials of the first person to use the vial were to be recorded on the multi-dose vials. The surveyor discussed the above findings with the Director of Nursing, on [DATE] at 11:00 a.m. | 2014-04-01 | ||
| 4087 | 4087 | THE NEWTON CTR FOR REHAB & NUR | 205012 | 35 JULY STREET | SANFORD | ME | 4073 | 2010-11-17 | 224 | G | TCGZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the necessary care and services to ensure 1 of 1 sampled resident (#1) was not neglected while using a bedpan. The facility's failure to ensure that a resident was not left on a bed pan. This neglect resulted in Resident #1 sustaining an injury from the prolonged pressure of the bedpan into his/her skin. Finding: Resident #1 had [DIAGNOSES REDACTED]. The annual MDS assessment for Resident #1, dated 6/13/10, documented that the resident was totally dependent on staff for toileting needs with the physical assistance of 1 person. A nurse's note, dated 11/6/10, at 1:30 a.m., documented that the resident was found on a bedpan with "dark red indentations noted from the rim of pan" in the resident's skin. In an interview with the Registered Nurse and the Acting Director of Nurses on 11/17/10, at 10:10 a.m., the surveyor was informed that the facility review of this incident was unable to determine who put the resident on the bed pan or how long the resident had been on the bed pan. On 11/17/10 at 2:38 p.m., the surveyor conducted an interview with the Certified Nursing Assistant (CNA) who discovered the resident on the bed pan. The CNA stated that at approximately 1:15 a.m. to 1:30 a.m. on the morning of 11/6/10, she had entered the resident's room with another CNA to check on the resident and reposition the resident. The CNA stated that when she was getting ready to reposition the resident, she noticed there was a bed pan underneath the resident. The CNA stated that the evening staff did not make them aware that anyone was on a bedpan and the bed pan was full of both stool and urine. The CNA stated that when the bed pan was removed the resident had a very dark red indentation of the skin which matched the outline of the bed pan. A review of the nurse's notes showed that the skin injury was monitored for 6 days and was documented as resolved on 11/12/10. | 2014-03-01 |
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CREATE TABLE [cms_ME] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );