Katahdin Health Care LLC

Inspectors wroteBased on record reviews, facility policy review, and interviews, the facility failed to ensure that physician orders were followed for 1 of 5 residents reviewed for unnecessary medications (Resident #19 [R19]).

Inspectors wroteBased on facility policy review, record reviews and interviews, the facility failed to ensure that the Consultant Pharmacist (CP) reported an irregularity to the Director of Nursing (DON) and Physician after completing the monthly medication regimen review (MRR) for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #19 [R19]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that baseline care plans were completely developed and implemented within 48 hours that included health care instructions needed to provide minimum healthcare for 4 of 4 residents reviewed that were admitted in the last 30 days (Resident #16 [R16], [R25], [R31], R37]).

Inspectors wrote3. On 2/11/25, R16's clinical record was reviewed and indicated R16 was admitted to the facility on [DATE]. R16 was sent to the hospital and admitted on [DATE] and returned to the facility on 2/4/25. The admitting orders from the hospital included Amiodarone 200 milligrams (mg) daily and sucralfate 1 gram tablet four times a day. A review of the orders entered into R16's electronic record upon re-admission to the facility did not include Amiodarone 200 mg daily (heart arrhythmia medication) and the frequency of the sucralfate (ulcer treatment medication) was three times a day and not the ordered four times a day. In addition, ferrous sulfate 325 mg (iron medication) and folic acid 0.8 mg (vitamin B medication) were added to the facility's physician orders but were not on the orders from the hospital. [...]

Inspectors wroteBased on observations and interviews, the facility failed to label supplements with a thaw date that were located in the walk-in refrigerator and reach in refrigerator which were located in the kitchen, failed to label and date bags of cereal in the dry food storage area and failed to ensure kitchen staff properly wore hairnets by leaving hair uncovered and unrestrained for 2 of 3 days of survey (2/10/25, 2/11/25).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 12 sampled residents reviewed for code status or advanced directive for 4 of 12 sampled residents (Resident #6 [R6]), R23, R15, R25) and 1 of 3 reviewed for hospitalization (R16).

Inspectors wroteBased on record reviews, facility policy review, and interviews, the facility failed to ensure residents were offered Pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 2 of 5 residents reviewed for immunizations (Resident #20 ([R20] and R12).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a care plan was created after a comprehensive assessment in the area of diabetes and pain for 1 of 1 resident received for Hospice (Resident #25 [R25]).

Inspectors wroteBased on record review and interview, the facility failed to review, revise and update a care plan in the area for a pressure ulcer 1 of 1 resident reviewed for pressure ulcer (Resident #16 [R16]).

Inspectors wroteBased on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 2 of 3 days of survey (2/10/25 and 2/11/25) for Resident #16 (R16).

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 12 residents reviewed (Residents #31 [R31]).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 1 of 12 sampled residents (Resident #31 [R31,].

Inspectors wroteBased on observation, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 1 medication storage refrigerator.

Inspectors wroteBased on review of the facility's Legionella Water Management Program and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens in the area of testing protocols for 1 of 1 review of water management program.

Inspectors wroteBased on record reviews, Medication Administration Records (MARs) and interviews, the facility failed to follow physician orders for 4 of 9 sampled residents (Resident #15 [R15], R4, R19, and R31).

Inspectors wroteBased on observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing food in a sanitary manner, not sanitizing the thermometer used for food temperature checks, as well as not monitoring sanitizer levels in the chemical sanitizer bucket to prevent food borne illness for 2 of 3 days of survey (3/11/24, 3/12/24). This has the potential to effect all residents in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to update a care plan for the problem area of care/assistance for 1 of 1 residents reviewed for fall with major injury (Resident #10 [R10]).

Inspectors wroteBased on time card reviews and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 2 of 2 weekend dates reviewed for RN coverage (2/25/24 and 3/9/24).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that physician ordered labs (bloodwork) were attempted or completed for 1 of 6 sampled residents reviewed (Resident # [R]19).

Inspectors wroteBased on employee file reviews and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, annual training on dementia for 2 of 3 Certified Nursing Assistants (CNA) reviewed (CNA4, CNA5).