Kennebunk Center for Health & Rehabilitation, LLC

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for the medication storage room and the laundry room for 2 of 4 days of survey.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a care plan was developed in the area of dementia care for 1 of 2 residents reviewed for dementia (Resident #55), and in the area of accidents for 1 of 4 residents reviewed for falls (Resident #9).

Inspectors wroteBased on record reviews and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 7 of 21 residents whose care plans were reviewed (Resident #2, #7, #8, #23, #35, #40, & #79).

Inspectors wroteBased on policy reviews, record reviews, and interviews, the facility failed to adequately follow physician orders for blood sugar checks before meals for 2 of 3 residents reviewed and failed to adequately follow the facility's policy for administering long-acting insulin for 1 of 2 residents reviewed (Resident #15, #43 & #69).

Inspectors wroteBased on record review, interview and Payroll Based Journal Report (PBJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarters reviewed (10/1/25 through 12/31/25).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired lab supplies were removed from supply, available for use for 4 of 4 units, and the facility failed to ensure treatment carts were locked when unattended for1 of 1 carts, for 1 of 4 days of survey.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner related to floors, walls, food preparation surfaces, the walk-in freezer, and the dish room for 1 of 1 initial kitchen tour. Additionally, the facility failed to ensure foods were sealed, labeled, and dated in a food preparation area, a dry storage room, a reach-in refrigerator, a walk-in refrigerator, and a walk-in freezer for 2 of 2 kitchen tours. Furthermore, the facility failed to maintain an emergency food supply for 2 of 4 days of survey (4/12/26, 4/13/26).

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to conduct regular inspection of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattresses and bed frames are compatible and identify areas of possible entrapment for 4 of 4 units observed (Eagle, [NAME], Sagamore, and Windmere).

Inspectors wroteBased on observation and interviews, the facility failed to provide care to residents in a manner that maintains each resident's dignity by failing to serve all residents seated at the same table at the same time for 1 of 2 dining observations on 1 of 4 days of survey (4/12/26).

Inspectors wroteBased on record review, interview and facility policy, the facility failed to ensure the physician was notified of a significant change and/or incident for 1 of 3 residents reviewed for hospitalizations. (Resident #91)

Inspectors wroteBased on record review and interview, the facility failed to issue a written transfer/discharge notice and a bed hold notice to include cost of care and a statement of the resident's appeal rights to the legal representative for 1 of 5 sampled residents reviewed for transfer to an acute care hospital (Resident #77).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure physician orders were followed for 1 of 1 resident receiving oxygen therapy (Resident #11).

Inspectors wroteBased on observation, interviews, record review, and facility policy, the facilities interdisciplinary team failed to determine if it was clinically appropriate for a resident to keep a medication at bedside and self-administer medications for 4 of 5 residents reviewed. (Resident ##2, #3, #4 and #5).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medications including treatments were stored properly on 2 of 4 units observed (Sagamore and [NAME] units). for 1 of 1 day of survey. (2/25/25)

Inspectors wroteBased on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of a chemical not being properly secured for 1 of 1 days of survey (2/25/25).

Inspectors wroteBased on observations, record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents reviewed for medications (Resident #5).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 4 of 4 units (Windermere, Eagle, Sagamore and Regena, and Laundry Room) for 1 of 4 days of survey.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide Activities of Daily Living (ADL) care for 6 of 6 resident reviewed for ADL's (Resident #126, #6, #19, #64, #226 and #230). In addition, the facility failed to follow the care plan in the area of oral hygiene for 1 of 1 reviewed. (Resident #6).

Inspectors wroteBased on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care (Resident # 16 and #20). In addition, the facility failed to follow physician orders for 1 of 3 reviewed for respiratory care (Resident #16).

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on observations, interviews, record review and the facility's own Personal Appearance and Dress guidelines and the Personal Hygiene for Food Handlers policy and procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to serve food in accordance with professional standards for food service safety, failed to monitor food temperatures to prevent food borne illness prior to serving residents for 1 of 2 days of survey (1/13/25), and failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code. This has the potential to affect all residents in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to the residents or their representatives and not required as a condition of admission due to the agreement being a part of the admission paperwork for 5 of 5 residents reviewed for Arbitration (Resident #126, #230, #23, #64, and #19).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident's choice in the area of clothing were followed for 1 of 9 sampled residents (Resident #234).

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to adequately evaluate a resident after an unwitnessed fall and complete neurological assessments as per facility policy for 1 of 2 residents reviewed for falls (Resident #125).

Inspectors wroteBased on observations, and interviews, the facility failed to maintain adequate pharmaceutical services to ensure that outdated medications, were removed from the medication carts making them no longer available for use in 1 of 3 medication carts.

Inspectors wroteBased on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 11 of 14 residents reviewed for Advance Directive. (Resident #8, #3, #35, #17, #18, #19, #37, #64, #226 and #230)

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure that two people, who are authorized to administer medications, signed the Narcotic Bound Book Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts between 8/14/24 and 9/3/24 (total of 56 shifts) for 1 of 4 units reviewed for drug diversion (Sagamore).

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 observation.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 2 of 4 units (Sagamore and [NAME]) for 1 of 1 environmental tour.

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan to reflect the current needs for 3 of 27 residents reviewed in the areas of transmission-based precautions and respiratory care (#51, #173, #176); and failed to revise the care plan after each assessment for 1 out of 3 sampled residents (#39) receiving in-house therapy services.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to develop and implement a safe discharge plan that focused on a resident's discharge goals, preparation, and effective transition of care for 5 out of 6 sampled residents discharged from the facility. (#25, #168, #268, #269 and #271)

Inspectors wroteBased on record reviews and interviews, the facility failed to follow doctor's orders and their own Weight Policy & Procedure to document weights for 4 out of 4 residents (#6, #13, #26 and #53) with daily or weekly weight orders.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide respiratory services as directed by physician orders related to oxygen use and monitoring for 2 of 2 residents reviewed for oxygen therapy (#51, #173).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide food that accommodated resident preferences for 2 out of 3 residents (#3 and #13) sampled about the food choices available.

Inspectors wroteBased on closed record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (Form CMS -10055) (SNFABN) were provided to 1 out of 2 residents reviewed whose Medicare Part A services were discontinued. (Resident #267)

Inspectors wroteBased on closed record reviews and interviews, the facility failed to permit a resident's return to facility for 1 out of 1 resident reviewed for facility-initiated discharge to the hospital (Resident #270).