Mainegeneral Rehab & Long Term Care - Gray Birch

Inspectors wroteBased on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 of 3 residents reviewed during a complaint investigation (Resident #2). Observations of Resident #2 on 6/30/26 at 9:42 a.m., 11:32 a.m., 12:45 p.m., and 2:16 p.m., a urinary catheter was observed hanging from bedframe visible from door containing a yellow liquid. During an interview on 6/30/26 at 11:32 a.m., Resident #2 stated it bothers him/her that the foley can be seen from the door. During an observation of Resident #2 on 6/30/26 11/45 a.m., Licensed Practical Nurse (LPN)1 states that the foleys the facility uses have the cover attached and normally they are changed out on admission. At this time LPN1 observed Resident #2 and noted the foley is visible from the door and is not covered. [...]

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 2 of 2 units (Birches and Pines) and for a common area dining room for 1 of 1 facility tour (1/14/26).

Inspectors wroteBased on observations, interviews, the facility's Dish Machine Temperature Logs, the facility's Refrigerator/Freezer Temperature Logs, and the facility's the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a water softening machine, food disposal units, floors, ceiling tiles, and ceiling lights; failed to ensure foods were covered/sealed and/or dated and labeled; failed to ensure dishes weren't wet stacked; failed to ensure refrigerators/freezers and dish washing machines temperatures were monitored/documented; and failed to ensure facial hair protection was used by staff with facial hair. Additionally, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (1/12/26 and 1/13/26).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to inform visitors and staff of an Influenza outbreak. Furthermore, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) for 2 of the 3 days of survey.

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 resident reviewed with a current diagnosis of PTSD (Resident #9).

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were removed from available supply in 1 of 3 medications carts observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. (1/12/26).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the licensed medication administration personnel coming on duty and going off duty signed the shift count logbook indicating that they counted all Scheduled II controlled substances and other medications with a risk of abuse or diversion at the change of shirt for 6 of 6 controlled log books reviewed for several shifts between 6/13/25 and 1/9/26.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the confidentiality of protected resident health information by displaying on monitors next to a resident's name and room number identification, what therapeutic needs they required, time of a meal corresponding with a group activity, what device was required to obtain the resident's weight, walking program, and shower day for 2 of 3 days of survey. In addition, the facility failed to protect and promote a resident's privacy and confidentiality for 1 of 1 residents reviewed for privacy (Resident #54 [R54]).

Inspectors wroteBased on record reviews and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 1 of 5 residents reviewed for Respiratory (Resident #15 [R15]) and failed to ensure that a care plan was developed in the area of Post Traumatic Stress Disorder (PTSD) for 1 of 1 residents reviewed for PTSD (R56).

Inspectors wroteBased on observations, record reviews, facility policy, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 6 residents reviewed for respiratory care (Resident #9 [R9]), Resident #60 [R60], Resident #221 [R221]), Resident #15 [R15], Resident #49 [R49]).

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the clinical record contained information necessary to meet the professional standards of practice for monitoring a dialysis catheter site for 1 of 1 residents reviewed for dialysis (Resident #56 [R56]).

Inspectors wroteBased on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 2 of 3 meals observed. (Resident #21 [R21], R11, and R7).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 3 sampled residents reviewed for PASRR (Resident #56 [R56]).

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure that physician's orders were followed for 1 of 2 sampled residents for wound management (Resident #12 [R12]) and 1 of 5 residents reviewed for unnecessary medications. (Resident #47 [R47])

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 dishes and food in a sanitary manner, not maintaining a clean kitchen floor, and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (8/5/24 and 8/6/24). This has the potential to effect all residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to wound management for 1 of 2 residents sampled for wound care. (Resident #12 [R12]).

Inspectors wroteBased on record reviews and interview, 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 #54 [R54] and R66).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately for 1 of 1 resident reviewed for discharged to the community (Resident #68 [R68]) and 1 of 3 residents reviewed for Pre admission Screening And Resident Review (PASARR) (Resident #47 [R47]).

Inspectors wroteBased on facility policy, record review and interview, the facility failed to provide an environment free of abuse and neglect for 1 of 2 residents reviewed for facility reported investigations (Resident #1).

Inspectors wroteBased on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 5 residents, and failed to obtain a providers order for 1 of 1 residents reviewed for documentation (Resident's #1 and #5).

Inspectors wroteBased on clinical record review, interviews, observation, and review of facility policy, the facility failed to ensure that the resident's environment was free of accident/ hazards relating to a food allergy. As a result of this failure, a resident experienced an anaphylactic reaction, requiring administration of epinephrine and emergency transport to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident #32).

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 2 of 2 units (Birches Unit and Pines Unit) for 1 of 1 environmental tour.

Inspectors wroteBased on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions in the area of suicidal ideation and pacemaker maintenance for 1 of 1 resident reviewed for mood and behavior and cardiac conditions(Resident #15), and in the area of smoking for 1 of 1 resident reviewed for smoking (Resident #48).

Inspectors wroteBased on observations, interviews, the facility's refrigerator/freezer temperature Logs and the facility's Food Storage policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted air conditioners, piping, a food disposal unit, and ceiling grids. Further, the facility failed to ensure foods were dated, labeled, and/or discarded by use by date in the dry storage room, the walk-in refrigerator, and the walk-in freezer for 1 of 1 tour. Additionally, upon kitchen documentation review, the facility failed to monitor temperatures of the sandwich bar refrigerator/freezer, the double door refrigerator, the Pepsi/food cooler, the ice cream freezer, the tall reach-in refrigerator, the walk-in refrigerator and the walk-in freezer.

Inspectors wroteBased on record reviews, facility policy, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 3 residents reviewed for advanced directives (Resident #12 and #15).

Inspectors wroteBased on record reviews and interview's, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 21 sampled residents (Resident #15).

Inspectors wroteBased record review and interviews, the facility's Quality Assurance and Performance Improvement failed to identify, monitor, analyze the cause, and implement preventive actions for 3 of 3 adverse resident events, when a resident received food for which he/she was allergic. (Resident #32)