Edgewood Rehab & Living Ctr
For profit - Corporation
33 Beds
NORTH COUNTRY ASSOCIATES
Data: November 2025
Trust Grade
50/100
#50 of 77 in ME
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Edgewood Rehab & Living Center has a Trust Grade of C, which means it is average compared to other facilities, sitting in the middle of the pack. With a state rank of #50 out of 77 in Maine, the facility is in the bottom half, although it ranks #1 out of 3 in Franklin County, indicating it's the best local option. Unfortunately, the facility is worsening, with issues increasing from 7 in 2023 to 11 in 2024. Staffing is a relative strength here, rated at 4 out of 5 stars; however, the turnover rate of 54% is about average for the state. While the facility has no fines on record, which is a positive sign, there are concerning incidents, such as the failure to maintain safe food storage temperatures, inadequate housekeeping in multiple areas, and not completing necessary post-fall assessments for residents. Overall, while there are some strengths like staffing and no fines, the increasing number of issues and specific incidents raise red flags for potential residents and their families.
- Trust Score
- C
- In Maine
- #50/77
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maine facilities.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Maine. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 36%
No red flags
7 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 7 issues
2024: 11 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Maine average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Maine avg (46%)
Higher turnover may affect care consistency
Chain: NORTH COUNTRY ASSOCIATES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 22 deficiencies on record
Oct 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that a baseline care plan was developed and implemented within 48 hours, that included instructions needed to provide minimum health...
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Based on interview and record review, the facility failed to ensure that a baseline care plan was developed and implemented within 48 hours, that included instructions needed to provide minimum healthcare information necessary to properly care for 1 of 1 residents reviewed for new admissions (Resident #31).
Finding:
Resident #31 was admitted to this facility on 7/12/24. The admission history and physical states Resident #31 had a diagnosis of Acute Ischemic Stroke where the Medical Doctor (MD) noted that he/she had mild left upper extremity weakness along with reports of difficulty swallowing, mixed Alzheimer's and Vascular Dementia with some agitation requiring the resident to be redirected and newly anticoagulated for Atrial Fibrillation. Resident #31 had medication orders for an anticoagulant, antidepressant, beta blocker, and an opioid. As of 10/17/24 there was no evidence of a baseline care plan that included instructions necessary to provide safe and effective care to Resident #31.
On 10/17/24 at 9:39 a.m., the above information was confirmed with the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and Material Safety Data Sheet (MSDS) review, the facility failed to ensure doors were locked ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and Material Safety Data Sheet (MSDS) review, the facility failed to ensure doors were locked where potentially dangerous chemicals were stored for 1 of 3 days of survey.
Findings:
On 10/15/24 at 9:48 a.m., a surveyor observed the Soiled Utility room, located on the Long-Term Care unit unlocked. Inside the Soiled Utility room, were four cabinets with four unlocked padlocks that contained the following: 1 bottle of Eco lab Rapid Multi Surface Disinfectant cleaner, 1 can of 3M Glass cleaner, 1 container of Simplex scour power and instant chlorine bleach, 1 can of WD-40, 1 bottle of True Clean Emerald Optically Enhanced floor cleaner and 1 bottle of Apollos Power Clean Industrial Grade cleaner & detergent.
The Material Safety Data Sheets, each dated 1/1/2007, were reviewed and indicated the following:
1. Eco Rapid Multi Surface Disinfectant cleaner
Section 4 First Aid Measures
Eyes: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Continue rinsing. Get medical attention immediately.
Skin contact: Wash off immediately with plenty of water for at least 15 minutes. Wash clothing before reuse. Thoroughly clean shoes before reuse. Get medical attention immediately.
Ingestion: Rinse mouth with water. Do not induce vomiting. Get medical attention immediately.
Section 7 - Handling and Storage
Conditions for safe storage: Keep out of reach of children. Store in suitable labeled containers.
2. 3M Glass cleaner Concentrate
Section 4 First Aid Measures
Eyes: Immediately flush with large amounts of water. Get medical attention.
Skin contact: Immediately wash with soap and water, if signs/symptoms develop, get medical attention.
Ingestion: Rinse mouth. If you feel unwell, get medical attention.
Precautions for safe handling: Keep out of reach of children.
3. Simplex scour power and instant chlorine bleach
Section 4 First Aid Measures
Eyes: Flush eyes with plenty of water for at least 15 minutes. Continue rinsing. Get immediate medical advice/attention.
Skin: Flush skin with plenty of water. If skin irritation occurs get medical advice/attention
Ingestion: not induce vomiting. Rinse mouth with water. If victim is conscious and alert, give 2 to 4 capfuls of water. Get medical attention immediately.
Section 2. Hazards Identification
Keep out of reach of children.
4. WD-40 Multi-Use Product Aerosol
Section 4 First Aid Measures
Eyes: Flush thoroughly with water. Get medical attention if irritation persists.
Skin: Wash with soap and water. If irritation develops and persists, get medical attention.
Ingestion: Aspiration Hazard. Do not induce vomiting. Call physician.
Section 7 Handling and Storage
Keep out of reach of children.
5. True clean Emerald Optically Enhanced floor cleaner
Section 4 First Aid Measures
Eyes: Rinse immediately with water for 15 minutes. Consult physician if symptoms occur.
Skin: Rinse with soap and water. Consult physician if symptoms occur.
Ingestion: Do not induce vomiting. Get medical attention.
Section 7 Handling and Storage
Wash thoroughly after handling. Avoid repeated contact with skin. Keep out of reach of children.
6. [NAME] Power clean Industrial Grade cleaner & detergent
Section 4 First Aid Measures
Eyes: Flush eyes thoroughly with plenty of water for 15 minutes.
Skin: Sensitive-skinned persons should wash off with soap and water.
Ingestion: Do not induce vomiting. Give lots of water and call a physician if necessary.
On 10/15/24 at 9:49 a.m. during an interview with Certified Nursing Assistant #1 (CNA) and CNA #2, the surveyor confirmed this finding. CNA #1 and CNA #2 stated that the key to the Soiled Utility room is kept above the door and the door should be locked. The cabinets inside the Soiled Utility room are supposed to have the padlocks locked.
On 10/15/24 at 9:59 a.m. a surveyor discussed the above finding with the Administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to post nurse staffing information on a daily basis including: the total number and the actual hours worked by licensed and unlicensed nursing s...
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Based on observation and interview, the facility failed to post nurse staffing information on a daily basis including: the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 2 of 3 survey days.
Finding:
On 10/15/24 and 10/16/24, a surveyor observed the nurse staffing information, posted in the main entrance, the posting lacked the total number of hours and the actual hours worked for the Registered Nurse, Licensed Practical Nurse and unlicensed nursing staff responsible for direct resident care.
On 10/16/24 at 9:26 a.m., the above was confirmed with the Director of Nursing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 9 of 18 resident rooms, a dining room, a whirlpool room, a bathroom and the laundry room for 1 of 1 Environmental Tour.
Findings:
On 10/17/24 from 8:33 a.m. to 9:00 a.m., an Environmental Tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed:
> The laundry room had debris in the two ceiling lights by the dryers. The wooden stand, under the washing machine's chemicals, was untreated creating an uncleanable surface.
> The standing floor fan in large dining room was heavily soiled with dust/dirt.
> The bathroom by the nurses station had a chipped/worn toilet seat and the floor was heavily soiled with dirt around the edges and over the entire floor.
> The whirlpool room was missing floor tiles along the edge of the wall and had a large brown stain on one ceiling tile.
> Resident room [ROOM NUMBER] - The bed footboard laminate and edging was peeling off the bed by the window. The standing floor fan was heavily soiled with dust/dirt.
> Resident room [ROOM NUMBER] - The bathroom had a urinal on the floor and a bed pan stored on the back of the toilet
> Resident room [ROOM NUMBER] - The room entrance door jamb had broken surface protectors.
> Resident room [ROOM NUMBER] - Resident #29's wheelchair seat was soiled and stained.
> Resident room [ROOM NUMBER] - The walls around the entire room and in the bathroom were marred, chipped and gouged creating uncleanable surfaces. The standing floor fan was soiled with dust/dirt.
> Resident room [ROOM NUMBER] - Resident #26's wheelchair had ripped/torn armrests.
> Resident room [ROOM NUMBER] - The walls around the entire room were marred, chipped and gouged creating uncleanable surfaces. The baseboard heater had chipped/missing paint creating an uncleanable surface. The room entrance door jamb had broken surface protectors.
> Resident room [ROOM NUMBER] - The base board heater had marred/chipped paint. The room entrance door jamb had broken surface protectors.
> Resident room [ROOM NUMBER] - The room entrance door had chipped/gouged wood and paint. The room entrance door jamb had broken surface protectors.
On 10/17/24 at 9:00 a.m., in an interview, the Administrator and the Maintenance Director confirmed the findings.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review and interviews, the facility failed to complete post fall neurological assessments along...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review and interviews, the facility failed to complete post fall neurological assessments along with appropriate fall assessments for 3 of 3 residents reviewed for falls (#17, #3, #333). In addition, the facility failed to follow physician orders for 1 of 2 residents reviewed for positioning (#18).
Findings:
Section V. Procedure of the Fall Management Policy (dated 7/2019), subsection E states to, Complete Post Fall Observation tool, following a fall and subsection F states Documentation must be completed in the nurse's note on each shift X3 following the fall.
The Neurological Assessment Policy (dated 1/2019) states, Residents with suspected neurological compromise will have a neurological sign monitored and recorded for a minimum of 12 hours. Subsection III Procedures states A neurological assessment following resident head injury will be completed for all residents sustaining head trauma or suspected head trauma. In EMR: Neuro Checks will be conducted-every 15 minutes x4, every 30 minutes x4, every 1 hr. x4, every 4 hr. x2, and every 8 hr. x1. Frequency of neuro checks after 24 hours is determined by resident's observed signs and symptoms of neurological compromise.
1. Resident #17 was admitted on [DATE] with a diagnosis of Dementia with Behavioral Disturbances and has a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Nurse documentation states Resident #17 had four unwitnessed falls one on 9/1/24, 9/29/24,10/2/24, and 10/14/24. Further review of Resident #17's medical record lacked evidence of the facility continuing to monitor him/her for further injuries and/or neurological changes after the unwitnessed fall.
On 10/16/24 at 10:53 a.m., during an interview, the Director of Nursing (DON) stated all unwitnessed falls with a resident with a low BIMS score should have a neurological check's done per the facilities neurological assessment policy.
On 10/16/24 at 1:13 p.m., during an interview, the Quality Improvement Specialist (QIS) stated that the post fall observation tool is what triggers nurses to do the neurological assessments, and the nurses should document in a nurses note daily for three days following a fall. At this time, the QIS confirmed Resident #17's record lacked evidence of a post fall observation tool being completed and daily nursing notes for each shift for 3 days following all 4 of the falls.
4. Resident #333 was admitted to the facility on [DATE] with diagnosis of Dementia, walking difficulty, muscle weakness, osteoporosis and had a BIMS score of 6, indicating severe cognitive impairment. The medical record states on 7/25/23 Resident #333 was found on the bedroom floor after an unassisted attempt at ambulation which resulted in bruising. Further review of the medical record lacked evidence of the facility continuing to monitor him/her for further injuries and/or neurological changes after the unwitnessed fall.
On 10/16/24 at 2:15 p.m., during an interview, the Director of Nursing confirmed the above.
2. Resident #3 was admitted on [DATE] with a diagnosis to include Dementia, Cerebral Infarction, Neurocognitive Disorder with Lewy Bodies, Vertigo and had a BIMS score of 11, indicating moderate cognitive impairment. Nurse documentation indicated Resident #3 had an unwitnessed fall on 5/27/24. The clinical record lacked evidence that documentation was completed in the nurse's note on each shift x3 following the fall.
On 10/17/24 at 10:25 a.m., the DON confirmed that there were no nursing notes about the incident initially and for the next three shifts as facility policy states.
3. Resident #18 was admitted on [DATE] with a diagnosis to include Dementia, difficulty walking, Kidney Disease, Delirium and had a BIMS score of 7, indicating severe cognitive impairment. Current signed physician orders, dated 9/24/24, noted the following: 6/18/2024 Active (Current)Treatment, Knee brace - left knee -on when out of bed
On 10/15/24 at 9:30 a.m., a surveyor observed Resident #18 in his/her wheelchair eating breakfast in the dining room and he/she was not wearing a knee brace on his/her left knee.
On 10/16/24 at 8:50 a.m., a surveyor and the QIS interviewed Certified Nurse's Assistant, (CNA #1) who stated that she has taken care of the resident for a long time and the resident has never had a knee brace and doesn't wear one.
On 10/16/24 at 9:00 a.m., a surveyor and the QIS observed and interviewed Resident #18, who stated that he/she was supposed to get a left knee brace a long time ago but never got one so he/she does not wear one.
On 10/16/24 at 9:10 a.m., a surveyor and the QIS reviewed the resident clinical record and the physician's order for a left knee brace at all times when resident out of bed. At this time, the QIS confirmed that the facility was not following the physician's order for a left knee brace for the resident to be worn while he/she is out of bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on facility policy, record review and interviews, the facility failed to adequately ensure medications and biologics were monitored and stored at appropriate temperatures in 1 of 1 refrigerator ...
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Based on facility policy, record review and interviews, the facility failed to adequately ensure medications and biologics were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed and 3 of 3 months of medication refrigerator logs reviewed.
Findings:
Facility policy and procedure for Omnicare Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 8/1/24 states, Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance . refrigeration: 36° to 46°F.
On 10/15/24 at 12:15 p.m., observation of the medication storage room with Registered Nurse (RN) contained a refrigerator containing insulin, 8 boxes of influenza vaccinations, and Tuberculin Purified Protein. At this time, the RN states that refrigerator temperatures are checked twice daily.
The facilities Medication Refrigerator log indicates temperatures are to be monitored twice daily. Review of the temperature logs from 8/2024 through 10/2024 lacked evidence of temperatures being monitored twice daily, or maintained at the appropriate temperature ranges for the following dates:
- August 2024 lacked evidence of temperature readings for 16 out of 31 days and temperatures were out of range for 11 out of 31 days.
- September 2024 lacked evidence of temperature readings for 17 out of 30 days and temperatures were out of range for 11 out of 30 days
- October 2024 lacked evidence of temperature readings for 5 out of 15 days and temperatures were out of range for 2 out of 15 days reviewed.
On 10/16/24 the above was confirmed with the Director of Nursing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and review of the facility's Dish Machine Temperature and Sanitizer Log Form, the Refrigerator/Freezer Food Storage and Temperature policies and procedures, the faci...
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Based on observations, interviews, and review of the facility's Dish Machine Temperature and Sanitizer Log Form, the Refrigerator/Freezer Food Storage and Temperature policies and procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, a food mixer, ceiling vents, ceiling lights, ceiling tiles and a door thresh hold; failed to ensure foods were sealed in the walk-in freezer; failed to monitor the temperatures of the walk-in freezer and the walk-in refrigerator; failed to monitor the dishwasher wash and rinse cycle temperatures as well as the chemical sanitizer levels for the sanitizing sink and the sanitizing buckets for 1 of 1 kitchen tour and for 1 of 1 survey days (10/15/24). This has the potential to affect all residents.
Findings:
The facilities Dish Machine Temperature and Sanitizer Log Form noted: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles after each meal.
The facilities Refrigerator/Freezer Food Storage policy and procedure noted: 13. Refrigerated food storage: b. Thermometers should be checked at least two times each day. d. Refrigerator/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. f. All foods should be covered, labeled and dated. 14. Frozen foods: c. All foods should be covered, labeled and dated
The facilities Refrigerator/Freezer Temperature policies and procedures noted: 9. Refrigerator/freezer temperatures a period take the internal temperatures of each unit and document.
1. On 10/15/24 from 8:50 a.m. to 9:40 a.m., during an initial kitchen tour, a surveyor observed the following findings: > The standing floor fan was heavily soiled with dust and dirty.
> The food mixer had chipped/missing paint on the mix arm and the base.
> The dish room had two ceiling vents and a small wall mounted fan that were dirty and heavily soiled with dust. > There were 3 ceiling vents in the kitchen and 1 ceiling vent in the kitchen office heavily soiled with dust and dirty.
> The kitchen office had a ceiling light missing the lens and didn't have bulb protectors on them.
> There were 2 ceiling tiles with brown stains on them over the hood system.
> There was 1 ceiling tile with a brown stain on it over the reach-in freezer by the kitchen bathroom.
> The ceiling vent by the ice machine was heavily soiled with dust.
> There was a cracked/broken ceiling light lens in the middle of the kitchen.
> The reach-in freezer, by the ice machine, had a bag of french fries that had been ripped open to the air. > The walk-in cooler door thresh hold was rusty, broken and spongy when stepped on.
On 10/15/24 at 9:40 a.m., in an interview, the Administrator confirmed the findings.
2. On 10/16/24 at 2:40 p.m., the Kitchen Refrigerator/Freezer temperatures, Sink/Bucket Sanitizer, and Daily High-temp Ware Wash Logs were requested by a surveyor for July, August, September and October 2024 and reviewed with the Food Service Director. The following findings were observed:
Missing monitoring and documentation of Refrigerator/Freezer Temperatures: Snack Refrigerator/Freezer- 2024
>July: Snack Freezer - 23-25
>August: Refrigerator - 1-21(am and pm), 24(pm) Freezer - 1-21(am and pm)
>September: Big Freezer - 24 and 25(am); 26-28(pm)
Vegetable Freezer - 24 and 25(am); 30(pm)
Bread Freezer - 24 and 25(am); 30(pm) Walk-in Refrigerator - 24 and 25(am); 30(pm) Walk-in Refrigerator IFT - 24 and 25(am); 30(pm)
Missing monitoring and documentation of Sink/Bucket Sanitizer-2024
>July: 5:00 a.m. - 28 9:00 a.m. - 28 1:00 p.m. - 2, 14, 20, 21 and 28 5:00 p.m. - 1-3, 9, 12, 18, 19, 28 and 31
>August: 5:00 a.m. - 11, 13-15, 23, 28 and 31 9:00 a.m. - 4, 9-11, 15, 16, 23, 28 and 31 1:00 p.m. - 2, 3, 5, 9, 10, 22, 26, 29 and 31 5:00 p.m. - 2, 5, 10, 22, 29-31
>September: 1-30
>October: 9:00 a.m. - 6 and 9 5:00 p.m. - 1
Missing monitoring and documentation of Daily High-Temperature Ware Wash Checklist - 2024
>July: Breakfast wash/rinse - 20-22 and 28
Lunch wash/rinse - 20 and 28
Supper wash/rinse - 1-3, 10-12, 18, 19, 28 and 31
>August: Breakfast wash/rinse - 10, 11, 15, 16, 25, 28, 30 and 31
Lunch wash/rinse - 16, 25, 28, 30 and 31 Supper wash/rinse - 2, 4, 5, 14, 24-26, 30 and 31
>September: 1-30
October: Breakfast wash/rinse - 5 and 6
On 10/16/24 at 2:40 p.m., in an interview, the Food Service Director confirmed the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days a...
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Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days and 2 of 2 dumpsters for 1 of 3 days of survey. (10/15/24, 10/16/24 and 10/17/24)
Findings:
1. On 10/15/24 at 9:30 a.m., a surveyor observed the large trash dumpster had left side slide door missing/open and the top left front door open both exposing trash, a small dumpster which had the front right top open on it and plastic and paper trash on the ground around the dumpsters. Additionally, trash was observed stored in an open top cart outside the laundry room exit. On 10/15/24 at 9:40 a.m., in an interview, the Administrator confirmed the findings.
2. On 10/16/24 at 7:35 a.m., a surveyor observed the left side door missing and the right side door of the large trash dumpster to be fully open, exposing trash. The surveyor also observed plastic and paper trash on the ground around the dumpster. On 10/16/24 at 8:30 a.m., in an interview, the Administrator confirmed the findings.
3. On 10/17/24 at 7:35 a.m., a surveyor observed the left side door missing of the large trash dumpster to be fully open, exposing trash. The surveyor also observed plastic and paper trash on the ground around the dumpster. Additionally, trash was observed stored in an open top cart outside the laundry room exit. On 10/17/24 at 8:00 a.m., in an interview, the Administrator confirmed the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for identified deficiencies from the annual Long Term...
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Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for identified deficiencies from the annual Long Term Care Recertification Survey, dated 10/17/24, was effective. Several issues were again identified during the revisit survey, on 12/30/24.
Findings:
During the revisit survey on 12/30/24, it was determined the Federal citations: F584, F655, F684, F761, F812, F883 and F887 would be recited for the same following issues:
F584 The POC indicated the facility educated the Maintence and Housekeeping Director and audits to be completed. The facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
F655 The POC indicated the facility educated the MDS Coordinator regarding appropriate care plannning time frames. The facility failed to ensure that baseline care plans were developed and implemented within 48 hours, that included instructions needed to provide minimum healthcare information necessary to properly care for new admissions.
F684 The POC indicated that nursing staff was educted on the Neurological Assessment Policy and Fall Policy. The facility failed to to monitor residents after a fall.
F761 The POC indicated that nursing staff was educated on the Pharmacy policies/procedures regarding Medication Storage and appopriate temperatures and the need to record temperatures. The facility failed to adequately ensure medications and biologics were monitored and stored at appropriate temperatures.
F812- The POC indicated that the kitchen staff were educated and to complete audits. The facility failed to ensure the kitchen was maintained in a clean and sanitary manner.
F883 The facility failed to identify current resisdent who were not offered the vaccine.
F887 The POC indicated the Infection Preventionist was educated and current residents were offered the vaccine and educated. The faciliy to educate, offer and/or administer the updated 2024-2025 COVID -19 vaccines to residents.
On 12/30/24 at 3:45 p.m., the above concerns were discussed with the Administrator and Director of Nursing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implemen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their pneumococcal immunization policy for 3 of 5 residents whose immunization records were reviewed (#18, #19, #28)
Findings:
The facility's Immunization Policy indicated in Procedure I: Before offering the Influenza or Pneumococcal vaccine, each resident, and/or resident's legal representative will receive education produced by the Maine and/or Federal Centers for Disease Control regarding the benefits and potential side effects of the vaccines for the current year. The resident's clinical record will include the following documentation: Signature of the person receiving the educational material, designating receipt and understanding of the material. Verbal consent may also be obtained if communication is done via a telephone conversation. Proof the resident either received the Influenza and/or the Pneumococcal vaccine, the vaccine(s) was contraindicated for medical reasons, or the resident refused the vaccine(s). Each resident will be offered a Pneumococcal Vaccine, upon admission unless the immunization is medically contraindicated, or the resident has already been immunized. Vaccines will be given in accordance with the Maine Center for Disease Control. For Immunocompromised adults aged 65 years or older. A single dose of PCV 20 may be administered or administered 1 dose of PCV 15, if not previously administered, followed by 1 dose of 23 valent pneumococcal polysaccharide vaccine (PPSV23) at a minimum interval of 8 weeks between both doses. The vaccine administration will be documented on the vaccine record in the medication administration record.
1. Resident #18's clinical record indicated that the resident was admitted to the facility on [DATE]. Resident #18's immunization records lacked evidence the resident's PCV 20 was current or offered and administered as directed by the facility's Immunization - Influenza, Pneumococcal Policy.
2. Resident #19's clinical record indicated that the resident was admitted to the facility on [DATE]. Resident #19's immunization record lacked evidence that the PCV 20 vaccine was current or offered and administered as directed by the facility's Immunization - Influenza, Pneumococcal Policy.
3. Resident #28's clinical record indicated that the resident was admitted to the facility on [DATE]. Resident #28's immunization record lacked evidence that the PCV 20 vaccine was current or offered and administered as directed by the facility's Immunization - Influenza, Pneumococcal Policy.
On 10/17/24 between 11:24 a.m. and 11:45 a.m., a surveyor confirmed the above findings in an interview with the Infection Preventionist and the Director of Nursing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review and interview, the facility failed to offer updated (COVID-19) vaccine ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review and interview, the facility failed to offer updated (COVID-19) vaccine doses for 5 of 5 residents reviewed. (#7, #15, #18, #19 & #28)
Findings:
The facility's policy, Policy for Suspected or Confirmed Coronavirus (COVID-19) revised 5/7/24 indicated under Vaccines: The facility will be required to educate residents and employees on vaccines and offer updated vaccines to all residents.
On 10/17/24, between 11:20 a.m. and 11:45 a.m., during an interview with the Director of Nursing and the Infection Preventionist, the following resident's vaccination records were reviewed and confirmed that the updated 2023-2024 COVID-19 vaccinations were not offered:
1. Resident #7 was admitted to the facility on [DATE]. Resident #7 was diagnosed with COVID-19 on 9/5/24. Resident # 7's last documented COVID-19 vaccination was 12/21/23. The clinical record lacked evidence of offering the updated COVID-19 vaccination.
2. Resident #15 was admitted to the facility on [DATE]. Resident 15's last documented COVID-19 vaccination was 12/20/22. The clinical record lacked evidence of offering the additional dose of the updated COVID-19 vaccination.
3. Resident #18 was admitted to the facility on [DATE]. Resident #18 was diagnosed with COVID-19 on 9/9/24. Resident #18's last documented COVID-19 vaccination was 10/20/22. The clinical record lacked evidence of offering the updated COVID-19 vaccination.
4. Resident #19 was admitted to the facility on [DATE]. Resident #19's last documented COVID-19 vaccination was 7/8/22. The clinical record lacked evidence of offering the updated COVID-19 vaccination.
5. Resident #28 was admitted to the facility on [DATE]. Resident #28 was diagnosed with COVID-19 on 9/9/24. Resident #28's last documented COVID-19 vaccination was 9/20/23. The clinical record lacked evidence of offering the updated COVID-19 vaccination.
Feb 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the Safety Data Sheet, the facility failed to ensure that the resident environmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the Safety Data Sheet, the facility failed to ensure that the resident environment remained free from the potential risk of accident when they failed to ensure that a chemical was properly secured for 2 of 2 observations during 1 of 3 days of survey (2/21/23).
Findings:
1. On 2/21/23 at 9:30 a.m., a surveyor observed a 10.1 fluid ounce spray bottle of Fabreze One - Fabric and Air Mist in a pink wash basin on the floor in the bathroom of Resident room [ROOM NUMBER].
2. On 2/21/23 at 1:25 p.m., two surveyors observed the same 10.1 fluid ounce spray bottle of Fabreze One - Fabric and Air Mist on the back of the toilet. The bathroom is shared by rooms [ROOM NUMBERS] and utilized by 4 residents.
The Safety Data Sheet for Fabreze One - Fabric and Air Mist noted:
Section 4. First Aid Measures
Eye Contact: Rinse with plenty of water. Get medical attention immediately if irritation persists
Skin Contact: IF ON SKIN(or hair), Remove/Take off immediately all contaminated clothing. Rinse skin with water/shower. Get medical attention immediately if symptoms occur.
Ingestion: Drink 1 or 2 glasses of water. Do Not induce vomiting. Get medical attention immediately if symptoms occur.
Inhalation: Move to fresh air. If symptoms persist, call a physician.
On 2/21/23 at 1:27 p.m., in an interview, the Director of Nursing confirmed the chemical spray bottle of Fabreze was stored incorrectly and should not have been in the resident bathroom.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview, review of the daily staffing postings the Payroll Based Journal Report, and the nursing working schedule the facility failed to have a Registered Nurse (RN) on duty for at least 8 ...
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Based on interview, review of the daily staffing postings the Payroll Based Journal Report, and the nursing working schedule the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 1 of 77 days reviewed for Sufficient and Competent Nurse Staffing.
Finding:
A review of the Payroll Based Journal Report for Fiscal Year Quarter 4 2022 (July 1- September 30) indicated that the facility failed to have Licensed Nursing Coverage 24 hours/Day with infraction dates on 07/04/22 (Monday), 07/16/22 (Saturday), 08/27/22 (Saturday) and 09/24/22 (Saturday).
A review of the nursing working schedule, indicated that on 7/16/22 (Saturday) the facility did not have an RN on duty for at least 8 consecutive hours.
On 2/24/23 at 11:44 a.m., in an interview with the Director of Nursing (DON), she reported that the facility did have a Registered Nurse coverage for 8 consecutive hours on 7/04/22, 8/27/22, and 9/24/22. In addition, the DON provided copies of the schedule showing a Registered Nurse worked for eight hours on these days.
On 2/24/23 at 12:21 p.m., in an interview with the DON, the surveyor confirmed the lack of sufficient RN coverage on 7/16/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 10 of 18 resident rooms, the whirlpool room and the laundry room for 1 of 1 Environmental Tour.
Findings:
On 2/24/23, from 8:33 a.m. to 9:03 a.m., an Environmental Tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed:
> Resident room [ROOM NUMBER]: The floor was dirty around base of toilet and the entire bathroom floor was heavily soiled with dirt/debris.
> Resident room [ROOM NUMBER]: The white raised toilet seat was dirty with brown fecal looking material. The paint was chipped/missing on the wall under the room window. The varnish is worn/missing on the bureau next to the sink.
> Resident room [ROOM NUMBER]: There were ten cracked/broken floor tiles as you enter the room. The floor was dirty around base of toilet and the entire bathroom floor was heavily soiled with dirt/debris.
> Resident room [ROOM NUMBER]: The floor was dirty around base of toilet.
> Resident room [ROOM NUMBER]: The floor was dirty around base of toilet and the entire bathroom floor was heavily soiled with dirt/debris. There were three cracked/broken floor tiles as you enter the room.
> Resident room [ROOM NUMBER]: The wall under the sink had scuffed/chipped/missing paint. There were seven cracked/broken floor tiles as you enter the room.
> Resident room [ROOM NUMBER]: The entire bathroom floor was heavily soiled with dirt/debris. The bathroom exhaust fan was dirty/dusty. The caulking around the base of toilet was stained yellowish/brownish and was dirty.
> Resident 16: The floor was dirty around base of toilet. There were four ceiling tiles with brown stains in the bathroom. The bathroom floor was heavily soiled with dirt/debris. There were five cracked/broken floor tiles by the television in the room. The room floor had dirt/debris build up around the edges. The floor mat near the bed by the door was dirty and ripped/torn.
> Resident room [ROOM NUMBER]: Resident #19's wheelchair had rips/tears in the right arm rest.
> Resident room [ROOM NUMBER]: Resident #4's wheelchair had rips/tears in the right arm rest. The floor was dirty around the base of the toilet. The room floor had dirt/debris build up around the edges. The escutcheon plate on toilet shut off was extremely rusty.
> Laundry room-: The flooring was ripped/missing pieces exposing untreated cement and creating uncleanable surfaces. The entire floor heavily soiled with dirt/debris. The wall fan, located in the clean area of the laundry room, was dusty/dirty.
> Whirlpool room: The caulking around the base of toilet was stained yellowish/brownish and was dirty. The table top fan on the sink counter was dusty/dirty. The exhaust fan by the whirlpool unit was dusty/dirty. One ceiling tile, above the toilet area, had a brown stain.
On 2/24/23 at 9:03 a.m., in an interview, the Administrator and the Maintenance Director confirmed the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that medications were stored properly by having unlabeled med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that medications were stored properly by having unlabeled medications stored in three resident's rooms for 1 of 3 days of survey. (Rooms #6, #7, #8)
Findings:
1. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], which is shared by two residents, there was an unlabeled medication (muscle rub ointment per DON) in a medication cup on the bedside table of Resident #11.
2. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], which is shared by two residents, there was an unlabeled medication (Nystatin powder per DON) in a medication cup on the shared sink. Nystatin powder is used to treat fungal or yeast infections of the skin.
3. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], an unlabeled medication (Nystatin powder per DON) on the bedside table and another unlabeled medication (Nystatin powder) in the bathroom on top of the paper towel dispenser. In addition, on the bedside table there was a bottle of Systane Eye drops sitting in a basket.
On 2/21/23 at 1:25 p.m. during a tour with the Director of Nursing (DON), the above findings were discussed and/or confirmed. The DON stated that residents in the above rooms do not have self-administration of medication evaluations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and review of the facility's sink/bucket sanitizer form/policy and procedure, the daily high-temperature ware wash checklist/policy and procedure, the freezers and r...
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Based on observations, interviews, and review of the facility's sink/bucket sanitizer form/policy and procedure, the daily high-temperature ware wash checklist/policy and procedure, the freezers and refrigerators temperature forms, and the food storage policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling lights, the food mixer, the dry storage room and the kitchen floor. The facility also failed to remove expired foods and failed to date, label and/or seal foods in the walk-in freezer and in the walk-in refrigerator. Additionally, the facility failed to monitor the temperatures of the walk-in freezer and the walk-in refrigerator. Further, the facility failed to monitor the dishwasher wash and rinse cycle temperatures as well as the chemical sanitizer levels for the dishwasher, the sanitizing sink, and the sanitizing bucket for 1 of 1 survey days (2/21/23) in the kitchen. This has the potential to affect all residents.
Findings:
On 2/21/23 from 8:40 a.m. to 9:20 a.m., in an initial kitchen tour with the Food Service Director, the following findings were observed:
1. The dish room:
- two ceiling lights that had cracked/broken lens covers.
- the walls by the hand washing sink and the dishwasher were covered in dried liquid splatter.
- the wall mounted fan was dusty/dirty,
2. The food mixer had dried food particles on the mix arm and base and also had chipped/missing paint on the mix arm.
3. The kitchen floor had dirt, trash and food debris around the edges and under the equipment and shelving.
4. The dry storage room had dirt, food debris and trash under the shelving.
5. Reach-in Freezer #2, closest to the cook stove, had one package of meat not dated and labeled, two packages of imitation crab meat that was not dated and labeled, one pre-opened bag of blue berries and one pre-opened bag of cranberries that were not dated, five pie shells that were not dated and labeled, two balls of pizza dough that were not dated and labeled, and a pre-opened bag of Bay Scallops with a large amount of ice crystals in the bag that was not dated.
6. The walk-in refrigerator had three thickened lemon flavored waters that were outdated. One was expired 12/5/22 and two were expired on 1/19/23.
7. The facility's Sink/Bucket Sanitizer Forms were missing documentation on the following dates:
December 2022
12/1/22 to 12/4/22 at 5:00 p.m.
12/10/22 at 5:00 p.m.
12/12/22 at 5:00 p.m.
12/13/22 at 1:00 p.m. and 5:00 p.m.
12/15/22 at 5:00 p.m.
12/17/22 at 5:00 p.m.
12/18/22 at 9:00 a.m. and 5:00 p.m.
12/19/22 to 12/21/22 at 5:00 p.m.
12/22/22 at 1:00p.m. and 5:00 p.m.
12/24/22 at 5:00 p.m.
12/27/22 to 12/28/22 at 5:00 p.m.
12/29/22 at 1:00p.m. and 5:00 p.m.
January 2023:
1/7/23 to 1/11/23 at 5:00 p.m.
1/13/23 at 1:00p.m.
1/14/23 1:00p.m. and 5:00 p.m.
1/17/23 at 5:00 p.m.
1/18/23 at 1:00p.m. and 5:00 p.m.
1/22/23 at 1:00p.m.
1/27/23 at 5:00 p.m.
1/29/23 to 1/30/23 at 5:00 p.m.
1/31/23 at 1:00p.m. and 5:00 p.m.
February 2023:
2/5/23 at 1:00 p.m.
2/7/23 at 5:00 p.m.
2/9/23 at 5:00 p.m.
2/12/23 to 2/14/23 at 5:00 p.m.
2/17/23 at 5:00 p.m.
2/20/23 at 5:00 p.m.
8. The facility's Freezer and Refrigerator Temperature Log forms were missing documentation on the following dates:
December 2022, January 2023 and February 2023
Big Freezer:
12/1/22, 12/11 22, 12/12/22, 12/18/22, 12/30/22, 12/31/22, 1/9/23, 1/10/23, 1/12/23, 1/15/23, 1/23/23, 12/31/22, 2/2/23
Kitchen Freezer:
12/1/22,12/11 22, 12/12/22, 12/18/22, 12/31/22, 1/10/23, 1/15/23, 1/23/23, 2/2/23
Back Freezer:
12/1/22, 12/11 22, 12/12/22, 12/18/22, 12/31/22, 1/2/23, 1/10/23, 1/12/23, 1/15/23, 1/23/23
2/2/23, 2/12/23
Walk-in Refrigerator:
12/1/22, 12/12/22, 12/18/22, 12/31/22, 1/2/23, 1/10/23, 1/12/23, 1/23/23, 2/2/23
Snack Refrigerator:
12/1/22, 12/11 22, 12/12/22, 12/18/22, 12/31/22, 1/2/23, 1/10/23, 1/12/23, 2/2/23
Snack Freezer:
12/1/22, 12/11 22, 12/12/22, 12/18/22, 12/31/22, 1/2/23, 1/10/23, 1/12/23, 1/15/23, 1/23/23, 2/2/23, 2/12/23
IFT Milk Cooler:
12/1/22, 12/12/22, 12/18/22, 12/31/22, 1/2/23, 1/10/23, 1/12/23, 1/15/23, 1/23/23, 2/2/23, 2/16/23
9. The Daily High-Temperature Ware Wash Checklist Forms were missing documentation on the following dates for various meals:
December 2022, January 2023 and February 2023
1/2/22, 1/3/22, 1/5/22, 1/7/22, 1/8/22, 1/13/22, 1/18/22, 1/19/22, 1/20/22, 1/22/22, 1/30/22, 1/31/22, 1/3/23, 1/4/23, 1/5/23, 1/8/23, 1/12/23, 1/13/23, 1/17/23, 1/22/23, 1/27/23, 1/31/23, 2/1/23 to 2/6/23, 2/11/23, 2/13/23 to 2/15/23, 2/17/23, 2/19/23,
The facility's Food Storage Policy and Procedure noted:
4. All containers must be legible and accurately labeled and dated.
7. c. Food should be dated as it is placed on the shelves if required by state regulation.
13. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated.
14. b. Thermometers should be checked at least 2 times each day. See sample freezer and refrigerator temperature forms.
14. f. All food should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
The facility's Sink/Bucket Sanitizer Policy and Procedure Form, updated 10/23/12 noted: Take and record sanitizer parts per 1,000,000 strength in solution temperature at designated times or when the solution looks dirty. Periodically ensure sanitizer is still at full strength before the 4 hours is up, especially if it is being used often.
The facility's Dish Machine Temperature(Daily High-Temperature Ware Wash Checklist Forms) and Sanitizer Log form policy and procedure noted: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles after each meal. A period the director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures.
The facilities Freezer and Refrigerator Temperatures Form Policy and Procedure Manual 3-19 dated 2013 noted: Record both internal and external temperatures of the freezers and refrigerators at least twice a day quotation approximately 6:00 AM and 7:00 PM quotation. All units must be monitored daily.
On 2/21/23 at 9:20 a.m., in an interview, the Food Service Director confirmed the initial findings in the kitchen. On 2/25/23 at 1:00 p.m., in an interview, the Food Service Director confirmed the lack of documentation on the Daily High-Temperature Ware Wash Checklist Forms, the Freezer and Refrigerator Temperature Log forms and the Sink/Bucket Sanitizer Forms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days o...
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Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days of survey. (2/21/23, 2/22/23 and 2/24/23)
Findings:
1. On 2/21/23 at 9:20 a.m., the surveyor and the Food Service Director observed 1 of 2 dumpsters with the left front lid and the back right lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The Food Service Director confirmed the finding at this time.
2. On 2/22/23 at 8:20 a.m., a surveyor and the laundry worker observed 1 of 2 dumpsters with the left front lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The laundry worker confirmed the finding at this time.
3. On 2/24/23 at 8:05 a.m., a surveyor observed 1 of 2 dumpsters with the left front lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The surveyor discussed the finding with the Administrator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropri...
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Based on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#2 & #3).
Findings:
On 9/24/23 during a review of facility staff education records the following were noted:
CNA #2 was hired on 12/5/12. The last Abuse training received by CNA #2 was completed on 11/11/20. The record lacks evidence of mandatory Abuse training in 2021.
CNA #3 was hired on 8/6/96. The last abuse training received by CNA #3 was completed on 8/19/20. The record lacks evidence of mandatory Abuse training in 2021.
On 2/27/23 at 2:50 p.m. the Director of Nursing confirmed that not all of the mandatory training required was done in 2021 for the staff reviewed.
Aug 2021
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to ensure that the resident environment remained free ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to ensure that the resident environment remained free from the potential risk of accident when they failed to ensure that chemicals and an electrical closet were properly secured during 1 of 3 days of survey.
Findings:
On 8/2/2021 at 10:14 a.m. a surveyor observed an unlocked soiled utility closet on the Mountain View East Wing and noted the following chemicals easily accessible to ambulatory residents:
-(2) bottles of 3M Disinfectant Cleaner 40. Review of the Material Safety Data Sheet (MSDS) indicates If swallowed: rinse mouth. Do not induce vomiting. Immediately call a Poison Center or doctor/physician.
-(1) container of Microdot Bleach Wipe. Review of the MSDS indicates Causes moderate eye irritation. If in eyes, hold eye open and rinse slowly and gently with water for 15-20 minutes. Ingestion: May cause gastrointestinal irritation and upset.
-(1) gallon container of Kleen [NAME] Naturally Enzymes, [NAME] Power Clean. Review of the MSDS indicates Eye Contact: Flush eyes thoroughly with plenty of water for 15 minutes. Ingestion: Do not induce vomiting. Give lots of water and call a physician if necessary
On 8/2/2021 at 11:32 a.m. a surveyor observed an unlocked Electrical closet that was easily accessible to ambulatory residents.
These above findings were confirmed with the Administrator on 8/2/2021 at 11:34 a.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the plan of correction, and interviews, the facility's Quality
Assurance Committee failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the plan of correction, and interviews, the facility's Quality
Assurance Committee failed to ensure that the plan of correction for an identified deficiency from the Recertification Survey dated 8/4/21 was effective. The deficiency, F584, (Safe/Clean/ Comfortable/ Homelike Environment) was again identified during the 9/23/21 Revisit Survey.
Finding:
During the Recertification Survey, dated 8/4/21, a deficiency was cited at F584 (Safe/Clean/ Comfortable/Homelike Environment) for the failure to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 14 of 18 resident rooms and the facility dining room for 1 of 3 days of survey.
The facility's Plan of Correction for F584, with a completion date of 9/18/21, indicated that they would fix the whirlpool room walls and floors, clean the hallway and resident room floors, repair damaged resident room doorframes, repair damaged closets, replace a damaged bureau, repair or replace damaged baseboard heaters, and conduct routine audits which would be reported to the Safety Committee monthly for 6 months. Any items that were not completed by 9/18/2021 would have estimates and contracts secured with work to be completed as soon as the vendor was able, or replacement items arrived, or materials arrived.
During the Revisit Survey observations on 9/23/2021, F584 was again cited for failure to follow their Plan of Correction to clean and maintain cleanliness and items in good repair in 4 of 18 cited resident rooms (room [ROOM NUMBER], 4, 6, and 12), and in the hallways, the whirlpool room, and the dining room. In addition, new environmental findings were observed in 14 of 18 resident rooms ( 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 16, 17, and 18), and for the 2 Hoyer patient lifts, and one Reliant patient stand lift, a linen closet, an employee bathroom, and a visitor bathroom.
On 9/23/2021 at 9:35 a.m. during an interview, the Administrator and the Maintenance Director confirmed the findings of continued non-compliance in the area of Safe/Clean/Comfortable/ Homelike Environment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 16 of 18 resident rooms and the facility dining room for 1 of 3 days of survey.
Findings:
On 8/4/2021, from 12:25 p.m. to 1:20 p.m., during an environmental tour of the building with the Administrator and the Maintenance Director, the following findings were observed:
-The whirlpool room walls and floor had dirt/debris around the edges of the floor and stained areas on the floor.
-The laminate between the wall and the floor in the whirlpool room was cracked creating an uncleanable surface.
-The resident room floors were stained and soiled with dirt/debris around the whole floor in resident Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9,11, 12, 13, 14, 15, 16, 17.
-The hallway floors were soiled and stained with dirt/debris.
-The resident room entrance door/frame and bathroom door/frame are chipped/gouge creating uncleanable surfaces in Rooms: 3, 4, 6, 7, 12, 17
-The dresser is chipped and marred in room [ROOM NUMBER].
-The closet doors are chipped/marred in resident Rooms 4, 14, 15, 16, 17, 19
-The baseboard heaters are rusty creating uncleanable surfaces in the dining room and resident Rooms: 7, 8, 9, 11, 12, 13, 15, 16, 17, 18, 19 and resident bathrooms 4, 11.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews and temperature log reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by not...
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Based on observations, interviews and temperature log reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by not monitoring the temperatures of the walk-in freezer, kitchen freezer, back freezer, snack freezer, walk-in refrigerator, and the snack refrigerator to ensure temperatures were kept at safe storage parameters, as well as monitoring the dishwasher wash and rinse cycle temperatures and chemical sanitizing sink and bucket sanitizer levels. This has the potential to effect all residents in the facility.
Findings:
1. On 8/2/2021 at 9:45 a.m., during a kitchen tour done with the cook, the following was observed:
The temperature logs identified as Freezer and Refrigerator Temperatures for the month of July 2021 revealed:
Entries for the temperatures for the a.m. temperature readings were missing 18 times out of 62 opportunities days for the Big freezer.
Entries for the temperatures for the p.m. temperatures readings were missing 16 times out of 62 opportunities for the Big freezer.
Entries for the temperatures for the a.m. temperatures readings were missing 19 times out of 62 opportunities for the Kitchen freezer.
Entries for the temperatures for the p.m. temperatures readings were missing 16 times out of 62 opportunities for the Kitchen freezer.
Entries for the temperatures for the a.m. temperatures readings were missing 20 times out of 62 opportunities for the Back freezer.
Entries for the temperatures for the p.m. temperatures readings were missing 16 times out of 62 opportunities for the Back freezer.
Entries for the temperatures for the a.m. temperatures readings were missing 62 times out of opportunities days for the Walk-In refrigerator.
Entries for the temperatures for the p.m. temperatures readings were missing 62 times out of opportunities days for the Walk-In refrigerator.
Entries for the temperatures for the a.m. temperatures readings were missing 22 times out of 62 opportunities for the Snack refrigerator.
Entries for the temperatures for the p.m. temperatures readings were missing 17 times out of 62 opportunities for the Snack refrigerator. times
Entries for the temperatures for the a.m. temperatures readings were missing 21 times out of 62 opportunities for the Snack freezer.
Entries for the temperatures for the p.m. temperatures readings were missing 17 times out of 62 opportunities for the Snack freezer.
2. On 8/2/2021 at 9:45 a.m. during the facility kitchen tour, in a review of the temperature logs of the facility dishwasher wash and rinse cycles, the logs revealed that the temperatures for the wash and rinse cycle of the facility dishwasher were not documented for the month of July 22 times out of 62 opportunities for the breakfast schedule, 22 times out of 62 opportunities for the lunch schedule and 30 times out of 62 opportunities for the dinner schedule.
3. On 8/2/2021 at 9:45 a.m. during the facility kitchen tour, in a review of the temperature logs of the facility Sink/Bucket Sanitizer chemical log, revealed that the logs are to be completed four times a day at 6:00 a.m. , 10:00 a.m., 2:00 p.m. and 6:00 p.m. for the sanitizer parts per million (PPM) and the solution temperatures. The log lacked documentation of chemical testing and temperatures of the sink/bucket sanitizer for 20 out of 31 days for the 6:00 a.m. schedule, 17 out of 31 days for the 10:00 a.m. schedule, 15 out of 31 days for the 2:00 p.m. schedule and 14 out of the 31 days for the 6:00 p.m. schedule.
The facility Policy & Procedure Manual 3-22 Title Food Storage, #14 Refrigerator food storage - section B states: TCS (temperature control for safety) foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by law Temperatures for refrigerators should be between 35 degrees to 39 degrees. Thermometers should be checked at least two times each day. (See Sample Freezer and Refrigerator Temperature Forms on the following pages).
The facility Policy & Procedure Manual 3-22 Title Food Storage, #15 Frozen Foods - section B states: Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. (See Sample Freezer and Refrigerator Temperature Forms on the following pages).
In an interview with the the cook, the cook stated, the temperatures are being done daily. It's just people are forgetting to write it down.
On 8/2/2021 at 10:00 a.m. In an interview and tour with the Administrator, the Administrator confirmed the temperature logs for the freezers and the refrigerators, dishwasher wash and rinse cycles and the chemical sanitizer solution for the sink/bucket sanitizer were incomplete.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maine facilities.
Concerns
- • 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Edgewood Rehab & Living Ctr's CMS Rating?
CMS assigns Edgewood Rehab & Living Ctr an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Maine, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Edgewood Rehab & Living Ctr Staffed?
CMS rates Edgewood Rehab & Living Ctr's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 54%, compared to the Maine average of 46%.
What Have Inspectors Found at Edgewood Rehab & Living Ctr?
State health inspectors documented 22 deficiencies at Edgewood Rehab & Living Ctr during 2021 to 2024. These included: 22 with potential for harm.
Who Owns and Operates Edgewood Rehab & Living Ctr?
Edgewood Rehab & Living Ctr is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NORTH COUNTRY ASSOCIATES, a chain that manages multiple nursing homes. With 33 certified beds and approximately 29 residents (about 88% occupancy), it is a smaller facility located in FARMINGTON, Maine.
How Does Edgewood Rehab & Living Ctr Compare to Other Maine Nursing Homes?
Compared to the 100 nursing homes in Maine, Edgewood Rehab & Living Ctr's overall rating (2 stars) is below the state average of 3.0, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Edgewood Rehab & Living Ctr?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Edgewood Rehab & Living Ctr Safe?
Based on CMS inspection data, Edgewood Rehab & Living Ctr has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Maine. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Edgewood Rehab & Living Ctr Stick Around?
Edgewood Rehab & Living Ctr has a staff turnover rate of 54%, which is 8 percentage points above the Maine average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Edgewood Rehab & Living Ctr Ever Fined?
Edgewood Rehab & Living Ctr has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Edgewood Rehab & Living Ctr on Any Federal Watch List?
Edgewood Rehab & Living Ctr is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.