Pinnacle Health & Rehab Canton

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 3 of 3 days of survey (9/22/25, 9/23/25 and 9/24/25) for resident rooms, hallways and the laundry room for 3 of 3 facility tours.Findings:1. On 9/22/25 at 8:00 a.m., a surveyor toured and observed the facility to smell of stale urine and feces throughout the facility.2. On 9/23/25 at 7:55 a.m., a picture was handing on the wall by room [ROOM NUMBER]. The frame was observed to be broken in the bottom left corner and was held together with scotch tape. There was also picture hanging directly across the hall on the wall with the bottom right edge of the frame coming apart. On 9/23/25 at 8:03 a.m. Licensed Practical Nurse (LPN #1) confirmed the finding.3. On 9/23/25 at 9:23 a.m., two surveyors noted a very strong urine order at door of room [ROOM NUMBER]. wet floor sign noted on entrance.4. On 9/24/25 at 8:00 a.m., surveyor again toured and observed the facility to smell of urine and feces throughout the facility. 5. On 9/24/2025 from 8:30 a.m. to 9:05 a.m., a surveyor did an Environmental Tour with the Maintenance Director in which the following findings were discussed and observed:- Resident room [ROOM NUMBER] - Resident #26's wheelchair had rips in both arm rests material. There was clean briefs and clothing on closet floor. The bathroom door trim had chipped/missing paint.- The shower room across from resident room [ROOM NUMBER] had a toilet with a seat that was stained yellowish in color. There were numerous commode buckets, soiled gloves and briefs on the floor. The shower non-skid transition strip was chipped and missing pieces creating an uncleanable surface. - Resident room [ROOM NUMBER]- The inside the toilet bowl was dirty/stained. - Hallway base board heater, outside resident room [ROOM NUMBER], had chipped/missing paint. - The Hallway wall light, across from resident room [ROOM NUMBER], had a broken cover which was dislodged from the lighting unit.- The bathroom across from dining room kitchenette had chipped/missing paint on the doorframe. - The walls in the dining room were marred with black marks and had chipped/missing paint. Laundry:- There were 2 wooden folding tables and 5 wooden laundry carts that had chipped/missing paint and were uncleanable. - The wooden frame, under the small dryer, had chipped missing paint creating an uncleanable surface. - The laundry room floor has chipped/missing paint creating

an uncleanable surface. - The wooden drying rack had worn surfaces exposing untreated wood.- The wall exhaust fan was dusty/dirty. On 9/24/25 at 8:15 a.m., in an interview with 2 surveyors present, the laundry aide confirmed the laundry room findings.On 9/24/2025 at 9:05 a.m., in an interview with a surveyor, the Maintenance Director confirmed the findings.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Health & Rehab Canton

26 Pleasant St Canton, ME 04221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews, record review and facility policy, the facility failed to thoroughly investigate an allegation injury of unknown origin for 1 of 1 facility incident reports reviewed (Resident #12).Findings:Review of Abuse Investigation policy (undated) states All reports of resident abuse, neglect, and.shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will.Review the completed concern/complaint report; Interview the resident, Interview any witnesses to the incident; Review the resident's medical record to determine events leading up to the incident; interview staff members who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors as applicable; Interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. Witness reports are required to be written with signature and date. On 12/31/24 the Department of Licensing received a facility reported incident stating: On 12/31/24; 12:35 p.m.,. Resident [12], asked to speak with the SW [Social Worker]. [He/she] reported that aide, [Certified Nursing Assistant (CNA)4], pressed [his/her] forehead and pulled [his/her] ear. During an interview on 9/23/25 at 10:49 a.m.

Licensed Social Worker (SW) confirmed she was the one that conducted the investigation, but there were no findings. At this time SW was asked to provide complete investigation details. SW stated the whole investigation was in the 5 day follow up. Review of the 5 day follow up dated 12/31/24 states [1/7] Investigation closed. No findings. At this time SW again stated that the entire investigation was on the original incident report, and she had no more information. States she did not interview anyone besides [Resident 12] and [CNA4], and there was no facility education was provided, but she did tell CNA4 not to pull Resident 12's ear anymore. SW confirmed she did not and did not talk to any other residents or staff because she didn't know she needed to.During an interview on 9/24/25 at 11:11 a.m., the above was discussed with Director of Nursing. ?

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Health & Rehab Canton

26 Pleasant St Canton, ME 04221

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, the facility failed to implement and maintain an effective training program for nursing staff contracted through the AllShifts Application (App) in the areas of dementia care, resident rights, and abuse and neglect training by failing to ensure contracted AllShifts Professionals completed training prior to independently providing services to residents for 4 of 4 contracted staff reviewed

during a complaint investigation (Certified Nursing Assistant [CNA] #8, #9, and #10, and Licensed Practical Nurse [LPN] #3).Finding:Review of the AllShifts Terms of Service states, under section 2.1 ALLSHIFTS MARKETPLACE, LLC AS A MARKETPLACE, AllShifts merely makes the Site and Services available to enable Professionals and Facilities to find and transact directly with each other.Users alone are responsible for evaluating and determining the suitability of any shift, Facility, or Professional. and under section 2.2 USERS ARE INDEPENDENT FROM ALLSHIFTS states, .Facilities are solely responsible for and have complete discretion with regard to their use of and activities on AllShifts Marketplace, including.decisions

they make with respect to any Professionals with whom they connect for shifts. No actions or decisions of a facility shall in any way affect the relationship of Professionals with AllShifts, which shall remain that of an independent contractor under all circumstances. and under section 3.1 SAFETY AND SUPERVISION BY FACILITIES, states, .It is the sole responsibility of Facilities to monitor and enforce all policies and procedures with Professional, both by including such information in Facilities' User Profiles on the Site and notifying Professionals of such information when they arrive and carry out their responsibilities at Facilities' Facilities.Review of Facility Assessment-Pinnacle Health & Rehab, updated 6/10/25, under Staff training/education and competencies, states, .Upon hire and annually, all employees will attend a comprehensive education program which will include .resident rights, abuse, neglect and exploitation, what constitutes abuse, neglect, exploitation .Each employee must have an orientation check off list completed .A review of the facility's staffing sheets for the dates referenced in the complaint (6/12/24-12/8/24) revealed

the following:CNA #8's first shift through AllShifts was 6/17/24, and she worked a total of 16 shifts throughout the above-referenced timeframe. A review of CNA #8's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.CNA #9's first shift through AllShifts was 6/12/24, and she worked a total of 25 shifts throughout the above-referenced timeframe. A review of CNA #9's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.CNA #10's first shift through AllShifts was 6/18/24, and

she worked a total of 11 shifts throughout the above-referenced timeframe. A review of CNA #10's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.LPN #3's first shift through AllShifts was 8/8/24, and she worked a total of 10 shifts throughout the above-referenced timeframe. A review of LPN #3's employee file lacked evidence that she received education in the areas of Abuse and Neglect, Resident Rights, and dementia.On 9/24/25 at 12:26 p.m., during an interview, the Director of Nursing (DON) stated that she relies on AllShifts' packet for each contracted Professional that is hired from the App, and that the facility does not provide education to staff contracted through the App. The DON then stated that when a surveyor requested evidence of Abuse and Neglect; Resident Rights; and Dementia training for the above contracted staff yesterday, she contacted AllShifts and requested evidence of the training but has not received it. The DON was unable to provide evidence that the above contracted staff had received the training prior to the end of the survey.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet