Hibbard Skilled Nursing & Rehabilitation Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on record reviews and interviews, the facility failed to provide care in accordance with the resident's comprehensive care plan for 1 of 3 residents reviewed for falls during a complaint investigation (Resident #2).Finding:Resident #2 has diagnoses to include dementia, visual loss, and falls.Review of Resident #2's care plan, dates12/21/25 states, The resident has had an actual fall with minor injury r/t [related to] seizure, poor balance, unsteady gait and poor safety awareness d/t [due to] Blindness and Dementia.Continue interventions on the at-risk plan. and The resident is a high risk for falls r/t Dementia, gait/balance problems, Unaware of safety needs, and vision/hearing problems.The resident uses floor mats and hip protectors as ordered.A review of Resident #2's active physician orders revealed an order with a start date of 10/1/24 for Check to ensure that HIP Protectors are on resident at all times unless being laundered.On 12/30/25 at 10:44 a.m., during an interview, Certified Nursing Assistant #2 (CNA2) stated Resident #2 has fall mats and

a low bed in place and that she is not aware of anything else being done for falls. When the surveyor asked about hip protectors, CNA2 lifted Resident #2's blanket, and the surveyor and CNA2 observed that hip protectors were not in place. On 12/30/25 at 10:48 a.m., during an interview, RN1 stated that Resident #2 had a recent fall and that fall mats and the low bed have been in place because Resident #2 tends to crawl off his/her bed. When the surveyor asked about Resident #2's hip protectors, RN1 stated that he/she had hip protectors and is supposed to be wearing them but has not had them since transferring to this unit several months ago.On 12/30/25 at 11:06 a.m. the above finding was discussed with the Long Term Care (LTC) Manager. At this time, the LTC manager stated that Resident #2 is supposed to have hip protectors in place and is not sure why he/she does not have them and that she will order a new set today.On 12/30/25 at 2:06 p.m. during an interview, the above finding was discussed with the Director of Nursing (DON).

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

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hibbard Skilled Nursing & Rehabilitation Center

1037 West Main Street Dover Foxcroft, ME 04426

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review, interviews, and facility policy, 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 by failing to follow their own Enhanced Barrier Precautions (EBP) policy for 1 of 1 resident reviewed for wounds (Resident #1).Finding:Facility policy Enhanced Barrier Precautions, revised 3/2025 states, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.EBPs are indicated.for residents with wounds.Wounds generally include chronic wounds (i.e. pressure ulcers, diabetic foot ulcers, venous stasis ulcers .).EBPs remain in place for the duration of the resident's stay or until resolution of the wound.Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the residents room indicating the type of precautions and PPE required.Resident #1 has diagnoses to include peripheral vascular disease, chronic venous insufficiency, and chronic right leg ulcers.On 12/30/25 at 10:37 a.m. during an observation of Resident #1's room, there was no EBP sign posted on the door or on the wall outside the room. The surveyor observed Resident #1 lying in bed with his/her right lower leg exposed with a visible wound that appeared to have betadine applied. At this time, during an interview, Certified Nursing Assistant #1 (CNA1) stated Resident #1 is not

on EBP or any type of precautions.A review of Resident #1's care plan indicated The resident has a hx [history] of a venous wound on [his/her] right lower leg .follow EBP.A review of Resident R1's active physician orders revealed the following: An order with a start date of 12/17/25 for Cleanse R [right] dorsal foot wound with NS [normal saline], apply santyl and calcium alginate and cover with dry dressing, every day shift for wound care. An order with a start date of 12/4/25 for Cleanse RLE [right lower extremity] wound, apply betadine and leave open to air, every day shift. An order with a start date of 12/19/25 for Santyl External Ointment 250 UNIT/GM.Apply to R dorsal foot wound topically every day shift for wound careA review of Resident #1's December 2025 Treatment Administration Records (TAR) indicated Registered Nurse #2 (RN2) provided Resident #1's wound care on 12/18/25, 12/19/25, 12/22/25, 12/23/25, 12/24/25, 12/26/25, 12/29/25, and 12/30/25 (date of survey).On 12/30/25 at 1:49 p.m. during an interview, RN2 stated that she thinks Resident #1 was on EBP at some point, but that his/her wounds had also improved at one point, so he/she was taken off EBP.On 12/30/25 at 2:30 p.m. during an interview, the above concerns were discussed with the Infection Preventionist (IP). The IP stated that every Friday at the Risk meeting, the facility discusses all residents with open wounds and devices and stated that RN2 is usually the one who discontinues a resident's precautions because she does the wound treatments. The IP then stated that if a wound is not draining the resident would not need to be on EBP. On 12/30/25 at approximately 2:45 p.m.

the above findings were discussed with the Director of Nursing.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet