Eastport Memorial Nursing Home

F-F636, signed on 2/14/25, indicated the facility would print weekly MDS reports to identify residents needing assessments, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents have a Comprehensive Minimum Data Set (MDS) assessment timely.

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence the PoC was implemented, that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly.

2. The facility's accepted PoC for

F-F637, signed on 2/14/25, indicated the Director of Nursing would monitor nursing documentation of resident significant change and MDS assessment submission, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents with a significant change in status have a Comprehensive Minimum Data Set (MDS) assessment timely. The PoC indicated an anticipated date of compliance of 3/5/25. The facility lacked evidence that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly.

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by the MDS coordinator, that a monitor was completed weekly, and deficient practice was identified after the PoC's anticipated date of compliance.

3. The facility's accepted PoC for

F-F656, signed on 2/14/25, indicated nursing staff would receive education

on how to add a diagnosis to a resident's diagnosis list and update the care plan to correspond with the diagnosis, and the Director of Nursing would monitor all physician's notes after visits and ensure any new diagnoses were updated.

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by nursing staff, or that monitoring was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 205146 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205146 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Eastport Memorial Nursing Home 23 Boynton Street Eastport, ME 04631

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 0865 4. The facility's accepted PoC for

F-F684, signed on 2/14/25, indicated staff would receive education, and the Director of Nursing would monitor all orders and Gradual Dose Reduction (GDR) recommendations for 6 Level of Harm - Minimal harm or months. potential for actual harm

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor Residents Affected - Some confirmed the facility lacked evidence that the PoC was implemented, that education was provided to staff, that education was received by staff, or that monitoring was completed for GDR recommendations.

5. On 2/14/25, the facility signed a Plan of Correction (PoC) indicating an Elopement/Wandering policy would be established by 3/15/24, staff would be educated on the new policy, drill would be conducted at randomly selected times, and a monitor of staff response to the drills would be completed. The PoC indicated the anticipated date of compliance as 3/5/25. The facility lacked evidence that the policy was established, education was provided to staff, received by staff, drills completed, and/or a monitor of staff response was completed.

On 3/18/25 at 10:15 a.m., during an interview with a surveyor and the Director of Nursing, the Elopement and Wandering Policy draft was reviewed. The DON indicated staff had not received education as this policy has not been approved by the board of directors. At this time the surveyor confirmed the Plan of Correction had not been implemented to prevent a resident identified as an elopement risk from leaving the building unnoticed.

6. The facility's accepted PoC for

F-F689 (Free of Accident Hazards/Supervision/Devices) was implemented in order to prevent repeat deficient practice. The deficiencies

F-F695, signed on 2/14/25, concentrators will be cleaned, weekly walking rounds would be completed to residents with oxygen orders, staff would receive education, and monitored results would be documented. The PoC identified 3/5/25 as the anticipated date of compliance.

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, that weekly walking rounds and/or monitoring were completed / documented. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance.

7. The facility's accepted PoC for

F-F761, signed on 2/14/25, indicated staff would receive education on dating insulin vials / pens, discarding insulin after the expiration date, and weekly monitors would be conducted for 6 months.

On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, or that weekly audits were completed. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 205146 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205146 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Eastport Memorial Nursing Home 23 Boynton Street Eastport, ME 04631

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 17282 potential for actual harm Based on review of the facility's Water Management Program/Legionella and interview, the facility failed to Residents Affected - Few fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens in the area of testing protocols.

Finding:

On 1/28/25, a review of the facility's Water Management Program/Legionella (revised on 5/24/22) was completed. There was no evidence of testing protocols in the Water Management Program if water testing was necessary. There was no evidence of testing protocols for control measures, acceptable ranges, how

this would be monitored and what interventions would be used if water tests positive for Legionella or other opportunistic waterborne pathogens.

On 1/28/25 at 1:57 p.m., in an interview with a surveyor, the Maintenance Supervisor stated he could not show evidence of a plan or protocol in place for Legionella/water pathogen testing, acceptable test ranges or monitoring of the water for potential Legionella or other opportunistic waterborne pathogens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 205146