Orchard Park Rehab & Living Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on record review, interview and review of the facility's internal investigation, the facility failed to ensure that 1 of 1 resident reviewed for dignity was provided care in a manner that maintained and respected his/her dignity. (Resident #1) The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in

a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt. CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately. The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

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

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Park Rehab & Living Center

107 Orchard Street Farmington, ME 04938

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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately.

The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

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

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Park Rehab & Living Center

107 Orchard Street Farmington, ME 04938

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 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, interview, facility's internal investigation and Restraint Policy, the facility failed to ensure that 1 of 1 resident was free from the use of restraints. (Resident #1 The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. The facilities restraint use policy indicates: The facility must ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. II.

Procedure Examples of facility practices and meeting the definition of a physical restraint include but are not limited to: C. Tucking in a sheet tightly so the resident cannot get out of bed or fastening fabric or clothing, so a resident's freedom of movement is restricted. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in

a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt.

CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed

these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately. The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet