High View Manor

F-F558 for details).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 205114 Department of Health & Human Services Printed: 08/31/2025 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 205114 B. Wing 04/09/2025

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

High View Rehabilitation and Living Center 517 Riverview St Madawaska, ME 04756

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 0909 On 3/31/25 at 1:10 p.m., during an interview with a surveyor, the Maintenance/Housekeeping/Laundry Supervisor stated the facility has a tool to measure the bed rail gaps, but he does not know how to use it, or Level of Harm - Immediate what the proper measurements are supposed to be (between mattress and bed side rail). He stated bed jeopardy to resident health or inspections were recently completed but he was not sure what the inspection included. safety

On 4/1/25 at 7:15 a.m., during an interview with a surveyor, the Administrator stated the recent bed Residents Affected - Some inspections only evaluated the electrical mechanics of resident beds. At this time a surveyor confirmed that bed inspections did not evaluate bed mattress and bed frame compatibility or identify areas of possible entrapment.

The immediate jeopardy that began on 3/31/25 when the facility failed to implement an effective inspection of all resident bed equipment or identify the existing risk for entrapment of body parts. The Administrator was notified of the immediate jeopardy at 12:25 p.m. on 4/1/25.

Please See F-000 Initial Comments related to the IJ removal plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 205114

F-F689 for details).

3. On 3/31/25 at 2:00 p.m., a surveyor observed Resident R13's mattress length was not compatible with the length of

the bed frame creating a 3 inch gap between the end of the mattress and the foot board (See

F-F700 details).

2. On 3/31/25 at 11:22 a.m., 2 surveyors observed a skin tear on Resident R3's right upper forearm. Resident R3's mattress observed to be smaller than the bed frame, exposing a mechanical hinge, a screw, and sharp metal edges where plastic caps are missing. At 2:19 p.m., the Maintenance/Housekeeping/Laundry Supervisor stated the mattress does not fit the frame, the mattress is 36 inches, and the frame is 39 inches (See

F-F812 was cited again for failure to ensure the kitchen was maintained in a clean and sanitary manner and failure to discard expired foods;

F-F880 was cited again for failure to implement a water management program to monitor for and prevent the growth and spread of Legionella and other water-borne pathogens; and

F-F883 was cited again for failure to offer the updated Pneumococcal vaccination to 3 of 5 residents.

On [DATE REDACTED] at 8:25 a.m., during an interview with a surveyor and the Administrator, repeat deficiencies were reviewed. The Administrator stated the plan of correction from the previous survey indicated monitoring for 3 months, monitoring was not continued beyond that time. At this time the surveyor confirmed the above finding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 205114 Department of Health & Human Services Printed: 08/31/2025 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 205114 B. Wing 04/09/2025

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

High View Rehabilitation and Living Center 517 Riverview St Madawaska, ME 04756

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 33242 potential for actual harm Based on facility policy review and interviews, the facility failed to notify the Centers for Disease Control and Residents Affected - Some Prevention (CDC) of an outbreak of Norovirus in the facility. In addition, based on review of the facility's Legionella Water Management Program and interview, the facility failed to fully develop and implement a water management program to monitor for and prevent the growth and spread of Legionella and other water-borne pathogens.

Findings:

The facility's policy, Reporting Communicable Diseases, revised 3/20/25, indicated that the Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases. The Maine CDC Notifiable diseases and Conditions List, dated 2/17/21, indicated that any cluster/outbreak of illness with potential public health significance needs to be reported.

1. On 3/31/25 at 10:15 a.m., the Administrator stated that the facility is experiencing what was thought to be

an outbreak of Norovirus. On 3/31/25 at 3:59 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated the CDC had not been notified of the outbreak. She also stated that they have not tested residents for Norovirus but five (5) residents have symptoms of nausea, vomiting, and diarrhea.

On 4/1/25, the DON provided a statement that she had contacted the CDC and that she was advised that

they are not required to test symptomatic individuals for Norovirus and to continue precautions per guidance.

A line list of affected residents will be sent to the CDC when the outbreak is completed and that an outbreak of unknown etiology is reportable (to the CDC).

On 4/2/25 at 2:10 p.m., during an interview with a surveyor, the Nurse Manager-Infection Preventionist stated

she was away part of last week and that the DON filled her in on the communication with the CDC.

2. On 4/3/25, a review of the facility's Legionella Water Management Program was completed by the surveyor with the Administrator and Maintenance/Housekeeping/Laundry Supervisor. The program lacked evidence of testing protocols and acceptable ranges for control measures, documentation of the results of testing, and what corrective actions would be taken if control limits are not maintained. The program also lacked evidence of validating the effectiveness of the program by testing the water for Legionella/water pathogens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 205114 Department of Health & Human Services Printed: 08/31/2025 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 205114 B. Wing 04/09/2025

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

High View Rehabilitation and Living Center 517 Riverview St Madawaska, ME 04756

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 33242 potential for actual harm Based on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) Residents Affected - Some recommendations, and interview, the facility failed to offer the updated Pneumococcal vaccination to 3 of 5 residents (Resident #3 [Resident R3], Resident R22, and Resident R29).

Findings:

The facility's policy, Pneumococcal Vaccine, revised 3/2025, indicated prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series and when indicated, are offered

the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessments of Pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Administration of the Pneumococcal vaccines are made in accordance with current CDC recommendations at the time of the vaccination.

On 4/3/25 at 9:10 a.m., during an interview with a surveyor, the Nurse Manager-Infection Preventionist stated

she was unable to find information to indicate that Resident R3, Resident R22, and Resident R29 were offered the most recent Pneumococcal vaccination, and that the facility does use the PneumoRecs VaxAdvisor: Vaccine Provider App | CDC tool to determine Pneumococcal vaccination recommendations. The following were confirmed at

this time:

1. The documentation in Resident R3's clinical record indicated that Resident R3 received the Pneumococcal Conjugate Vaccine (PCV) 13 in 2019. The CDC recommendation was to give one dose of PCV20 or PCV21 at least 1 year after PCV13.

2. The documentation in Resident R22's clinical record indicated that Resident R22 received the PCV13 in 2015 and the Pneumococcal Polysaccharide Vaccine (PPV) 23 in 2011. The CDC recommendation was based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after

the last pneumococcal vaccine dose.

3. The documentation in Resident R29's clinical record indicated that Resident R29 received the PCV13 in 2016 and the PPV23

in 2007. The CDC recommendation was based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 205114 Department of Health & Human Services Printed: 08/31/2025 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 205114 B. Wing 04/09/2025

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

High View Rehabilitation and Living Center 517 Riverview St Madawaska, ME 04756

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Immediate jeopardy to resident health or 49635 safety Based on observation, interview, and record review, the facility failed to identify the existing risk for Residents Affected - Some entrapment of body parts through bed inspections, this failure created the potential for severe bodily injury including death by entrapment of body parts, for 3 of 35 residents [Resident #26 (Resident R26), (Resident R3) and (Resident R13)]. In addition to the resident in immediate jeopardy, the facility's failure to implement an effective inspection of all resident bed equipment (bed frames, mattresses, and bed rails) to ensure that bed mattresses fit the bed frames to prevent entrapment of body parts, this has the potential to effect 35 out of 35 residents with bed rails.

Findings:

On 3/31/25, the facility's Bed Safety policy, undated, was reviewed. The policy indicated, to prevent deaths/injuries, maintenance staff would inspect all beds and related equipment to identify risks and problems including potential entrapment of body parts using the Bionix Bed System Measurement Device (Please see

F-F909 for details). The bed rail at the height of the resident's head measured 10 inches from the mattress, this safety had the potential to cause death as a result of entrapment of body parts (See