Oak Grove Center

F-F584 for failure to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment;

F-F625 failure to issue a written bed hold notice to include cost of care to the Resident and/or resident representative;

F-F656 for failure to implement a comprehensive person-centered care plan;

F-F689 for failure to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured;

F-F725 for failure to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents;

F-F842 for failure to ensure that clinical records were complete and contained accurate information and

F-F880 for failure to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases.

On 3/24/25 at 12:28 p.m., during an interview, the above findings were discussed with the Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 205091 Department of Health & Human Services Printed: 09/04/2025 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 205091 B. Wing 03/24/2025

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

Oak Grove Center 27 Cool St Waterville, ME 04901

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 37015 potential for actual harm Based on observations, interviews, clinical record review, and facility policy review, the facility failed to Residents Affected - Few maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Resident #33)

on 1 of 3 facility units.

Findings:

On 3/18/25 at 1:20 p.m., a surveyor observed 2 CNAs (Certified Nursing Assistants) wearing gloves enter Resident #33's room with a mechanical hoyer lift. The resident's door was posted with a Contact Precautions sign which included a picture of a person wearing a gown, gloves, mask and face shield. The instructions stated Perform hand hygiene before and after patient contact, contact with environment and after removal of PPE (personal protective equipment). Wear N95/approved KN-95 respirator, gown, face shield and gloves upon entering this room. Change gown after EACH patient contact (written in red). Keep room door closed. Patient must wear a face mask when out of room and maintain social distancing. Perform all procedures/tests in patient room, if able. Pull curtain between roommates. Please do not remove dedicated or single use disposable equipment from this room. When dedicated equipment is not possible, disinfect shared patient equipment with EPA-approved disinfectant.

The surveyor observed Resident #33 had a foley catheter hanging from the bed. One CNA picked up the foley catheter and placed it across the resident's legs while the other CNA was hooking the hoyer pad to the hoyer lift. At this time the surveyor requested to speak with both CNAs and asked them what type of PPE

they should be wearing. One CNA stated gloves. The surveyor noted the posted sign and asked if the resident required the PPE as per the posted precautions. The CNA stated the resident was on Advanced Barrier Precautions, and that only when staff provide foley or pericare is a gown required, otherwise, only gloves are required.

On 3/18/25 at 1:25 p.m., the surveyor asked LPN #1, what type of precautions Resident #33 required. LPN #1 stated the resident had ESBL (Extended-Spectrum Beta-Lactamase) in the urine, and an SP (supratubic) tube. The LPN stated when providing care for the foley (SP tube), we gown up.

On 3/18/25 at 1:30 p.m., in an interview with the surveyor, the Unit Manager (JUM) stated Resident #33 had

a history of ESBL which had been treated in November, 2024. However, the resident had been treated in the emergency department (ED) over the weekend and was diagnosed with a urinary tract infection (UTI). The JUM stated he/she was not sure what kind of precautions the resident was currently on.

A review of Resident #33's record noted a provider note, dated 3/18/25, which stated recent ED visit with diagnosis of UTI - per culture and sensitivity - Pseudomonas aeruoginosus, Serratia marcescens. Resident #33's care plan, last revised 3/18/25, stated the resident required Enhanced Barrier Precautions.

On 3/19/25 at 10:25 a.m., a surveyor observed Resident #33's door with the same Contact Precautions sign.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 205091 Department of Health & Human Services Printed: 09/04/2025 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 205091 B. Wing 03/24/2025

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

Oak Grove Center 27 Cool St Waterville, ME 04901

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 On 3/19/25 at 11:30 a.m., in an interview with the surveyor, the Director of Nursing (DON) and the Market Clinical Advisor stated Resident #33 was previously on Enhanced Barrier Precautions for ESBL in the urine Level of Harm - Minimal harm or and use of an indwelling urinary catheter. At some point, the signage on the door was changed to Contact potential for actual harm Precautions. The resident was seen in the ED over the weekend and was currently undergoing treatment for

an active UTI. The DON stated Resident #33 required Enhanced Barrier Precautions at the present time and Residents Affected - Few confirmed that staff were not following correct precautions as posted when observed yesterday. The Market Clinical Advisor stated staff received education last night on proper procedures for use of Enhanced Barrier Precautions.

The facility's policy regarding Enhanced Barrier Precautions, with a revision date of 12/16/24, stated In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact Precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms (MDROs). Section 4, Implement Contact Precautions versus EBP per following table, stated under Patient Status: Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized.

United States Centers for Disease Control and Prevention (CDC) recommendations poster for use of EBP's, dated 7/31/22, stated, Providers and staff must also wear gloves and a gown for the following high contact resident-care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 205091