Clover Health Care

Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4, CNA5). Findings: 1. CNA1 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 2. CNA2 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 3. CNA3 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 4. CNA4 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 5. CNA5 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. On 5/9/2025 at 12:24 p.m., in an interview with the surveyor, the Administrator and Regional Director of Operations stated that when the previous administration sold the company, all employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility's Dish Machine Temperature Monitoring policy/procedure, the facility's Refrigerator and Freezer Monitoring Standard policy/procedure and the facility's Food Preparation -Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ice machine, ceiling tiles, ceiling vents, fans, walls and floors; failed to ensure kitchen staff with facial hair wore facial protection; failed to ensure foods were dated in the reach in refrigerator; and failed to ensure the ice machine was properly installed to prevent backflow as required by the Maine State Plumbing Code requirements to prevent food contamination for 1 of 1 kitchen tour. (4/28/25) Findings: The facility's Dish Machine Temperature Monitoring policy/procedure last reviewed 8/23/2018 noted: Policy: Dish machine should be monitored at each meal to ensure proper washing, rinsing and sanitizing. Procedure: 2. At each meal the temperature of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for activities of daily living care. (Resident #67) Findings: Review of Resident #67's medical record lacked evidence of completed documentation for: -Missing documentation of ADL Bathing/Showering for day shift on 4/4/25, 4/8/25, and 4/10/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of B&B-Elimination, Urinary for day shift on 4/4/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of Oral Hygiene for day shift on 4/4/25, 4/8/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of Toileting Hygiene for day shift on 4/4/25, 4/8/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 5/9/25, were effective. The Federal citations F684 and F812 were cited again during the re-visit for the Annual Long Term Care Recertification Survey, completed 6/30/25. Finding: During the follow-up survey on 6/30/25, it was determined that F684 and F812 would be re-cited for the same reasons: F684 for failure to adequately assess and monitor a resident after an unwitnessed fall and F812 for failure to ensure the kitchen was maintained in a clean and sanitary manner and ensure foods were labeled and dated. (see F684 and F812) On 6/30/25 at 4:55 p.m., the above was discussed during the exit conference with the Executive Director and interim Director of Nursing.

Based on record reviews and interview, the facility failed to ensure staff received mandatory training on it's Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 5 of 5 employee files reviewed (Certified Nurse Assistant #1 [CNA1], CNA2, CNA3, CNA4, CNA5). Findings: Review of the facility's Quality Assurance/Assessment and Performance Improvement Plan policy, undated, stated Education: All staff, including contracted staff are educated on the principles of QAPI. QAPI is included in the orientation of new employees and in the annual education that all staff are required to attend. Staff will be trained in using QAPI principles, identifying areas for improvement, and how they can be involved in the QAPI process including participation on a PIP (performance improvement project) team. The QAPI program is sustained during transitions in leadership and staffing through all-staff education and involvement in the QAPI process. A review of employee education files lacked evidence that CNA1, CNA2, CNA3, CNA4,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to create a homelike environment and promote each resident's dignity and respect on 1 of 4 units ([NAME]) for the evening meal for 1 of 5 days of survey (5/5/25). Findings: On 5/5/25 at 5:05 p.m., a surveyor observed in the [NAME] dining room, 6 residents seated at the dining room tables eating their dinner meal. These 6 residents had their meals served to them on trays and it was not homelike, dignified or respectful. On 5/5/25 at 5:10 p.m., in an observation and interview, the Regional Director of Operations confirmed that the meals should not have been served on trays and it was not homelike, dignified or respectful for the residents.

Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination for 1 of 1 residents reviewed for PASRR (Resident #78) Finding: On 3/6/25, clinical record review indicated Resident #78 was admitted in March of 2025. Admitting diagnosis includes Post-Traumatic Stress Disorder. Review of Resident #78's PASRR, dated 3/7/25, indicated Resident #78 had a Convalescence Categorical exemption (a time-limited 30-day exemption). Further review the clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after the Residents stay changed from short-term to long-term. On 5/8/25 at 2:30 p.m., during an interview with the Area Manager of Clinical Reimbursement, the above was confirmed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 1 residents reviewed for baseline care plans (Resident #4). Finding: Resident #4 was recently admitted with diagnoses to include Repeated Falls, Difficulty in Walking, Muscle Weakness, and Need for Assistance in Personal Care. Review of admission Minimum Data Set (MDS), dated [DATE], revealed Resident #4 requires substantial/maximal assistance with Activities of Daily Living (ADLs). Review of Resident #4's care plan, initiated 4/2/25, lacked evidence that goals and interventions were put into place for ADLs. On 5/8/25 at 9:25 a.m. during an interview, Certified Nursing Assistant (CNA) #6 stated Resident #4 is sometimes incontinent but toilets in the bathroom and walks to the bathroom with his/her walker but needs help. On 5/8/25 at 12:30 p.m., the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of smoking (Resident #45) and respiratory needs (Resident #78) for 2 of 28 sampled residents reviewed for comprehensive care plans. Findings: 1. Resident #45 was admitted to the facility in May of 2018. A review of the resident's Smoking Safety Screening completed on 11/21/24 indicates that he/she is safe to smoke with supervision. Further review of the resident's medical record lacks evidence of the need to smoke with supervision in his/her care plan. On 5/7/25 at 2:20 p.m., the above information was confirmed with the Facility Administrator. 2. Resident #78 was admitted to the facility in March of 2025. Review of the resident's physician orders indicates that he/she has been using his/her Continuous Positive Airway Pressure (CPAP) since 3/13/25. Further review of his/her medical record lacks evidence of a care plan for CPAP usage. On 5/7/25 at 2:00 p.m., the above information was confirmed with the Director of Nursing.

Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care. (Resident #23 and #78) Findings: 1. On 5/5/25 at 9:03 a.m., 5/6/25 at 2:10 p.m., and on 5/7/25 at 12:45 p.m., a surveyor observed Resident #23's unbagged nebulizer mask and tubing on the bedside table. Review of Resident #23's clinical record indicated a physician order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, with instructions to give 1 dose three times a day for cough, which was discontinued on 4/23/25. Further review shows an active physician order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, with instructions to give 1 dose every 4 hours as needed for cough. Review of the medication administration record/treatment administration record indicated that his/her last time using the nebulizer was on 4/23/35. On 5/8/25 at 2:25 p.m., during an interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and facility policy, the facility failed to ensure that a resident who requires dialysis receives such services, consistent with the professional standards of practice in the areas of monitoring a dialysis fistula and assessing and monitoring a resident before and after dialysis treatments for 1 of 1 resident receiving dialysis (#21). Finding: Review of facility policy, Dialysis-Access Site Management-Skilled, revised 6/30/22, states, The staff must assess and note placement of the resident's access site on their eMAR [electronic Medication Administration Record] or eTAR [electronic Treatment Administration Record] and care plan .Licensed staff is to note every shift for any sign/symptom of infection .at the access site and document findings .Every shift on the access arm licensed staff will note color and temperature of fingers, and presence of radial pulse .If an AV fistula or graft is present, the licensed staff will palpate the site to feel the 'thrill' or use a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of facility Resident Self-Administration of Medication - Skilled policy/procedure, the facility failed to ensure medications were stored properly and that the facility failed to obtain physician orders and complete a safety assessment for a medication observed located at a resident's bedside, for 1 of 1 sampled resident (Resident #24). The facility failed to ensure medications were stored properly in a refrigerator for 1 of 3 medication storage refrigerators ([NAME] Unit). Findings: The facility's Resident Self-Administration of Medication - Skilled policy/procedure, reviewed 4/9/24, noted: Policy: If a resident requests to self-administer their medications, it is the responsibility of the community to determine that it is safe for the resident to do so before the resident may exercise that right. Procedure: 2. The Self-Administration Review . shall be completed in the EHR[Electronic Health Record] by a licensed nurse. 3. The licensed nurse will notify the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain a garbage storage area and in a sanitary condition to prevent the harborage and feeding of pests for one trash dumpster and for an area outside the back kitchen door for 1 of 5 days of survey (5/5/25). Findings: On 5/5/25 at 9:15 a.m., a surveyor and the Food Service Director(FSD) observed food and trash to be on the ground outside the back kitchen door and observed one of two dumpsters with a right-side slide door open exposing trash. Additionally, there was trash on the ground around the open dumpster. On 5/5/25 at 9:15 a.m., in an interview, the FSD confirmed the findings.

Based on observation, and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and spread of infection related to Enhanced Barrier Precautions (EBP) for 1 of 1 sampled resident reviewed for intravenous medication administration (Resident #206). Finding: A review of the sign posted on resident #206's room indicated the following: Before entering the resident's room, a sign posted outside resident #206's room indicated that the Resident was on EBP. The sign indicated that staff were required to wear personal protective equipment (PPE), a gown, gloves and a face mask/eye protection when providing care. On 5/6/25 at 1:54 p.m. a surveyor observed an intravenous medication administration for Resident #206 with the Registered Nurse #1 (RN1), Belfast Unit. The RN1, Belfast Unit was wearing PPE's. The resident requested pillows placed under his/her right foot and leg. The RN1, Belfast Unit placed a pillow under his/her foot, and then removed her PPE to leave the room for a clean pillow case for a second pillow for R206's right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 4 units ([NAME] Unit and [NAME] Unit) for 2 of 2 environmental tours (1/22/25). Findings: 1. On 1/22/25 from 10:27a.m. to 10:40 a.m., a surveyor observed the following: > [NAME] Unit [core 1] - The sit-to-stand patient lift, sitting along a wall in the center area, was heavily soiled with food debris and dirt in the foot base area. > [NAME] Unit [core 2] - The sit-to-stand patient lift, sitting along a wall in the center area, was heavily soiled with food debris and dirt in the foot base area. > [NAME] Unit - The sit-to-stand patient lift, sitting along a wall in the center area, was heavily soiled with food debris and dirt in the foot base area. On 1/22/25 at 10:45 a.m., in an interview, Registered Nurse (RN #1) confirmed the 3 sit-to-stand patient lifts were heavily soiled with food debris and dirt in the foot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and staffing reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: On 1/22/25 at 9:30 a.m., in an interview with a surveyor, Resident #4 stated he/she ambulates with assistance but sometimes he/she can't because there is not enough staff to walk him/her when he/she needs to get up. He/she stated she normally gets up and goes to the bathroom but the staff has had to use a bed pan when they don't have enough available staff to assist him/her. He/she stated that he/she and their roommate had to wait a long time for their call bells to be answered because the staff would say that they don't have enough people and that nursing couldn't always get them up to take them to the bathroom, resulting in staff using the bedpan with him/her and the roommate. On 1/22/25 at 10:10 a.m., in an interview, RN (Registered Nurse) #2 stated the facility has often been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, 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 related to linen handling for 2 of 2 observations ([NAME] Unit and [NAME] Unit) for 1 of 1 day of survey. (1/22/25) Findings: The facility's Community Infection Control Policy - Assisted Living and Skilled last date reviewed: 8/23/24. Handling of Soiled and Clean Linens: Laundry must be held away from the body at all times. Soiled laundry must be bagging rooms and when carried in the hallways. 1. On 1/22/25 at 9:30 a.m., a surveyor observed Certified Nursing Assistant (CNA #4) on the [NAME] Unit carrying a small bag of soiled lined in her gloved right hand with a visibly soiled bundle of unbagged linen on top of the bag to the soiled utility room. At this time, in an interview, CNA #4 confirmed that the heavily soiled linen was not put in the bag as it should have been. She stated she had come from a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed knock on the resident's door and announce who they were before they entered the resident's room for 1 of 4 residents reviewed (Resident #4). Finding: On 1/22/25 at 10:50 a.m., a surveyor observed a tall male facility worker, dressed in black jeans and a black shirt, enter Resident room [ROOM NUMBER] without knocking on the door and requesting permission or announcing he would like enter before entering. He went up to the resident's door, moved the Velcro stop sign aside from across the door and went into the room and then came out with a wheeled bag of tools. On 1/22/25 at 10:58 AM, in an interview, the tall male facility worker who identified as a maintenance staff member, confirmed that he had entered the room without knocking and it was a dignity issue. On 1/22/25 at 11:50 AM, in an interview, a surveyor discussed the finding with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure that the residents environment was free from the potential risk of serious accidents/tripping hazards relating to loose, unsecured linoleum flooring that had pulled up along an edge and is not secure for 1 of 4 units ([NAME] unit [core 1]) for 1 of 1 day of survey. (1/22/25) Finding On 1/22/25 at 11:27 a.m., 2 surveyors observed in the center of [NAME] unit (core 1) an approximately 2 foot by 1 foot area of linoleum flooring missing and the edges were coming up causing a trip hazard. At his time, in an interview, Certified Nursing Assistant (CNA #6) stated that the desk that had been here had been removed and she confirmed that the linoleum was coming up and it was a trip hazard accident hazard. Additionally, she stated that there are ambulatory residents on the unit. On 1/22/25 at 11:50 a.m., in an interview, a surveyor discussed the finding with the Administrator who confirmed this was a trip hazard and accident hazard and that there are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and a sample lunch test tray, the facility failed to ensure the food served from the kitchen was monitored throughout the meal service to ensure foods were maintained at adequate and proper hot temperatures to ensure palatable food for meals. Additionally, the facility failed to ensure the residents nutritional needs/diets were assessed and identified before receiving meals from the kitchen. This has the potential to affect all residents. Findings: On 1/22/25 at 9:30 a.m., in an interview, Resident #4 stated that the food was always cold and he/she has to have nursing heat it up for him/her and it didn't taste good when it came cold and it usually was mushy. On 1/22/25 at 10:00 a.m., in an interview, Certified Nursing Assistant (CNA #2) stated that the food does not come hot a lot of the time and there are complaints from residents about the food not being hot so the staff have to heat it up for the residents. On 1/22/25 at 10:33 a.m., in an interview, Licensed Practical Nurse (LPN) stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 4 Units ([NAME] Place, [NAME] Place and [NAME] Place) and the Laundry room. Findings: On 2/9/24, from 10:16 a.m. to 11:05 a.m., a surveyor did an environmental tour with the Maintenance Director, the Administrator, the Director of Nursing and the Regional Director of Clinical 0perations in which the following findings were was observed: [NAME] Place: > There were 3 chairs near rooms #34 and #35, and 2 chairs in common area near the unit entrance door with torn/ripped cushions. > Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair. Resident #82's wheelchair had a left armrest that was ripped/ torn. > Resident room [ROOM NUMBER] - The room had a strong odor of urine. > Resident room [ROOM NUMBER] - The privacy curtains were missing hooks, hanging down and in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to maintain respiratory equipment consistent with the facility's Respiratory Therapy instructions for 3 of 3 residents reviewed that were receiving respiratory services (#22, #21, #26). Findings: Review for the facilities Policy and Procedure for Respiratory Therapy, revised November 2011, states: Steps in the procedure, Infection control considerations related to Oxygen Administration. 7. Change Oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep Oxygen cannula and tubing used PRN in a plastic bag when not in use. 9. Wash filters from Oxygen concentrators every seven days with soap and water. Rinse and Squeeze dry. 1. On 2/5/24 at 11:23 a.m., observation of resident #22's oxygen concentrator with an unlabeled nasal cannula lying on the floor. At this time in a brief interview, Resident #22 stated, I use it sometimes at night if I need it. Additional observation on 2/6/24 at 11:04 a.m., of resident #22's oxygen tubing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 3 of 4 units observed (Belfast Place, [NAME] Place and [NAME] Place). Findings: Facilities Policy and Procedure: Storage of Medications, revised November 2020 states: #4 Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1. On 2/5/24 at 9:31 a.m., observation of Belfast Place medication room and Treatment cart with the Registered Nurse (RN) Manager the following was observed: the medication room contained one box of Earwax Removal drops with expiration date of 1/24. The treatment cart contained an opened and unlabeled Basaglar insulin pen and a Humalog Insulin pen both with manufacturer's directions to use within 28 days after initial use. 2. On 2/5/24 at 9:42 a.m., observation of [NAME] Place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to serve and store food in a sanitary manner on 3 of 5 survey days. Also the facility failed to keep accurate and complete temperature logs in the main kitchen and unit kitchens. Findings: 1. On 2/5/2024 at 7:56a.m. during the initial observation of the kitchen with the Assist Dietary Manager, it was observed that 2 of the 6 kitchen staff were not wearing hair coverings. -Observation of the reach-in-prep-fridge found two large containers of fruit and undated and unlabeled. Also, a pan of hotdogs that were unlabeled and undated. -When asked to see the temp logs for the breakfast cooking the cook provided a Hot/cold food log showing breakfast lunch and dinner. There was no recording for the dinner column for any of the days on the sheet. -The survey team entered on 2/5/2024 and the temperature in the breakfast column were already filled in thru 2/7/2024. -When asked if there was a cleaning schedule, he said that there is one on the wall, but there are no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to personal toileting items, Transmission Based Precautions (TBP) and linen handling for 3 of 5 days of survey on 3 of 4 units. ([NAME] Place, [NAME] Place and [NAME] Place) Finding: Review for the facilities Policy and Procedure for Infection Prevention and Control Program, revised May 2023 states: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. [NAME] Place: On 2/5/24 at 11:34 a.m. and 2/6/24 at 8:06 a.m., observations of room [ROOM NUMBER] -35 shared bathroom with 2 unlabeled and uncovered bed pans and a pair of salad tongs hanging on the wall behind the toilet on hooks, a shelf with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for 1 of 4 meals observed (2/5/24 lunch). Findings: On 2/5/24 from 12:04 p.m. through 1:07 p.m., on the [NAME] House, two surveyors observed the lunch meal pass. 4 residents were seated at the table near the television area. The first 2 residents at this table were served at 12:22 p.m. and 12:26 p.m. At 1:02 p.m., 36 minutes later, the other 2 residents were served their lunch. During these 36 minutes, surveyors observed staffing serving the additional 4 tables in their entirety, delivering meals to residents who remained in their rooms for lunch and collecting up dirty plates and clearing off tables from the residents who were finished with their lunch. On 2/9/24 at 11:16 a.m., during an interview with the Director of Clinical Operations the surveyor discussed the above concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to make reasonable accommodations to bed side rails and a bed extender for 1 of 1 resident (#449) reviewed for accommodations on 3 of 5 days of survey. Findings: Resident #449 was admitted on [DATE] with diagnosis of cervical and lumbar abscess resulting in quadriplegia. On 2/6/24 at 9:07 a.m., observation of Resident #449 in bed with his/her head at the very top of the bed and feet off the end of the bed. At this time, during an interview, Resident #449 stated, I've been complaining of it since I got here and I have no guard rails on this bed, I asked for them the first day I got here. On 2/7/24 at 10:13 a.m., observation of Resident #449 lying flat in bed with his/her head at the top of bed and feet just shy of end. On 2/7/24 at 10:15 a.m., during an interview with the Director of Rehabilitation, she stated Resident #449 was evaluated on 1/26/24 for bed mobility which resulted in a request for side rails sent to nursing. Both the surveyor and Rehab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to end of Skilled services for 2 of 4 residents whose Medicare Part A Skilled services were discontinued (Residents #66 and #450). In addition, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form 10055, which included appeal rights and liability of payment was provided at least two days prior to a resident's last covered day and with the correct date of services ending for 3 of 4 sampled residents (#91, #349 and #450) whose Medicare Part A services were discontinued. Findings: 1. Resident #66's NOMNC indicated that the resident's Medicare Part A services would end on 12/19/23 and was verbally consented by Power of Attorney on the same day. The resident remained living in the facility. 2. Resident #450's NOMNC indicated that the resident's Medicare Part A services would end on 1/23/24 and was verbally consented by Power of Attorney on 1/22/24. In addition, the SNFABN notice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to ensure a resident's privacy during his stay on the [NAME] Unit. (Resident #302). Finding: On 2/6/2024, observation of Resident #302s room found that there was no bed curtain that separated his/her bed area from the door to the room. The only curtain in the room separated the other resident in the room from him/her. Additionally, the resident can not get his/her wheelchair into the bathroom and the staff does not move the commode out of the bathroom and if the did there would be no way to provide privacy for the resident. On 2/6/2024 at 1:09 p.m. during an interview, Resident #302 stated There is no privacy. I have been waiting 3-4 weeks to get usable commode. They make me use a bedpan, and it is depressing. On 2/6/2024 at 3:00p.m the Administrator and the Director of Nursing confirmed the above finding.

Based in interviews, record review and facility policy review, the facility failed to thoroughly investigate an allegation of medication diversion for 1 of 1 misappropriation of medication allegation investigated. Findings: A review of the facility's Management of Controlled Substances Policy revision effective date: 3/3/23, under Policy states, The facility will manage controlled substances in a manner to prevent drug diversion and maintain safety. Section: 5.11 states, The facility Administrator or Director of Nursing Services shall be notified by the designated supervisor immediately upon suspicion of drug diversion. Division of Licensing and Regulatory Services (DLRS) and the Attorney General's office will be notified within 72 hours . An internal investigation will be conducted. Staff interviews will be conducted . A written report will be submitted to DLS within five business days. On 2/1/24 the Division of Licensing & Certification received a faxed Reportable Incident Form, dated 2/1/24 from Clover Health Care indicating that on 1/24/24, two Gabapentin (Schedule V controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 1 of 4 sampled residents who had been transferred to the hospital (#55). Finding: 1. Resident #55's clinical record revealed the resident was transferred to an acute care hospital on 1/24/24. The clinical record contained an incomplete bed-hold notice for the transfer, which did not include the daily bed hold cost. On 2/8/24 at 2:32 p.m., during an interview, the Regional Director of Operations the above was confirmed the facility's current forms do not meet the requirements of the regulation for bed hold notices, including information for daily bed hold costs.

Based on observations, record review and interviews, the facility failed to ensure documentation of Enhanced Barrier Precautions (EBP) in the clinical record for 1 of 1 residents sampled from a list of residents on EBP. ( #56 ) Findings: On 2/8/24 at 1:40 p.m. a surveyor reviewed the clinical record of Resident #56. No documentation was found in the clinical record to support or rationalize usage of EBP for Resident #56. Review of CDC definition of Enhance Barrier Precautions states: Enhanced Barrier Precautions are an infection Control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Enhanced Barrier Precautions are not used instead of Standard or Transmission based precautions but in conjunction with Standard and Transmission based precautions. On 2/8/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative, Resident #67) and the facility failed to ensure a care plan was updated in the areas of Activities of Daily Living for Resident (#10) to increase independent activity/mobility for 2 of 36 sampled residents. Findings: 1. On 2/5/24 at 12:28 p.m., during an interview with resident #67 he/she stated, I don't recall when asked if he/she had been invited and/or attended IDT meetings. Upon review, the resident's medical record lacked documentation of the resident's participation in the last four IDT meetings dated, 4/27/23, 7/27/23, 11/15/23, and 1/26/24. Further review indicated that resident #67's family representative was invited but did not attend the IDT dated 11/15/23. On 2/8/24 at 11:02 a.m., during an interview the Licensed Social Worker (LSCW) #1 stated, the facility remains unable to produce any documentation that the resident or the family was invited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to determine that drug records are in order and that an account of all controlled drugs is maintained, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts between 1/15/24 through 2/6/24 and failed to ensure that the nurse receiving a pharmacy delivery of controlled substance had two signatures confirming entry to bound book for 1 of 1 deliveries reviewed on 1 of 4 units ([NAME] Place). Findings: A review of the facility's Management of Controlled Substances Policy revision effective date: 3/3/23, under Policy states, The facility will manage controlled substances in a manner to prevent drug diversion and maintain safety. Section: 5.3.1 states,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and interviews, the facility failed to assist the resident in obtaining routine and emergency dental care within 3 days, after lost of dentures for 1 of 1 resident revewed for dental (#3). Findings: Facility policy and procedure for Dental Services, revised 2016 states: 6. Direct care staff will assist residents with denture care, including removing, cleaning and storing dentures. 7. Dentures will be protected from loss or damage, to the extent practicable, while being stored. 8. Lost or damaged dentures will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures. 9. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. 10. All dental services provided are recorded in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Medical Record review, menu review and interviews Resident (#302), Assistant Dietary Manager, and Charge Nurse on Belfast Unity, the facility diet ordered for Resident 302 with increased protein requirement. Findings: On 2/6/2024 at 1:09p.m. during an interview with Resident #302, He/She stated that, I am not getting the protein I need. A review of Resident #302's Clinical Record under Physician's Orders it states that the Resident will have a diet of Increased Protein portions for all meals. A review of the Dietitian's Plan for Resident #302 indicates that Resident #302 will have increased protein portions for all meals. Observation of Resident #302 meal ticket for 2/7/2024 Lunch, it states that the diet is Regular and does not mention any increased protein requirement. On 2/7/2024 at 2:00p.m. in an interview with the Assistant Dietary Manager, he stated that the computer program that the facility had been using has been changed to a different program and that information must not have been transferred. The above findings were confirmed with the Assistant Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure documentation for Enhanced Barrier Precautions (EBP) in the clinical record for 1 of 1 residents sampled from a list of residents on EBP. (#56 ) Finding: On 2/8/24 at 1:40 p.m. a surveyor reviewed the clinical record of Resident #56 following observation of EBP signage on their door. No documentation was found in the clinical record to support or explain usage of EBP for Resident #56. Review of CDC definition of Enhance Barrier Precautions states: Enhanced Barrier Precautions are an infection Control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Enhanced Barrier Precautions are not used instead of Standard or Transmission based precautions but in conjunction with Standard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, resident rights and dementia management by failing to ensure that 5 of 5 Certified Nursing Assistant's (CNA) employed, completed the required annual training (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5). Findings: On 2/9/24, during a review of employee personnel records, the following was noted: 1. CNA #1's employee personnel record lacks evidence of mandatory abuse, resident rights and dementia training within the last twelve months. 2. CNA #2's employee personnel record lacks evidence of mandatory abuse, resident rights and dementia training within the last twelve months. 3. CNA #3's employee personnel record lacks evidence of mandatory abuse training within the last twelve months. 4. CNA #4's employee personnel record lacks evidence of mandatory abuse, resident rights and dementia training within the last twelve months. 5. CNA #5's employee personnel record lacks evidence of mandatory abuse, resident rights and dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to ensure that a care plan was developed for the risk of wandering/elopement for 1 of 1 sampled resident reviewed for wandering. (#41) Finding: The Policy and Procedure for Wandering and Elopements, revised 3/2019, under Policy heading indicates The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety. Resident #41's Minimum Data Set (MDS) 4.0 Quarterly assessment, dated 10/11/21 and 12/29/21 and the Annual MDS 4.0 Annual assessment dated [DATE], under section E0900 is checked to indicate Resident #41 Wandering - Presence & Frequency, 2. Behavior of this type occurred 4 to 6 days, but less than daily. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, the facility's Dishwasher Temperature Log review, the facility's Dish Machine Use policy and the facility's Sanitation Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ice machine, fans, the dishwasher hood, shelving, ceiling tiles, ceiling air vents, the food slicer, the standing mixer and the walk-in refrigerator. Additionally, The facility also failed to date, label and/or seal foods in a reach-in freezer, in two reach-in refrigerators and in the walk-in refrigerator. Further, the facility failed to monitor the dishwasher rinse cycle temperatures for 1 of 1 kitchen tours on 1 of 3 days of survey (2/7/22). Findings: On 2/7/22 from 9:10 a.m. to 10:15 a.m., a surveyor did an initial tour of the kitchen in which the following was observed: > The ice machine filter and filter housing was dirty/dusty. > The fan on the half wall above and to the left of the dish machine, was dirty/dusty. > The large wall fan facing the dish room, was dusty/dirty. > The metal hood above the dish machine had rust in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.