Bangor Nursing & Rehabilitation Center

Based on interview. the facility failed to designate a qualified staff member to function as the Infection Preventionist who was responsible for the facility's Infection Control Program and worked at least part time in the role for 4 of 4 months reviewed (September, October, November, and December 2025). This has the potential to affect all residents in the facility. Finding: On 1/6/26, at 9:16 a.m., during an interview with a surveyor, the Infection Preventionist (IP) stated that she had not completed the training yet. She has hired in July 2025, and the old IP left the end of August 2025. She stated she had started the Center for Disease Control (CDC) modules but during the process, the CDC changed the version, and she had to start all over again.

Based on record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interviews, the facility failed to offer/administer a Pneumococcal vaccination to 2 of 5 residents (Resident # [R28] and R33).Findings:1. On 1/5/26, a surveyor reviewed R28's clinical record and noted that the resident was admitted in September 2024; a review of the immunizations tab in the electronic clinical record contained no documentation regarding a pneumococcal vaccination status and uploaded in the files of the clinical record was a blank pneumococcal consent form, dated September 2024. On 1/5/26 at 2:50 p.m., during an interview with a surveyor, the Infection Preventionist (IP) stated they were waiting on consents from the guardian. On 1/6/26 at 9:13 a.m., during an interview with a surveyor, the IP stated she called the guardian, got consent to administer the pneumococcal vaccine, and ordered the vaccine after the surveyor inquired yesterday. 2. On 1/5/26, a surveyor reviewed R33's clinical record and noted that the resident received the Pneumococcal polysaccharide vaccine…

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 and interviews, the facility failed to promote care for residents (Resident #48 [R48 and R7) in a manner that maintains the resident's dignity and respect during resident observations on 1 of 1 days of survey (1/8/26) Findings: 1.On 1/8/26 at 10:15 a.m., during a resident observation R48 was being assisted by a staff person down the hallway, R48's feet were dragging on the floor, and R48 stated stop my feet, the staff person then said to R48 well if you would lift your feet it wouldn't hurt, It was observed that R48 was wheeled to an office to sit with this staff person. On 1/8/26 at 10:30 a.m. during an interview with the Director of Nursing (DON) she was made aware of the observation. The surveyor asked the DON what the facilities policy was for transporting residents in a wheelchair. She stated that residents who can self-propel the footrests are removed to prevent any trip hazards. If staff transport the residents they need to have the footrests in place. She then stated they are all aware of this as they have been working with therapy to find the footrests…

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, the facility policy and procedure for reporting and interview, the facility failed to notify the State Agency (Division of Licensing and Certification) of a resident -to-resident sexual altercation in a timely manner for 1 of 1 resident reviewed for a resident -to-resident sexual. altercation (Resident #28 [R28]). Finding:On 1/6/26, a review of R28's clinical record was completed. R28 is cognitively impaired and is wheelchair dependent. In the nurse note section, a note indicated on Saturday/1/3/25, in the afternoon, R28 was inappropriately sexually touched by a cognitively impaired male resident who is wheelchair dependent).A nurse note dated 1/5/26 (Monday), indicated the Director of Nursing and the Social Worker were notified of the resident-to-resident sexual altercation.On 1/8/26, a review of the facility Abuse-Risk Management Folder, under Take Action - (When an allegation of abuse is made), #3 Based on allegation: notify State agency, Adult Protective agency .A review of the facility Compliance with Reporting Allegations of…

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 provide a written bed hold notice to a resident who was transferred to the hospital for medical evaluation for 1 of 3 closed record residents reviewed (R61).On 1/7/26, R61's clinical record was reviewed. On 2/24/25 R61 was transferred to the hospital for medical evaluation and treatment following a fall with major injury. The clinical record lacked evidence that R61 and/or R61's representative received a bed hold notice upon transfer.On 1/8/26 at 9:45 a.m., during an interview with a surveyor, the Licensed Social Worker stated she looked through the entire record and found several bed holds but not for the day in question. At this time the surveyor confirmed R61 did not receive a bed hold notice for the transfer to the hospital on 2/24/25.

Based on record review and interview, 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 properly care for 1 of 7 residents reviewed (Resident #42 [42])Finding: Review of Resident #42's clinical record noted that he/she was admitted to the facility on 1218/25. The clinical record lacked evidence that the base line care plan was developed to include the instructions needed to provide minimum healthcare information necessary to properly care for R42. On 1/8/26 at 12:54 p.m., during a clinical record for R42 and during an interview with the Director of Nursing the surveyor confirmed that R42's baseline care plan was not developed within the 48 hours after admission.

Based on observations and interviews, the facility failed to ensure opened Fluticasone Propionate (Advair Discus) inhalation medication was labeled with an open date and that liquid Lorazepam was kept in a refrigerator in 2 of 2 medication carts (Skilled and Long-Term Care). Findings: 1. On 1/6/26 at 8:15 a.m., during a review of the Skilled Medication cart with Licensed Practical Nurse #1 (LPN1), a surveyor confirmed the following were not labeled or stored properly: - There were 2 bottles of liquid Lorazepam kept in the locked narcotic box with a sticker on the bottle that read refrigerate. LPN1 called the pharmacy in the presence of a surveyor; the pharmacy personnel informed LPN1 that the unrefrigerated Lorazepam were no good. - There were 2 opened packages of Fluticasone Propionate that were not labeled with an open date. The directions on the box indicated the medication was good for 30 days from opening. 2. On 1/6/26 at 8:40 a.m., during a review of the Long-Term Care Medication cart with Certified Nursing Assistant - Medication #1 (CNA-M), a surveyor confirmed the following…

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 interview, the facility failed to provide assistive devices (Kennedy cups; which is a spill proof drinking cup with a secure lid and handle) for 1 of 2 residents reviewed for nutrition (Resident #16 [R16]) and in addition the facility failed to have enough eating equipment/utensils for between meals and snack times for 3 of 4 days of survey. (1/6, 1/7 and 1/8/26)Findings:On 1/6/26 at 12:13 p.m. during a meal observation with R16, an observation of his/her lunch tray in front of R16. R16 had finished his/her meal the surveyor observed R16 had a Kennedy cup with milk in it and a regular cup of coffee (mug). Surveyor requested to review his/her meal slip and on this slip it documented for this resident to use an assistive device which was a Kennedy cup. Surveyor asked if R16 always received their coffee this way? R16 stated yes the coffee is always in a regular mug and not the cup with cover (Kennedy cup) The Son who was present stated this was a daily thing not having his coffee in a Kennedy cup.On 1/6/26 at 1:45 p.m., a Certified Nursing…

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 4 days of survey (1/7/25).Finding:On 1/07/26 at 8:51 a.m. a surveyor and the Administrator along with the Food Service Director observed a bag of garbage on the ground and not contained in the dumpster, additionally on the back dock there were several soiled gloves on the floor/ground and not contained in a garbage bag. The Surveyor confirmed the findings at the time of the observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 sampled residents (Resident #42 [R42], R4). Findings:1.R4's clinical electronic medical record was reviewed. Prescriber written Order Summary Report, dated [DATE], indicated under Other Order Summary, Advance Directive: CPR (cardiopulmonary resuscitation) Order Status, Active. R4's clinical electronic medical record was reviewed, an attachment under misc. [miscellaneous], topic CODE STATUS was signed by a provider on [DATE] and is checked DO NOT RESUSITATE. An attachment under misc., topic DO-NOT-RESUSCITATE (DNR) DIRECTIVE, handwritten, -DO NOT INTUBATE- was signed by R4's representative and a provider on [DATE]. On [DATE] at 2:58 p.m., the Director of Nursing (DON) and a surveyor reviewed R4's electronic clinical record. The surveyor confirmed in an interview with the DON that R4's clinical medical record contained two different directions for code…

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, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 7 of 14 residents reviewed for Advance Directive. (Resident #19 [R19], R16, R17, R11, R18, R37 and R102) Findings: 1. R19 was admitted to the facility on [DATE]. A review of R19's clinical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 2. R16 was admitted to the facility on [DATE]. A review of R16's clinical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were…

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 1 of 1 environmental tour (12/18/24). Findings: On 12/18/24, between 10:47 a.m. through 11:13 a.m., an environmental tour was completed with the Director Plant Operations, Healthcare Services Group District Manager, and three surveyors, the following findings were confirmed at the time of observations: 1. - In room [ROOM NUMBER], there was paint chipped near both televisions and by the headboard for Bed 2. The metal bed enabler on Bed 1 had chipped paint. - In room [ROOM NUMBER], both nightstand coverings were damaged, the wall above the sink was damaged, there was a water-stained ceiling tile, there were handles missing on the dresser drawers, the trim on the headboard and footboard for Bed 1 were broken, the metal bed enablers for Bed 1 had chipped paint and the bedside table edges were damaged. - In room [ROOM…

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 interviews, the facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 3 of 4 sampled resident (Resident #19 [R19, R16, and R37]). Findings: 1. On 12/17/24 at 9:58 a.m., during a record review of R16's clinical record, the PASARR II dated 10/7/24 has the PASRR determination explanation that R16 met the State of Maine's definition for serious mental illness due to a diagnosis of depression over the past three to six months, your diagnosis has led to intermittent functional limitations in interpersonal functioning, concentration or adaptation to change. Onset of symptoms and persistence causes significant distress and impairment in your ability to function independently. R16's PASRR Level II required: Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing…

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 interviews, the facility failed to ensure that physician orders for treatments were followed for 2 of 20 sampled residents. (Resident #11 [R11]), R19). The facility failed to monitor a residents treatment until 4 days after treatment was administered for 1 of 1 sampled resident (12/13/24 to 12/16/24). Findings: 1. On 12/17/24 at 11:03 a.m,, during a clinical record review a diet order dated 11/16/24 instructs that R11 needs constant supervision with meals. On 12/18/24 at 8:35 a.m., an observation was made that R11 was in his/her room and in bed. The privacy curtain was pulled halfway causing R11's upper body to not be visible. At this time CNA #2 was coming out of his/her room with the breakfast tray. A surveyor asked if she had assisted R11 with his/her meal and she stated that he/she eats by himself/herself after they set him/her up. She then stated that she had just come to pick up the tray because they were done eating. The surveyor confirmed, at this time that R11 was not in constant supervision during their breakfast meal. On 12/18/24 at 8:38 a.m.…

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 follow up on pharmacist recommendations timely, for 4 of 6 residents reviewed for medications (Resident #11 [R11], R16, R34 and R37). Findings: 1. On 12/18/24 during R11's clinical record review it was noted that on 10/30/24 the Pharmacist completed a medication record review and had made the following recommendations: - To confirm a diagnosis for Buspar therapy as the current diagnosis is not an approved indication for use, this medication is generally used to treat anxiety. - That this resident has been taking Risperidone 4 milligrams (mg) twice daily since 7/5/24. Please evaluate the current dose and consider a dose reduction. During clinical record review there is no evidence that the Pharmacist recommendations have been reviewed or responded by the Medical Provider. 2. On 12/18/24 during R16's clinical record review it was noted that on 9/22/24 the Pharmacist completed a medication record review and had made the following recommendations: - To review dosing schedule for Oxybutynin and Gabapentin schedule. Both orders…

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 an Infection Control Program designed to prevent the development and transmission of disease and infection for residents on precautions and during a medication pass observation for 3 of 4 days of survey (12/16/24, 12/17/24, and 12/18/24). Findings: 1. On 12/17/24 at 7:00 a.m., in the hallway by the nurses station, a surveyor observed Certified Nursing Assistant - Medication #1 (CNA-M1) with medications in her bare hands, giving them to Resident #16. The surveyor confirmed this observation with CNA-M1 at this time. 2. On 12/17/24, Resident #21 (R21)'s clinical record was reviewed which indicated that R21 had a Foley catheter and a history of a bacteria, Extended-spectrum beta-lactamase (ESBL), requiring contact precautions when providing care. At 8:43 a.m., the surveyor observed a sign on the the door to R21's room indicated that which required staff to put on gloves and a gown before entering the room; the surveyor did not…

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, and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for 5 of 5 residents reviewed for immunizations (Resident [R]3, R43, R25, R28, and R12). Findings: On 12/18/24 at 12:01 p.m., during an interview with the Infection Preventionist (IP), she stated that per the facility pharmacist, and CDC guidance, if a resident received the PCV13 and PPSV23, they should receive the PCV20 five years after the last pneumococcal vaccine given. 1. R3's admission date to the facility was on 12/6/23. During review of immunization records, R3 received a PPSV23 on 1/16/18, and a Pneumovax Dose 2 on 8/25/06. A surveyor could not locate evidence that R3 was reviewed, offered, or received a pneumococcal vaccine according to CDC recommendations. The Resident is over [AGE] years of age. 2. R43's admission date to the facility was on 3/29/24. During review of immunization records, R43…

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 notify the Provider of a change in status for 1 of 1 sampled resident (Resident #11[R11]). Finding: On 12/16/24 at 3:01 PM during a clinical record review for R11, a nursing note dated 10/11/24 labeled Health Status note documents that R11 vomited once, a large amount (copious) of dark brown/black liquid with undigested food and medication. Bowel sounds were noted to be less active than normal (hypoactive) but active (positive) in all four sections (quadrants). Low pitched (Course crackles) were heard (auscultated) throughout all lung lobes. Afebrile at 98.0. pulse 87, BP 97/66 though patient frequently is hypotensive. O2 95% on RA, respirations 20. Resident does present with cough, although this is not a new finding. Resident states he/she feels better since vomiting. He/She denies any further nausea. Will continue to observe. Upon Further review of his/her clinical record R11 has a Physicians order dated 8/10/24 to notify provider if recurrence in condition (vomiting) occurs. There is no evidence in the clinical record…

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 and interview, 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 properly care for 1 of 2 residents reviewed that were admitted in the last 30 days (Resident #54 [R54]), Finding: On 12/16/24, R54's clinical record was reviewed which indicated that R54 was admitted to the facility on [DATE] after R54 had a fall which resulted in fractures prior to admission, requiring therapy and pain monitoring with diagnoses that included diabetes, use of an anti-coagulant, and a pressure ulcer to sacrum. These care areas were not added to the baseline care plan until after 48 hours of admission. On 12/18/24 at 9:47 a.m., during an interview with a surveyor, the Director of nursing stated that the nurses are responsible for the baseline care plan. R54's baseline care plan was reviewed and the surveyor confirmed that fall with fractures, pain, diabetes, anti-coagulant…

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 and interview, the facility failed to provide recommended nutritional services for 1 of 1 residents reviewed for dialysis [Resident #102 (R102)]. Finding: Review of the Dialysis Patient Care Policy created and approved on 05/21/2018 indicated, Dietary management involves restriction of protein, sodium, potassium, and/or fluid intake per physician's orders. On 12/17/24, clinical record review revealed: R102 was admitted on [DATE] with a diagnosis of dependence on renal dialysis. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE] with the same care plan in place. The care plan revised on 9/29/24 indicated the resident was on a renal diet. The dietary notes on 10/24/24 indicated the resident was on a renal, carb consistent, low sodium diet. The discharge orders from the hospital dated 12/12/24 indicated R102 continue the carb consistent, low sodium diet on return to the facility. On 12/12/24, the dietary communication slip indicated R102 was placed on…

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 and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 1 of 2 sampled residents using oxygen (Resident #25 [R25]). Finding: On 12/18/24 at 10:55 a.m., during an environmental tour with the Director of Plant Operations, Healthcare Services Group District Manager, and surveyor observed R25 wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator filter located on the back of the machine was dusty. On 12/18/24 at 10:55 a.m. in an interview with the Director Plant Operations, and Healthcare Services Group District Manager, a surveyor confirmed R25's oxygen concentrator was dusty.

Based on record review and interview, the facility failed address the needs of a resident in order to minimize triggers that may cause re-traumatization for 1 of 2 resident reviewed for Mood/Behavior (Resident #15 [R15]). Finding: R15 was admitted to the facility with hospice services on 11/28/23. R15's diagnoses are significant for anxiety disorder, hallucinations, delusional disorder, dementia with behavioral disturbance, and need for assistance with personal care. On 12/15/24 at 8:08 p.m., a nurse note stated, [patient] stated to [2 staff] that the last two people who were in [his/her] room molested [him/her]. On 12/17/24 at 4:01 p.m., a nurse note stated, This afternoon the Hospice nurse and social worker reported to me [R15] was very upset when they saw [him/her] today. [He/She] reported being afraid and made claims of a sexual assault. Upon probing, the resident could not identify when it happened and stated it was not here. ? if [he/she] may have had a previous trauma triggered by a male caregiver. On 12/18/24, the provider signed a note stating, report to [Director of…

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 and interviews, the facility failed to ensure that physician ordered medications were available for use to meet the needs of the residents for 1 of 3 residents reviewed as a closed record. (Resident #51 [R51]). Finding: On 12/19/24 at 1:07 p.m., during a review of Resident #51's clinical record, R51 was admitted to the facility on [DATE] after a stay at the hospital for the treatment of a surgical wound infection. He/she was admitted with an order for Vancomycin HCI in dextrose intravenous (IV) solution 1.25-5 gram (GM)/250 milliliters (ML) -% use 250ml intravenously two times a day for infection with a start date of 12/15/24 at 8:00 p.m. The Treatment Administration Record (TAR) shows documentation that on 12/15/24 at 8:00 PM a code of 9 was entered. The code 9 using the chart codes on the TAR indicated other/see progress notes. The progress note dated 11/15/24 documents the vancomycin HCI in dextrose intravenous solution 1.25-5gm/250ml% (antibiotic) was not in yet from the pharmacy,…

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, and interviews, the facility failed to monitoring food temperatures to prevent food borne illness prior to serving residents for 1 of 4 days of survey (12/17/24), and the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code on 2 of 4 days of survey (12/17/24, and 12/18/24). This has the potential to effect all residents in the facility. Findings: 1. On 12/17/24 at 11:38 a.m., a surveyor observed the Kitchen Manager serve mashed potato, pureed green bean, and ground chicken onto an early plate from the steam table. The plate was covered and put to the side in preparation of being served ahead of the lunch service. At 11:39 a.m., a surveyor observed the Kitchen Manager begin to check holding temperatures of the food on the steam table, prior to serving the lunch service. The ground chicken was observed to be 133 degrees Fahrenheit, and the pureed chicken was observed to be 126 degrees Fahrenheit (Minimum safe holding temperature for hot foods is 135 degrees Fahrenheit). On…

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 interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #42 [R42]) and 1 of 1 reviewed for Respiratory care. Findings: 1. On 12/16/24, a surveyor reviewed information provided for a facility reported incident, dated 12/6/24, involving Licensed Practical Nurse #1 (LPN1) documenting that dressing changes were completed on R42's right heel on 12/2/24 and 12/4/24, but on 12/6/24, the dressing was observed and labeled last changed on 11/30/24 by Registered Nurse #3. Upon further review, the surveyor noted that LPN1 also documented a skin check was completed on 12/1/24 that included documentation of Foot evaluation completed and that R42's right heel pressure wound was a blister but on 11/25/24, the Family Nurse Practitioner #1 documented that the wound (that was a blister) was now unstageable and open, with drainage, to the right heel. On 12/17/24 at 3:15 p.m., during an interview with the Director of Nursing, a surveyor confirmed this…

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 observations the facility failed to provide incontinence care timely for 4 of 7 residents interviewed during a complaint investigation [Resident # (R1), (R2), (R3), and (R4)]. Findings: 1. On 10/21/24, record review indicated R1 was admitted on [DATE] with Acute cystitis without hematuria (urinary tract infection that causes a bladder infection). R1's care plan indicates, [R1] has potential for impairment to skin [related to] incontinence, impaired mobility, and lists Keep skin clean and dry for an intervention. R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. On 10/21/24 at 10:46 a.m., during an interview with a surveyor, Resident (R1) stated that call bells can go unanswered for 40 minutes and R1 was not checked for incontinence on the night shift on 10/18/24 or 10/20/24. R1 stated he/she is prone to urinary tract infections and is afraid the delay in care will lead to another one. 2. On 10/21/24, record review indicated R2 was admitted on…

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 observation, the facility failed to ensure sufficient staff were scheduled and on duty to meet the needs of residents [Resident #1 (R1), R2, R3, and R4]. This has the potential to effect all residents. Findings: During the week of 10/21/24-10/25/24 interviews were conducted with anonymous staff [Anonymous Staff #1 (A1) and (A2)]. A1 stated the facility is not staffing to acuity and had recently cared for a resident immediately on entering the facility as they were heard screaming for help related to incontinence. A1 stated we have a lot of patients who are alert and oriented enough to know when someone comes but not enough to know to use the bathroom . so a lot of them are sitting in it. A2 stated the facility could use more staff as call bells go on for about 40 minutes, but staff are busy. 1. On 10/21/24 at 10:46 a.m., during an interview with a surveyor, Resident (R1) stated that call bells can go unanswered for 40 minutes and R1 was not checked for incontinence on the night shift on 10/18/24 or 10/20/24. R1 stated he/she is prone to urinary tract…

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 and interviews, the facility failed to ensure that a resident's representative was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents reviewed for a change in condition [Resident #8(R8)]. This had the potential to delay decisions in medical care. Findings: During a medical record review, R8 was admitted on [DATE] including diagnoses Parkinsonism, Dementia, and hallucinations. The daughter/Power of Attorney (POA) for medical and financial was listed as the responsible party. R8 had a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The care plan indicated The resident is resistive to care, refusal of medications, and listed May call daughter when refuses medications or care. Nursing notes indicated the following: On 10/2/24 at 4:18 a.m., R8 was found on the floor and an SBAR (Situation, Background, Assessment, and Recommendation) was left for the provider. The note states request day shift to call…

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 reviews, the facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application (App) in the areas of dementia care, resident rights, and abuse, neglect and exploitation training by failing to ensure contracted Clipboard Professionals (Users) completed trainings prior to independently providing services to residents. Findings: Review of the Clipboard app Terms of Service Agreement last updated on October 9, 2023 states, Clipboard operates an online, marketplace, accessed through the Site, that allows third-party clients (each, a Client) to post open shifts at facilities (each, a Facility), and allows independent contractor professionals (each, a Professional) to view and sign up to work such shifts if they so choose. Under the subheading 2.1 CLIPBOARD'S ROLE AS A MARKETPLACE states, Clipboard merely makes the Site and Services available to enable Professionals and Clients to find and transact directly with each other . Users alone are responsible for evaluating and determining 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 interviews and record review the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff attempted to have a resident receive nail care in contrast to their preferences and to disclose a private conversation for 1:1 resident(s) reviewed (Resident #1 [R1]). Findings: On 6/11/24 at 12:01 p.m., in an interview with a surveyor, R1 stated he/she was brought into the office and questioned about a private conversation between R1 and Adult Protective Services (APS). R1 stated he/she cried due to fear of being kicked out if R1 did not disclose the conversation. R1 also stated not wanting to have their nails trimmed as they are R1's preferred length. On 6/12/24 review of R1's clinical record indicated the Licensed Social Worker (LSW) spoke with R1 regarding R1's nail care needing attention. LSW continues to discuss nail trimming with R1 even after the resident verbalizes refusal for nail trimming. On 6/12/24 at 10:40 a.m., in an interview with a surveyor, the LSW stated she spoke with R1 about nail grooming because an…

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 interviews, the facility failed to ensure that physician orders were followed for 1 of 3 residents reviewed for provider orders (Resident #1 [R1]). Findings: On 12/7/24 a provider order was placed in R1's electronic medical record stating Referral to dentist for dental infection of bilateral posterior lower gums; [discontinue] this order when completed [or] scheduled. On 4/26/24 a provider instructed a referral be sent for dental services for R1. This order was placed in the paper chart and initialed as acknowledged by staff on 4/29/24 and 4/30/24. On 5/30/24 a provider instructed R1 to have a dental examination for teeth grinding and oral health. On 6/11/24 at 12:01 p.m., in an interview with a surveyor, R1 stated they had not been to a dentist but needed an appointment because a chipped tooth had turned into multiple broken teeth. On 6/11/24 at 12:30 p.m., in an interview with the Scheduler, the surveyor confirmed there were no dental appointments scheduled for R1. This delay in dental services extended over a period of 6 months (December 7, 2023,…

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 interviews, the facility failed to obtain dental services for a resident with chipped and broken teeth for 1 of 1 resident reviewed for dental services (Resident #1 [R1]). Findings: On 6/11/24 at 12:01 p.m., in an interview with a surveyor, R1 stated they had not been to a dentist but needed an appointment because a chipped tooth had turned into multiple broken teeth. At 12:30 p.m., in an interview with the Scheduler, the surveyor confirmed there were no dental appointments scheduled for R1. On 6/12/24, review of R1's clinical record revealed a provider order was placed 12/7/24 in R1's electronic medical record stating Referral to dentist for dental infection of bilateral posterior lower gums; [discontinue] this order when completed [or] scheduled. Review of the paper chart revealed a second provider wrote instructions for R1 to receive a dental examination for teeth grinding and oral health on 4/26/24 and 5/30/24. Dental services were delayed for a total of six months (December 7th, 2023, through June 12th, 2024). On 6/12/24 at 11:00 a.m., in an…

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 interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 3 (April 1 - June 30, 2023). This has the potential to affect all residents (51). Findings: Interview with the Administrator on 10/25/23 at 11:05 a.m. revealed that he/she is the responsible person for the submission to CMS of staffing information based on payroll data. Administrator verbalized, the finance/payroll department used to do this, but he got done in June 2023 and the Employee Experience Coordinator thought she had until the end of August 2023 to submit the data. A document titled PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) 1705D FY (Fiscal Year) Quarter 3 2023 (April 1 - June 30) states that the facility Failed to Submit Data for the Quarter was triggered. Triggered' was defined as no data submitted for quarter. A facility document titled…

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 and interview, the facility failed to ensure the confidentiality of protected health information for 9 of 51 residents during 1 of 4 days of survey (Resident (R) #1, #10, #206, #17, #105, #43, #31, #9, and #47). Finding: On 10/24/23 at 10:26 a.m., a surveyor observed on the nurses station counter near the front entrance, an unattended, printed, email from the Director of Nursing displayed, visible and easily accessible to residents, visitors, or other unauthorized persons. The subject of the email was entitled, Covid update for 10/23/23, and listed R1 is off isolation; R10 day 1; R206 day 2; R17 day 2; R105 day plus C-diff; R43 day 2; R31 day 5; R9 day 1; and R47 day 5 as Residents that have or had Covid, and/or Cdiff. On 10/24/23 from 10:26 a.m. through 10:41 a.m., three staff, and two visitors passed by the nursing station counter where the displayed email was sitting. On 10/24/23 at 10:41 a.m. in an interview with a surveyor, the Educational Director acknowledged the unsecured medical information, and she moved and turned over the printed email, stating they…

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, interviews and facility policy review, the facility failed to follow a physician order for making a referral to a specialist for 1 of 5 residents reviewed for unnecessary medications (Resident #26 [R26]) and failed to follow it's own policy for 1 of 2 residents reviewed with a fall (Resident #46[R46]). Findings: 1. On 10/23/23, R26's clinical record was reviewed and contained a physician order, dated 7/17/23, to obtain a urology referral for recurrent urinary tract infections and a gynecology referral for frequent vaginal pain, irritation, and atrophic vaginitis. On 8/2/23, a physician progress note was completed by the Medical Provider that indicated both referrals were pending. The surveyor was unable to find evidence that these appointments were made. On 10/24/23 at 2:18 p.m., during an interview with a surveyor, the Director of Nursing stated she was unable to find evidence that these referrals were addressed. 2. The facility's Fall Training Materials policy, dated 1/15/2020, directed staff that in the event a resident falls, the following measures will…

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 and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #37 [R37], and Resident #39 [R39]). Findings: 1. Review of R37's Consultant Pharmacist's Medication Regimen Review dated 6/26/23 states: Please consider clarifying the diagnosis listed for Donepezil therapy. The Medication administration record (MAR) currently lists a diagnosis anxiety which is not an approved indication for use. This medication is generally used to treat Alzheimer's dementia. Thank you. Review of R37's clinical record lacked evidence that the provider was provided the pharmacy consultant report dated 6/26/23. Review of R37's clinical record lacked evidence that this recommendation was addressed. On 10/26/23 at 12:20 a.m. the surveyor confirmed with the Educational Director that the pharmacy recommendation was not provided to the provider. 2. R39 was originally admitted to the facility…

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 and interviews, the facility failed to ensure the kitchen was maintained in a clean manner on 3 of 4 days of survey (10/23/23, 10/24/23, 10/25/23) the facility failed to ensure that dented cans were removed from use, failed to label thawed whipped topping with a thaw date on 1 of 4 days of survey. (10/23/23) Findings: On 10/23/23 at 11:11 a.m. during the initial tour the following was observed: -The kitchen floors were observed to be heavily soiled with food and food peelings, the grout lines in the tile floor are heavily soiled with dirt and grime. -The table on left hand side of stove the bottom shelf was observed to be heavily soiled with dirt/grime. -The bottom of the steamtable was observed to be soiled with dirt/dust and grime. -The ceiling tiles throughout the kitchen were observed to have black marks including handprints, water stains and areas were observed to be bubbled. -The floor drain near the stove was heavily soiled with food debris, dirt and grime, the floor mats were torn and uncleanable. -The wall behind the stove was soiled with grease and…

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 interview, the facility failed to ensure that the facility's Infection Preventionist (IP) had completed specialized training prior to starting the IP position. Finding: On 10/25/23 at 1:15 p.m., in an interview with the surveyor, the Educator/Infection Preventionist (Educator/IP) stated she started this position in March 2023 and has enrolled in an on-line training for Infection Control and Prevention but has not completed the training. On 10/25/23 at 1:20 p.m., in an interview with the surveyor, the Educator/IP confirmed that no other staff/IP is overseeing or consistently training her and that she has not completed the specialized training-Certificate in Infection Prevention and Control.

Based on employee record review and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on dementia for 4 of 5 licensed staff reviewed (Certified Nursing Assistant #1 [CNA1], CNA2, Certified Nursing Assistant-Medications #1 [CNA-M1], and CNA-M2). Findings: On 10/25/23 the following employee records were reviewed: 1. CNA1 was hired on 3/11/20. There was no documented dementia training. 2. CNA2 was hired on 9/27/22. There was no documented dementia training in over 12 months. 3. CNA-M1 was hired 8/19/11. There was no documented dementia training in over 12 months. 4. CNA-M2 was hired 1/7/22. There was no documented dementia training in over 12 months. On 10/25/23 at 3:15 p.m., in an interview with a surveyor, the Employee Experience Business Partner, Senior Employee Experience Business Partner, and Director of Employee Experience confirmed the above findings.

Based on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 1 sampled residents (Resident #26 [R26]). Finding: On 10/24/23 at approximately 8:15 a.m., during an interview with a surveyor, R26 stated that he/she didn't get a shower last Tuesday evening (10/17/23) but received one the Tuesday before (10/10/23) but not the Tuesday before that (10/3/23). R26 stated that last week they told him/ her there wasn't enough staff but then found out that there was and that they just didn't want to do it. On 10/24/23, R26's clinical record was reviewed which indicated that R26 was to receive a shower on Tuesday evening shift. On 8/18/23, an annual Minimum Data Set (MDS) 3.0 was completed which included documentation under Section F0400 C. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath to which the response was - 1. very important. 10/26/23 at 10:08 a.m., a surveyor and the Director of Nursing (DON) reviewed R26's bathing documentation for the months of August thru…

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 and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnoses, and was updated for 1 of 2 residents reviewed for PASRR (Resident 39 [R39]). Finding: During review of R39's medical record, it was determined that R39 was admitted to the facility on [DATE] and the record contained a PASRR Level I Screen dated 6/10/22 completed while the resident was at St. [NAME] Hospital. The PASRR Level I Screen in the diagnosis section, stated, No mental health diagnosis is known or suspected regarding mental health diagnoses, and did not include a diagnosis of anxiety or depression. The resident record lacked evidence that the PASRR Level I Screen was updated to include R39's current diagnosis of anxiety, and depression and was forwarded to the State-designated authority to determine if a Level II assessment was needed. On 10/25/23 at 10:31 a.m., in an interview with the Director of Social Services, a surveyor confirmed that the PASRR Level…

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 review/revise and update care plan interventions for the problem areas of Post Traumatic Stress Disorder (PTSD) for 1 of 17 sampled residents/care plans reviewed (Resident #19)(R19). Findings: On 10/24/23, R19's clinical record was reviewed. A review of the resident's diagnoses indicated a diagnosis of PTSD and R19's current medication orders indicated R19 received Risperidone for PTSD. A review of the Physician progress notes, dated 6/26/23 and 7/24/23, on the follow-up/acute visits, the last sentence of the first paragraph indicated PTSD started after the resident's son's untimely death. R19's care plan indicated that one of his/her current PTSD problems was, 'Resident has a psychosocial well being problem related to PTSD.' There was no evidence of interventions addressing what the triggers are that may re-traumatized the resident. No trigger specific interventions that staff should or should not do that may cause re-traumatization. Another care plan problem that addressed PTSD, according to the Director of Nursing, was…

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, observation, and interviews, the facility failed to ensure that a treatment was followed for 1 of 1 resident reviewed for pressure ulcers (Resident #33 [R33]). Finding: A review of R33's clinical record noted an admission date of 3/9/23. The Medication Review Report, under other, order summary listed, on 9/3/23, wash sacrum with Dermal wound cleanse, apply Lotrisone (generic name, Clotrimazole/Betamethasone, a combination medication, clotrimazole, is an antifungal, and betamethasone, is a corticosteroid that works by stopping the fungus from being able to make a protective covering, making it difficult for the fungus to grow or survive, and corticosteroid - that lowers certain chemicals in your body that cause inflammation in your skin) to peri wound . every day shift for sacral wound. The Treatment Administration Record (TAR), listed under, schedule for [DATE] lists, wash sacrum with Dermal wound cleanse, apply Lotrisone to peri wound (around the wound) . On 10/23/23 at approximately…

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 a resident's physician supervised and evaluated weight loss for 1 of 1 residents reviewed with significant weight loss (Resident #31 [R31]). Finding: On 10/24/23, R31's clinical record was reviewed. On 9/26/23, the resident's admission weight was documented at 144 lbs. Additional weights were documented as follows: 10/3/23 144.2 lbs 10/10/23 125.4 lbs -12.99 percent loss from admission weight 10/17/23 123 lbs. - 14.58 percent loss from admission weight. The clinical record contained documentation that on 10/11/23, the Dietitian visited R31 to discuss food allergies but no mention of weight loss was included in this note. Further review of the clinical record indicated that on 10/18/23, R31 was diagnosed with the Coronavirus but this was after the weight loss started. On 10/26/23 at 1:03 p.m., a surveyor and the Director of Nursing (DON) reviewed R31's clinical record and there was no evidence that the physician was notified of significant weight loss nor were there any Provider Progress Notes in the clinical record…

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 interviews, the facility failed to ensure that physician ordered medications were available for use to meet the needs of the residents for 1 of 4 sampled residents (Resident #22[R22]). Finding: On 10/25/23 at 9:38 a.m., a surveyor observed Certified Nursing Assistant - Medication (CNA-M) #2 prepare R22's medications. CNA-M #2 was unable to locate any Artificial Tears to be able to administer to R22 who was supposed to receive 1 drop to each eye three times a day and as needed as instructed per physician order dated 1/23/23. CNA-M #2 reported to the Charge Nurse and a hold order was received. CNA-M #2 and CNA-M #1 looked for unopened Artificial Tears in the medication storage rooms and were unable to locate any. On 10/26/23 at 8:15 a.m., during an interview with a surveyor, CNA-M #1 stated that the process is to notify the Charge Nurse and/or Unit Secretary when the medication is not available. At this time, the surveyor and CNA-M #1 observed Central Supply and noted that there were no Artificial Tears located here. On 10/26/23 at 9:44 a.m., during an…

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, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 resident reviewed for pressure ulcers (Resident #33 [R33]). Finding: A review of R33's clinical record noted an admission date of 3/9/23. The Medication Review Report, under other, order summary listed, on 9/3/23, wash sacrum with Dermal wound cleanse, apply Lotrisone (generic name, Clotrimazole/Betamethasone, a combination medication, clotrimazole, is an antifungal, and betamethasone, is a corticosteroid that works by stopping the fungus from being able to make a protective covering, making it difficult for the fungus to grow or survive, and corticosteroid - that lowers certain chemicals in your body that cause inflammation in your skin) to peri wound . every day shift for sacral wound. The Treatment Administration Record (TAR), listed under, schedule for [DATE] lists, wash sacrum with Dermal wound cleanse, apply Lotrisone to peri wound . The Wound…

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 interviews the facility failed to ensure that physician orders were followed for 1 of 3 resident's reviewed that were transferred to the hospital (Resident #1 [R1]). Findings: R1's clinical record was reviewed and included hospital ED (emergency department) discharge instructions with a diagnosis of urinary tract infection (UTI), and physician order, dated 8/16/23 at 4:07 p.m., for the medication Cefdinir (an antibiotic medication to treat bacterial infections in many different parts of the body) 300 mg (milligrams) oral capsule, 1 cap oral, every 12 hours, Duration: 10 days. R1's Medication Administration Record (MAR) was reviewed and lacked evidence that the ordered medication Cefdinir was given from 8/16/23 9:00 p.m. through 8/19/23 9:00 p.m., a total of 7 doses. R1 did not receive Cefdinir until 8/20/23 9:00 a.m., four days after the physician's order. On 8/18/23 at 4:47 p.m., a progress note title, infection note stated, .pharmacy did not send due to a allergies alert. Nurse followed up today and med will be started Saturday morning 8/19/23 On…

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.