Maine Veterans Home - Bangor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews, the facility failed to ensure physician orders were followed for 1 of 2 sampled residents (Resident #6, [R6]). Findings: Review of R6's physician order sheet, handwritten, dated 10/28/24, stated, in one month present case to Doctor #1 (DR1). Review of R6's physician order sheet, handwritten, dated 10/29/24, stated, medroxyprogesterone 2.5 m.g PO (by mouth) daily for hypersexual behaviors. POA (power of attorney) consented for use. Review of R6's physician order sheet, handwritten, dated 11/11/24, stated, increase medroxyprogesterone to 5 m.g QD (every day). Review of R6's physician orders signed 11/14/24, page 3, stated under medications, 11/11/24 medroxyprogesterone acetate 5 m.g tablet by mouth daily given for antisocial sexual behavior (sexual-associated behavior disruptive to others). Review of R6's physician order sheet, handwritten, dated 12/13/24, increase medroxyprogesterone to 10 m.g PO daily. Re-present to DR1 next opportunity. Review of R6's physician…

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 a care plan was resident centered and updated accurately for 1 of 6 residents reviewed during complaint investigations (Resident #5 [R5]). Findings: 1. Clinical record review indicated R5 has a diagnosis of vascular dementia. The care plan updated 2/26/25 identified the following: -A care area identified on 9/21/23, indicated Dementia. No goal listed. An approach dated 1/31/25 indicated Resident may exhibit sexual behaviors with male residents and If resident displays sexual behaviors, assess resident for signs of behavior changes related to sexual behaviors. If resident appears agitated, anxious, or is crying, redirect resident away from male residents. Notify supervisor or nurse manager if sexual behavior is occurring and is creating an unwanted interaction. If resident is engaging in consensual sexual behavior, provide privacy. On 3/12/25 at 2:28 p.m., during an interview with a surveyor and RN6, R5's care plan was reviewed. The care plan did not address R5's cognitive ability to engage in consensual sexual…

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 ensure that bowls were dried properly and failed to ensure the kitchen was free from insects for 1 of 2 kitchen tour ([DATE]). In addition, the facility failed to ensure that milk was not expired during 1 of 2 meal observations on the B Unit ([DATE]). Findings: 1. On [DATE] at 10:20 a.m. an initial tour of the kitchen was done with the Nutrition Manager. Observed on a shelf, available for use, were 30 cereal bowl and 30 small white bowls that were wet stacked/nestled. Near the baking station area, fruit flies were observed coming from and around the floor drain. These findings were confirmed at the time of the observation.2. On [DATE] at 12:39 p.m., during a lunch observation in the East Wing dining room on B Unit, a surveyor observed in the beverage trays with ice, 2 unopened 1% milk with an expiration date of [DATE]. The surveyor confirmed this with the Registered Nurse.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record reviews and interviews, the facility failed to ensure that resident records contained accurate, complete, and/or readily accessible information for 3 of 5 resident records reviewed for falls (Resident #84 [R84], R74 and R7). Findings: The facility's policy, Neurological Assessments, (neuro checks) last reviewed 5/8/24, indicates that a neurological assessment will be completed and documented in ECS (electronic medical record) after any incident or fall in which a head injury is suspected. In the case of an unwitnessed fall, the resident will be considered to have hit their head unless he/she can reliably state he/she did not. Assessments will be completed every 15 minutes for the first hour after the fall, every 30 minutes for the subsequent 4 hours, every shift for the next 72 hours. 1. On 8/21/24, R84's clinical record was reviewed and indicated that on 8/15/24 at 12:00 p.m., R84 was observed on the floor in the dining room and neuro checks were started. A review 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 facility policy review, record review, and interview, the facility failed to maintain an effective infection control program, and failed to analyze and follow-up on known infections in the facility. This has the potential to affect all residents receiving an antibiotic in the facility. In addition, the facility failed to ensure a shared glucometer was cleaned after each use for 1 of 2 observations (8/20/24), Findings: Review of facility policy Infection Prevention and Control Program dated 9/25/23 states will establish, implement and maintain an infection prevention and control program that will provide safe, sanitary and comfortable environment to help prevent, recognize, and control, the onset, development and transmission of communicable disease and infection to residents . Surveillance and investigation to prevent and control the onset and spread of infection within the facility.Program Record Keeping maintains records of incidents and corrective actions related to infections . 1. Review of facility provided Infection Report revealed the following: -During the month 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 facility policy review, record reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of the facility policy Antibiotic Stewardship Program dated 2/2/23 states .To improve patient safety and assist in the prevention of multi-drug resistant organisms (MDRO) and Clostridium difficile infections (CDI) by optimizing use of antibiotic drugs and to provide continuous improvement by utilizing prescribing and outcomes data to identify opportunities of targeted initiatives and optimal antibiotic prescribing .Tracking and trending for appropriate antibiotic selection and identification . Review of facility policy Medication Regimen Review dated 1/2019 states .The consultant pharmacist compiles and analyzes data collected from MMR's and presents findings to the Quality Assurance and Process Improvement (QAPI) Committee as part of the facility continuous improvement (CQI)…

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 promote care to residents in a manner that maintains each resident's dignity for 3 of 4 meal observations in 2 dining rooms on the B Unit. Findings: 1. On 8/19/24 between 12:30 p.m. - 12:55 p.m., during lunch observation in the East Wing dining room on B Unit, a surveyor observed the following: A surveyor observed Certified Nursing Assistant #1 (CNA1) assisting Resident (R46) with eating at 12:43 p.m. The surveyor observed R46 in his/her chair with CNA1 standing up as she was feeding R46. During an interview with a surveyor, CNA1 stated that she was standing because there were no extra chairs to sit in, in the dining room. R46's tablemate did not receive his/her meal tray until 12:53 p.m. Resident #79 (R79) was observed eating at 12:35 p.m., but his/her tablemate(s) did not receive their food until 12:49 p.m. There was a table with 6 residents, R65 received his/her lunch at 12:43 p.m. The surveyor left the dining room at 12:55 p.m., and 3 of 6 tablemates had not received their lunch by this time. On 8/19/24 at 12:51 p.m., 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.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was admitted with a diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 5 sampled residents reviewed for PASRR (Resident #30 [R30]). Finding: On 8/21/24, R30's clinical record was reviewed which included a PASRR evaluation completed by the hospital, dated 4/4/24, that indicated no PASRR level II was required and there was a mental health diagnosis of anxiety. A review of R30's diagnosis list included in the clinical record: Post-traumatic stress disorder (PTSD), and anxiety disorder, all added to the clinical record on 4/9/24, the date of admission. On 8/21/24 at 12:43 p.m., in an interview with the surveyor, the Licensed Social Worker confirmed that the PASRR should have been updated to include the diagnosis of PTSD and the State mental health authority should have been notified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to update/implement a care plan in the area of communication for 1 of 1 resident reviewed for communication (Resident #76). Finding: Resident #76 was admitted on [DATE] and has diagnoses to include a hearing deficit requiring use of hearing aids. Review of Resident #76's care plan updated 6/21/24 states communication: Impaired communication. Goal: 3 months Approach: assess for unmet needs such as pain, toileting, hunger, thirst. allow extra time to respond. validate understanding. Allow time to respond face resident, speak clearly Further review of Resident #76's care plan lacked evidence that goals and interventions were put into place for his/her hearing needs. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #76 is hard of hearing and requires hearing aids. Review of Resident #76 clinical record revealed Physician Order Sheet dated 7/12/24 for ENT referral for [right] ear pain/clear drainage/ruptured tm [tympanic membrane] . 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, facility policy review, and interviews, the facility failed to complete neurological assessments after unwitnessed falls for 1 of 4 residents reviewed for falls (Resident #7 [R7]). Finding: Clinical Record Review indicated R7 was admitted on [DATE] with a diagnosis of Vascular Dementia. According to the Minimum Data Set (a standardized assessment tool) on 6/19/24, R7 had a Brief Interview for Mental Status (BIMS) score of 1, and a BIMS of 3 on 8/16/24 (a score of 0-7 suggests severe cognitive impairment). Nurse documentation indicated R7 had two unwitnessed falls on 8/14/24. The clinical record lacked evidence that follow-up assessments were completed after the unwitnessed falls. The Fall Prevention policy (dated 4/24/23) indicates a fall may be witnessed, reported by the resident or an observer, or identified when a resident is found on the floor or ground, and An Occurrence Report will be completed in ECS following a resident fall, and Neurological Checks will be implemented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to recognize a potential significant weight loss for 1 of 1 sampled residents reviewed for nutrition (Resident #101 [R101]). Finding: On 8/20/24 at 9:59 a.m., clinical record review indicated R101 was admitted on [DATE] with a diagnosis of dementia and abnormal weight loss. R101's weight on admission was 111.4 pounds (lbs). On 4/18/24, the Baseline Care Plan for R101's dementia included the dietary intervention Provide ordered diet, Identify likes/dislikes, Offer substitute foods, Dietary consult PRN. On 7/25/24, the Potential for Unintended weight loss was added to the Care Plan, including request for dietary evaluation. Monthly weight documentation indicated: On 4/19/24 the resident weighed 112 pounds (lbs). On 5/7/24 the resident weighed 111.1 lbs. On 6/4/24 the resident weighed 106.7 lbs On 7/2/24 the resident weighed 108.7 lbs On 8/6/24 the resident weighed 100.0 lbs (8% weight loss in 1 month and 10.23% in 4 months) On 8/21/24 at 8:10 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 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 #101 [R101]). Finding: On 8/20/24 at 9:59 a.m., R101's clinical record was reviewed. On 4/17/24 the resident's admission weight was 111.4 pounds (lbs). On 7/2/24 the resident weighed 108.7 lbs. On 8/6/24 the resident weighed 100.0 lbs (an 8% weight loss in one month, and a 10.23% weight loss in 4 months). On 8/21/24 at 8:10 a.m., in an interview with the B Unit Manager, a surveyor confirmed that the clinical record lacks evidence the provider was notified of significant weight loss, nor were there any Provider Progress notes that addressed the significant weight loss.

Based on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #19 [R19]). Finding: On 8/20/24 at approximately 2:03 p.m., a surveyor and the B Unit Manager reviewed R19's clinical record which included an order, dated 4/18/24, for Trazodone 50 milligrams as needed (PRN) at bedtime with no duration of the order. The surveyor reviewed the pharmacist recommendations, dated 4/19/24 and 5/16/24, for the medication Trazodone, with both of the recommendations indicating use of PRN (as needed) antidepressants must be limited to 14 days with the exception that the prescriber documents their rationale in the patient's medical record and indicates the duration for that PRN order. This order was not discontinued until 6/11/24. The surveyor confirmed with the B Unit Manager this finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, interviews, and record reviews, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS), used to monitor for potentially irreversible side effects of antipsychotic medications, was completed when an antipsychotic medication was started, when a dose changed, or every 6 months, for 2 of 4 sampled residents reviewed (Resident [R] 19. R74). In addition, the facility failed to ensure the physician wrote a rationale and/or order with a duration to extend an as needed (PRN) psychotropic medication beyond the 14-day limit, for 1 of 1 resident reviewed (R19) . Findings: The facility's policy, Antipsychotic Medications, last reviewed [DATE], defines that an AIMS test will be done at the initiation of the antipsychotic (medication) or with a change in dosage and at least every 6 months there after. On [DATE] 2:35 p.m. During an interview with a surveyor the Director of Nursing (DON) and Assistant DON (ADON) stated that an AIMS test should be completed as a baseline, 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.

Based on record review and interview, the facility failed to ensure that 1 of 5 residents reviewed for immunizations included documentation in the medical record to indicate the resident received a pneumococcal immunization (Resident #7). Finding: Review of Resident #7's clinical record revealed .Pneumococcal Vaccine Consent signed 11/6/23. Further review of resident's clinical record lacked evidence that this vaccination was administered. During an interview on 8/20/24 at 10:54 a.m., the Education Coordinator reviewed the clinical record and confirmed Resident #7 signed pneumococcal immunization consent on 11/6/23, and did not receive the vaccination.

Based on facility policy, record reviews and interviews, the facility failed to follow physician orders for 1 of 3 sampled residents review for medications (Resident #3). Findings: Facilities Medication Administration Procedure dated 1/2020 states, Assign AM and PM for medication administration times unless specified otherwise by physician services . physician services will specify if they want medications administered every twelve hours or other hourly times . Schedule hypothyroid medication to be administered on an empty stomach, but must be scheduled for consistency, however not before 7:00 AM unless resident prefers. On 7/8/24 at 11:45 a.m., during an interview, Resident #3's family representative stated his/her Parkinson's medication is not being given timely with regards to doses being to close together, given with meals or as instructed by the neurologists. Review of the scheduled mealtimes for resident #3 are as follows: Breakfast served at 8:30 a.m., Lunch at 12:30 p.m. and Dinner at 5:30 p.m. A review of Resident #3's clinical record containing Provider orders and 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 observations and interviews, the facility failed to ensure that a resident requiring feeding assistance was done in a dignified manner for 1 of 1 resident observed requiring feeding assistance (Resident #2). Finding: On 7/8/24 during observation of breakfast tray pass. Resident #2 was sitting in a Broda chair at one of the entrances to the dining area. Next to resident #2 was a dining room chair. A Certified Nurse's Assistant (CNA) placed Resident #2's breakfast tray on the tray table in front of him/her at 8:24 a.m. and walked away. The same CNA continued to deliver trays to the other residents in the dining room and two additional residents outside the dining area. At 8:50 a.m., the CNA approached Resident #2 standing in front of him/her and feed the resident two bites of food, put the spoon down and walked away. At 9:02 a.m., the same CNA returned and collected the uneaten tray without speaking to the resident or asking if he/she wanted more food. On 7/8/24 at 9:32 a.m., the above was discussed with the Director of Nursing and Assistant Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to provide interventions outlined in the resident's care plan in the area of Self-care deficit and Nutrition for 1 of 3 sampled residents. (Resident #2) Finding: Resident #2 was admitted to the facility on [DATE] with diagnosis of Dementia and Dysphagia. The History and Physical dated 2/21/24 states he/she is a nonverbal resident. Review of Resident #2's care plan, initiated 2/20/24, last revised 5/28/24 for self -care deficit in the area of eating has a nursing intervention of, I am dependent. One assist. Please alternate 1 to 2 bites of food followed by a sip of liquid. If client refuses a meal, please reapproach . The care plan initiated on 2/29/24, last updated on 5/28/24 for nutrition has a nursing intervention of, Assist to eat, Set up foods as needed. Feed all meals. Maintain eye contact during feeding. On 7/8/24 observation of Resident #2 in a Broda chair at the entrance of the dining room with an empty chair next to him/her. At…

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 care plans were updated to reflect a resident's current needs for 8 of 8 residents reviewed that had a diagnosis of Post Traumatic Stress Disorder. (Resident #2 [R2], Resident #15 (R15), Resident #23 (R23), Resident #25 [R25], Resident #37 (R37), Resident #54 [R54], Resident #80 (R80) and Resident #83 (R83)]. Findings: 1. On 9/26/23, R2's clinical record was reviewed. R2 had a diagnosis of PTSD. R2's current care plan was reviewed. There was no evidence of interventions that identified triggers which may re-traumatize the resident with a history of PTSD, no interventions indicating to staff what behaviors may cause a trigger, under the problem care area; Mood-PTSD, depression, nightmares, Cerebral Vascular Accident (CVA) with left hemiparesis. On 9/27/23 at 8:15 a.m., in an interview with the Director of Nursing, she confirmed that the care plan did not have interventions addressing the resident's PTSD care needs. 2. On 9/26/23, R25'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 9/26/23, R2's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The most recent MDS was dated 7/17/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. The surveyor was unable to find information in the clinical record that indicated what R2's PTSD was caused by or what events might cause re-traumatization. On 9/27/23 at 10:55 a.m., in an interview with the surveyor, the Social Services Director (SSD) confirmed there were no trauma assessments completed that identified the cause of the resident's PTSD and what triggers would cause re-traumatization. 3. On 9/26/23, R25's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The most recent MDS was dated 8/16/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. The surveyor was unable to find information in the clinical record that indicated what R25's PTSD was caused by or what events might cause…

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 revise/update care plans to reflect/address residents current needs and behaviors for 2 of 22 sampled residents (Resident [R] 202 and R252). Findings: 1. On 9/26/23, during a record review for R202, the clinical record reflected that R202 was admitted to the facility on [DATE] from a lower level of care facility. An elopement assessment was completed on 9/8/23 with a score of 6 (per the unit manager a score above 5 indicates the resident is at a high risk for elopement). Upon review of R202's care plan with a completion date of 9/14/23, the care plan lacked evidence that a wandering/elopement problem and interventions were implemented to address this risk. On 9/14/23, a physician request form was completed with a note indicating R202 was sitting in his/her room and dining room yelling intermittently, refused to believe he/she lives at facility, he/she was exit seeking, appears to become very distressed, up during the night shift, and appears to be…

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 treatment was followed for 1 of 2 sampled residents reviewed for pressure ulcers (Resident [R} 83). Finding: On 9/26/23, R83's clinical record was reviewed which indicated the resident had an unstageable pressure ulcer on the back of the left heel. On 8/18/23, a treatment was added to apply Prevelan boots in bed as resident allows every shift. On 9/26/23 at 1:20 p.m., a surveyor observed Certified Nursing Assistant (CNA) #3 assist R83 into bed. After R83 was in bed and covered up, the surveyor asked CNA #3 about the Prevelan boots. CNA #3 showed the surveyor that they were in the closet and that they were worn by the resident at night. CNA #3 did not attempt to place the Prevelan boots on R83 during this observation. On 9/27/23 at 7:22 a.m., a surveyor discussed the observation on 9/26/23 with the B Unit Manager. On 9/27/23, after further review of the clinical record, the surveyor noticed that the Charge Nurses are signing off on this treatment in the electronic clinical record as the Charge…

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 the physician completed a required visit before renewing an as needed (PRN) anti-psychotic medication for 1 of 3 residents reviewed on PRN anti-psychotics (Resident (R) 60). Finding: On 9/26/23, R60's clinical record was reviewed. The physician orders contained a telephone order, dated 9/6/23, to Renew Risperdal (anti-psychotic) 0.5 milligrams (mg) twice a day (BID) PRN x 14 days but there was no face to face physician visit in the clinical record for 9/6/23. On 9/27/23 at 8:14 a.m., during an interview with the Director of Nursing, a surveyor confirmed that there was no visit completed by the physician on 9/6/23, prior to renewing the PRN anti-psychotic.

Based on observations, interviews, and record reviews, the facility failed to maintain an environment to help prevent the development of urinary tract infections on 3 of 4 survey days (9/25/23, 9/26/23, and 9/27/23), and also failed to use appropriate personal protection equipment, use of gowns, to prevent the risk of infection on 1 of 4 survey days (9/26/23). Findings: 1. On 9/25/23 at 12:35 p.m., a surveyor observed the urinary catheter bag that was attached to the bed frame, was resting on the floor matt. On 9/26/23 at 12:37 p.m., a surveyor observed the urinary catheter bag that was attached to the bed frame, was resting on the floor matt. On 9/27/23 at 7:07 a.m., a surveyor observed the urinary catheter bag that was attached to the bed frame, was resting on the floor matt. On 9/27/23 at 7:17 a.m., a surveyor and the B Unit Manager observed the urinary catheter bag resting on the floor mat. At 8:26 a.m., during an interview with a surveyor, the Director of Nursing stated that they do not have a policy for urinary catheter bags but that they follow the Centers for Disease Control…

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 implement and maintain an effective training program which includes, at a minimum, training on abuse, and dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant's (CNA) employed, completed the required annual training (CNA1). Findings: On 9/28/23, during a review of employee personnel records, the following were noted: 1. CNA1's employee personnel record lacks evidence of mandatory abuse training within the last twelve months. 2. CNA1's employee personnel record lacks evidence of mandatory dementia training within the last twelve months. On 9/28/23 at 10:51 a.m., during an interview with a surveyor, the Administrator stated that he was unable to find any dementia trainings or abuse trainings for CNA1 within the past twelve months. The surveyor confirmed this finding during this interview.