Harbor Hill Center

Based on observation, record review, and interviews, the facility failed to provide the necessary services for a resident to maintain personal hygiene for 1 of 2 residents reviewed for activities of daily living and who were dependent on staff for their care [Resident #46 (R46)].Findings:On 1/12/26 at 1:45 p.m., a surveyor observed R46's hair appeared greasy and the hair around his/her temple area was standing on end. During an interview with the surveyor, R46 stated they have not had a shower/bath or had their hair washed since admission. On 1/13/26 at 1:02 p.m., a surveyor observed R46 sitting on his/her bedside. A physical therapy staff member came to bring R46 to the gym. R46 stated, I'm not dressed yet. The physical therapist stated she would return after R46 finished eating lunch. At 1:05 p.m., the physical therapist returned and stated the therapy session was moved to 2 p.m., so R46 will have time to get dressed after eating.On 1/13/26 at 1:06 p.m., during an interview with a surveyor, R46 stated his/her hair was brushed not washed. R46 stated he/she was able to wash up 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.

Based on clinical record review and interviews, the facility failed to initiate a resident's bowel regime protocol timely for 1 of 5 residents reviewed for unnecessary medications (Resident #2 [R2]). Findings:Review of R2's clinical record, effective date: 12/31/25 9:42 a.m., Type: Care Plan Meeting. Summary of meeting. Occupational Therapy (OT) - Initiated beginning OT with an evaluation on 12/30/25). R2 was in significant pain resulting to inability to do ADLs(activities of daily living)/functional mobility assessment, but agreeable to evaluation write up to be complete. 9/10 pain due to constipation during evaluation.Review of Order Summary Report, active orders as of 1/14/26 pertaining to bowel protocol are as follows:Polyethylene Glycol 3350, MiraLax Powder, Give 17 gram by mouth as needed for Constipation in 4 to 8 ounces of fluid-if resident has not had a bowel movement in past 72 hours., ACTIVE, 9/24/2025.Magnesium Hydroxide, Milk of Magnesia (MOM) Suspension 400 MG(milligram)/5ML(milliliter), Give 30 ml by mouth as needed for Constipation give at bedtime if no BM (bowel…

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, pharmacy consultant monthly review, and interview, the facility failed to adequately monitor a resident who was on an antipsychotic medication for tardive dyskinesia and/or other movement disorders for 1 of 5 residents reviewed for unnecessary medications (Resident #3 [R3]) and failed to ensure that a resident's drug regimen was free from unnecessary medications by administering an excessive dose of an antibiotic in less than 12 hours for 1 of 5 residents reviewed for unnecessary medications (R2).Findings:1.On 1/14/26, a review of R3's clinical record was completed. On 1/2/26, a pharmacist consultant recommended that an Abnormal Involuntary Movement Scale (AIMS) be done within 30 days of admission or start of the antipsychotic, and once every 6 months. (AIMS is a clinical tool used to detect and measure involuntary movements such as tardive dyskinesia-it helps assess severity and monitor treatment effectiveness). Documentation in the clinical record indicated that when R3 was admitted to…

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 store, prepare, and serve food in accordance with professional standards for food service safety by not ensuring emergency food supplies were labeled with expiration dates and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 3 days of survey (1/13/26). This has the potential to effect all residents.Findings: On 1/13/26 at 10:44 a.m., during an interview with a surveyor and the Dietary Account Manager, the emergency food supply was observed and confirmed to be unlabeled with dates of expiration. The Dietary Account Manager stated the food parcels are labeled with the month and day they are received but not the year, and the expiration dates are on the boxes the food parcels come in, but the boxes are discarded to save space. On 1/13/26 at 11:04 a.m., a surveyor observed and confirmed with the Dietary Account Manager that the ice machine outside the kitchen did not have a 1 air gap. The floor was observed to be wet around the drain, 3 drain…

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 3 of 4 sampled residents reviewed during a complaint investigation (Resident [R] 1, R3 and R4).1.Review of R1's care plan updated 2/5/25 states It is important for me to be offered a shower Mon Wed Fri but can choose an alternate form of bathing at any time. Review of R1's tub/shower schedule: Monday 7-3 and Wednesday 7-3 and Friday 7-3. Review of R1's GG Bathing task revealed R1 has only received bed baths from 7/1/25 through 7/22/25.During a follow up interview on 7/22/25 at 10:13 a.m., Certified Nursing Assistant (CNA)1 states she was not aware R1 preferred showers because it's not on her task sheet and always gives him/her bed baths because [he's/she's] unable to stand on [his/her] own. CNA1 further states she does not know how to find bathing preferences in the Electronic Medical Record.During an interview on 7/22/25 at 9:53 a.m. Director of Nursing reviewed R1's care plan with this writer and stated R1 should be offered a shower…

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 call bell was accessible for 1 of 3 residents reviewed during a complaint investigation (Resident [R]1). Review of policy Call Lights dated 7/15/25 states Patients will have a call light or alternative communication device at each personas bedside, toilet and bathing room to allow patients to call for assistance when attended. Staff will respond to call lights and communication devices promptly. Each patient will be evaluated for unique needs and preferences to determine any special accommodation's that may be needed in order for the patient to use the call system. Special accommodations will be identified on the patients person-centered care plan of care and provided accordingly (examples include touch pads, larger buttons, bright colors etc.). Staff will ensure the call light is within reach of the patient and secured as needed. The call system will be accessible to patients while in their beds or other sleeping accommodations withing the patient's room.During observations of Resident [R1] on 7/22/25 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.

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 falls (Resident [R]1).Review of policy Person-Centered Care plan dated 10/24/22 states .The care plan must be customized to each individual patient's preferences and needs.Care plans will be: communicated to appropriate staff, patient, patient representative, family; Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment's, and as needed to reflect the response to care and changing needs and goals.Resident [R]1was admitted with diagnoses to include anoxic brain damage (brain damage caused by lack of oxygen) and is considered a fall risk.During an observation of Resident [R1] on 7/22/25 at 8:35 a.m. R1 was observed lying in bed. A fall mat was observed on the floor on the left side of the bed.Review of R1's care plan updated 2/5/25 states [R1] is at risk for falls: cognitive loss, lack of safety awareness; Goal: [R1] will have no falls with major…

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 the resident environment remained as free of accident hazards, as is possible, related to side rail use for 1 of 3 complaint investigations (Resident [R]5).The Department of Licensing received a complaint indicating bed 107-B side rail was broken during the previous residents' stay from 7/2/25 through 7/15/25.Review of Tels work order #8718 dated 7/2/25 states Left grab rail needs to be fixed to lick Comments Checked both beds and they are locking.Observation of room [ROOM NUMBER]-B, currently occupied by R5 revealed side rail on left of bed is not attached appropriately to bed causing it to extend outward when grabbed. The resident currently occupying the bed states he/she gets out of the bed on the left side. At this time a surveyor asked R5 how he/she would use the bed rail to assist him/her. R5 stated that staff help him/her get out of bed, but he/she uses the side rail to get support. At this time R5 used his/her left hand to grab the side…

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 and record review the facility failed to follow professional standards of practice to provide a sanitary environment to help prevent the development and transmission of disease and infection related to bed pan storage, and failed to maintain equipment in a sanitary manner related to a ripped floor mat (Resident [R]1).1. During an observation of Resident [R1] on 7/22/25 at 8:35 a.m., a fall mat was observed on the floor of R1's left side with two tears in it, making it an uncleanable surface.2. Observations of R1's bathroom r on 7/22/25 at 8:35 a.m., 10:17 a.m., revealed an unwrapped bed pan leaning on side of wall next to toilet available for use.During an observation of R1 10:17 a.m., with Registered Nurse (RN)1 observed the unbagged bed pan and stated it should be wrapped. At this time RN1 put the bed pan in a bag and stored it.On 7/22/25 at approximately 9:53 a.m., the above was discussed with The Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary condition for 2 of 2 environmental tours, both on 12/3/24, on 2 of 2 units[Harbor Hill and Fort Point]. Findings: On 12/3/24 at 8:00 a.m. through 8:45 a.m., an environmental tour was conducted with the Senior Maintenance Supervisor and Maintenance Supervisor. Findings were confirmed at the time of the observations. 1. Fort Point room [ROOM NUMBER], bathroom walls are gauged and scuffed with black marks. The cover of the safety fall mats next to bed 1 have cracks and torn areas creating an uncleanable surface. Next to bed 2, the wall is gauged and has several black scuff marks. room [ROOM NUMBER], the room divider curtains are soiled and stained. The wall behind bed 2 has areas of missing paint. room [ROOM NUMBER], bathroom walls have scuffed marks and areas with unpainted patches of putty. room [ROOM NUMBER], bathroom walls have scuffed marks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 2 of 4 sampled residents (Resident #26 [R26] and [R29]). Findings: 1. On 12/4/24, clinical record review indicated R26 was admitted on [DATE]. Admitting diagnoses included Type 2 Diabetes. Orders for this diagnosis include administering 15 units of Insulin Glargine subcutaneously, at bedtime. The surveyor was unable to locate a care plan for the management of diabetes and/or insulin. On 12/4/24 at 12:02 p.m., during an interview with the Marketing Clinical Advisor, a surveyor confirmed R26's care plan does not address the diagnosis of diabetes or the use of insulin. 2. Resident #29 was admitted on [DATE] with a current physician order dated 10/16/24 noting Wander Guard/Wander Elopement Device due to poor safety awareness. Review of Resident #29's current care plan indicated there were no Focus, Goals and Interventions addressing wandering/elopement. On 12/4/24 at 12:25 p.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 observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 4 residents reviewed for respiratory care (Resident #4 [R4] and [R26]). Findings: 1. On 12/2/24 at 11:12 a.m., a surveyor observed R4's oxygen concentrator to have dust / debris accumulations over the filter vents. R4's nebulizer was observed on the bedside table, exposed to the environment. On 12/4/24, a surveyor observed R4's oxygen concentrator to have dust / debris accumulations over the filter vents. R4's nebulizer mask was hanging from a hook on the wall and exposed to the environment. 2. Record review for R26 indicated the resident was admitted with acute and chronic respiratory failure and dependence on supplemental oxygen, for which R26 receives 1-2 liters of oxygen via nasal cannula continuously. On 12/2/24 at 11:16 a.m., a surveyor observed R26's oxygen concentrator to be heavily soiled with dust / debris. On 12/4/24, a surveyor observed…

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 interview and record review, the facility failed to ensure accommodations were made for a resident, to include the facility's bathing schedule and resident preferences for 1 of 1 resident reviewed for bathing (Resident #295). Findings: On 1/11/24, the state agency received a facility reported incident stating that Resident #295 did not receive a shower for over a week after admission. Clinical record review indicated Resident #295 was admitted on [DATE] and discharged on 1/10/24. The admission minimum data set (MDS) dated [DATE], under section F preferences for customary routine and activities states it is very important for him/her to choose their bathing options. On 12/4/24, review of Certified Nurse's Assistant(CNA) bathing documentation noted Resident #295 received showers on 12/25/24 and 12/31/24 on the day shift and there had been no refusals documented during the resident's stay. The documentation lacked evidence that Resident #295 received showers the week of December 17th-23rd and January…

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, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 3 days of survey (12/2/24). Findings: On 12/2/24 at 11:15 a.m., during a tour of the Harbor House, a surveyor observed a hallway storage area containing personal protective equipment (PPE) supply bins and oxygen concentrators that had a 1 pound 2.94 ounce container of Micro-Kill Bleach Germicidal Bleach Wipes stored in it at wheelchair height. The Safety Data Sheet for Micro-Kill Bleach Germicidal Bleach Wipes noted the following: 4. First Aid Measures General advice: Never give anything by mouth to an unconscious person. If you feel unwell, seek medical advice (show the label where possible). Inhalation: Assure fresh air breathing period allow victim to rest. Eye contact: If In Eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Skin contact: If irritation occurs, remove affected…

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, review of the plan of correction, and interview, the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Recertification Survey, dated 12/4/24, were effective. The deficiency F584 (Safe/ clean/ comfortable/ homelike Environment) was again identified during the 1/28/25 Re-visit Survey. Findings: During the Recertification Survey, dated 12/4/24, a deficiency was cited at F584 (Safe/ clean/ comfortable/ homelike Environment for the failure to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 2 of 2 units. The facility's Plan of Correction, with a completion date of 1/14/25, for F584 indicated that they would correct the deficiencies in all cited rooms and all rooms through auditing, repairing of flooring, walls, bathrooms, divider curtains unpainted surfaces and caulking around toilets in the cited rooms. Additionally, the facility indicated that they would perform weekly audits x 4 of the environment to ensure that all areas…

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 review of the facility's Quality Performance Improvement (QAPI) Committee meeting attendance sheets and interview, the facility failed to provide evidence that a quarterly meeting was held for 1 of 4 quarters. Finding: On 12/4/24 at 10:00 a.m., a review of the facility's QAPI attendance sheets was completed. The facility held quarterly meetings on 9/27/24, 6/18/24, and on 3/5/24. The facility was unable to provide evidence that a quarterly meeting was held in 12/23 or 1/23. On 12/4/24 at 10:10 a.m., in an interview with the surveyor, the Marketing Clinical Advisor confirmed that the facility did not hold a quarterly QAPI meeting in 12/23 or 1/23, for the fourth quarter meeting, and that the last documented meeting she could find was dated 10/24/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and review of facility Safety Data Sheets, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 2 of 2 units(Harbor House and Fort Point), a common area and the laundry room for 1 of 1 facility tours (10/19/23). Findings: On 10/19/23 from 8:20 a.m. to 9:20 a.m., an environmental tour was conducted with the Administrator, the Maintenance Supervisor and the Health Care Services District Manager in which the following findings were observed: Common Area: > There were three(3) ceiling tiles near the reception desk that had brown stains on them. Harbor House Unit: > There were two(2) ceiling tiles above the Menu sign that had brown stains on them. > The shower room had an inflatable hair wash tray that was observed dirty and soiled. > The low ceiling near resident room [ROOM NUMBER] had dark black markings on it. > Resident room [ROOM NUMBER] - The floor had dirt,…

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.

4. On 10/18/23, the facility Falls Management policy and procedure was reviewed. Under Section 5-#5.3-any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy. R16's clinical record was reviewed for neurological checks post the 4/21/23 unwitnessed fall. There was no evidence that neurological checks were completed per facility post fall management policy and procedure. On 10/18/23 at 1:30 p.m., in an interview, the RCL confirmed that the facility was unable to locate any neurological checks post the resident's unwitnessed fall on 4/21/23.

Based on performance evaluations and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA1, CNA2, and CNA3). Findings: 1. CNA1 was hired on 1/18/07. The last performance evaluation was completed on 2/12/21. The facility was unable to provide evidence of a completed annual performance evaluation for 2022 and 2023. 2. CNA2 was hired on 1/20/21. The facility was unable to provide evidence that any annual performance evaluations were completed. 3. CNA3 was hired on 8/19/20. The facility was unable to provide evidence that any annual performance evaluations were completed. On 10/19/23 at 12:13 p.m., in an interview with a surveyor, the Director of Nursing and Regional Clinical Lead confirmed the above findings.

Based on observations, the facility failed to ensure that proper hand sanitizing and proper food handling during lunch service was followed for 1 of 2 lunch observations (10/16/23) on the Fort Point Unit. The facility also failed to ensure the kitchen was maintained in a clean, sanitary and safe manner for a food slicer, ceiling vents, the dish machine, the food disposal unit and wiring, the walk-in freezer, and a kitchenette refrigerator; and failed to ensure that chemicals were not stored openly in a multipurpose storage room with food for 1 of 1 kitchen tour (10/16/23). Findings: 1. On 10/16/23 at approximately 12:20 p.m., the meal server pushed the steam cart onto the Fort Pine Unit and set it up for lunch service. The meal server did not sanitize his hands before starting to serve up plates. At 12:35 p.m., the surveyor observed the meal server contaminate his hands by touching a transport handle on the steam cart and wiping his hands on his pant legs while dishing food onto meal plates from the steam cart. The meal server did not wash his hands after contaminating them. 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 maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 trash dumpster and the surrounding grounds for 2 of 4 days of survey. (10/16/23, and 10/19/23) Findings: 1. On 10/16/23 at 10:50 a.m., a surveyor and the Food Service Director (FSD) observed paper trash, plastic, used disposable gloves and a large cardboard box on the ground around the dumpsters. At this time, in an interview, the FSD confirmed the finding. 2. On 10/19/23 at 8:15 a.m., a surveyor observed the right side door of trash dumpster open, exposing trash. On 10/19/23 at 8:20 a.m., in an interview, the surveyor discussed the finding with the Administrator.

Based on interview, the facility failed to ensure that the facility Infection Preventionist (IP) had completed specialized training prior to starting the IP position. Finding: On 10/18/23 at 1:00 p.m., in an interview with the surveyor, the Registered Nurse-Infection Preventionist (RN-IP) stated she started this position in September and has enrolled in an on-line training for Infection Control and Prevention. She stated she has not been consistently trained or been overseen by another IP. On 10/19/23 at 1:00 p.m., in an interview with the Regional Clinical Lead, the surveyor discussed that there was no IP overseeing and training the current IP and that the IP has not completed the specialized training-Certificate in Infection Prevention and Control.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to meet the requirements for a facility-initiated discharge for 1 of 1 resident reviewed for facility-initiated discharge (Resident 35 [R35]). Finding: On 10/16/23 at 2:00 p.m., during a resident interview, R35 stated he/she was told he/she had to leave the facility tomorrow because he/she was no longer skilled and his/her needs are long-term care (LTC) needs, R35 asked to stay and was told the facility didn't have any LTC beds available and there were two people waiting to get in. Medical record indicated R35 was admitted on [DATE] for skilled services after a partial amputation of his/her right foot, the initial plan was to gain strength and go to a lower level of care (assisted living). During his/her skilled rehabilitation R35 was not able to complete the rehab program due to a decline in his/her health status and was subsequently discharged from skilled services on 10/15/23. Once discharged from skilled services the facility set a discharge date 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 respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #34 [R34]). Findings: The medical record indicated R34 was originally admitted to the facility on [DATE] and has diagnoses to include unspecified depression, unspecified mood disorder and anxiety. Review of R34's Omnicare Consultation report dated 8/13/23 states: This resident has been receiving an antipsychotic, risperidone without documentation of diagnosis and adequate indication for use, in the medical record. Recommendation from the consultant Pharmacist: If the antipsychotic order is to continue, please update the medical record to include the specific diagnosis/indication requiring treatment that is based upon an assessment of the resident's condition and therapeutic goals, a list of symptoms or target behaviors including their impact on the resident and documentation that the other causes 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.