Windward Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility procedure, the facility failed to follow their own Enhanced Barrier Precautions (EBP) procedure for 1 of 1 resident reviewed for urinary catheters (Resident #1 [R1]) and failed to provide a sanitary environment to help prevent the development and transmission of infections related to personal protective equipment (PPE) for 1 of 4 units observed (Windward). Findings: 1 Facility Procedure Enhanced Barrier Precautions, revised 5/1/25 states, .Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door. Personal protective equipment (PPE) should be readily accessible and located outside of the patient's room. perform hand hygiene upon exiting the room. The procedure also states, Follow the Centers for Disease Control and Prevention [CDC] guidance per table below . The table indicates gown and gloves are required PPE during urinary catheter care and that .Face protection may also be needed if performing activity with risk 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 interviews, the facility failed to designate a qualified staff member to function as the Infection Preventionist who works at least part time and who is responsible for the facility's Infection Control Program since September 2025. This has the potential to affect all residents in the facility. Findings: On 12/4/25 at 7:49 a.m., during an interview with 2 surveyors, the Director of Nursing (DON) stated that she had completed the Infection Preventionist (IP) Training and was the IP until September, when she took the role of DON and had worked full time in the role of DON since then. Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated she was hired as the Infection Preventionist and currently is working 20 hours a week in that role, in addition to working the floor as a Charge Nurse. The Market Lead Clinical Specialist stated that part time is considered 20 hours a week. When a surveyor asked if LPN/IP had completed the training for the role of IP, LPN/IP stated that she was on module 12 for training and had not completed the training yet. The surveyors confirmed…

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 interview, the facility failed to ensure physician orders for an as needed (PRN) anti-psychotic contained a duration/stop date and failed to ensure the physician evaluated a resident and wrote a new physician order to renew the PRN anti-psychotic medication every 14 days, for 1 of 5 residents reviewed for unnecessary medications (Resident #10 [R10]). Finding: The facility's policy, Medication Management, revised 1/25, indicated that PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. On 12/3/25, R10's clinical record was reviewed and included a physician order, dated 10/9/25, for Haloperidol, an anti-psychotic medication, to administer 2 tablets of 0.5 milligrams (mg) every 8 hours as needed and did not have a stop date. On 12/2/25 at 12:07 p.m., during an interview with the Market Lead Clinical Specialist, a surveyor confirmed this finding.

Based on facility policy, record review, and interview, the facility failed to notify the State Agency after potential abuse concerns were identified, failed to investigate allegations of potential abuse, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 1 incident reviewed for abuse.Findings:Facility policy titled Abuse Prohibition states Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or Designee will preform the following.Report allegations to the appropriate state and local authority(s) involving neglect, exploitation, or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two hours after the allegation is made if the event results in serious bodily injury.Initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent.The investigation will be thoroughly…

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

Based on record reviews and interview, the facility failed to ensure that the admission Minimum Data Set (MDS) 3.0 was coded accurately to indicate that a resident had a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 2 residents reviewed for PASRR (Resident #2 [R2]).Finding:On 12/2/25, R2's clinical record was reviewed and included a PASRR Level II uploaded the day of admission in the documents section of the electronic record. R2's admission MDS 3.0, dated 5/27/25 under Section A1500, was coded as NO for the question: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? On 12/2/25 at 9:30 a.m., during an interview with the MDS Registered Nurse, a surveyor confirmed this finding.

Based on record reviews and interview, the facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASRR) Level II determination outcome into a resident's assessment, care planning, and transitions of care for 1 of 2 sampled resident (Resident #2 [R2]). Findings:On 12/2/25, R2's clinical record was reviewed and included a Notice of PASRR Level II outcome, dated 4/22/24, that indicated R2 qualified for Level II services due to serious mental health diagnoses that included bipolar disorder and anxiety. The PASRR Outcome Notice of Nursing Facility Approval indicated that R2 was to receive specialized services while at the nursing home that included ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. In addition, R2 was to receive individual therapy by a licensed behavioral health professional for ongoing counseling services. On 12/2/25 at 9:07 a.m., the Licensed Social…

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 and record review the facility failed to update a care plan with goals and interventions after a resident obtained a leg fracture for 1 of 11 complaints reviewed during an annual survey (Resident #35).Findings:Resident #35 was admitted in 9/23 and had diagnoses to include dementia with psychotic disturbance and anxiety.Review of Resident #35's clinical record revealed he/she sustained a left leg fracture around 10/20/25.Review of Resident 35's care plan last reviewed 8/7/25 lacked evidence that goals and interventions were put into place after left leg fracture sustained [approximately]10/20/25.During an interview on 12/3/25 at 10:25 a.m., the above was discussed with Consulting Administrator-Maine

Based on interviews and record review the facility failed to ensure a care plan was accurately revised for 1 of 2 residents reviewed for nutrition. (Resident #37)Findings:Resident #37 was admitted in June of 2025 with a Gastrostomy Tube (G-Tube). A review of his/her clinical record shows the removal of his/her G-Tube on 9/18/2025. Further review of the clinical record shows a care plan meeting taking place on 9/23/25. Review of Resident #37's care plan does not reflect the removal of his/her G-Tube.On 12/4/25 at 1:30 p.m., During an interview with the Market Lead Clinical Specialist, the above information was confirmed.

Based on record review, observations, and interviews, the facility failed to ensure a physician order was followed for 1 of 3 residents reviewed for nutrition. (Resident #37)Findings:Review of Resident #37 clinical record shows physician orders to have All meals DIRECTLY SUPERVISED. Small bites and sips. Pt (patient) to be bolt upright in chair. Please stay up 30-45 mins (minutes) after meals. Discontinue intake if pt begins to cough significantly, ordered on 6/12/25. On 12/1/25 at 9:05 a.m., observation of Resident #37 being served breakfast by CNA #2 (Certified Nursing Assistant). The surveyor then witnessed CNA #2 leaving the dining room for approximately 30 seconds. At 9:10 a.m. CNA #2 was then observed leaving the dining room with no additional staff present.On 12/1/25 at 12:43 p.m., observation of Resident #37 being served lunch by CNA #2, who then left the resident in an unattended dining room from 12:43 p.m. to 12:45 p.m During this time the surveyor observed Resident #37 take 2 bites of cake. At 12:45 p.m. to 12:50 p.m., the surveyor observed RN #1 (Registered Nurse), RN…

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 post nurse staffing information on a daily basis for 1 of 4 days of survey (12/1/25).Finding:On 12/1/25 at 7:30 a.m., upon entry to the facility, 2 surveyors observed posted staffing sheets that were dated Wednesday, 11/26/25; Thursday, 11/27/25; and Friday 11/28/25.On 12/4/25 at 2:30 p.m. the above finding was discussed with the Administrator, Market Clinical President, and Market Clinical Lead during the exit conference.

Based on observations, record review, and interviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 of 1 resident reviewed for food choices (Resident #78 [R78]).Finding:On 12/1/25 at 8:48 a.m. a surveyor observed Certified Nursing Assistant #2 (CNA2) deliver R78's breakfast tray, consisting of a main entree of pancakes. R78 asked if the pancakes were made without milk. CNA2 stated she was not sure and would have to find out, then left R78's room. At 8:54 a.m., CNA2 returned and stated an alternative entree would be sent. At this time, during an interview, R78 stated that he/she has a dairy allergy and has had to ask at every meal since he/she was admitted if the meal was prepared according to his/her allergy needs. Surveyor review of R78's breakfast tray meal ticket, indicated Allergies: Lactose, bell pepper, Pear, Green/Red Peppers and allergic to cayene [cayenne] Further review of the ticket states, .Pancakes-2 .2% Milk- 8 Oz.A review of R78's clinical record revealed a physician order for Regular/Liberalized diet…

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 record review the facility failed to follow provider orders for wound care and failed to follow the facilities Skin Integrity and Wound Management policy for 1 of 2 Residents reviewed for pressure ulcer management. (Resident #310) Findings: The facilities Skin Integrity and Wound Management policy revised 5/1/25 states under Practice Standards, the Licensed nurse will: Evaluate any reported or suspected skin changes or wounds. Document newly identified skin/wound findings and the 24-hour report. Perform and document skin inspections on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition. Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, within unanticipated decline in wounds . Perform daily monitoring of wounds or dressings for presence of complications or declines. Document daily monitoring of ulcer/wound site with or without dressing. Monitor: signs of decline in would status. On 6/10/25, Adult…

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, interview and Payroll Based Journal Report (PPJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarter reviewed (10/1/24 through 12/31/24/ [39 days]). Findings: Review of Center for Medicare & Medicaid (CMS)PPJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). During a review of first quarter weekend staffing with Administrator and Scheduler on 4/17/25 at 12:27 p.m., the Administrator confirmed the facility was not adequately staffed for 32 of 39 days reviewed.

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, orderly, and comfortable environment on 4 of 4 wings (North Wind, Spring Gardens, Windward Center and Penobscot House), the laundry room and a hallway for 2 of 2 facility tours. Findings: 1. On 4/14/25 at 9:05 a.m., a surveyor and the Administrator observed a large open top, wheeled garbage bin outside the facility with trash in it. At this time, the Administrator confirmed the trash storage bin didn't have a cover and the trash was not maintained in a condition to prevent the harborage and feeding of pests. 2. On 4/17/25 from 8:10 a.m. to 8:45 a.m., an Environmental tour was conducted with the Senior Maintenance Director and the Administrator in which the following findings were observed and discussed: Support Service Hallway > The hallway had 2 ceiling tiles that had brown stains on them. Laundry Room > An open window by a washing machine had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on care plan review, observations, interviews, and facility policy, the facility failed to provide a resident with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities. Findings: Review of facility policy Recreation Participation Record dated 8/7/23 states Recreation Participation Records: are maintained monthly; Document each person's involvement and response in specific opportunities/experiences in accordance with the person's preferences, interest, routines, and plan of care. Independent, individual, and group recreation participation will be documented on the participation record. the Current participation record will be maintained daily, organized, and easily accessible . 1. Resident #13(R13) was admitted in the fall of 2022 and has diagnoses to include schizoaffective disorder, major depression and is considered bedbound and reliant on staff for activities of daily living. Review of annual Minimum Data…

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 assess and monitor a resident after a fall, and failed to follow their own Fall management and Neurological evaluation policies and procedure by obtaining neurological assessments a resident who has an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident #18). In addition, the facility failed to ensure a resident received wound care/orders for 1 of 1 residents reviewed for pressure ulcers. (Resident #37). Findings: 1. On 3/16/25 Resident #18 had an unwitnessed fall and was found lying on the floor. The post fall neurological evaluation flow sheet lacked continued neurological assessments with only 3 of the 9 shifts completed for the 72 hour monitoring. On 3/22/25 Resident #18 had an unwitnessed fall and was found on the bathroom floor. The nurses note dated 3/22/25 at 5 a.m., stated, per patient he/she hit the post auricular area [behind the ear] on the right, no c/o (complaint) pain at this time, small raised bump on the right post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards by ensuring room, closet and bathroom doors had laminate that was not gouged and splintered creating sharp edges on 2 of 4 units(North Wind and Windward Center) for 2 of 2 environmental tours (4/14/25 and 4/16/25). In addition, the facility failed to store oxygen tanks securely for 1 of 4 days. Findings: 1. On 4/14/25 at 8:10 a.m., 3 surveyors observed the following chemicals in the unlocked office on the Administrative wing which residents had access to. The Administrative unit is separated from the Windward Center unit by unlocked double doors that residents can access and get through. On 4/14/25, Resident #51 was observed on the administrative unit by a surveyor. - Poopsy [NAME] Pre-Toilet Spray/ 2 ounces bottle - Febreze Air Freshener/ 8.8-ounce bottle - Purell Hand Sanitizer/ 20-ounce bottle The Safety Data Sheet for Poopsy [NAME] Pre-Toilet…

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

Based on observations, interviews, and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood system, a fan, ceiling lights, ceiling tiles, ceiling vents, floors, a chemical hose, a food slicer and an exit door. Additionally, the facility failed to ensure that foods in the walk-in freezer were sealed, dated and labeled. Findings: On 4/14/25 from 8:15 a.m. to 9:00 a.m., during an initial kitchen tour, the following findings were observed and discussed with the Head [NAME] and Kitchen aide: > The hood over the dish washing machine was dusty and had rust build-up in it. > The dish room had a wall mounted fan, a ceiling vent and an entire ceiling grid system that was dusty/dirty. > There were 2 ceiling lights in the dish room that had dirt/debris in the lenses. > The floor in front of the dish machine had an approximately 2-foot by 2-foot section of laminate missing which exposed untreated cement. > The 3-bay pot sink had a long chemical hose hanging down inside the center bay. > The kitchen…

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 2 residents reviewed for palliative care/hospice (Resident #308), falls for 1 of 1 (Resident #258), and weights/catheter care and Activities of Daily Living (ADL) documentation for 1 of 9 resident's reviewed for a complaint (Resident #37). Findings: 1. Resident #308 was recently admitted with diagnoses to include severe protein calorie malnutrition and adult failure to thrive. Review of Resident #308's hospital discharge summary revealed, .Specialist appointment .Palliative care in 2 weeks . Review of Resident #308's clinical record revealed the following physician progress notes: -progress note, dated [DATE] states, . has been having weight loss and decreased appetite .A palliative care consult was obtained .determined with [his/her] son that [he/she] would be evaluated for possible Hospice therapy .Long conversation with family and will proceed 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, interview and facility policy, the facility failed to ensure the resident's representative was notified timely of a significant change and/or incident for 1 of 3 residents reviewed for falls (Resident #56). Finding: On 2/26/25 the Division of Licensing and Certification received a complaint that after a resident obtained a fall, the family was not notified. On 4/17/25, review of Resident #59's medical record contained an Interdisciplinary Team (IDT) meeting dated 1/23/25 at 12:10 p.m., which stated, family was updated about the recent unwitnessed fall which happened night of 01/22/25. The family mentioned that they were not informed of the fall from last night. Review of the nursing documentation dated 1/22/25 at 7:37 p.m. stated, Called to patient room for fall in the bathroom, observed patient lying on the floor on [his/her] back with pants down below the waist, patient stated [he/she] was going to the bathroom and slipped and fell, no obvious bone deformities, no redness or bruising at this time, c/o low back pain 3/10. Further review of the medical 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 review and interview, the facility failed to ensure that 1 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #18). Finding: 1. Resident #18 was re-admitted to the facility in May 2024 with diagnoses of generalized anxiety and bipolar disorder. Resident #18's clinical record contained a PASRR Level I Screen, dated 5/22/24, and indicated the screen was for a change in condition and that Resident #18 would reside in the facility for permanent placement (LTC) [Long Term Care]. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed. On 4/15/25 at 11:15 a.m. the above findings were discussed with the Market Clinical Advisor.

Based on record review and interview, the facility failed to review, revise and update a care plan for a newly discovered pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]). Finding: On 2/19/25, R1's clinical record was reviewed. Documentation indicated that R1 had an admission care plan (dated 12/19/24) for at risk of skin breakdown. On 1/15/25, the resident was diagnosed with a Stage 3 pressure ulcer on the sacrum. there was no evidence that the care plan was updated to reflect the new skin care needs. On 2/19/25 at 12:30 p.m., this was confirmed with the Director of Nursing and Marketing Clinical Advisor.

Based on record review and interview, the facility failed to ensure that a physician order for a wound clinic consultation was followed for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]). Finding: On 2/19/25, a review of R1's clinical record was completed. Documentation indicated that on 1/15/25, the resident had a Stage 3 pressure ulcer on the sacrum. On 1/16/25, the resident was sent to the hospital emergency department (ED) for an evaluation of lightheadedness. R1 returned to the facility with ED instructions for a referral to the hospital wound clinic. On 1/17/25, R1's primary physician signed the orders and the facility nurse noted the order. On 2/19/25 at 12:22 p.m., in an interview with the surveyor, the Licensed Practical Nurse-Nurse Manager confirmed that the order for a wound clinic referral was not done.

Based on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 1 resident reviewed (Residents #1 [R1]). Finding: On 02/19/25, R1's clinical record was reviewed and included block orders (30 day) signed by the physician on 12/10/24. The next block order, including a 10-day grace period, needed review and the Physician's signature by 1/20/25; there are no further visits from the physician. On 2/19/25 at 2:50 p.m., in an interview with the surveyor, the Marketing Clinical Advisor confirmed that the last block order was signed on 12/10/24, making them 8 days late at the time of R1's discharge from the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 1 of 1 sampled residents (Resident #1 [R1,]. Findings: On 2/19/25, a review of R1's clinical record indicated that R1 was admitted on [DATE] and had a physician visit on 12/10/24. The next 30 day physician visit, including a 10-day grace period, which needed a review and written progress note was due on 1/20/25; there are no further visits from the physician. On 2/19/25 at 2:50 p.m., in an interview with the surveyor, the Marketing Clinical Advisor confirmed that the last visit was on 12/10/24, making the review and progress note 8 days late at the time of R1's discharge from the facility.

Based on record review and interview, the facility failed to notify the resident's representative (Resident #1 [R1]) of a fall with fracture. Finding: On 1/22/25, a review of R1's clinical record was completed. A nurse's note dated 12/23/24, indicated R1 had a fall and complained of right shoulder pain. A medical provider note dated 12/23/24, indicated that x-rays were order. A Radiology Report dated 12/24/24, indicated R1 sustained an acute right humeral neck fracture from the fall. There as no evidence to indicate that the resident's representative was immediately notified of the fall and fracture. On 1/22/25 at 3:00 p.m., in an interview with the surveyor, the Administrator stated he was unable to locate evidence that R1's representative was promptly notified of the fractured humerus.

Based on record review and interview, the facility failed to ensure that a care plan was developed for a change in a resident's condition-fractured right humerus for 1 of 1 resident reviewed for a fracture. (Resident #1 [R1]) Finding: On 1/22/25, a review of R1's clinical record was completed. A nurse's note dated 12/23/24, indicated R1 had a fall and complained of right shoulder pain. A medical provider note dated 12/23/24, indicated that x-rays were order. A Radiology Report dated 12/24/24, indicated R1 sustained an acute right humeral neck fracture. A review of R1's care plan indicated there was no evidence that from 12/24/24 through to 1/19/25 (when R1 was discharged from the facility) a care plan was developed with interventions that would guide staff in the care of the fractured humerus and R1's decreased functional ability to use his/her upper extremity. On 1/22/25 at 3:00 p.m., in an interview with the surveyor, the Administrator confirmed there was no care plan problem or interventions that addressed R1's fractured arm.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information in the area of weights for 2 of 3 Residents (Resident #1, and #2), meal intakes for 3 of 3 Residents (Resident's #1, #2, and #3), palliative care for 1 of 3 Residents (Resident #1), falls for 1 of 1 Resident (Resident #1), and positioning for 1 of 1 Resident (Resident #2) reviewed during a complaint investigation. Findings: Review of policy Nutrition/Hydration Care and Services dated 2/1/23 states .Staff will provide nutritional and hydration care and services to each patient, maintain fluid and hydration balance. Monitor patient's weight as ordered. Resident #1 was admitted on [DATE] and has diagnoses to include heart failure, and dementia, and severe anxiety. Review of Resident #1's provider orders revealed the following orders: -Order with start date of 12/19/24 for diuretic Furosemide Oral Tablet 40 MG (Furosemide) Give 40 mg orally one time a day for…

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 notify the physician of significant change in condition when a resident was noted to have a change in meal intakes and significant weight loss for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Change of Condition dated 7/1/24 states A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in patient's physical mental, or psychosocial status (that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change and existing form of treatment due to adverse consequences, or to commence a new forma of treatment) . Resident #1 was admitted on [DATE] and has diagnoses to include recent Urinary tract infection, congestive…

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, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Person-Centered Care Plan dated 10/24/22 states .The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional instructions needed to provide effective and person-centered care that meet professional standards of quality care. a baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy…

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, interviews and facility policy, the facility failed to follow-up on significant weight loss, and reduced meal intake for 1 of 3 residents reviewed during a compliant investigation (Resident #1). Findings: Review of policy Nutrition/Hydration Care and Services dated 2/1/23 states .Staff will provide nutritional and hydration care and services to each patient, consistent with the patient's comprehensive assessment . Use the Diet Order and Communication Form to initiate consult with Dietitian, when indicated. Obtain orders per recommendations. Contact physician/advanced practice provider (APP) to convey the recommendations. Develop .Plan of care for enhancing oral intake, promoting adequate nutrition and hydration, and identifying individualized goals, preferences, and choices. Maintain fluid and hydration balance. Monitor patient's weight as ordered . Address any changes in condition that affect or potentially affect the patient's nutritional status with Dietitian and physician/APP . Review…

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, interviews, and facility policy, the facility failed to monitor for side effects of psychotropic medications for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings: Review of policy Medication Monitoring/Medication Management dated 1/24 states .When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences . Resident #1 was admitted on [DATE] for skilled care services and had diagnoses to include severe anxiety, depression, and delirium. Review of Resident #1's care plan initiated on 12/19/24 states Resident is at risk for complications related to the use of psychotropic drugs : antipsychotic, anxiolytics, antianxiety Goal: Resident will have the smallest most effective dose without side effects throughout review period Intervention: .monitor for changes in mental status and functional level and report to MD as indicated. Review of active…

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, interviews, and facility policy, the facility failed to assess a resident after returning from a surgical procedure for 1 of 3 residents reviewed during a complaint investigation (Resident #1), and failed to complete admission assessment for 1 of 3 residents (Resident #3). Findings: 1. Review of Resident #1's clinical record revealed progress note dated 5/15/24 stated Received call from [Doctor] at [Hospital], wants resident transferred to surgery ASAP for a pacemaker battery change, Resident returned at 1830 (6:30 p.m.), set up the Medtronic relay, device is on the nightstand and working properly, provided the dinner food tray resident ate 50%, increased confusion, not following restriction protocol, family informed back at facility. Review of Resident #1's clinical record lacked evidence that Resident #1' s surgical wounds were assessed upon his/her return to facility. On 5/23/24 the Department of Licensing received a complaint indicating Resident #1 underwent a surgical procedure for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, the facility failed to update/implement goals and interventions for 3 of 3 care plans reviewed during a complaint investigation (Resident's #1, #2, and #3). Findings: 1. Resident #1 was admitted on [DATE] with diagnoses to include heart failure, hypertension, and complete atrioventricular block requiring pacemaker placement in 2010. Review of Resident #1's care plan, initiated 2/2/24, states Resident is at risk of complications related to pacemaker/internal defibrillator .Monitor for signs/symptoms of pacemaker complications i.e.: S.O.B., weakness, syncope, fatigue, cyanosis, bradycardia .Notify physician as needed. Review of Resident #1's clinical record lacked evidence that he/she was being monitored for above pacemaker complications. 2. Resident #2 was originally admitted on [DATE] with diagnoses to include osteoarthritis and recent total right hip replacement. Review of Resident #2's clinical record revealed Discharge Summary Orthopedics dated 3/13/24 states Status post…

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, interview, and facility policy, the facility failed to adequately assess, and obtain wound care orders for 1 of 3 residents reviewed during complaint investigation (Resident #1). Findings: On [DATE] the Department of Licensing received a complaint indicating Resident #1 underwent a surgical procedure for pacemaker battery replacement on [DATE] and cardiology department made multiple attempts to contact facility for post op wound care and did not get in contact with facility staff until 5 days later. When contact was made, the nurse was not aware the resident had 2 wound sites. Review of Resident #1's clinical record revealed progress note, dated [DATE] stated Received call from [Doctor] at [Hospital], wants resident transferred to surgery ASAP for a pacemaker battery change, Resident returned at 1830 (6:30 p.m.). Review of Resident #1's clinical record lacked evidence that Resident #1' s surgical wounds were assessed upon his/her return. Review of Resident #1's clinical record revealed…

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 facility policy, record review, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 14 of 17 residents reviewed for advanced directives (Resident's #5, #14, #19, #21, #22, #26, #27, #34, #44, #49, #52, #54, #58 and #219). Findings: Review of facility policy titled Review of facility policy Health Care Decision Making dated 1/8/24 states Centers must: Inform and provide written information to all patients concerning the rights to accept or refuse medical or surgical treatment and, at the patient's option, formulate an advance directive: .approach a capable patient who does not have an advance directive upon admission , . so that patient's rights will be honored and their wishes will be executed at the appropriate time .Upon admission, determine whether the patient has an advance directive and .If the patient/patient representative has copies with them,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 4 of 4 units (Spring Gardens, North Wind, Penbscoto and Windward Center), the laundry room and hallways for 2 of 2 facility tours (4/22/24 and 4/25/24). Findings: 1. On 4/22/24 at 9:20 a.m., during a tour of Spring Gardens Unit, 2 surveyors, and the Corporate Nurse Educator (CNE) observed the following findings: > The shower room had a black headband, a white towel and a razor on the sink. > Resident room [ROOM NUMBER] - The toilet seat was visibly dirty/soiled and the call bell cord had blue yarn tied to it as an extender. > Resident room [ROOM NUMBER] - The toilet was continuously running. > Resident room [ROOM NUMBER] - The bathroom toilet was visibly dirty. There were 3 large holes in the wall above the toilet. The bathroom door was marred/gouged on the inside and outside of the door. > Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on care plan review, observations, interviews, and facility policy, the facility failed to provide residents with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities. Findings: Review of facility policy Recreation Services Policies and Procedures dated 8/7/23 states Centers/Communities must provide, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of an and support the physical, mental, and psychosocial wellbeing of each patient, encouraging both independence and integration in the community.Programs will be scheduled seven days a week. Weekend activities include secular and non-secular opportunities. 1. Resident #10 was admitted to the facility on [DATE] and relies on staff for Activities of Daily Living. Review of Resident # 10's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) 15 of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to base board hot water heating units for 2 of 2 observations and failed to ensure that that chemicals were properly secured for 1 of 4 days of survey. (4/22/24) Findings: 1. On 4/22/24 at 11:45 a.m., a surveyor observed the following on the Penobscot House Unit: > Resident room [ROOM NUMBER]- The base board heating unit cover was partially off exposing sharp metal edges and hot pipes. > Resident room [ROOM NUMBER] - The base board heating unit was missing approximately an 18 inch section of pipe covering which exposed hot piping. > Resident room [ROOM NUMBER] - The base board heating unit was missing approximately an 18 inch section of pipe covering which exposed hot piping. On 4/22/24 at 11:55 a.m., in an interview, the Administrator confirmed the findings. 2. On 4/22/24 at 12:40 p.m., a surveyor observed the following in Resident 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 observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer mask/tubing for 2 of 2 residents reviewed for respiratory care (Residents #19 and #49) for 2 of 2 observations (4/22/24 and 4/23/24). Findings: 1. On 4/22/24 at 12:15 p.m., and on 4/23/24 at 8:50 a.m., a surveyor observed the unlabeled oxygen tubing for Resident #19. A review of the Resident #19's clinical record revealed that there was no order to change the tubing and no documentation showing that the tubing had been changed weekly. On 4/24/24 at 2:15 p.m., in an interview, the Senior Director of Nursing confirmed that Resident #19's oxygen tubing had not been changed weekly and that Resident #19's clinical record lacked evidence showing that the tubing had been changed weekly. 2. On 4/22/24 at approx. 10:03 a.m., and on 4/23/24 at 8:00 a.m., observations of Resident #49's nebulizer mask stored on the nightstand labeled with a dated of 4/1/24. In a brief interview…

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 performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant [CNA]). Findings: 1. CNA #1 was hired on 2/4/2019. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 2. CNA #2 was hired on 2/4/2020. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 3. CNA #3 was hired on 4/5/2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 4. CNA #4 was hired on 10/12/2021. The facility was unable to provide evidence of a completed annual performance evaluations for 2022 and 2023. 5. CNA #5 was hired on 7/2/2018. The last annual performance evaluation was completed in 2021. The facility was unable to provide evidence of a completed annual performance evaluations…

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

Based on observations, interviews, record reviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure proper vaccine storage temperatures for 2 of 2 medication storage room refrigerators (Spring Harbor and Penobscot House). Findings: Review of facility policy titled Medication Storage Guidance .influenza vaccine dated 2023 states, Store in the refrigerator at 36 degrees to 46 degrees Fahrenheit. Review of CDC guidance Vaccine Storage and Handling Toolkit dated 1/23 states .Refrigerators should maintain temperatures between 2° C and 8° C (36° F and 46° F) .Every vaccine storage unit must have a Temperature Monitoring Device (TMD). An accurate temperature history that reflects actual vaccine recommended temperature range. 1.On 4/23/24 at 7:15 a.m., two surveyors and Director of Nursing (DON) observed Spring Garden medication room refrigerator containing 3 vials of influenza vaccine available for use. Further observation of the medication room lacked evidence of monitoring refrigerator temperatures. At this time, the DON indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and the facility's policies, the facility failed to ensure products in the walk-in refrigerator and freezer were labeled and/or dated and failed to remove expired foods available for use for 1 of 1 kitchen tours. Further, the facility failed to ensure that the freezers were monitored, and temperatures documented accurately and that the dish machine was maintaining proper temperature ranges for proper washing/cleaning. This has the potential to affect all residents. Findings: Facilities Cold food policy and procedure revised 4/2018 states, All Time/Temperature Control for Safety (TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. 4. An accurate thermometer will be kept in each refrigerator and freezer a written record of daily temperatures will be recorded. 5. All foods will be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Facilities…

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

Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed for medication administration (Resident #10 and #219). Findings: 1. Resident #10 was admitted to facility on 11/17/22 and has diagnoses to include dementia, and major depressive disorder. Review of Resident #10's active orders effective April 2024 revealed: -Order with start date of 2/29/24 for antipsychotic Risperdal oral tablet (Risperidone). Give 0.125 mg by mouth two times a day for mood stabilizer, agitation. Review of Resident #10's entire clinical record lacked evidence of behavior monitoring for side effects. - Order with start date of 11/3/23 for antidepressant Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth in the morning for major depression . Review of Resident #10s clinical record lacked evidence of behavior monitoring for side effects. On 4/23/24 at 2:50 p.m., review of Resident 10's entire clinical record with the Senior Director of Nursing confirming the above findings. 2. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to personal toileting items, wash basins, medical supplies and linen for 2 of 4 days of survey on 3 of 4 units (Windward Gardens Penobscot and Spring Gardens). Findings: 1. On 4/22/24 and 4/23/24, a surveyor observed on Windward Gardens unit a bedpan and a wash basin located in a shared bathroom on the floor under the sink in room [ROOM NUMBER]. On 4/23/24 at approximately 9:45 a.m., in an interview with a surveyor, the Administrator confirmed the above observations did not support good infection control practice. 2. On 4/22/24 at 10:54 a.m. to 11:06 a.m., observation of Penobscot to have the following: - room [ROOM NUMBER] had bariatric bed pan stored on the floor next to the toilet and a wash basin on shower floor. - room [ROOM NUMBER] had a bed pan stored upside down on the toilet…

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

Based on record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, resident rights and dementia management by failing to ensure that 4 of 5 Certified Nursing Assistant's (CNAs) employed, completed the required annual training (CNA #1, CNA #2, CNA #4 and CNA #5). Findings: On 4/25/24, during a review of employee personnel records, the following was noted: 1. CNA #1 was hired on 2/4/2019. CNA #1's employee personnel record lacked evidence of mandatory resident rights education and dementia training within the last twelve months. 2. CNA #2 was hired on 2/4/2020. CNA #2's employee personnel record lacked evidence of mandatory abuse education, resident rights education and dementia training within the last twelve months. 3. CNA #4 was hired on 10/12/2021. CNA #4's employee personnel record lacked evidence of mandatory resident rights education within the last twelve months. 4. CNA #5 was hired on 7/2/2018. CNA #5's employee personnel record lacked evidence of mandatory abuse education,…

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 the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 2 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (#274 and #276). Findings: 1. Resident #274's Medicare Part A coverage for skilled services ended on 11/24/23. The medical record lacked evidence that Resident #274 or his/her legal representative was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. 2. Resident #276's Medicare Part A coverage for skilled services ended on 3/14/24. The medical record lacked evidence that Resident #276 or his/her legal representative was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility. On 4/25/24 at 8:28 a.m., during an interview, the Administrator confirmed the SNFABN…

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 that 2 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #34 and Resident #52). Finding: 1. Resident #34 was admitted to the facility on [DATE] with diagnosis of Bipolar Disorder. Resident #34's clinical record contained a PASRR Level I determination letter dated 12/11/23 that stated further PASRR evaluation was not required due to Resident #34 met the criteria for a short-term convalescence admission. Resident #34 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and…

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 update/implement goals and interventions in the area of antipsychotic medication use for 1 of 6 residents reviewed for medications (Resident #10) Finding: Resident #10 was admitted to facility on 11/17/22 and has diagnoses to include dementia, and major depressive disorder. Review of Resident #10's active orders effective April 2024 revealed order with start date of 2/29/24 for antipsychotic Risperdal oral tablet (Risperidone). Give 0.125 mg by mouth two times a day for mood stabilizer, agitation. On 4/23/24 at 2:51 p.m., during review of Resident #10's entire clinical record, the Senior Director of Nursing confirmed Resident #10's care plan lacked goals/interventions and monitoring of side effects for antipsychotic use.

Based on interview, observation and record review, the facility failed to revise the care plan to reflect a resident's current status for 1 of 3 residents reviewed for falls (#49). Findings: 1. On 4/23/24 at 8:01 a.m., during an interview, Resident #49 stated, I lost my balance and fell hit my head . I was getting up to take my walker to go to the dining room. The Surveyor asked if staff was with him/her when the fall occurred, resident stated, Yes, it happened so quick. At this time, the surveyor observed a rolling walker across the room. Resident #49's care plan initiated on 2/22/24 states, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent illness, hospitalization, etc. resulting in fatigue, activity intolerance, confusion, etc. with intervention of: Provide resident/patient with extensive assist of 1 for ambulation using a wheelchair. Review of Therapy notes stated on 3/7/24 Resident #49 goals were met for Patient will safety ambulate on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to follow physician orders for 2 of 11 sampled residents (Resident #219 and Resident #269). Findings: 1. On 4/24/24, Resident #219's clinical record was reviewed. Resident #219 had a medication order, dated 4/11/24, for Lorazepam Oral Tablet 0.5 MG (milligrams) Give 0.5 mg by mouth two times a day for anxiety. A review of Resident #219's Medication Administration Record indicated that Resident #219 did not receive Lorazepam on 4/20/24 and 4/21/24. On 4/24/24 at 12:05 p.m., in an interview, the Senior Director of Nursing confirmed that Resident #219 did not receive his/her Lorazepam on 4/20/24 and 4/21/24 as ordered. 2. Resident #269 was admitted to the facility on [DATE] with diagnosis of Benign non-nodular prostatic hyperplasia with lower urinary tract symptoms. A provider's note dated 3/8/24 stated, review of symptoms: genitourinary - frequency. Assessment/plan: urinary frequency- will check UA (urinalysis- urine sample). A Providers order dated…

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 treatment plans were followed, and resident records were accurate for 1 of 1 resident reviewed for pressure and venous ulcers (Resident #60). Finding: Resident #60 was admitted on [DATE] with a Pressure ulcer to his/her right hip, and venous ulcers to bilateral lower extremities (shin). Review of the medical record contained the following Provider orders: - Order dated 4/17/24 for Venous - Right shin: Cleanse with wound cleanser, apply xeroform to wound base and cover with foam dressing. Every day shift for Wound care. - Order dated 4/17/24 for Venous - Left shin: Cleanse with wound cleanser, apply xeroform to wound base and cover with foam dressing. Every day shift for Wound care. - Order dated 4/16/24 for Pressure Injury - Right hip: Cleanse with wound cleanser, apply maxorb AG to wound base and cover with foam border. Every day shift for Wound care AND as needed. - Order dated 3/6/24 for Wound(s): Monitor site(s) (L) shin,…

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

Based on record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts between 4/11/24 through 4/22/24 on 1 of 3 units observed. (North Wind) Findings: Genesis HealthCare policy titled Controlled Drugs: Management of states, A complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations. Review of bound medication book labeled WWG, NW, Book 2 revealed that oncoming nurse failed to sign the shift count page on 4/11/24 at 7:00 a.m., 4/17/24 at 7:00 a.m. and 4/18/24 at 7:00 a.m. The outgoing nurse failed to sign 4/18/24 at 1900 and on 4/21/24 evening shift. On 4/24/24 at 10:41 a.m., during an interview, the…

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

Based on record review, interview, and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#10). Findings: Review of facility policy Psychotropic Medication Use dated 11/28/16 states . All medications used to treat behaviors must have a clinical indication and be uses in the lowest dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: Efficacy, risks, benefits and harm or adverse consequences. Antipsychotic medications used to treat Behavioral or Psychosocial Symptoms of Dementia must be clinically indicated, be supported by adequate rational for uses, and may not be used for behavior with an unidentified causes .Facility should ensure that Physician/Prescriber has conducted a comprehensive assessment for the resident and has documented in the clinical record that the psychopharmacological medication is necessary .Facility staff should monitor the resident's behavior pursuant to facility policy using a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 3 of 4 units (Spring Gardens, Windward Center and North Wind) for 1 of 1 facility tours (1/9/24). Findings: On 1/9/24 from 11:10 a.m. to 11:40 a.m., an environmental tour was conducted with a Maintenance Director and the Marketing Clinical Advisor in which the following findings were observed: Spring Gardens Unit: > The television/sitting area, across from resident room [ROOM NUMBER], had a small table that had a worn/missing surface treatment exposing bare wood and creating an uncleanable surface. > Resident room [ROOM NUMBER] - There were 2 broken window shades. > The hallway wooden hand railings were missing surface treatment exposing bare wood creating uncleanable surfaces. > The wood trim on the nurse's station had missing surface treatment exposing bare wood creating an uncleanable surface. > The 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that the residents environment was free from the potential risk of accident relating to moving dollies, a floor heater unit, and exit doors and exit pathways for 2 of 2 observations for 2 of 2 days of survey. (1/8/24 and 1/9/24) In addition, the facility failed to provide adequate supervision and complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking (#24, #26). Findings: 1. 0n 1/8/24 at 10:35 a.m., during a facility tour with the Administrator, the following findings of accident hazards were observed: Spring Gardens Unit: > There were 2 rolling moving dollies sitting on the floor in the television/sitting room. > The floor heater unit in the dining room was missing an access panel exposing wiring, hot water pipes and sharp metal. > The exit doors and exit pathways were not cleared of snow, ice and open for use as exits to a public way after a recent…

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 foods in the kitchenette refrigerators and cupboards we're labeled and securely closed for 1 of 4 kitchenettes (Spring Gardens Unit) for 1 of 2 survey days (1/8/24). Additionally the facility failed to ensure that staff working in the kitchen we're wearing hair protectors and/or facial hair protectors for 1 of 1 kitchen tour on 1 of 2 survey days (1/9/24). Findings: 1. 0n 1/8/24 at 10:30 a.m., a surveyor observed the following in the refrigerator and a cupboard on the Spring Gardens Unit: > The refrigerator had an open pudding cup that was not sealed or labeled with a name. > The bread cupboard had a previously opened unsealed loaf of bread. 0n 1/8/24 at 10:30 a.m., in an interview, a certified nursing assistant (CNA) confirmed the findings. 2. 0n 1/9/24 at 9:40 a.m., a surveyor observed a male kitchen worker with a full beard not wearing a facial hair protector and a female kitchen worker with long hair not wearing a hair protector. 0n 1/9/24 at 9:40 a.m., in an interview, the Food Service Director confirmed…

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

Based on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 7 of 7 residents reviewed for activities of daily living (#11, #12, #13, #14, #15, #20, #21). Findings: 1. A review of Resident #11's Certified Nursing Assistant (CNA) documentation of activities of daily living (ADLs) for November 1-30, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 22 out of 30 days Behavior Monitoring and Interventions: 21 out of 30 days Eating: 21 out of 30 days Bathing: 23 out of 30 days Dressing: 23 out of 30 days Drinks/snacks other than meals: 23 out of 30 days Hygiene: 23 out of 30 days Toileting: 21 out of 30 days Transfers: 22 out of 30 days Wheelchair mobility - 24 out of 30 days Walking - 24 out of 30 days Mouth care - 21 out of 30 days 2. A review of Resident #12's CNA documentation of ADL's for August 1-31, 2023, revealed multiple days lacking documentation on multiple shifts as follows: Bed Mobility: 23 out of 31 days Behavior Monitoring and Interventions: 24…

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

Based on interviews and facility policy review, the facility failed to implement their Abuse Prohibition policy to ensure an alleged violation involving verbal abuse was reported within 2 hours to the Division of Licensing and Certification (State Agency) for 1 of 29 residents reviewed. (#5) Finding: The facility's Abuse Prohibition, revised 10/24/22 on Page 6 reads Report allegations involving abuse (physical, verbal, sexual, mental) no later than two hours after the allegation is made and Notify local law enforcement, licensing board and registries and other agencies as required. On 4/20/23, the Division of Licensing and Certification received from the facility a reportable incident form which indicated an allegation of verbal abuse towards Resident #5 by a Licensed Practical Nurse (LPN) who was witnessed raising his/her voice, in a derogatory manner and using profanity while working with the resident. Further review of the Nursing Facility Reportable Incident Form, reveals the date of the alleged incident to have occurred on the evening of 4/15/23. On 1/9/24 at 3:00 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 record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 7 residents sampled for hospitalizations. (#22) Finding: Documentation in Resident #22's clinical record indicated that the resident was transferred to the hospital on 4/23/23 and subsequently admitted . The clinical record lacked evidence that Resident #22 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. On 1/9/24 at approx. 11:00 a.m., during an interview, the Director of Nursing confirmed the above finding.

Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 1 of 7 residents sampled for hospitalizations. (#22) Finding Resident #22's clinical record revealed the resident was transferred to an acute care hospital on 4/23/23 and subsequently admitted . The clinical record lacked evidence that Resident #22 and/or the resident representative were provided with a written bed hold notice. On 1/9/24 at approx. 11:00 a.m., during an interview, the Director of Nursing confirmed the above finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 6 residents that were reviewed for baseline care plans. (#21) Finding: Resident #21 was admitted to the facility on [DATE]. The discharge summary from the hospital included information that the resident had a diagnosis of diabetes, peripheral neuropathy, bilateral foot drop which requires braces for ambulating, spinal stenosis and frequent falls. Review of the clinical record revealed that it lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #21's immediate health and safety needs for the above concerns. The care plan was initiated on 8/18/23, 7 days after admission. In addition, the care plan lacked information on Resident #21's bilateral foot drop…

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 area of Activities of Daily Living (ADL) care for 1 of 2 residents reviewed for falls. #21 Findings: Review of Resident #21's care plan initiated on 8/18/23 in the area of ADL's states, provide resident/patient with extensive assist of 2 for transfers using a lift to wheelchair and Provide resident/patient with extensive assist of 2 for toileting. admission Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 8/17/23, was coded on section GG Mobility, that Resident required partial moderate assist and, helper does less than half of the effort, for sit to stand and chair/bed to chair transfer. The Certified Nursing Assistant (CNA) documentation reviewed for 8/12/23 - 8/25/23 revealed Resident #21 required limited to extensive assist of 1 staff for transfers/walking in room and supervision/limited assist of 1 staff for toileting. Interviews conducted with staff during the complaint survey revealed that Resident #21 required limited assistance of 1 staff…

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 identify a resident's care needs and provide timely treatment to manage pain for 1 of 2 residents reviewed for falls with injury (#13). Findings: A review of the facility's Falls Management policy, with a revision date of 8/7/23, stated Purpose: To evaluate the patient for injury post-fall and provide appropriate and timely care. Section 5, Post-Fall Management: 5.2.2. If the extent of injuries cannot be determined, the nurse will notify emergency medical services (EMS) for evaluation and transport to the hospital. A review of the clinical record of Resident #13, noted a [AGE] year old, admitted to the facility on [DATE] following repair of a right hip fracture. Additional diagnoses included Dementia and Parkinsonism. The admission Minimum Data Set (MDS) 3.0, completed 10/24/23, identified Resident #13's need for maximum to moderate assistance with activities of daily living (ADL's) including dressing, transfers, toileting, and bed mobility. The MDS…

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 ensure a treatment cart containing multiple medicated creams, powders, ointments, syringes, insulin and inhalation treatment medications was locked on 2 of 7 units. (Penobscot House & Spring Gardens) Findings: 1. On 9/6/23 at 10:55 a.m., a surveyor observed an unattended, unlocked treatment cart in the hallway across from the Penobscot House nurses station. The treatment cart contained multiple medicated creams, powders, ointments and syringes. Resident residents and unauthorized personnel were observed crossing through area. A surveyor confirmed the above finding, at the time of the observation with Registered Nurse #1 (RN) at 11:00 a.m., who immediately locked the cart and confirmed that the treatment cart should be locked. 2. On 9/6/23 at 11:48 a.m to 11:56 a.m , a surveyor observed an unattended, unlocked treatment cart in the hallway across from the Spring Gardens nurses station. The cart contained multiple medicated creams, powders, ointments, inhalation treatments, needles, and syringes. There were four residents…

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.