Durgin Pines

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 5 of 5 residents reviewed. (#10, #15, #18, #23, #47) Findings: 1. Resident #18 was admitted in January of 2025. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #23 was admitted in February of 2025. A review of the entire electronic medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. Review of facility policy Advance Directives, with a revision date of September, 2024, stated The resident has the right to formulate an advance directive, including the right 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 7 of 9 reviewed for care planning. (Resident #1, #49, #40, #32, #13, #55 and #3). Findings: 1. On 3/10/25 at 11:34 a.m., during an interview, Resident #1 stated he/she is not invited or remembers having care plan meetings. Review of Resident #1's IDT care plan meeting notes stated IDTs occurred on 4/24/24, 7/24/24, 10/23/24, 11/22/24 and on 3/5/25. The medical record lacked evidence that he/she was invited and/or participated in his/her IDT meetings. 2. On 3/10/25 at 11:49 a.m., during an interview, Resident #49 stated his/her representative attends the IDT meetings via phone, but he/she is not invited. Review of Resident #49's IDT care plan meeting notes stated IDTs occurred on 2/5/24, 7/10/24, 10/16/24 and on 1/15/25. The medical record lacked evidence 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.

Based on observation, interview and the facility's Dietary Dress Code Policy, the facility failed to ensure facial hair protection was worn on 1 of 3 days of survey. Finding: On 3/10/25 from 9:34 a.m. to 9:50 a.m., an initial kitchen tour was conducted in which the following finding was observed and confirmed with the Food Service Director: > There were 2 male kitchen workers with facial hair that was not wearing facial hair protection while preparing food in the kitchen. A review of the Dietary Dress Code Policy - updated 10/31/23, states All employees are required to wear a hair net or hat and beard guard (when appropriate) in food prep areas. On 3/10/25 at 2:20 p.m., in an interview with the Administrator, two surveyors discussed the above finding.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure a resident was free from an avoidable accident hazard when the resident sustained 1st degree burns on his/her bilateral lower extremities while receiving a whirlpool bath. Finding: A review of Resident #1's clinical record notes indicated that on 3/25/24 Resident #1 was given a whirlpool bath and had complained of the water being too hot. Upon assessment, Resident #1's bilateral lower extremities were warm to touch, red and swollen. Resident #1 was advised to elevate/his/her feet and apply cool rags to the area. Resident #1 refused. Resident #1's family member was called and advised that Resident #1 be sent to the emergency room for an evaluation. Resident #1 was sent to the emergency room for an evaluation and diagnosed with 1st degree burns on his/her bilateral extremities and advised to treat with cool rags and Tylenol or Motrin. The facility investigation indicates that during an interview with Resident #1, he/she stated that he/she was…

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

Based on observation, interviews and record review, the facility failed to ensure that the residents' whirlpool was maintained, according to the manufacture's recommendations, and in good repair to provide a safe, functional, and comfortable environment for residents to bathe in for residents who receive whirlpool baths on 1 of 2 resident care units (Marions Way Hand Wing). Finding: On 4/2/24 between 11:20 a.m. and 12:00 p.m. during a observation with the Maintenance Director. A surveyor observed a whirlpool tub on Marions Way Hand Wing with a digital thermometer near the knobs for hot/cold water. As the hot water was running, the surveyor and Maintenance Director observed that the digital thermometer was not functional. A review of the Integrity Bath Safety Instructions on page 1 under Warnings: hot water above 110°F 43°C can scald people. Some individuals using the integrity bath may not be able to communicate to the attendant the existence of painful and uncomfortable conditions. Water temperatures entering the bathing system must be constantly monitored using the built-in…

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

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ceiling vents, and the food slicer, 1 of 4 days of survey. Additionally, the reach-in refrigerator was found to have a container of unlabeled and undated food. Findings: 0n 12/18/2023, at 9:15 a.m., during the initial tour of the kitchen with the Food Service Director/Dietician the following findings were observed and confirmed: The kitchen had dirty/dusty ceiling vents in all areas of the kitchen. The exhaust vent just across from the prep sink had a long piece of dust/debris blowing in the wind of the exhaust fan. The reach-in fridge had a small container of bacon that was undated and unmarked. On 12/20/2023 at 12:40p.m. During the return observation of the Kitchen with the Food Service Director/Dietician, it was observed and confirmed that there was a build-up of a foreign material on the blade guard of the food slicer. The Food Service Director stated that it looks like some kind of plastic material.

Based on record review, interviews and observation, the facility failed to revise a care plan to reflect the current needs for 1 of 2 residents sampled for skin conditions (#36). Findings: On 7/19/21 at 9:28 a.m., during an interview with Resident #36, the surveyor observed a tubigrip stocking and gauze dressing on the resident's left lower extremity. The resident questioned if he/she had an infection of the toe. On 7/22/21 at 9:30 a.m., the surveyor observed Resident #36 with a bed cradle which kept the bed linens from resting on the resident's feet. A review of the clinical record revealed that on 6/4/21, the physician prescribed an antibiotic and wound care for the treatment of cellulitis of the left second toe. Resident #36's current care plan, with a revision date of 6/11/21, addressed the risk for skin breakdown and a Stage II pressure injury of the right glute. The clinical record contained a care plan note dated 3/18/21, indicating the Stage II pressure ulcer on the glute as healed. On 6/10/21, a social services note discusses a care plan meeting, in which family members…

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 clinical record review, the facility failed to ensure that the clinical record of a resident who requires dialysis services, contained complete and accurate documentation from 5/1/21 through 7/22/21, for 1 of 1 resident receiving dialysis (#43). Finding: On 7/19/21 at 9:33 a.m., in an interview with the surveyor, Resident #43 stated he/she goes to dialysis on Mondays, Wednesdays and Fridays. He/She showed the surveyor the arteriovenous fistula access site on his/her right arm. When asked, he/she did not know if staff assessed the site daily. Resident #43's clinical record revealed a diagnosis of End Stage Renal Disease with a Dependence on Hemodialysis. A review of the medication/treatment administration records (MAR/TAR) from May 1, 2021, through July 21, 2021, revealed the following: - A physician's order with a start date of 11/15/17: Remove post-dialysis pressure dressing 4-6 hours post treatment. Monitor for bleeding in the evening every Monday, Wednesday and Friday post-dialysis. The record lacked evidence the dressing was removed and the hemodialysis…

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 respond to a pharmacist's reported irregularity related to the use of a psychotropic medication for 1 of 5 (#36) residents reviewed for unnecessary medications. Finding: During a review of Resident #36's clinical record, the surveyor could not locate the Monthly Medication Regimen Reviews (MRR) and asked the Director of Nursing (DON) if she could locate a formal report of irregularities. On 7/21/21, the DON stated that during the pandemic, the pharmacist consultant completed record reviews remotely. Resident #36 was noted to have had a review on 5/6/21. The surveyor requested a copy of the pharmacist's recommendation. On 7/22/21 at 11:55 am, the Director of Clinical Operations, stated she had contacted the pharmacy to obtain the recommendation from the MRR completed 5/6/21. The pharmacy emailed a copy of the recommendation which stated this resident is currently on PRN (as needed) Prochlorperazine (an antipsychotic/antiemetic medication). New requirements of participation (483.45) require that the use of PRN…

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 documentation for 2 of 30 sampled residents (#2, #36). Findings: 1. A review of Resident #2's clinical medication administration record/treatment administration record (MAR/TAR) revealed the following: -Order for wound care with a start date of 4/28/21: change foot ulcer dressing every day to ¼ strength H2O2 (peroxide) cleanser, clean using forceps and 4X4 gauze. Then pack with ¼ of a 2X2 gauze and cover with ABD (abdominal) pad, secure corners with medipore tabe, cover with tubigrip sleeve, cover toes. A review of the May 2021 TAR revealed no documentation that the wound care was completed on 5/6/21, 5/7/21, 5/9/21. -Order for Prevlon boot with a start date of 4/28/21: on right foot while in bed at bedtime. A review of the May 2021 TAR revealed no documentation that the boot was applied on 5/1/21, 5/5/21, 5/21/21, 5/22/21. A review of the June TAR revealed no documentation for 6/5/21, 6/7/21, 6/9/21, 6/18/21, 6/24/21. A review of the July TAR revealed no…

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