Orono Commons

Based on record review and interviews, the facility failed to provide respiratory care as order by the Provider for 1of 3 residents that use oxygen. Resident #165 [R165]) Finding: On 5/6/25 during a clinical record review for R165, it was noted that R165 uses oxygen daily and has had an order change dated 5/1/25 for oxygen to be administered by nasal cannula (NC) at 2 liters/min every shift for maintaining peripheral oxygen saturation (SPO2) between 88-93% evaluate HR (heart rate), respiratory rate, pulse oximetry, skin color and breath sounds. R165's clinical record was reviewed and there is no evidence that this order was completed as ordered as there is no documentation showing that his/her respiratory rate, skin color and breath sounds were evaluated as ordered. On 5/06/25 at 2:46 p.m., during a clinical record review for R165 the surveyor confirmed with the Director of Nursing, the Administrator and the Clinical Market Advisor that there is no nursing documented evidence of R165's respiratory rate, skin color and breath sounds being evaluated every shift as ordered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and two lunch meal test trays, the facility failed to serve hot foods at an appetizing and palpable temperature for 1 of 2 lunch trays tested on [DATE] and 5/6/25. Findings: On 5/4/25 between 10:15 a.m. and 11:30 a.m., during a facility initial tour, several residents stated to the surveyors that hot foods were served cold. On 05/5/25 at 12:45 p.m., two surveyors tested food temperatures on a lunch test tray at the end of lunch delivery service to the residents on the Riverview Unit. The following food temperatures were: Cubed chicken was 96.4 degrees Fahrenheit and had a taste sensation of cool to cold. Macaroni and cheese was 94.3 degrees Fahrenheit and had a taste sensation of cool to cold. Cubed potatoes were 96.6 degrees Fahrenheit and had a taste sensation of cool. On 5/6/25 at 1:10 p.m., after the second lunch meal tray was tested, in an interview with the surveyor, the District Manager of Health Services Group, confirmed that the hot foods temped on 5/5/25 were not…

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

Based on record reviews and interviews the facility failed to respond to residents request for assistance in a manner that maintained or enhanced their dignity by not answering the call bells in a timely manner for 3 of 9 residents interviewed (Resident #18 [R18], R9, R4). In addition, the facility failed to provide morning bathing care for 1 of 1 sampled resident (R9) and facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for meal observations on 1 of 2 units (Homestead). Findings: 1. On 5/19/24, R18's clinical record was reviewed. R18 was diagnosed with Cerebral Vascular Accident (CVA) with hemiplegia and hemiparesis, wheelchair dependent, and the care plan indicated R18 requires extensive assist with toileting. On 5/19/24 at 10:35 a.m., in an interview with the surveyor, R18 stated he/she rang the call bell at around 10:00 a.m. because they had to move their bowels and needed the bedpan right away. R18 stated a half an hour had past and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain an environment free from offensive odors for 2 of 3 days of survey (5/19/24 through 5/21/24) and to maintain the building in good repair and in a sanitary condition for 1 of 1 environmental tour (5/21/24). Findings: On 5/19/24 at 10:30 a.m., a surveyor observed a strong, foul odor of urine in the corridor outside room [ROOM NUMBER]. On 5/19/24 at 10:45 a.m., in room [ROOM NUMBER]-1, in an interview with the surveyor, Resident #9 (R9) stated that almost every day a strong urine odor from the hall seeps into his/her room and is very unpleasant. On 5/19/24, between 10:30 a.m. and 1:15 p.m., a surveyor observed a lingering, strong, foul urine odor in the corridor outside room [ROOM NUMBER]. On 5/20/24 at 7:30 a.m., in the corridor outside room [ROOM NUMBER], the strong, foul odor of urine continued and was observed throughout the day until 2:00 p.m. when the observations were…

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

Based on record reviews and interviews, the facility failed to complete neurological assessments as directed, failed to follow physician orders for obtaining vital signs, referrals, medication administration, and failed to order urgent/stat diagnostic testing timely for 6 of 10 sampled residents (Resident #37 [R37], R24, R68, R168, R26, and R71). Findings: The facility's policy, Neurological Evaluation, revised 2/1/23, directed staff to completed a neurological evaluation when a resident sustains an injury to the head, or face, and/or has an unwitnessed fall. Evaluations will be performed every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 60 minutes for 4 hours, and then every 8 hours until at least 72 hours as elapsed. 1. On 5/20/24, R37's clinical record was reviewed and included documentation that on 3/28/24 R37 was observed sitting on floor in-between the bed and nightstand and had a small bruise noted to forehead. On 5/20/24 at 10:18 a.m., during an interview with the Homestead Unit Manager, a surveyor confirmed that the Neurological Evaluation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to follow its own policy for oxygen use and humidification, failed to ensure physician orders were followed for oxygen administration, failed to ensure that oxygen tubing was changed weekly, and failed to ensure that respiratory equipment was maintained in a clean manner for 4 of 4 days of survey (5/19/24-5/22/24) for Resident #168 (R168). Findings: The facility's policy and procedure for Oxygen:Nasal Cannula, revised 8/7/23, indicated the following: - Verify order, -Determine if humidification is needed by using the table - 2 liters of oxygen per minute does not indicate the use for humidification, -Nasal cannula labeled with date of initial set-up, - If humidifier is used, label with date, - Replace disposable set-up every seven days, date and store in a treatment bag when not in use. R168 was admitted to the facility on [DATE]. The physician orders contained an order, dated 5/7/24, to administer oxygen at 2 liters per minute. The…

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

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all 73 residents that reside on the Homestead and Riverview units. This has the potential to affect all residents that need assistance with Activities of Daily Living (ADL). Findings: 1. On 5/19/24, R18's clinical record was reviewed. R18 was diagnosed with a Cerebral Vascular Accident (CVA) with hemiplegia and hemiparesis, wheelchair dependent, and the care plan indicated R18 requires extensive assist with toileting. On 5/19/24 at 10:35 a.m., in an interview with the surveyor, R18 stated he/she rang the call bell at around 10:00 a.m. because they had to move their bowels and needed the bedpan right away. R18 stated a half an hour had past and no one has answered his/her call bell. R18 stated their anal area was on fire and it hurt. R18's call bell was observed being answered at 10:50 a.m., fifty minutes after R18 stated he/she turned the call bell on. 2. On 5/19/24, R9's clinical record was reviewed. R9 was diagnosed 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 observations and interviews the facility failed to provide adequate dietary staff to ensure the dietary needs of residents were met timely for 3 of 4 days of survey (5/19/24, 5/20/24, and 5/21/24). Findings: Review of the posted meal times for Homestead dining room indicated breakfast is served at 8:00 a.m., lunch is served at 12:00 p.m., and dinner is served at 5:00 p.m. On 5/19/24 at 12:30 p.m., observation of lunch services in the Homestead dining room revealed residents in the dining room were served lunch one-half hour late. Meal trays were delivered to resident rooms up to 1:45 p.m., one and three quarter hours late. On 5/20/24 at 8:32 a.m., a surveyor observed breakfast trays arrived to the Homestead dining room one-half hour late. On 5/20/24 at 8:35 a.m., in an interview with surveyor, a resident stated, they are always late during the week, they are usually early on weekends. On 5/20/24 at 12:30 p.m., a surveyor observed lunch trays arriving to the Homestead dining room one-half hour late. On 5/21/24 at 8:32 a.m., a surveyor observed the breakfast trays arriving to…

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

Based on interviews and observations, the facility failed to serve hot foods hot and cold food cold on 1 of 4 days of survey (5/21/24). Findings: On 5/19/24 at 11:36 a.m., during a resident interview they stated concerns regarding the temperature of meals. On 5/19/24 at 12:30 p.m., observation of lunch service revealed residents in the Homestead dining room were served one-half hour late. Meal trays were delivered to resident rooms up to 1:45 p.m., one and three quarter hours late. On 5/20/24 at 8:29 a.m., during a resident interview they stated meals are always late during the week, hot foods are not always hot. On 05/20/24 11:56 a.m., during a resident interview they stated the food is not always warm. On 5/21/24 at 12:55 p.m., two surveyors received test trays with American Chop Suey and Pineapple Crisp (cold dessert) with whipped topping. The temperature of the chop suey was 116.9 degrees Fahrenheit, and 116.8 degrees Fahrenheit. The temperature of the Pineapple Crisp for both trays was 66.8 degrees Fahrenheit. The hot and cold foods on the test trays were found not to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to monitor food temperatures to prevent food borne illness prior to serving residents for 1 of 4 days of survey (5/19/24), failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing food in a sanitary manner for 2 of 4 days of survey (5/19/24, and 5/20/24) and failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code on 4 of 4 days of survey (5/19/24, 5/20/24, 5/21/24, and 5/22/24). This has the potential to effect all residents in the facility. Findings: On 5/19/24 at 10:10 a.m., during the initial tour of the kitchen, a surveyor observed on the shelf and available for use in the dry storage: 1 package- Lays Classic chips, opened and undated. 1 package- white powder, open, unlabeled, and undated. The package was resting on the shelf with biscuit mix and pancake mix. Staff were unable to determined what was in the package.…

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 interviews, the facility failed to ensure that a resident's preference for a second serving of the main meal choice for lunch was available on 5/21/24, for 1 of 1 residents (Resident #37 [R37]) reviewed for weight loss and received an appetite stimulant. Finding: On 5/21/24 a during lunch meal service on Homestead Unit, a surveyor observed that chop suey and salad was part of the main menu choice for lunch. R37 requested seconds because he/she did not get enough. A surveyor observed Certified Nursing Assistant #6 (C.N.A.6) call down to the kitchen and reported to R37 that there wasn't any left. On 5/21/24 at 1:10 p.m., during an interview with surveyors, the Food Service Director (FSD) stated that they ran out of the main meal choice of chop suey and salad. It is the last day before our delivery tomorrow, so we ran out, usually I would run to the store to buy lettuce but I couldn't because I was working as staff. Sometimes we do not have enough of something at the end of a supply period. We have a lot of double portions, we are not compensated double…

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 develop a care plan for the area Post Traumatic Stress Syndrome (PTSD) for 1 of 1 sampled resident with a diagnosis of PTSD (Resident #18 [R18]). Finding: On 5/21/24, a review of R18's care plan, under the care problem of 'Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to: depression, anxiety, PTSD.' There was no documented evidence of a care plan developed to address the issues of PTSD. On 5/22/24 at 9:55 a.m., in an interview with the surveyor, the Director of Nursing (DON) stated she did not find a care plan for PTSD other than it being mentioned as one of the problems under fluctuating mood symptoms in the care plan. The DON stated the Licensed Social Worker (LSW) told the DON an assessment of R18's PTSD was not done. The DON confirmed there was no care plan for PTSD.

Based on record reviews, observation, and interviews, the facility failed to ensure that weekly pressure ulcer assessment documentation, used to monitor the healing progress of the wounds, were completed, failed to follow physician orders in obtaining a wound clinic referral, and failed to follow a care plan for 3 of 4 residents reviewed with pressure ulcers (Resident #15 [R15], R68, and R31). Findings: 1. On 5/22/24, R15 clinical record was reviewed. Pressure wound documentation for wound #7, left gluteus; #8 right gluteus; and #9 left gluteus, were reviewed with the Riverview Unit Manager. The Wound Evaluation documentation in the clinical record lacked evidence of weekly assessments/evaluations for the week of 3/31/24-4/6/24 and 4/28/24-5/4/24. On 5/22/24 at 10:01 a.m., in an interview with the Riverview Unit Manager, a surveyor confirmed weekly pressure ulcer wound evaluation assessment/measurements for R15 were not done for the week of 3/31/24-4/6/24, and 4/28/24-5/4/24. 2. On 5/21/24, R68's clinical record was reviewed and included a physician order, dated 10/31/23, for 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 identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #18 [R18]). Finding: On 5/21/24, a review of R18's clinical record, in the Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate R18 had an active diagnosis for Post Traumatic Stress Syndrome (PTSD). The surveyor was unable to find information in the clinical record that indicated what R18's PTSD was caused by or what events might cause re-traumatization. On 5/22/24 at 9:55 a.m., in an interview with the surveyor, the Director of Nursing (DON) stated she did not find a care plan (goal and trauma interventions) for PTSD other than it being mentioned as one of the problems under fluctuating mood symptoms in the care plan. The DON confirmed the Licensed Social Worker (LSW) did not assess Resident #18's PTSD.

Based on record reviews and interviews, 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 8 sampled residents (Residents #15 [R15]). Finding: Documentation in R15's clinical record stated that the Physician signed the Physician Orders (block orders) on 2/12/24. These orders were in effect for 60 days. The next Physician Orders (block orders), including a 10-day grace period, needed review and the Physician's signature by 4/22/24. The medical record lacked evidence that Physician reviewed and signed orders on or around 4/22/24. Documentation in R15's clinical record stated that the Physician signed the Physician Orders (block orders) on 5/21/24, 29 days late, including the 10-day grace period. On 5/22/24 at 1:13 p.m. in an interview with the Senior Director of Nursing, a surveyor confirmed the above finding.

Based on observations and interviews, the facility failed to ensure opened insulin was labeled with an open date in 1 of 2 treatment carts (Homestead unit) and failed to remove expired medications from the supply available for use in 2 of 2 medication storage rooms (Homestead and Riverview units) Findings: On 5/19/24 at 11:16 a.m., a surveyor and a Licensed Practical Nurse (LPN1) observed a Basaglar KwikPen (Lantus) for Resident #35 that was in the treatment cart that did not have an open or discard date (Lantus is good for 28 days once opened and at room temperature). On 5/19/24 at 11:26 a.m. a surveyor and LPN1 observed the medication storage room on the Homestead Unit and found the following expired medications available for use: 2 bottles of Stool Softener 100 milligram with expiration date of 4/2024. On 5/19/24 at 11:32 a surveyor and LPN2 observed the medication storage room on the Riverview Unit and found the following expired medications: 2 bottles of Aspirin 325 milligram with an expiration date of 4/2024 These findings were confirmed by the surveyor at the time of 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 employee file reviews and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse for 1 of 4 Certified Nursing Assistants (CNA) reviewed (CNA3). Finding: On 5/22/24, the following employee record was reviewed: CNA3 was hired on 1/29/24. There was no documented abuse training completed by CNA3 in the employee file. On 5/22/24 at 3:09 p.m., in an interview with the surveyor, the Director of Nursing confirmed that she was unable to locate documentation indicating CNA3 completed her abuse training.

Based on facility policy review, facility reportable incident review and investigation with written statements, and interview, the facility failed to protect a resident from physical and mental abuse (intimidation) when a Certified Nursing Assistant (CNA) grabbed Resident (R)4's foot/ankle when R4 attempted to kick CNA1 a second time, after making contact the first time. CNA1 held R4's foot/leg against the bed to stop R4 from kicking, only letting go after R4 said he/she wouldn't kick CNA1 again. The action of CNA1 grabbing R4's foot/ankle resulted in right ankle swelling, bruising, and mild pain to R4. Finding: On 7/11/23, the Division of Licensing and Certification (State Agency) received a fax from the facility, alleging that on 7/11/23 at 2:50 a.m., R4 kicked CNA1, attempted to kick CNA1 again, when CNA1 grabbed R4's right foot/leg to stop resident from kicking. CNA 1 was sent home pending investigation and the Medical Provider would see R4 in the morning. Immediate treatment to R4 was his/her right lower leg was elevated, ice applied, with 1 to 1 attention provided to R4 to…

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

Based on facility policy review, facility's Reportable Incident Form, facility investigation, and interview, the facility failed to report an allegation of Abuse to Adult Protective Services (APS) and law enforcement for 1 of 1 investigated allegations of Abuse (7/11/23). Finding: The facility policy, Abuse Prohibition, last revised 10/24/22, indicated that staff are to 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. The External Abuse Reporting Requirements table indicated reporting to Law Enforcement and Adult Protective Services (APS) was required with the responsible person being the Administator or Director of Nursing. The Division of Licensing and Certification (DLC) received the facility's Reportable Incident Form, dated 711/23, alleging that on 7/11/23 at 2:50 a.m., Resident (R)1 kicked Certified Nursing Assistant (CNA)1 in the groin and attempted to kick CNA1 again, when CNA1 grabbed R4's right…

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

Based on observations and interviews the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for 2 of 6 meals observed (2/26/32 Lunch, 2/27/23 Breakfast) Findings: On 2/26/23 on the Homestead unit during the lunch meal observation between 12:00 p.m. and 12:45 p.m., residents at the long table nearest the doors, 3 residents were served their meals and 2 residents sat watching their tablemates eat and being assisted with their lunch. At the table nearest the back wall there were 3 residents eating their lunch meal and 3 residents were waiting for their lunch meals to be served. In the bar area near the nursing station there were 6 residents sitting, 3 residents were eating their meals and 3 residents were waiting for their meals to be served. 2 residents voiced being hungry and wanting their lunch. One resident stated, this happens every day. On 2/27/23 between 8:00 a.m. and 8:38 a.m. during breakfast service on Homestead unit, 6 residents were…

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

Based on observations and interviews, the facility failed to ensure that residents were allowed to choose their preferences for beverages throughout the day for 2 of 4 days of survey (2/26/23 and 2/27/23) Findings: On 2/26/23 between 12:00 p.m. and 12:45 p.m. during lunch meal observation on the Homestead unit it was observed that no coffee was served with the lunch meal. On 2/27/23 at approximately 8:00 a.m. a resident requested a cup of coffee. Staff were asked to assist resident with his/her request for coffee. Staff then stated that he/she already had a cup of coffee. When staff was asked if residents were limited for coffee, she stated the residents get coffee with breakfast only. When asked why the limitation she stated that the kitchen only sends up so much coffee and that the kitchen does not send up coffee carafes to be able to make more coffee. On 2/27/23 at 8:15 a.m. during an anonymous staff interview, it was stated that drink choices and being able to offer coffee except during breakfast has stopped a long time ago. They stated it was because the kitchen didn't send up…

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 good repair and in a sanitary condition on 2 of 2 unites (Riverside and Homestead) for 1 of 1 Environmental Tour. In addition, the facility failed to create a homelike dining experience for residents dining in the dining room and the bar area by serving their lunch and breakfast meals on a tray for 2 of 6 meals observed on the Homestead unit. Findings: On 3/01/23 from 1:52 p.m., to 2:00 p.m., two surveyors did an environmental tour with the facility Administrator, Maintenance Director, and Director of Housekeeping in which the following was observed: 1. Riverview Unit: - Cracked ceilings in Riverview entrance, and in Riverview hall near Activity room -[NAME] observed on the walls outside activity room - not cleanable surface -Water stain around ceiling speaker outside of employee staircase -Peeled wallpaper where wall meets ceiling, stained pulling apart from…

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 record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on the Riverview and Homestead Units. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL)'s. Findings: 1. Review of Facility Incident/Accident Report dated February 2023 revealed there were 17 falls, 5 resident to resident altercations and 6 injuries of unknown origin. During an interview on 2/26/23 at 11:13 a.m., Certified Nursing Assistant (CNA)7 indicated that on some weekends there are just 2 CNA's along with the med tech and the nurses do not help on the floor. During an interview on 2/26/23 at 11:30 a.m., CNA #6 indicated that staffing is really bad and quite often the nurse will have to cover the whole building during the evening shifts and when the residents with Alzheimer sundown [behaviors that begin in the evening] there is a lot going on and no one around to help. During an interview on 2/26/23 at 12:00 p.m., a Homestead family member…

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, observations, and interviews, the facility failed to follow a written physician's order for heart rate parameters prior to administering a medication for 1 of 6 residents observed during medication administration (Resident #10). Findings: 1. On 2/11/23 during a clinical record review, the surveyor noted Resident #10 had a written physician's order dated 11/1/21 for Metoprolol Succinate ER Tablet Extended Release 24 Hour Give 100 mg (milligrams) by mouth one time a day for A-Fib (Atrial Fibrillation, irregular heart beat), HTN (hypertension, high blood pressure) HOLD FOR HR (heart rate) < (below) 60 BPM (beats per minute). 2. Upon review of Resident #10's electronic medical administration record (EMAR), there is no evidence that Resident #10 had his/her heart rate taken prior to administration of the medication Metoprolol on 2/28/23. On 2/23/23 at 8:11 a.m., in an interview with a surveyor, the Director of Nursing confirmed that Resident #10's heart rate was not taken before the administration of the medication Metoprolol, and the medication was given without…

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 staff interviews and observations the facility failed to offer snacks to all residents on 1 of 2 units (Homestead Unit) Findings: During the recertification and complaint survey on 2/26/23 thru 3/1/23 through observations and during anonymous interviews with staff, the staff stated that on a regular basis there are no snacks to offer residents. The activity person will have snacks for them at times but if someone is hungry there is nothing to offer them. The staff denied having any sandwiches on the unit to offer the residents, the staff can call down to the kitchen but only if the kitchen is open, and by the time it comes up the resident has forgotten they are hungry. The staff stated that the residents with labeled snacks, (snacks that come from the kitchen with individual resident names), are the only ones that get snacks, and the snacks are passed by the Certified Medication Aide (C.N.A.-M), and it is usually a supplement shake. On 2/26/23 during Homestead unit observations it was observed by two surveyors that there were no snacks to offer the residents. Mother's…

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

Based on record reviews and interview the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for Treatment Administration (Resident's #43). Findings: Resident #43 was admitted to facility on 5/28/19 with diagnoses to include dementia, major depressive disorder, adult failure to thrive, and is receiving end of life care. During an initial observation of Homestead kitchenette on 2/26/23 at 12:43 p.m. two surveyors observed 1 vanilla magic cup (dietary supplement) dated 2/25 for with Resident #43's name on it in refrigerator. At this time Certified Nursing Assistant #6 observed the magic cup, confirming it belonged to Resident #43 and should have been given to him/her yesterday 2/25/23. Review of Resident #43's provider orders active for February 2023 revealed order with start date of 5/10/21 states: other. Two times a day magic cup/nutritional treat appropriate for those on thickened liquids BID. Review of Resident #43's February 2023 Treatment Administration Record (TAR) revealed on 2/25/23 Resident…

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.