Breakwater Commons

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 the storage chemicals being properly secured for 2 of 2 observations for 1 of 4 days of survey. (4/6/26)Findings:The Safety Data Sheet for Febreze Air Effects Gain Original noted in Section 4:Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention immediately if irritation persists.Skin Contact: None under Normal Use.Ingestion: Not an expected route of exposure. If swallowed, clean mouth with water and afterwards drink plenty of water.Inhalation: None under Normal Use. On 4/6/26 at 9:40 a.m., a surveyor observed in resident room [ROOM NUMBER], two 8.8 ounce spray bottles of Febreze Air Effects Gain Original sitting on a shelf at the foot of the resident's bed.On 4/6/26 at 9:46 a.m., in an observation and interview with a surveyor, a Licensed Practical Nurse (LPN)…

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, facility policy, 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 3 sampled resident reviewed with a current diagnosis of PTSD. (Resident #74)Findings:Review of the facilities policy titled Trauma Informed Care developed in 10/2019 under section Purpose states Trauma-specific intervention(s) will be placed on the residents' care plan, and this will be reviewed quarterly and updated as necessary. A review of Resident #74's clinical record indicated he/she was admitted to the facility in 2023 with the diagnosis post-traumatic stress disorder (PTSD). Further review of his/her clinical record revealed a quarterly Minimum Data Set (MDS) 3.0 completed on 4/8/26 which showed, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #74 had an active diagnosis for Post Traumatic Stress Syndrome (PTSD). Review of Resident #74's Trauma Screen indicated that he/she has trauma related to…

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

Based on observations and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment for 2 of 3 medication refrigerators observed (West Unit medication refrigerator, South Unit medication refrigerator). Additionally, the facility failed to ensure medications were stored properly in medication storage refrigerators on 3 of 3 units ( East Unit, [NAME] Unit, and South Unit).Findings:1. On 4/8/26 at 10:40 a.m. during an observation of the South Unit Medication Room, Certified Nursing Assistant Medication-Medication Tech (CNA-M) #2 accessed the locked medication room with her employee badge. Inside the unlocked refrigerator was an unaffixed plastic box with a handle, containing three 30 milliliter (mL) vials of lorazepam oral concentrate (a Schedule IV controlled medication).Additionally, the refrigerator was a dormitory-type refrigerator (a compact, combination refrigerator/freezer unit outfitted with one exterior door), which is not proper for storing medications due to temperature fluctuations. There was ice buildup in the freezer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2 Review of Center for Disease Control: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated July 12, 2022 states Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Review of facility provided Foley Catheter list revealed Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 had indwelling foley catheters.…

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 obtain a physician order to change an indwelling urinary catheter (Foley catheter) for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Finding: Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and Foley catheter. Review of Resident #1's clinical record revealed a nursing progress note, dated 4/29/25, stating, Resident complained of pain with [his/her] foley catheter. Foley was not flowing. This nurse flushed foley with no relief. Foley catheter 16 french was changed out. Balloon filled with 10 cc [cubic cenimeters]. Resident stated relief from pain. No issues with the foley change. Resident tolerated well. 750 urine output. Further review of Resident #1's clinical record lacked evidence of a provider order for an as-needed (PRN) Foley catheter change. On 5/28/25 at 1:51 p.m., during an interview, Nurse Practitioner (NP) #1 stated she was unaware of the above Foley catheter change on 4/29/25. On 5/28/25 at 4:28 p.m.…

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 ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Findings: 1. Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and indwelling urinary catheter (Foley catheter). Review of Resident #1's active physician orders revealed an order with a start date of 1/13/25 for, Intake and Output (I & O) 2 Times Daily . Review of the April and May 2025 Treatment Administration Records (TAR) revealed I & O is scheduled daily at 5:00 a.m. and 6:00 p.m. Further review of the April 2025 and May 2025 TAR lacked documentation of intake and lacked evidence that output was recorded on the following dates: -4/1/25 at 5:00 a.m. -4/6/25 at 5:00 a.m. -4/8/25 at 5:00 a.m. -4/11/25 at 5:00 a.m. -4/27/25 at 6:00 p.m. -5/7/25 at 6:00 p.m. On 5/28/25 at 11:15 a.m., during an interview with 2…

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 its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, related to intake and output (I & O) documentation resulting in inaccurate and incomplete documentation.During the revisit survey on 7/16/25, F-842 was recited related to incomplete intake and output (I & O) documentation. The facility POC indicated a date of correction date of 7/10/25 that included the following corrective actions: A house audit was performed by the unit managers of resident charts for residents with an order for I & O tracking. Educate nurse managers on documenting the facility order protocol inclusive of entering verbal provider orders into the clinical chart. Nurse managers/designee will conduct weekly audits for 60 days. Audit results will be reviewed in QAPI. On 7/16/25 a.m. at 2:00 pm during an interview with a surveyor, the above finding was confirmed with the Regional Quality Improvement Specialist.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement and maintain an effective training program for nursing staff in the areas of urinary catheter care, as part of the facility's follow-up to their facility reported incident dated 5/12/25. Additionally, the facility failed to implement and maintain an effective training program for nursing staff contracted through a staffing agency, in the areas of urinary catheter care and infection prevention, for 2 of 2 staff reviewed during an investigation of a facility-reported incident (Licensed Practical Nurse [LPN] #2, #3). Findings: 1. The facility's 5-day follow-up, submitted to the state agency on 5/19/25, states, .The clinical coordinator will educate licensed staff on foley catheter policies and procedures . Upon entrance to the facility, the survey team requested evidence of the above education. A folder, containing educational materials titled, Flushing Urinary Catheters, Catheter Care Competency, Urinary Catheter or Urinary Tract Infection…

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 3. Resident #16 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #84 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 5. Resident #17 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 6. Resident #83 was admitted 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 adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 units (East and South) for 3 of 3 days of survey. Findings: East Unit: 1. On 1/21/25 at 11:28 a.m., observations of room [ROOM NUMBER]'s, shared bathroom with 2 basins stored on the floor under the sink. One of the basins had a commode bucket stored in it. room [ROOM NUMBER]'s bathroom had a wash basin on the floor with commode bucket stored inside of it. 2. On 1/22/25 at 8:41 a.m., observations of room [ROOM NUMBER]'s bathroom had a commode bucket on the floor with the basin stored inside of it. room [ROOM NUMBER]'s bathroom had a commode bucket stored on the floor. 3. On 1/23/25 from 8:13 a.m. to 8:21 a.m., the Surveyor and the Director of Nursing discussed the above observations and observed both rooms [ROOM NUMBERS]'s bathrooms with commode buckets stored on the floor. South Unit: 4. On 1/21/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of cardiac pacemaker (Resident #86, #83), hospice services (#243), respiratory needs (#54, #16) and psychoactive medications (#71) for 6 of 26 sampled residents reviewed for comprehensive care plans. Findings: 1. On 1/21/25 at 9:56 a.m., during an interview, Resident #86 stated he/she had a pacemaker placed about 1 year ago and is followed by cardiology. Review of Resident #86's medical record states he/she was admitted on [DATE] with a diagnosis of sick sinus syndrome, chronic atrial fibrillation and nonrheumatic aortic insufficiency with the presence of cardiac pacemaker. The medical record lacked evidence that a comprehensive care plan had been developed in the area of a cardiac pacemaker. On 1/22/25 at 11:32 a.m., during an interview, the [NAME] President of Quality Improvement and Nursing Services the care plan lacks pacemaker. 2. Resident #83 was admitted on [DATE] with diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8. Resident #71's medical record, surveyor noted two MDS Significant change assessments, dated 2/15/24 and 5/1/24 and two MDS Quarterly assessments dated 7/1/24 and 9/4/24. The clinical record lacked evidence that a care plan meeting was held by the IDT for the 2/15/24, 5/1/24, 7/1/24 and 9/4/24 assessments. On 1/23/25 at 1:41 p.m., the above finding was confirmed with the [NAME] President of Quality Improvement and Nursing Services 3. On 1/21/25 at 9:07 a.m., during an interview, Resident #90 stated he/she was not sure if he/she had an IDT meeting. Resident #90 was admitted on [DATE] and had an admission MDS completed on 1/1/25. The medical record lacks evidence that an IDT meeting, which included the participation of the resident and resident's representative, was held within 7 days of this assessment. On 1/21/25 at 2:29 p.m., during an interview, the [NAME] President of Quality Improvement and Nursing Services stated social services believes they had one on either the 7th or the 14th but they failed to have…

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, facility policy, and manufacturer directions, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition for 1 of 2 residents reviewed (Resident #60) and in the area of falls for 2 of 3 residents reviewed (Residents #79, #37). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled residents (Residents #40, #70). Findings: 1. Review of manufacturer directions dated November 2024 states NovoLog is a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults . with diabetes .NovoLog starts acting fast. Eat a meal within 5 to 10 minutes after taking it . Resident #60 was admitted on [DATE] and has diagnosis to Diabetes Mellitus II. Review of Resident #60 active orders dated January 2025 reveled order with state date of 11/30/24 for Novolog U-100 Insulin; Aspart 100 unit/mL subcutaneous…

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 3. On 1/21/25 at 9:15 a.m., 1/22/25 at 8:41 a.m., and on 1/23/25 at 8:21 a.m., observations of Resident #17's oxygen nasal cannula tubing dated 1/13 and an undated nebulizer pipe stored on the back of the nebulizer machine and the bedside dresser. Review of resident #17's medical record had providers orders dated 1/9/25 to Change Tubing 1 Time Weekly, Clean/Store oxygen tubing not in use 1 Time Weekly and provider orders dated 1/4/25 for ipratropium 0.5 mg (milligram)-albuterol 3 mg (2.5 mg base)/3 mL (milliliter) nebulization solution .Inhalation Three Times Daily. The most recent care plan for Impaired Respiratory secondary to Acute on Chronic Respiratory Failure, RLL (right lower lobe) Pneumonia, COPD AEB (chronic obstructive pulmonary disease acute exacerbation) need for hospitalization, respiratory medications/treatments and supplemental Oxygen with interventions of Change oxygen tubing weekly; label and date. Review of the January treatment administration records states the oxygen tubing was changed on the…

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

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 3 of 5 medication/treatment carts reviewed for medication storage. Findings: 1. On 1/22/25 at 7:30 a.m., observation of the South unit nurse treatment cart #2 with the Registered Nurse #2 (RN#2), the cart contained an opened and undated vail of Tuberculin Purified Protein Derivative with manufactures instructions of Store between 36 degrees - 46 degrees F and Once entered vial should be discarded after 30 days. At this time, RN#2 confirmed the Tuberculin vial was not labeled or stored correctly and immediately wasted the vial. 2. On 1/22/25 at 7:36 a.m., observation of the South unit medication cart with the Certified Medication Technician #1 (CNA-M #1), the cart contained an opened bottle of Acidophilus w/Pectin with the manufactures instructions to refrigerate after opening, one opened bottle of Famotidine 10mg (milligram) with an expiration date of…

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

Based on observations, interviews, and policy review the facility failed to ensure foods were dated and labeled in, stand up freezer, dry storage room and the walk in freezer. In addition, the facility failed to discard obvious freezer burned food on 1 of 3 survey days. Additionally, the facility failed to ensure a sanitary environment during 1of 2 dining observations of meal service on 1 of 3 units. Findings: Review of policy Food Storage undated states . All containers must be legible and accurately labeled and dated .Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days (4 days or 96 hours per Maine regs) or discarded. During an initial kitchen tour with 2 surveyors and the Dietary Manger on 1/21/25 between 8:22 a.m. and 8:45 a.m., the following was observed: -Dry storage area: A rolled up unlabeled clear bag containing unknown brown crumbly substance with open date of 11/12 available for use. -Stand up freezer: Small undated blue squeezable…

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 Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings On 1/22/25, a surveyor reviewed the following employee education files: 1. CNA #1 was hired 12/5/1994. Review of CNA #1 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 2. CNA #2 was hired 8/31/2020. Review of CNA #2 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 3. CNA #3 was hired 3/18/2013. Review of CNA #3 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 4. CNA #4 was hired 2/8/2021. Review of CNA #4 Employee In-service/attendance Records lacked evidence that she completed…

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 a medical provider and the resident's representative were notified of a significant change in medical condition for 1 of 2 residents reviewed for death (Resident #243). Finding: Upon review of Resident #243's clinical record, a hospice Discharge Summary dated 10/16/24 stated during a telephone call, the resident's representative reports anger with the facility that she was not notified of [Resident #243's] change in status from transitioning to active and was not given the opportunity to be present when [Resident #243] died. Review of all the Nursing notes from 10/2/24 through 10/5/24 included all of the following: Nursing note on 10/2/24 at 1:37 p.m. stated, Alert but not swallowing well and pocketing of food noted at lunch. [Doctor] notified. New orders received and noted to downgrade to puree texture diet. Notified [resident representative] of new order. Nursing note on 10/2/24 at 6:11 p.m. stated, Had eaten all of (his/her) mashed potatoes for lunch today, however at dinner resident has been holding puree…

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 a Minimum Data Set, Version 3.0 (MDS) Significant Change in Status Assessment was completed within 14 days from the effective date of the Hospice election, for 1 of 2 sampled residents reviewed for hospice (Resident#243). Finding: The Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, page 2-23 reads that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Resident #243's clinical…

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 the review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 1 of 5 CNA's reviewed with employment greater than 1 year. (CNA#4) Finding: CNA #4 was hired on 2/8/21. The employee lacked evidance of a annual preformance evaluaion being completed for 2024. On 1/23/25 at 11:32 a.m , during an interview, the [NAME] President of Clinical Services and Qaulity Improvement confirmed CNA #4 did not have a preformace evaluation on file for the year of 2024.

Based on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, meeting attendance sheet and Power Points provided, the facility failed to present evidence that the required members attended 3 of 4 quarters provided. Finding: The facilities QAPI Plan under Governance and leadership states, The Administrator is responsible for the successful implementation of the QAPI Program through enforcement of scheduling and education to participants. On 1/22/25 at 11:37 a.m., during an interview with 3 surveyors present, the Administrator was only able to provide an attendance sheet for the 12/19/23 QAPI meeting stating, the previous Director of Nursing put the power point presentations together, and he thought she was taking attendance. He then stated the Medical Director at the time was not at the 3rd quarter QAPI. Review of the QAPI power points from Quarter 1 (4/23/24), Quarter 2 (7/23/24) and Quarter 3 (11/26/24) lacked evidence of the required member's attendance. In addition, the QAPI failed to include the infection preventionists for 4 of 4…

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 record review, the facility failed to maintain an Infection Control Program designed to help prevent the development of infections related to Subcutaneous injected medication for 1 of 1 resident observed for subcutaneous medication administration (Resident #60). Finding: The facilities Injectable Medication Administration policy revised 1/2018, states under Purpose: To administer medications via subcutaneous .routes in a safe, accurate and effective manner and Equipment Required .Examination gloves The facilities Medication Administration - General Guidelines policy revised 1/2018, states under Administration . Hands are washed before putting on examination gloves and upon removal for administration of . injectable medications. On 1/22/25 at 7:20 a.m. during observation of Resident #60's medication administration with a Register Nurse #1(RN#1). The RN#1 prepared the Novolog Insulin for a subcutaneous injection and entered the resident's room, without performing hand hygiene and donning gloves, he immediately cleansed the residents right lower…

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 immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed (#16) Finding: The facility's Immunization Policy indicated in Procedure I: Before offering the Influenza or Pneumococcal vaccine or COVID vaccine, each resident, and/or resident's legal representative will receive the appropriate Vaccine Information Statement (VIS) produced by the Maine and/or Federal Centers for Disease Control regarding the benefits and potential side effects of the vaccines for the current year. The resident's clinical record will include the following documentation: Signature of the person receiving the educational material, designating receipt and understanding of the material. Verbal consent may also be obtained if communication is done via a telephone conversation. Proof the resident either received the Influenza, COVID and/or the Pneumococcal vaccine, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed (#16) Finding: The facility's Immunization Policy indicated in Procedure I: Before offering the Influenza or Pneumococcal vaccine or COVID vaccine, each resident, and/or resident's legal representative will receive the appropriate Vaccine Information Statement (VIS) produced by the Maine and/or Federal Centers for Disease Control regarding the benefits and potential side effects of the vaccines for the current year. The resident's clinical record will include the following documentation: Signature of the person receiving the educational material, designating receipt and understanding of the material. Verbal consent may also be obtained if communication is done via a telephone conversation. Proof the resident either received the Influenza, COVID and/or the Pneumococcal vaccine, 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 interviews and review of the facility internal investigation reports, the facility failed to ensure that 2 of 5 residents reviewed were treated with dignity and respect (#1, #4) . Findings: 1. On 10/21/24, the Division of Licensing and Certification received a facility reported incident. The report noted that a Resident #1 complained to his/her family member that there was a bar under him/her. The family member moved the bed linens and saw that a bedpan had been left underneath the resident. A review of the clinical record for Resident #1 revealed diagnoses that included Alzheimer's Disease and recent fractures of the left hip and humerus. A review of the Minimum Data Set (MDS) 3.0, admission Assessment, dated 10/17/24, noted in Section C0500, Cognitive Patterns, a BIMS (Brief Interview of Mental Status) score of 3, indicating severe cognitive impairment. Section GG0130, Self Care, Resident #1 was dependent on staff for toileting, lying to sitting, and sitting to standing for bed mobility. A review of the facility's internal investigation noted staff had failed 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 observation and interviews, the facility failed to serve food in accordance with professional standards for food service safety by not delivering food in a sanitary manner for 1 of 1 units observed during the noon meal service. (East unit) Finding: On 11/12/24 at 12:10 p.m., a surveyor observed the noon meal service on the East unit. A CNA (Certified Nursing Assistant) was observed carrying a tray with an uncovered plate of pot pie and an uncovered dessert down a hallway to a resident's room. The CNA returned to the serving line with the tray and stated the resident wanted a salad instead. The surveyor asked if meals were always delivered to residents in their rooms in this manner. The dietary aide stated meals were always delivered on trays this way. At this time, the surveyor observed several CNAs were present at the serving line. The surveyor asked if they knew the correct way the trays should be delivered. One CNA picked up a plate cover and placed it over the next meal tray's plate. The CNA who had delivered the uncovered tray asked the surveyor if all items 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, the facility failed to maintain a comfortable homelike environment for 1 of 2 units reviewed during a complaint investigation (Memory). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received an anonymous compliant indicating on 9/8/24 at 10:30 a.m., indicating on multiple times when [family member] has visited her mother/father in the morning, his/her room has been very cold. Resident #1 was admitted on [DATE] and has diagnoses to include dementia, anxiety, depression, and is receiving Hospice services for end of life care and resided on the Memory Care unit. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. During an interview with 2 surveyors on 9/26/24 at 10:30 a.m., Memory Care Unit Manager (UM) indicated a couple of weeks ago he/she came to work in the am and observed a resident coming out of his/ her room and they looked cold, UM went over 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 record review, interviews, observations, and facility policy, the facility failed to update and include goals and interventions on the resident's current comprehensive care plan for the areas of falls for 1 of 3 residents reviewed (Resident #2), incontinent care for 1 of 3 residents (Resident #3), and psychotropic medication use for 3 of 3 residents reviewed during a complaint investigation. Findings: Review of facility policy Psychoactive Medication Use Policy dated 9/18 states Psychoactive medications will only be used in conjunction with the Individual Care Plan . 1. Resident #1 has diagnoses to include hypertension (HTN), kidney disease, dementia, anxiety, and depression and is receiving Hospice for end of life care. Review of active medication orders dated September 2024 revealed Resident #1 was taking anti-anxiety medications Ativan and Lorazepam, antidepressant Sertraline, and antipsychotic Risperdal. Review of Resident #1 Care plan most recently reviewed on 9/24/24 revealed Mood: I have…

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 policy review, record reviews, and interviews the facility failed to establish/implement their own grievance policy reviewed for 1 of 4 records reviewed during a complaint investigation (Resident #3). Findings: On 7/29/24 at 9:24 a.m., the Department of Licensing received a complaint indicating they filed a grievance on behalf of their family member (Resident #3) on 7/25/24 and did not receive a response for 30 days, even though [complainant] kept inquiring. Complainant further indicated [he/she] was informed the Grievance Officer was the Director of Nursing (DON) and the facility provided [him/her] with 2 different grievance policies, one policy states a response will be received in 15 days, and the other says they will respond in a reasonable amount of time, but they never told [him/her] what a reasonable amount of time was. Review of facility provided Grievance Policy dated 10/18 states The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed through the investigation and resolution process. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that an injury of unknown origin was reported to the State Agency after a resident was found on the floor and bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received a compliant indicating on 9/8/24 at 10:30 a.m., Resident #1, who is a high fall risk was left in his/her room unattended in a Broda chair and was found face down on the floor, sustaining head and right hand laceration requiring transfer to and acute care hospital for evaluation and treatment. Resident #1 has diagnoses to include dementia, anxiety, depression, is dependent on staff for all Activities of Daily Living (ADL)'s and is receiving Hospice services for end of life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Review of facility…

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 investigate an injury of unknown origin after a resident was found on the floor, bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1). Findings: On 9/11/24 at 8:00 a.m., the Department of Licensing received a compliant indicating on 9/8/24 at 10:30 a.m., Resident #1 who is a high fall risk was left in his/her room unattended in a Broda chair and was found face down on the floor, sustaining head and right hand laceration requiring transfer to and acute care hospital for evaluation and treatment. Resident #1 has diagnoses to include dementia, anxiety, depression, and is receiving Hospice services for end of life care. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Review of Resident 1's clinical record revealed that he/she is dependent on staff for Activities of Daily Living (ADL)'s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for incontinent care (Resident #1). Findings: Resident #3 was originally admitted on [DATE] and has diagnoses to include neurogenic bladder. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed he/she is dependent on staff for all Activities of Daily Living (ADL). Review of Resident #3 Care plan initiated on 6/18/24 revealed Urinary Continence: I am incontinent of urine. I require your total assist for incontinence care.Check for incontinence at times such as before or after meals, HS, and prn; change if wet/soiled [minimum of 6 times daily]. Review of ADL Verification Worksheet dated July 2024 revealed Resident #3 received incontinent 1 (one) time on 7/10/24, 7/18/24, 7/24/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 3 sampled residents observed for accommodation of needs. (Resident #3). Findings: Review of Facility assessment dated (4/5/24 currently under revision) states .Typed of Disease and Conditions: .Below is a list of common diseases, conditions, physical and cognitive disabilities .that require complex medical care and management that we commonly provide care .Vision: Cataracts, Glaucoma, Macular Degeneration, Blindness . Review of facility email dated 8/10/23 at 6:36 p.m. states .Subject: division for blind FYI: Finally made contact with Division of the blind for our visually impaired resident that has fallen outside and has ADA complaints The person is out next week for training but will be in the following week to map the building and outside . The facility did not provide any further information for this visit. Resident 3 was originally admitted to facility on 3/1/22 with diagnoses to include blindness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, the facility failed to notify the State Agency after two (2) falls that resulted in head injury. (Resident 1, and Resident 2.) Findings: 1. Resident 1 was originally admitted on [DATE] with diagnoses to include diabetes myelitis, Heart failure, hypertension, aphasia, dementia, hemiplegia, and seizure disorder. On 11/2/24 Resident 1 was found on the floor in his/her room after an unwitnessed fall. Resident 1 was sent to the emergency room and subsequently admitted with a brain bleed. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 1 has a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating he/she is not cognitively intact. Further review of MDS revealed Resident 1 had a history of falls and needs substantial assistance with Activities of Daily Living. Review of Resident #1's clinical record revealed the following progress note dated 11/2/23 stating Resident was found face down on the floor by writer. Resident stated [he/she] fell off 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review and facility policy, the facility failed to thoroughly investigate two falls with head injury (Resident 1 and Resident 2). Findings: Review of facility policy Accidents/Incidents Involving Residents dated 12/14/21 states, Each incident or accident must be detailed in the medical record. This includes happening or experience which may be traumatic or inflict bodily injury to a resident . Each incident, accident . must be investigated immediately for determination of root cause. The DNS (or designee) will audit the system for completion/compliance . 1. Resident 1 was originally admitted on [DATE] with diagnoses to include diabetes myelitis, Heart failure, hypertension, aphasia, dementia, hemiplegia, and seizure disorder. On 11/2/24 Resident 1 was found on the floor in his/her room after an unwitnessed fall. Resident 1 was sent to the emergency room and subsequently admitted with a brain bleed. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 1 has 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 interviews, record review and policy review the facility failed to update/implement care plans in the area of falls for 2 of 3 residents reviewed for falls (Resident's 1 & 2) and in the area of psychotropic medication use for 1 of 3 residents reviewed for medications (Resident 3). Findings: Review of facility policy Falls Management Policy dated 7/19 states .DNS or designee will review fall incident reports regularly and identify potential patterns or trends. Resident's care plan will be updated with all new interventions. Review of facility policy Psychoactive Medication Use Policy dated 9/18 states .A psychoactive drug is any medication affecting brain activity associated with mental processes and behavior . Psychoactive medications will only be used in conjunction with the Individual Care Plan. 1. Resident 1 was originally admitted on [DATE] with diagnoses including dementia, left sided hemiplegia, and seizure disorder. On 11/2/24 had an unwitnessed fall and was transferred to the emergency room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician and the resident representative of significant changes in the resident's condition in a timely manner for 1 of 1 sampled residents. (1#) Finding: On 3/13/24, a review of Resident #1's clinical record was completed. Resident #1's clinical record indicates he/she was hospitalized on [DATE] and diagnosed with a Hemorrhagic stroke. A Physician/Nurse Communication Tool dated 2/19/24 at 10:08 a.m. indicates Resident #1 had left sided weakness, slurring speech and drooping on the right side of his/her face. The blood sugar was noted to be 65 and Blood Pressure 196/90. Nursing progress notes on 2/19/24 at 10:57 a.m. indicate that Resident #1 had a low blood sugar of 65 before breakfast and was given juice, also noticed left sided weakness, slurry speech and facial drooping as well as incontinence of bladder, leaning to the left side, lethargy and confusion noted. Resident #1's blood pressure was noted to be 196/90. Resident #1 was given…

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 for 2 of 3 units(East Wing-100s and South Wing-200s) for 1 of 1 environmental tour. Findings: On 11/1/23 from 1:20 p.m. to 2:10 p.m., during a tour of the facility/resident rooms with the Environmental Services Director and the Maintenance Assistant, the following findings were observed: East Wing-100s > Resident room [ROOM NUMBER] - There was a bedpan on the floor in the bathroom. > Resident room [ROOM NUMBER] - There were two (2) commode buckets on the floor in the bathroom. > Resident room [ROOM NUMBER] - There was a wash basin on the floor under the sink in the bathroom. > The sit-to-stand patient lift, in the hallway by room [ROOM NUMBER], had debris and dirt in the base area and the arm pads and frame were dusty/dirty. > Resident room [ROOM NUMBER] - There were two (2) commode buckets on the floor in the bathroom.…

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, interview, and the facility's Food Storage and Leftover Food Storage policy, Daily High-Temp Ware Wash checklist Policy, Daily High-Temp Ware Wash checklist Policy, and Refrigerator and Freezer Temperatures checklist Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food slicer and ceiling vents; failed to ensure all staff were wearing facial hair protectors; failed to ensure foods were labeled and/or in the dry storage room, reach-in refrigerator, the reach-in freezer, the walk-in refrigerator and the walk-in freezer for 1of 1 kitchen tour on 1 of 3 days of survey. (10/30/23). Additionally, the facility failed to ensure temperatures were monitored for the dish machine and the refrigerators/freezers for dates in August, September and October 2023. Findings: The facility's Food Storage and Leftover Food Storage policy noted: Procedure: 4. All containers must be legible and accurately labeled and dated. 7. c. Food should be dated as it is placed on the shelves if required by state regulation. d. Date marking 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 observations, interview and review of the Safety Data Sheets, the facility failed to ensure that the resident environment remained free from the potential risk of accidents when they failed to ensure that two chemicals were properly secured during 1 of 3 days of survey (10/30/23). Findings: 1. On 10/21/23 at 9:30 a.m., a surveyor observed a 19-ounce spray can of Lysol Disinfectant Spray and a jar of pumpkin spice scent crystal beads sitting on Resident #20's bedside table. The Safety Data Sheet for the Lysol Disinfectant Spray noted: Section 2. Hazards identification: Keep out of reach of children. Section 4. First Aid Measures: Eye Contact: Immediately flush with plenty of water, occasionally lifting the upper and lower eyelids. Check for and remove any contact lenses. Continue to rinse for at least 10 minutes. Get medical attention if irritation occurs. Inhalation: Remove victim to fresh air and keep at rest in a position comfortable for breathing. If not breathing, if breathing is irregular or if…

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's Quality Assurance Committee failed to ensure that the plan of correction for an identified deficiency from the Annual Long Term Care Recertification survey dated 11/1/23 was followed and effective. The Federal citation F584 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 12/7/23. Findings: During the annual Long Term Care Recertification survey, dated 10/30/23 through 11/1/23, a deficiency was cited at F584 for the failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. The facility's POC, dated 11/18/23, indicated that the facility would be cleaned and repairs made to ensure that the building and equipment would be in good repair and in a sanitary condition, with plan of POC completion date of 12/1/23. On 12/7/23 at 11:55 a.m., in an exit interview with the Director of Nursing, she confirmed that the environment had not been brought into compliance as stated in the facility's Plan of Correction.

Based on observations, interviews and record review the facility failed to ensure that a resident's care plan was implemented, for 1 of 1 sampled resident reviewed for a hearing aids (#1). Findings: On 9/26/23 the surveyor reviewed Resident #1's current care plan. dated 9/5/23. under cognitive loss interventions noted: Attempt to remove hearing aid at night x1 and put on charger. If he/she refuses/resists, notify nurse to call [resident representative] Attempt to put hearing aid in x1 in morning. If [he/she] refuses/resists notify nurse to call [resident representative]. On 9/26/23 at 9:35 a.m., a surveyor observed Resident #1 dressed for the day and resting in his/her bed. The resident was having a hard time hearing the surveyor. The surveyor observed a clear locked box secured to the night stand which contained a cell phone and a hearing aid charger with a hearing aid in the charger. On 9/26/23 at 10:00 a.m., in an interview, CNA #1 confirmed that she had not put the hearing aid in the Resident #1's ear or attempted to this morning. CNA #1 stated, I thought the night shift, who…

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 and syringes was locked on 1 of 3 units. (Memory Care Unit) Finding: On 9/26/23 at 12:27 p.m., a surveyor observed an unlocked, unattended treatment cart for 3 minutes outside the Memory Care unit nurses station. There was no staff in sight. During this time, the surveyor was able to open all 3 of the treatment cart draws, all which contained multiple medicated creams, powders, ointments and syringes. At approximately 12:30 p.m., a Certified Nurses Assistant - Medication Technician (CNA-Med tech) returned to her locked medication cart. The surveyor asked the CNA-Med tech if the treatment cart should be locked? The CNA-Med tech stated It should be locked. It's the nurses cart today, and walked away from the treatment cart leaving it unlocked. At approximately 12:33 p.m. LPN #1 returned to the treatment cart and locked it. LPN #1 acknowledged that the treatment cart should have been locked. On 9/26/23 at approximately 3:10 p.m., a surveyor…

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.