Woodlawn Rehabilitation & Nursing Center

Based on observations and interviews, the facility failed to ensure medications were stored in a locked compartment for 1 of 3 medication areas (East Medication Storage Room), opened insulin was labeled with an open date, and expired medications were removed from the available for use supply in 2 of 3 medication storage rooms (West Medication Storage Room and East Medication Storage Room).On 7/29/25 at 9:30 a.m., during an observation and interview with two surveyors and the Licensed Practical Nurse #1 (LPN1), the following were observed and confirmed to be on the shelf and available for use in the [NAME] Medication Storage room:1 open box containing 650 milligrams (mg) Acetaminophen Suppositories with an expiration date of 12/20241 tube containing 1 ounce (oz) Vagicaine Anti-itch Cream, with an expiration date of 6/30/241 box containing Miconazole Vaginal Antifungal 7 day treatment with an expiration date of 5/24/251 pre-filled 3mL insulin pen labeled Lantus Solostar (Insulin Glargine) 100u/mL , the pen was labeled with conflicting open dates (cap labelled with an open 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 review of the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the three-bay pot sink and the walk-in freezer. Additionally, the facility failed to ensure foods were dated and/or discarded after best used by date in the walk-in refrigerator and on a beverage cart on a unit for 2 of 2 tours (7/28/25, and 7/29/25). The facility's Food Storage policy/procedure, dated 3/4/25, noted under Procedure: …All containers or storage bags must be legible and accurately labeled and dated. Refrigerated Food Storage: All foods must be covered, labeled, dated and routinely monitored to assure foods are used by their use by dates or discarded. 1.On 07/28/25 from 11:10 a.m. to 11:55 a.m., two surveyors completed an initial kitchen tour in which the following findings were observed: - The maintenance man was observed in the kitchen with no hair or face protection for his facial and head hair. - The three bay pot sink had 2 chemical hoses hanging down in the sinks. - The dry…

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's laundry room and equipment presented safety hazards to the employees by having a frayed/ripped power supply wire for the washing machines for 3 of 4 days of survey (7/28/25, 7/29/25, and 7/30/25) by not having safe and properly functioning washing machines for 2 of 2 washing machines and for having broken floor tiles for 4 of 4 days of the survey (7/28/25, 7/29/25, 7/30/25, and 7/31/25).On 7/30/25 at 9:05 a.m., a surveyor observed the following in the laundry room:- The entire laundry room tiled floor was heavily soiled with dirt. - There were approximately 16 cracked/broken and loose floor tiles, creating a trip hazard for staff. - There was exposed/untreated cement flooring in front of, to the sides of, and behind the two washing machines.- The control panel on the left washing machine was missing 4 buttons. - The control panel on the right washing machine was missing 1 button. - There was a bucket under a leak from the left washing machine that also had a wire running from the washing machine and hanging down in the bucket and…

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

Based on record review and interview, the facility failed to provide education and/or obtain informed consent from a resident's representative regarding the use of bed rails for 1 of 6 residents reviewed for accidents (Resident #7 [R7]).On 7/30/25, R7's clinical record was reviewed and indicated the following:On 4/30/24, R7 completed an advanced directive identifying a representative to make medical decisions on his/her behalf.On 6/20/25, R7 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment.On 6/30/25, Informed Consent Regarding Side Rail Usage was provided to R7 to sign, indicating having considered all of the above (Risks in the use of side rails), I hereby consent to rails. The clinical record lacked evidence that education was provided for the resident representative to give informed consent.On 7/30/25 at 8:37 a.m., during an interview with a surveyor and the Director of Nursing (DON), R7's clinical record was reviewed. The DON stated R7's son/daughter is responsible for R7, and the bed rail consent should have been completed 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 interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) which included the participation of the resident and resident's representative after a Minimum Data Set (MDS) Quarterly Assessment, for 1 of 17 residents whose care plans were reviewed (Resident #2 [R2]).A clinical record review indicated R2 was admitted in 2021. The latest MDS Quarterly assessment was completed on 5/16/25. A review of R2 clinical record lacked evidence that a care plan meeting was held at any point as of 7/31/25 by the IDT that included, to the extent possible participation of R2 and/or his/her representative to review the Care Plan. On 7/31/25 at 9:15 a.m., in an interview with a surveyor, the Social Services Director confirmed that R2 clinical record lacked evidence that a care plan meeting was held after the last Quarterly assessment was completed on 5/16/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a resident's right to formulate an advanced directive regarding code status (indicates the type of medical interventions to receive, such as cardiopulmonary resuscitation [CPR] in the event of a medical emergency) was accurate in the resident electronic clinical record for 1 of 7 residents reviewed for advanced directives (Resident #24 [R24]).On [DATE], Resident #24 medical record was reviewed. The electronic record indicated a code status of DNR/DNI (Do Not Resuscitate / Do Not Intubate). The electronic record and the paper chart also contained a Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicates a code status of Attempt Resuscitation/CPR. On [DATE] at 8:50 a.m., during an interview with a surveyor and the Director of Nursing, the medical record was reviewed for R24's advanced directive regarding code status. At this time the surveyor confirmed R24's advance directive regarding code status had conflicting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an Interdisciplinary Care Plan Meeting (IDT) was held within 7 days after a Minimum Data Set (MDS) for 1 of 17 residents reviewed (Resident [R]17).Review of Resident [R]17 clinical record revealed Minimum Data Set (MDS) dated [DATE]. Further review of R17 clinical record revealed an Interdisciplinary Meeting (IDT) meeting was held 7/28/25 (17 days late).During an interview on 7/29/25 at 3:00 p.m., the Social Services Director (SSD) stated she is supposed to schedule IDT meetings within 7 days of the MDS completion. At this time SSD confirmed R17's IDT meeting was held yesterday (7/28/25). SSD stated she originally scheduled the meeting for 7/24/25 (6 days late) but thinks the family couldn't make it on the 24'th so it was rescheduled to 7/29/25. At this time the SSD confirmed the original IDT meeting would not have been within the 7 days of the MDS completion. The surveyor then asked if SSD offered/provided a copy of the care plan after each…

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 hearing aids were in use for 1 of 1 resident reviewed for communication (Resident #[R] 17).Observations of R17 on 7/28/25, 7/29/25 and 7/30/25 lacked evidence of hearing aid use.Review of R17 care plan updated 7/17/25 states Communication: ensure hearing aids are place appropriately .Review of R17 New admission Personal Item Inventory dated 10/13/24 states [he/she] was admitted with both left and right hearing aids. Interview on 7/30/25 at 1:10 p.m., Licensed Practical Nurse #2 (LPN2) stated [he/she] was not aware that R17 had hearing aids.During an interview on 7/30/25 at 1:05 p.m., R17 stated [he/she] does have hearing aids, and they are in a box in [his/her] room, [his/her] sister mailed batteries, but [he/she] can't get them in and is waiting for someone to help [him/her]. R17 further stated she really needs them because [he/she] has a hard time hearing during activities and keeps having the Activity Director repeat what she's saying.Interview on 7/30/25 at 1:15 p.m. Certified Nursing Assistant #3 (CNA3) stated…

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 maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection on 2 of 4 days of survey (7/28/25 and 7/29/25).On 7/28/25 at 11:45 a.m., a surveyor observed Resident #24 (R24)'s oxygen tubing labeled 7/28/25, connected to an oxygen concentrator. The filter on the concentrator was observed to be heavily soiled with dust/debris. On 7/29/25 at 3:30 p.m., during an interview with two surveyors and the Licensed Practical Nurse (LPN1), R24's oxygen concentrator was observed to have new tubing related to the addition of humidification dated 7/29/25. The nasal cannula tubing was observed to be dated 7/28/25. The concentrator filter was observed to be heavily soiled with dust/debris. LPN1 stated the filter should be washed with tubing changes. At this time the surveyor confirmed the filter was not cleaned with the tubing change and was heavily soiled with dust/debris.

Based on observations and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for two trash receptacles for an area outside by a dumpster for 1 of 4 days of survey (7/28/25).On 07/28/2025 from 11:10 a.m. to 11:55 a.m., two surveyors completed an initial kitchen tour in which the following finding was observed: - There were two of three, approximately 30 to 40 gallon trash receptacles, that had the swing lids open and exposed trash hanging out. On 7/28/25 at 11:55 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings.

Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 records reviewed (Resident #1 [R1]). R1 is has diagnoses to include paraplegia, Chronic kidney Disease (CKD) and Diabetes Mellitus (DM).Review of R1's care plan updated 7/10/25 states Monitor and document intake and output as per facility policy.Review of R1's Nutrition: amount eaten lacked evidence of documented intakes during:-Breakfast on 7/1/25, 7/6/25, 7/19/25,7/20/25, 7/22/25, 7/23/25, 7/24/25, 7/30/25-Lunch 7/1/25, 7/3/25, 7/6/25, 7/9/25,7/14/25, 7/17/25, 7/23/25-Dinner 7/11/25, 7/13/25, 7/27/25, 7/30/25.During an interview on 7/30/25 at 4:15 p.m., the above was discussed with Director of Nursing.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the second quarter (January1 through March 31, 2024). On 8/28/24 at 6:15 p.m., review of weekend staffing for January 1 through March 31, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to monitor and document targeted behaviors to support the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #37 [R37]). Findings: R37 was admitted on [DATE] and has diagnoses to include depression. Review of R37's active orders for August 2024 revealed order with start date of 3/12/24 for Escitalopram oxalate 10 mg [milligram] tablet 1 tablet by mouth daily for depressed mood. Further review of R37's clinical record lacked evidence that he/she was being monitored for side effects of this medication. During an interview on 8/27/24 12:02 p.m., Registered Nurse #1 confirmed that the facility does not monitor for side effects of psychotropic medication. During an interview on 8/27/24 at 2:12 p.m. Senior Director of Nursing indicated that the facility documents for side effects of psychotropic in nursing notes only by exception.

Based on record review, interviews and observations the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters, and multi drug resistant organisms [MDRO] for 2 of 3 days of survey (8/26/24, and 8/27/24). Findings: 1. Review of facility provided Coronavirus (COVID-19) line list revealed the first resident tested positive for Coronavirus (COVID-19) on 8/9/24. As of 8/24/24 there were a total of 17 residents and 13 staff members tested positive for Coronavirus. Observation of Resident #191 [R191] on 8/27/24 at 11:01 a.m., unmasked and self-propelling down [NAME] Unit passing 3 residents. Review of COVID-19 line list revealed R191 tested positive for COVID-19 on 8/9/24. During an interview on 8/27/24 at 11:03 a.m., Certified Nursing Assistant #1 [CNA1] indicated R191 won't stay in his/her…

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 record review the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of facility provided Infection Report revealed the following: -During the month of April 2024, there were 3 documented antibiotics prescribed. -During the month of May 2024, there were 7 documented antibiotics prescribed. -During the month of June 2024, there were 7 antibiotics prescribed. -During the month of July 2024, there were 11 antibiotics prescribed. Review of facility provided RX Quality Pharmacy Report dated 1/26/24, 4/26/24 and 7/2/24 lacked evidence of antibiotic use/discussion on these forms. During an interview on 8/27/24 at 9:12 a.m., Licensed Practical Nurse (LPN) (Infection Preventionist) indicated she is currently halfway through the infection Preventionist program and does not know how to track the infections and what to do with the orders she prints out. She does not check for culture…

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, the facility failed to ensure that the facility's Infection Preventionist (IP) had completed specialized training prior to starting the IP position. Findings: During an interview on 8/27/24 at 9:12 a.m., with 3 surveyors, Licensed Practical Nurse (LPN) indicated she started with the facility in October 2024 for the purpose of becoming the Infection Preventionist but did not start the IP class until February 2024. LPN is currently halfway through the course and has not had any training by anyone and is unsure of what to do. During an interview on 8/27/24 at 2:21 p.m., Senior Director of Nursing Services confirmed that LPN was the facilities designated Infection Preventionist. During an interview on 8/27/24 at 10:27 a.m., with 3 surveyors, Regional Quality Improvement Manager confirmed LPN has been acting as IP since October of 2023 and was not enrolled in IP class until February 2024 and has not yet been completed it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 3 residents reviewed for advanced directives (Resident #20 [R20] and R31). Findings: 1. Review of R20's entire clinical record lacked evidence that [he/she] was offered/refused the opportunity to formulate an advanced directive upon [his/her] admission on [DATE]. 2. Review of R31's entire clinical record lacked evidence that [he/she] was offered/refused the opportunity to formulate an advanced directive upon [his/her] admission on [DATE]. During an interview on 8/27/24 at 9:53 a.m. with a surveyor, the Social Worker confirmed that she has not asked/offered advanced directive information for R20 and R31 upon their admission.

Based on record review, interviews, and facility policy, the facility failed to ensure an injury of unknown origin was investigated and reported to appropriate state agencies timely for 1 of 3 facility reported incidents reviewed (Resident #12 [R12]). Findings: On 7/8/24 at 8:40 a.m. the Division of Licensing and Certification for the State of Maine (DLC) received an initial Facility Incident or Complaint report, from the facility, that R12 was found to have injuries of unknown origin with small bruise on left temple area, date incident 7/4/24, time of incident 16:00 (4:00 p.m.). R12 has dementia and unable to say what happened. On 7/10/24 at 9:21 a.m. DLC received a follow-up Facility Incident or Complaint report, from the facility, that R12 was noted to have a small spot, nickel sized on 7/3(/24) on the left temple area that developed into a bruise noted on 7/4(/24). Bruise initially was size of quarter. During review of R12's clinical record, nursing note on 7/4/24 at 4:22 p.m. by Registered Nurse #2 [RN2] states R12 presents with large bruising on the left side of his/her…

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, observations and record reviews, the facility failed to update/implement care plans for a resident diagnosed with Coronavirus (COVID-19) (Resident #191 [R191]). Findings: R191 was admitted on [DATE] and tested positive for Coronavirus (COVID-19) on 8/24/24 requiring quarantine isolation precautions. Observation of R191 on 8/27/24 at 11:01 a.m., self-propelling down [NAME] Unit, unmasked and passing 3 residents and 1 staff member in the hall. During an interview on 8/27/24 at 11:01 a.m., Certified Nursing Assistant #1 indicated that R191 won't stay in the room, and she doesn't know what to do with him/her because he/she comes out of his/her room all the time, and no one has given her any direction on what to do if he/she is not following quarantine precautions. Review of R191's care plan updated 8/16/24 lacked evidence that goals and interventions were put into place for infection COVID-19 or for his/her noncompliance with isolation precautions. During an interview on 8/27/24 at 2:13 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 observation, interviews, and record review, the facility failed to update/implement care plans for isolation precautions for 1 of 1 care plans reviewed for isolation precautions (Resident #26 [R26]). In addition, the facility failed to update/implement goals and interventions for 1 of 1 resident reviewed for a cardiac pacemaker (R37). Findings: R26 was admitted on [DATE] and tested positive for Coronavirus (COVID-19) on 8/10/24 and was placed on isolation precautions. Observation of R26 on 8/26/24 at 11:30 a.m., in hallway outside room [ROOM NUMBER]. There were no precaution signs or personal protective equipment (PPE) observed outside of room [ROOM NUMBER]. During an interview on 8/28/24 at 7:14 a.m. Registered Nurse #1 [RN1] confirmed that R26 had been off quarantine precautions quite a while. Review of R26's care plan updated 8/12/24 states COVID 19 I have tested positive . Maintain my isolation with droplet and contact precautions administer oxygen as needed turn, cough and deep breath administer…

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 physician's orders were followed for 1 of 3 sampled residents receiving insulin coverage (Resident #19 [R19]). Findings: 1. On 8/28/24, R19's clinical record was reviewed and included a physician order, dated 5/11/24, to administer Insulin Aspart FlexPen 100UNIT/ML Solution Pen-injector, 10 units subcutaneous to [inject medication between skin and muscle, under the skin] daily at 7:30 a.m The instructions state, Hold for blood sugar less than 170. On 8/3/24, R19's blood sugar result at 7:30 a.m. was 119. Documentation indicated that R19 received 10 units and should have been held (not given). On 8/5/24 R19's blood sugar result at 7:30 a.m. was 165. Documentation indicated that R19 received 10 units and should have been held (not given). On 8/25/24 R19's blood sugar result at 7:30 a.m. was 166. Documentation indicated that R19 received 10 units and should have been held (not given). 2. On 8/28/24, R19's clinical record was review and included a physician order, dated 5/11/24, to administer Insulin Aspart…

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, interview, and record review, the facility failed to ensure that tube feedings were administered according to provider orders for 1 of 1 resident observed for tube feeding (Resident #9 [R9]). Findings: R9 was admitted on [DATE] with diagnose to include failure to thrive. Review of R9 Minimum Data Set, dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 4 of 15 indicating he/she is not cognitively intact. Review of R9's active orders August 2024 revealed order for Osmolyte 1.2 Cal/Nutritional Supplements. Liquid (1430ml [milliliter]) at 89 ml per hour enteral tube continuous rate for 16 hours 1400 (2:00 p.m.-6:00 a.m.) for nutritional support. Give 200 ml of water prior to feeding, pause feeding at 10 p.m. to give 200 ml of water. Give 200 ml of water after feeding. During an observation on 8/27/24 at 7:00 a.m., R9 was observed sitting in a wheelchair. IV (intravenous) pole/machine was noted next to bed with a bag hanging from the pole containing 300 ml's of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 1 resident reviewed for respiratory care (Resident #38 [R38]). Findings: R38 was admitted on [DATE] and has diagnoses to include chronic obstructive pulmonary disease. Review of facility Coronavirus (COVID-19) line list revealed R38 tested positive for COVID 19 on 8/9/24. Observations of room [ROOM NUMBER]-1 on 8/19/24 at 9:22 a.m., 8/20/24 at 2:45 p.m., and 8/21/24 at 10:02 a.m., revealed an oxygen concentrator at bedside with tubing tucked in concentrator handle, dated 8/11/24 and not bagged. A nebulizer machine was observed on the armchair of a recliner with tubing connected to nebulizer pipe, hanging off the side of the recliner. Tubing was not bagged and dated 8/11/24. Review of R38 clinical record revealed nursing note dated 7/13/24 states, Respirations labored, can't take full breath. SOB…

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

Based on observation and interview, the facility failed to post the nurse staffing information in a prominent place, readily accessible and visible to all residents, for 1 of 3 days of survey (8/26/24). Finding: On 8/26/24, surveyors observed that the nurse staffing information was not posted in an area visible to residents and visitors. On 8/27/24 at 1:08 p.m., in an interview, the Administrator confirmed that the nurse staffing information was not posted in an area visible to residents and visitors on 8/26/24.

Based on interviews, the facility failed to ensure the facility's Food Services Supervisor met the qualifications of a Certified Food Service Director(FSD). This has the potential to affect all the residents. Findings: On 3/13/23 at 9:00 a.m., in an interview, the Food Service Director (FSD) indicated that he has been the Food Service Director since December 2022. At this time, the FSD stated that he has no current qualifications for the job and that he is not currently enrolled in any qualifying course or a manager ServSafe course. On 3/13/23 at 9:50 a.m., in an interview, the surveyor discussed the finding with the Administrator. The surveyor asked for qualifications and dates of hire for the last two FSDs. None were provided as of the end of survey. On 3/17/23 at 11:34 a.m., the surveyor emailed the Administrator with a request of dates of employment for Food Service Directors in and received an email from the Administrator confirming that the current FSD was hired on 4/5/22 in the kitchen but did not take over the FSD position until December 2022. The Administrator confirmed…

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

Based on interviews and records review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 46 of 46 beds. Findings: The facility's policy and procedure for Bed Safety, effective 06/2016 and Revised 02/2022 noted: Policy Interpretation and Implementation: 2. Try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risk and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimensions established by the FDA (the review shall consider situations that could be caused by the resident's weight, movement or bed position.): c. Ensure that when bed system components are worn and need to be replaced, components meat manufacturer…

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 observations, the facility failed to ensure that accommodations were made for residents that included call bells being within reach for 1 of 4 resident's (Resident #14), failed to ensure a bed was maintained and in working condition for 1 of 1 resident (Resident #15), and failed to ensure that accommodations were made to include the use of grab bars/side rails for a residents capable of using them for bed mobility and transfer assistance for 2 of 2 sampled residents accommodation of needs (Resident #16 and #25). Findings: 1. Resident #14 was admitted to facility on 5/21/21 with diagnoses to include Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), right and left knee and hip contractures, and dystonia (involuntary muscle contractures that cause repetitive or twisting movements and poor posture). Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 2 of 2 units (100's and 200's) for 2 of 2 environmental tours (3/15/23 and 3/16/23). Findings: 1. On 3/15/23 at 10:00 a.m., a facility tour to review bed mattresses was completed with the Director of Nursing (DON) in which the following findings were observed: > Resident room [ROOM NUMBER] (single bed room) was observed to have a peeling mattress creating an uncleanable surface. > Resident room [ROOM NUMBER] (bed 1 by the wall) was observed to have a peeling mattress creating an uncleanable surface. > Resident room [ROOM NUMBER] (single bed room) was observed to have a mattress that was peeling creating an uncleanable surface and was noted to have a strong odor of urine, along with peeled and cracked pillows. On 3/15/23 at 10:00 a.m., in an interview, the DON confirmed that these mattresses were uncleanable. 2. On 3/16/23, from 8:28 a.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 reviews and interviews, the facility failed to provide interventions outlined in the resident's care plan in the area of weights (Resident #12), in the areas of nutrition and safety (Resident #14), and in the area of respiratory for (Resident #15), Findings: Review of facility policy Comprehensive Care Plan dated 6/23 states A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .includes measurable objectives and timeframe's . 1. On 3/15/23, a review of Resident #12's nursing home electronic clinical record indicated in the resident's current care plan to weigh me every week initiated on 1/17/23. Staff documentation noted that weights were only done on 2/3/23 and 3/6/23. On 3/15/23 at 11:13 a.m., in an interview, the Director of Nursing confirmed that Resident #12's current care plan for weights was not being followed. 2. Resident #14 was…

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

Based on observations, interviews, and Payroll-Based Journal (PBJ) review, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL)'s. Findings: Review of facility PBJ staffing data report for quarter 1 (October-December 31, 2022) revealed the facility triggered for excessively low weekend staffing. A review of facility provided staffing from 3/1/23 through 3/15/23 (15 days) revealed the staffing sheets were not updated to include call outs or late entries. Review of Resident Council Meeting Minutes dated 1/24/23 revealed. Sometimes waiting half an hour for bell to be answered. Further review of Resident Council Minutes lacked evidence this concern was followed up on. During an interview on 3/13/23 at 9:03 a.m,. Resident #15 indicted that his/her bed has been broken since Friday and he/she is unable to raise the head of the bed. During an interview on 3/13/23 at 9:15 a.m. the Director 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 and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a ceiling vent and the ceiling. Additionally, the facility failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated, and failed to label whipped topping with a thaw date. Findings: On 3/13/23 from 8:35 a.m. to 9:00 a.m., a kitchen tour was conducted with the Food Service Director in which the following findings were observed: - The ceiling exhaust vent and ceiling above the dishwasher was dusty/dirty. - The Walk-in Refrigerator had one (1) 16 ounce whipped topping package with no thaw date. The package states good for 14 days when thawed. - The Walk-in Freezer had 4 packages of bagels, 2 packages of cookie dough and 1 package of bread sticks that were unlabeled and undated, and a box of pie shells with large chunks of ice built up on the box. On 3/13/23 at 9:00 a.m., in an interview, the Food Service Director confirmed the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, and interviews, the facility failed to follow their own policy and failed to provide an environment to help prevent the development and transmission of disease and infection related to wound care (Resident #6). In addition, the facility failed to implement Infection Control Contact Precautions for a resident (Resident #6) diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) for 1 of 3 days of survey. (3/16/23). This has the potential to affect all 18 residents on the 100 unit. Findings: Review of facility policy titled Wound Care dated 2/22 states: .1. Use disposable cloth (paper towel) to establish clean field on resident's overhead table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and body sites. 4. Put on exam glove. Loosen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain the dignity of 1 of 2 resident's during a dressing change observation (Resident #6). Findings: Resident #6 was admitted to the facility on [DATE] and had diagnoses to include quadriplegia and a facility acquired stage 4 pressure ulcer on his/her left buttock/sacral area. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status of 14 of 15, indicating he/she was cognitively intact. Further review revealed Resident #6 needs extensive assist with Activities of Daily Living. On 3/15/23 at 10:47 a.m., 2 surveyors observed Licensed Practical Nurse (LPN)#1 during a dressing change for Resident #6. While LPN#1 was applying tape to secure the dressing to residents left buttock/sacral area, Resident #6 repeatedly stated Fuck this place, Fuck this place. LPN#1 was observed to complete securing the dressing and then turned away from Resident #6 towards the wall. LPN#1 was then overheard by 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 was unable to provide evidence that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055, which included appeal rights and liability of payment was provided at least 2 days prior to the resident's last covered day for 1 of 2 residents whose Medicare Part A services were discontinued, and the resident remained in the facility (#39). Finding: On 3/13/23 at 8:47 a.m., surveyor requested a form, Beneficiary Notice - Residents discharged Within the Last Six Months; this form stated that Resident #39 was discharged from skilled services on 1/16/23 to Long Term Care. On 3/13/23 during review of Resident #39's clinical record, he/she received Medicare Part A services that ended on 1/16/23 and remained in the facility after services ended. On 3/15/23 the facility provided the ABN for Medicare D form with handwritten documentation on the form stating the notice was verbally reviewed with the resident representative on 1/16/23, day of discharge from skilled services. This form was signed by the resident representative 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.

Based on interviews, record review, and facility policy, the facility failed to ensure an injury of unknown origin was investigated timely for 1 of 2 facility reported incidents reviewed. (#193). Findings: Review of the facility policy Resident Abuse Prevention Policy & Procedure states; Identification: Incidents, which might be considered abuse, neglect or exploitation, will be referred to investigation and reporting as appropriate. Reporting/response: Reports will be made to the Department of Human Services (DHS) licensing and certification in Adult Protective Services as required. Investigation: Any incident which may in fact be abuse, neglect or exploitation will be logged, assigned to the director of nursing or the social services director to investigate . a copy of the written report will also be sent to DHS licensing and certification within 5 business days. Review of facility policy Accident & Incidents investigating and Reporting, revised 2/2022 states, All accidents or incidents involving residents, employees, visitors, vendors etc., occurring on our premises shall 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 record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 1 was accurately completed for 1 of 1 sampled resident reviewed for PASRR (#5). Finding: On 3/15/23 during record review for Resident #5, it was noted that he/she was admitted to the facility on [DATE]; the clinical record included a diagnosis of bipolar disorder at the time of admission. The PASRR Level 1 screen in the clinical record lacked evidence of this mental health diagnosis on the Level I screening. On 3/16/23 at 9:53 a.m., during an interview with the Director of Nursing (DON) both the surveyor and the DON reviewed Resident #5's PASRR Level I, there is no evidence that the facility updated or submitted a new PASRR to include his/her bipolar disorder diagnosis. The surveyor confirmed with the DON that the diagnosis of bipolar disorder should have been included on Resident #5's PASRR.

Based on clinical record reviews (electronic and paper) and interviews, the facility failed to ensure Physician orders were followed and clarified for 1 of 1 sampled resident receiving antibiotics (Resident # 5). In addition, the facility failed to ensure a Physician order for weights were followed for 1 of 1 resident reviewed for Nutrition (Resident #12). Findings: 1. During record review Resident #5 was noted to have a suprapubic catheter that was plugged with mucus. The Doctor and the Power of Attorney for Resident #5 was made aware, a decision for no invasive treatment was desired and a treatment for urinary tract infection (UTI) was started. On 3/7/23 an order for Ceftriaxone Sodium (Rocephin) 1 gram intramuscular (IM) daily for 7 days first dose due on 3/7/23 was received. On 3/10/23, the culture and sensitivity report (report used to identify which antibiotic will work best for treatment of the infection) for the UTI was received. An order dated 3/10/23 for Ceftriaxone 1 milligram (mg) IM daily for 5 days was received. The facility got a clarification order for the dose 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 observation and interview, the facility failed to maintain respiratory equipment consistent with the facilities Respiratory Therapy - Infection Control policy and procedure for 1 of 2 residents reviewed for respiratory care. (#8) Findings: Facilities Respiratory Therapy policy and procedure, revised 2/22, under Infection control considerations related to Oxygen administration, instructs nursing to Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use On 3/13/23 at 9:47 a.m., observation of the oxygen nasal cannula wrapped up and stored under the handle of the oxygen concentrator. At this time, Resident #8, stated he/she uses oxygen only during the night. On 3/15/23 at 10:00 a.m., and on 3/16/23 at 8:45 a.m., additional observations were made of Resident #8's oxygen cannula wrapped up and stored under the handle of the oxygen concentrator. On 3/16/23 at 8:48 a.m., during an interview with the Director of Nursing, she confirmed the nasal cannula was not stored correctly stating, nasal cannulas should be stored in a plastic baggie to protect…

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 label both an Insulin pen and a Insulin vial that was available for use, with an open date, in 1 of 2 medication storage refrigerators. (Unit 200's) Finding: On 3/13/23 at 9:34 a.m., during review of the medication room on the 200 unit, the surveyor and the Registered Nurse (RN) observed the following: - An opened, unlabeled Tresiba insulin flex pen with manufactures directions, After opening: use within 8 weeks - An opened, unlabeled Insulin Admelog with manufactures directions, Discard open vial after 28 days. At this time, the RN stated both insulins should be dated with the date they were opened.

Based on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 1 of 3 days of survey. (3/13/23) Findings: On 3/13/23 at 8:35 a.m., the surveyor observed 1 of 2 dumpsters with the left side door opened with a full trash bag hanging out of it. Additionally, there was cigarette butts, plastic, papers, and used purple gloves on the ground around the two dumpsters. On 3/13/23 at 9:00 a.m. in an interview, the Food Service Director confirmed the findings.