Market Square Health Care Center, LLC

Based on observations, record review, and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 5/14/26, were effective. The Federal citations F584 and F812 were cited again for the same concerns during the follow-up survey completed on 7/7/26.At the annual recertification survey completed on 5/14/26, deficiencies F584 and F812 were cited. During the follow up survey on 7/7/26, it was determined that F584 and F812 would be recited for the same concerns: 1. F584: Safe/clean/comfortable/homelike environment: Observation of laundry room on 7/7/26 revealed the surface of the cement floor was worn off and untreated creating an uncleanable surface. There were 15 (fifteen) cracked/broken and/or missing floor tiles. The cove base was missing from the bottom of the wall to the left of the dryers. Review of facility plan of correction, signed 6/11/26, with completion date of 6/26/26 states: The cement floor has been repainted; the cracked…

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 review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBP), sanitizing glucometers, linen handling, hand hygiene during resident care, and applying transmission based precaution for 3 of 4 days of survey (5/11/26, 5/12/26, 5/13/26). Additionally, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). Findings: 1.Observation of Enhanced Barrier Precautions (EBP) room [ROOM NUMBER] on 5/13/25 at 9:50 a.m., Certified Nursing Assistant (CNA)#7 was observed opening the door with her ungloved, left hand, and holding a full trash bag in her ungloved right hand. CNA#7 was not wearing a gown. At this time a surveyor asked CNA#7 if she had been wearing 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 facility policy the facility implements, and maintain an effective training program for all staff. Appropriately trained staff can improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. This has the potential to affect all three units.Findings:Review of facility policy Orientation Program dated 5/12/08 states It is the policy of North Country Associated is to provide all new staff members with a comprehensive orientation resulting in an in-depth knowledge of our established policies and procedures. The Administrator will ensure that each new staff member receives and follows the facility's Orientation Program: Objectives: to familiarize the new staff member with the entire facility; To introduce the new staff to the specific policies and procedures of the facility; to assure that the new staff member is able to perform all necessary functions relating to his/her respective job description. WITHOUT…

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

Based on observations and interviews, the facility failed to ensure a resident's call bell was within reach for 2 of 2 sampled residents (Residents #5, #51) for 2 of 4 days of survey (5/11/26, 5/12/26).Findings:1. On 5/11/26 at 9:28 a.m., a surveyor observed Resident #5 asleep in his/her bed with his/her call bell hanging between the top of his/her mattress and headboard, extending to the floor and not within Resident #5's reach.A review of Resident #5's care plan states, .High risk for falls r/t [related to] balance issues, history of falls . Call bell in reach at all times .On 5/12/26 at 9:09 a.m., during a repeat observation, Resident #5 was lying in bed with his/her call light hanging behind his/her bed, extending down to the floor, out of Resident #5's reach.2. On 5/11/26 at 8:50 a.m., a surveyor observed Resident #51 sitting on the side of his/her bed, with call light cord tucked between the mattress and the wall. The surveyor could not locate the call bell itself.A review of Resident #51's care plan states, . Fall History: At risk for falls . Call light within reach, instruct…

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 confidentiality of protected health information for 1 of 70 residents during 1 of 4 days of survey. (Resident #38)Findings:On 5/12/26 from 2:41 p.m. to 2:43 p.m., 2 surveyors observed an open computer screen showing Resident #38's personal medical information on an unattended treatment cart on the Tuttle Unit. It was visible and easily accessible to residents, visitors, and unauthorized personnel. Upon surveyor intervention, the Tuttle Unit Manager walked over to the treatment cart and closed the computer screen at 2:43 p.m On 5/13/26 at 8:20 a.m., the above information was confirmed with the Facility Administrator.

Based on record review, interviews, and facility policy, the facility failed to thoroughly investigate a resident's injury of unknown origin for 1 of 3 facility-reported incidents (Resident #27).Finding:Facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, revised 10/18 states, under section E. Investigation, .Procedure: The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. Investigation of injuries of Unknown Origin or Suspicious injuries: The facility may initially evaluate an occurrence to determine whether it meets the definition of an 'alleged violation'. upon discovery of an injury, the facility must immediately take steps to evaluate whether the injury meets the definition of an injury of unknown source.On 2/21/26 at 1:10 p.m., the State of Maine's Division of Licensing and Certification (DLC) received a facility-reported incident that indicated that staff was providing care to Resident #27 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 ensure the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded in the area of therapy services for 1 of 20 sampled residents (Resident #38).Finding:Review of Resident #38's clinical record revealed a physician order with a start date of 2/9/26 for OT (Occupational Therapy) for a duration of 12 weeks.Resident #38's Quarterly Minimum Data Set (MDS) Version 3.0 assessment, dated 2/24/26, Section O - Special Treatments, Procedures, and Programs, under O0390 Therapy Services indicated None of the above.On 5/14/26 at 12:32 p.m. a surveyor discussed the finding with the MDS Coordinator. At this time, the MDS Coordinator reviewed Resident #38's clinical record and confirmed that Resident #38 was receiving OT services at the time of the 2/24/26 quarterly assessment and confirmed that the assessment was not accurately coded.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of quality of care and accurate for opioid therapy for 1 of 1 resident reviewed. (#77) Findings:Review of Resident #77's medical record stated he/she was admitted in April 2026 with a diagnosis of displaced trimalleolar fracture of right lower leg, fracture of unspecified metatarsal bone(s) left foot and encounter for other orthopedic aftercare. On 4/1/26, the nurse to nurse report between the facility and the hospital noted under admitting diagnosis to include Displaced trimalleolar fracture of right lower leg, Fracture of unspecified metatarsal bone(s) left foot and Encounter for other orthopedic aftercare.On 4/1/26, Resident #77 signed an Informed Acknowledgement and Agreement for Opioid Therapy form on 4/1/26 declining the use of Opioid Therapy.On review of the Resident #77's base line care plan, the care plan lacked evidence of the problem, goals and interventions for the resident's diagnosis of fractures/breaks. Additionally, Resident #77 had been care…

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 the clinical record was accurate and complete for 1 of 2 residents reviewed for therapy services (Resident #85) and 1 of 2 residents reviewed for Activities of Daily Living (ADL) (Resident #17).Findings: 1. Resident #85 was admitted 5/26 for skilled care services. Review of Resident #85 active orders revealed order with start date of 5/5/26 for PT- Treatment Clarification orders: Therapeutic Exercise: Therapeutic Activities: Gait training: Neuro re-education; wheelchair management. Frequency 60 Duration 12 weeks order with start date of 5/5/26 for PT: Evaluate and Treat were both unsigned. During an interview on 5/12/26 at 11:09 a.m., the Occupational Therapist (OT) confirmed Resident #85 has been receiving physical Therapy (PT) and Occupational Therapy (OT) services 5 days a week, and they have a restorative aide on weekends. At this time OT reviewed Resident #85's clinical record and confirmed the orders were not signed by a provider. During…

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 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 1 of 5 randomly selected CNAs employed greater than 1 year. (CNA #1)Finding:CNA #1 was hired in February of 2025. Review of CNA #1 Employee In-service/attendance records lacked evidence of the required 12 hours of continuing education from 2/2025 to 2/2026. On 5/14/26 at 2:36 p.m., during an interview with the Facility Administrator, the above information was confirmed.

Based on record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection relating to Legionella and failed to implement the elements of the Legionella Water Management Program. This has the potential to affect all 68 residents. Findings: 1. The facility's Legionella Water Management Program revised on 1/9/25, under Control Measures states, Various control measures are in place to ensure a healthy water management program. Please refer to Appendix A of the water management program for a description of where controls are located. Monitoring states, monitoring provides data for determining whether a water system is operating within the parameters needed to control the growth of Legionella. Please refer to Appendix A of the water management program for the description of how monitoring will be conducted. Market Square receives its water from Maine Water . Maine Water uses a Total Chlorine system so the facility will use a Total Chlorine testing kit to take water samples. 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 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 3 of 3 units ([NAME] East, [NAME] and Tuttle) for 1 of 1 facility tour. Findings: On 3/5/25 from 8:30 a.m. to 9:15 a.m., a surveyor conducted an Environmental Tour with the Environmental Services Director and the Quality Improvement Specialist, in which the following findings were observed: [NAME] East > There was an EZ sit-to-stand patient lift, in the hallway by room [ROOM NUMBER], that had food debris and dirt in the foot base area. > Resident room [ROOM NUMBER] - The wall behind bed 2 had chipped/missing paint and was marred with black marks. The base board heater front cover was off at the end of the bed exposing heating elements. Resident #32's grabber/reacher was coated with a thick brown substance on the grabber part and the entire handle. > Resident room [ROOM NUMBER] - The room was very cold 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 issue a bed hold notice which included the daily bed hold cost, to a resident, known family member and/or legal representative for 3 of 3 sampled residents who had been transferred to the hospital (Residents #7, #66, and #69). Findings: 1. Resident #7's clinical record revealed the resident was transferred to an acute care hospital on 5/23/24 and subsequently admitted . The clinical record lacked evidence that Resident #7 and/or the resident representative were provided with a written bed hold notices upon transfer. 2. Resident #69's clinical record revealed the resident was transferred to an acute care hospital on [DATE] and subsequently admitted . The clinical record lacked evidence that Resident #69 and/or the resident representative were provided with a written bed hold notices upon transfer. 3. Documentation in Resident #66's clinical record indicated that he/she transferred to an acute care hospital on 1/18/25 and subsequently admitted . 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 2. Resident #67 was recently admitted to the facility. A review of the nursing assessments, dated 2/11/25 for Resident Smoking Screen and a Resident Smoking Contract state he/she can smoke unsupervised. As of 3/3/25 the residents' care plan lacked interventions and goals relating to smoking. On 3/3/25 at 4:01 p.m., the above was discussed with the Quality Improvement Specialists Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours. That included the instructions needed to provide minimum healthcare information necessary to care for 3 of 25 care plans reviewed (Resident's (R)4, R55, and R67). Findings: Review of policy 48 Hour Baseline Care Plan dated 10/18 states a baseline care plan will be created within 48 hours of admission. Based on the admission assessment, physician orders and resident preferences a care plan will be created to facilitate a smooth transition of care and to provide effective, person care…

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

Based on record reviews and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 2 of 2 units reviewed for medication storage (East and [NAME] Units). Findings: 1. Review of East Wing Med Cart Controlled Substance Log on 3/5/24 at 11:55 a.m., revealed the following: - No outgoing signature on 3/1/25 at 6:30 a.m., 3/2/25 at 6:30 a.m., 2/14/25, 2/21/24, 1/24/25, 1/20/25, 12/23/24, 12/30/24, at 7:00 a.m., 1/23/25 at 6:30 a.m., 1/18/15 at 5:00 a.m., 1/7/25 at 8:00 a.m., or 12/26/24 unknown time. - No incoming signature on 2/13/25 at 7:00 a.m., 1/27/24 at 11:30 p.m., or 12/24/24 at 11:15 p.m., 2. Review of East Wind Treatment Cart Controlled Substance Long on 3/5/25 at 12:30 p.m., revealed: -no incoming signature on 1/29/25 at 11:00 p.m. -no outgoing signature on 1/15/25 at 7:15 p.m., 11:00 p.m., 2/2/25 11:00 p.m, 2/7/25 no time noted. 3. Review of [NAME] Wing Controlled Substance Log revealed: -No outgoing signature on 2/20/25 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 observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, the food disposal unit, a wall mounted fan, and a plunger. Additionally, the facility failed to ensure foods were sealed, labeled, dated and/or discarded if past use by date in a reach-in freezer, in a walk-in refrigerator, a unit kitchenette refrigerator and in a dry storage room for 2 of 2 kitchen/kitchenette tours for 1 of 1 day of survey (3/3/25). Findings: The facility's Food Storage policy and procedure dated 2023 noted: 13. Refrigerated food storage: f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen(where applicable) or discarded. 14. Frozen foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. 1. On 3/3/25 from 8:40 a.m. to 9:40 a.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that a clinical record contained complete and accurate documentation for 2 of 2 residents reviewed for smoking (Resident's #55 #67), and for 2 of 5 residents reviewed for medication review (Resident #45 and #55). Findings: 1. On 3/3/25 at 9:16 a.m., during an interview, Resident #67, stated he/she smokes cigarettes independently outside approximately 4-5 times a day and he/she stores the lighter and cigarettes in his/her room. A review of the nursing assessment dated [DATE] for Resident Smoking Screen states, Resident smoking status based upon above information is: Non-smoker, Supervised smoker or Unsupervised neither of the 3 choices listed are checked. The section stating, Include in nursing care plan & interdisciplinary resident care plan. 30 day assessment: Resident can smoke unsupervised has yes checked. A review of the Resident Smoking Contract states, I have read and understand the resident smoking policy. Please check one of the…

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

Based on interviews and record review, the facility failed to ensure accommodations were made for a resident to include the facility's bathing schedule and resident preferences for 1 of 3 residents reviewed for activities of daily living (Resident #7). Finding: On 3/4/25 at 9:30 a.m., during an interview, Resident #7 stated that he/she wants to and is supposed to get a shower twice a week, on Sundays and Wednesdays. But due to staffing, he/she no longer gets a shower consistently. He/she stated that staff will come in and tell him/her that he/she will be getting a bed bath instead. On 3/4/25 at 9:40 a.m., observation of the weekly shower schedule indicated Resident #7 was to receive a shower on Sunday and Wednesday early evenings. On 3/4/25 at 9:48 a.m., in an interview and review of Resident 7's February 2025 bathing documentation, the Quality Improvement Specialist(QIS) confirmed that Resident #7's bathing documentation lacked evidence that he/she received showers on 2/5/25, 2/9/25, 2/12/25, 2/23/25 and 2/26/25. The QIS additionally confirmed that there was no documentation of the…

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

Based on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions for diuretic and anticoagulant medication use for 1 of 1 resident reviewed for (Resident #11). Findings: Review of policy Comprehensive Person-Centered Care Planning dated 1/19 states: The facility must develop and implement person-centered care plan for each resident, which includes measurable objectives and timeframe's to meet a resident's medical, nursing, . needs identified in the comprehensive assessment evaluation. Review of Resident #11 (R11) active medication orders, dated March 2025 revealed: - order with start date of 4/27/24 for anticoagulant Eliquis 5mg tablet two times daily for atrial fibrillation - order with start date of 11/30/24 for diuretic Lasix 20 mg tablet 1 time daily for atrial fibrillation. Review of R11's care plan, updated 11/15/24, lacked evidence that goals and interventions were put into place for the use of diuretic and anticoagulant medications. On 3/4/25 10:15 a.m., Dduring a review of R11's care plan with Quality Improvement…

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 clinical record review and interview, the facility failed to ensure physician orders were followed for 1 of 2 sampled residents for (Resident #67). Finding: On 3/3/25 Resident #67's clinical record was reviewed and included several physician orders for wound care instructing nursing to: Right shoulder: Cleanse with Vashe solution soaked gauze applied to wound bed and left in place for 5 minutes. Apply skin prep spray to periwound. Apply Kaltostat to high draining areas (center of wound bed). Apply generous amount of Medihoney to rest of wound bed. Cover with fluffed dry gauze to fill the wound cavity. Cover with dry gauze and ABD (abdominal pad). Secure with Hypafix tape Change daily and PRN (as needed). Anterior neck: Cleanse with Vashe solution soaked gauze applied to wound bed and left in place for 5 minutes. Apply skin prep spray to periwound. Apply Medihoney and moist gauze to wound. Apply dry gauze to cover. Secure with Hypafix tape Change daily and PRN. Lateral neck: Cleanse with Vashe solution soaked gauze applied to wound bed and left in place for 5 minutes. Apply…

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

Based on observations, record review, 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 #29). Finding: Resident #29 has diagnoses to chronic obstructive pulmonary disease (COPD). On 3/3/25 at 11:31 a.m. and 3/4/25 at 1:49 p.m., a surveyor observed Resident #29's, unbagged nasal cannula tubing, draped on top of the oxygen concentrator located next to the bed, with the nasal cannula prongs in direct contact with the surface of the oxygen concentrator. An empty plastic storage bag was observed tied to the nightstand drawer handle. Review of Resident #29's clinical record revealed an active order, dated 2/10/25, for Change tubing one time weekly .change all oxygen tubing . and an active order, dated 2/10/25 for Clean/store oxygen tubing not in use .Place in plastic bag when not in use. Review of Resident #29's care plan, dated 2/10/25, revealed, Change oxygen tubing weekly; label and date . On 3/4/25 at 2:00…

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

Based on record review and interviews, the facility failed to ensure an as needed (prn) psychotropic medication met the required 14-day limit for 2 of 6 residents reviewed for psychotropic medications (Resident #4 and #67). Findings: 1. Resident #4's medical record contained a provider order, dated 2/13/25, for Diazepam 5 mg (milligram) tablet PRN(as needed) every 8 hours for muscle spasms, with no stop date. The medical record lacked evidence of clinical rational to continue the medication. On 3/5/25 at 2:17 p.m., the above was confirmed with the Assistant Director of Nursing 2. Resident #67's medical record contained a provider order, dated 2/11/25, for Lorazepam 1 mg (milligram) tablet Oral as Needed One Time for anxiety disorder prior to wound change, with no stop date. The medical record lacked evidence of clinical rational to continue the medication. On 3/5/25 at 1:16 p.m., the above was discussed with the Quality Improvement Specialist.

Based on observations, interviews and record reviews, the facility failed to ensure medications including treatments were stored properly for 2 of 3 days of survey (3/3/25 and 3/4/25). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 1 of 1 sampled resident (Resident #322). Findings: Review of Facility Policy Self-Administration of Medications, dated 5/2018, states, .residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team [IDT] has determined that the practice would be safe .and there is a prescriber's order to self-administer .an assessment is conducted by the IDT .the results of the IDT assessment .are recorded .on the care plan . Review of policy, Specific Medication Administration Procedures, dated 5/2018, states, .administer medication and remain with resident while medication is swallowed .Do not leave medications at bedside . During observations on 3/3/25 at 10:27 a.m. and 3/4/25 at 9:55 a.m., a 0.5 fluid ounce bottle of thera tears lubricant eye drops…

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, interviews, and facility policy, the facility failed to ensure a resident's care plan was updated to reflect the resident's current care needs in the area of falls for 1of 3 residents reviewed (Resident #4). Finding: Facility policy, Falls Management Policy, states, Residents' care plan will be updated with all new interventions . Review of Resident #4's clinical record revealed he/she sustained a fall on 10/14/24, 10/16/24, 11/19/24, and 12/1/24. Review of Resident #4's care plan, updated on 11/12/24, revealed, Problems: .requires extensive assistance with self-care .inability to perform ADLs independently . Further review of Resident #4's care plan lacked evidence of goals and interventions for falls. On 12/19/24 at 2:19 p.m., during an interview with 2 surveyors, the Administrator stated it is her expectation that the resident care plan would be updated after a fall. On 12/19/24 at 5:37 p.m., during an interview with 2 surveyors, the Assistant Director of Nursing (ADON) reviewed the entire clinical record and confirmed that Resident #4's care plan was not…

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

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed. (Residents #4 and #5). Findings: Facility policy, Falls Management Policy, revised July 2019, states, .E. Complete the Post Fall Observation Tool, following a fall .F. Documentation must be completed in the nurse's note on each shift x 3 following the fall . 1. Review of Resident #4's clinical record revealed he/she sustained falls on 10/14/24, 10/16/24, 11/19/24, and 12/1/2024. The medical record lacked evidence that the Post Fall Observation Tool was completed for the 10/14/24, 10/16/24, or 12/1/24 falls. Further review of Resident #4's clinical record revealed the following progress notes: -11/29/24 at 8:41 p.m., CNA called this nurse to resident's room. Resident found lying on the floor beside her bed . -12/2/24 at 9:25 a.m., Yelling heard by nursing staff with original origin unknown. Upon arrival of CNA staff resident observed holding self up on opposite bed in room. Resident lowered to floor by CNA staff .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to help prevent the development of infection for 1 of 3 sampled residents. (Resident 3) Findings: Review of policy Oxygen Use & Storage Policy dated 10/24 states Respiratory Care: A sanitary environment must be maintained to prevent the transmission of disease. When nebulizer parts are not in use, after [NAME] air dried, the mask and/or hand held devices shold be stored in a plastiv bag to the risk of it becoming contaminated . During observations of room [ROOM NUMBER] on 12/19/24 at 10:13 a.m., and 12:15 p.m., the following was observed: -an unbagged bedpan was observed on the bathroom floor. -an unused catheter bag dated 12/17 was observed in a cardboard box containing pudding cups belonging to Resident 3. -a nebulizer was observed on bedside table. The apparatus was apart and left on top of the bedside table. Nebulizer tubing was observed rolled up and in a pink wash basin containing…

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

Based on observations, interviews, and record review, the facility failed to ensure that the facility's laundry equipment was maintained, according to manufacturer's instructions, and operated to ensure proper cleaning and disinfecting of linens for 1 of 1 day of survey(11/5/24). This has the potential to affect all residents. Findings: On 11/5/24, review of Documentation provided by the facility from Patriot [laundry chemical supply company] noted: Stain treatments: > B-Gone grease and oil remover wash in hot water, 140 degrees Fahrenheit[F]for colors and 165°F for whites. > Blood and stain remover wash in hot water 140°F for colors and 165° for white. > For washing machines and nursing homes, especially when dealing with various products like > Patriot Frontier Soap[detergent], Patriot Frontier Bleach, Patriot Powerhouse[heavy duty detergent], Patriot Ultra Soft[ fabric softener], and Patriot Stain Away[stain remover], the temperature requirements are generally based on the need to disinfect linens and properly activate the chemicals in the detergents and bleach. Here's 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.

Based on observations, interview, the facility's Daily High-Temp Ware Wash checklist directions, the facility's Refrigerator/Freezer Temperature Logs and the facility's Sink/Bucket Sanitizer Log directions, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted air conditioning units, the floors, a plunger, a dish air dry machine, a grease trap, a wall vent, a ceiling light and a walk-in freezer. Additionally, the facility failed to ensure the walk-in refrigerator/freezer temperatures were monitored; failed to ensure the dishwasher temperatures were monitored; failed to ensure the sink/buckets sanitizers were monitored and failed to ensure food was properly labeled and dated in the walk-in freezer for 1 of 1 kitchen tour for 1 of 1 day of survey (10/7/24). Findings: Review of the facility's Daily High-Temp Ware Wash checklist directions noted: Notify food service director if there are any standards that are out of compliance parentheses I dot E dot wash temperatures that are less than 150° or rinse temperatures that are less than…

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

Based on observations and interviews, the facility failed to ensure that the small and large steam tables were maintained in good repair and in safe operating condition for 2 of 2 kitchen tours (10/7/24). Findings: 1. On 10/7/24 at approximately 9:30 a.m., the surveyor observed a small steam table in the middle of the kitchen that had a broken electrical plug end and was plugged into an outlet and also observed a large steam table against a wall that had the electrical plug end cut off of it. In an interview, both the dietary aide and the cook stated that they still use the steam tables to serve food to the residents in the dining areas. The surveyor asked how long the small steam table had a broken plug and how long the large steam table was missing the plug end. The dietary aide and the cook were not sure how long the plug had been broken on the small steam table but they stated maintenance did know about it and they had a part for it. The dietary aide stated that it hadn't worked properly for a while and didn't always heat up consistently like it was supposed to. She also 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 observations and interviews, the facility failed to ensure 2 of 2 dietary food service workers had the appropriate competencies and were adequately trained around knowing the proper temperatures for foods served to residents. This has the potential to affect all 45 residents in the facility. Findings: Review of facility provided policy No [NAME] in the Kitchen undated states, Staff other than the dietary staff will know how to prepare a meal in case there is an immediate emergency in the kitchen.Non dietary staff will be oriented to basic kitchen operations. Choose a few people from each dept who cross-train to learn basic kitchen procedures. Orient those cross-trained staff to: Temperature taking and documentation; ie. cooking and cold and hot holding temps During an interview on 8/1/22 at 9:35 a.m., Dietary Aide indicated that she has had no training regarding food safety and does not know what temperatures would be safe to serve food. During a lunch meal preparation observation on 8/2/22 at 11:15 a.m. the fill in cook indicated that she had not received education…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and facility policy, the facility failed to ensure care plans were updated/implemented for side rails for 1 of 1 Resident (#12), smoking for 1 of 1 Resident's (#35) and in the area of dental for 1 of 1 Resident (#41) of 17 residents reviewed for comprehensive care plans. Findings: Review of facility policy Comprehensive Person-Centered Care Planning dated 1/19 states, The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with Resident Rights, which includes measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment/evaluation .a comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment 1. Resident #12 was admitted to the facility on [DATE] with diagnoses to include spinal fusion, lumbar region, respiratory failure, spinal stenosis, Parkinson's disease, and arthritis. Observations 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 Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications and expired medications in 2 of 3 units, [NAME] East and [NAME] West. Findings: 1. On 8/1/22 at 2:38 p.m., during review of [NAME] East medication storage fridge with the Register Nurse (RN), an opened multi use vial of Tuberculin Purified Protein Derivative (TB) labeled with an opened date of 6/13/22 was observed with manufactures directions of once opened vial should be discarded after 30 days. 2. On 8/1/22 at 2:47 p.m., during review of [NAME] medication storage fridge with the RN, an opened multi use vial of Tuberculin Purified Protein Derivative (TB) labeled with an opened date of 6/26/22 with manufactures directions of Discard opened product after 30 days and an opened box of Bisacodyl Suppositories with expiration date of 5/2022 were observed. On 8/1/22 at 3:05 p.m., the above was confirmed with the Director of Nursing 3. On 8/2/22 at 8:35 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 observations and interview, the facility failed to maintain a clean/sanitary environment on 2 or 3 wings observed ([NAME] East and [NAME] West) for 3 of 3 days of survey. Findings: 1. On 8/1/22, 8/2/22 and 8/3/22 the following was observed on [NAME] East: -room [ROOM NUMBER] and 5 shared bathroom had a 2 basins on the floor, on either side of the toilet and a unlabeled urinal hanging on the hand rail. -room [ROOM NUMBER] and 6 shared bathroom had an unlabeled bed pan on the floor with a basin in it, another unlabeled bed pan on the floor with a plastic bag, an unlabeled urinal on the back of the toilet and a basin stored on top of the paper towel dispenser and - On 8/1/22 and 8/2/22 room [ROOM NUMBER] and 9 shared bathroom had an unlabeled bariatric bed pan and a commode cover stored on the floor behind the toilet. 2. On 8/1/22, 8/2/22 and 8/3/22 the following was observed on [NAME] West: -room [ROOM NUMBER] and 27 shared bathroom had 2 unlabeled bed pans stored on the floor next to the toilet. -room…

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

Based on record review and interview, the facility failed to ensure a plan of care was updated in the care area of Nutrition for 1 of 17 resident care plans reviewed. (#2) Finding: Resident #2's clinical record revealed a physician diet order dated 5/17/22 for a Fluid Restriction 2000 milliliters, Reduce Sodium 2 grams. The plan of care was reviewed on 7/29/22 during the interdisciplinary team meeting that states Continue current plan of care and meet again next quarter. As of 8/2/22 the current care plan was not updated to reflect the new physician instructions. On 8/2/22 at 11:11 a.m. in an interview, a surveyor confirmed with the Director of Nursing that the care plan was not updated to reflect the current nutritional needs for the resident.

Based on interviews and record review the facility failed to follow physician order for wound evaluation and failed to follow the facilities Skin Management policy for 1 of 1 Resident reviewed for pressure ulcer management. (#20) Findings: Skin Management Program Policy, revised 2/20 states, Each resident will be assessed for the risk of developing skin breakdown or pressure ulcers and will receive the care and services to prevent pressure ulcers or to heal existing pressure ulcers. Skin risk assessments will be done using weekly skin assessment . Section B. Upon identification of a risk or presence of a pressure ulcer, the following will be initiated: a. a pain assessment will be completed b. a treatment will be established per physician order c. A care plan will be initiated or updated. Section C. Daily documentation of: a. the site b. dressing status and/or surrounding skin areas if the site is covered c. Weekly wound measurements by a registered nurse. d. Care plan will be reviewed and updated based on assessed outcomes. Review of Resident #20's medical record indicated 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.