Lakewood A Continuing Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice and a bed hold notice to include cost of care to the legal representative for 2 of 3 sampled resident reviewed for transfer to an acute care hospital. (Residents #82, #2 [R82, R2]).Findings: Resident #82 was originally admitted to the facility in August 2022 with diagnoses to include Heart Failure and Chronic Kidney Disease. Review of Resident #82's complete clinical record revealed he/she was transported to an acute care hospital and subsequently admitted on [DATE]. Further review of Resident #82's clinical record lacked evidence that the resident representative received a written transfer/discharge notice and a written bed hold notice. On 12/10/25 at 9:36 a.m., in an interview with a surveyor, the Nurse Manager for the Long Term Care unit confirmed that a written transfer/discharge notice and a bed hold notice were not provided to the resident representative in writing for the above-named date. On 12/10/25…

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 resident's physician supervised and evaluated weight loss for 1 of 5 residents reviewed with potentially significant weight loss (Resident #7 [R7]). On 12/8/25, R7's clinical record was reviewed and revealed the following:-Review of documented weights indicated R7's weight on 10/29/25 was 119.8 pounds, R7's weight on 11/28/25 was 112.2 pounds, which is a -6.34% weight loss in 1 month.-Review of R7's brief interview for mental status dated 12/5/25, indicated R7 has moderate cognitive impairment. -Review of the Provider's Progress Note dated 12/5/25 indicated R7 denied weight loss. The progress note lacked evidence that the potentially significant weight loss was identified or addressed. On 12/9/25 at 3:03 p.m., during an interview with a surveyor, a Licensed Practical Nurse (LPN) and the Unit Manager (UM), R7's clinical record was reviewed. The LPN stated if a resident has weight loss, staff will tell the provider first, and they would try a nutritional supplement such as Ensure or Glucerna. Then we will do weekly…

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, observations, 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 multiple shifts, for 2 of 6 Controlled Substances Books reviewed (Long Term Care House 5/6 [LTC House 5/6] and LTC House 7/8 Medication Tech med cart books).Findings:1. On 12/9/25 at 10:27 a.m., during a medication storage observation, Controlled Substances Book and Shift Counts for the LTC House 5/6 medication tech med cart were reviewed, which indicated the facility counts at the change of each shift, approximately 2 times per day, and revealed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 4/14/25 at 5:30 a.m., 6/22/25 at 2:30 p.m., 6/27/25 at 11:00 p.m., and 7/15/25 at 11:00 p.m.- The person authorized to administer medications going off duty failed…

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

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use for 1 of 2 medication storage rooms observed (Long Term Care [LTC] House med storage room). Finding:On 12/10/25 at 9:00 a.m. during an observation of the LTC House med storage room with the LTC Unit Manager, a bottle of Lido-Nystatin 50/50 (a medication commonly known as Magic Mouthwash) labeled for R74 with a written date of 10/8/24 and an expiration date of 10/8/25, was available for use. At this time, the surveyor confirmed the finding with the LTC House Unit Manager, and the unit manager discarded the expired medication.On 12/10/25 at 3:45 p.m., the finding was discussed with the Director of Nursing.

Based on observation, interview and the facility's Food Storage, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a dish machine, metal shelving and the floor; and failed to ensure foods were sealed, labeled, dated and/or discarded if past use by date in a walk-in refrigerator for 1 of 1 kitchen tours. (12/8/25) Findings: The facility's Food Storage policy effective 03/2025 noted: All foods must be covered, labeled, dated and routinely monitored to assure foods are used by their use by dates or discarded. On 12/8/25 from 10:45 a.m. to 11:20 a.m., a surveyor completed a kitchen tour with the facility Food Service Director and a Food Service Director from a sister facility, in which the following findings were observed:-The dish machine had large amounts of food debris, dried liquid residue and dried chemical residue on the top and sides of it. -The metal shelf under the hot water booster was rusty. -There was a one pound box of corn starch on a kitchen shelf that was open to the air and not sealed.-There was food debris and dirt on the floor…

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 provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 1 residents reviewed for rehabilitative services (Resident #7 [R7]).On 12/9/25, review of R7's clinical record indicated the following:-R7 had a diagnoses included a left femur fracture with routine healing.-Review of Physician's Telephone Orders, signed on 11/5/25, indicated and order to Continue current [Physical Therapy (PT)]/[Occupational Therapy (OT)]/[Speech Therapy(ST)] [Plan of Care (POC)] under new therapy provider, Reliant Rehabilitation, effective 11/01/25.-Review of the Order Summary Report indicated an active order to Continue current PT/OT/ST POC under new therapy provider Reliant Rehab, effective 11/1/25 and an active order clarifying Physical Therapy to see R7, 5 times per week.-Review of the Care Plan was not updated to address R7's physical needs related to a femur fracture (See F657).The surveyor was unable to find therapy documentation.…

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 review of the facility Reportable Incident Form, record review and interviews, the facility failed to notify timely the Medical Provider of an unwitnessed fall with head injury for 1 of 3 residents reviewed who sustained a head injury from a fall (Resident #1 [R1]).On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed. Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., R1 had an unwitnessed fall in his/her room. From the fall, R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist.A review of the clinical record indicated that on 11/7/25 the Charge Nurse/Registered Nurse (RN1) who assessed R1 after the fall filled out a Risk Management Form. RN1 documented a message containing information regarding the fall on the Risk Management Form for the Medical Provider to review at his/her next visit. The Provider reviewed the message and visited R1 on 11/10/25.On 11/18/25 at 11:26…

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

Based on the Reportable Incident Form, the facility policy and procedure for reporting and interviews, the facility failed to notify the State Agency (Division of Licensing and Certification) of an unwitnessed fall with head injury for 1 of 3 residents reviewed that sustained a head injury from a fall.On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed. Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., R1 had an unwitnessed fall in his/her room. From the fall, R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist.A review of the facility's reporting a fall with injury policy and procedure indicated under Section: To state and federal agencies: Falls with serious injury must be reported to the stated survey agency within 24 hours.On 11/18/25 at 11:26 a.m., in an interview with the surveyor, RN1 confirmed that he did not notify the Division of Licensing and Certification of the fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (the Skilled Unit, the Long-Term Care Unit and the Memory Care Unit) for 1 of 1 facility tour. Findings: On 11/14/24 from 9:15 a.m. to 9:45 a.m., two surveyors conducted an Environmental tour with the Facilities Director in which the following findings were observed: > Activity Room by front entrance - the ceiling, in the far-left corner of the room, had an area hanging down exposing sheetrock. There were multiple floor seams that were held down with black tape. > The skilled unit common area had a blue manual sit-to-stand lift and a mechanical Sara Plus sit-to-stand lift that had dirt/debris in the foot base areas; and had a manual sit-to-stand lift that had a foot base that had ripped/torn non-skid tape and chipped/peeling paint on the base and legs creating uncleanable surfaces. > Resident…

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

Based on the facility's policy, record review, and interview, the facility failed to notify the State Agency after an allegation of potential neglect concerns were identified, failed to investigate an unwitnessed fall resulting in a major injury, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 2 of 4 complaint investigations reviewed during an annual survey. Findings: A review of the facility's policy, Policy/Procedure #23-007, Reporting and Investigating Compliance Concerns, Section B. Investigations, states, Any alleged violation will be acted upon promptly by the individual receiving a report of non-compliance from a Workforce Member . A review of the facility's policy, Policy/Procedure #004, Resident Abuse, Neglect, or Exploitation, states, Section III. Reporting and Procedures .7. A Nursing Facility Reportable Incident Form will be completed, and written documentation of action taken shall be maintained. 8. The Administrator, Director of Nursing, or designee will report all incidents of actual or…

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, observations and record review, the facility failed to ensure that physician orders were followed for 1 of 2 Resident's reviewed for oxygen. (Resident #3) Additionally, the facility failed to follow recommendations given by Physical Therapy (PT) for 1 of 1 residents reviewed for restorative care (Resident #87). Findings: 1. On 11/12/24 during Resident #3's clinical record review, Resident #3 had a current physician order filed in the paper record and scanned into the electronic record dated 8/26/24 that noted: O2 [oxygen] therapy cont[continuous]/daily 4L[liters] via Nasal Canula q [every] shift am [morning] pm [evening] NOC [night] - 8/26/24. On 11/12/24 at 11:20 a.m., a surveyor observed Resident #3's oxygen concentrator set at 3 liters. On 11/13/24 at 9:00 a.m., a surveyor observed Resident #3's oxygen concentrator set at 3 liters. On 11/13/24 at 3:20 p.m., a surveyor and the Director of Nursing [DON] reviewed Resident #3's Treatment Administration Record (TAR) for oxygen administration and found documentation from September 6, 2024 to November 13, 2024 that…

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

Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 5 residents reviewed for respiratory care (Resident # 5, #23, #49, #3, #13). Findings: 1. On 11/12/24 at 9:15 a.m. and on 11/13/24 at 7:42 a.m., Observation of Resident #5's nebulizer mask unlabled and stored on their bedside table. 2. On 11/12/24 at 10:00 a.m. and on 11/13/24 at 9:00 a.m., observation of Resident #23's nasal cannula tubing unlabeled and stored on their bedside table. 3. On 11/13/24 at 8:20 a.m., 2 surveyors observed Resident #49 nasal cannula tubing unlabeled and stored on a wheelchair in the hallway. On 11/13/24 at 9:12 a.m., the above was confirmed by the Director of Nursing. 4. On 11/12/24 at 11:28 a.m., during an observation of Resident 3's bathroom, 2 surveyors noted a currently being used oxygen concentrator with the oxygen tubing for the concentrator taped to the floor across the room that had two (2) filters that were heavily built up with dust. On 11/13/24…

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

Based on observations, record reviews and interviews, the facility failed to properly store medications and biologicals in medication refrigerators, treatment carts and medication carts for 3 out of 3 units surveyed for medication storage. Findings: 1. Record review of the facility policy #PHARM903 states: All drugs shall be stored at appropriate temperatures that do not exceed manufacturer's recommendations or warnings. Refrigerator: A cold place in which the temperature is held between 36F and 46F. On 11/13/24 at 10:02 a.m. a surveyor observed the medication room for the long-term care unit with the Administrator and found the following: The refrigerator was a dorm style unit with a freezer compartment which is inappropriate for storing medications due to temperature fluctuations. Thermometers located under the freezer and in the lower drawer showed a 10 degree Farenheit difference in temperatures. Significant ice buildup in the freezer and pools of water on the top shelf with 3 medications in the water including a plastic bag containing a Spice Vax vaccination. Two boxes with…

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

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, ceiling vents, and ceiling lights and failed to ensure that the kitchen ice machine and the skilled unit ice machine were plumbed in accordance with code requirements to prevent food contamination for 2 of 2 tours. Findings: This direct connection of waste water and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. 1. On 11/12/24…

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

Based on observations, interviews and record review, the facility failed to ensure that a resident's choice in the area of bathing and hygiene were being followed for 1 of 20 sampled residents (Resident #37). Findings: On 11/12/24 at 9:10 a.m., observation of Resident #37 lying in bed with a splint on his/her right hand. His/her face was unshaven with flakey skin around his/her scalp. During an interview, Resident #37 stated, Tuesdays is his/her whirlpool bath day and Since I hurt myself .I haven't gotten it for a few weeks. It's usually a whirlpool bath. The surveyor asked if he/she can shave him/herself. Resident stated, Before I hurt myself, I've been waiting for over a week. I'm right-handed, with this especially, showing the surveyor his/her right hand in the splint. The resident confirmed the split is always in place and he/she would like his/her face shaved. The surveyor then asked if he/she had asked the staff to help. He/she stated, yes, but they are always busy. At this time the Registered Nurse #3 (RN #3) entered the room. Resident #37 asked the RN #3 about 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 a review of the Nursing Facility Reportable Incident submitted to the Division of Licensing and Certification on 10/21/24, the facility's internal investigation, written statements by staff, facility policy, clinical record review and interviews, the facility failed to protect a resident's right to be free from physical and emotional abuse by staff when a Certified Nursing Assistant (CNA #1) forcibly dressed and transferred a resident. (Resident #70) Findings: The incident on 10/21/24 came to the attention of DHHS-DLC in a facility reported incident dated 10/21/24 alleging that CNA #1 was abusive towards Resident #70. A surveyor reviewed the facility policy Resident Abuse, Neglect, or Exploitation stated that Abuse is The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #70's medical records showed diagnoses of dementia, anxiety, depression,…

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 a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 2 of 2 observations for 2 of 3 days of survey. (11/12/24 and 11/13/24) Findings: The Safety Data Sheet for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes noted the following: 4. First Aid Measures General advice: Show this safety data sheet to the doctor in attendance. Eye contact: Rinse thoroughly with water as necessary. Get medical attention if irritation develops and persists. Skin contact: Wash skin with soap and water. Give medical attention if irritation develops and persists. Inhalation: If symptoms develop move victim to fresh air. If breathing is difficult, [trained personnel should] give oxygen. If symptoms persist, call a physician. Ingestion: Drink 1 to 2 glasses of water. Get medical attention if symptoms occur. On 11/12/24 at 10:38 a.m., during an…

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

Based on interviews and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on the Long Term Care Unit. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL)'s. (Resident #4, #45, and #87). Findings: 1.On 11/12/24 at 10:13 a.m., Resident #4 stated, staff take between 30 mintues to 1 hours for staff to answer his/her call bell. In an attitional interview on 11/13/24 at 1:20 p.m. Resident #4 stated that he/she believed waiting over 20 minutes for staff to respond to a call bell is too long. Review of quarterly Minimum Data Set (MDS) revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. Record review of the Individual Account Report from 11/5/24 through 11/12/24 states Resident #4 waited approximately 25 minutes to 1 hour and 18 minutes 10 times. 2. On 11/12/24 at 8:51 a.m., Resident #45 states the unit is often short staffed, taking up to 1 hour for staff to answer his/her call…

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 follow appropriate infection control procedures related to hand hygiene during 1 of 2 medication pass observations. Review of Policy/Procedure #31-202, Hand Hygiene Program for Northern Light Member Organizations that Provide Clinical Patient Care, states, .Hand Hygiene is to occur: 1. Before touching a patient .The use of gloves does not replace Hand Hygiene .Hand Hygiene shall occur prior to donning gloves and after doffing gloves . During a medication pass observation on the Memory Lane unit on 11/14/24 between 11:30 a.m. and 11:38 a.m., Registered Nurse (RN) #2 was observed in room [ROOM NUMBER], checking Resident #61's blood sugar, with gloved hands. RN #2 was observed exiting room [ROOM NUMBER] with gloved hands and walking to the medication cart located outside of room [ROOM NUMBER]. RN #2 doffed (removed) her gloves and placed them in the trash bin hanging on the side of the medication cart. Without using the hand sanitizer observed on top 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 that a call bell was functional for 1 of 20 sampled residents (#37). Finding; On 11/12/24 at 9:10 a.m. during an interview, Resident #37 stated his/her call bell has not been working and they said they fixed it. At this time, the surveyor pushed the call bell, the light above the door did not illuminate. The surveyor then went to the nurse's station and checked the call bell screen and asked the Registered Nurse (RN#3) if the call bell screen shows active call bells. RN#3 stated if it's highlighted red is an active call bell. Resident #37's room had no indication of the call bell being activated. Both the Surveyor and RN #3 went to resident #37's room. A Certified Nurses Aid also entered the room and stated the call bell was not working. At this time the Minimum Data Set project manager came to the door stating she would grab a hand bell for resident #37 to use. RN#3 attempted to put call bell on and it did not work. At this time RN #3 wiggles the call bell box and the light illuminated, then shut off. RN #3 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 Units. (Skilled unit, Dementia unit and Long Term Care unit) for 2 of 2 environmental tours (08/29/23 and 8/31/23) Findings: 1. On 8/29/23 at 1:16 p.m., a surveyor did an environmental tour with the Infection Preventionist in which the following findings were observed: Resident room [ROOM NUMBER] - Shared bathroom with a resident tooth brush not labeled for who it belonged to and basin stored on floor not covered. Resident room [ROOM NUMBER] - Basin stored on floor not covered. Resident room [ROOM NUMBER] - Basin and bedpan stored on floor not covered. On 8/29/23 at approximately 3:00 p.m., a surveyor reviewed the above findings with the Infection Preventionist and confirmed basins should not be stored on the floors, personal items in shared bathrooms should be labeled. 2. On 8/31/23 from 8:15 a.m. to 8:45…

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 weekly pressure ulcer documentation were completed as per facility policy for 1 of 1 residents reviewed for pressure ulcers (Resident #68 [R68]. Finding: The facility's policy and procedure, Pressure Injury and Wound - Elsevier, directed staff to use the organization-approved assessment tool (located in the computer software) to complete assessments. Areas that needed to be documented included: anatomic location on the body, type of pressure injury (PI) or wound, extent of tissue involvement, color, type, and percentage of tissue involved, length, width, and depth measures in centimeters, presence of undermining at the PI or wound edges, tunnels, or sinus tracts (measure and record depth and direction of each), amount, color, and consistency of exudate, presence of foul odor, and periwound skin integrity and to document this in the clinical record. On 8/29/23, R68's clinical record was reviewed and included a physician order for treatment to measure weekly on Thursdays which started on 6/29/23 for a Stage III…

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.

2. On 8/28/23 at 12:10 p.m. a surveyor observed R27 wearing oxygen that was being administered by a nasal cannula (NC) at a rate of 3 liters (L). On 8/28/23 R27's clinical record was reviewed and there was no evidence of a physician's order for the use of oxygen. A review of R27's nursing notes dated 6/19/23 to 7/11/23 shows documentation of R27 using oxygen daily at a rate of 3L per minute by nasal cannula. R27's clinical record review shows documentation that on 7/7/23 R27 transitioned from skilled care to long term care, the facility continued to monitor his/her use of oxygen daily until 7/11/23 (4 days after skilled services ended). R27's clinical record lacked evidence that R27's had a physician's order for the use of oxygen. A surveyor observed the oxygen concentrator and the vents located on the back of the machine were covered in dust. On 8/29/23 at 9:25 a.m. a surveyor observed that R27's oxygen concentrator continued to be covered in dust. At 10:00 a.m. a surveyor confirmed with the Skilled Unit Manager that R27's oxygen concentrator was covered in dust. At this time 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 observation and interviews, the facility failed to ensure that portable oxygen was available for 1 of 1 resident (Resident #1 [R1]) to leave their room for activities and to eat in the dining room for breakfast, lunch and supper for 4 of 6 meals served (8/27/23 supper, 8/28/23 breakfast, 8/28/23 lunch, and 8/28/23 supper). Findings: On 8/28/23 at 1:07 p.m. in an interview with a surveyor, R1 stated he/she did not receive lunch and that he/she goes to the dining room to eat, but there were no portable oxygen tanks in storage or available, so was told by staff he/she could not go to the dining room and has to eat in his/her room, and could not attend activities. He/she had to eat in room, where there is an oxygen concentrator machine, on 8/27/23 supper, 8/28/23 breakfast, 8/28/23 lunch, and 8/28/23 supper. He/she stated there was a portable oxygen machine that someone donated to the facility, but he/she could not use that because it was not holding a charge. On 8/28/23 at 1:15 p.m., in an interview with a surveyor, Registered Nurse #2 [RN#2] stated that R1 was not given lunch…

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

Based on observation and interviews, the facility failed to ensure that portable oxygen was available for 1 of 1 resident (Resident #1 [R1]) to leave their room to eat in the dining room for breakfast, lunch and dinner for 3 of 5 meals served (8/27/23 dinner, 8/28/23 breakfast, and 8/28/23 lunch). Findings: On 8/28/23 at 1:07 p.m. in an interview with a surveyor, R1 stated he/she did not receive lunch and that he/she goes to the dining room to eat, but there were no portable oxygen tanks available or in storage so was told by staff he/she could not go to the dining room and has to eat in his/her room. He/she had to eat in room on 8/27/23 supper, 8/28/23 breakfast, and 8/28/23 lunch, where there is an oxygen concentrator machine. On 8/28/23 at 1:15 p.m., in an interview with a surveyor, Registered Nurse [RN] stated that R1 was not given lunch today, not sure why, and ate breakfast in his/her room this morning because there were no portable oxygen tanks available for R1's use. A surveyor confirmed at this time that R1 was not able to go to the dining room for meals, per 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 record reviews and interviews, the facility failed to notify the resident and the resident's representative in writing of the transfers/discharges to an acute care hospital for 3 of 3 residents sampled for hospitalization ( Resident #53 [R53], Resident #15 [R15], and Resident #83 [R83]). In addition, the facility failed to notify the State Ombudsman of facility initiated transfer/discharges. Findings: 1. On 8/28/23 at 12:49 p.m., during an interview with a surveyor, R53 stated that he/she was recently admitted to the hospital but did not recall receiving any paperwork from the faciltiy regarding this hospital transfer. On 8/29/23. R53's clinical record was reviewed and indicated the R53 was transferred and admitted to the hospital on [DATE] and returned to the facility on 7/18/23. The surveyor was unable to find a transfer/discharge notice in the clinical record. On 8/30/23 at 10:26 a.m., during an interview with a surveyor, the Administrator in Training (AIT) stated she was unable to find evidence of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately for 3 of 22 sampled residents (Resident #87 [R87], Resident #101 {R101}, and Resident #86 [R86]). Findings: 1. On 8/28/23 at 1:05 p.m., a surveyor observed R87 wearing oxygen being administered by nasal cannula. On 8/30/23, R87's clinical record was reviewed and included a physician order, dated 4/28/23, to administer oxygen. Review of R87's most recent quarterly MDS, dated [DATE], for Section: O Special Treatments and Programs was not checked on O100C for oxygen use. On 8/30/23 at 11:47 a.m., a surveyor confirmed this finding with the Administrator in Training (AIT). 2. On 8/31/23, R101's clinical record was reviewed and included a physician order, dated 2/11/23, that indicated a Hospice referral was made on 2/8/23. On 8/31/23 at a.m., during an interview with a surveyor, the Resident Assessment Coordinator (RAC) stated she would check on the date that R101 was accepted into the Hospice…

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 baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 5 sampled residents admitted for skilled care services (Resident #27 [R27]). Finding: Review of R27's clinical record noted that he/she was admitted to the facility on [DATE] with a primary diagnoses of medically complex, morbid obesity, chronic diastolic congestive heart failure, obstructive sleep apnea, bipolar disorder, major depressive disorder, and post-traumatic stress disorder (chronic). The clinical record lacked evidence that the base line care plan was not developed for the use of oxygen to include the instructions necessary to properly care for R27. On 8/30/23 at approximately 1:31 p.m. during an interview with the Skilled Nurse Manager, the surveyor confirmed that that baseline care plan was not developed to include the use of oxygen and the instructions…

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 ensure that care plans were developed to reflect a resident's current needs for 2 of 19 residents reviewed (Resident #87 [R87] and Resident #27 [R27]). Findings: 1. On 8/28/23 at 1:05 p.m., a surveyor observed R87 wearing oxygen being administered by nasal cannula. On 8/30/23, R87's clinical record was reviewed and included a physician order, dated 4/28/23, to administer oxygen. A review of R87's current care plan, last reviewed on 7/5/23, did not include a care area or interventions that identified that R87 used oxygen. On 8/31/23 at 12:14 p.m., a surveyor confirmed this finding with the Administrator in Training (AIT). 2. On 8/28/23 at 12:10 a surveyor observed R27 wearing oxygen that was being administered by a nasal cannula at a rate of 3 liters (L) and a bilevel positive airway pressure (BiPAP) machine on his/her bedside table. On 8/28/23 R27's clinical record was reviewed and there was no evidence of a physicians order for 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 review and interview, the facility failed to complete daily assessments and weekly or as needed dressing changes to a midline catheter for 1 of 1 sampled residents reviewed (Resident #53 [R53}). Finding: The facility's policy and procedure, Vascular Access Devices (VADS): Ongoing Assessment, Site Care, and Dressing Change, indicated that a sterile dressing is applied and maintained on all peripheral, nontunneled, peripherally inserted central catheters, and access implanted VADs. Midline catheter site care and dressing changes are performed at established intervals, and immediately when the integrity of the dressing is compromised; if moisture, drainage, or blood is present; or for further assessment if site infection or inflammation is suspected. Gauze dressings are changes every 2 days, transparent semipermeable membrane dressings are changed every 5 to 7 days. R53 returned from the hospital on 7/18/23 with a midline catheter in place so intravenous (IV) medications could still be received. A nurses note, dated 7/18/23 2:34 p.m., indicated patient noted with…

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

Based on observations and interviews, the facility failed to ensure that the resident environment remained free from the potential risk of accidents, for 1 of 1 days of survey (8/28/23), when they failed to ensure a toilet was secured to the floor in a resident bathroom. Finding: On 8/8/23 at 12:26 p.m., a surveyor observed Resident #83's bathroom toilet to be loose and not secured to the floor. On 8/8/23 at 12:29 p.m., in an interview, Registered Nurse [RN] #2, he stated that Resident #83 does use the toilet and that there has been trouble with this toilet before. 0n 8/28/23 at 12:33 p.m., in an interview, the Facilities Maintenance Director confirmed that Resident #83's toilet was not properly secured to the floor and was a potential accident hazard. The Regional Facilities Director had the toilet immediately fixed by a maintenance worker. 0n 8/28/23 a 1:17 p.m., a surveyor discussed the finding with the Administrator in training [AIT], the Director of Nursing [DON], and the Interim Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #27 [R27]). Finding: 1. On 8/28/23, R27's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE] with a diagnosis of PTSD. R27's admission minimum data set (MDS) 3.0 was dated 6/26/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. The surveyor was unable to find information in the clinical record that indicated what R27's PTSD was caused by or what events might cause re-traumatization. On 8/30/23 at approximately 2:00 p.m , during an interview with the Administer in training a surveyor confirmed the finding that the facility had not obtained information regarding R27's PTSD or what triggers/events might cause traumatization.

Based on observations, interviews, the facility's Purchasing, Receiving, Storage, and Issuance of Food and Supplies Policy/Procedure #: FNS-4, and The facility's Sanitation, Infection Control, HACCP and Safety Policy/Procedure #: IC-FNS- 8, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall fans, a hanging pot rack, and hood filters; failed to ensure that staff with facial hair utilized beard restraints; and failed to ensure that food is stored, served and prepared in a safe, sanitary manner as evidenced by improper food storage in the walk-in freezer on 1 of 1 days of kitchen observations (8/28/23). In addition, the facility failed to monitoring for sanitizer solution levels in sanitizing buckets and failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. This has the potential to affect all residents. Findings: On 8/28/23 from 11:30 a.m. to 12:05 p.m., an initial Kitchen Tour was conducted with the Kitchen Manager in which the following findings were observed: 1. >The dish…

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 the facility's Sanitation, Infection Control, HACCP, and Safety Policy/Procedure #: IC-FNS- 8, the facility failed to ensure that the kitchen high temperature dish machine was maintained in good repair and in safe operating condition for 4 of 4 dish machine observations (8/28/23, 8/29/23, 8/30/23 and 8/31/23) and failed to ensure proper cleaning and sanitizing of dishes for 1 of 4 kitchen tours (8/28/23). Findings: The facility's Sanitation, Infection Control, HACCP, and Safety Policy/Procedure #: IC-FNS- 8, last revised on 12/30/2020 noted the following: Procedure - General Principles - l. Pots are hand washed and then run through the dishwasher where they are rinsed at 180 degrees for proper sanitation. M. Dishes and silver will be washed by machine at wash temperature of 150 degrees[Fahrenheit] and above and the final rinse at least 180 degrees [Fahrenheit] (120[Fahrenheit] chemical rinse, if applicable). Temperatures will be recorded after each meal. x. Food and Nutrition Services Department equipment and facilities are on the plant…

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.