Every finding on record at Augusta Center for Health & Rehabilitation, LLC

Based on interviews and record reviews, the facility failed to ensure that a resident was free of accidents/hazards for a resident who had rolled out of bed during personal care resulting in a fracture for 1 of 3 residents reviewed for falls. (Resident #1).Findings:On 4/19/26 Division of Licensing and Certification received an incident report indicating the following: On Thursday 4/15, staff member (Certified Nursing Assistant CNA #1) was giving care to [Resident #1]. [Resident #1] began to fall out of bed. The [CNA#1] called out for help. Two other staff arrived and helped lower [Resident #1] to the floor. [Resident #1] had persistent pain. X-ray results today show bilateral fractures above the knee. Facility investigation, dated 4/21/26, indicated the following: [CNA #1] attempted to provide care to [Resident#1] alone with bed in the high position. Kardex and care plan reflect that resident is a 2-assist for bed mobility. CNA#1 entered the room alone and helped resident roll onto her side so that she could begin washing her up for the day. After rolling resident onto her side, CNA#1 saw that resident began gaining momentum and sliding off the side of the bed. Due to resident's size, CNA#1 was unable to stop resident descent. CNA#1 called out for assistance. An LPN came to assist. LPN also attempted to stop residents' descent and called out to Medication Tech for further assistance. Resident was lowered to ground. LPN completed evaluation of resident.Care plan, revision date 4/2/26 for ADL self-care deficit, related to Parkinsons, obesity -PERSONAL HYGIENE/ORAL CARE: DependentOn 5/14/26 at 8:46 a.m., during an interview with a surveyor, the Assistant Director of Nursing (ADON) stated that Resident #1 was a 2-person assist and there was only one staff assisting the resident at the time of the incident.On 5/14/26 at 12:17 p.m., in an interview with Licensed Practical Nurse (LPN) #1, they stated that they never perform care for Resident #1 alone, he/she is too big, I always get help.On 5/14/26 at 9:05 a.m., review of the emergency room visit documentation dated 4/19/26 states: You have been evaluated in the Emergency Department today for pain. your evaluation, including physical evaluation and Computed Tomography scan, suggests that your symptoms are related to bilateral femur fractures that are comminuted and extensive.On 5/14/26 around 12:30 p.m., in an interview with a surveyor, the Administrator confirmed the above findings.As a result of the facility's investigations of this fall incident, the following corrective actions were initiated:On 4/19/26, CNA #1 was suspended from working at the facility during the investigation.On 4/19/26, per the family's request, they met with the Administrator to address their concerns and questions and to incorporate their suggestions into future safety and risk planning.On 4/20/26, the remaining staff did a reenactment of the incident to create a sequence of events for analysis.On 4/20/26, the facility provided staff education on reading the Kardex and reportable incidents.On 4/22/26 CNA #1 was terminated.On 4/23/26 at 2:07 p.m., the facility notified the CNA registry via email regarding CNA #1's termination following a serious incident.Audits for falls were completed from 4/22/26 to 5/3/26.Audits for bed mobility to ensure that it is accurately listed in the Kardex for each resident were done from 4/24/26 to 5/5/26.On 5/14/26 during observation of the resident, resident was in a newly ordered wheelchair to ensure their comfort and participation in any activities as they heal.At the time of the onsite investigation, the facility presented corrective actions taken to address the incident to the surveyor including conducting a root cause analysis The facility was determined to be in past non-compliance after the review and verification of the implemented corrective actions.

Based on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 7 residents reviewed for care planning (Residents #3, #6, #7, #9, and #24).Findings:1. Review of Resident #3's clinical record revealed an MDS Quarterly Assessment was completed on 11/27/25. Further review of Resident #3's clinical record revealed that an IDT meeting was held 12/10/25 (13 days after assessment) and lacked evidence that an IDT meeting was held within 7 days following the assessment.Additional review of Resident #3's clinical record indicated that he/she sustained an unwitnessed fall at the facility on 12/17/25 and was subsequently admitted to an acute care hospital on [DATE], was diagnosed with a left hip fracture, and underwent left hip surgery on 12/18/25. Resident #3 returned to the facility on 1/3/26. The clinical record revealed an MDS Significant Change Assessment was completed on 1/13/26 but lacked evidence that an IDT meeting was held within 7 days following the assessment.A review of Resident #3's provider History & Physical dated 1/5/26 states, .seen today for readmission following hospitalization for a mechanical fall resulting in left proximal femoral fracture. maintain post-op dressing precautions and monitor for bleeding, erythema, warmth, purulent drainage, wound dehiscence, or fever; reinforce to staff close supervision given attempts to remove Steri-Strips.A review of Resident #3's physician orders revealed the following:An order with a start date of 1/27/26 for Monitor L [left] hip incision, leave OTA [open to air] every day and evening shift for 7 Days.An order with a start date of 1/20/26 for Monitor dressing on L hip. Change dressing every 3 days and PRN [as needed] every day and evening shift for 7 days.A review of Resident #3's care plan lacked evidence that goals and interventions were put into place for the left hip incision.On 2/5/26 at 8:30 a.m., the above finding was discussed during an interview with the Administrator and Regional Director of Clinical Operations. At this time, the Administrator reviewed Resident #3's care plan and stated that she would expect to see goals and interventions for the care of the left hip incision and confirmed the care plan was not revised to reflect Resident #3's current needs.2. Review of Resident #6's clinical record revealed an MDS Annual Assessment was completed on 10/30/25 and an MDS Quarterly Assessment was completed on 1/22/26. Further review of Resident #6's clinical record lacked evidence that an IDT meeting was held within 7 days following the above assessments.3. Review of Resident #7's clinical record revealed an MDS Quarterly Assessment was completed on 1/7/26. Further review of Resident #7's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment.4. Review of Resident #9's clinical record revealed an MDS Quarterly Assessment was completed on 11/18/25 and an MDS Significant Change Assessment was completed on 12/22/25 and that Resident #9 was admitted to hospice services. Further review of Resident #9's clinical record revealed that an IDT meeting was held 1/28/26 and lacked evidence that an IDT meeting was held within 7 days following the above assessments.5. Review of Resident #24's clinical record revealed an MDS Annual Assessment was completed on 8/18/25 and that an IDT meeting was held on 9/10/25. Further review of Resident #24's clinical record revealed an MDS Quarterly Assessment was completed on 11/11/25 and that an IDT meeting was held on 12/11/25. Resident #24's clinical record lacked evidence that an IDT meeting was held within 7 days following the above assessments.On 2/5/26 at 8:05 a.m., during an interview, the MDS Coordinator stated that the facility does not schedule IDT meetings based off of MDS Assessment dates and that IDT meetings are scheduled based off of the date that the last IDT meeting was held. On 2/5/26 at 8:18 a.m. during an interview, the Licensed Social Worker (LSW) stated that she schedules IDT meetings based off of a report she receives, and that it is her understanding that IDT meetings for Long Term Care residents should be scheduled within 7 days of the review date indicated on the report and within 14 days of the review date for Skilled residents.On 2/5/26 at 8:30 a.m., the above findings were discussed with the Administrator and Regional Director of Clinical Operations.

Based on observations, interviews and record reviews, the facility failed to ensure medications, including treatments, were stored properly by failing to obtain physician orders for medications located at a resident's bedside for 2 of 20 sampled residents (Residents #64, #9). In addition, the facility lacked evidence of consistent monitoring of medication storage room refrigerator temperatures to ensure proper medication and vaccine storage temperatures for 5 of 7 months reviewed. Findings: 1. On 2/1/26 at 9:45 a.m., during an observation of Resident #64's room, a 43 g bottle of miconazole topical 2% powder with a pharmacy label for Resident #64 and a medicine cup containing an unknown white substance was located on the counter next to the shared sink. During an interview at this time, Resident #64 stated that he/she cannot apply the medications himself/herself because he/she is disabled and that staff apply his/her medications. 2. On 2/1/26 at 10:24 a.m., during an observation of Resident #9's room, a 6 fluid ounce bottle of Calamine lotion with a pharmacy label for Resident #9 was located on the counter next to the shared sink. A review of Resident #9's clinical record lacked evidence of a physician order for Resident #9 to self-administer medications. On 2/1/26 at 2:51 p.m., the above findings were discussed during an interview with the Director of Nursing (DON). At this time, the DON stated that topical medications are stored in a separate bag for each resident in the treatment cart and should not be stored at the resident's bedside. 3. On 2/5/26 at 11:46 a.m., the surveyor observed the medication storage room refrigerator, which contained insulin, vaccinations and other medications requiring refrigeration. Review of the facility policy titled Medication Storage - Storage of Medication (Section 4.1, revised 01/25 directed that refrigerators storing vaccines be monitored. And recorded twice daily and maintained within 36 F – 46 F. The policy further indicates insulin products are to be stored in the refrigerator until opened and must not be frozen. Review of the Refrigerator Temperature Log, which instructs staff to record temperatures twice daily, revealed missing documentation as follows: August 2025 4 of 31 days missing AM documentation 2 of 31 days missing documentation September 2025: 1 of 30 days missing AM documentation 1 of 30 days missing PM documentation October 2025: 4 of 31 days missing AM documentation November 2025: 1 of 30 days missing AM documentation December 3 of 31 days missing AM documentation 3 of 31 days missing PM documentation On 2/5/26 at 1:30 p.m., the above findings were discussed with the Administrator and Regional Director of Clinical Operations.

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 3 of 3 units ([NAME], Penobscot and Kennebec Units) and a common area for 1 of 1 environmental tour (2/5/26).Findings: On 2/5/26 from 8:55 a.m. to 9:25 a.m., a surveyor conducted an Environmental Tour with the Maintenance Director and the Administrator in which the following findings were discussed and observed: Common Area:- A hallway ceiling tile, by the main entrance door, had a large brown stain on it. Penobscot Unit:- Resident room [ROOM NUMBER] - There was a full cup of liquid, with a straw in it, on floor next to bed B. There was an unbagged bed pan on the bathroom floor.- Resident room [ROOM NUMBER] - There was a medium size bottle of powder lying on floor behind the head of bed A. The oxygen concentrator, located between the beds, had dirt/debris and dried liquid residue on it.- Resident room [ROOM NUMBER] - The over the bed table, for bed B, had dried food particles and dried liquid residue on it. Kennebec Unit:- Resident room [ROOM NUMBER] - The window blind was broken in many places, hanging down and in disrepair. The bathroom had a container of purple wipes on a rollator walker with a wipe sticking out. [NAME] unit- Resident room [ROOM NUMBER] - The baseboard heating unit had chipped/missing paint creating an uncleanable surface.- Resident room [ROOM NUMBER] - The baseboard heating unit had chipped/missing paint creating an uncleanable surface.- Resident room [ROOM NUMBER] - The window blind was broken in many places, hanging down and in disrepair. On 2/05/2026 at 9:25 a.m., in an interview with a surveyor, the Maintenance Director and the Administrator confirmed the discussed and observed findings.

Based on observation, interviews, and Centers for Disease Control and Prevention (CDC) guidance, 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 transporting soiled linens and disinfecting a soiled surface during a wound dressing observation for 1 of 3 residents reviewed for wounds (Resident #9). Findings: On 2/1/26 from 12:14 to 12:43 PM, during an observation of Resident #9's left leg wound dressing change, Registered Nurse (RN) #1 sanitized her hands and donned (put on) Personal Protective Equipment (PPE) per the Contact precautions sign hanging outside Resident #9's door. RN #1 then placed Resident #9's left leg on a towel located on top of his/her bed and proceeded to remove Resident #9's existing dressing, provide wound care, and apply a new dressing. Resident #9's open wounds were in direct contact with the towel during the wound care and dressing change. After the dressing change, RN #1 discarded the soiled dressing and then removed the soiled towel from under Resident #9's leg. RN #1 then placed the unbagged, soiled towel on the counter of the sink that Resident #9 and Resident #61 share. RN #1 then placed her bandage scissors in the sink basin and proceeded to wash her hands, reposition Resident #9, and cover him/her with blankets. RN #1 then doffed (took off) her PPE and then picked up the unbagged, soiled towel with her ungloved hands and carried it out of the room and across the hall to the soiled utility room (Whirlpool room), where she discarded the towel. RN #1 then returned to Resident #9's room, sanitized her hands, donned new PPE, and cleaned the bandage scissors in the sink with disinfectant wipes. RN #1 then doffed her PPE, sanitized her hands, and without cleaning the sink counter, proceeded to leave the room. On 2/1/26 at 12:43 p.m. during an interview, Resident #61 stated that he/she and Resident #9 share the sink, and stated that he/she uses the sink to wash his/her face and bathe. On 2/1/26 at 12:45 p.m. during an interview, RN #1 stated that Resident #9 is on Contact precautions for Shingles. At this time, the surveyor discussed the above observation, and RN #1 stated that she does not like carrying soiled linens with her bare hands, but that she is not supposed to wear gloves in the hall. The surveyor also discussed the placement of the soiled towel on the shared sink counter, and that the counter was not cleaned after RN #1 removed the soiled towel. At this time, RN #1 stated she was going to go get disinfectant wipes to clean the sink and counter and proceeded to do so. On 2/1/26 at 1:10 p.m., the above finding was discussed during an interview with the Director of Nursing, the Administrator, and the Regional Director of Clinical Operations. At this time the Administrator stated that the facility's procedure is that staff do not wear gloves when transporting soiled linens in the hall. Centers for Disease Control and Prevention (CDC) Best Practices for Environmental Cleaning in Global Healthcare Settings, Appendix D- Linen and laundry management, dated 3/19/24 states, Always wear reusable rubber gloves before handling soiled linen.

Based on observation and interview, the facility failed to ensure the confidentiality of protected health information when resident identifiable assignment sheets and a monthly weight documentation sheet were left unattended in the solarium, an area accessible to residents and visitors, on 1 of 4 days of survey. Finding:On 2/1/26 at 11:00 a.m., a surveyor observed copies of multiple resident care assignment sheets and a document titled December Monthly Weights left unattended on a table in the solarium, an area accessible to residents and visitors. At the time of the observation, two residents and one visitor were present in the solarium. The assignment sheets contained resident identifiable information including resident names, room numbers, diagnosis, continence status, required assistance with activities of daily living (ADL's), transfer needs (including Hoyer use), fall risk status and other personal care instructions. The monthly weight sheet contained resident names and recorded weights. The documents were left unattended in a publicly accessible area without safeguards to maintain confidentiality of resident information.On 2/1/26 at approximately 11:20 a.m., the surveyor confirmed this finding with the Human Resources Assistant, who acknowledged the assignment sheets contained sensitive and private protected health information and stated the documents should not have been left unattended in the solarium.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall and the floor; failed to ensure foods were labeled and dated in a reach-in freezer; and failed to ensure kitchen staff with facial hair wore facial protection for 1 of 1 kitchen tour for 1 of 1 day of survey (2/1/26). Findings: On 2/1/26 from 9:05 a.m. to 9:35 a.m., a surveyor conducted an Initial Kitchen Tour in which the following findings were observed: - Two male kitchen workers with facial hair (beards and moustaches) were not wearing facial hair protection. - The wall behind the toaster had chipped/missing paint creating an uncleanable surface. - The kitchen floor had food debris and trash throughout the kitchen, under equipment and under shelving. - The Reach-in freezer, nearest the walk-in refrigerator, had a previously opened package of strips/tenders that was not labeled and dated. On 2/1/26 at 9:38 a.m., in an interview, a surveyor discussed the findings with the Dietary Aide. On 2/1/26 at 11:25 a.m., in an interview, a surveyor discussed the findings with the Acting Administrator.

Based on record review and interview, the facility failed to ensure that the resident's medical record included documentation that indicated that the resident or resident representative accepted a COVID-19 vaccine that the resident received for 1 of 5 residents reviewed for immunizations (Resident #24).Finding:Review of Resident #24's clinical record revealed a signed Immunization Consent Form dated 6/6/25, indicating Resident #24 declined the COVID-19 vaccine. Further review of the clinical record revealed that Resident #24 received the COVID-19 immunization on 11/5/25. On 2/5/26 at 1:08 p.m. during an interview, the Director of Nursing and the Administrator stated that they were looking for evidence that Resident #24 had consented to receive the COVID-19 vaccine administered on 11/5/25. At this time, the Regional Director of Clinical Operations stated that Resident #24 had refused the 2024-2025 COVID-19 vaccine but consented to receiving the 2025-2026 vaccine.The facility failed to provide evidence that Resident #24 consented to receiving the vaccine by the end of the survey.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition and wound care for 2 of 20 sampled residents (Residents #6, #9).Findings:1. Resident #6 was admitted in May 2023 with diagnoses to include Parkinson's Disease and dysphagia.On 2/5/26 at 8:05 a.m., a surveyor observed Resident #6 in bed with his/her over-the-bed table set up with his/her breakfast meal, including a spoon in the bowl of oatmeal and a fork by the entree plate. No staff were in the room at the time of the observation.On 2/5/26 at 9:45 a.m. during an interview, the Director of Nursing (DON) stated that there have been concerns with aspiration and an overall functional decline and that staff have been assisting Resident #6 more with feeding recently. A review of Resident #6's clinical record revealed an active physician order with a start date of 5/14/25 for Full supervision with all meals.Further review of Resident #6's clinical record revealed a quarterly nutrition evaluation dated 1/21/26 that states, .holding food in mouth/cheeks or having residual food in mouth after meals. needing supervision all meals . and a physician progress note dated 1/27/26 that states, .requires supervision with meals.On 2/5/26 at 12:53 p.m., during an interview, CNA #1 stated that Resident #6 feeds himself/herself about 50% of the time, and that when he/she can eat on his/her own, the staff will set him/her up and then leave the room to get trays for the other residents. She then stated that the staff periodically check in on Resident #6.On 2/5/26 at 1:15 p.m., during a follow-up interview with 2 surveyors, the above finding was discussed with the DON. At this time, the DON stated that sometimes Resident #6 feeds himself/herself and sometimes he/she needs assistance and that she was unaware that an order for full supervision with meals has been in place since May.2. Resident #9 was admitted in August 2025 with diagnoses to include chronic ulcer of the left leg.A review of Resident #9's clinical record revealed an active physician order with a start date of 1/23/26 for Wound care for LLE [left lower extremity] wound: cleanse LLE wound with sterile water (on days that we change collagen), apply a light dusting of collagen. to entire wound bed. apply oil emulsion over the collagen dusting, then apply barrier cream to wound edges (only outside wound edges) cover with large Abd pads [an absorbent, multi-layer dressing], and wrap with kerlix [a type of gauze bandage].On 2/1/26 from 12:14 p.m. to 12:43 p.m., a surveyor observed Registered Nurse (RN) #1 perform Resident #9's wound care. RN #1 removed the existing dressing and cleansed the wound with sterile water. RN #1 then applied the collagen to the wound bed, then applied oil emulsion, then covered the wound with the Abd pads, and wrapped Resident #9's lower leg with Kerlix.On 2/1/26 at 12:45 p.m., during an interview, the surveyor and RN #1 discussed Resident #9's wound care orders. At this time, RN #1 stated that Resident #9 often refuses barrier cream, but that she should have offered the treatment to him/her and missed that. Additional review of Resident #9's clinical record revealed a late-entry nursing progress note dated 2/1/26 that states, This RN inadvertently did not apply barrier cream to wound edges during dressing change to left lower extremity. Reapproached resident and asked if [he/she] would like me to apply it. [He/She] states [he/she] did and I applied the barrier cream to wound edges.On 2/1/26 at 1:10 p.m., the surveyor discussed the finding with the DON, the Administrator, and the Regional Director of Clinical Operations.

Based on observations, record review, and interviews, the facility failed to provide adaptive utensils for 1 of 3 residents reviewed for nutrition (Resident #6).Finding:Resident #6 was admitted in May 2023 with diagnoses to include Parkinson's Disease and dysphagia.On 2/5/26 at 8:05 a.m., a surveyor observed Resident #6's breakfast meal set up on his/her over-the-bed table. A standard spoon was resting in the bowl of oatmeal and a standard fork was set up next to Resident #6's entree, served on a lip plate. There were no adaptive utensils or cups.Review of Resident #6's care plan revealed the following: .ADL [Activities of Daily Living] self-care performance deficit.Lip plate with meals.L [left] and R [right] angled spoons.adaptive dining equipment: lip plate at meals. Blue insulated mug. Left and right angled spoon.On 2/5/26 at 12:53 p.m., during a repeat observation, Resident #6 received his/her lunch tray in his/her room. The meal ticket indicated .Blue insulated mug Left and right-angled spoon . There were no adaptive utensils or specialized mug. During an interview at this time, Certified Nursing Assistant (CNA) #1 stated that the kitchen sends the specialized eating and drinking utensils on the resident's tray and confirmed that the specialized mug and spoon were not on Resident #6's meal tray. CNA #1 then stated that Resident #6 feeds himself/herself about 50% of the time and when he/she can eat on his/her own, the staff will set him/her up and then leave the room to get trays for the other residents.On 2/5/26 at 1:10 p.m., during an interview, the Food Service Director stated that all resident specialized eating and drinking equipment is listed on the meal ticket and put on the resident's meal tray when it is sent to them.On 2/5/26 at 1:15 p.m. during an interview with 2 surveyors, the above finding was discussed with the Director of Nursing (DON). At this time, the DON stated that sometimes Resident #6 feeds himself/herself and sometimes he/she needs assistance and that he/she does not require adaptive utensils if staff is feeding him/her. The surveyors discussed that the kitchen does not know whether Resident #6 is feeding himself/herself that meal or if he/she will need assistance, so the kitchen has no way of knowing which meals Resident #6 will require adaptive utensils or which meals he/she will have staff assistance.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap, a baseboard heater register and the floor. Additionally, the facility failed to ensure foods were sealed, labeled and dated in a reach-in freezer and in a walk-in refrigerator for 1 of 1 kitchen tour for 1 of 1 day of survey (11/17/24). Findings: On 11/17/24 from 11:30 a.m. to 11:58 a.m., two surveyors conducted a kitchen tour in which the following findings were observed: > The grease trap exterior had rust on the lid and the base. Additionally, the caulking around the base was dirty and stained with a black substance. > The baseboard heater register, located between the grease trap and a sink, was dusty/dirty and had dried liquid residue and food splatter on it. > The floor, under the sink across from the steam table, was heavily soiled with food debris and dried liquid residue. > The reach-in freezer had a 10.2 ounce box of cinnamon donuts and an 18 ounce box of waffles that were not sealed and open to the air. > The walk-in refrigerator had a metal tray containing 3 custard-type pies that were uncovered, unlabeled, and undated. Additionally, there were 6 cakes that were unlabeled. On 11/17/24 at 11:58 a.m. in an interview with two surveyors, confirmed the findings with the Head Cook.

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units ([NAME] Unit, and Kennebec Unit) for 1 of 1 environmental tour (11/19/24). Findings: On 11/19/24, from 10:05 a.m. to 10:30 a.m., an environmental tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed: [NAME] Unit: > 3 hallway ceiling vents by resident rooms [ROOM NUMBER] were rusty and had dust on them. > Resident room [ROOM NUMBER] - The toilet surface and behind the seat were dirty with dried liquid residue. The bathroom exhaust vent was dusty/dirty. The caulking on floor around the bathroom door frame was dirty and stained. There was a urine collection cup on the floor by the toilet. > Resident room [ROOM NUMBER] - The bathroom floor was dirty. There was a yellow/brown stain on a ceiling tile near the vent above the toilet. The caulking at base of the room and bathroom door trim was dirty and stained. > Resident room [ROOM NUMBER] - The bathroom floor was dirty. The caulking around the base of the toilet was dirty/stained. The caulking at base of the room and bathroom door trim was dirty and stained. The bathroom exhaust vent was dusty/dirty. Kennebec Unit: > Resident room [ROOM NUMBER] - Resident #8's wheelchair had both left and right armrests that were cracked/broken. The caulking around the base of the toilet was dirty/stained. The bathroom exhaust vent was dusty/dirty. On 11/20/24 at 9:42 a.m. in an interview with a surveyor, the Administrator and the Maintenance Director confirmed the above findings.

Based on record review, observation and interviews, the facility failed to provide the proper adaptive equipment to a resident during a meal service for 1 of 6 observed meals for Resident #35 [R35] who was involved in an incident on 11/6/24. Finding: On 11/7/24, the Division of Licensing and Certification received from the facility a reportable incident form which indicated that on 11/6/24 R35 had spilled hot chocolate on his/her lap which caused burns which later in the day developed into blistered areas on both his/her thighs. On 11/18/24, during resident observations it was noted that R35 was sitting in the dining room with a Kennedy cup (spillproof cup). During interviews it was noted that R35 was evaluated by Occupational Therapy (OT) on 11/12/24 with recommendation for use of covered mug for hot liquids secondary to decreased fine motor coordination. On 11/20/24 at 8:30 a.m., R35 was observed in the dining room for breakfast, he/she had a plate of pureed food and a bowl of oatmeal in front of him/her on the table. R35 was observed by the surveyor drinking using a regular coffee cup with no cover. It was then confirmed that the cup contained hot chocolate, R35 was observed taking 2 additional sips from the uncovered cup. The surveyor brought it to the attention of the Administrator and the Regional Director of Clinical Operations. R35 was then given a cup with a cover. At this time, the surveyor confirmed that R35 was not using a spillproof cup (adaptive equipment) with his/her hot chocolate.

Based on observation, interviews, and record review, the facility failed to provide respiratory care according to physician orders for 1 of 1 sampled residents (Resident #7 [R7]). Findings: Resident R7 was admitted on [DATE] and has diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). A review of R7's active orders revealed a physician order, dated 5/30/24, for Oxygen therapy 1-2Lpm [liters per minute] titration to keep O2 sat (oxygen saturation) at 90-92%. every shift for SOB (shortness of breath)/cough. During an observation of R7 in the [NAME] unit dayroom, on 11/20/24 at 10:48 a.m., R7 was seated in a wheelchair at a table, working on a puzzle. R7 was wearing a nasal cannula, and the oxygen tubing was connected to a portable oxygen tank that was secured on the back of the wheelchair. The oxygen flow rate was set to 3Lpm, and the needle on the oxygen tank gauge was observed in the red area of the gauge marked, empty. During an interview on 11/20/24 at 10:53 a.m. with a surveyor, Registered Nurse (RN) 1 confirmed that R7 utilizes continuous oxygen therapy and that she interpreted the physician order to mean the oxygen was to be titrated to keep R7's oxygen saturation (O2 sat) between 90-92%. RN1 stated she had given R7 a nebulizer treatment approximately 15 minutes ago after his/her O2 sat was measured at 85-86% and then increased the oxygen flow rate from 2Lpm to 3Lpm and that she intended to re-check the O2 sat but got busy. At this time, a surveyor pointed out that the gauge on the portable oxygen tank indicated, empty. RN1 stated the gauge on the portable tank was in the full range when she had connected the oxygen tubing to the tank 15 minutes prior and proceeded to disconnect the oxygen tubing from the portable tank and connected it to an oxygen concentrator located by the table. During an interview on 11/20/24 at 11:04 a.m. with a surveyor, the Regional Director of Clinical Operations (RDCO) reviewed R7's oxygen order and stated she interpreted the order to mean that titration would occur within the 1-2Lpm, not above a 2Lpm flow rate, but that the facility may have standing oxygen orders. During an interview on 11/20/24 at 11:05 a.m. with a surveyor, the Director of Nursing Services (DNS) confirmed that the facility does not have standing oxygen orders, and stated the physician is in building, so RN1 may have titrated beyond order with intention of discussing with the physician. At this time, a surveyor reviewed the above findings with the DNS. On 11/20/24 at 11:40 a.m., in an interview with a surveyor, the Assistant Director of Nursing Services (ADNS) and RN1 requested to speak with a surveyor. At this time, with 2 surveyors present, ADNS and RN1 again confirmed the above findings and stated that R7's oxygen saturation is now improved to 89%, and that R7's oxygen saturation is usually 89% at baseline, and the physician has been notified.

Based on record review and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 1 of 1 residents reviewed for falls (Resident #27 [R27]). Finding: On 11/20/24, R27's clinical record was reviewed and the surveyor requested to review the facility's fall report for R27 that occurred on 9/29/24. Documentation on the fall report, completed 9/29/24 at 2:48 p.m. by Registered Nurse #2 (RN2) indicated that R27 was transferring self, fell forward towards the wall, and a staff member was able to grab R27 and sit back down on the bed. R27 sustained a nosebleed. The fall report indicated that the physician (Third Eye) was notified at 2:57 p.m. Review of the Third Eye health note documented in R27's progress notes, completed by Third Eye, on 9/29/24 at 10:44 p.m., indicated that on 9/29/24 at 1:53 p.m. (central time) which is 2:53 p.m. (eastern time), it was reported by RN2 that R27 had an unwitnessed fall, likely slid onto floor in bedroom, found on buttocks, with no head strike or trauma reported. On 11/20/24 at 2:07 p.m., during an interview with the Director of Nursing Services (DNS), the surveyor confirmed that RN2 documented that R27 had a nose bleed after falling towards the wall and that Third Eye documentation does not match the fall report (which was the only fall report found for R27). At 2:59 p.m., during an interview with a surveyor, DNS stated that she spoke with RN2 who did not recall if a neurological monitoring sheet was started or not after R27 sustained a nosebleed after falling into the wall.

Based on record review and interviews, the facility failed to complete neurological assessments for 1 of 1 resident reviewed for fall with major injury (Resident #27 [R27]). Finding: The facility's paper form for a neurological (neuro) assessment indicated the following: Vital signs/Neuros to be done initially then every (q) 15 minutes x 2, q 30 minutes x 4, q 2 (hrs) x 4, then q shift x 3 (24 hours). The columns on the form to be completed included nurse's initials, date, time, vital signs (temperature, pulse, respirations, blood pressure) and neurological check (pupils, level of consciousness, motor function, speech, and facility symmetry). On 11/20/24, R27's clinical record was reviewed. On 9/10/24 at 4:06 a.m., a health status note was documented that indicated at approximately 3:30 a.m., a staff member went into R27's room to find the resident face down on the floor with a puddle of blood under his/her face. Emergency Medical Services (EMS) was called and when EMS got resident into the stretcher for transport, R27 had visible facial swelling, a laceration to the forehead, cheek, and chin. R27 returned to the facility after a Computed Tomography (CT) scan was completed which indicated no immediate head bleed, sustained a nasal fracture, and returned to the facility later that morning. On 11/20/24 at 11:00 a.m., during an interview with a surveyor, the Director of Nursing Services (DNS) stated that neuro assessments were not initiated upon return from the emergency room . At 11:56 a.m., during an interview with the Physician Assistant - Certified (PAC) with the DNS present, a surveyor asked what the expectation of neuro assessments would be for a resident with a fall with head injury and a negative CT scan. PAC stated if a resident had a negative CT scan and returned to the facility within 2 days, that he would expect neuros to be completed. A surveyor confirmed this finding with the DNS at the time of this interview.

Based on interviews and record review, the facility failed to ensure residents were treated in a dignified manner when staff failed to respond and attend to a resident's request for incontinence care during meal service. (Resident #40 [R40] and R41) Finding: On 11/17/24 at 1:10 p.m. during resident interviews with R40 and R41 they stated they make me wait. I get very anxious, and I get a bad headache, and that they are not changing him/her as frequently as he/she should be. R41 stated they just don't have enough staff, and they tell me I have to wait to use my urinal, and I don't want to wet my brief, and they make me wait. I want to use my urinal. I want to keep it going so I don't wet myself. On 11/18/24, during a record review a Health Status Note for Behavior dated 11/12/24, was documented in R40's clinical record stating It's policy that staff does not interrupt passing trays until they are all passed during mealtime. R40 has been informed of this policy many times. The nurse documented that R40 was informed again of the above policy, yet he/she continues to ring and holler out when staff walk by. On 11/19/24 at 10:00 a.m., during an interview with the Administrator and the Regional Directors, the surveyor asked about the above-mentioned policy for resident assistance during mealtimes. At this time the surveyor shared the Health Status note, dated 11/12/24, documented by a charge nurse. They stated that the facility does not have that policy. On 11/19/24 at 3:30 p.m., during an interview with a Certified Nursing Assistant, she stated that the process they are following during mealtime is that they pass out all the trays then they will change the residents. They have not been told not to help the residents, but they have to finish passing the meal trays first. She has heard a nurse tell the residents about the policy that staff does not interrupt the meal service.

Based on observation and interview, the facility failed to adequately date open medications and properly dispose of expired medications, according to manufacturer specifications for two inhalers in 2 of 3 medication carts ([NAME] Unit, and Penobscot Unit) observed. Findings: On 11/19/24 at 8:50 a.m., two surveyors and Certified Nurse Med Tech (CNA-M) 1 observed, in the medication cart on the [NAME] unit, a Trelegy Ellipta Inhalation Aerosol device, labeled for Resident (R) 314, with a pharmacy label stating, came in on 10/4/24. The manufacturer box states, Discard 6 weeks after opening or when the counter reads '0'. The box and the device itself were not labeled with a date indicating when the device was opened. On 11/19/24 at 8:55 a.m., during an interview with CNA-M1, two surveyors confirmed that the Trelegy Ellipta device was not labeled with an opened date to ensure use and disposal according to manufacturer specifications. On 11/19/24 at 9:43 a.m., two surveyors and CNA-M2 observed, in the medication cart on the Penobscot unit, a Fluticasone Salmeterol 250-50 mcg (microgram) inhalation device, labeled for R22, with opened date of 9/20/24 marked on the box, with the device itself not dated. The manufacturer packaging stated, Discard the inhaler 1 month after opening the foil pouch or when the counter reads '0' (after all blisters have been used), whichever comes first. On 11/19/24 at 9:49 a.m., during an interview with CNA-M2 and Licensed Practical Nurse (LPN) 1, two surveyors confirmed that the Fluticasone Salmeterol device was not labeled with an opened date and a discard date to ensure use and disposal according to manufacturer specifications.

Based on observations and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff spoke and acted rudely to residents in their care for 2 of 2 residents reviewed (Resident #43 and Resident #33). Findings: 1. On 5/28/24 at 1:49 p.m., during an interview with Resident #43 he/she stated that there is one Certified Nursing Assistant (CNA) who is rude and on his/her case all the time. Resident #43 stated that this CNA does things just to get Resident #43 upset, the examples were that when the resident requests their door be closed due to the noise level this CNA (CNA #4) comes in the room and opens the window shades and turns on the roommates television. Resident #43 also stated that when he/she knows CNA #4 is on, they are in for it. Resident #43 told the surveyor to ask CNA #3 who this person was because she knows that they just don't get along. Resident #43 also stated there are other staff who know that CNA is rude and disrespectful. At approximately 2:00 p.m., the Social Worker stopped by Resident #43's room and when Resident #43 asked the Social Worker to tell this surveyor who CNA #4 was the Social Worker stated that she is not a local person. On 5/29/24 at 12:10 p.m., during an interview with an anonymous staff member, it was told that Resident #43 had told several staff members that CNA #4 is mean to him/her when she works and that CNA #4 always works with Resident #43. On 5/29/24 at 12:23 p.m. during an interview with the acting Director of Nursing she found through a small investigation that Resident #43 had been verbalizing the interactions with CNA #4 to many staff and it was not addressed. The facility provided Resident #43 ear plugs to assist with the noise level and roommates television and they will address CNA #4's interactions with Resident #43. 2. Observation on 5/30/24 at 7:20 a.m., as surveyor was in the hallway near room [ROOM NUMBER], this surveyor overheard a staff member (CNA #3) speaking to Resident #33. She was heard saying to the resident in a frustrated tone of voice why are you ringing, I haven't even left the room yet. You need to give us time, you're not being fair to us. You need to be patient. The surveyor went to the doorway of the room and CNA #3 was standing at the foot of residents bed, facing the resident. Resident #33 was telling the CNA that he/she didn't know she was still there, and he/she wanted her to stay with them. The Regional Director of Clinical Operations (RDCO) and the Administrator were made aware of the conversation. The CNA was asked by the Administrator to go speak to them (Administrator and RDCO) and while in the hallway, CNA #3 stated in a frustrated tone Resident #33's not being patient, he/she asked for ginger ale, and I told him/her that I would, just give me time to clean first. The Social Worker (SW) went in to see Resident #33, found that Resident #33 was not feeling well and wanted someone to reassure them and get them some ginger ale because, they were not feeling well. The SW did not address this incident (interaction with CNA #3) with Resident #33.

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 interior for the 3 of 3 units ( Penobscot, [NAME] and Kennebec) and a nurse's station for 1 of 1 facility tours (5/30/24). Findings: 1. On 5/30/24 from 1:30 p.m. to 2:00 p.m., during a tour of the facility, a surveyor and the Maintenance Director, the Regional Housekeeping Manager, the [NAME] Health Services Laundry Manager, the Housekeeping/Laundry Manager, the Lead Maintenance Director/National the Administrator observed the following findings: > The nurse's station had ripped/torn duct tape around the entire front edge of counter top creating an uncleanable surface. Penobscot Unit > Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty and stained. > Resident room [ROOM NUMBER] - The room entrance floor had 8 broken/cracked floor tiles and a buildup of dirt at the door entrance edges. The bathroom floor and the caulking around the base of the toilet were dirty. > The utility room entrance floor had 2 broken floor tiles. > Resident room [ROOM NUMBER] - The room entrance floor had 4 broken/cracked floor tiles and had dried gray liquid residue spatter on it. The bathroom floor around the base of the toilet was dirty. > Resident room [ROOM NUMBER] - The room entrance floor had 4 broken/cracked floor tiles. > Resident room [ROOM NUMBER] - The room entrance floor had 10 broken/cracked floor tiles. The bathroom floor around the base of the toilet was dirty. [NAME] Unit > Resident room [ROOM NUMBER] - Resident #43's wheelchair had a ripped/torn armrest. > Resident room [ROOM NUMBER] - The bathroom floor around the base of the toilet was dirty and the entire floor was dirty. Kennebec Unit > Resident room [ROOM NUMBER] - The bathroom floor and the caulking around the base of the toilet were dirty. > Resident room [ROOM NUMBER] - There was a hole in wall near the outlet by the television. > Resident room [ROOM NUMBER] - The room entrance door had dried gray liquid residue spatter on it. > Resident room [ROOM NUMBER] - The room entrance door had dried gray liquid residue spatter on it. > Resident room [ROOM NUMBER] - The room entrance door had dried gray liquid residue spatter on it. On 5/30/24 at 2:00 pm, in an interview, the Administrator, the Maintenance Director, the Regional Housekeeping Manager, the [NAME] Health Services Laundry Manager, the Housekeeping/Laundry Manager, and the Lead Maintenance Director/National confirmed the findings.

Based on record review, interview, and facility policy review, the facility failed to transfer a resident timely to the hospital after the resident experienced a significant change in condition for one resident (Resident (R)22) of six sampled residents reviewed for hospitalization . This resulted in harm when R22 was admitted to the hospital's Critical Care Unit (CCU) with a diagnosis of acute metabolic encephalopathy likely secondary to sepsis and urinary tract infection (UTI) and acute kidney injury likely prerenal in the setting of septic shock. Findings include: Review of R22's electronic Admission Record located in the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism, hypertension (high blood pressure), chronic atrial fibrillation and hyperlipidemia. Review of R22's Significant Change in status Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/06/23, revealed R22's Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating moderate cognitive impairment. Review of the May 2023 Certified Nursing Assistant (CNA) documentation located in the EMR under Clinical - Reports - Documentation Survey Report revealed that R22 had refused breakfast, lunch, and dinner on 05/20/23. Review of R22's Progress Notes located under the Progress Notes tab in the EMR revealed the following entries were documented by Licensed Practical Nurse (LPN) 2: 05/20/23 at 11:23 PM: Received report from evening nurse that resident was not feeling good all day and was unable to eat or drink all day. This reporter went to assess resident after shift report. I observed resident to have pallor, dry mucous membranes, and was unable to get resident to respond. Resident's pupils were reactive to light but was unable to squeeze my hands. Resident's right side warm to touch, left side is cold to touch. V/S (vital signs) = 100.0 [degrees Fahrenheit (F)]-106 [pulse]-36 [respirations]-107/69 [blood pressure]-87% O2 [oxygen saturation] on RA [room air]. Mouth care given to resident to stimulate thirst reflex. Tylenol supp [suppository] 650 mg [milligrams] given due to resident not being able to take P.O. [by mouth] Tylenol. 05/20/23 at 11:36 PM: Addendum to last note: Call place to (name of provider) Answering Service. 05/21/23 at 1:41 AM: Assessed resident again, v/s= 98.6 [degrees F]-108 [pulse]-28- [respirations] 81/50 [B/P], 93% 02. Resident now showing facial droop to right side, with tongue also deviating to right side. 2nd call placed to (name of provider) answering service to update latest assessment data. 05/21/23 at 3:08 AM: Spoke with resident's son [name], updated him about resident. Son wants resident transferred to ER [emergency room ] to be evaluated. 05/21/23 at 3:26 AM: resident picked up by [name of ambulance service] at 0327 [3:27 AM]. 05/21/23 at 8:58 AM: Spoke with [name of hospital] ED [emergency department]. admitted to CCU [Critical Care Unit] with ? urosepsis [when a UTI becomes a life-threatening response to an infection requiring prompt treatment]. Family is present in the ED. Review of R22's hospital History and Physical located under the Miscellaneous tab in the EMR, revealed on 05/21/23, R22 presented to the hospital emergency room unresponsive with a low-grade temperature of 100.2 F, was tachycardic with a heart rate of 135, and hypotensive (low blood pressure). The resident was admitted to the CCU with acute metabolic encephalopathy likely secondary to sepsis and urinary tract infection and acute kidney injury likely prerenal in the setting of septic shock. R22 was treated in the hospital with intravenous (IV) fluids and IV antibiotics. The resident was readmitted to the facility on [DATE]. Interview with Licensed Practical Nurse (LPN)1 on 08/02/23 at 12:52 PM confirmed she was assigned to the care of R22 on 05/20/23 on the evening shift. LPN1 revealed R22 was more tired than usual. When asked if she performed a nursing assessment, LPN1 stated she was not allowed to do an assessment because she is an LPN, not a Registered Nurse (RN). LPN1 did not recall giving report to the oncoming nurse, LPN2. Interview with LPN2 on 08/02/23 at 3:43 PM confirmed he was the nurse assigned to the care of R22 during the night shift of 05/21/23 and he was nervous about transferring R22 to the hospital without having a physician's order. LPN2 stated that the resident's son was called after a second attempt to contact the provider was unsuccessful. LPN2 stated he felt like the resident needed to be sent to the hospital sooner rather than later. LPN2 stated that in an urgent situation he would call the supervisor for guidance but could not recall if he had called the on-call supervisor, and that his gut was telling him to send the resident out sooner, but he was trying to follow the chain of command. Interview with the Regional Nurse Consultant (RNC) on 08/03/23 at 10:45 AM confirmed that two telephone calls were placed to the provider answering service one on 05/20/23 at 11:23 PM and on 05/21/23 at 1:41 AM. R22's son was notified of the resident's change in condition on 05/21/23 at 3:08 AM and the resident was transferred to the hospital at 3:27 AM. The RNC confirmed that the on-call physician did not respond to the notification because it was texted to her. The RNC stated that the expectation would be for the nurse to reach out to the on-call nursing supervisor for further direction and as a last resort, the Medical Director. Review of the facility's Clinical Services policy and procedure for Change of Condition Notification dated 04/2001 and revised 04/2023 revealed that if the attending physician does not return the phone call in a timely manner, the Nurse Manager/Supervisor/Designee will contact the Medical Director; repeated attempts will be made to reach the attending physician and/or Medical Director and family until successful; and, in the event of an emergency, the licensed nurse can transfer the resident to the hospital via 911. Review of the infectious disease consult dated 05/24/23, located under the Miscellaneous tab of the EMR revealed Impression: 1. Complicated urinary tract infection with septic shock: Blood cultures growing out E coli, Proteus mirabilis and Enterococcus faecalis (ampicillin susceptible) in multiple bottles and urine culture also growing out greater than 100,000 colonies gram-negative rods x2. Repeat blood cultures May 23rd currently are pending. TTE [transthoracic echocardiogram] shows no evidence of vegetation. Currently, the patient is on broad-spectrum coverage with IV vancomycin and meropenem. 2. Polymicrobial bacteremia. 3. Acute toxic metabolic encephalopathy. 4. Acute kidney injury. 5. Lactic acidosis. 6. Atrial fibrillation. 7. Hypercalcemia. 8. Leukocytosis. 9. Thrombocytopenia. 10. Hypokalemia. 11. Hypertension. 12. Hypothyroidism.

Based on interviews and document reviews, the facility failed to provide adequate supervision to a resident who was a known elopement risk with a history of suicidal ideation. This failure resulted in the resident exited the facility on two occasions and was found in and by the road for 1 of 3 residents reviewed for elopement (Resident #1). This failure created an immediate jeopardy situation. Findings: On 9/13/22 the Department of Licensing and Certification received a complaint from an anonymous source indicating that he/she saw a Facebook (social media) post indicating that a resident was seen beside the road trying to wheel him/herself into traffic in an attempt to kill him/herself. Resident #1 was admitted to facility on 9/13/21 with diagnoses to include, seizure disorder, hemiplegia, right leg below the knee amputation, major depressive disorder, malignant bladder cancer and a cognitive communication deficit. Resident #1 was placed Hospice services for end- of- life care on 6/29/22 and has a wander guard placed on his/her left ankle for safety. Review of quarterly Minimum Data Set (MDS) dated [DATE] indicates Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating moderate impairment. Resident #1 self ambulates in wheelchair. Review of Resident #1's care plan initiated 8/5/21, updated 9/12/22 states the following: -Concern initiated 3/8/22 states [Resident] is at a High Risk for elopement Recent attempts to leave premises/unit. Goal: [Resident #1] will be safely housed on designated unit over the next 3 months without incident. Interventions: 1:1 as needed. Wander guard placed (R) ankle. -Concern initiated 9/16/21 states [Resident #1] has impaired cognitive function/dementia or impaired thought process related to/ Difficulty making decisions, long term memory loss. Short term memory loss. During an interview on 9/21/22 at approximately 2:15 p.m., Resident #1 indicated that the first time he/she got out (7/13/22) nobody was watching me or the back door (Kennebec Unit), so I just put the code in, went around the building to the front to head to the road with the intent on killing myself, but the nurse got to me first and wouldn't let me go in the road and I was mad. When asked how he/she got the code to the back door, he/she replied, I watch, and I see. This writer then asked Resident #1 how he/she was able to get the front door open on 9/10/22 to assist Resident #3 out of the building. He/she lifted his/her left leg and pointed to a wander guard on his/her ankle and replied, I have my ways, but they changed the code, I can't go out alone. At this time writer asked how he/she got out of the building on 9/11/22. He/she replied [LPN] let me out to sit outside and nobody was watching so I beet feet to the road and I will do it every time. At this time Resident #1 again stated, the second they turn their backs on me, I will beet feet right to the road. During an interview on 9/21/22 at 12:25 p.m. Maintenance Director (MD) indicated the Kennebec Unit door does not have a wander guard alarm on it and in order for someone to get out they must know the code. MD further indicated that the front door has a wander guard alarm so resident should not have been able to open the door to get out on 9/10/22 and somehow, resident was able to get the door open and move fast enough to get to the door fast enough to keep it open. During a phone interview on 9/21/22 at 3:13 p.m., Registered Nurse (RN) indicated that on 7/13/22 Resident #1 used a security code to leave the Kennebec Unit and leave the building and was found outside, in front of the building heading toward the busy road and indicated to her that it was his/her desire to kill himself/herself. RN indicated that she had to physically restrain wheelchair with Resident #1 in it to prevent resident from going into oncoming traffic. RN indicated she called the Director of Nursing (DNS) who came in and it took 1.5 hours to get Resident #1 back into the building. RN further indicated that the Kennebec Unit door only needs a code, but the front door has a separate code and Resident #1 knew them both. RN further stated on 9/10/22 Resident #1 was caught assisting Resident #3 (who is also an elopement risk and wears a wander guard) out the front door when she heard the alarm sound. RN indicated that she saw Resident #1 holding the door open for Resident #3 and was able to get them both back inside and then called the Administrator who informed her that he and Resident #1 had a man-to-man talk, and he/she promised the Administrator that he/she would not let anyone else out. At this time RN indicated that the Administrator told her that he gave Resident #1 the code to the front door. During a phone interview on 9/21/22 at 3:07 p.m. Licensed Practical Nurse (LPN) indicated that on 9/11/22 he let Resident #1 outside with the understanding that he/she would stay under the awning. LPN observed him/her under the awning x2 and went to obtain some blood sugars. When he returned Resident #1 was gone. LPN indicated that on his way out the door [passerby 2] was coming inside to get him and he and passerby 1 had to psychically pick up the wheelchair with Resident #1 in it out of the road and into the building for safety. At this time LPN indicate that residents with wander guards were not normally allowed outside alone, but management said he could go under the awning. During an interview on 9/22/22 at 12:25 p.m., Passerby (1) indicated that while driving by the facility on 9/11/22 between 5-5:15 p.m., he/she saw [Resident #1] in the busy road and it seemed that he/she was deliberately trying to wheel him/herself in front of oncoming traffic and cars had to drive around the resident. Passerby 1 stopped his/her car and ran to resident, who was actively attempting to wheel out into the busy traffic and had to physically restrain the wheelchair. At this time Passerby (2) stopped to help and went into the facility and got Licensed Practical Nurse (LPN) to come help. LPN and Passerby 1 physically picked up Resident #1 in his/her wheelchair and moved resident into the facility for safety. During an interview on 9/21/22 at 10:02 a.m., Director of Nursing indicated that Resident #1 has expressed the desire to go to his/her brother/sister's house in [NAME] and the wander guard was put on him/her in March of 2022 and if we don't let him/her go outside well have a huge fight on our hands. At this time DNS confirmed that as of 9/21/22 staff have not received education regarding recognizing signs of/or what to do when a resident elopes. after Resident #1's 2 elopement attempts. During an interview on 9/21/22 at 3:45 p.m., the Administrator indicated that anyone with a wander guard on is not allowed outside unsupervised. At this time a surveyor confirmed with Administrator that Resident #1 was found unattended on 2 occasions attempting to go into the road. Based on the above information, IJ was called on 9/22/22 for the facility's failure to provide adequate supervision to a resident with a history of suicidal ideation, that had left the faciity on two occasions and was found in/by the road. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial comments related to the IJ removal plan. Review of facility policy titled Elopement dated 3/13 states Elopement: the unauthorized absence of a resident from the facility who is unable to make decisions due to mental capacity or guardianship .Resident will be accounted for at all times .A risk evaluation will be done on all new admissions and with a change of condition. A photo of residents that are identified at risk will be place at reception desk .if a resident is found off the facility premises, an A/I [accident/incident] will be completed and the Department of Health will be notified (as appropriate). A completed body audit will be conducted, upon the return of the resident who was found off the premises. The MD will be notified with the findings and will determine if the resident will need further medical assistance.

Based on interviews and document review, the facility failed to ensure that a resident who had signs of suicidal ideation received the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 3 residents reviewed for mood/behavior (Resident #1). Findings: On 9/13/22 the Department of Licensing and Certification received a complaint from an anonymous source indicating that he/she saw a Facebook (social media) post indicating that a resident was seen beside the road trying to wheel him/herself into traffic in an attempt to kill him/herself. Resident #1 was admitted to facility on 9/13/21 with diagnoses to include, seizure disorder, hemiplegia, right leg below the knee amputation, major depressive disorder, malignant bladder cancer and a cognitive communication deficit. Resident #1 was placed Hospice services for end-of-life care on 6/29/22 and has a wander guard placed on his/her left ankle for safety. Review of quarterly Minimum Data Set (MDS) dated [DATE] indicates Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating moderate impairment. Resident #1 self ambulates in wheelchair. During an interview on 9/21/22 at approximately 2:15 p.m., Resident #1 indicated the first time I had the code, second time the nurse let me out and wasn't watching. He/she indicated his/her intent was to head to the road to kill himself/herself and the nurse stopped him/her. Twice I tried to kill myself and twice I failed. At this time Resident #1 indicated that the second they turn their backs on him/her, he/she would beet feet right to the road. During a phone interview on 9/21/22 at 3:13 p.m., Registered Nurse (RN) indicated that on 7/13/22 Resident #1 was found outside of the building heading toward the busy road and indicated to her that it was his/her desire to kill himself/herself. RN indicated that she had to physically restrain wheelchair with Resident #1 in it to prevent resident from going into oncoming traffic. During an interview on 9/22/22 at 12:25 p.m., Passerby 1 indicated that on 9/11/22 between 5-5:15 p.m., he/she saw [Resident #1] in the road and it seemed that resident was deliberately trying to wheel him/herself in front of oncoming traffic. Passerby indicated that [Resident #1] stated, I don't want to fucking live anymore. Passerby physically restrained the resident's wheelchair to prevent resident from going in front of oncoming traffic. Facility staff and passerby physically picked up Resident #1 in his/her wheelchair and moved him/her into the facility for safety. Review of Resident #1's clinical record revealed nursing note dated 7/4/22, states [pt] was at door trying to get out, nurse asked what going on, [he/she] reply wants to get out of [here], to kill [himself/herself], Nurse asked resident to please talk to Director of Nursing or Administrator in morning to discuss. Will continue to monitor. Review of Resident #1's clinical record revealed progress noted dated 7/4/ states [pt] was [overhear] by another [res] that [he/she] was going to get out and get a gun to kill [himself/herself], brought to nurse attention, nurse asked [pt] [he/she] said yes [he/she] said it when asked why [no response] . Review of Resident #1's clinical record revealed social service note dated 7/5/2022 states The writer reached out to [Resident #1] today due to resident expressing [he/she] wanted to buy a gun and shoot [himself/herself] . [He/she] has no current plan and feels safe in his environment with no indication of self harm .[he/she] is unhappy and wants to return into the community.'' Review of Resident #1's clinical record lacked evidence that Resident #1 received mental health treatment/services regarding this incident. During an interview on 9/22/22 at 2:50 p.m. Social Worker (SW) indicated that she met with Resident #1 on 7/5/22 and at that time he/she did not have any plan in place and had no suicidal ideation and did consult with the doctor. The facility did not refer him/her to a psyche provider because he/she was already getting Hospice support and someone from hospice is here almost daily and didn't feel the need to discuss this with the medical provider. SW was not aware of Resident #1's elopement on 7/12/22. SW further indicated that after the 9/11/22 incident she asked Resident #1 if he/she wanted to see a psychiatric practitioner and he/she said, absolutely not. States she did not document this discussion or look into it any further. When asked if other placement had been discussed SW indicated she did not consider having him/her involuntarily committed or a placement in a facility more sufficient for residents needs as she felt he/she was safe in the facility, and she didn't think he/she would be happy anywhere else. During an interview on 9/22/22 at 9:07 a.m., Nurse Practitioner (NP) indicated that he was not made aware of Resident #1's statement of self harm made on 7/4/22 and that he should have been consulted. Review of Resident #1's care plan initiated 8/5/21, updated 9/12/22 states the following: -Concern initiated 7/5/22 states Focus: The resident has depression with suicidal ideation tendencies due to feeling a sense of loss, missing family and wanting to return back to the community. Goal:[Resident #1] will demonstrate effective coping behavior as evidenced by a decrease in emotional distress. Interventions: Arrange for psych consult, follow up as indicated Concern initiated 10/7/21 states [Resident#1] is at risk for a mood problem. Goal: [Resident #1] will have improved mood state . Intervention: Monitor/record/report to MD prn acute episode feeling or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt .Monitor/record/report to MD prn(as needed) mood patterns s/sx(signs and symptoms) of depression, anxiety, sad mood as per fatuity behavior monitoring protocols. Review of Resident #1's Hospice Care Meeting held on 7/14/22 lacked evidence that Residents recent statement of suicidal ideation was discussed. Further review of Resident #1's clinical record lacked evidence he/she received the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning. Review of facility provided Business Associate Agreement dated 6/22/22 for psychiatry services. Further review indicated contracted psychiatrist resigned her contract with the facility on 5/11/22. During an interview on 9/22/22 at 2:15 p.m. Administrator indicated that National Health Care ended their contract with the facility on 5/11/22 and they do not currently have any psyche provider (3 months 10 days) and if there was an immediate need the facility would notify the Medical Director or the Nurse Practitioner and confirmed that the Medical Director or Nurse Practitioner were not consulted regarding the above concerns. At this time Administrator confirmed that Resident #1 did not receive the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning. Facility failed to provide behavior monitoring protocols by the end of survey on 9/22/22 at 3:45 p.m. Based on the above information, Immediate Jeopardy (IJ) was called on 9/22/22 for the facility's failure to ensure that a resident who had signs of suicidal ideation received care and services. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial comments related to the IJ removal plan. Review of Facility assessment dated [DATE] states .[NAME] Center will use a competency-based approach that focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practical physical, mental and psychological well-being Mental health and behavioral health: Manage the medical conditions and medications related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairments, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, intellectual or developmental disability. There is a licensed clinical Psychiatrist on Consult who visits weekly as needed.