Every finding on record at Borderview Rehab & Living CTR

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 condition for 3of 3 days of survey (5/12/25, 5/13/25, and 5/14/25). Findings: 1. On 5/12/25 at 12:00 p.m., during an observation in the dining room, the surveyor observed the ice/water machine had heavy dust on the side vent panel, the chrome front and drip tray were noted to be coated in a white buildup and the drip tray had peeled coating exposing rusted metal. 2. On 05/13/25 at 2:41 p.m., during a second observation in the dining room the surveyor observed the ice/water machine in the dining room with a white buildup on the front of the machine and the drip tray were noted to be coated in a white buildup and the drip tray had peeled coating exposing rusted metal and the side vent panel had a heavy amount of dust. On 5/13/25 at 2:53 p.m., a surveyor confirmed the above finding with the Minimum Data Set (MDS) Nurse. 3. On 5/12/25 at 1:10 p.m,. during initial observation of room [ROOM NUMBER], Resident #3's (R3) wheelchair arms and wheelchair legs were cracked, creating uncleanable surfaces. 4. On 5/12/25 at 11:39 a.m., during initial observation of room [ROOM NUMBER], R2's pole used to hold a feeding nutrition bag, had dirt/debris on the base of the pole and the protective coating was worn off, and R2's oxygen concentrator and filters were dusty/dirty. On 5/13/25 at 3:55 p.m., an Environmental Tour was conducted with the Infection Preventionist in which a surveyor confirmed the above findings. 5. On 5/14/25 at 9:30 a.m., during an observation of the dining room two surveyors confirmed with the Maintenance Supervisor that the tablecloths still had food debris on them from breakfast, the discs under the feet of the ice/water machine were dirty, and the sink had debris around the edges.

Based on observations and interviews, the facility failed to provide residents with oral care for 1 of 6 residents observed (Resident #21 [R21]). Finding: On 5/12/25 at 11:45 a.m., during an interview/observation with R21 the surveyor observed that his/her dentures were not clean. They appeared to be caked with an unknown white substance. The resident stated that the only concern he/she has is that they do not brush his/her teeth every day. R21's care plan was reviewed, and the care plan addresses that he/she does need extensive assistance of 1 staff to assist with care and is not able to perform activity of daily living (ADL) independently. On 5/13/25 at 10:26 a.m., during a resident observation it was noted that R21 was sitting in his/her wheelchair on the side of the bed. It was noted that he/she had just been assisted with ADLs. The surveyor observed that his/her dentures/teeth remain with food particles and caked with an unknown white substance and visually dirty. On 5/13/25 at 12:34 p.m., during an interview with Certified Nursing Assistant #1 [CNA1] who was doing whirlpools (wp's) today and had R21 scheduled. Due to medical reasons R21 does not go into the wp and gets a complete bed bath instead. CNA1 stated that she washed him/her up at bedside. The surveyor asked if she assisted him/her with brushing their teeth. She stated, oh no, I just used mouthwash. The surveyor asked why his/her teeth were not brushed and CNA1 stated, I meant to go back I just forgot. The surveyor confirmed at this time that R21 was not assisted with oral care.

Based on observation and interviews, the facility failed to ensure food temperatures were maintained at the proper holding temperature for 1 of 3 meal services observed. (5/12/25, lunch meal). In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (5/13/25, 5/14/25). Findings: 1. On 5/12/25 at 12:10 p.m., a meal service (lunch meal) was observed in the skilled hallway outside the dining room. The food was transported in a portable steamtable to the skilled hallway. The temperatures were taken prior to meal service. The lunch meal was temped, the Steak sandwich was 120 degrees Fahrenheit, the French fries (steak cut) was 120 degrees. The pureed meals were served in divided plates. The surveyor asked what the serving temperatures of the pureed food items should be, the dietary aide was not aware that the pureed meals needed to have temperatures taken. At this time the temperatures were taken, and the temperature of the pureed meat was 122 degrees Fahrenheit. These temperatures were below the required 135-degree Fahrenheit holding temperatures. This was confirmed with the dietary aide who was serving the lunch meal at that time. 2. This direct connection of wastewater 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. On 5/13/25 at 2:41 p.m., the surveyor observed the air gap on the ice machine drain line. The drainpipes for the ice machine were pushed into the drainpipe located under the sink. The drain lines did not have the 1-inch air gap as required. On 5/14/25 at 9:30 a.m. during an observation of the dining room two surveyors observed and confirmed with the maintenance supervisor that the ice machine did not have the 1-inch air gap as required.

Based on observations and interviews the facility failed to respond to resident call bell requests for assistance in a manner that maintained or enhanced their dignity for 3 of 12 residents (Resident [R] 18, R7, R13). Findings: 1. On 4/17/24 at 8:35 a.m., R18 stated that he/she feels there is not enough staff at times; this morning (during night shift), they turned off my call bell and didn't check to see what I needed and at times I may need my brief changed or my urinal emptied, and they just wait for day shift to do it. Another surveyor observed R18 call bell was activated to request assistance with his/her brief and noted the call bell was turned off from a location other than the resident's room. R18 used call bell again to state he/she still needed assistance, because no one had come yet. The resident used the call bell a third time to request assistance. On 4/17/24 art 8:40 a.m., during a follow up interview, R18 stated that yesterday sometime after lunch yesterday, family visited. R18 stated that he/she rang his call bell because he/she needed assistance after using the bathroom. R18 stated that he/she called numerous times, probably took an hour before someone finally came and helped him/her. 32540 2. On 4/16/24 at 11:44 a.m. during a resident interview R7 became very upset and stated, the call bell, I ring it and I have time to die twice over before they come in and they tell me they were busy, and it isn't my turn. Then stated, at one time I sat on the toilet for two hours before they came to help me. R7 stated that all they need is assistance to pull up their pants, but it takes so long. During this survey surveyors noted that the staff person who was at the desk would answer the call lights through their intercom system and turn off the call lights. They would ask the resident that was ringing what they needed and state ok, someone will be right with you. This action would turn off the call light, and when no one was right with you, the residents would have to call back then the person would page on the overhead speaker that the room and number (room [ROOM NUMBER]) needs assistance. On several occasions it was heard that the same room number kept calling for assistance. 3. On 4/18/24 at 8:25 a.m. R13 used their call light to call for assistance, the call bell was heard at the nurses station. It was a double (fast) ring sound which indicated the call light was on for a few minutes. The nurse at the nurses station Registered Nurse [RN] 2 answered the call light via the intercom and told R13 be right there. This surveyor was observing call lights in the alcove nearest the front door, room [ROOM NUMBER] call light went on at 8:33 a.m. RN2 went into room [ROOM NUMBER], asked the resident if they were all done and turned off the call bell light. RN2 entered R13's room at 8:34 a.m. and asked him/her what they needed R13 stated they needed to use the bathroom. RN2 said, let me find your Certified Nursing Assistant [CNA] because they will want to wash you up at the same time and she left the room. At 8:46 a.m. R13 used their call bell light again RN2 paged overhead at 8:47 a.m. a CNA went in R13's room to assist with morning care and assisted to bathroom at 8:48 a.m., 23 minutes after first calling and notifying staff he/she needed to use the bathroom, each time the resident used the call bell and RN2 answered by using the intercom system the residents voice became more anxious (tone of voice was more urgent, they needed staff's assistance to use the bathroom). At 8:41 a.m. and again at 8:43 a.m., the overhead pager announced that room [ROOM NUMBER] needed assistance. The person answering the call bell light at the desk was answering via the intercom system turning off the residents call bell light and staff were not responding to the residents request for help timely causing the resident to use their call bell light again. On 4/18/24 at 12:49 p.m. another surveyor observed several call bell lights were on and ringing at the nurses station, this surveyor observed the call bell light for R13 was on and red in color (indicating the assistance was needed in the bathroom) the sound of the call light had been silenced and only the light was illuminated above the door. R13's room is in the front alcove near the front door and is not visible from other areas. At 12:51 p.m. R13's call bell light rang at nurses station and Licensed Practical Nurse [LPN] 2 answered via the intercom be right with you and silenced the call bell light, R13 was in the bathroom sitting on the toilet and needed assistance to get up and readjust his/her clothing and get back into their wheelchair. At 12:57 p.m. R13's call light began to ring at the nurses station and LPN2 answered the call bell light via the intercom and again stated, be right with you and turned off the sound of the call bell. At 1:00 p.m. LPN1 walked by R13's room and did not assist him/her. At 1:05 p.m.RN2 entered the room to assist R13. R13 sat on the toilet waiting for assistance for 16 minutes. On 4/18/24 at 2:15 p.m during an interview with the Assistant Administrator, two surveyors confirmed call lights were being turned off at the nurses station and that residents are having to call multiple times for assistance. A surveyor also confirmed an observation that R13 had waited for 23 minutes in the morning for assistance and 16 minutes in the afternoon for assistance to get off the toilet.

Based on review of Resident Council meeting minutes and interview, the facility failed to document results of the grievances voiced by members of the Resident Council for 3 of 3 months reviewed (January, February, March 2024). Finding: 1. In review of Resident Council meeting minutes from January 25, 2024, grievances were voiced regarding call bells taking a while to answer and reported to Director of Nursing Services (DNS) French toast were served cold for breakfast that morning and reported to Food Service Director. 2. In review of Resident Council meeting minutes from February 29, 2024, grievances were voiced regarding call bells take a long time to be answered and reported to Director of Nursing. 3. In review of Resident Council meeting minutes from March 28, 2024, grievances were voiced regarding call bells take a while to be answered this was passed to nursing, food was cold all week and this was reported to the Food Service Director who addressed this concern, and residents were informed on how this will be fixed (attached documentation showed they started to use steamtable for meal services). On 4/17/24 at 9:10 a.m., during an interview with the Assistant Administrator, she stated that the DNS was not aware that she had to respond to the Resident Council concerns, and the outcomes were not shared with the Residents. At this time, a surveyor confirmed the Resident Council meeting minutes lacked evidence that all the areas of concern were addressed by all departments, and the outcomes were not conveyed to the residents.

Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 of 62 days reviewed for RN coverage (October 2023 and December 2023). Finding: On 4/16/24, during a review of nursing working schedules from 10/1/23 - 12/3/23, they indicated that on 10/1/23 (Sunday), 10/8/23 (Sunday), 10/9/23 (Monday), 12/2/23 (Monday), and 12/3/23 (Sunday) the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 4/16/24, at 2:17 p.m., in an interview with the Assistant Administrator, a surveyor confirmed the lack of RN coverage for at least 8 consecutive hours a day, 7 days a week on the dates identified in October of 2023 and December of 2023.

Based on record reviews and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 2 of 5 residents reviewed for immunizations (Resident [R] 7, and R16). Findings: On 4/17/24 at 1:34 p.m., during an interview with the Infection Preventionist (IP), she stated that per the facility pharmacist, and CDC guidance, if the resident received the PCV13 and PPSV23, they should receive the PCV20 five years after the last pneumococcal vaccine given. 1. R7's admitted to the facility was on 10/12/22. During review of immunization records, R7 received a PPSV23 on 12/6/17, and a PCV13 on 12/22/16. A surveyor could not locate evidence that R7 was reviewed, offered, or received a PCV20. The Resident is over [AGE] years of age. 2. R16's admitted to the facility was on 1/24/24. During review of immunization records, R16 received a PPSV23 on 2/29/11. A surveyor could not locate evidence that R16 was reviewed, offered, or received the PCV20. The Resident is over [AGE] years of age. On 4/17/24 at 1:34 p.m., during an interview with the IP, a surveyor confirmed that R7, and R16 were not offered, or received a PCV20, and should have been.

Based on record reviews, and interview the facility failed to ensure that physician orders were followed for 1 of 5 residents reviewed for unnecessary medications. (Resident [R] 8). Finding: On 4/17/24 during a clinical record review, R8 had a written order dated 3/7/24 documenting 3/5/24 labs were reviewed CBC (complete blood count), CMP (comprehensive metabolic panel), iron, and Hgb (hemoglobin) of 7.6 results meets the transfusion criteria. The order directs that if family and resident is willing, to send R8 to the Emergency Department, and if not to please obtain occult blood stool ASAP (as soon as possible). And to repeat CBC today. There is no evidence in the clinical record electronic or paper records that the occult blood stool was completed as ordered. On 3/11/24 another order was written that 3/8/24 labs were reviewed, R8 declined the transfusion, and that R8 needs an occult blood stool ASAP as previously ordered. (previously ordered ASAP on 3/7/24) and to consider comfort care. On 4/17/24 at 2:45 p.m. during the clinical record review and during an interview with the charge nurse Licensed Practical Nurse [LPN] 1 there is no evidence that the ASAP occult blood stool sample was collected/completed. LPN1 reviewed the laboratory calendar book and R8's electronic Treatment Administration Record (TAR). There is no evidence that this order was completed as ordered. LPN1 called the lab to verify if this order was completed and per the laboratory this order was not completed as of this date 4/17/23, 41 days after the ASAP order was received from the provider to address the low hemoglobin results. During this interview the surveyor confirmed the above finding.

Based on observation and interview the facility failed to ensure kitchen staff properly wore hair nets by leaving hair uncovered and unrestrained for 1 of 3 days of survey (4/17/24). Findings: On 4/17/24 at 7:00 a.m., during the breakfast meal service, a surveyor observed that the dietary aide serving breakfast from the steamtable did not have a beard restraint on while performing food service tasks. On 4/17/24 during an interview with the cook at 7:08 a.m., he stated that they were not aware that the beards had to be covered. At this time, it was observed that the cook had facial hair as well and was not covered. On 4/17/24 at 7:10 a.m. this surveyor observed a second dietary aide bring a hair net for the dietary aide serving breakfast to cover his facial hair. On 4/17/24 at 8:30 a.m. the surveyor confirmed with the Food Service Director that the dietary aide and the cook did not have a beard restraints on while performing food preparation and service tasks.

Based on observation, interviews, and record reviews the facility failed to ensure there was sufficient staff available to provide needs for residents receiving Long Term Care in the areas of Activities of Daily Living (whirlpools) for 3 of 3 residents reviewed. (Resident #1, Resident #2, and Resident #4) Findings: On 12/28/22 at 11:28 a.m., during a resident observation and interview, Resident #1 was well dressed with his/her hair was oily looking. He/she stated that it has been quite a while since his/her last whirlpool, it all depends on if they book (schedule) enough staff. He/she stated that they can't depend on getting a whirlpool. They don't really wash my hair, but they do wet it and comb it down. It really depends on the number of staff they have. On 12/28/22 at 1:30 p.m., during an interview with a staff member she stated with only 2 Certified Nursing Assistants (CNA's) you can't get the whirlpools (wp) done that would only leave 1 CNA on the floor and that's not safe. We just don't have time to give them when we only are 2 on the floor, we have some that need 2 assists. Most days we are scheduled 2 CNA's on the floor. A review of resident's bathing/shower schedules and facility's Long Term Care Activities of Daily Living report reveals that following: Residents #1, #2 and #4 have not received their whirlpools as outlined on the CNA assignment sheets. Resident #1 is scheduled to receive a whirlpool on Wednesdays. LTC ADLs report dated 12/28/22, documents that he/she did not receive a whirlpool from 12/1/22 to 12/28/22. Resident #3 is scheduled to receive a whirlpool on Mondays and Thursdays. The LTC ADLs report dated 12/28/22 documents that he/she received 1 whirlpool from 12/1/22 to 12/28/22. Resident #4 is scheduled to receive a whirlpool on Mondays and Thursdays. The LTC ADLs report dated 12/28/22 documents that he/she did not receive a whirlpool from 12/1/22 to 12/28/22. On 12/28/22 at 3:15 p.m. during an interview with the Director of Nursing, the surveyor reviewed the documentation regarding resident whirlpool baths from 12/1/22 to 12/28/22 with the above findings confirmed regarding scheduled whirlpools not being completed as scheduled.

Based on record reviews and interviews, the facility failed to provide services to maintain and/or improve residents highest level of ambulation and Active Range of Motion (AROM), the facility failed to provide Residents Ambulation program and Range of Motion Program as care planned for 2 of 3 sampled residents (Resident #1 and #2). Findings: 1. Resident #1 has a care plan that directs staff to Perform AROM to lower left extremity x 10 repetitions in sitting or supine position 3x per week as resident directs and directs staff to perform AROM to right lower extremity x 10 repetitions in sitting or supine as resident directs The facility was not able to provide any documented evidence that Resident #1 received his/her AROM as directed by his/her care plan from 12/1/22 to 12/27/22 2. Resident #2 has a care plan for an Restorative Nursing Aide Program for ambulation: to ambulate with Hemi-walker and moderate assist with wheelchair pulled behind. 40 feet daily, increase or decrease as tolerated use walker d/c Hemi-walker. The facility was not able to provide any evidence that Resident #2 received his/her Restorative ambulation program from 12/1/22 to 12/27/22. On 12/28/22 at 2:00 p.m. during an interview with the Director of Nursing the surveyor confirmed the above findings.

Based on record reviews, Administration failed to ensure that the Plan of Correction for an identified deficiency from the Federal Monitoring Survey (FMS) on 7/23/19 and the Life Safety Code Survey of 4/8//21 was completed. This has the potential to effect all residents in the facility. Findings: On 10/3/22 at approximately 9:00 a.m. to 2:30 p.m., during an Life Safety Code Survey, it was determined that K353 would be recited for the same issues that were cited during a Life Safety Code Survey of 4/8/21 an FMS on 7/23/19. In review of the facility POC submitted on 10/15/19, indicated that a contracter was scheduled to completed the work between 10/22/19 to 10/24/19. On 4/8/21 the facility was again cited K353. The facility POC, dated 4/20/21 stated the citation would be corrected as of 4/12/21. These findings were verified by the Maintenance Supervisor, Infection Control Officer, Assistant Facility Administrator and former Administrator at time of records review on 10/3/22 by the Fire Marshal. On 10/5/22 at 3:20 p.m., in an interview with the Assistant Administrator, a surveyor confirmed that the facility did not follow their Plan of Correction for an FMS survey on 7/23/19.

Based on record review, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction(POC) for an identified deficiency from the Federal Monitoring Survey (FMS) on 7/23/19 and the Life Safety Code Survey of 4/8//21 was completed. This has the potential to effect all residents in the facility. Finding: On 10/3/22 at approximately 9:00 a.m. to 2:30 p.m., during an Life Safety Code Survey, it was determined that K353 would be recited for the same issues that were cited during a Life Safety Code Survey of 4/8/21 an FMS on 7/23/19. In review of the facility POC submitted on 10/15/19 indicated that a contracter was scheduled to complete the work between 10/22/19 to 10/24/19. On 4/8/21 the facility was again cited K353. The facility POC, dated 4/20/21, stated the citation would be corrected as of 4/12/21. These findings were verified by the Maintenance Supervisor, Infection Control Officer, Assistant Facility Administrator and former Administrator at time of records review on 10/3/22 by the Fire Marshal. On 10/5/22 at 3:20 p.m., in an interview with the Assistant Administrator, a surveyor confirmed that the facility did not follow their Plan of Correction for an FMS survey on 7/23/19.

Based on record review and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), which included the participation of the resident and resident's representative, after each assessment, for 10 of 10 residents whose care plans were reviewed. (Resident #5, #24 #26, #12, #15, #16, #22, #8, #14 and #20) Findings: 1. On 10/4/22 upon review of Resident #5's clinical record, the surveyor noted Minimum Data Sets (MDS) 3.0 assessments dated 5/4/21, 7/28/21,10/21/21 and 1/14/22 the clinical record lacked evidence that the resident and resident representative were included in the care plan meetings. 2. On 10/4/22 upon review of Resident #24's clinical record, the surveyor noted MDS 3.0 assessments dated 9/8/21 and 12/26/21, the clinical record lacked evidence that the resident and resident representative were included in the care plan meetings. 3. On 10/4/22 upon review of Resident #26's clinical record, the surveyor noted MDS 3.0 assessments dated 7/11/21, 10/6/21, 12/29/21 and 3/29/22 the clinical record lacked evidence that the resident and resident representative were included in the care plan meetings. 4. On 10/4/22, upon review of Resident #12's clinical record, the surveyor noted that the care plan meeting held on 7/20/22 lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessment, dated 7/16/22, was completed. 5. On 10/5/22, upon review of Resident #15's clinical record, the surveyor noted that the care plan meetings held on 3/10/22 and 6/22/22 lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 3/1/22 and 5/30/22 were completed. 6. On 10/4/22, upon review of Resident #16's clinical record, the surveyor noted that the care plan meetings held on 3/10/22 and 8/31/22 lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 3/1/22 and 8/25/22 were completed. 7. On 10/5/22, upon review of Resident #22's clinical record, the surveyor noted that the care plan meetings held on 3/30/22, 6/22/22, and 9/21/22 lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 3/24/22, 6/20/22 and 9/13/22 were completed. 8. On 10/5/22 upon review of Resident #8's clinical record, the surveyor noted that the care plan meetings held on 5/11/22, and 8/3/22, lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 4/27/22, and 7/24/22 were completed. 9. On 10/5/22 upon review of Resident #14's clinical record, the surveyor noted that the care plan meetings held on 8/22/22, and 5/25/22, lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 5/20/22, and 8/16/22 were completed. 10. On 10/5/22 upon review of Resident #20's clinical record, the surveyor noted that the care plan meetings held on 1/26/22, and 4/27/22, lacked evidence that the resident and resident representative were invited after the quarterly MDS 3.0 assessments, dated 1/24/22, and 4/23/22 were completed. On 10/4/22 at 2:00 p.m. the surveyors confirmed with the Director of Nursing that the facility failed to review and revise the care plan by an interdisciplinary team (IDT), which included the participation of the resident and resident's representative, after each assessment.

Based on record review and interviews, the facility failed to ensure weekly pressure ulcer assessments were documented with the required information for 5 of 5 weekly assessments for 1 of 1 resident reviewed for pressure ulcers (Resident #16). Finding: On 10/4/22, the Director of Nursing (DON) provided the surveyor with a document, Pathway Health Services - Wound Documentation Guidelines, and stated that this was what the facility uses as its standards of practice because it directed staff to what information was required on the weekly wound assessments, in addition, two copies of the weekly wound assessments that were completed from week ending (w/e) 9/1/22 to 10/1/22 were provided to the surveyor. The facility's policy, Skin Management Program Policy, last revised 2/20, directed that weekly wound measurements by a registered nurse would be completed. The Pathway Health Services - Would Documentation Guidelines, version 10/5/09, directed staff to complete the following components as part of the weekly charting: location (of pressure ulcer), stage, dimensions, undermining/tunneling, wound base (bed) description, drainage, wound edges, odor, pain, and progress of healing. The surveyor reviewed the weekly pressure ulcer assessments provided by the DON: - 8/31/22 assessment lacked evidence of the stage, wound bed description, and undermining/tunneling. - There was no weekly assessment completed for w/e 9/10/22. - There was no weekly assessment completed for w/e 9/17/22. -9/19/22 assessment lacked evidence of the stage. -9/26/22 assessment lacked evidence of wound bed description, undermining/tunneling, and drainage. On 10/4/22 at 10:58 a.m., during an interview with the DON, the surveyor confirmed that the weekly pressure ulcer assessments were not being completed as directed.

Based on interview and employee personnel training record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on Abuse Prevention and Dementia by failing to ensure that 1 of 3 Certified Nursing Assistant's (CNA) employed for greater than 1 year completed the required annual trainings for 2 years (CNA #3). Findings: On 10/5/22, during a review of employee personnel records, the following were noted: CNA #3 was hired on 12/5/17. The record lacked evidence of mandatory Abuse Prevention and Dementia training since 4/1/20. On 10/5/22 at 8:06 a.m., during an interview with a surveyor, the Assistant Administrator stated she was unable to find a more recent training for CNA #3. The surveyor confirmed this finding during this interview.

Based on interviews and record review, the facility failed to revise a care plan related to oxygen administration on 1 of 1 residents reviewed for respiratory care (Resident #26). Finding: On 4/6/2021, at 9:40 a.m., a surveyor observed Resident #26 receiving oxygen (O2) by nasal cannula (n/c) from an O2 concentrator at the resident's bedside, with the O2 flow rate set at 4 liters per minute (L/min). The surveyor reviewed the clinical documentation of Resident #26, which included reviews of 2 quarterly Minimum Data Set (MDS) assessments dated 1/3/2021 and 3/28/2021. The MDSs reflected Resident #26's use of oxygen during this time period. Further record review revealed that Resident #26 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was change on 4/1/2021, when it was decreased to 2 L/min via n/c with humidity continuously. A review of Resident #26's care plan included an approach, dated 9/25/2020, to administer supplemental oxygen as ordered via face mask to maintain sats [oxygen saturation] > 90% per orders. On 4/8/2021, at 8:00 a.m., during an interview with the MDS Coordinator, the Interim Administrator and the Interim Director of Nursing, the surveyor confirmed that the care plan did not reflect the resident's current orders and respiratory care delivery method by nasal cannula, not by face mask.

Based on observations, interviews, and record review, the facility failed to provide respiratory services as directed by physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding: On 4/6/2021 at 9:40 a.m., a surveyor observed Resident #26 receive oxygen (O2) via nasal cannula (n/c) from an O2 concentrator at the Resident's bedside, with the O2 flow rate set at 4 liters per minute (L/min). On 4/7/2021 at 9:00 a.m., a surveyor observed Resident #26 receive O2 by n/c from an O2 concentrator at the resident's bedside, with the O2 flow rate set at 4 L/min. On 4/7/2021 at 1:16 p.m., a Registered Nurse, with the surveyor, observed and confirmed administration flow rate of 02 was at 4 L/min. The surveyor reviewed the clinical documentation of Resident #26. Resident #26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the order was change on 4/1/2021, when it was decreased to 2 L/min via n/c with humidity continuously. On 4/7/2021 at 1:49 p.m., during an interview with the Interim Administrator, the surveyor confirmed the oxygen flow rate administered at 4 L/min did not reflect the resident's current orders.

Based on Resident Incident Reporting Form, interviews, and clinical record report, the facility failed to ensure that 1 of 6 sampled residents reviewed for medications was free of significant medication errors when the wrong medications were administered to a resident (#19). Finding: A review of the facility's Resident Incident Reporting Form stated that on 3/15/2021 at 7:40 a.m. Resident #19 received the following wrong medications by mouth, [MEDICATION(S)] 50 milligrams (mg) (a medication to treat depression with potential side effects of drowsiness, dizziness, tiredness, blurred vision), [MEDICATION(S)] 10 mg ( a medication to treat depression and anxiety with potential side effects of tiredness, drowsiness, dizziness), and [MEDICATION(S)] 1 mg (an atypical antipsychotic medication to treat certain mental/mood disorders with potential side effects of drowsiness, dizziness, lightheadedness, tiredness, and rarely a condition known as tardive dyskinesia that causes stiff, jerky movements of your face and body that you cannot control.). At the time of the medication error Resident #19 was not on any medications for depression, anxiety or mental/mood disorders. In an interview with a surveyor on 4/7/2021, at approximately 2:00 p.m., the Certified Nursing Assistant - Medications (CNA-M) stated that when she went into Resident #19's room, she had medications that were intended for the roommate. Before she gave the roommate the medications, Resident #19 called her to the bedside. The CNA-M then gave the medications intended for the roommate to Resident #19 in error. The CNA-M became aware of the medication error almost immediately; however, Resident #19 had already swallowed the medications. The CNA-M informed the Charge RN immediately, and the Charge RN contacted the provider, family and interim Administrator. In a telephone interview with a surveyor on 4/8/2021 at 11:46 a.m., the Certified Family Nurse Practitioner (FNP-C) was informed of the medication error and told the Charge RN to monitor Resident #19 for possible grogginess and drowsiness. Monitoring was done by the facility. On 4/8/2021 at 1:00 p.m., in an interview with the Interim Administrator, the surveyor confirmed the significant medication error.

Based on observations and interviews, the facility failed to label whipped topping with a thaw date; failed to remove dented cans from use in the dry good storage in the kitchen; in the Birches Unit refrigerator, they failed to label and date food, failed to remove expired food; and the facility failed to maintain the Birches Unit refrigerator in a clean and sanitary manner on 2 of 3 days of survey ([DATE] and [DATE]). Findings: 1. On [DATE] at 8:45 a.m., during the initial tour of the kitchen, a surveyor observed in the walk-in refrigerator a case with 11, 16-ounce bags, of thawed whipped topping on a shelf that were not labeled with a thaw date. Storage and handling instructions on the bags of whipped topping was: shelf life 9 months frozen, 14 days refrigerated. 2. In the dry good storage area the following dented cans were observed and available for use on the shelfs: a 6 pound 10 ounce can of fruit cocktail, a 49 ounce can of beef broth, an 8 pound can of date filling and a 6 pound 10 ounce can of diced pears in light syrup. The surveyor confirmed this finding with the Food Service Supervisor/Dietician at the time of the observation. 3. On [DATE] at 8:44 a.m., a surveyor observed in the Birches Unit refrigerator, two 4 ounce containers of yogurt with an expiration date of [DATE] still available for use on [DATE]. In the Birches Unit freezer there was a package of food wrapped in tin foil that was loosely wrapped open. The package of food was not labeled or dated. There were 3 popscicles that had thawed and refroze. The refrigerator and freezer was not clean and had sticky substances on the shelfs, and the bottom shelf of the refrigerator was cracked and broken. The surveyor confirmed this finding with the Food Service Supervisor/Dietician on [DATE] at 9:00 a.m