Every finding on record at Breakwater Commons

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (East, [NAME] and South Units) and the laundry room for 3 of 3 facility tours/observations. (4/6/26, 4/7/26 and 4/9/26)Findings:1. East UnitOn 4/6/26 at 9:10 a.m., a surveyor observed a sit-to-stand patient lift by the central sitting area and a sit-to-stand patient lift by the nurse's station near resident room [ROOM NUMBER], that had food particles and debris in the foot base areas. Additionally, resident room [ROOM NUMBER] had a commode bucket on the floor in the bathroom.On 4/6/226 at 9:15 a.m., in an interview with a surveyor, a Certified Nursing Assistant/Medication Technician (CNA/M) confirmed the finding. 2. On 4/9/26 from 8:05 a.m. to 8:45 a.m., a surveyor conducted an Environmental tour the Maintenance Director and the Housekeeping Director in which the following findings were discussed and/or observed. South Unit- Resident room [ROOM NUMBER]- The floor mat by the right side of the bed was ripped/torn creating an uncleanable surface. The bathroom shower threshold strip was ripped/torn.- Resident room [ROOM NUMBER] - There was a wash basin and a commode bucket on the floor in the bathroom. - Resident room [ROOM NUMBER] - The baseboard heater was broken apart and in disrepair. There was a commode bucket on the floor under the sink in the bathroom. - Resident room [ROOM NUMBER] - The wall across from the foot of the bed was marked/marred and had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The bathroom walls had chipped/missing paint creating uncleanable surfaces.- Resident room [ROOM NUMBER] - The toilet, the toilet seat and the seat riser had dried feces and urine on and under them. - Resident room [ROOM NUMBER] - There was a commode bucket on the floor under the sink in the bathroom. - Resident room [ROOM NUMBER]- The bathroom shower threshold strip was ripped/torn.- Resident room [ROOM NUMBER]- The bathroom shower threshold strip was ripped/torn.- Resident room [ROOM NUMBER] - The were multiple layers of white tape, approximately 10 inches wide and approximately 2 feet wide, on a shower wall covering holes in the wall. [NAME] Unit- Resident room [ROOM NUMBER] - The bathroom shower threshold strip was ripped/torn.On 4/9/26 at 8:45 a.m., in an interview with a surveyor, the Maintenance Director and the Housekeeping Director confirmed the discussed and observed findings.3. LaundryOn 4/7/26 at 8:00 a.m., two surveyors observed 4 wooden pallets under supplies in the clean section of the laundry room that were untreated, creating uncleanable surfaces. On 4/7/26 at 8:05 a.m., in an interview with two surveyors present, the Administrator confirmed the finding. On 4/9/26 at 8:45 a.m., in an interview with a surveyor, the Maintenance Director and the Housekeeping Director confirmed the discussed and observed finding.

Based on record review and interviews, the facility failed to report, allegations of Abuse to the Division of Licensing and Certification (DLC) (State Survey Agency) 5 incidents of resident-to-resident abuse, 4 incidents of resident-to-staff abuse, 3 incidents of resident-to-staff abuse and 1 incident of resident-to-visitor abuse for 1 of 21 residents reviewed during an annual recertification survey.Findings:Resident #61 was admitted 3/26 and has diagnoses to include Alzheimer's and Dementia.Review of Resident #61's clinical record revealed progress notes stating the following:3/11/26: 22:09 Resident was aggressive towards resident in room [ROOM NUMBER]B as [he/she] went up to [him/her] and slapped [him/her] in [his/her] face.3/11/26:26 14:07 Resident was aggressive with CNA's this afternoon, slapping one of them in the ribcage area .3/27/26: Resident was walking around in the common area and became very agitated with another resident that was yelling out loudly. [Resident #61] swung [his/her] arm and smacked the other resident in the upper arm with [his/her] hand flat.3/28/26: . it was reported to writer that this resident had first slapped one of the aides, across the face after grabbing her breast. [He/she] then made [his/her] way down the hallway to another resident's room, where [he /she] then verbally attacked that resident calling [him/her] a shit face and then verbally attacking the daughter who was visiting that resident .3/31/26: [Resident #61] was pacing around unit with 1:1 staff member due to [his/her] increased agitation. Per CNA, they were walking past a resident, [Resident #61] jerked [his/her] hand free from [his/hers], turned and slapped the resident on the left shoulder. While walking through the dining area [he/she] grabbed a staff members arm and would not let go. [His/her] agitation continued to increase after incident. [He/she] was yelling out and going towards other residents. [He/she] continues to walk around unit with 1:1 staff member.4/3/26: Alerted by CNA Resident was holding a chair and trying to swing the chair at others.4/4/26: Resident at nurses' station, along with this writer, a CNA and a visitor. resident took hold of the visitor's arm and was pulling her. visitor started to yell stop, I will fall. This writer and CNA went to the resident and had to peel residents' finger back to get [him/her] to release the visitor.While walking with [him/her] [he/she] would not let go of my hand, and started to push this writer into another resident's room.4/5/26: Reported by CNA that resident hit her fairly hard x2 on her hand and is fixated on certain residents. Trying to walk with them and pushing on them.Review of the DLC incident reporting portal lacked evidence that the above incidents were reported to the state agency.During an interview on 4/9/26 at 4:50 p.m., the Administrator confirmed these incidents were not reported to DLC.

Based on record reviews and interviews, the facility failed to provide written notice of transfer/discharge to resident/representatives, in addition the facility failed to provide written notice of bed hold to include cost of care and appeal rights to resident/representatives for 8 of 8 residents reviewed for hospitalization (Residents #1, #3, #7, #11, #54, #64, & #78).Findings: 1. Documentation in Resident 1's clinical record indicated that he/she was transferred to an acute hospital on 1/7/26 and 1/24/26. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 2. Documentation in Resident #3's clinical record indicated that he/she was transferred to an acute hospital on 3/9/26. Further review of the clinical record revealed a Transfer and Discharge Notice dated 3/9/26. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 3. Documentation in Resident 7's clinical record indicated that he/she was transferred to an acute hospital on 8/13/25. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 4. Documentation in Resident 11's clinical record indicated that he/she was transferred to an acute hospital on 7/21/25 and 7/24/25. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 5. Documentation in Resident 54's clinical record indicated that he/she was transferred to an acute hospital on 3/31/26. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 6. Documentation in Resident 65's clinical record indicated that he/she was transferred to an acute hospital on [DATE]. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 7.Documentation in Resident 's 64's clinical record indicated that he/she was transferred to an acute hospital on [DATE]. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. 8. Documentation in Resident 's #78's clinical record indicated that he/she was transferred to an acute hospital on 2/24/26. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. The notice lacked the name, address (mailing and email), and telephone number of the entity which receives appeal requests, and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. The notice also lacked the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Additionally, the notice indicated verbal consent obtained but lacked evidence that the facility issued a written transfer and discharge notice and bed hold notice to the resident's representative. On 4/8/26 at 9:34 a.m., in an interview with Social Service Assistant and Social Service Director stated that Transfer/Discharge notice and bed hold notice are not sent to the resident representative and the bed hold notice does not contain appeal process/rights and numbers to call if wanted.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 10 residents reviewed for new admissions (Resident #61).Findings:Review of Resident #61's clinical record revealed progress notes stating the following:3/4/26: CNA reported that resident took off the toilet tank cover and attempted to hit CNA with it. Resident then tore off towel bar .: 3/7/26: 23:35 Resident got upset when spoken to and defecated on the nurses chair and at the nurses station.3/7/26: 21:48 Resident slapped another resident from room [ROOM NUMBER] on [his/her] arms thinking that it was [his/her] wife .3/11/26: Resident was aggressive towards resident in room [ROOM NUMBER]B as [he/she] went up to [him/her] and slapped [him/her] in [his/her] face.3/11/26: 26 14:07 Resident was aggressive with CNA's this afternoon, slapping one of them in the ribcage area .3/13/26: 322 was noted by this writer guiding Resident #61 out of his room and appeared to be becoming agitated with Resident #61. Resident #61 turned around and was attempting to go back into 322 which was making 322 more agitated. This writer was able to intervene in the situation and to redirect Resident #61 back down the hall to breakfast. 322 then calmed down and went down to breakfast as well.3/18/26: . resident was visualized in dining room rolling table on it side .3/20/26: Resident became very agitated and wander into other residents' rooms. and CNA found [him/her] trying to throw the TV out the window. Window was opened and TV was on floor when this writer came in the room. [He/she] then went to the living room and was tearing the chairs apart and throwing the chair .3/23/26:Pt found in room incontinent of Bm all over self, linens and room. Pt assisted to shower. Halfway thru shower pt became agitated and combative.3/27/26: Resident was walking around in the common area and became very agitated with another resident that was yelling out loudly. [Resident #61] swung [his/her] arm and smacked the other resident in the upper arm with [his/her] hand flat.3/28/26: . it was reported to writer that this resident had first slapped one of the aides, across the face after grabbing her breast. [He/she] then made [his/her] way down the hallway to another resident's room, where [he /she] then verbally attacked that resident calling [him/her] a shit face and then verbally attacking the daughter who was visiting that resident . 3/31/26: [Resident #61] was pacing around unit with 1:1 staff member due to [his/her] increased agitation. Per CNA, they were walking past a resident, [Resident #61] jerked [his/her] hand free from [his/hers], turned and slapped the resident on the left shoulder. While walking through the dining area [he/she] grabbed a staff members arm and would not let go. [His/her] agitation continued to increase after incident. [He/she] was yelling out and going towards other residents. [He/she] continues to walk around unit with 1:1 staff member.4/3/26: Alerted by CNA Resident was holding a chair and trying to swing the chair at others.4/4/26: Resident at nurses' station, along with this writer, a CNA and a visitor. resident took hold of the visitor's arm and was pulling her. visitor started to yell stop, I will fall. This writer and CNA went to the resident and had to peel residents' finger back to get [him/her] to release the visitor.While walking with [him/her] [he/she] would not let go of my hand, and started to push this writer into another resident's room.4/5/26: reported by CNA that resident hit her fairly hard x2 on her hand and is fixated on certain residents. Trying to walk with them and pushing on them.Review of Resident #61's care plan created 3/4/26 lacked evidence that goals and interventions were put into place for the above behaviors.During an interview on 4/9/26 at 1:45 p.m., the Director of Nursing reviewed Resident #61's care plan and confirmed goals and interventions were not put into place for the above concerns.

Based on record reviews and interviews, 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 14 of 21 residents reviewed for care planning (Residents #1, #3, #7, #9, #11, #15, #54, #64, #65, #68, #74, #78, #105, #108). Findings: 1.Review of Resident #1's clinical record revealed a MDS Quarterly Assessment was completed on 11/4/25. Further review of Resident #1's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. Review of Resident #1's clinical record revealed a MDS Quarterly Assessment was completed on 1/22/26. Further review of Resident #1's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 2. Review of Resident #3's clinical record revealed an MDS Annual Assessment was completed on 1/28/26. Further review of Resident #3's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 3. Review of Resident #7's clinical record revealed a MDS Quarterly Assessment was completed on 2/3/26. 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 1/22/26. Further review of Resident #9's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 5. Review of Resident #11's clinical record revealed a MDS Quarterly Assessment was completed on 2/13/26. Further review of Resident #11's clinical record revealed that an IDT meeting was held on 2/12/26, one day prior to the assessment. 6. Review of Resident #15's clinical record revealed quarterly MDS completed 1/26/26. Review of Resident #15's clinical record lacked evidence that an IDT was held for this MDS. 7. Review of Resident #54's clinical record revealed a MDS Quarterly Assessment was completed on 8/21/25. Further review of Resident #54's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. Review of Resident #54's clinical record revealed a MDS Annual Assessment was completed on 12/5/25. Further review of Resident #54's clinical record revealed that an IDT meeting was held on 12/4/25, one day prior to the assessment. 8. Review of Resident #64's clinical record revealed the following: -Quarterly MDS with completion date 3/5/26. Review of Resident #64's clinical record revealed IDT meeting was held on 2/25/26. 9 days before completion of MDS. -Quarterly MDS completed 12/5/25. IDT meeting held 11/25/25. 11 days before MDS completion. -Quarterly MDS with completion date of 8/13/25. IDT meeting held 8/12/25. 1 day prior to MDS completion). 9. Review of Resident #65's clinical record revealed a MDS Quarterly Assessment was completed on 11/13/25. Further review of Resident #65's clinical record revealed that an IDT meeting was held on 11/11/25, two days prior to the assessment. Review of Resident #65's clinical record revealed a MDS Annual Assessment was completed on 12/22/25. Further review of Resident #65's clinical record revealed that an IDT meeting was held on 1/22/26 which was not within 7 days following the assessment. 10. Review of Resident #68's clinical record revealed a Significant Change MDS Assessment was completed on 1/12/26. Further review of Resident #68's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 11. Review of Resident #74's clinical record revealed that a Quarterly MDS Assessment was completed on 4/8/26. Further review of Resident #74's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 4/08/2026 at 4:17 p.m., during an interview, the social worker stated that he is unable to provide evidence that an IDT meeting occurred for the above MDS assessment. 12. Review of Resident #78's clinical record revealed MDS with completion date of 1/13/26. Review of Resident 78's clinical record revealed IDT Meeting dated 2/5/26 stating Current copy of care plan and IDT note emailed to POA. Further review of clinical record lacked evidence that an IDT meeting was held within 7 days of this MDS. 13. Review of Resident #105's clinical record revealed an MDS admission Assessment was completed on 12/29/25. Further review of Resident #105's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 4/08/2026 at 2:00 p.m., in an interview with the DON, she confirms that an IDT meeting had not taken place during his/her admission. 14. Review of Resident #108's clinical record revealed an MDS Quarterly Assessment was completed on 8/14/25. Further review of Resident #108's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 4/8/26 at 11:00 a.m., in an interview with a surveyor, the LSW/Social Service Director stated that some of the IDT meetings were completed before the MDS assessments were completed while others were not completed within 7 days following the assessments. During an interview on 4/9/26 at approximately 2:40 p.m., the above concerns were discussed with the Administrator.

Based on record review, observations, and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and ensure that two people who are authorized to administer medications signed the Shift Count page of the Controlled Substances Book [a logbook used to record controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 3 units observed (West Unit, South Unit, and East Unit).Findings:1. On 4/8/26 at 9:40 a.m., during a medication storage observation on the [NAME] Unit, a surveyor reviewed the Controlled Substances Book and Shift Counts located on the [NAME] Unit medication (med) cart, which indicated the facility counts at the change of each shift, approximately 3 times per day, and observed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on 9/21/25 at 2:30 p.m.- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 7/23/25 at 2:30 p.m., 9/21/25 at 9:00 p.m., and 10/1/25 at 6:59 p.m.- Additionally, on 7/24/25, 7/25/25, 8/6/25, 8/16/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 3/9/26, 3/10/26, 3/11/26, and 3/26/26, there are incomplete entries that lack date, time, and/or the status of count.On 4/8/26 at 9:55 a.m., the above findings were discussed during an interview with the [NAME] Unit Manager.2. On 4/8/26 at 12:18 p.m., during a medication storage observation on the South Unit, a surveyor reviewed the South Unit Controlled Substances Book #2 and Shift Counts located on med cart #2, which indicated the facility counts at the change of each shift, approximately 3 times per day, and observed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 12/28/25 at 2:00 p.m., approximately 2/9/26 (entry after 2/9/26 at 10:45 p.m. lacks date and time),- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: approximately 12/27/25 (pg. 274-entry after 12/27/25 at 11:00 p.m. lacks date and time), 1/9/26 at 11:00 p.m., 1/15/26 at 6:45 a.m., and 2/10/26 at 3:00 p.m.- Additionally, on approximately 12/27/25 (pg. 274-entry lacks date and time), 1/16/26, approximately 2/10/26 (pg. 278-entry lacks date and time), and 4/5/26, there are incomplete entries that lack date, time, and/or the status of count.3. On 4/8/26 at 3:35 p.m., during a medication storage observation on the East Unit, a surveyor reviewed the Controlled Substances Book and Shift Counts located on the East Unit med cart, which indicated the facility counts at the change of each shift, approximately 3 times per day, and observed the following:- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on 11/18/25 at 11:00 p.m.- Additionally, on 12/18/25 and 4/3/26, there are incomplete entries that lack the time and the status of count.On 4/8/26 at 3:38 p.m., the surveyor discussed the above findings with the Director of Nursing.On 4/8/26 at 4:52 p.m., the surveyor discussed the above findings with the Administrator.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food slicer, a food mixer, a food disposal unit, fans, chemicals, a hood system, a stove, floors and kitchenette refrigerators/freezers; and failed to ensure foods in food bins, a reach-in freezer, a walk-in refrigerator and a walk-in freezer were dated, labeled and/or sealed; and failed to ensure that kitchen staff members with facial hair wore facial hair protection for 3 of 3 kitchen/kitchenettes tours. (4/6/26)Findings:1. On 4/6/26 from 8:05 a.m. to 8:35 a.m., a surveyor conducted an Initial Kitchen Tour in which the following findings were observed and shared with the cook:- The dry storage room had three large bags of cereal that were not dated. - A reach-in freezer had two packages of waffles that were not labeled and dated. - The walk-in refrigerator had a large bag of diced onions that was not labeled and a pan of beans that was not covered/sealed. - The walk-in freezer had a package of wraps that was not labeled and dated. - A large bin of flour, a large bin of sugar and a large bin of gluten free flour were not dated. Additionally, the gluten free flour bin had a scoop inside of it. - The food slicer had dried food particles and dried liquid residue on it. - The food mixer had dried food particles and dried liquid residue on it.- The food disposal unit had dried food particles and dried liquid residue on it. - There were two circular floor fans that were dusty/dirty. - There were chemicals stacked on the floor that were not stored in a metal cabinet. - The hood system was dusty/dirty. - There was food and debris on the floor around and under the cook stove. - The cook stove had dried food particles and dried liquid residue on the front and surface of it. - A male cook with facial hair and was not wearing facial hair protection.On 4/6/26 at 8:35 a.m., in an interview with a surveyor, the cook confirmed the findings.On 4/6/26 at 8:40 a.m., a surveyor discussed the findings with the Administrator. 2. On 4/6/26 at 9:00 a.m., a surveyor observed the East unit refrigerator/freezer shelving had dried food particles and dried liquid residue on them.On 4/6/26 at 10:00 a.m., a surveyor observed the South unit refrigerator/freezer shelving had dried food particles and dried liquid residue on them.On 4/6/26 at 12:05 p.m., a surveyor observed the [NAME] unit refrigerator/freezer shelving had dried food particles and dried liquid residue on them.On 4/6/26 at 12:10 p.m., a surveyor discussed the findings with the Administrator. 3. On 4/6/26 at 12:30 p.m., a surveyor did a follow-up visit to the kitchen and observed the male cook and another male employee with facial hair in the kitchen with no facial hair protection. At this time, the male cook and another male employee confirmed the findings.On 4/06/2026 at 12:40 p.m., a surveyor discussed the finding with the Administrator.

Based on record reviews, interviews, and policy review, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 2 residents reviewed for neurological assessments (Resident #78 and #105) and 1 of 1 resident reviewed for pressure ulcers (Resident #9). Findings: A review of the facilities Fall Management Policy Under Section V. subsection F states A neurological assessment tool will be for falls where there is a known head bump. A review of the facilities Neurological Assessment Policy states, Residents with suspected neurological compromise will have neurological signs monitored and recorded for a minimum of 12 hours. Further review of the policy under the procedure section states Neurological assessments following a residents head injury will be completed for all residents sustaining head trauma or suspected head trauma. In EMR (electronic medical record): Neuro checks will be conducted every 15 minutes X4, every 30 minutes X4, every 1 hour X4, every 4 hour X2, and every 8 hour X1. Frequency of neuro checks after 24 hours is determined by resident observed signs and symptoms of neurological compromise. 1. A review of Resident #105's clinical record indicated he/she sustained an unwitnessed fall on 2/15/26 at 4:00 a.m Review of the residents' neurological assessment lacked evidence of fully completed 30 minute and 1 hour neurological assessments. Further review of his/her clinical record showed he/she sustained another fall on 2/15/26 at 1:20 p.m Review of the residents' neurological assessment lacked evidence of fully completed 1 hour and 4 hour neurological assessments. On 4/7/26 at 12:23 p.m., in an interview with the Director of Nursing (DON) and 2 surveyors present, the DON confirmed the residents 30 minute neurological checks and 1 hour neurological checks were not fully complete for the fall at 4 a.m She also confirms that the 1 hour neurological checks and the 4 hour neurological checks were not fully completed for the fall occurring at 1:20 p.m 2. A review of Resident #78's clinical record indicated he/she sustained an unwitnessed fall's on 11/19/25 at 2:45 p.m., 2/24/26 at 18:22, and on 3/3/26 at 11:31 p.m Review of the residents' neurological assessments lacked evidence of fully completed 30 minute and 1 hour neurological assessments. During an interview on 4/8/26 at 3:45 p.m. the Director of Nursing confirmed neurological assessments were not completed for the above unwitnessed falls. 3. Facility Policy, Skin Management Program Policy revised 6/25 states under Procedure, section C, Daily documentation of.the site.dressing status and/or surrounding skin areas if the site is covered. weekly wound measurements by a registered nurse. care plan will be reviewed and updated based on assessed outcomes. Resident #9 has diagnoses to include but not limited to stage 4 pressure injury of the right heel. On 4/7/26 at 11:02 a.m. a surveyor observed Resident #9 seated in his/her wheelchair with a gauze dressing and a surgical shoe on his/her right foot. During an interview at this time, Resident #9 stated that he/she has a right heel wound and that he/she goes to the wound center, but that the facility performs his/her wound treatments. Resident #9's most recent Minimum Data Set (MDS) quarterly assessment, completed 1/22/26, indicated that Resident #9 has a Stage 2 pressure ulcer. Review of Resident #9's care plan states, Wound Care and Management . Assess and monitor wound healing . Record wound measurements. A review of Resident #9's daily wound documentation completed by the Registered Nurse on 4/8/26 lacked evidence of the Pressure Injury Stage, measurements, and description of the wound. Review of Resident #9's daily wound documentation prior to the 4/8/26 assessment also lacked evidence that staging and measurements of the wound were completed. A review of Resident #9's active physician orders revealed an order with a start date of 3/24/26 for Dressing Change Three Times Weekly. PRESSURE ULCER OF RIGHT HEEL, STAGE 2. There is a round open stage 4. A review of Resident #9's physician progress notes revealed a provider progress note dated 1/21/26 that states, .Stage 2 pressure ulcer on the right heel and under Wound Assessment(s) states, Wound #1 Right Heel is a Stage 3 Pressure Injury. The progress note then states, under Plan, .Right Heel: There is a round open stage 2. Further review of Resident #9's clinical record revealed an outpatient wound clinic After Visit Summary dated 1/22/26 that indicated Resident #9 has a stage 4 pressure injury of the right heel. Subsequent wound clinic progress notes dated 2/24/26 and 3/24/26 also indicated the heel wound was a stage 4 pressure injury. On 4/9/26 at 8:49 a.m. during an Interview, Licensed Practical Nurse (LPN) #1 stated she cannot stage pressure ulcers, but that she believes Resident #9's heel wound is a stage 3. LPN #3 then stated that the wound has improved significantly and is no longer open. On 4/9/26 at 11:12 a.m. during an interview with the interim East Unit Manager and the Nurse Practitioner (NP), the NP stated that the facility defers to the wound clinic for assessment of Resident #9's wound and that treatment is consistent with the wound center's recommendations. When the surveyor discussed the conflicting pressure injury staging in Resident #9's clinical record, including in the NP's progress notes, and asked for clarification of the staging of Resident #9's pressure injury, the NP stated that she has not seen the wound in months but when she last saw the wound, it was a Stage 3 or 4, but that she does not know what stage it is now because it has improved. On 4/9/26 at 11:46 a.m. the surveyor discussed the above findings during an interview with the Director of Nursing (DON). At this time, the DON stated the facility does not reverse-stage wounds, and that it is her expectation that the daily wound evaluation documentation is completed, including the staging and description of the wound.

Based on facility policy review, record reviews, and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 2 of 4 residents reviewed for advanced directives. (Resident #15 and #78).Findings:1.Resident #15 was admitted 10/2025. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive.2. Resident #78 was admitted 1/2025. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive.During an interview with 3 surveyors on 4/8/26 at 11:48 am Director of nursing confirmed Resident's #15 and #78's records showed no evidence of the opportunity for filling out advanced directive.

Based on record review and interview the facility failed to complete a Minimum Data Set (MDS) upon a residents death (Resident #97).Review of Resident 97's clinical record revealed he/she died in mid January of 2026. Review of Resident 97's Minimum Data Set (MDS) lacked evidence that a MDS was completed upon his/her death.During an interview on [DATE] at 2:15 p.m., the Director of Nursing reviewed Resident #97's clinical record and confirmed an MDS was not completed after resident died.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage chemicals being properly secured for 2 of 2 observations for 1 of 4 days of survey. (4/6/26)Findings:The Safety Data Sheet for Febreze Air Effects Gain Original noted in Section 4:Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention immediately if irritation persists.Skin Contact: None under Normal Use.Ingestion: Not an expected route of exposure. If swallowed, clean mouth with water and afterwards drink plenty of water.Inhalation: None under Normal Use. On 4/6/26 at 9:40 a.m., a surveyor observed in resident room [ROOM NUMBER], two 8.8 ounce spray bottles of Febreze Air Effects Gain Original sitting on a shelf at the foot of the resident's bed.On 4/6/26 at 9:46 a.m., in an observation and interview with a surveyor, a Licensed Practical Nurse (LPN) confirmed the finding and stated that there are confused residents that move around the unit and could go into the residents room and access the hazardous chemicals. On 4/6/26 at 10:20 a.m., a surveyor discussed the finding with the Administrator.

Based on record review, facility policy, and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 3 sampled resident reviewed with a current diagnosis of PTSD. (Resident #74)Findings:Review of the facilities policy titled Trauma Informed Care developed in 10/2019 under section Purpose states Trauma-specific intervention(s) will be placed on the residents' care plan, and this will be reviewed quarterly and updated as necessary. A review of Resident #74's clinical record indicated he/she was admitted to the facility in 2023 with the diagnosis post-traumatic stress disorder (PTSD). Further review of his/her clinical record revealed a quarterly Minimum Data Set (MDS) 3.0 completed on 4/8/26 which showed, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #74 had an active diagnosis for Post Traumatic Stress Syndrome (PTSD). Review of Resident #74's Trauma Screen indicated that he/she has trauma related to combat/exposure to war. Further review of the trauma screen shows his/her triggers are loud noises or when things go missing or are misplaced in in {his/her} room. Review of Resident #74's care plan updated 3/6/2026 lacked evidence that a trauma informed care plan was established to include triggers for this resident's PTSD diagnoses. On 4/8/26 at 3:04 p.m., in an interview with the Social Worker, he confirmed that Resident #74's care plan lacked evidence of Resident #74's triggers that might cause re-traumatization.

Based on observations and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment for 2 of 3 medication refrigerators observed (West Unit medication refrigerator, South Unit medication refrigerator). Additionally, the facility failed to ensure medications were stored properly in medication storage refrigerators on 3 of 3 units ( East Unit, [NAME] Unit, and South Unit).Findings:1. On 4/8/26 at 10:40 a.m. during an observation of the South Unit Medication Room, Certified Nursing Assistant Medication-Medication Tech (CNA-M) #2 accessed the locked medication room with her employee badge. Inside the unlocked refrigerator was an unaffixed plastic box with a handle, containing three 30 milliliter (mL) vials of lorazepam oral concentrate (a Schedule IV controlled medication).Additionally, the refrigerator was a dormitory-type refrigerator (a compact, combination refrigerator/freezer unit outfitted with one exterior door), which is not proper for storing medications due to temperature fluctuations. There was ice buildup in the freezer compartment, and medications, including insulin, were stored in the refrigerator.2. On 4/8/26 at 12:57 p.m., during an observation of the [NAME] Unit Med Storage Room with the [NAME] Unit Manager, the unlocked refrigerator contained an unaffixed plastic tackle-type box with a handle, containing four 30mL boxes of lorazepam oral concentrate.Additionally, the dormitory-type refrigerator's freezer compartment contained significant ice buildup, and medications, including insulin, were stored in the refrigerator.At this time, the surveyor discussed the findings with the [NAME] Unit Manager.3. On 4/8/26 at 1:36 p.m., during an observation of the East Unit Medication Room with Licensed Practical Nurse (LPN) #2, the dormitory refrigerator's freezer compartment contained ice buildup, and medications, including insulin, were stored in the refrigerator.On 4/8/26 at 2:30 p.m., during an interview in the presence of 4 surveyors, the above findings were discussed with the Director of Nursing (DON). At this time, the DON stated that it is her understanding that all medication techs and all nurses employed by the facility have their badges programmed to access all medication rooms throughout the facility. The DON then stated that the South Unit Manager (UM) would have the best knowledge of how controlled medications are to be stored in the facility.On 4/8/26 at 2:57 p.m. a surveyor, CNA-M #3, LPN #3, and the South UM observed the South Unit Medication room, including the unlocked refrigerator. During an interview at this time, CNA-M #3 stated that she has no idea where the keys to the refrigerator are, and that she has never had a key for the refrigerator, and LPN #3 confirmed that staff do not keep the refrigerator locked. The South UM then confirmed that any nurse or medication tech from any of the facility's units can access this medication room and remove the unaffixed box containing lorazepam.On 4/8/26 at 3:17 p.m. a surveyor and the South UM observed the [NAME] Unit Medication Room. At this time, the South UM confirmed that the refrigerator was not locked and that the box containing the four vials of lorazepam is unaffixed. During an interview at this time, CNA-M #4 stated that she has voiced concerns about how the lorazepam is stored, but that previous leadership told her that the refrigerator does not need to be locked.On 4/8/26 at 3:25 p.m. the surveyor discussed the above findings during a follow-up interview with the DON.On 4/8/26 at 4:52 p.m. the surveyor discussed the findings with the Administrator.

2 Review of Center for Disease Control: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated July 12, 2022 states Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Review of facility provided Foley Catheter list revealed Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 had indwelling foley catheters. During an observation of above resident rooms on 5/28/25 between 12:00 and 12:20 p.m., with two surveyors and Quality Improvement Specialist (QIP) revealed the following: East Wing -room [ROOM NUMBER]B, belonging to Resident #2, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER]A, belonging to Resident # 3, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER]-1, belonging to Resident #1, lacked signage at the door, no PPE available for use. -room [ROOM NUMBER] belonging to Resident #6, lacked signage at the door, no PPE available for use. room [ROOM NUMBER] belonging to Resident #8 revealed a sign on the footboard of the bed stating Enhanced Barrier Precautions. There is no signage at the door and no PPE available for use. South Wing -room [ROOM NUMBER]-A belonging to Resident #5 revealed a sign attached to footboard stating Enhanced Barrier Precautions. There is no signage at the door and a bag hanging over the back of the door that is empty. There is no PPE available for use. -room [ROOM NUMBER]-1 belonging to Resident #4 revealed an Enhanced Barrier Sign face down on the floor behind the door. There is no PPE available for use. -room [ROOM NUMBER] belonging to Resident #9 revealed no sign on door, and no PPE available for use. At this time QIP confirmed above findings. During an interview on 5/28/25 at 11:28 a.m., QIP stated facility follows Lipincott for Enhanced Barrier Precautions. At this time provided surveyor with Clinical & Nursing Services Policy (Not otherwise Specified) dated 10/18 states The Lippincott Manual of Nursing Practice will be utilizes as a reference guide for standard clinical information and procedures. The Lippincott Manual of Nursing will be updated annually or when new additions are published. North Country Associates will utilize the Maine CDC website for infection control issues . During in interview on 5/28/25 at 1:30 p.m., The Director of Nursing (DON) was asked to the facilitys Lippincott Manual. At the time DON stated that she did not know where it was as the had been looking for it the other day. Based on record review, observations, interviews, facility policy, and Center for Disease Control (CDC) guidance the facility failed to maintain and implement an infection control program to help prevent the development and transmission of infectious disease for 9 of 9 residents reviewed for foley catheters. (Residents #1, #2, and #3, #4, and #5, #6, #7, #8, and #9). Findings: Review of facility policy Infection Control: Multi-Resistant Organism (MDROs) Policy dated 4/18/24 states Enhanced Barrier Protection (EBP): Gowns and gloves are worn during high-contact resident care activity. Examples of high-contact activity are: Providing device care Device care would include, . Catheters . Residents being treated for an active MDRO infection will be placed on Contact Precautions. EBP is indicated for anyone with chronic wounds and indwelling medical devices regardless of MDRO status 1. Resident #1 has diagnoses to include urinary tract infection requiring an indwelling urinary catheter. Review of Resident #1's care plan, most recently updated on 5/13/25, revealed, .has an Infection related to Urinary tract infection .Contact precautions . Review of Resident #1's hospital Discharge summary, dated [DATE], revealed, Urine positive for klebsiella and e. Coli [Escherichia coli] . On 5/28/25 at approximately 12:00 p.m., an observation of Resident #1's room lacked signage/Personal protective equipment (PPE) for transmission-based precautions (TBP). On 5/28/25 at 11:55 a.m., during an interview, Registered Nurse #1 stated there are no residents on the East Wing on any precautions. On 5/28/25 at 1:43 p.m., during an interview, a surveyor discussed the above finding with the Regional Quality Improvement Specialist, and she stated Resident #1 should be on contact TBP. On 5/28/25 at 2:45 p.m. during an interview, the Infection Preventionist (IP) stated that the facility currently does not have any residents on TBP. At this time, a surveyor reviewed the above finding with the IP, and the IP stated Resident #1 should be on contact TBP. During an interview on 5/28/25 at 4:05 p.m., Certified Nursing Assistant (CNA)1 stated she was never made aware that Resident #1 was on contact precautions.

Based on record review and interview, the facility failed to obtain a physician order to change an indwelling urinary catheter (Foley catheter) for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Finding: Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and Foley catheter. Review of Resident #1's clinical record revealed a nursing progress note, dated 4/29/25, stating, Resident complained of pain with [his/her] foley catheter. Foley was not flowing. This nurse flushed foley with no relief. Foley catheter 16 french was changed out. Balloon filled with 10 cc [cubic cenimeters]. Resident stated relief from pain. No issues with the foley change. Resident tolerated well. 750 urine output. Further review of Resident #1's clinical record lacked evidence of a provider order for an as-needed (PRN) Foley catheter change. On 5/28/25 at 1:51 p.m., during an interview, Nurse Practitioner (NP) #1 stated she was unaware of the above Foley catheter change on 4/29/25. On 5/28/25 at 4:28 p.m. during a telephone interview, NP #2 stated a nurse should have an order to change a foley catheter and that he was not made aware of the above concerns with Resident #1's Foley catheter, did not give an order for a PRN Foley catheter change on 4/29/25, and was not contacted about it until the next day when the Director of Nursing called him. On 5/28/25 at 5:04 p.m. during a telephone interview, Licensed Practical Nurse (LPN) # 1 stated Resident #1's catheter slipped out and there was no liquid in the balloon, so she used a PRN order to change the Foley catheter and stated she did not check Resident #1's orders to ensure there was a PRN order prior to changing the Foley catheter.

Based on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1). Findings: 1. Resident #1 has diagnoses to include benign prostatic hyperplasia (enlarged prostate), retention of urine, urinary tract infection, and indwelling urinary catheter (Foley catheter). Review of Resident #1's active physician orders revealed an order with a start date of 1/13/25 for, Intake and Output (I & O) 2 Times Daily . Review of the April and May 2025 Treatment Administration Records (TAR) revealed I & O is scheduled daily at 5:00 a.m. and 6:00 p.m. Further review of the April 2025 and May 2025 TAR lacked documentation of intake and lacked evidence that output was recorded on the following dates: -4/1/25 at 5:00 a.m. -4/6/25 at 5:00 a.m. -4/8/25 at 5:00 a.m. -4/11/25 at 5:00 a.m. -4/27/25 at 6:00 p.m. -5/7/25 at 6:00 p.m. On 5/28/25 at 11:15 a.m., during an interview with 2 surveyors, the above finding was discussed with the Regional Quality Improvement Specialist. At this time, the Regional Quality Improvement Specialist stated I&O should be entered on the TAR by the nurse and should include any I&O documented by the Certified Nursing Assistant (CNA) because the provider reviews the TAR, not CNA documentation to determine urinary output. 2. Review of Resident #1's clinical record revealed the following nursing progress note, dated 5/8/25 by the East Unit Manager ([NAME]): Resident advised this RN that [he/she] 'felt like [he/she] had to urinate.' This RN assessed resident's catheter bag to see if there was urine draining into the bag. Bag contained very little urine . Unable to flush tubing. This RN removed catheter .Following sterile procedure for insertion of catheter, this RN inserted a 16 Fr [French] into resident's bladder .Secured tubing to left leg .Urine flowing freely into catheter bag. Further review of the clinical record revealed the progress note did not specify a late entry and was not entered until 5/13/25 at 11:23 a.m. On 5/28/25 at 11:15 a.m., during an interview, the Regional Quality Improvement Specialist stated the above progress note was entered late because during the facility's investigation of an incident concerning Resident #1, the facility discovered the [NAME] had not documented the above concern on 5/8/25 when it occurred. On 5/28/25 at 1:47 p.m., during an interview, the [NAME] stated she had a really busy day and did not document the progress note until 5/13/25. 3. Review of Resident #1's active physician orders revealed an order with a start date of 3/26/25 for, Insert indwelling catheter (16 french) Every Twenty-Eight Days starting 3/26/25 . Review of Resident #1's April 2025 TAR revealed his/her indwelling catheter was changed, according to the above order, on 4/23/25. Review of Resident #1's clinical record revealed a nursing progress note, by the East Unit Manager ([NAME]), dated 5/8/25 stating, Resident advised this RN that [he/she] 'felt like [he/she] had to urinate.' This RN assessed resident's catheter . Unable to flush tubing. This RN removed catheter . Following sterile procedure for insertion of catheter, this RN inserted a 16 Fr into resident's bladder . Further review of the clinical record lacked evidence of a provider order for the indwelling catheter insertion on 5/8/25. On 5/28/25 at 1:47 p.m., during an interview with 2 surveyors, and in the presence of the Regional Quality Improvement Specialist, the [NAME] stated she had received a verbal order from NP #1 for the catheter change and didn't enter the order and should have.

Based on record review and interview, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, related to intake and output (I & O) documentation resulting in inaccurate and incomplete documentation.During the revisit survey on 7/16/25, F-842 was recited related to incomplete intake and output (I & O) documentation. The facility POC indicated a date of correction date of 7/10/25 that included the following corrective actions: A house audit was performed by the unit managers of resident charts for residents with an order for I & O tracking. Educate nurse managers on documenting the facility order protocol inclusive of entering verbal provider orders into the clinical chart. Nurse managers/designee will conduct weekly audits for 60 days. Audit results will be reviewed in QAPI. On 7/16/25 a.m. at 2:00 pm during an interview with a surveyor, the above finding was confirmed with the Regional Quality Improvement Specialist.

Based on record review and interviews, the facility failed to implement and maintain an effective training program for nursing staff in the areas of urinary catheter care, as part of the facility's follow-up to their facility reported incident dated 5/12/25. Additionally, the facility failed to implement and maintain an effective training program for nursing staff contracted through a staffing agency, in the areas of urinary catheter care and infection prevention, for 2 of 2 staff reviewed during an investigation of a facility-reported incident (Licensed Practical Nurse [LPN] #2, #3). Findings: 1. The facility's 5-day follow-up, submitted to the state agency on 5/19/25, states, .The clinical coordinator will educate licensed staff on foley catheter policies and procedures . Upon entrance to the facility, the survey team requested evidence of the above education. A folder, containing educational materials titled, Flushing Urinary Catheters, Catheter Care Competency, Urinary Catheter or Urinary Tract Infection Critical Element Pathway, and Urinary Catheter Care Education for RNs [Registered Nurses]; and facility Policy, Urinary Catheters Insertion and Maintenance, was provided by the Director of Nursing Services (DNS). Scheduled Friday 5/30 2pm was written on a Post-It note on the cover of the folder. On 5/28/25 at 9:52 a.m., during an interview, the East Unit Manager ([NAME]) stated she conducted a debriefing with her staff following the incident, but staff has not received any education and that the Educator is responsible for conducting education. On 5/28/25 at 10:18 a.m., during an interview, RN #2 stated that she has not received education following the incident and that the Educator is responsible for staff education. On 5/28/25 at 1:47 p.m., during an interview, the Regional Quality Specialist stated that skills checklists for nurses and Certified Nursing Assistants (CNA) were established but have not been implemented. On 5/28/25 at 3:43 p.m, during an interview, the DNS stated the Educator gathered information and gave it to the unit managers to provide education. At this time, the DNS confirmed education had not been implemented prior to the survey team entrance today. 2. Review of Reportable Incident Form, dated 5/12/25, indicates LPN #1 was a witness to the incident dated 5/11/25. Review of LPN #1's Core Mandatory Clinical Assessment competency, completed 2/23/25 by the staffing agency lacked evidence of education on urinary catheter care. Review of LPN #2's Core Mandatory Clinical Assessment competency, completed 2/23/25 by the staffing agency lacked evidence of education on urinary catheter care. During an interview on 5/28/25 at 2:32 p.m., Nurse Educator stated at the time of the incident she was asked to find education for foley care, which she did. She made 4 folders that included all the education resources she gathered. She was never directed to start education, just to gather the information. Confirmed only facility staff receive new hire orientation. On 5/28/25 at 3:32 p.m. during an interview, the DNS and the IP stated agency staff do not receive an orientation or education, other than a handbook emailed to them, and the facility relies on competencies provided by the staffing agency. On 5/28/25 at 4:03 p.m., during a telephone interview, LPN #2 stated she has the option for education through her staffing agency but has not been offered any training by the facility. On 5/28/25 at 4:21 p.m., during a telephone interview, LPN #1 stated she was the dayshift nurse on the day the facility-reported incident occurred, and that she has not had any training on urinary catheter care, transmission-based precautions (TBP), or enhanced barrier precautions (EBP). LPN #1 then stated that she wears gloves to provide catheter care but does not wear a gown unless a resident is on TBP. When a surveyor asked what Enhanced Barrier Precautions require, LPN #1 stated she knows EBP are regarding skin tearing and skin health and means residents are at an increased risk of friction, shearing, and pressure ulcers, so staff need to keep an extra eye on the resident's bottom and provide good incontinence and perineal care.

Based on facility policy review, record reviews, and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 11 of 13 residents reviewed for advanced directives. (Resident #13, #79, #16, #84, #17, #83, #86, #54, #85, #37, #33). Findings: Review of facility policy Advanced Directives dated 10/18 states .The resident has the right and the facility will assist the resident to formulate an advanced directive at their option. Upon admission, the facility will inform and provide the resident and/or resident's representative with information about advance directives. Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advanced directive. a resident has the option to execute an advance directive but will not be required to do so. 1.Resident #13 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 2. Resident #79 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 33639 3. Resident #16 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #84 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 37648 5. Resident #17 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 6. Resident #83 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 7. Resident #86 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 51331 8. Resident #54 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 9. Resident #85 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 51669 10. Resident #37 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representative, or that the resident and/or resident representative were provided, written information concerning the right to formulate an advanced directive. 11. Resident #33 was admitted on [DATE]. A review of the entire electronic medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representative, or that the resident and/or resident representatives were provided, written information concerning the right to formulate an advanced directive. During an interview on 1/22/25 at 9:54 a.m., the Quality Improvement Specialist confirmed that the above residents and/or resident representatives were not offered/reviewed or provided with written information concerning the right to formulate an advanced directive.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 units (East and South) for 3 of 3 days of survey. Findings: East Unit: 1. On 1/21/25 at 11:28 a.m., observations of room [ROOM NUMBER]'s, shared bathroom with 2 basins stored on the floor under the sink. One of the basins had a commode bucket stored in it. room [ROOM NUMBER]'s bathroom had a wash basin on the floor with commode bucket stored inside of it. 2. On 1/22/25 at 8:41 a.m., observations of room [ROOM NUMBER]'s bathroom had a commode bucket on the floor with the basin stored inside of it. room [ROOM NUMBER]'s bathroom had a commode bucket stored on the floor. 3. On 1/23/25 from 8:13 a.m. to 8:21 a.m., the Surveyor and the Director of Nursing discussed the above observations and observed both rooms [ROOM NUMBERS]'s bathrooms with commode buckets stored on the floor. 42531 South Unit: 4. On 1/21/25 at 9:23 a.m., and on 1/22/25 at 7:31 a.m., observations of room [ROOM NUMBER]'s bathroom with an uncovered bed pan stored on shelf in between 2 wash basins. 5. On 1/21/25 at 9:37 a.m., and on 1/22/25 at 7:35 a.m., observations of room [ROOM NUMBER]'s bathroom with an uncovered bed pan on shower shelf with 3 briefs stored inside it. On 1/23/25 at 9:20 a.m., during an interview with 4 surveyors, the Director of Nursing confirmed the bed pans were not stored properly.

Based on record review and interviews, the facility failed to provide accessible call bell assistance devices necessary to prevent an avoidable accident from occurring for 1 of 3 sampled residents who experienced a fall (Resident #21) . Finding: Resident #21 was admitted to the facility from an acute hospital early in February of 2020, with a diagnosis of lack of coordination, unsteadiness on feet, history of falling and abnormalities of gait and mobility. A review of the care plan, initiated on 2/4/20, noted that the resident was a Moderate risk for falls r/t (related to) deconditioning and included the intervention to Be sure call light is within reach and encourage use for assistance as needed. On 10/10/21 Resident #21 had an unwitnessed fall resulting in lower back pain. A nurse's Fall Note dated 10/10/21 stated, [Resident] got up from [his/her] chair to get [his/her] call bell. On 10/18/21 Resident #21 had another unwitnessed fall which resulted in a left [CONDITION(S)] requiring surgical repair on 10/19/21. A nurse's Fall Note dated 10/18/21 stated, Pt (patient) injury is likely due to the fact that Pt was placed on the commode without a call bell within reach. It was assumed [resident] was attempting to reach [his/her] call bell by self ambulating to it. And details of the event stated, Pt fall likely due to call bell not placed within reach. On 1/4/22 at 9:30 a.m., during an interview, Resident #21 confirmed the call bell was not within reach prior to falling stating, no, that's the problem, that's what I was trying to reach. On 1/4/22 at 1:43 p.m., during an interview with the Director of Nursing and Clinical House Coordinator, they confirmed both falls and the major injury of a [CONDITION(S)] were avoidable if the resident had had access to the call bell.

Based on record reviews, observations and interviews, the facility failed to ensure residents were maintained in a safe environment, when the facility failed to develop and implement a policy and procedure for the use of rice packs. This failure resulted in a rice pack burning the bed linens of 1 of 7 residents who were using or who had been using rice packs (#1). In addition, once the facility became aware of the incident the facility failed to develop and implement a policy and procedure for the making, heating and use of rice packs for residents with pain. During on-site visit a resident was observed using a rice pack for pain management purposes (#2). Finding: On 11/02/10, the Division of Licensing and Regulatory Services received from the facility, a notification that on 11/1/10, a rice pack overheated, causing burns to pieces of bed linen. Resident #1's plan of care, dated 10/26/10, indicated the resident had an identified need for pain management. The use of rice packs was a common practice used by this facility to manage pain. The plan of care did not include interventions addressing the use of a rice pack. On 11/4/10 between 10:30 AM and 3:00 PM and on 11/5/10 between 10:30 AM and 12:30 PM, a surveyor interviewed four Certified Nursing Assistants (CNAs), a Physical Therapist and 3 Licensed Nurses regarding the use of rice packs. During the interviews staff stated that they would make the rice packs, would heat them in a microwave for anywhere from 1 to 3 minutes (or a "couple of minutes"), would wrap the rice pack in a towel or blanket, would place it on the resident and then remove the packs anywhere between 10 and 30 minutes later. The staff interviews confirmed that there were no policies or procedures for the making, heating or use of the rice packs. On 11/4/10 at 9:00 AM, in an interview with a surveyor, the Administrator showed the surveyor a bed blanket and sheet that had burn marks on them. The Administrator identified that these were the bed linens that had been burnt by the rice pack used by Resident #1. The sheet had a brown circular spot approximately the size and shape of a jelly bean measuring 3 cm by 1.5 cm with a light brown area surrounding the burned area measuring 4 cm by 2.5 cms. The green blanket had a burn hole measuring 1 cm by 1.2 cm and a light brown burned area measuring 3 cm by 3.5 cms. The Administrator stated Resident #1 was in the bed asleep at the time the rice pack burned the bed linens. On 11/4/10 at 11:50 AM, in an interview with a surveyor, Resident #1 stated he/she did not remember much about the incident. The resident stated he/she had slept through the commotion and woke up when staff were removing his/her covers. The resident stated he/she did not see any smoke or flames and denied any injuries as a result of the burning rice pack. The resident stated he/she had removed the rice pack after it had been applied because it was too hot. On 11/4/10 at 10:10 AM, in an interview with a surveyor, Resident #2 (roommate to Resident #1) stated that he/she had been asleep and woke up when staff entered the room. The resident remembered staff placing the rice pack in the sink and that the "stench was terrible." During the interview with Resident #2, a surveyor observed the resident in bed with a rice pack positioned on the resident's shoulder. The resident stated that the rice packs usually stayed warm for about a half hour. On 11/4/10 at 11:35 AM, in an interview with a surveyor, a Unit Manager indicated that rice packs were applied for residents' comfort, like giving them a warm blanket. The Unit Manager stated that she was not aware of any policies, procedures or standards of practice regarding the use of rice packs. On 11/5/10, surveyors reviewed employee files and in-service training records. There was no evidence that the facility had provided training on the making, heating or use of rice packs for residents. On 11/4/10 at approximately 12:30 PM, in an interview with a surveyor, the Administrator confirmed that the facility did not have a policy or procedure in place for the application of rice packs. The Administrator indicated that the microwave used to heat rice packs on this unit was old and was replaced with a new microwave after the incident. As of 11/4/10, the facility continued to use rice packs without a policy and procedure creating the potential for a resident to be burned.