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

Based on review of a reportable incident form, record review, and interviews the facility failed to ensure that a resident was free from injury when the facility staff failed to properly transfer a resident causing the resident to sustain a fractured rib for 1 of 1 residents reviewed for falls [Resident #1 (R1)].Findings:On 6/8/26, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 6/5/26 at 1:00 p.m., Resident #1 had a controlled fall to the floor during a transfer. with an outcome of an 8th rib fracture.On 6/8/26, The Division of Licensing and Certification received the facility's 5 day Follow up on Incident reported 6/5/26, which indicated R1 experienced a fall during a mechanical lift transfer from wheelchair to bed in the resident's room while being assisted by 2 [Certified Nursing Assistants (C.N.A.s)]. During the transfer, the resident's legs were positioned on either side of the lift boom. The mechanical lift was stationary at the time of the incident. While staff were rotating the suspended resident to achieve proper alignment with the bed, the lift tipped, resulting in a controlled fall. Staff guided the resident to the floor, and the resident's knees made contact with the floor and [he/she] slides onto [his/her] butt. During the incident, the bar made contact with the resident's head. Resident states the mechanical lift also made contact with [his/her] chest . The mechanical lift was evaluated and found to be functioning appropriately with no evidence of equipment malfunction.Review of the Emergency Department Provider Note indicated on 6/6/26, Details: [computed tomography imaging (CT) of the] chest with apparent 'small, nondisplaced anterior right 8th rib fracture'.On 6/23/26 at 9:10 a.m., during an interview with a surveyor, the Administrator stated the leg base (of the Hoyer) was moved in to navigate around the furniture, but when the resident was turned the balance was off.On 6/23/26 at 3:10 p.m., during an interview with a surveyor, a CNA stated the legs of the lift were not fully opened to navigate around the resident's room and furniture.On 6/23/26 at 4:00 p.m., during an interview with a surveyor, the Director of Nursing Services, the Regional Director of Clinical Operations and the Assistant Director of Nursing, the above finding was discussed. As a result of the facility's investigation, the following corrective actions were initiated and completed by 6/10/26:-The resident's care plan and transfer interventions were reviewed and updated as appropriate.-The resident continues to be monitored for pain, respiratory status, and any further complications related to the incident.-The mechanical lift involved in the incident was immediately removed from service pending inspection.-Maintenance reviewed preventative maintenance logs.-Maintenance evaluated the mechanical lift for proper operation and found no mechanical malfunction, equipment failure, or maintenance concerns. Preventative maintenance records confirmed the lift was maintained.-The facility initiated immediate education and competency validation for all nursing staff regarding safe mechanical lift procedures.-Audits of transfers were conducted through random observations of mechanical lift transfers to identify any potential areas of concern for immediate corrective action, re-education.-Results of audits and observations will be reviewed monthly through the Quality Assurance and Performance Improvement (QAPI) Committee for ongoing monitoring and determination of additional interventions as needed.

Based on clinical record reviews and interviews, the facility failed to ensure physician orders were followed for 4 of 6 resident's reviewed for medications (Resident #45 [R45], R103, R125, and R74). Findings: 1. On 4/29/26, a review of R45's clinical record was completed. Documentation in the physician orders indicated that an order was written on 4/23/26 for Ceftriaxone Sodium (antibiotic) injection solution, reconstitute 1 gram (Ceftriaxone Sodium), inject 1 gram intramuscularly one time a day for a urinary tract infection for 5 days. A review of R45's Treatment Administration Record (TAR) indicated that the antibiotic was administered on 4/23/26, 4/24/26, 4/26/26 and 4/27/26. There was no evidence that the resident received the antibiotic on 4/25/26. On 4/29/26 at 11:58 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the antibiotic Ceftriaxone had not been administered on 4/25/26. 2. On 4/28/26 at 12:53 p.m., during an interview with a surveyor, R103 stated he/she has had trouble with constipation and diarrhea since admission to the facility. On 4/29/26, R103's clinical record was reviewed and indicated the following: An active order for Loperamide [Hydrochloride (HCl)] Capsule 2 [milligrams (MG)] Give 1 capsule by mouth as needed for diarrhea after loose stool, may repeat [one time (x1)], with a start date of 11/2/25. An active order for Sennosides Tablet 8.6 MG Give 2 tablets by mouth two times a day for constipation Hold for loose stools in the last 24 hours, with a start date of 4/27/26. Review of the Bowel Elimination History indicated that on 4/3/26, R103 did not have a bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that R103 had a Loose/Diarrhea bowel movement on 4/4/26. Review of the MAR indicated Loperamide was not given after a loose stool as ordered. Review of the Bowel Elimination History indicated that on 4/6/26, R103 did not have a bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that on 4/7/26, R103 did not have a bowel movement and on 4/8/26 R103 had a normal bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received 2 doses of Loperamide on 4/8/26. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that on 4/9/26, R103 had 2 normal bowel movements. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that R103 had Loose/Diarrhea bowel movements on 4/10/26 and 4/11/26. Review of the MAR indicated Loperamide was not given after loose stools as ordered. Review of the Bowel Elimination History indicated that on 4/16/26, R103 did not have a bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that on 4/21/26, R103 did not have a bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that on 4/23/26, R103 had a normal bowel movement. Review of the Medication Administration Record (MAR) indicated R103 received a dose of Loperamide. The Loperamide was not given as ordered. Review of the Bowel Elimination History indicated that R103 had 2 Loose/Diarrhea bowel movements on 4/24/26. Review of the MAR indicated Loperamide was not given after loose stools as ordered. Review of the Bowel Elimination History indicated that R103 had a Loose/Diarrhea bowel movement on 4/26/26. Review of the MAR indicated that a dose of Sennosides was given on 4/27/26b within 24 hours of a loose stool. The Sennosides order was not followed. Review of the Bowel Elimination History indicated that R103 had a Loose/Diarrhea bowel movement on 4/28/26. Review of the MAR indicated Loperamide was not given after a loose stool as ordered, and R103 was given Sennosides on 4/29/26 within 24 hours of a loose stool. The Sennosides order was not followed. 04/29/2026 11:44 PM during an interview, a surveyor and the Regional Director of Clinical Operations reviewed R103's clinical record and confirmed that the physician orders for Loperamide and Sennosides were not followed. 3. On 4/28/26 at 12:53 p.m., during an interview with a surveyor, R103 stated he/she had an appointment with a Urologist who ordered an antibiotic. R103 stated the prescription was filled and in the facility, but the staff refused to provide it for weeks. On 4/29/26, R103's clinical record was reviewed and indicated: On 3/6/26, a provider request form indicated that R103 experienced dysuria and hematuria and R103 made an appointment with the Urologist for 3/18/26. On 3/21/26, a provider request form indicated a request for orders to administer the antibiotic received from the pharmacy. On 4/1/26, a faxed order was sent to the facility stating R103 was seen in the office on 3/18/26 and was ordered an antibiotic to be taken every 8 hours for 7 days. Review of the Medication Administration Record indicated R103 received the first dose of antibiotic on 4/1/26 (12 days after receiving the antibiotic from the pharmacy). On 4/29/26 at 12:51 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated the Urologist did not have a discharge note prepared after R103's visit for the Certified Nursing Assistant or R103 to return with. The DON stated that multiple staff attempted to follow up but were unable to reach the Urologist. At this time the surveyor confirmed the clinical record lacks evidence that staff followed up with the Urologist regarding the antibiotic and/or for a progress note to be maintained in the medical record resulting in the delay of treatment (12 days). 4. On 4/28/2026 during a clinical record review the surveyor noted that Resident #125 had a provider request dated 1/2/26 identifying R125 was having complaints of shortness of breath (SOB), the nurse asked for nebulizer treatments. The provider's response was that R125 already has an order for as needed (PRN) nebulizer ordered which was dated 12/30/25. During review of R125's electronic medication administration record for January 2026 there is no evidence that R125 received any PRN nebulizer treatments as ordered on 1/2/26 when he/she was experiencing SOB. On 4/28/26 at 3:28 p.m. during an interview and a record review for R125 with the Director of Nursing the surveyor confirmed that there was no evidence that R125 received a nebulizer treatment for SOB as ordered on 1/2/26. 5. On 4/29/26 at 8:54 a.m. during a medication administration observation a surveyor observed Certified Nursing Assistant – Medications (CNA-M) administer medications to R74. R74 was seated at a table in the dining room with a Speech Therapist sitting next to him/her. The CNA-M handed R74 a medication cup that contained 14 pills and R74 brought the medication cup to his/her mouth and emptied all 14 pills into his/her mouth and then took a drink of the water provided by the CNA-M to swallow the pills. The Speech Therapist asked the CNA-M if she usually gives R74 his/her medications this way. The CNA-M stated that she usually gives them one at a time. She stated, she sets the medication cup on the table and R74 takes the medication one at a time. The Speech Therapist reminded the CNA-M to give the medications to R74 one at a time. On 4/30/26, a review of R74's clinical record was completed. Documentation in the physician orders indicated an order written on 4/9/26 for Dietary orders Meds whole with water one at a time and upright position. On 4/30/26 at 8:55 a.m. in an interview with the CNA-M, a surveyor confirmed that R74 received his/her medications all at once and not one at a time as ordered by the provider.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes and food in a sanitary manner. 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 4 days of survey (4/27/26 and 4/29/26).Findings:On 4/27/26 at 10:48 a.m., during the initial tour of the kitchen, a surveyor, the Food Service Director (FSD) and the Maintenance Director observed and confirmed that the ice machine had 3 draining pipelines, one drain pipeline extended several inches into the receiving vessel, and one was less than 1 inch from the receiving vessel, 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).On 4/27/26 at 11:50 a.m., a surveyor and the FSD observed and confirmed that the interior of the plate warmer machine was soiled with food debris in all three storage chambers. The FSD stated she was unsure how the machine is cleaned as it does not appear to come apart.On 4/29/26 at 9:30 a.m., during an interview, a surveyor and the FSD observed and confirmed that 1 of the 3 drains for the ice machine in the kitchen did not have the minimum 1 air gap to prevent backflow of water.On 4/29/26 at 9:55 a.m., during an interview, a surveyor and the Maintenance Director observed and confirmed the ice machine drain on A-unit did not have the minimum 1 air gap.

Based on observation and interview the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 units observed for dining services (Unit A).Finding: On 4/27/26 at 12:50 p.m., a surveyor observed a Certified Nursing Assistant (CNA) serve lunch to 2 residents at a table of 3. Resident #98 (R98) was not served at that time. On 4/27/26 at12:54 p.m., a surveyor observed the CNA serve another table of 3 residents. R98 was still waiting to be served. R98 began calling out to staff in the room stating, is that mine? and gesturing toward a meal tray sitting at the other end of the room. On 4/27/26 at 12:58 p.m., a staff member stopped assisting a resident to eat in response to R98's request for food. The meal tray at the end of the dining room did not belong to R98. The staff member requested a meal tray from the kitchen for R98. On 4/27/2026 at 1:00 p.m., R98 was served their meal (10 minutes after his/her table mates). On 4/27/26 at 1:03 p.m., during an interview with a surveyor, the CNA stated that usually there are 4 staff assisting in the dining room, but they only had 3 today and 2 needed to help residents with feeding assistance. R98 was listed to eat in their room so his/her meal went to the wrong place. At this time, the surveyor confirmed that R98 was not served with dignity when meals were not served to all residents at a table at the same time, and another table was served before R98.

Based on interviews and clinical record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission that included the instructions needed to provide the minimum healthcare information necessary to properly care for 1 of 5 sampled residents (Resident #122 [R122]). Finding: On 4/27/26 at 11:42 a.m., in an interview with a surveyor, R122 stated he/she was admitted to the facility recently and the facility has not discussed his/her plan of care and thinks that it will be done today or tomorrow. R122's clinical record was reviewed and the clinical record lacks evidence that R122's baseline care plan was implemented or developed to provide the instructions needed to provide minimum healthcare necessary to properly care for R122 within 48 hours of admission. On 4/29/26 at 11:51 a.m., during an interview with the Regional Director of Clinical Operations, a surveyor confirmed that R122's baseline care plan was not developed within 48 hours of admission.

Based on observations, interviews, and record review, the facility failed to ensure bed mattresses were compatible with bed frames and identify areas of possible entrapment for 3 of 102 residents observed on survey [Resident #78 (R78, R47, and R45].Findings:1. On 4/28/26 at 8:56 a.m., a surveyor observed R78 lying in bed. The bed frame was observed to be larger than the mattress with several inches exposed at the foot end of the bed creating a potential area for entrapment of body parts. During an interview with the surveyor, R78 stated his/her foot has gotten caught in the gap more than once over the past several months when he/she attempted to get up to the bathroom at night.On 4/28/26 at 2:32 p.m., during an interview, a surveyor and the Maintenance Director observed and confirmed that R78 was lying in bed; the mattress did not fit the bed frame leaving a 5-inch gap at the foot of the bed creating the potential for entrapment of body parts.2. On 4/28/26 at 9:40 a.m., a surveyor observed R47 lying in bed. The bed mattress did not fit the bed frame with a 7-inch gap between the mattress and side rail at the head of the bed creating a potential space for entrapment of body parts. R47 stated that he/she has used this mattress and bed frame for the past month and has not rolled off the side of the mattress onto the exposed bedframe and is able to independently reposition in bed.On 4/28/26 at 2:34 p.m., during an interview, a surveyor and the Maintenance Director observed and confirmed that R47 was lying in bed; the mattress did not fit the bed frame leaving a 7 inch gap at the head of the bed between the top of the mattress and the head board, and a 7 inch gap between the side of the mattress and the siderail, creating potential spaces for entrapment of body parts.3. On 4/28/26 at 9:50 a.m., a surveyor observed R45 lying in bed. The bed frame was observed to be larger than the mattress with several inches exposed at the foot end of the bed creating a potential area for entrapment of body parts.On 4/28/26 at 2:30 p.m., during an interview, a surveyor and the Maintenance Director observed and confirmed that R45 was lying in bed; the mattress did not fit the bed frame leaving a 5-inch gap at the foot of the bed creating the potential for entrapment of body parts.On 4/28/26 at 2:36 p.m., during an interview, a surveyor and the Maintenance Director reviewed the bed assessments. At this time, the surveyor confirmed the bed assessments lack evidence that the foot-end of the beds were assessed for the potential entrapment of body parts.

Based on record review, facility investigation and interview, the facility failed to ensure that a resident's care plan was followed for transfer assist for 1 of 1 sampled resident (Resident #1 [R1]).On 2/19/26, R1's clinical record was reviewed. Documentation indicate that in the past year, R1 suffered a stroke and his/her left side is affected. R1's left arm is flaccid and R1 is unable to move the left arm. Documentation in a nurse note, dated 2/10/26, indicated CNA1 was transferring R1 from his/her wheelchair to the bed. The transfer failed and CNA1 lowered R1 to the floor. The charge nurse assessed the resident and no visible injuries were identified.A review of R1's care plan for the problem deficit in functional mobility, dated 7/28/25, indicated two staff are needed for transfers.A review of the facility investigation and CNA1's written statement regarding the incident was completed. CNA1 wrote that she did not follow the care plan which instructed that two staff are needed for R1's transfers.On 2/19/26 at 9:10 a.m., in an interview with the surveyor, the Administrator confirmed that CNA1 did not follow the care plan which required R1 to be transferred with two staff.

Based on observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 8 residents reviewed on survey (Resident #14 [R14], [R40] [R29], [R32], and [R82]). Findings: 1. On 3/3/25 at 12:36 p.m., a surveyor observed R14's oxygen concentrator filters to be heavily soiled with dust/debris. Record review indicates R14 receives oxygen 2 liters (L) / minute (min) continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia (inadequate oxygen to the body), and Chronic Obstructive Pulmonary Disease (COPD). 2. On 3/3/25 at 12:40 p.m., a surveyor observed R40's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R40 receives oxygen 4 L/min continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Respiratory Failure with Hypercapnia (elevated levels of carbon dioxide in the blood), and COPD. 3. On 3/3/25 at 1:32 p.m., a surveyor observed R29's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R29 receives oxygen 1-2 L/min continuously for shortness of breath related to Acute and Chronic Respiratory Failure with Hypoxia, and COPD. 4. On 3/3/25 at 2:28 p.m., a surveyor observed R32's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R32 receives oxygen 2 L/min continuously for Chronic Respiratory Failure with Hypoxia. 5. On 3/3/25 2:33 p.m., a surveyor observed R82 wearing oxygen tubing attached to an oxygen concentrator. The concentrator did not appear to be functioning. The concentrator filter was observed to be heavily soiled with dust/debris. On 3/3/25 at 2:41 p.m., during an interview with a surveyor and the RN Supervisor, R82's concentrator was observed. The RN Supervisor confirmed the machine was not turned on, and stated that the machine should be running continuously. On 3/5/25 at 1:48 p.m., during an interview with the Administrator, a surveyor confirmed above residents oxygen concentrator filters was heavily soiled with dust /debris.

Based on clinical record reviews and interview, the facility failed to ensure the attending physician made required visits, at least every 60 days for 6 of 8 sampled residents (Resident #1 [R1], [R25], [R37], [R40], [R8], and [R3]). Findings: 1. On 3/5/25, a review of R1's clinical record indicated that R1's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late. 2. On 3/5/25, a review of R25's clinical record indicated that R25's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late. On 3/5/25 at 11:45 a.m., in an interview with the surveyor, the Director of Nursing, confirmed that the last required physician visit to sign the 60 day orders was 26 days late. 49635 3. On 3/5/25, a review of R37's clinical record indicated that R37's last physician visit was on 12/10/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 2/18/25. On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R37 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 14 days late. 4. On 3/5/25, a review of R40's clinical record indicated that R40's last physician visit was on 11/7/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 1/16/25. On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R40 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 47 days late. 5. On 3/5/25, a review of R8's clinical record indicated that R8's last physician visit was on 11/21/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 1/30/25. On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R8 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 34 days late. 6. On 3/5/25, a review of R3's clinical record indicated that R3's last physician visit was on 12/3/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 2/11/25. On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R8 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 22 days late.

Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4). Findings: 1. CNA1 was hired on 11/7/2015. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 2. CNA2 was hired on 8/29/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 3. CNA3 was hired on 3/19/2003. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 4. CNA4 was hired on 6/18/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. On 3/6/24 at 2:40 p.m., in an interview with a surveyor, the Director of Nursing confirmed that the above CNA's annual performance evaluations for 2023 and 2024 were not completed.

Based on record review and interview, the facility failed to respect a resident's choice for the use of an incontinent product preference for 1 of 1 sampled resident (Resident #11 [R11]) who's incontinent product choice was denied. Finding: On 3/3/25, a review of R11's clinical record was completed. Documentation indicated that one of R11's medical concerns was incontinence. On 3/3/25 at 11:50 a.m., in an interview with the surveyor, R11 stated they have always worn yellow colored incontinent briefs during the day and wears the white colored incontinent briefs at night. R11 stated the white briefs at night make him/her feel safer as not to leak urine and is more comfortable. R11 stated on Fridays, the supply clerk stocks her dresser drawer with yellow and white briefs to last her over the weekend. R11 stated this past Friday, 3/1/25, the supply clerk was not working and R11's drawer was not stocked with white briefs; all that was left were yellow briefs. On 3/3/25 at 1:40 p.m., in an interview with the surveyor, the supply clerk stated he does stock R11's dresser with yellow briefs for the daytime and white briefs for night time use. He stated the briefs have the same absorbency but R11 prefer's the white briefs at night. He stated he was unable to stock the drawer on 3/1/25, because he was not working. He stated the nursing staff have two stock closets they can go too and get incontinent briefs. On 3/3/25 at 2:10 p.m., in an interview with the surveyor, the evening/night Registered Nurse #3 (RN3), stated she did work this past week end. She confirmed that R11 asked her for white briefs for the night, but RN3 stated all she had was yellow briefs in her drawer and that was the color/size that fit her best. RN3 confirmed she did not provide R11 with any white briefs that weekend, even though R11 was asking for them.

Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive, and/or ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the electronic record for 2 of 10 residents (Residents #98 [R98] and [R8]). Findings: 1. During a record review R98 was admitted in January of 20251. A review of R98's paper and electronic clinical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. On [DATE] at 2:15 p.m., during an interview with the Director of Nursing and the Regional Clinical Director the surveyor confirmed that some new admissions that were admitted after the facility identified an issue with Advanced Directives in [DATE] and after they developed a plan to address Advanced directives with new admissions R98's clinical record lacked evidence that he/she was offered or provided with written information concerning the right to formulate an Advanced Directive. 49635 2. On [DATE], R8'c clinical record was reviewed. R8's electronic chart indicates (Advanced Directives) Do Not Intubate, Do Not Resuscitate (Do not perform CPR). The (Advanced Directives) is a link to the scanned image of R8's signed Physician Orders for Life-Sustaining Treatment (POLST) form. R8's POLST form indicated Attempt Resuscitation/CPR. On [DATE] at 12:10 p.m., during an interview with a surveyor and the Administrator, R8's code status and scanned POLST form were reviewed. The Administrator stated the POLST may be old and should be updated. At this time, the surveyor confirmed R8's advance directive regarding code status had conflicting information.

Based on record reviews and interviews, the facility failed to notify the physician of a change in condition after a resident developed blisters after an incident with spilled hot soup for 1 of 4 residents reviewed for Accidents (Resident #203 [R203]). Finding: During a review of R203's clinical record and the facilities incident/accident reports. It was documented that R203 had an incident at 12:00 p.m. on 1/28/25. R203 nursing progress note documents that R203 accidentally dumped hot soup on his/her chest and upper abdomen. The chest and upper abdomen were reddened with a little bit of peeled skin. The provider was notified, and she gave a one-time order for topical bacitracin antibiotic. On 1/31/25 at 3:54 p.m., documentation of a late entry for 1/30/25 on this day I was doing treatments on the coccyx and noticed the blisters on the chest going to the right side of the body /breast, was told he/she burnt self with the coffee from A wing, resident did not complain of discomfort to the area, evening supervisor also saw the blisters. Review of R203's clinical records (paper and electronic) lacks evidence of a medical provider being made aware of the worsening of this burn and blisters developing. The Provider was made aware 5 days after the blisters were found. Provider progress note dated 2/4/25 documented by the provider, documented that she was made aware of the wound from the burn 6 days after the burn occurred. On 3/5/25 at 9:57 a.m., during an interview with the Director of Nursing, the surveyor confirmed that the Provider was not made aware of the change in the burn and the developing blisters until 2/4/25.

Based on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 of 2 sampled resident's reviewed for PASRR evaluation (Resident #90 [R90]). Finding: R90's clinical record was reviewed and there was a PASRR Level I Screen Outcome, dated 11/26/24, that determined No Level II Required. R90's PASRR Level I Screen Outcome dated 11/26/24 did not include all R90's diagnoses. R90's care plan dated 12/16/24 was reviewed and stated, Focus: PASRR outcome: referred for Level II, awaiting assessment completion. Date initiated: 12/12/24; under Goal: Monitor resident for need of new PASRR screening throughout assessment period; and, under Interventions: Request PASRR screening as needed. On 3/6/25 at 1:45 p.m., during an interview with the Social Worker (SW), a surveyor requested additional information about if another PASRR screening was completed for R90. The SW obtained a copy of R90's PASRR Level I Screen Outcome determination dated 12/2/24 that stated to refer R90 for Level II onsite, and stated, shows that you need a face-to-face Level II evaluation, and obtained a copy of R90's PASRR Level II. The surveyor confirmed at this time that the facility did not have the PASRR Level II determination until 3/6/25. On 3/6/25 at 1:45 p.m., during an interview with a surveyor, the Social Worker (SW) stated that a PASRR Level I screen was resubmitted on 12/3/24 with additional diagnoses but did not have the outcome of the screening. The SW was able to obtain the PASRR Level II recommendations on 3/6/25, and a surveyor confirmed that the SW was responsible to obtain these services and could not find documentation that indicated that these services had been offered or refused.

Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination for 1 of 3 residents reviewed for PASRR (Resident #24 [R24]). Finding: On 3/6/25, clinical record review indicated R24 was admitted in December of 2024. Admitting diagnosis included Anxiety Disorder, Major Depression, and Obsessive Compulsive Disorder (OCD). Review of R24's PASRR, dated 10/28/24, indicated R24 had a Convalescence Categorical exemption (a time-limited 30 day exemption). Review of R24's care plan for PASRR, initiated 1/2/25 indicated, Will submit reassessment if resident remains in facility after 30 days of admission On 3/6/25 at 10:52 a.m., during an interview with a surveyor and the Social Worker (SW), the clinical record for R24 was reviewed. At this time the SW confirmed R24 was not referred for a PASARR level II determination after the 30 day Convalescence period ended.

Based on observations, interviews and record review, the facility failed to provide recommended nutritional services to 1 of 1 resident (Resident #258 [R258]) observed during mealtimes for 1 of 3 lunch meals observed (3/3/25, lunch). Finding: During an initial observation of R258 on 3/3/25 at approximately 12:50 p.m. and interview with R258's spouse, the spouse remarked that R258 hasn't had lunch yet and that a lunch tray usually comes by 12:30 p.m. The surveyor observed a closed lunch cart in the hallway and on 3/3/25 at 1:20 p.m. in an interview with a surveyor, the LPN, charge nurse stated that all trays were passed and confirmed at this time that R258 did not receive a lunch meal.

Based on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #53 [R53]). Finding: On 3/6/25, a review of R53's clinical record was completed. Documentation in the physician orders indicated the resident had an insulin (Novolog) sliding scale for insulin coverage on Mondays, Wednesdays and Fridays (a sliding scale is the amount of insulin to be administered changes or slides up or down based on the persons blood sugar). A review of the pharmacist recommendations, dated 12/31/24 and 2/26/25 indicated the pharmacist recommendation for 12/21/24 was to confirm the Novolog sliding scale for Mondays, Wednesdays, and Fridays because there was no insulin coverage for the other days of the week. Documentation next to this recommendation indicated no changes to this order, but there was no evidence as to when this documentation occurred. On 2/26/25, during the pharmacist's monthly visit, again made a recommendation to confirm the Novolog sliding scale for Mondays, Wednesdays, and Fridays because there was no insulin coverage for the other days of the week. On 3/5/25, a provider responded to the pharmacist's recommendation, 64 days after the original recommendation was made. On 3/6/25 at 8:10 a.m., in an interview with the Director of Nursing, she confirmed that the 12/31/24 response to the pharmacy recommendation had no evidence when done and that the siding scale was not responded to and dated until 3/5/25.

Based on observation and interview, the facility failed to ensure medications were labelled, stored at the appropriate temperature, and secured properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 3 survey days (3/5/25). Findings: On 3/5/25 at 9:31 a.m., during review of the B-unit Treatment Cart #1, a surveyor and the Unit Manager #1 (UM1) observed, an unopened Basaglar KwikPen (insulin glargine) 100 units (u) / milliliter (mL) was observed in the top drawer. The 3 mL pre-filled syringe was labeled with a refrigerate sticker. The UM stated it should be stored in the refrigerator until it is used. On 3/5/25 at 9:42 a.m., during review of the B-unit Medication Cart #1, a surveyor and Certified Nursing Assistant-Medications (CNA-M) observed: -a box labeled Breyna (Budesonide Formoterol Fumarate) 80 microgram (mcg)/ 4.5 mcg. The box was observed to contain 2 inhaler devices. One device had a dose of 80 mcg /4.5 mcg, the second device has a dose of 160 mcg/4.5 mcg and labeled with R53's initials. Review of R53's electronic record revealed an order for Budesonide Formoterol Fumarate 80 mcg/4.5 mcg. -a Trelegy Ellipta inhaler was observed unlabeled and stored inside a Breo-Ellipta box labelled as belonging to R14. CNA-M stated the Trelegy inhaler belongs to R15, as he/she is the only resident who has Trelegy. An unlabeled Breo-Ellipta inhaler was observed loose in the medication drawer, CNA-M stated that Breo-Ellipta inhaler belongs to R14. During this review, CNA-M stated individual inhalers, and nasal sprays are unlabeled as the facility labels patient identifier and expirations on the container box(s) only. On 3/5/25 at 10:29 a.m., during review of the treatment cart on the ABI unit, a surveyor and Unit Manager #2 (UM2) observed: -the treatment cart was unattended and left unlocked in the hallway where residents have direct access. The cart contains insulin(s) and sharps in addition to dressings and ointments. -1 multidose 10ml vial of Lantus (Insulin Glargine) 100u/mL , opened and unlabeled. -2 pre-filled 3mL insulin pen labeled Lantus Solostar (Insulin Glargine) 100u/mL stored in a bag. One of the insulin pens was labeled with conflicting open dates (cap labelled with an open date of 2/24, pen base labelled as opened 3/3/25), the second insulin pen was unopened/unlabeled, and not stored in the refrigerator. UM2 stated the pen should have been stored in the refrigerator when it was received. On 3/5/25 at 10:45 a.m., during review of the A-wing treatment cart, a surveyor and UM2 observed, 1 pre-filled 3mL insulin pen labeled Insulin Lispro 100u/mL, unlabeled / unopened, stored in a bag with a sticker indicating it should be refrigerated. UM2 stated that it should have been stored in the refrigerator. On 3/6/25, review of the Storage of Medication policy indicated under the procedures heading, 12. Insulin vials should be stored in the refrigerator until opened. Date insulin vials when first opened. May store opened vial in refrigerator or at room temperature. The above findings were observed and confirmed at the time of the finding.

Based on record reviews and interviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 1 residents reviewed for dental services (Resident #8 [R8]). Finding: On 3/4/25 at 3:00 p.m., during an interview with R8, a surveyor observed R8's gums appeared red and enflamed with several broken teeth with visible decay. R8 stated they were painful. On 3/6/25, Review of R8's clinical record revealed the following: - On 3/31/16 the care plan was revised to include focus area The resident has oral/dental health problems [related to] Poor oral hygiene. The Intervention for this care area indicates Coordinate arrangements for dental care, transportation as needed/as ordered, and Document /report [as needed] any [signs or symptoms] of oral/dental problems needing attention: Pain .Teeth missing, loose, broken, eroded, decayed, . -On 5/29/24 the Pre-Care Conference Review Form indicated [R8] asks about dentist appt daily. -On 7/16/24 at 11:25 p.m., the provider wrote in a regulatory review note, When I ask how [R8] is doing, [R8] tells me he/she wants false teeth. I tell [R8] that it can be difficult to get insurance to pay for them, but that I can ask [Social Worker] about it. -On 7/25/24 at 2:36 p.m., the provide wrote in a progress note, poor dentition, missing several teeth, remaining teeth with visible decay. -On 8/12/24 at 10:38 a.m., the Care Plan Meeting note indicated R8 Has complained of oral pain recently. On 3/6/25 at 12:25 p.m., during an interview with a surveyor and the Director of Nursing, R8's clinical record was reviewed. At this time the surveyor confirmed the medical record lacked evidence that the facility addressed R8's dental concerns and/or requests for dental services.

Based on record review and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 6 residents reviewed (Resident #52 [R52]). Finding: During review of R52's medical record it contained a PASRR Level I Screen dated 8/10/23. The PASRR Level I Screen in the diagnosis section, did not include a current diagnosis of bipolar disorder. R52's current diagnosis list includes a diagnosis of bipolar disorder. The resident record lacked evidence that the PASRR Level I Screen was updated to include his/her diagnosis of bipolar disorder and was resubmitted/forwarded to the State-designated authority to determine if a Level II assessment was needed. On 2/14/24 at 12:50 p.m during an interview with the Licensed Social Worker, the surveyor confirmed that the PASRR Level I for R52 did not include a diagnosis of bipolar disorder and was not resubmitted to PASRR for an updated Level II.

Based on review of the Facility Reported Incident report, facility's investigation, facility's Fall Prevention Program, record review (care plan and Kardex), and interviews, the facility failed to ensure that care plan interventions for the use of a gait belt during transfers were followed for 1 of 3 sampled residents (#1). This failure to use a Gait Belt resulted in Resident #1 falling and sustaining a distal femur fracture. Finding: During a review of the Facility's Reported Incident form, the report indicated that on 2/3/23 at 3:00 p.m., [Resident #1] was being transferred from his/her wheelchair back into bed with the assistance of a Certified Nursing Assistance (CNA). During this transfer the CNA did not use a gait belt during the transfer. During this transfer Resident #1's legs buckled, and the CNA and [Resident #1] fell on the floor twisting [Resident #1's] left leg resulting in an instant pain that was later identified as a distal femoral fracture. On 3/7/23 at 3:49 p.m., during an interview with the involved CNA, the CNA stated she was transferring [Resident #1] from his/her wheelchair back into their bed. During this transfer resident's bottom half (legs) gave out causing him/her to step back and fall to the floor. The CNA stated she did not use a gait belt because she thought since she had done this transfer so many times that she didn't need to use it. On 3/7/23 Resident #1's care plan, with a revision date of 12/15/21, under the Focus area of Activities of Daily Living (ADL) self-performance deficit, contained an intervention that directed staff that Resident #1 was an extensive assist by 1 staff to move between surfaces using a gait belt and verbal cueing to resident when transferring. On 3/7/23 during a review of resident Kardex under Transferring section, directs staff transfers are done with extensive assist by 1 staff to move between surfaces using gait belt and verbal cueing to resident when transferring. Review of the facility's Fall Prevention Program with a revision date of 9/2017 directs staff on page 2 to develop interventions and incorporate them into the resident care plan and on page 3 the program directs staff to follow directions for care as indicated on the resident care flow sheets. (Kardex) On 3/7/23 at 2:02 p.m. the surveyor discussed and confirmed with the Administrator that the CNA did not use the gait belt during this transfer that resulted in a distal femur fracture. At this time the Administrator notified the surveyor that the facility had identified and acted upon this finding on the day after the fall to prevent future occurrences. See list below for actions facility initiated. As a result of the facility's investigation, the following corrective actions were initiated on 2/3/23: - Resident was assessed immediately by Nursing. - Order for an x-ray was obtained on 2/3/23 - X-ray completed on 2/4/23. - Resident was sent out on 2/4/23 for treatment and evaluation. - Resident care plan was reviewed for how to transfer resident and the facility - 2/3/23 Unit Manager contacted the involved CNA and identified the transfer was done without the use of a gait belt. - CNA was informed of the need to complete an on-the-job education regarding proper transfers following interventions listed on residents care plan. - All care plans were audited to ensure accuracy for transfer methods were listed on CNA Kardex - Regional Clinical Support person contacted - Wrote a root cause analysis - Wrote a plan of action for this event - Created audits for monitoring transfers being completed per care plans - Unit manager completed an audit to ensure all residents who require a gait belt for transfers had a gait belt available in their rooms. - On 2/5/23, started to provide education to those who were in the building. - On 2/6/23, reviewed new POC and KPI developed over the weekend as a response to the fall with fractures with Leadership team and logged as an interim QAPI. - Nurse assigned to complete education with the nursing team. Added in this education was fall prevention policy, accident/incident policy and procedure, no lift acknowledgement, and how to access the Kardex. Training was completed from 2/4/23 until 2/1523. - Audits have been done weekly since fall.

Based on record reviews and interviews the facility failed to follow patient lift Manufacturers User Manual while transferring a resident resulting in a resident fall, hitting head on the sink, and resulting in resident having increase anxiety with patient lift transfers for 1 of 2 residents reviewed for accidents. (Resident #24) Finding: On 10/24/22 the Department of Licensing and Certification received a Report a Medical Facility Incident form stating that on 10/21/22 while a resident was being transferred in a mechanical lift, the mechanical lift tipped while preparing to lower resident into the wheelchair. The lift tipped over and the aide tried to help brace the resident's fall. The resident fell to the floor and hit [his/her} head onto the sink On 10/31/22 at 2:00 p.m. during an interview with Resident #24 he/she stated that he/she has heard the reason the lift tipped over was because the staff did not have the legs completely opened. During the fall he/she hit his/her head on the sink. Resident #24 stated that he/she does not want to use the patient lift for his/her transfers, he/she is anxious about falling again but stated the facility is using more staff during the transfers and that makes him/her feel better about the transfer with the patient lift. During review of the facility's investigation and written statements from the CNA's involved, the investigation documented that the legs/base of the patient lift was not opened for optimum stability and safety and the patient lift tipped with the resident still attached in the lift sling. The written statement of a CNA involved acknowledges the legs of the patient lift were not in the open position and the left tipped over with the resident falling to the floor and hitting his/her head on the sink On 11/2/22 at 6:16 p.m. during an interview with one of the CNA's involved, she stated that she was under the impression the legs on the patient lift were not to be opened until you moved forward towards the wheelchair. She also stated the other CNA's have been doing the same thing as well and that was how she was trained when she started to work the floor in December of 2021. User Manual instructions for Invacare Reliant 600 Battery powered patient lift Warning; the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed return the legs of the lift to the maximum open position and lock the shifter handle immediately. On 11/2/22 during a record review, Social Worker Notes dated 10/27/22, stated Social Worker (SW) spoke with resident to follow up on last week's fall. Resident shared that he/she has had some increased anxiety since fall last week; resident reports experiencing some feelings of panic and tearfulness at times. Social Services note dated 10/29/22, Summary of psychosocial from fall to present day: Resident overall physically feels ok, states head is tender, and body is sore but healing. Emotionally and mentally having some increased anxiety surrounding transfers but feels with the support of the extra staff member during patient transfers it will be comforting. On 11/2/22 at 2:13 p.m., the surveyor confirmed during an interview with the Director of Nursing that staff did not have the legs/base of the patient lift open for stability which resulted in the patient lift tipping and the resident falling to the floor and hitting his/her head on the sink. As a result of the facility's investigation, the following corrective actions were initiated: - Removed the 2 staff people from the floor and education was provided before returning to floor; - Resident was assessed immediately by Medical Provider and sent to emergency room ; - Lift was removed and inspected; - Neuro checks were completed, as ordered; - Education was provided to staff on 10/21/22 by Staff Development Coordinator including policy review, competency completion and review of lift manual; - Competency for the two CNA's was completed on 10/28/22; - On 10/26/22 residents care plan was reviewed and updated. -Therapy is working with resident to return to stand pivot transfer and decrease dependence on mechanical lifts; and - An Annual Performance Improvement Plan was created and approved by regional on 10/27/22.

Based on a review of the facility's Medication Incident Report, clinical record report, facility Medication Pass Policy, Medication Error Policy, and interviews, the facility neglected to protect a resident from receiving another residents medication/significant medication error. This significant medication error resulted in putting the residents health and safety in jeopardy and the resident being rushed to an acute care facility for emergency treatment for 1 of 1 sampled resident (Resident #1). Finding: A review of the facility's Medication Incident Report stated that on 11/16/2020 at 9:45 p.m., Registered Nurse #1 (RN #1) administered 80 units of [MEDICATION NAME] to the wrong resident-Resident #1. Resident #1 is not diabetic and did not have a physician order [REDACTED].>The report stated the action taken was sending Resident #1 to the Emergency Department for intravenous (IV) [MEDICATION NAME] (a glucose/sugar) ([MEDICATION NAME] is used for acute insulin overdose) and close glucose monitoring. Documentation in Resident #1's clinical record stated that Resident #1 was diagnosed with [REDACTED]. Documentation in Resident #1's clinical record, under the Nurse's Progress Note section, nurse's note dated 11/16/2020, written by RN#1 stated, this writer inadvertently administered 80 units of [MEDICATION NAME] to this resident (Resident #1). Upon exiting the room, it was immediately caught. Resident #1 does not have an order for [REDACTED]. A review of the facility's Medication Pass Policy stated under the Procedure section, page 1, bullet number 4, Identify each resident prior to administration of medication (picture, ID bracelet, etc. In addition, on page 3 of the Medication Pass Policy, under bullet number 2, Remember the 6 rights of Medication Pass, bullet number 1, 'Right Resident.' A review of the facility's Medication Error Policy, page 1, under Definitions, bullet number 2, stated, Significant medication error means one that causes an adverse effect to the resident, i.e. discomfort or jeopardized his or her health and safety. Criteria for determining if there is a significant medication error includes the resident condition, drug category, and frequency of error. In addition, on page 2, under What Constitutes a Medication Error section, bullet number 7, stated, Medication given to the wrong resident. On 12/14/2020 at 10:15 a.m., in an interview with the surveyor, the Director of Nursing confirmed that RN#1 administered another resident's insulin to Resident #1. On 12/14/2020 at 1:07 p.m., in an interview with the surveyor, RN#1 confirmed that she did administer another resident's insulin to Resident #1. RN#1 stated the facility policy is to check a resident's identification by cross checking the residents picture with the resident. RN#1 stated she did not correctly check the picture ID to ensure that Resident #1 was the right resident to receive the insulin. RN#1 stated she gave 80 units of [MEDICATION NAME] to Resident #1 by mistake and she confirmed that she did not follow the facility's Medication Pass Policy. RN#1 stated Resident #1 was sent to the Emergency Department for [MEDICATION NAME] treatment and monitoring of blood sugars. In addition, RN#1 stated she did not notify the resident's legal representative that the resident was being rushed to the Emergency Department for immediate treatment until the next day. RN#1 neglected to ensure she was administering insulin to the right resident and by not ensuring Resident #1 was the right resident, a significant medication error occurred. A reasonable and prudent person would experience fear of a caregiver that administered a medication to them that was ordered for a different resident. A reasonable and prudent person would experience fear and anxiety being suddenly rushed off to the hospital all alone and not understanding what is happening. On 12/14/2020 at 11:15 a.m., in an interview with the surveyor, the Director of Nursing confirmed she did look into the medication error and that it is a significant medication error. 2/14/2020 at 11:20 a.m., the facility Clinical Operations Regional Consultant, confirmed administering 80 units of insulin to the wrong resident was a significant medication error.

Based on record review, review of the facility internal investigation and interviews, the facility neglected to provide care and services to 1 of 1 sampled residents (Resident #1) when the facility failed to implement the Resident's plan of care which resulted in the resident sustaining a laceration on the forehead, two chipped teeth, broken nose, and bilateral subdural hematomas. Finding: Documentation in Resident #1's electronic clinical record indicated that a few of Resident #1's [DIAGNOSES REDACTED]. Documentation in Resident #1's admission Minimum Data Set 3.0, dated 9/1/16, was coded to indicate that the resident requires extensive assistance of two persons physical assist for bed mobility and toileting. Documentation in Resident #1's care plan, initiated on 8/30/16, indicated under the problem of Activity of Daily Living (ADL) self-care performance deficit, that Resident #1 required maximum assist by two staff to turn and reposition in bed as needed. Documentation in the Certified Nurse Assistant (C.N.A.) Kardex (a shortened version of the care plan for C.N.A.'s to review) indicated that the resident required maximum assist by two staff to turn and reposition in bed as necessary. Documentation in the facility internal investigation, dated 9/3/16, indicated that the Director of Nursing (DON) completed the investigation. The DON documented that on 9/1/16, C.N.A. #1, stated she was turning the resident alone in order to change and provide toileting care and the resident rolled off the bed. The DON wrote when C.N.A. #1 was asked why she was doing it alone when the Resident is a two person assist with care and C.N.A. #1 stated she does it alone all the time. Also written by the DON is the care plan does state that the resident is a two person assist for care. On 11/9/16 at 12:10 p.m., in an interview with the surveyor, C.N.A. #2 stated that it was rumored that on 9/1/16, C.N.A. #1 did not ask anyone to help her with Resident #1 and that C.N.A. #1 provided care alone and the resident rolled out of bed and was face down on the floor. C.N.A. #2 stated she was there the day of the incident and that she helped get the resident off the floor. C.N.A. stated that Resident #1 was face down on the floor, moaning and there was blood all around his/her head. His/her lips were swollen and he/she had chipped teeth. C.N.A. #2 stated the resident's nose was swollen and looked broken and the resident had a laceration on his/her forehead. On 11/9/16 at 1:35 p.m., in an interview with the surveyor, C.N.A. #3 stated that the resident was face down on the floor. C.N.A.#3 stated he helped hold pressure on the laceration on the resident's forehead. C.N.A. #3 stated he didn't think C.N.A. #1 knew how to navigate the facility computer system and wouldn't be able to view the Kardex. On 11/9/16 at 12:57 p.m., in an interview with the surveyor, C.N.A. #1 stated that on 9/1/16, sometime mid-morning, she did roll Resident #1 over on her side facing away from her in order to provide incontinent care. C.N.A. #1 stated she held the resident with one hand while she reached behind her to grab an incontinent wipe. C.N.A. #1 stated all of a sudden the resident rolled off the bed on the opposite side from C.N.A. #1. C.N.A. #1 stated she was not informed that the resident was a two person lift. She stated that she had not looked at Resident #1's care plan or at the C.N.A. Kardex. C.N.A. #1 stated that the C.N.A. that oriented her did not tell her that two staff were needed to care for this resident. On 11/9/16 at 1:25 p.m., in an interview with this surveyor, the DON stated that there seems to have been a big discrepancy in communication between staff and what the care plan directs them to do.

Based on record review, review of the facility internal investigation and interviews, the facility failed to implement interventions for bed mobility and incontinent care according to the resident's plan of care which resulted in the resident sustaining a laceration on the forehead, two chipped teeth, broken nose, and bilateral subdural hematomas. Finding: Documentation in Resident #1's electronic clinical record indicated that a few of Resident #1's [DIAGNOSES REDACTED]. Documentation in Resident #1's admission Minimum Data Set 3.0, dated 9/1/16, was coded to indicate that the resident requires extensive assistance of two persons physical assist for bed mobility and toileting. Documentation in Resident #1's care plan, initiated on 8/30/16, indicated under the problem of Activity of Daily Living (ADL) self-care performance deficit, that Resident #1 required maximum assist by two staff to turn and reposition in bed as needed. Documentation in the Certified Nurse Assistant (C.N.A.) Kardex (a shortened version of the care plan for C.N.A.'s to review) indicated that the resident required maximum assist by two staff to turn and reposition in bed as necessary. Documentation in the facility internal investigation, dated 9/3/16, indicated that the Director of Nursing (DON) completed the investigation. The DON documented that on 9/1/16, C.N.A. #1, stated she was turning the resident alone in order to change and provide toileting care and the resident rolled off the bed. The DON wrote when C.N.A. #1 was asked why she was doing it alone when the Resident is a two person assist with care and C.N.A. #1 stated she does it alone all the time. Also written by the DON is the care plan does state that the resident is a two person assist for care. On 11/9/16 at 12:10 p.m., in an interview with the surveyor, C.N.A. #2 stated that it was rumored that on 9/1/16, C.N.A. #1 did not ask anyone to help her with Resident #1 and that C.N.A. #1 provided care alone and the resident rolled out of bed and was face down on the floor. C.N.A. #2 stated she was there the day of the incident and that she helped get the resident off the floor. C.N.A. stated that Resident #1 was face down on the floor, moaning and there was blood all around his/her head. His/her lips were swollen and he/she had chipped teeth. C.N.A. #2 stated the resident's nose was swollen and looked broken and the resident had a laceration on his/her forehead. On 11/9/16 at 1:35 p.m., in an interview with the surveyor, C.N.A. #3 stated that the resident was face down on the floor. C.N.A.#3 stated he helped hold pressure on the laceration on the resident's forehead. C.N.A. #3 stated he didn't think C.N.A. #1 knew how to navigate the facility computer system and wouldn't be able to view the Kardex. On 11/9/16 at 12:57 p.m., in an interview with the surveyor, C.N.A. #1 stated that on 9/1/16, sometime mid-morning, she did roll Resident #1 over on her side facing away from her in order to provide incontinent care. C.N.A. #1 stated she held the resident with one hand while she reached behind her to grab an incontinent wipe. C.N.A. #1 stated all of a sudden the resident rolled off the bed on the opposite side from C.N.A. #1. C.N.A. #1 stated she was not informed that the resident was a two person lift. She stated that she had not looked at Resident #1's care plan of at the C.N.A. Kardex. C.N.A. #1 stated that the C.N.A. that oriented her did not tell her that two staff were needed to care for this resident. On 11/9/16 at 1:25 p.m., in an interview with this surveyor, the DON stated that there seems to have been a big discrepancy in communication between staff and what the care plan directs them to do.