Every finding on record at Caribou Healthcare Center, LLC

Based on interviews, observations, and record review, the facility failed to promote care for all residents in a manner that maintains each resident's dignity and respect during repositioning, bed mobility, and activities of daily living [ADL] care for 1 of 1 resident reviewed for resident rights (Resident #9 [R9]).Findings: 1. On 7/7/26 at 2:13 p.m. during an interview with a surveyor, R9 stated that earlier today staff locked his/her bed in the low position and locked it so that he/she could not raise or lower the head of the bed. R9 stated that he/she does not like the bed in the low position, closed to the floor, he/she doesn't know why but it has been since childhood, and the staff know this. On 7/7/26 at 2:13 p.m. a surveyor observed R9's bed in the low position and attempts by R9 to raise/lower the bed and raise/lower the head of the bed were unsuccessful. The remote that operates the bed was observed not working. On 7/7/26 at 2:18 p.m. during an interview with a surveyor, Certified Nursing Assistant #1 [CNA1] stated that earlier today staff put R9's bed in a low position for safety. R9's clinical record review stated under Administration Note 7/7/26 at 8:39 a.m., Diazepam oral tablet 5 mg [milligrams] give 1 tablet by mouth every 8 hours as needed for muscle spasms, res[ident] having muscle spasms. On 7/7/26 at 2:38 p.m. during an interview and observation with a surveyor, the Director of Nursing [DON] and CNA1 observed R9's bed, and bed remote and confirmed that the bed's remote functioning for R9 was locked [in locked position the remote to reposition bed does not work] and R9 could not reposition his/her bed. The DON unlocked the bed functions at time of observation and stated the bed's remote should not be locked. The DON stated that she is aware that R9 does not like his bed in the low position. 2. On 7/7/26 at 2:13 p.m. during an interview with a surveyor, R9 stated that sometimes he/she requires 2 staff to assist with repositioning, bed mobility, and ADL care because of the symptoms he/she has due to Parkinson's disease. R9 stated that staff wanted to assist him/her with 1 staff, even though R9 requested 2 staff due to increase in symptoms, tremors, stiffness, and pain. R9's clinical record review stated under Care Plan Report initiated on 4/17/26, Focus, the resident is resistive to care on occasion r/t [related to] adjustment to nursing home, Anxiety and Parkinson's Disease, Goal. The resident will cooperate with care through next review date. Interventions/Tasks. Allow the resident to make decisions about treatment regime, to provide sense of control . Provide resident with opportunities for choice during care provision. Review of Facility Reported Incident form received on 4/23/26 from the facility to the State of Maine, Department of Health and Human Services, Division of Licensing and Certification stated R9's family called the facility and stated he/she overhead staff via telephone having a verbal argument with R9 on 4/22/26 at approximately 8:20 p.m The Registered Nurse, Clinical Coordinator went to R9's room, R9 verbalized that he/she was having an episode of increased tremors, stiffness, and pain decreasing his/her ability to assist the staff with bed mobility. He/she requested that CNA2 get a second CNA to assist. CNA2 made attempts to reassure R9 that she was able to complete the task independently, Unsuccessful reassurance of these attempts caused increased anxiety and agitation for R9. R9 was still requesting 2 people to assist and CNA2 was continuing to attempt care by herself. On 7/7/26 at 2:52 p.m. in an interview with a surveyor, the DON stated that if R9 is requesting 2 person assist staff should assist with 2 people. The surveyor confirmed at this time that R9 requested 2 person assist with repositioning, bed mobility, and ADL care on 4/22/26, and CNA2 was continuing to attempt care with 1 person.

Based on review of reportable incident forms, clinical record review, facility policies, and interviews, the facility failed to ensure that 3 of 4 residents reviewed for falls (Resident #1, #3, and #4) were free from accident hazards and provided with supervision and assistance devices to prevent accidents, resulting in 3 avoidable falls, with major injuries to 2 residents. Specifically, the facility staff failed to maintain the required extensive assistance for Resident #1 (R1) during peri-care, which caused R1, who had hemiplegia, to roll out of bed and sustain a displaced fracture of the right femoral neck upper thigh bone. Additionally, staff failed to ensure the correct and safe use of assistive devices for two other residents: staff failed to attach footrests during R3's wheelchair transport, causing R3 to fall forward and sustain a nasal bone fracture; and staff failed to use the mechanical lift (Hoyer) with the legs open, causing R4 to slip out onto the floor. Findings: 1. Review of R1's, Reportable Incident Form for Certified, Licensed or Registered Providers Complaint Line received by Division of Licensing and Certification (DLC), State of Maine on 10/25/25 at 1:17 p.m., indicated that on 10/24/25 at 1935 (7:35 p.m.), Certified Nursing Assistant #1 (CNA1) was providing care for R1, rolled R1 to his/her left side to provide peri-care, turned to throw brief in trash, upon turning back to place new brief, R1 had rolled from the bed and landed on the floor mat beside his/her bed. R1 was on his/her stomach with head against the night-stand. R1 had a 2 cm (centimeter) laceration noted to the left side of his/her forehead, and c/o (complaint of) right hip pain with movement. Resident was transferred to emergency room on [DATE] at 9:30 p.m. and admitted to the hospital with a closed displaced fracture of the neck of the right femur (a broken right thigh bone just below the hip joint). Review of Nursing Facility Reportable Incident 5 Day Investigation Follow-Up report dated 10/27/25 stated, CNA1 turned around to throw the dirty attends away and when she turned back around R1 was already in the process of falling. R1 fear of falling and R1 did assist by holding onto the assist rail with his/her right arm. Review of R1's Care Plan, attached to reportable incident form signed by provider on 8/28/25, indicated under Problem Interest-Need-Condition 1. Self-care deficit R/T (related to) hx (history) of Traumatic Hemorrhage of cerebrum . hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side.M/B (manifested by) inability to perform ADLs independently ., Approach Method-Activity-Medication He/she is max assist for all his/her bathing, dressing, and personal hygiene and 2. Altered mobility . M/B weakness . Long- Term Goals Criteria Res will not be injured d/t (due to) a fall this quarter. Approach Method-Activity-Medication He/she is extensive assist x 1 for bed mobility with use of bilateral upper assist rails . He/she is a fall risk. and 5. Approach Method-Activity-Medication He/she is extensive assist for bed mobility using bilateral upper assist rails. and 7. Altered elimination. M/B always incontinent of bladder and of bowel. Approach Method-Activity-Medication He/she is extensive assist for toilet hygiene and for toilet transfer. Review of R1's x-ray report on 10-24-2025 22:36, reported 10-25-2025 10:33, Findings: There is an acute displaced subcapital fracture of the right hip.Impression: Displaced subcapital right femoral neck fracture. This was also noted by the treating emergency room provider. On 11/5/25 at 3:21 p.m. in an interview with a surveyor, CNA1 stated that she was providing care for R1, the side railings were up, and the resident was on his/her left side holding onto the railing with his/her right hand. CNA1 said she turned away from R1 to dispose of a soiled brief, and when she looked back R1 was in the air falling, already rolling off the bed, feet first onto the mat on the floor. R1 did not have the mobility ability to prevent himself/herself from rolling out of bed due to hemiplegia, hemiparesis to the left upper and lower extremities. 2. Review of R4's Progress Note dated 11/3/25 at 11:07 a.m. stated, Type: Incident Note: Resident was being hoyered out of bed to chair, by 2 CNA's when R4 slipped out of canvas and down to the floor. R4 has no bumps, lacerations, or bruising to head. Small abrasion to mid upper back. Review of R4's Social Service Note dated 11/3/25 at 12:12 p.m. stated, .It was explained that the current room is too small and poses a safety risk. We discussed moving the resident to another room that has a human (overhead) lift. The resident will be moved today.Review of R4's Care Plan, signed by provider on 8/14/25, indicated under Problem Interest-Need-Condition 1. Self-care deficit R/T (related to Multiple Sclerosis. M/B Hoyer Transfer and inability to ambulate. Long- Term Goals Criteria Ris will not have any falls this quarter. Approach Method-Activity-Medication [He/She] is total dependent assist x2 staff via Hoyer lift transfers and ext [extensive] assist for canvas placement. He/she does not ambulate.Hoyer with x2 assist and W/C [wheelchair] for mobility. A policy review indicated, Policy: Lifting Machine, Using a Mechanical Department: Nursing - PM004 Positioning and Moving, Effective: 11/2017, Revised: 03/2025, page 1 of 3, under Steps in the Procedure 4. Prepare the environment: a. Clear an unobstructed path for the lift machine; b. Ensure there is enough room to pivot. On 11/5/25 at 3:00 p.m. in an interview with a surveyor, CNA3 stated that while transferring R4 from his/her bed in a mechanical lift (Hoyer) to specialized wheelchair, the legs of the Hoyer were not open, the legs were in.I wasn't able to open the legs in a tight place. They were under the bed, and as I go to the chair, I open them. CNA3 stated that R4 was leaning to one side, which was usual for R4, and when she pulled the Hoyer back out from under the bed, it (Hoyer) jolted a little, questioned whether maybe hitting dresser, but doesn't really know and noticed R4 was leaning more, he/she was slipping, and actually slipped out of the sling.On 11/5/25 at 4:17 p.m. in an interview with a surveyor, the Social Worker stated that, we had approached R4 before the slip from Hoyer on 11/3/25, there had been discussions about moving R4's room due to space, with R4'recliner, etc. that the room was too small for staff to move the resident around.On 11/5/25 at 4:35 p.m. in an interview with a surveyor, R4 stated, swearing, that it hurt, when he/she fell from Hoyer onto the floor.3. On 11/4/25 at 3:12 p.m. the DLC, State of Maine received a facility reported incident stating that on 11/3/25 at 12:28 p.m. R3 suffered a fall with major injury during wheelchair transport. A policy review indicated, Policy: Falls and Fall Risk, Managing, Department: Nursing - FR003 Falls and Fall Risk, Effective: 11/2017, Revised: 03/2025, page 1 of 3, under Fall Risk Factors 1. Environmental factors that contribute to the risk of falls include: d. obstacles in the footpath; e. improperly fitted or maintained wheelchairs. A surveyor observed a sign posted behind the C/D wing nurses station, that stated, May 9, 2023, Foot pedals (footrests) need to be used when transporting any resident in a wheelchair at all times. This is for the resident's safety to prevent injury. On 11/5/25 at 11:35 a.m. in an interview with a surveyor, CNA4 stated that R3 wanted a ride to his/her room via wheelchair from the dining room, R3's hips were bothering him/her and couldn't lift their legs up. I didn't realize R3 put his/her legs down. R3 fell forward onto the ground, and he/she started bleeding from the nose. CNA4 stated, I know I should have had the foot pedals (footrests) on. I didn't. On 11/5/25 at 4:45 p.m. in an interview the Director of Nursing, and Administrator, a surveyor confirmed that 1) CNA1 turned away from R1 when throwing away a soiled incontinent brief, and in failing to maintain extensive assistance for R1 caused an avoidable fall with major injury. Interventions were in place to include adequate supervision consistent with the resident's needs, goals, and plan of care. 2) CNA3 failed to ensure that the feet of a Hoyer lift were placed in an open position prior to moving R4 due to space constraints in the room, R4 slid out of the Hoyer lift to the ground causing pain to R4, with no lasting injury. 3) CNA4 failed to put footrests on a wheelchair prior to transporting R3 that caused an avoidable fall with major injury. As a result of the facility's investigations of these isolated incidents, the following corrective actions were initiated: On 10/24/25, R1 was assessed by Charge Nurse and an order to send to the emergency room was obtained after speaking to the on call Medical Provider due to right hip/leg pain.On 10/24/25, CNA1 self-reported to the Charge Nurse the circumstances of R1's transfer. Education was provided by the Director of Nursing to the Charge Nurse, and CNA1 regarding bed mobility and safety. Immediate education to Nursing staff on Resident safety with ADL's Immediate education Nursing staff on bed mobility As a result of the facility's investigation the following correction actions were immediately taken on 11/3/25 and 11/4/25 regarding incidents involving R3 and R4 on 11/3/25: On 11/3/25, R3 was assessed and an order to send R3 to the emergency room was obtained by the Medical Provider. Actions taken by the facility - Immediate education provided to the staff member involved. - Maintenance Director reassessed all wheelchairs and replaced missing or lost foot pedals. - Storage bag placed on the back of the wheelchair for foot pedal storage when not in use by the resident by easy access for the employee if assist needed. - Education/Inservice provided on 11/5/25 at 1:30 p.m. and also on 11/6/25 at 3:30 p.m. on Resident safety with ADL's, bed mobility, wheelchair and Hoyer transfers. R4 was immediately moved to a room that has an overhead mechanical lift to allow for adequate space during transfers. Immediate education on Hoyer transfers. Nursing staff completed education on mechanical lift safety including videos, in person training and tests. At the time of the survey, the facility presented the surveyor with corrective actions taken to address these incidents. The facility was determined to be in past non-compliance after the review and verification of the implemented corrective actions. The facility conducted a root cause analysis and identified factors contributing to falls with injury.

Based on observations and interviews, the facility failed to ensure that medications and medical equipment were stored properly by having an unlocked, unattended medication cart on 1 of 3 days (A wing medication cart) (6/30/25), and a treatment cart on 2 of 3 days of survey (7/1/25, and 7/2/25) allowing residents and unauthorized people access to medications, and medication equipment. Findings: 1. On 6/30/25 at 11:11 a.m., during a surveyor observation of a medication administration pass, the Certified Nursing Assistant-Medications (CNA-M) left the A wing medication cart in the dining/activity area of the locked Special Care Unit for residents with advanced cognitive impairment. The cart was left unattended and unlocked while the CNA-M left the cart to give medications to Resident #31 (R31) who was sitting two tables away from the unlocked cart. There were several residents in the dining/activity area, and a surveyor observed R214 sitting in a wheelchair, self-propel himself/herself to the front of the unlocked medication cart, stop, and place his/her hand on the lock, and a drawer before moving away from the cart. On 6/30/25 at 11:12 a.m. in an interview with a surveyor regarding the unlocked and unattended medication cart, the CNA-M stated she was okay to not lock the cart because she always has the medication cart in sight when administering medications. The surveyor asked if she saw R214 attempt to open the medication cart, and she stated she did not, her back was turned away from the medication cart while she was administering medications to R31. On 6/30/25 at 11:30 a.m., in an interview with a surveyor, the CNA-M stated that she doesn't keep the A wing medication cart keys with her, she keeps them hooked to a nail in the medication storage room on B wing. A surveyor confirmed with the CNA-M and the Assistant Director of Nursing (ADON) that the medication cart was left unlocked and unattended. 2. On 7/1/25 at 10:15 a.m., a surveyor observed a treatment cart in a resident hallway unattended. Multiple residents and other staff were observed passing by the cart. The cart was observed to be unlocked, and contained syringes, lancets, medicated creams, ointments, and powders. At 10:18 a.m., the Charge Nurse returned to the cart and stated she had been down to a resident's room, then went to get another resident a drink. The Charge Nurse stated that the cart does not have a lock. At this time the surveyor confirmed the cart contained medications and sharps and was left unlocked, unattended and easily accessible to residents. 3. On 7/2/25 at 7:51 a.m., a surveyor observed an unattended treatment care to be in a resident hallway with the drawers facing the wall. The treatment cart drawers contained syringes, lancets, medicated creams, ointments, and powders, secured by a swivel snap hook. At 8:00 a.m., the surveyor observed and confirmed with the Charge Nurse that the treatment cart contained medications and sharps and was not secured with a locking device. On 7/2/25 at 8:20 a.m., during an interview with the Director of Nursing (DON), ADON, and 2 surveyors, the treatment cart in the medication room was observed and confirmed to be secured with a swivel snap hook. The DON confirmed that the cart needs a lock to secure the drawers. At this time 2 surveyors confirmed the treatment cart was not secured with a locking device, and multiple residents are capable of accessing the contents when it is not stored in the medication room.

Based on review of the facility's water management program and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens. Finding: On 7/2/25, a surveyor reviewed the facility's Water Management Program to Reduce Legionella Growth and Spread in Buildings policy that was last reviewed by the facility on 10/14/24 and photos of areas where Legionella could grow were updated as needed. The program lacked evidence of measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. There was no evidence of testing protocols for control measures, including how and when this would be monitored, acceptable control limits, what interventions would be taken if control limits were found to be outside of range, and instances when water testing for legionella would be needed. On 7/2/25 at 11:04 a.m., during an interview with Maintenance, a surveyor confirmed this finding.

Based on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing food in a sanitary manner for 2 of 3 days of survey (6/30/25 and 7/2/25). Finding: On 6/30/25 at 9:03 a.m., during observation of the walk-in freezer, a surveyor and the Dietary Supervisor observed and confirmed the following: 1 container of Veggie Lasagna, open and exposed to the environment. 1 container of pasta with meat sauce, exposed to the environment, freezer burn observed. 1 pizza on a round cooking sheet plastic wrap partially peeled up and pizza crust exposed to the environment. 6 slices of raw meat sitting on a shelf and exposed to the environment. The Dietary Supervisor identified them as Philly chicken. 1 package of cauliflower, open and undated. 1 package of breaded chicken patties, open and undated. 1 package of pre-cooked chicken cubed, open and undated. 1 package of yellow beans, open and undated. 1 package of tater-tots, open and undated. 1 package of fish sticks, open and undated. On 7/2/25 at 7:48 a.m., a surveyor observed and confirmed with a Certified Nursing Assistant (CNA) in the dayroom refrigerator and available for use: 1 half gallon of milk with an expiration date of July 01, 2025 2 open quart size containers of prune juice, undated. 1 open quart size container of apple juice, undated. 1 open quart size container of orange juice, undated. 1 pint size container of raspberries, observed to be shriveled and moldy.

Based on record review and interview, the facility failed to ensure a resident's right to formulate an advance directive regarding cardiopulmonary resuscitation (code status) was clear in the clinical record for 1 of 9 sampled residents reviewed for advanced directives (Resident #214 [R214]). Finding: On 7/1/25, R214's clinical electronic health record (EHR) and paper health record were reviewed. R214's electronic clinical assessment in the EHR states, Code Status: FULLCODE, and the clinical paper health record, dated 6/23/25 Discharge Summary (from hospital) states, DNR/DNI [do not resuscitate/do not intubate] in regard to [his/her] CODE STATUS. On 7/1/25 at 2:05 p.m. a surveyor and the Assistant Director of Nursing (ADON) reviewed R214's EHR and paper health record. The ADON stated that the code status in the EHR should read DNR/DNI, not full code. In an interview at this time with the ADON, a surveyor confirmed that the code status for R214, full code is not accurate on the EHR.

Based on record review and interview, the facility failed to review, revise and update a care plan for a newly discovered pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #19 [R19]). Finding: On 6/30/25, R19's clinical record was reviewed. Documentation indicated that R19 had a care plan with a revision date of 6/9/25 for alteration in skin. The care plan was not updated to address the new onset of a 3rd pressure ulcer as a stage III to the posterior of left foot. There was no evidence that the care plan was updated to reflect the new skin care needs. On 7/01/25 at 11:37 a.m., R19's care plan was reviewed with the Assistant Director of Nursing. The surveyor confirmed that the care plan does not reflect R19's current wound status and the care required for treatment.

Based on observation, interviews, and record review, the facility's interdisciplinary team meeting (IDTM) group failed to determine if it was clinically appropriate for a resident to keep medications at bedside and self-administer a medicated powder topically for 1 of 1 Residents observed with a medicated powder at bedside (Resident #165 [R165]). Finding: Review of facility policy, Pharmaceutical Services, reviewed on 8/21 stated, there shall be no self-administration of medication unless the Interdisciplinary Team Meeting (IDTM) group decides that the resident is able to self-administer and store the drugs safely. Physician's order will be maintained. On 6/30/25 at 10:37 a.m., a surveyor observed a medicated antifungal foot powder (Desenex), on R165's nightstand. R165 stated that he/she applies this powder themself, as needed. On 6/30/25 at 11:04 a.m., during an interview with a surveyor, the Director of Nursing (DON) stated that she will contact the doctor about the use of the Desenex because R165 has an order for miconazole (antifungal) for a rash. The DON stated that there had not been an evaluation to self administer medication completed. On 7/1/25, documentation in R165's clinical record included a physician order that the resident could self administer the Desenex and keep at the bedside; the clinical record also included a note that Licensed Practical Nurse #1 (LPN1) evaluated R165 for safe application of the product but there was no evidence that the IDTM had yet determined if this was clinically appropriate.

Based on observation and interviews, the facility failed to promote care for all residents in a manner that maintains each resident's dignity and respect during resident transportation on 1 of 3 days of survey (7/1/25) and during meal services on 1 of 3 days of service (6/30/25). Findings: 1.On 7/1/25 at 11:00 a.m. in the hallway near the conference room (Bears Den) a staff member was observed pulling a resident backwards in their wheelchair, causing this residents feet to drag on the floor. On 7/1/25 at 11:35 a.m., during an interview with the Assistant Director of Nursing, the surveyor confirmed that a staff member was pulling a resident backwards while in their wheelchair. 2. On 6/30/25 at 12:21 p.m., during the lunch service, a surveyor observed a staff member standing while assisting a resident to eat. This observation was observed and confirmed with Activities staff at the time of observation.

Based on record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interviews, the facility failed to offer the updated Pneumococcal vaccination to 1 of 5 residents (Resident #24 [R24]). Finding: On 7/1/25, R24's clinical record was reviewed. The documentation in R24's clinical record indicated that R24 received the Pneumococcal Conjugate Vaccine (PCV) 13 in 2015 and the Pneumococcal Polysaccharide Vaccine (PPV) 23 in 2017. The CDC recommendation was based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. On 7/1/25 at 9:14 a.m., during an interview with a surveyor, the Assistant Director of Nursing stated there was no evidence of offering the PCV20 to R24. On 7/2/25 at 10:00 a.m., during an interview with a surveyor, the Director of Nursing/Infection Preventionist stated that they use the CDC recommendations for administering the pneumococcal vaccines.

Based on record reviews and interview, the facility failed to follow physician orders for 1 of 3 residents reviewed for use of sliding scale insulin (Resident #49 [R49]). Finding: On 7/1/25, R49's clinical record was reviewed and included a physician order to administer insulin if finger stick blood sugars (FSBS) were at a certain result. The order for FIASP FlexTouch (insulin), dated 4/29/25, directed staff to inject subcutaneously as per sliding scale: 3 units for 200-250 (FSBS result) 6 units for 251-300, 9 units for 301-350, 12 units for 351-400, 15 units for 401-450, and to call physician if over 451. R49's May Treatment Administration Record (TAR) indicated that on 5/22/25, R49's FSBS was 563. The TAR documentation indicated that R49 received 15 units of insulin. The clinical record lacked evidence of calling the physician and obtaining a physician order for insulin for a FSBS result greater than 451. R49's June TAR indicated that on 6/27/25, R49's FSBS was 288. The TAR documentation indicated that R49 received 3 units of insulin, instead of 6 units as ordered. On 7/1/25 at 12:10 p.m., during an interview with the Assistant Director of Nursing, a surveyor confirmed these findings.

Based on record review, review of the facility incident report, observation, and interviews, the facility failed to monitor an unlocked and/or non-alarmed door to prevent a resident identified as an elopement risk from leaving the building unnoticed. A staff member, who was informed by a visitor, told staff she saw a resident outside, unattended. The failure to have monitoring of unlocked, and/or non-alarmed doors, resulted in an avoidable elopement for 1 of 3 resident reviewed for elopement risk (Resident # 1 [R1]). Finding: R1 was admitted to the facility in February 2025 with a diagnosis of Dementia. R1 was identified as an elopement risk and wears a wander guard alert (a safety device that alarms if resident wanders too close to a door). Review of R1's Reportable Incident Form dated 5/26/25 indicates that on 5/25/25 at approximately 3:15 p.m., R1 was outside for thirty-three minutes and he/she was sitting in a wheelchair near the gazebo on the lawn across the employee parking lot. Another residents family member saw him/her outside .R1 was wearing a wander guard, but the door was unlocked, and the wander guard did not alarm. On 6/5/25 at 3:15 p.m. in an interview with a surveyor, the Licensed Practical Nurse stated that on 5/25/25 she observed R1 outside with in a wheelchair, stuck in the mud we alerted other staff, and ran to bring R1 inside. On 6/5/25 at 5:00 p.m. in an interview with a surveyor, the Director of Nursing (DON) states the facility was able to determine through video surveillance footage that R1 exited the building from the D Wing door, it did not appear that the alarm from his/her wander guard went off or locked the door. R1 was returned to the facility on 5/25/25 at approximately 3:51 p.m., thirty-three minutes after elopement. R1 was outside on a day that was mild in temperature. R1 was assessed, and monitored, there were no lasting effects to R1. During this interview a surveyor confirmed that R1 had elopement unnoticed by staff.

Based on observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was clean, for 3 of 3 days of survey for Resident #33 (R33), R13, R35, R24, and R48). Findings: 1. On 6/24/24 at 9:01 a.m., a surveyor observed that R33's O2 concentrator filter was heavily soiled with dust and debris. On 6/25/24 at 1:17 p.m., a surveyor observed that R33's O2 concentrator filter was heavily soiled with dust and debris, and a trash receptacle containing a plastic trash bag was directly in front of the filter, the plastic trash bag was pulled toward/ against the filter. On 6/26/24 at 7:45 a.m., a surveyor observed that R33's O2 concentrator, the filter was observed to be heavily soiled with dust and debris. 2. On 6/24/24 at 9:48 a.m., a surveyor observed that R13's oxygen (O2) concentrator filter was heavily soiled with dust. On 6/25/24 at 8:55 a.m., a surveyor observed that R13's O2 concentrator filter was heavily soiled with dust. 2. On 6/24/24 at 9:57 a.m., a surveyor observed that R35's O2 concentrator filter was heavily soiled with dust. On 6/25/24 at 12:04 p.m., a surveyor observed that R35's O2 concentrator filter was heavily soiled with dust. 3. On 6/24/24 at 9:58 a.m., a surveyor observed that R24's O2 concentrator filter was heavily soiled with dust and debris. On 6/25/24 at 1:12 p.m., a surveyor observed that R24's O2 concentrator filter was heavily soiled with dust and debris. On 6/26/24 at 7:37 a.m., a surveyor observed that R24's O2 concentrator filter was heavily soiled dust and debris. 4. On 6/24/24 at 2:58 p.m., a surveyor observed that R48's O2 concentrator filter was soiled with dust. On 6/25/24 at 2:17 p.m., a surveyor observed that R48's O2 concentrator filter was soiled with dust. 49635 On 6/26/24 at 8:37 a.m., during an interview with a surveyor, Registered Nurse #1 (RN1) stated that cleaning the filters on the O2 concentrators is part of a Charge Nurse weekly task. A surveyor and RN1 then observed the above mentioned 02 concentrator filters and the surveyor confirmed that they were dusty. On 6/26/24 at 9:16 a.m., during an interview with the Director of Nursing (DON), a surveyor confirmed with the DON that the O2 concentrator filters are dusty even though there was a weekly treatment for the task. The DON and surveyor then observed R35's O2 concentrator's dusty filters.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 1of 2 Medication Carts reviewed (B Wing Medication Cart), and 2 of 2 Medication Storage Rooms reviewed (B Wing Medication Storage and C-D Wing Medication Storage). Findings: On 6/24/24 at 1:53 p.m., review of the C-D Wing Medication Storage Room revealed on the shelf and available for use: 1 bag containing Prochlorperazine 25 milligram (mg) suppositories with an expiration date of 2/24 1 box Premarin vaginal cream conjugated estrogens 0.625mg/gram with an expiration date of 4/30/24 1 bag containing Acetaminophen Suppositories 650mg with an expiration date of 6/23 In the locked narcotic cabinet, on the shelf and available for use: 1 blister pack of Hydrocodone and Acetaminophen 5mg-325mg with an expiration of 4/5/24 A surveyor observed and confirmed the above findings with Registered Nurse #1 at the time of the observation. On 6/24/24 at 2:45 p.m., review of the B-Wing Medication Storage Room revealed on the shelf and available for use: 1 bag containing Bisacodyl 10mg suppositories, 5 suppositories had an expiration date of 4/24, and 5 suppositories had an expiration date of 6/23 1 bottle 44 milliliter Deep Sea Premium Saline nose spray 0.65% with an expiration date of 5/24 2 boxes Acetaminophen suppositories 650mg with an expiration date of 4/24 1 bottle Pain Relief Acetaminophen 250mg / Aspirin 250mg / Diphenhydramine 38mg with an expiration date of 2/24 1 bottle Loratadine 10mg with an expiration date of 12/23 Review of the B-Wing Medication Cart revealed available for use: 1 bottle Loratadine 10mg with an expiration date of 12/23 A surveyor observed and confirmed the above findings with Registered Nurse #2 at the time of the finding.

Based on observations, and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters for 3 of 3 days of survey (6/24/24, 6/25/24, and 6/26/24). Findings: On 6/24/24, from 7:30 a.m. to 3:45 p.m., surveyors observed no personal protective equipment (PPE) other than gloves or signage notifying of EBP's for Resident #48 (R48) who had a urinary Foley catheter or any other Resident who had urinary Foley catheters. On 6/25/24 at 10:32 a.m., a surveyor observed no PPE other than gloves or signage notifying of EBP's for R10 who had a urinary Foley catheter or any other Resident who had urinary Foley catheters. On 6/25/24 at 11:11 a.m., a surveyor could not find any documentation pertaining to the use of Enhanced Barrier Precautions (EBP's). On 6/25/24 at 1:52 p.m. in an interview with the Director of Nursing (DON) and Assistant Director of Nursing, a surveyor confirmed that the facility is not using EBP's for Resident's who have a urinary Foley catheter and does not have a plan in place for the use EBP's. The DON stated that the use of EBP's are not being used for urinary Foley catheters or anything else. 33242 On 6/25/24 at 2:13 p.m., during an interview with a surveyor, R48 stated that staff just emptied the urinary Foley catheter bag and the staff member was wearing a uniform and no protective gown. On 6/26/24 at 3:30 p.m., a surveyor observed no PPE other than gloves or signage notifying of EBP's for R10 who had a urinary Foley catheter or any other Resident who had urinary Foley catheters On 6/26/24 at 3:33 p.m., during an interview with a surveyor, Registered Nurse #1 (RN1) stated she did not know what EBP's were. The surveyor asked RN1 about what PPE was worn when she performs urinary Foley catheter care to which the response was gloves, and if she was inserting a urinary Foley catheter, the equipment would be sterile.

Based on record review and interview, the facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within 14 days of completion date for 1 of 1 system selected residents reviewed for Resident Assessment (Resident #14 [R14]). Finding: R14's quarterly MDS, with a target date of 5/16/24, was completed on 5/17/24. This assessment was required to be electronically submitted to the State MDS database within 14 days (by 5/31/24) but was not submitted until 6/26/24, 26 days late. On 6/26/24 at 11:04 a.m., during an interview with a surveyor, the MDS Coordinator stated that she just submitted R14's quarterly MDS; she wasn't sure why it wasn't transmitted and was unaware that it didn't transfer until the surveyor asked about it.

Based on employee files review and interviews, the facility failed to develop and implement an education program that included annual training on the Infection Control program standards, policies, and procedures for 1 of 5 Certified Nursing Assistants (CNA) reviewed ( CNA1). Finding: On 6/25/24, CNA1's employee file and Inservice record was reviewed. CNA1's last documented Combined Inservice, which included training on the Infection Control program standards, was 12/6/22. On 6/25/24 at 2:45 p.m., during an interview with a surveyor, the Clinical Assistant stated that she was unable to find evidence that CNA1 completed the Combined Inservice in (December) 2023. On 6/26/24 at 3:12 p.m., during an interview with a surveyor, the Staff Educator stated that CNA1 completed the Infection Control training yesterday but it should have been done in 2023, but it was not. The surveyor confirmed this finding during these interviews.

Based on facility reported incident and investigation review, record review, and interviews, the facility failed to ensure that a resident who was identified as a stand pivot transfer received assistance from two staff members during a transfer for 1 of 1 facility reported incidents reviewed (4/24/24). Finding: On 4/24/24, the facility reported an incident to the State Agency (Division of Licensing and Certification), alleging that on 4/23/24, Certified Nursing Assistant (CNA)1 transferred Resident (R)1, who was a two person assist transfer, with a non-family member visitor instead of a staff member. The facility's investigation, which was completed on 4/24/24, included an X-ray that identified that R1 had an acute (sudden) to subacute (between acute and chronic) non displaced fracture of the lower tibial shaft but the evaluation was limited due to severe osteoporosis. On 5/7/24 at 9:59 a.m., during an interview with a surveyor, CNA1 stated that about 12:30 p.m. (on 4/23/24), R1 rang the call bell and wanted to go to bed; his teammate was at lunch and he explained to R1 that he/she needed to wait so he could get assistance. CNA1 stated R1 was a two person assist transfer. R1 was adamant that he/she wanted to go to bed so R1's roommate's family member offered to help transfer R1 to bed. CNA1 explained that about 2:00 p.m., R1 complained of pain in the right knee to right ankle area and reported this to Licensed Practical Nurse (LPN)1. CNA1 stated that he was educated after this incident to seek out another staff member and not accept assistance from non-family members. On 5/7/24 at 10:50 a.m., during an interview with a surveyor, LPN1 stated she assessed R1 and found no bruising or swelling and was able to move R1's leg and ankle with no pain, complaining of pain after she stopped moving it. LPN1 notified the Medical Provider who ordered an X-ray for the morning. LPN1 stated R1 was a two person assist transfer at that time. On 5/7/24 at 11:00 a.m., during an interview with a surveyor, CNA2 stated that R1 was a two person assist transfer and that she would use another staff member to assist with a transfer. On 5/7/24 at 11:05 a.m., during an interview with a surveyor, the Physical Therapist (PT) stated that the last time she evaluated R1 was 5/18/22 when R1 was at another facility, and R1 was a two person assist for transfers. R1 was a new admission to this facility and her admission evaluation was completed on 4/30/24, which was after the incident. R1 is now a Hoyer lift for transfers. As a result of this isolated incident, the following actions were initiated: On 4/23/24, R1 was assessed by LPN1 and an order for an X-ray was obtained after speaking to the Medical Provider. On 4/24/24, CNA1 self reported to the Director of Nursing the circumstances of R1's transfer. Education was provided to CNA1 on using other staff for two person assist transfers and not to accept offers of assistance from non -family members or non staff. (The facility has a process in place for family members who wish to assist their own family who reside in the nursing home). On 4/24/24, education was provided to the non-family member visitor to not offer to assist staff for residents that are not family. On 4/24/24, an X-ray was obtained, thereafter, pain management and an orthopedic consult obtained. Staff were to use a Hoyer lift for transfers. On 4/30/24, an admission PT evaluation was completed and R1 was now a Hoyer lift for transfers.

Based on observations, record reviews and interviews, the facility failed to provide residents a whirlpool/shower/shampoo as directed by the Resident's shower schedule for 5 of 5 residents reviewed for personal grooming care on A-Wing (Resident #30, Resident #35, Resident #44, Resident #45, and Resident #48). Findings: 1. Documentation on Resident #30's MDS 3.0, dated 2/27/23, stated the resident requires extensive assist of one staff for bed mobility, personal hygiene, toilet, dress and requires limited assist of one staff for transfers. Documentation for Resident #30's weekly whirlpool days was documented on the Certified Nursing Assistant (CNA) list #1 to be done every week on Monday day shift. Review of Resident #30's clinical record CNA documentation for whirlpools/showers, the record indicated that Resident #30 has no whirlpools documented from April 1st to April 26th, when he/she should have had 4 whirlpools in that time frame. 2. Documentation on Resident #35's Minimum Data Set 3.0 (MDS 3.0), dated 1/16/23, stated the resident requires extensive assist of one staff for bed mobility, transfers, personal hygiene, toilet use and to dress. Documentation for Resident #35's weekly whirlpool days was documented on the CNA list #1 to be done every week on Monday day shift. Review of Resident #35's clinical record CNA documentation for whirlpool/showers, the record indicated that Resident #35 has had one whirlpool from April 1st to April 26th when he/she should have had 4 whirlpools in that time frame. 3. Documentation on Resident #44's Minimum Data Set 3.0 (MDS 3.0), dated 1/16/23, stated the resident requires extensive assist of one staff for bed mobility, transfers, personal hygiene, toilet use and to dress. Documentation for Resident #44's weekly whirlpool days was documented on the CNA list #2 to be done every week on Monday day shift. Review of Resident #44's clinical record CNA documentation for whirlpool/showers, the record shows that Resident #44 has had one whirlpool from April 1st to April 26th when he/she should have had 4 whirlpools in that time frame. 4. Documentation on Resident #45's MDS 3.0, dated 3/17/23, stated the resident requires total assist of two staff for bed mobility, personal hygiene, toilet, dress and for transfers. Documentation for Resident #45's weekly whirlpool days was documented on the CNA list #2 to be done every week on Monday day shift with an added note to please wash hair every day. On 4/24/23, during initial tour of A-Wing main room, Resident #45 was sitting in his/her recliner chair. It was observed that Resident #45's hair was greasy and uncombed. On 4/25/23, during an additional observation tour of A-Wing, Resident #45 was observed in his/her bed and in the main room area and his/her hair was observed to be greasy. On 4/26/23, during A-Wing resident observations, Resident #45 was in the main room with his/her hair appearing greasy and unkempt. On 04/26/23 at 12:08 p.m., during an interview a Nursing Supervisor, the surveyor confirmed that Resident #45's hair was greasy and does not appear as his/her hair has been washed this week. Review of Resident #45's clinical record CNA documentation for whirlpool/showers, the record shows that Resident #45 has had one whirlpool from April 1st to April 26th when he/she should have had 4 whirlpools in that time frame. 5. Documentation on Resident #48's MDS 3.0, dated 3/11/23, stated the resident requires extensive assist of two staff for bed mobility, personal hygiene, toilet, dress and requires total assist of two staff for transfers. Documentation for Resident #48's weekly whirlpool days was documented on the CNA list #1 to be done every week on Monday day shift. On 4/24/23, during initial tour of A-Wing main room, Resident #48 was sitting in his/her recliner chair. It was observed that Resident #48's hair was greasy and uncombed. On 4/25/23, during an additional observation tour of A-Wing, Resident #48 was observed in his/her bed and in the main room area and his/her hair was observed to be greasy. On 4/26/23, during A-Wing resident observations, Resident #48 was in the main room with his/her hair appearing greasy and unkempt. On 04/26/23 at 12:08 p.m., during an interview a Nursing Supervisor, the surveyor confirmed that Resident #48's hair was greasy and does not appear as his/her hair has been washed this week. Review of Resident #48's clinical record CNA documentation for whirlpools/showers, the record shows that Resident #48 has had one whirlpool from April 1st to April 26th, when he/she should have had 4 whirlpools in that time frame. On 04/26/23 at 12:38 p.m., during an interview with the surveyor, CNA #1 stated that on A-Wing, on Monday they were very short staffed, and they had to keep the main room doors closed for a while until surveyors came in and the Supervisors sent us office staff to come help monitor the main room and residents in it. Also, our whirlpool was leaking and the maintenance worker was working on it. The CNA stated they would have had to use the other Wing's whirlpool and there was not enough staff to do that.

Based on observations, interview and record reviews, the facility failed to ensure that the resident's environment was free of accident hazards and potential entrapment hazards by failing to complete a safety bed assessment prior to the use of bed bolsters for 8 of 16 sampled residents (Resident #19, Resident #23, Resident #28, Resident #39, Resident #42, Resident #45, Resident #48, Resident #49). Findings: On 4/25/23 at 9:00 a.m., a surveyor observed staff releasing a wedge shaped bed bolster from Resident #39's bed. Staff swung the resident's feet on the side of the bed and then assisted Resident#39 to the standing position. The surveyor observed that the bed bolster was hanging off the bed and was noted to be held to the bed frame with straps. On 4/25/23 at 9:30 a.m. 3 surveyors entered the A-Wing and observed bed bolsters on Resident #23, Resident #39, Resident #42, Resident #45 and Resident #48's bed. The bed bolsters were placed on top of the mattresses and were attached to the mattress by one or two straps that go around bed mattress and are visible over the bottom sheet. The surveyors tested the fitting of the straps and it was noted that the straps were loose and had enough space between the straps and the bed mattresses for a potential entrapment of a resident's body part. There was no evidence that a resident's freedom of movement had been restricted. On 4/25/23, a review of Resident #23, Resident #39, Resident #42, Resident #45 and Resident #48's clinical record for safety assessments was completed. There was no evidence in the clinical records that a bed safety/entrapment hazard assessment was completed prior to or since the application of the bed bolsters. On 4/25/23 at 9:45 a.m., during an interview with the surveyors, the Director of Nursing (DON) stated the bed bolsters were placed on the beds to assist the residents in knowing and being aware of where the edge of the bed is. She stated that the bolsters assist the residents in not getting close to the edge of bed. The DON confirmed that no assessment for entrapment or resident safety was completed for the use of the bed bolsters. 04/25/23 10:15 a.m., during a tour of the B-Wing and C-Wing, it was observed that Resident #19, Resident #28 and Resident #49 had bed bolsters. The straps holding the bolsters to the bed were tested and found to be very loose and have enough space between straps and bed mattresses for potential entrapment of resident's body parts. There was no evidence that a resident's freedom of movement had been restricted. On 4/25/23, a review of Resident #19, Resident #28 and Resident #49's clinical record for safety assessments was completed. There was no evidence in the clinical records that a bed safety/entrapment hazard assessment was completed prior to or since the application of the bed bolsters. On 4/25/23 at 9:45 a.m., the DON confirmed no bed bolsters were assessed for resident safety or entrapment zones. 32540