Every finding on record at Cedar Ridge Center

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, and sanitary environment for 2 of 4 days of survey (4/13/26 and 4/14/26). Findings: 1.On 4/13/26 at 12:15 p.m., during an observation of the Blue Spruce unit (C unit) the surveyor observed the ice machine on the counter in the kitchenette area. The air gap was not visible; the Maintenance Director stated the air gap was in the secured doors of the cabinet. The Maintenance Director removed the screws from the doors, and it was noted that the air gap was improper (see F812) at this time an observation of the interior of the cabinet was made and it was noted that the bottom of the cabinet was warped exposing the edges of the wood panel and an area on the back left corner of the cabinet was caved in. This area was noted to have a dark substance on the edges of the exposed panel. At the time of this observation the above finding was confirmed by the surveyor with the Maintenance Director. 2.On 4/13/25 at 12:25 p.m., during an observation of the [NAME] unit (D unit) the surveyor observed the ice machine on the counter in the dining/common area. In the cabinet under the ice machine the air gap was observed to be correct, it was noted that the drain tube from the ice machine had a large buildup of a black substance hanging off the end of the drain tube. In the cabinet there were 2 urinals, 1 incontinence brief and an opened box of gloves along with several loose garbage bags. The above findings were confirmed by the surveyor with the Director of Nursing and the Market Clinical Advisor in training (MCAT). 3.On 4/13/26 at 12:40 p.m., during an observation of the Scotch Pine Unit (B unit) the surveyor observed the ice machine on the counter in a small kitchenette area, the area around the ice machine was observed to be heavily soiled with dark unknown substances. A staff member in the kitchenette stated that it was from when the coffee pot overflowed last week. The area behind the ice machine was observed, the counter behind the ice machine had been cut to allow for the piping for the ice machine leaving cut edges of the countertop that were exposed and was discolored from the spilled coffee. The above finding was confirmed by the surveyor with the staff at the time of the observation.

Based on record reviews and interviews, the facility failed to ensure that during the regulatory visit, the Provider reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the physician block orders for 5 of 5 residents reviewed for unnecessary medications (Residents #7 [R7]), R59, R5, R14, R33). Findings: 1. On 4/16/26, a review of R7's clinical record was completed. Documentation indicated a required regulatory visit was conducted on 2/24/26 a provider progress note was completed on 2/24/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 2/24/26 required regulatory visit. 2. On 4/16/26, a review of R59's clinical record was completed. Documentation indicated a required regulatory visit was conducted on 2/26/26. A provider progress note was completed on 2/26/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 2/26/26 required regulatory visits. 3. On 4/16/26, a review of R5's clinical record was completed. Documentation indicated a required regulatory visit was conducted on 3/3/26. A provider progress note was completed on 3/3/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 3/3/26 required regulatory visit. 4. On 4/16/26, a review of R14's clinical record was completed. Documentation indicated a required regulatory visit was conducted on 3/3/26. A provider progress note was completed on 3/3/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 3/3/26 required regulatory visit. 5. On 4/16/26, a review of R33's clinical record was completed. Documentation indicated a required regulatory visit was conducted on 3/17/26 a provider progress note was completed on 3/17/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 3/17/26 required regulatory visit. On 4/16/26 at 11:31 a.m., in an interview with the surveyors, the Market Clinical Advisor confirmed the findings.

Based on observation and interviews, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 4 days of survey (4/13/26). In addition, the facility failed to prepare food under sanitary conditions for 1 of 4 days of survey (4/14/26).Findings: 1.On 4/13/26 at 12:15 p.m. during a unit observation tour on the Blue Spruce unit (C unit) the kitchenette had an ice machine on the counter, the air gap was not visible. The Maintenance Director was asked to show the air gap to the ice machine, which was located under the sink, the cupboard doors were secured shut with screws. When the Maintenance Director unscrewed the doors, it was observed that the air gap to the ice machine was less than the 1 inch required.This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one-inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils.The above finding was confirmed by the surveyor at the time of the observation with the Maintenance Director. 2.On 4/14/26 at 11:40 a.m. a surveyor observed the Food Service Director (FSD) preparing lunch desserts. He brought a can of peaches from the supply room, the can was observed to have a dirty/dusty top, the FSD opened the can of peaches contaminating the peaches with the soiled lid. The FSD brought in a second can and wiped the top of the can with the sanitizing cloth and did not rinse the top leaving the sanitizing agent on the top lid, the can was brought over to the can opener, a surveyor intervened, the can top was rinsed then opened by the Dietary Aide. She then brought the can to the counter and placed it down near the dessert dishes. She put on gloves and with a gloved hand reached into the opened can grabbing some peach slices, she then began cutting them up in her hand with a knife and placed the cubed pieces into the small dessert dishes. She then reached into the open can with the same gloved hand and cut up the peach slices and filled dessert dishes an additional 2 times before the surveyor intervened. This finding was confirmed by the surveyor at this time with the Dietary Aide and with the Corporate Dietary Supervisor.

Based on record review, observation, and interview, the facility failed to maintain an infection control program to help prevent the spread of infection related to pressure ulcer treatment for 1 of 2 residents observed for a pressure ulcer dressing change (Resident #55 [R55].On 4/13/26, a review of R55's clinical record was completed. Documentation indicated R55 has a Stage 3 pressure ulcer on the left heel. Documentation in the physician orders indicated that the pressure ulcer treatment is to cleanse the wound with wound cleanser, apply a medihoney dressing to the wound bed and cover with a foam border once a day and as needed. On 4/14/26 at 6:50 a.m., a pressure ulcer dressing change observation was completed with RN1 performing the dressing change.Initially RN1 donned clean gloves, and set up a clean work field at the foot of the bed. RN1 placed the wound cleanser bottle on the soiled linen and medihoney dressing and foam cover on clean work field. RN1 went back to treatment cart and with the same clean gloves touched the cart with both gloved hands, took the keys from the cart, and put the keys in her pocket. She then picked up a camera (used for taking pictures of wounds) without cleaning it and went to bedside and placed camera on clean work field (contaminating the area). With the same gloves on; removed soiled dressing. RN1 changed gloves and cleansed wound. She then handled the camera and was unable to get a good picture. She lifts resident's leg and places it in a different position, moves the left leg again and takes a picture. With the now soiled gloves, she applied the medihoney dressing and foam. On 4/14/26 at 7:05 a.m., in an interview with RN1, the surveyor discussed the use of soiled gloves when applying a sterile dressing and working in contaminating a clean work field with a soiled camera. In addition, the surveyor discussed with RN1 the Enhanced Barrier Precaution (EBP) sign outside the residents room. RN1 did not follow the instructions for the EBP by not wearing a protective gown while performing a wound dressing change.

Based on record reviews and interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was ordered for 14-days or less unless there is a practitioner's rationale for PRN use beyond 14-days for 1 of 5 residents reviewed for unnecessary medications (Resident #59 [R59]).Findings: Review of R59's clinical record, on the physician order summary for medications states, Lorazepam (used to treat anxiety) give 0.5 mg (milligrams) by mouth every 8 hours as needed for anxiety for 6 months, with an order start date 11/24/25 and order end date 5/24/26. There was no evidence in the clinical record of a practitioner rationale for the extended use of the psychotropic PRN order beyond 14-days. On 4/16/26 at 11:28 a.m. in an interview with the Director of Nursing (DON), a surveyor confirmed that R59's clinical record lacked evidence of practitioner's rationale for extended use of 6 months for the PRN Lorazepam order. The DON stated upon her review of R59's clinical record she couldn't find a practitioner rationale for the extended use either.

Based on interviews, review of the facility's filed grievances, and record review, the facility failed to implement parts of its Grievance/Concern policy and procedure for 1 of 2 residents that filed grievances (Resident #44 [R44]).Finding: On 4/13/26 at 10:50 a.m., in an interview with a surveyor, R44 voiced concern that they had filed a few grievances in the past couple of months and no one from management has talked to them about the outcome of their grievances. R44 stated that they do attend resident council meetings most of the time and they did discuss one of the grievances regarding snacks, but no one saw the resident in person to discuss it. On 4/15/26, a review of the facility's Grievance Binder was completed. In the Grievance Binder were four grievance forms filed by R44. The grievances are as follows:A. On 1/15/26, the scalloped potatoes were hard on the evening of 1/14/26.Documentation indicated that the corrective action was the Administrator stated quality control is done prior to meals leaving kitchen.B. On 1/16/26, did not receive evening medications until 11 p.m.Documentation indicated the corrective action was that the Administrator did a face to face visit with R44 and explained the medication nurse was a new staff and was a bit behind that evening.C. On 2/16/26, R44 is not receiving snacks in the afternoon.Documentation indicated the corrective action was that the dietary staff and nursing staff were spoken to about their responsibilities to provide snacks. D. On 2/16/26, there are no Purell hand wipes provided to residents prior to meals.Documentation indicated the corrective action was to speak to staff about offering hand wipes prior to meals and ensure they are in stock. Other than the grievance regarding a medication pass, there is no documentation on the grievance forms indicating the resident was spoken to directly about the concerns.On 1/15/26, R44's clinical record was reviewed and there was no evidence that the resident had been directly spoken to regarding his/her grievances. On 1/15/26, the facility's Grievance Policy and Procedure was reviewed. Documentation in the facility policy 'Grievance and Concerns Policy and Procedure under section 6. The department manager will:6.1 contact the person filing the grievance to acknowledge receipt6.5 notify the person filing the grievance of resolution in a timely manner On 4/15/26 at 11:10 a.m., in an interview with a surveyor, the Administrator stated he remembered discussing some grievance resolutions with R44, but was unsure which ones other than the grievance form that indicated a face to face regarding the late medication pass. He stated the facility is going to improve the follow up process.

Based on clinical record reviews and interviews, the facility failed to ensure physician orders were followed for blood pressure parameters prior to administering a medication for 1 of 5 resident's reviewed for unnecessary medications (Resident #7 [R7]) and failed to follow physician's orders by holding a medication that was ordered for 1 of 5 resident's reviewed for unnecessary medications (R59). Findings: 1.On 4/15/26 during a clinical record review the surveyor noted R7 had an order dated 9/9/25 for Carvedilol (medication that works by relaxing blood vessels and slowing the heart rate) 3.125 milligrams (mg) by mouth every morning and at bedtime for hypertension (high blood pressure) with directions to take with food and to hold Carvedilol for systolic blood pressure (SBP) below 100 and to hold Carvedilol for diastolic blood pressure (DBP) below 60. Upon review of R7's electronic medical administration record (EMAR) there is no evidence that R7's SBP or DBP was monitored prior to receiving his/her scheduled Carvedilol for the months of March 2026 and April 2026. During a review of the electronic clinical record Point Click Care (PCC) there is no evidence of his/her SBP or DBP being taken twice a day. On 4/15/26 at 3:39 p.m. during interviews and record review for R7 with the Director of Nursing (DON), Market Clinical Advisor and Market Clinical Advisor trainee, a surveyor confirmed the above finding. 2. On 4/16/26 R59's clinical record was reviewed and the EMAR dated 4/1/2026-4/30/2026 states, Metoprolol (blood pressure medication) Succinate ER (Extended Release) Oral Tablet . 50 MG . Give 2 tablet by mouth one time a day for hypertension. Documentation on the EMAR states that the Metoprolol doses were held (not given) on 4/10/26, and 4/13/26. There is no evidence in R59's clinical record why the medication was held or that the provider was contacted pertaining to holding the Metoprolol. On 4/16/26 at 11:28 a.m., in an interview with the DON, a surveyor confirmed that R59's medication for Metoprolol was not given as ordered on 4/10/26, and 4/13/26.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 2 sampled residents reviewed for PASRR (Resident #1 [R1]).Finding:On 4/14/26, R1's clinical record was reviewed. R1's PASRR, completed on 12/24/25, did not require a level II determination due to his/her clinical record did not show that he/she had a serious mental illness. On 9/2/25, R1 was diagnosed with bipolar disorder, but the clinical record lacked evidence that the resident was referred to the State mental health authority for a new PASRR determination.On 4/14/26 at 1:35 p.m., during an interview with a surveyor, the Licensed Social Worker stated a new PASRR was not submitted for R1 with the diagnosis of bipolar disorder. At this time a surveyor confirmed the facility failed to refer R1 for a PASRR after a new diagnosis and/or experienced symptoms related to a mental disorder.

10. On 6/3/25 at 10:00 a.m., in an interview with a surveyor, Resident #10 stated that he/she had asked to use the bedpan at approximately 2:10 am this morning. They came and put me on it and I rang again when I was finished. No one came until 7 or 8 o'clock this morning. I ended up taking it out and it fell off the bed when I moved. The nurse was the one who found it. On 6/3/25 at 1:20 p.m., in an interview with a surveyor, the RN confirmed that he/she had found Resident #10's bedpan spilled on the floor and had to clean it up. He/she stated there had been no CNA from 6 a.m. to 8 a.m. on the unit and he/she was doing both jobs as the CNA and the nurse on the Blue Spruce unit. On 6/3/25 at 1:30 p.m., the finding was discussed with the Director of Nursing. Based on record reviews, interviews, and facility staffing schedules review, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of the facility's staffing schedules and the resident census of those days, showed the facility failed to assure staffing minimums were met for 23 of 31 days reviewed for staffing.(3/14/25 to 3/23/25 and 5/14/25 to 6/3/25) 1. On 6/3/25 at 9:15 a.m., in an interview with a surveyor, Resident #3 stated, I have had to wait a very long time on the evening shift because there is not enough staff to do my care. I have had accidents and wet myself because no one has come for over an hour when I ring the call bell. Then, I have to sit in wetness for over an hour before I am changed. The staff tell me they are short staffed and will get to me when they can. 2. On 6/3/25 at 9:30 a.m., in an interview with a surveyor, Resident #4 stated, When I put my call bell on, it takes a very long time for them to come answer it. Sometimes over half an hour. I get the are busy but they say they are short staffed and they will get to me when they can. I have to wait a long time for my care. 3. On 6/3/25 at 9:55 a.m., in an interview with a surveyor, Resident #1 stated, I have been told by the CNA[Certified Nursing Aide] staff to stop ringing my call bell so much. I have had a few of the CNAs say to me to stop asking for assistance so much because they are short staffed and are doing the best they can. I used to walk but I am too weak to now because they stopped walking me. I don't ask anymore because the staff tell me they don't have time to walk me. 4. On 6/3/25 at 10:00 a.m., in an interview with a surveyor, Resident #5 stated, They take half an hour to an hour to answer my call bell. I have to wait so long to get my care. The CNA staff tell me it is because they are short staffed. My roommate and I have both yelled for assistance because no one comes for the call bells for a long time. 5. On 6/3/25 at 10:10 a.m., in an interview with a surveyor, Resident #7 stated, I have to wait a very long time to get my care. I have had accidents because they haven't assisted me to the toilet when I needed to go. They made me wait too long. The tell me that they are short staffed and I have to wait. Ask my roommate. We both have yelled for someone to come help us. 6. On 6/3/25 at 10:20 a.m., in an interview with a surveyor, a staff member wishing to stay anonymous stated, We are so short staffed that care for the residents isn't being done sometimes and a lot not done timely. Residents have to wait so long for us to answer their call bells that some have accidents, as in soiling themselves. I have come in and found resident left in soiled beds and I don't know for how long. We tell the administration and they say we are staffed to correct ratios. The evening shift is so short that they don't get their baths done and days have to try to pick them up. Some nights there is only one CNA here with a nurse for the whole facility. 7. On 6/3/25 at 10:30 a.m., in an interview with a surveyor, a staff member wishing to stay anonymous stated, We work short all the time here. Baths and positioning and ADL[Activities of daily living] care is not getting done as it should. Especially on the evening shift. 8. On 6/3/25 at 13:00 p.m., in an interview with a surveyor, Resident #6 stated, I have put my call bell on and have had to wait longer than half an hour for staff and have had an accident because no one came to help me. It was very embarrassing. The CNA staff have told me they are short staffed and for me not to use my call bell so much. 9. On 6/3/25 at 3:45 p.m., in an interview with a surveyor, Resident #8 stated, The staffing is terrible at this facility. On the evening shift, there is 1 CNA to cover the D and C units. The CNA will start out here and then go to the other unit and we are left here all alone. I have put my call bell on and no one comes for over an hour and I shit myself. Then I have to wait to be cleaned up. It's just not right. I had my bell on for over an hour this morning before anyone came to help me. My family was here with me a few days ago and I had to go to the bathroom and they had to go to another unit to find someone to help me because no one came to answer my call bell for over half an hour. I have had accidents more than once because they aren't staffing with enough staff. On 6/3/25 at 4:30 p.m., 2 surveyors discussed the findings with the Administrator.

Based on record review and interviews, the facility failed to ensure equal access to services, including assistance with alternative placement, when the payor source changed from Medicare Part A to private pay for 1 of 1 residents reviewed for discharge. Findings: A review of the clinical record for R9 reveals he/she was admitted to skilled nursing services in May, 2023. On 9/24/24, the facility provided notice of Medicare non-coverage (NOMNC) to R9's health care power of attorney (POA) informing that skilled services would be ending on 9/26/24. On 11/12/24, a Medical Eligibility Determination Assessment was completed which found R9 was not medically eligible for nursing home level of care. Section Y of the assessment indicated R9 would be entering residential care. A review of the quarterly Minimum Data Set (MDS) 3.0, dated 11/29/24 revealed a BIMS (brief interview for mental status) score of 13, indicating R9 was cognitively intact. Section Q of the MDS - Participation in Assessment and Goal Setting, revealed R9 and the family participated and that no active discharge plan was in place for R9 to return to the community. A review of the facility's policy, Discharge and Transfer, dated 3/24/25, Section 4. Voluntary Discharge, stated 4.1 If patient is discharging to home, an assisted living center, or other community based/home alternative setting: 4.1.1. The Discharge Transition Plan is given to the patient, family member, or legal representative; 4.1.2., a copy of the Discharge Transition Plan will be placed in the patient's medical record; 4.2, A patient must not be forced, pressured or intimidated into leaving the center voluntarily. For patients who are admitted for short term, skilled rehabilitation under Medicare, in anticipation of completion of the rehabilitation program, the Center must assist the patient to evaluate their need for care and pursue payment options in the manner required by applicable laws/regulations. Unlawful discrimination based on payment source is prohibited. A review of a progress note, dated 11/21/24, stated staff met with R9 and the POA to discuss that he/she did not qualify for nursing home level of care and that it was necessary to move to a lower level of care to save money. The record indicated a bed was available at an assisted living facility in Farmington. Documentation in the record indicated R9 refused to move from the facility. On 2/27/25, the annual MDS was completed, which revealed a BIMS score of 3, indicating severely impaired cognition. Section Q stated no active discharge plan to return to the community was in place. Section GG, Functional Abilities, indicated R9 required set up/clean up assistance for ADLs, supervision/touch assistance for transfers to shower/tub, partial/moderate assistance with upper body dressing, and was independent with wheelchair mobility. The assessment indicated R9 required a lower level of care than nursing home. On 5/30/25, the quarterly MDS was completed, which revealed a BIMS score of 3, indicating severely impaired cognition. Section Q stated an active discharge plan to return to the community was in place and the discharge date was 3 or fewer months away. Section GG, Functional Abilities, indicated R9 required set up/clean up assistance for all ADLs, and was independent with transfers and wheelchair mobility. The assessment indicated R9 had improved in functional abilities and required a lower level of care than nursing home. No discharge plan was located within R9's clinical record. On 6/2/25, at 11:35 a.m., in an interview with a surveyor, R9's POA stated he/she had been paying privately for R9's care at the facility, and within 2 months, R9's money would be gone. The POA stated R9 did not belong at the facility but had chosen to remain there and the facility staff had indicated R9 was capable of making his/her own decisions. The POA stated facility staff threatened me with APS (Adult Protective Services) if I have attempted to move R9. On 6/3/25 at 2:00 p.m., two surveyors interviewed the Market Clinical Advisor, Administrator, Long-Term Care Unit Manager, Business Office Manager, and Social Worker. A surveyor discussed the POA's concerns that R9's savings were almost depleted, that the BIMS was only 3, and that R9 was not competent to make the decision to remain at the facility. The Administrator stated R9 was very sure he/she wanted to stay at the facility and under no circumstances wanted to go anywhere else. A surveyor discussed that when the POA had arranged to transport R9 to an assisted living facility (ALF), staff had threatened him/her with calling APS, and as POA, did he/she have the right to take R9 out of the facility? The nurse manager stated We did call APS. (R9) gets very psychotic and threatens to kill him/herself, whenever the discussion is held regarding transfer. The nurse manager stated the POA had never had any contact with staff about discharge. A surveyor asked what will happen if R9 is reassessed and does not qualify at nursing home level of care. The Administrator stated the resident would be involuntarily discharged and would qualify for days awaiting placement. A surveyor asked why had the facility not taken steps towards preparing for discharge since R9 had qualified at assisted living level of care since November, 2024. The Administrator stated The conversations we've had with R9 were not just recently, before the change in his/her BIMS. We need to re-engage in the conversation. We have had no contact with the (POA). The surveyor asked what will the facility's plan be when R9's money runs out in approximately 2 months and can no longer pay privately. The Business Office Manager stated R9 would be days awaiting placement pending Mainecare. He/she would have to take an ALF when available within 60 miles. We will need to reach out to (the POA).

Based on observations, interviews, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. Additionally, the facility failed to ensure foods were sealed, labeled, and dated in a dry storage room, a walk-in freezer and a walk-in refrigerator, as well as failed to ensure the emergency food supply was not stored with unsecured chemicals for 1 of 3 days of survey (1/27/25). Furthermore, the facility failed to ensure that the Dish Machine temperatures, Refrigerator temperatures, and Freezer temperatures were monitored for 3 of 3 months reviewed. Findings: Review of policy, Food Storage: Cold Foods, revised 4/2018, states, Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated . Review of policy, Food Storage: Dry Goods, revised 9/2017 states, Storage areas will be neat, arranged for easy identification, and date marked as appropriate .Toxic materials will not be stored with food . 1. On 1/27/25 between 6:10 p.m. and 6:40 p.m., a surveyor conducted a kitchen tour with Dietary Aide (DA) #1, during which the following findings were observed: -White ceramic bowls were stacked on a soiled, parchment-lined metal tray on a metal storage cart, located next to the reach-in refrigerator. The bottom surface of the cart was covered in food crumbs and debris, and there were clean kitchen linens and potholders touching the debris. -There were food crumbs and debris covering the top surface of the double-door oven. -Grease and food debris was built up on the burner plates on the stovetop. - Food debris was observed on the underside of the uncovered food slicer. - Food debris and crumbs were observed on top of the metal food prep table. - The wall mount air conditioner unit above the reach-in refrigerator was covered in dust and debris. - Four wall mount oscillating fans covered in dust and debris were observed in the dish-washing area, above clean/dry stacked dishes. - A gray basin containing unknown liquid, was on top of a folded blanket under the three-bay sink. - Floors throughout the kitchen were covered with food crumbs and debris, and debris was observed throughout the kitchen underneath equipment and shelving. - The reach-in refrigerator contained a tray containing 5 cups of sliced fruit that were unlabeled and undated. Observation of the walk-in refrigerator revealed the following available for use: -14-ounce container of Sysco Reliance Beef Flavored Base, opened and undated - large metal bowl containing a partial head of iceberg lettuce with obvious pink discoloration, uncovered, unlabeled, and undated -metal bowl on a wire shelf in the back of the refrigerator, containing a partial head of iceberg lettuce, 1/2 onion, a green bell pepper, and a tomato, unlabeled and undated. - ring-shaped, sponge-type cake was unlabeled and undated. - The walk-in freezer contained an open zip-loc bag of cooked potato wedges, dated 1/25/24, unsealed and open to air and a plastic bag containing a deep-dish pie shell, unsealed and open to air and available for use. - The Dry Storage room had a plastic bag of a white, flour-appearing substance, rolled and secured with a binder clip, that was unlabeled and undated and an open, undated 16-ounce bag of mini marshmallows. Observation of the food preparation area revealed the following: - open, undated, 3.2 ounce packet of ranch seasoning, a large metal bowl of wheat rolls, located on the top shelf of the steam table, undated and uncovered, open to air. -A piece of sponge-type cake in ceramic bowl, located next to the food slicer, was undated and unlabeled. On 1/28/25 at 6:40 p.m. the above findings were reviewed with Dietary Aide (DA) #1. On 1/28/25 at 9:00 a.m. the above findings were reviewed with the Food Services Account Manager and the Dietary District Manager. 2. On 1/27/25, between approximately 6:50 and 7:10 p.m., two surveyors observed the facility's Emergency Food Supply, located in the Central Supply Room. The emergency food supply was stored on open shelving, next to and directly across from shelves of approximately 50 bottles of unsecured chemicals, including Ecolab Grease Strip Plus and No-Rinse Alkaline Floor Cleaner, Oasis Multi-Quat Sanitizer, Lime Away, and Ice Machine Cleaner, as well as nursing supplies. On 1/27/25 at 7:15 p.m., two surveyors reviewed this finding with the Administrator and interim Director of Nursing Services.

Based on record review, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 4 of 4 units reviewed (Hickory, Elm, Blue Spruce and Scotch Pine) and failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of a resident requiring intravenous antibiotics (Resident #329). Findings: A review of the facility's Controlled Medication Storage policy and procedure dated: 1/24, under #6 states: At each shift change or when keys are surrendered, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses or approved individuals per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. On 1/29/25 during medication storage the following was reviewed: 1. Blue Spruce unit Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 9/29/24, 10/8/24, 10/9/24, 10/17/24, 10/21/24, 10/22/24, 10/30/24, 11/27/24, 11/28/24, 11/29/24, 12/4/24, 12/7/24, 12/21/24, 12/22/24, 1/8/25, 1/9/25, 1/17/25 and 1/18/25. 2. Hickory unit Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates:8/12/24, 8/21/24, 8/15/24, 10/16/24, 11/4/24, 11/14/24, 11/18/24, 1/4/25, 1/19/25 and 1/20/25. 3. Elm unit Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 9/27/24, 10/16/24, 10/21/24, 10/24/24, 12/6/24, 12/7/24, 12/8/24, 12/17/24, 12/21/24, 12/25/24, 1/13/25 and 1/14/25. 4. Scotch Pine unit Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 11/14/24, 11/19/24, 11/27/24, 1/8/25, 1/28/25 and 1/29/25. On 1/29/25 at 9:45 a.m., during an interview, the above was discussed with the Director of Nursing. 37015 5. On 1/28/25 at 1:18 p.m., in an interview with a surveyor, Resident #329 stated he/she had been admitted last Friday (1/24/25), and was supposed to receive an IV (intravenous) antibiotic but it was not available until Monday (1/27/25). A review of the clinical record confirmed Resident #329 was admitted on [DATE] with diagnoses including acute osteomyelitis of the left foot and underwent a below the knee amputation on 1/8/24. Resident #329 was readmitted to the hospital with vasculitis, viral pneumonia, urinary tract infection and pyelonephritis. A review of the physician orders noted the following, Aztreonam Injection Solution Reconstituted 1 GM (gram) - Use 1 gram intravenously three times a day for infection. A review of the medication and treatment administration record indicated the dose was to be given at 7:00 a.m., 1:00 p.m., and 7:00 p.m. each day. The record revealed that doses were not administered on 1/25/25, 1/26/25, and 1/27/25 7:00 a.m. This resulted in a total of 7 missed doses. A progress note, dated 1/25/25, at 1:10 p.m., stated The antibiotic is not available at this time due to the pharmacy's supply. Called on call-provider and we have to wait until the medication is available. The on-call provider note, dated 1/25/25 at 1:32 p.m., stated Awaiting IV antibiotics. Plan: IV antibiotics to commence Monday when received. No alternative antibiotics available at present. Follow-up scheduled for Monday. On 1/30/25 at 2:00 p.m., a surveyor discussed the finding with the Market Clinical Advisor, who stated the facility's pharmacy contracts with another pharmacy for all IV medications. The Market Clinical Advisor was unaware of local pharmacies which could handle an emergency order. On 1/30/25 at 3:38 p.m., the Market Clinical Advisor stated the facility's pharmacist had informed her its emergency pharmacy was Walgreen's, which does not provide IV medications. The Market Clinical Advisor did not have the pharmacy's policy or procedure for obtaining IV medications when unavailable.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 1/28/25 at 3:30 p.m., in an interview with a surveyor and review of weekend staffing for July 1, 2024, through September 30, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends. On 1/28/25 at 10:58 a.m., in an interview with a surveyor, Resident #327 stated on one day during the previous weekend, I had to pee myself, had to wait 30 minutes after using the call bell, due to lack of staff. When in bed Resident #327 stated compression devices are applied to both legs and he/she can't stand up without assistance due to dizziness. Resident #327 stated they need more help around here. On 1/28/25 at 2:35 p.m., in an interview with 4 surveyors, a family member stated one night between 1/17/25 to 1/19/25, he/she had received a call from the resident stating that he/she needed to use the bathroom and no one had answered the call bell. The family member stated he/she she tried to call numerous times, but no staff answered the phone. The family member came to the facility and found the call light for room still on. On 1/28/25 at 4:12 p.m., in an interview with a surveyor, Resident #16 stated he/she had a diagnosis of PTSD (post traumatic stress disorder), and I've been stuck in the bathroom and had to wait 20 minutes for someone to come. I panic if someone leaves me more than 20 minutes. It's hard, they can say they're sorry all they want but it doesn't take away that fear. They never have floats anymore. They try to make do with what they have. Resident #16 stated he/she requires a sit to stand lift for transfers and there is usually only 1 staff on the unit most of the time. This causes an extended wait due to staff needing to find assistance to complete the transfer. On 1/28/25 at 5:03 p.m., in an interview with a surveyor, Resident #9 stated I rang to go out in the dining room at 4:00 p.m., and I just got out there (4:45 pm). There's only 1 staff and she was giving a shower and had 4-5 (call) bells on. Resident #9 stated there had been one night where was he/she had been left wet all night when his/her catheter was leaking and no staff answered the call bell.

Based on interviews and record reviews, the facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to the residents or their representatives for 4 of 5 residents reviewed for Arbitration (Resident #35, #46, #57, #331). Findings: On 1/27/25 at 7:28 p.m., a surveyor conducted an entrance conference with the Administrator and the Director of Nursing and was told, when asked, that no residents in the facility had signed an arbitration agreement. 1. Review of Resident #35's medical record shows he/she was admitted to the facility on [DATE]. Further review of the resident medical record indicates he/she had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. On 1/30/25 at 3:50 p.m., a surveyor met with Resident #35 and asked if he/she signed an arbitration agreement with the facility during admission. He/she stated that he/she did not know what that was and stated that his/her child signed admission paperwork for him/her. Resident #35 then stated that they received no education on what an arbitration agreement entailed or even what that meant. A surveyor let him/her know that they had signed an arbitration agreement and explained what that meant. Resident #35 stated that they would not have signed that paperwork if they knew what the arbitration agreement was. 2. Review of Resident #46's medical record shows he/she was admitted to the facility on [DATE]. Further review of the resident medical record indicates he/she had a Brief Interview for Mental Status (BIMS) of 13 of 15, indicating he/she is cognitively intact. On 1/30/25 at 3:53 p.m., a surveyor met with Resident #46 and asked if he/she signed an arbitration agreement with the facility during admission. He/she stated that he/she did not know what that was and stated that he/she thinks his/her child signed admission paperwork for him/her. Resident #46 then stated that they received no education on what an arbitration agreement entailed or even what that meant. A surveyor let him/her know that they had signed an arbitration agreement and explained what that meant. Resident #46 stated that they would not have signed that paperwork if they knew what the arbitration agreement was. 3. Review of Resident #57's medical record shows he/she was admitted to the facility on [DATE]. Further review of the resident medical record indicates on 1/9/25 he/she had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. On 1/30/25 at 2:50 p.m., a surveyor met with Resident #57 and asked if he/she signed an arbitration agreement with the facility during admission. He/she did not think they signed an arbitration, but said they are unable to recall signing any documents. Resident #57 then stated that they received no education on what an arbitration entailed. A surveyor let him/her know that they had signed an arbitration agreement and explained what that meant. Resident #57 stated that he/she would not have signed this now knowing what it means. 4. On 1/30/25 at 3:00 p.m., in an interview with a surveyor, the spouse of Resident #331 stated he/she thought he/she had signed the admission paperwork. He/she had no recollection if arbitration agreements were explained to him/her or what they were. A review of the clinical record for Resident #331 noted an admitted [DATE]. Diagnoses included hepatic encephalopathy. The admission MDS (Minimum Data Set 3.0) assessment, dated 11/27/24, noted in Section C, Cognitive Patterns, a BIMS (Brief Interview of Mental Status) score of 8, indicating moderate cognitive impairment. A review of Resident #331's admission agreement noted that the arbitration agreement is embedded within the document. Resident #331's signature was noted throughout the agreement, dated 11/25/24. On 1/30/25 at 4:00 p.m., in an interview with Resident #331's spouse, a surveyor showed the contract which Resident #331 had signed on 11/25/24. The spouse stated Resident #331 was not cognitively intact at that time and was not able to understand what he/she had signed. A review of the facility's Voluntary Binding Arbitration Agreement stated under #20, Entire agreement. This agreement contains the entire agreement between the Parties with respect to Arbitration and no prior, concurrent, or subsequent oral written representations or agreements shall be of any force or effect, unless made in writing and signed by the parties. This agreement shall survive the termination, cancellation or expiration of the admission agreement. On 1/30/25 at 2:43 p.m., during an interview with 5 surveyors present and the facilities Market Clinical Advisor, the Admissions Director confirmed an arbitration agreement is within the admission agreement stating, the admission agreements are completed on a tablet. She stated she will go through the admission agreement by section and when it gets to Arbitration she tells them, If there is a problem you work it out between you and the facility before lawyers or others are involved. A surveyor asked if she explains to the residents that they have 30 days to revoke the arbitration. She stated, no. A surveyor asked if the resident would receive a new agreement with every admission. She stated, if they are readmitted after 30 days then they will have a new one to fill out. A surveyor then asked if the second signed arbitration would replace the first signed arbitration. She stated she believed it did. At this time, a surveyor informed the Admission Director that after 30 days the agreement is binding for any future admission/readmissions. the Admissions Director stated she was unaware that it was binding for all future admissions, and she has provided a new arbitration agreement to residents who have been readmitted . The surveyor asked how she identifies if the resident or representative understands what she is saying. She stated, I don't just go in and have them sign, I talk to them, I won't wake them up. At this time, the surveyors asked for a list of residents who have entered into a binding arbitration, she stated, everyone has. A surveyor asked for confirmation. The Admissions Director confirmed all of the residents had signed, entering into a binding arbitration. On 1/30/25 at 3:16 p.m., during an additional interview with the Admissions Coordinator and Market Clinical Advisor, a surveyor asked if the admission agreement is sent by email to the resident representative. The Admission Director stated, Yes. She would generate the packet and send it by email, and they get a text, I tell them to go to the link and sign it and I let them know if they have any questions, let me know. The surveyor then asked if the admission agreement is emailed how does she explain the Arbitration agreement. She stated, I'm not, it's in the email if they have any questions let me know. She then explained when the admission agreement is signed the program will use the signature for the rest of the document. It will prompt the residents and/or representatives to go to the next page, where they can then hit the signature button to automatically put in their signature. At this time, another surveyor joined the interview and asked, if the resident's record is checked for advanced directives, such as a power of attorney or guardianship before asking them to sign. The Director of Marketing and Admissions stated not all the time. 37015 37440 51331

Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Residents #327 and #331) on 1 of 5 facility units. Findings: 1. On 1/28/25 at 10:40 a.m., in an observation on the Elm House unit, a surveyor briefly reviewed the electronic record for Resident #327 before entering the room. The record indicated Resident #327, admitted on [DATE], required Enhanced Barrier Precautions for CRE (Carbapenemase-producing carbapenem-resistant Enterobacteriaceae), a drug-resistant organism. The surveyor could find no signage at the entrance of the room, or within the resident's room indicating precautions were necessary. The surveyor asked the Registered Nurse on duty if Resident #327 required special precautions. The RN at first stated the resident did not require precautions, then remembered he/she did. The surveyor pointed out there was no sign at the entrance of the room. The RN confirmed the finding and stated a sign would be posted. On 1/28/25 at 10:49 a.m., a surveyor asked CNA #1 (Certified Nursing Assistant) if he/she uses any special PPE (personal protective equipment) when providing care for Resident #327. The CNA stated Resident #327 did not require any special PPE and staff use gloves. The surveyor showed CNA #1 that Resident #327's electronic record stated Enhanced Barrier Precautions were required for CRE. CNA #1 stated I did not know that. A review of the clinical record for Resident #327 noted a hospital discharge summary, dated 1/21/25, which stated Precaution Alert: CRE. The base line care plan, initiated on 1/21/25, stated Resident #327 had actual colonization/infection with Multidrug Resistant Organism: CRE. The goal stated: Signage for PPE will remain on doors for resident and staff safety to prevent possible transmission through next review. Interventions included: Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing). Enhanced Barrier Precautions: Educate patient/family and visitors regarding precautions. 2. On 1/28/25 at 12:15 p.m., in an observation on the Elm House unit, a surveyor briefly reviewed the electronic record for Resident #331 before entering the room. The record indicated Resident #331, admitted on [DATE], required Enhanced Barrier Precautions. The surveyor could find no signage at the entrance of the room, or within the resident's room indicating precautions were necessary. At this time, the surveyor interviewed Resident #331's spouse, and asked if staff wore any type of PPE when providing care. The spouse stated no, but they wore gowns, gloves and masks when (he/she) had Covid. On 1/28/25 at approximately 12:20 p.m., a surveyor asked CNA #1 if Resident #331 required special precautions. CNA #1 stated he/she did not know. CNA #2 joined the conversation and stated he/she did not know if Resident #331 required special precautions when providing care. The surveyor showed both CNA's Resident #331's electronic record stated Enhanced Barrier Precautions were required for MRSA, VRE, and ESBL. A review of the clinical record for Resident #331 noted a hospital discharge summary, dated 11/22/24, which stated Precaution Alert: MRSA (Methicillin Resistant Staphylococcus Aureus), VRE (Vancomycin Resistant Enterococcus), and ESBL (Extended Spectrum Beta-Lactamase), all drug resistant organisms. A review of Resident #331's care plan, last revised 11/29/24, stated Resident #331 has actual colonization/ infection with MDRO: MRSA, VRE, ESBL and is on Enhanced Barrier Precautions. The goal stated, Signage for PPE will remain on doors for resident and staff safety to prevent possible infection transmission through next review. Interventions included: Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing). Enhanced Barrier Precautions: Educate patient/family and visitors regarding precautions. The facility's policy regarding Enhanced Barrier Precautions, with a revision date of 12/16/24, stated In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact Precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms (MDROs). The Centers for Disease Control and Prevention (CDC) Targeted MDRO's are defined as: (included in the list) * Carbapenemase-producing carbapenem-resistant Enterobacteriaceae. Additional MDRO's that might be included based on local requirements: *Methicillin-Resistant Staphylococcus Aureus (MRSA), * ESBL-producing Enterobacterales, *Vancomycin-Resistant Enterococci (VRE). On 1/28/25 at approximately 12:30 p.m., the findings were discussed with the Director of Nursing and the Senior Administrator. The Director of Nursing stated the signs had been up last Friday (1/24/25) and had been taken down some time since then. The Senior Administrator stated Maine CDC had provided guidance allowing facilities to use discretion regarding EBP's for epidemiologically important MDRO's. A copy of the Maine CDC email, dated 10/10/24, was provided to the surveyor in which it stated We have been recommending the use of EBP for epidemiologically important MDRO's - all the time.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of Post-Traumatic Stress Disorder(PTSD)/trauma for 3 of 4 sampled residents reviewed for PTSD. (#1, #5, #51) Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses to include PTSD. Review of Resident #1's clinical record on 1/28/25 revealed it lacked documented evidence that the current care plan had been developed and implemented in the area of PTSD to include goals, interventions and triggers. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses to include PTSD. Review of Resident #5's clinical record on 1/28/25 revealed it lacked documented evidence that the current care plan had been developed and implemented in the area of PTSD to include goals, interventions and triggers. 51331 3. Resident #51 was admitted to the facility on [DATE]. Review of the residents medical record indicates he/she has a diagnosis of Post-Traumatic Stress Disorder (PTSD). Further review of the his/her medical record lacks evidence of a care plan for PTSD . On 1/28/25 at 3:37 p.m., in an interview, the Market Clinical Advisor confirmed that the residents' current care plans did not include Goals, Interventions or triggers to address PTSD.

Based on observations and interviews, 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 3 of 4 days of survey. (1/27/25, 1/28/25 and 1/29/25) Findings: 1. On 1/27/25 at 6:15 p.m. a surveyor observed on the Blue Spruce Unit a portable oxygen machine and nasal canula and tubing on the floor next to the exit door. On 1/27/25 at 6:15 p.m., in an interview, Licensed Practical Nurse (LPN #1) confirmed that the portable oxygen machine, the nasal canula and the tubing should not be on the floor and that it should be bagged and stored off the floor. On 1/27/25 at 6:30 p.m., in an interview, Registered Nurse (RN#1) confirmed that the portable oxygen machine, the nasal canula and the tubing was and should not have be on the floor and went on to say that no resident was using it at that point. 2. On 1/27/25 at 6:20 p.m., a surveyor observed oxygen tubing and a nasal canula hanging on the left wheelchair handle and not stored in a bag which was hanging on the back of a wheelchair. On 1/27/25 at 6:17 p.m., in an interview, LPN #1 stated that it should be stored in a bag when not in use. On 1/27/25 at 6:30 p.m., in an interview, RN#1 stated that this oxygen tubing and nasal canula hadn't been used by a resident for 2 to 3 days and that it should be stored in a bag when not in use. 51669 3. On 1/28/25 at 9:14 a.m., during an observation of room [ROOM NUMBER], Resident #474's unbagged and undated nasal cannula tubing was draped over the top corner of the light fixture located above the resident's bed, with the nasal cannula prongs in direct contact with the surface of the light fixture. 4. On 1/27/25 at 6:32 p.m. and on 1/28/25 at 2:45 p.m., during observations of room [ROOM NUMBER], Resident #31's unbagged nasal cannula was lying at the head of the bed. The oxygen concentrator next to the bed had an empty plastic storage bag, dated 1/26/25. During a follow-up observation on 01/29/25 at 9:30 a.m., the unbagged nasal cannula tubing was tucked between the resident's sheets. On 1/29/25 at 3:06 p.m., during an interview both the surveyor and Registered Nurse (RN) #1 observed that Resident #31 was sleeping on top of his/her nasal cannula. At this time, RN #1 confirmed that nasal cannulas should be stored in a plastic bag when not in use and that tubing and bags are changed weekly.

Based on observation, record review, and interviews, the facility failed to provide care to residents in a manner that maintains each resident's dignity by failing to serve all residents seated at the same table at the same time for 1 of 2 dining observations on 1 of 1 days of survey. Finding: Review of the facility's Resident Council Meeting Minutes, dated 12/31/24, revealed resident concerns that residents are concerned that trays are being served in rooms on units before the dining room service . Resident Council Meeting Minutes , dated 11/27/24 states, Dining Services .Trays in order of room on carts .Nursing: Tray served in dinning [dining] room first by table before room trays . Resident Council Meeting Minutes, dated 10/30/24 states, CNA's [Certified Nursing Assistants] are not serving residents at the table in the dining room first . On 1/28/25 between 12:23 p.m. and 12:40 p.m., during a dining observation on the Hickory Unit, a surveyor observed a table seating 3 residents. At 12:29 p.m., Resident #60 received his/her meal. Staff then proceeded to deliver meals to other tables in the dining room and to residents who were eating in their rooms. At 12:34 p.m., Resident #55 received his/her meal. Staff again delivered to adjacent tables and residents in their rooms. Resident #12, seated at the same table, did not receive his/her meal until 12:39 p.m. At this time, Certified Nursing Assistant-Medication Tech (CNA-MT) #1 and Certified Nursing Assistant (CNA) #3 stated residents typically sit at the same table each day and that the meal truck is typically ordered by room number; staff serves residents in the dining room before serving residents in their rooms and should serve a complete table before serving residents at another table. On 1/28/25 at 1: 05 p.m., during an interview the Food Services Account Manager, stated the trays in the meal delivery trucks are organized by room number and that there has been talk about changing the order of stacking in the trucks to coordinate with how the residents are seated in the dining room, but nothing has been implemented. On 1/28/25 at approximately 1:10 p.m., during an interview, the above finding was discussed with the Director of Nursing (DNS), who stated the concern has been brought to Quality Assurance and Performance Improvement (QAPI) meeting for review. As of 1/30/25 upon the surveyors exit, the DNS was unable to provide evidence that a performance improvement process was in place.

Based on record review and interviews the facility failed to appropriately notify a resident and or resident representative in a timely manor, prior to changing a residents room, for 1 of 1 residents reviewed for room change. On 1/21/25 the Division of Licensing and Certification received a complaint in regards to a resident's room being changed without proper notification. On 1/27/25 at 8:00 p.m., during an interview Resident #57 and his/her family member both stated that they had not received any notification of a room change prior to it occurring. Review of Resident #57's clinical record indicates that the resident was moved from Elm Unit to Hickory Unit on 1/15/25. Further review of the clinical record lacked evidence that any notification of the room change occurred. On 1/30/25 at 2:31 p.m., during an interview with the Market Clinical Advisor the above information was confirmed.

Based on interview and record review, the facility failed to review, revise and update a care plan in the area of Post-Traumatic Stress Disorder (PTSD) for 1 of 4 residents whose care plans were reviewed for PTSD. (#18) Finding: Resident #18 was admitted the facility on 12/23/21. On 4/14/23, the resident was identified/diagnosed with Post-Traumatic Stress Disorder (PTSD). Review of Resident #18's clinical record revealed the current care plan was not reviewed, revised and updated to include goals, interventions or triggers for PTSD. On 1/30/25 at 12:47 p.m. in an interview, the Market Clinical Advisor confirmed that the Resident 18's care plan was not reviewed, revised and updated to include goals, interventions or triggers for PTSD.