Every finding on record at Clover Health Care

Based on record review and interview, the facility failed to promptly respond and act upon concerns of the resident council related to the call bell system not functioning and laundry services. Findings: 1. A review of Resident Council Minutes for the past 12 months revealed that residents raised issues with the call bell system, or that the call bell system was not working. The minutes from the November 21, 2025 meeting noted Maintenance staff reported the call bell system was not functioning reliably. No follow-up to this was addressed at the December, 2025 resident council meeting. The minutes from the January 27, 2026 meeting stated nursing staff reported needing a better call bell system. No follow-up to this was addressed at the February, 2026 resident council meeting. The minutes for the May 20, 2026 meeting noted nursing was not answering call bells in a timely manner. No follow-up to this was addressed at the June, 2026 resident council meeting. On 8/6/26 at 12:20 p.m., in an interview with a surveyor, the Resident Council President stated when staff follow-up on grievances voiced by the council, staff usually provides the rationale that it is related to staffing. The President stated It takes a long time for them to get back to the residents about the concerns. On 8/6/26 at approximately 3:30 p.m., the finding was discussed with the Regional Director of Operations. 2. A review of Resident Council Minutes for the last year showed that for 8 of 12 months there are issues with missing laundry: October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, April 2026, and July 2026, and never with a follow-up the next month. On 8/5/26, In a conversation with the Regional Director of Operations and the Maintenance Director, both confirmed these findings.

Based on observations and interviews, the facility failed to ensure that the call bell system was functioning for 1 of 4 units observed ([NAME] unit). Finding: 1. A review of Resident Council Minutes for the last year showed that there are issues with the call bell system or that the call bell system is not working. [DATE] – Maintenance - Reports that the call bell system is not functioning reliably – No follow-up in December [DATE] – Nursing - Need a better call bell system – No follow-up in February May 20, 2026 – Nursing – Not answering call bells in a timely manner – No follow-up in June 2. On 8/3/26 at 11:10 a.m., Resident #88 asked a surveyor to help them get into bed. The surveyor and Resident #88 pushed the call button. The surveyor went to observe the display at the nurse's station, the monitor displayed communication error. During an interview with a surveyor, the Licensed Practical Nurse (LPN) #3 confirmed that the call bell system was not working. During this time Resident #88 was observed not having a dingy bell. On 8/3/26 at 11:13 a.m. in an interview with a surveyor, LPN #3 stated that they just let the Director of Nursing know that the call bell system was down and submitted a ticket. They confirmed with the surveyor that this frequently occurs. On 8/5/26 at 2:30 p.m. in an interview with Certified Nursing Assistant (CNA) #3 stated that the call bell system typically goes down at least 1 time a week, they give some residents dingy bells, but not all of them due to their inability to use them. CNA#3 was unable to identify the residents who do or do not have dingy bells. On 8/5/26 at 2:36 p.m. in an interview with Medication Technician (MT) #1 stated the call bell system goes down at least once a day, and stated that staff frequently need help while providing residents assistance in the bathroom but cannot get help when the system is down, when we put someone on the toilet there is no way to know they are done when the system is down. On 8/6/26 at 9:30 a.m. in an interview with two surveyors the above was confirmed by the Regional Director of Operations.

Based on review of a report submitted to the State Agency ( SA), record review, and interview, the facility failed to ensure transportation was secured for a resident receiving dialysis treatment when the treatment day (s) schedule was changed during a holiday week for 1 of 1 resident reviewed for dialysis. (Resident #10). Finding: Review of a report submitted to the SA on January 13, 2026, indicates Resident #10 is a dialysis patient and goes to dialysis Monday, Wednesday, and Friday mornings. The report also indicated that around Christmas time arrangements were not made for transportation to the dialysis center resulting in a lack of treatment for 4 (four) days. A review of Resident #10s medical record reveals diagnoses to include end stage renal disease, and notes resident is dialysis dependent. Review of a progress note dated 12/30/25 states that Resident #10 was feeling ill and had not had dialysis since Friday [December 26, 2025], and that [he/she] was going to dialysis this afternoon [Tuesday, December 30, 2025] . Review of a Health Status Note dated 12/30/25 stated that during the morning shift Resident #10 stated that they were not feeling good. Vitals signs were obtained and resident was noted to have an oxygen saturation level of appx 78-81% on RA ( Room Air) oxygen was applied. The provider was on site at the facility and notified of the findings, Resident #10 did not want to go to the ER, preferred to go to dialysis and would go to the ER from the dialysis center if they had to go. The note further indicated that the resident was transferred to the ER from the dialysis center. Review of an email dated 12/11/25 regarding Resident #10s schedule to transport dialysis states the following: Resident 10 needs to arrive at the dialysis center at 7:45 AM There is a handwritten note next to 12/28 (Sunday) which states that ride showed and resident refused to go as this is not a regularly scheduled day for [him/her]. On 8/4/26 at 12:50 p.m. In an interview with Social Worker #1 and RN#1. The Social worker stated that the resident usually goes to the Dialysis Center on Mondays, Wednesdays, and Fridays. There is also a Dialysis Center in [neighboring town] that Center called and changed their appointment dates during the Christmas holiday week, she assumed it was changed for both Centers to the Sunday, Tuesday, and Friday schedule, and it was not. Additional review of the medical record lacks evidence that Resident#10's dialysis center was contacted to inquire/confirm any changes to the days of treatment during the Christmas holiday week, and lacks evidence that Resident #10 was questioned or informed regarding any potential changes to their dialysis schedule. On 8/4/26 at approximately 1:15 p.m.; in an interview with the Regional Director of Operations, the surveyor confirmed the lack of ensuring the transportation for a resident during the week of a holiday (Christmas) to a dialysis center.

Based on observation and interview, the facility failed to ensure clearly visible signage was posted at the facility entrance to alert visitors of an active respiratory outbreak one of one day of survey.Finding:On 2/17/26 at 7:45 AM the Director of Nursing ( DON) approached surveyors and advised them to wear a mask due to an active coronavirus outbreak within the facility. The DON stated there were thirteen (13) active coronavirus cases on the [NAME] unit and one (1) active coronavirus case on the [NAME] unit.The surveyor discussed concerns regarding the absence of visible signage at the facility entrance alerting visitors to the respiratory outbreak when the survey team entered the facility at 7:00 AM, the DON then showed the surveyor a sign taped to the [top] reception desk stating all visitors must wear masks, however, observation confirmed the sign was not readily visible upon entry into the facility.

Based on record reviews, interviews, and observation, it was determined the Facility has violated a Residents right to be free from discrimination, coercion, and interference as evidenced by the facility's refusal to readmit him/her when ready for discharge because of the resident's known behavior issues for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings:A review of the Facility Assessment, dated 2/8/25, indicated the Facility cared for individuals with a diagnosis of Psychosis (Hallucinations, Delusions, etc.) Impaired Cognition, Mental Disorders. Behavior that requires Interventions. Alzheimer's Disease, Non-Alzheimer's Dementia. Further review states [NAME] is reserved specifically for resident with dementing illness that require the safety of a secured neighborhood. Resident #1 was transferred to the Long Term Care facility from the Assisted Living Facility (ALF), (where [he/she] had known behaviors) in November of 2025 with a diagnosis of Alzheimer's dementia with behaviors, chronic obstructive pulmonary disease (COPD), and major depression.Review of Minimum Data Sets (MDS)assessment, dated 5/25/25 revealed Resident #1 had a Brief Interview for Mental Status score of 0 of 15 indicating he/she is not cognitively intact Review of Resident #1's Progress Notes revealed: -On 11/7/25 at 6:00 a.m., Resident was wandering the unit and was restless. Medication Technician (Med Tech) attempted to administer medication, but he/she threw them at her. Resident attempted to go after 2 CNA's and picked up an iPad in attempt to hit a staff member while trying to elope. Resident was not redirectable and 911 was called. At 7:06 a.m. Resident attempted to pull another resident out of a shower chair and started throwing furniture (chairs) across the room. Emergency medical and police arrived and attempted redirection, but resident attempted to strike out at them as well. They were able to get Resident in the stretcher and transported to [acute care hospital] for further evaluation.-11/7/25 at 11:11 a.m., states Spoken to [acute care hospital #1] ER nurse concerning patients' behavior.Informed [case manager] that we would not be accepting this patient back until we have a safety plan in place and a medicine regimen change.-11/12/25 14:22 Return from Hospital (acute care hospital #1): resident returned to facility at 1345 via stretcher (5 days later) .-On11/14/25 at 7:48 a.m., Resident punched CNA with left fist to her left cheek. Residents aggressively swing, kicking, and stomping staff and attempting to go after residents in common areas. Unable to redirect or provide incontinent care. 911 called due to safety [forothers]. Two staff members ambulated with resident to direct [him/her] away from other residents. Resident continued to stomp on staff feet when not ambulating or turning around. Police present and observing until EMS arrived. Patient transported to acute care hospital via ambulance. Resident returned from acute care hospital #1 at 10:58 a.m.,On 11/14/25 at 11:54 Resident was brought back by EMS [from acute care hospital #1]. After a few brief minutes resident walked out of his bedroom and tried walking into other residents' rooms. Doors were promptly closed, and residents were allowed to walk freely through the halls. Resident saw one female activities worker with a female resident and threatened to get them, he then changed his direction towards them. [a staff member stayed close by to redirect, but far enough to give space] At one point the resident was able to grab this writers hand and squeeze hard enough for a pop to be heard. Resident stated, I should hit you, but I won't.11/14/25 11:30 a.m., Resident sent to [acute care hospital #2] via ambulance for aggressive behavior towards staff.11/23/25 09:46 am Health Status Note called [acute care hospital #2) to see status of patient. RN told me .that he has a very flat affect that he is very somnolent. There have been no aggressive behavior or IM meds in 5 days, IV fluids for hydration Medications continue with no changes. [He/she] is taking medications whole with ice cream or pudding. Review of ED Physician Note dated 11/14/25 at 11:34 a.m., states BIBA (brought in by ambulance) for agitation, violent behavior, dementia hx, assaulted CNA coming from clover seen at [acute care hospital #1 this am for same x2, behavior health screen, Clover states cannot return.Review of ED Physician Note dated 11/14/25 at 14:49 p.m. states: .The patient does not appear to suffer from any acute comorbidities and has already had multiple evaluations in the past 24 hours, and it appears that [his/her] nursing home facility is seeking placement at a different facility that is more equipped for geriatric psychiatric patients. While I feel this would be beneficial for the patient, there is no acute indication for admission to the hospital to seek admission to such facility. And the nursing home that [he/she] is currently residing in is an appropriate place for him to await transfer to a geriatric psychiatric facility.Review of ED Physician Note dated 11/15/25 at 3:47 a.m., Apparently after case management was consulted earlier today to arrange for discharge, [his/her] current living facility was not comfortable or confident in managing his condition and was requesting the patient be placed in another facility that could better manage h[his/her] outburst of aggression.there is no medical indication for inpatient admission to the hospital.Review of ED Physician Note dated 11/17/25 at 9:57 a.m., states . no inpatient hospitalization at this time is indicated.Review of ED Physician Note-Addendum. dated 11/18/25 at 15:41: leadership would like to hold [him/her] in the ED for another 24 hour period. Still trying to get a plan in place with [facility] as they are not willing to create a safe d/c [discharge] plan at this time.Resident #1 was admitted to [acute care hospital #2] on 11/18/25 at 15:54.During an interview on 11/24/25 at 10:45 a.m., with acute care hospital staff, Senior [NAME] President of Operations (SVPO) stated that Resident #1 did not meet the requirements for hospital level of care, and the facility has been refusing to taking [him/her] back. SVPO states that the facility has the same resources for psychiatric evaluations as the hospital does and there is no medical reason for Resident #1 to not return to the facility.Review of Transfer and Discharge Policy dated 10/18/25 states In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for the transfer or discharge will be provided by a physician.During an interview on 12/24/25 at 3:10 p.m., facility Administrator stated that the facility has not refused to take Resident #1 back, but they wanted to ensure an appropriate safety plan was in place for staff and residents for [his/her] return. The Administrator was unable to provide this writer with written physician documentation indicating resident's clinical or behavioral status endangers the safety or health of individuals in the facility.Resident #1 was transferred back to the facility on [DATE] after an 11 day hospital stay.

Based on record reviews, interviews, and facility policy, the facility failed to ensure physician orders for an as needed (PRN) anti-psychotic contained a duration/stop date and failed to ensure the physician evaluated a resident and wrote a new physician order to renew the PRN anti-psychotic medication every 14 days, for 1 of 3 residents reviewed during a complaint investigation (Resident #1).Findings:Review of policy Psychotropic Medication Usage. dated 8/19/24 states .PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents the findings. When entering a PRN order for a psychotropic medication, the licensed nurse should indicate in the 'Scheduling section for the order a completion date of 14 days and check the box that a re-assessment is due. Review of Resident #1's active order dated 10/31/25 for antipsychotic Risperidone Oral Tablet 0.5 mg by mouth PRN (as needed) every 4 hours for dementia with behavioral disturbance: agitation. At least 4 hours apart and a max of 2 a day. End date: indefinite.During an interview with Administrator and DON on 11/24/25 at 2:39 p.m. the DON confirmed this finding.

Based on record review, interviews, and policy review, the facility failed to obtain written informed consent for use of psychotropic medications for 2 of 3 residents reviewed (Residents #1 and #2), and failed to obtain written informed consent for the use of opioid medication for 1 of 3 residents reviewed (Resident #2). In addition, the facility failed to monitor and document targeted behaviors to support the use of psychotropic medications for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Findings:Review of Psychotropic Medication Policy dated8/19/24 states: It is the policy of this Community. That residents will not receive unnecessary psychotropic medications., and that the resident/Responsible party will consent to the use of any psychotropic medications ordered by a physician. Psychotropic drugs are defined as Any drug that affects brain activities associated with mental processes and behaviors . Psychotropic drugs include, but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, hypnotics/sedatives, anti-convulsant.All psychotropic medications must have a consent form signed by the resident/authorized representative prior to the first administration, even if the resident has received the medication in the past. The consent will indicate the name of the medication, the drug glass and indication of use. Review of Resident #1's active Medication Administration Record (MAR) revealed the following:-Order with state date of 11/6/25 for antidepressant Mirtazapine Tablet 30 mg give 1 tablet by mouth at bedtime for Dementia with behaviors.-Order with start date 11/7/25 for antidepressant Sertraline HCT tablet 50 MG. Give 1 tablet by mouth one time a day for Dementia with behaviors.-Order with start date of 11/6/25 for antidepressant Trazodone HCL Tablet 100 mg Give 1 tablet by mouth one time a day for insomnia.-Order with start date of 11/7/25 for Risperidone Tablet 1 MG Give 1 tablet by mouth two times a day for agitation.-Order with start date of 11/12/25 for anticonvulsant Depakote Oral Table Delayed Release 5000 mg (Divalproex Sodium) give 1 tablet by mouth two times a day for dementia, danger to self/others.Review of Resident #1 clinical record revealed Anti-Anxiety Informed consent for medication [a] dated 11/6/25 states .Medication Category: Anti-anxiety; Medication: Ativan Diagnoses: dementia with behaviors. further review of this document lacks evidence that Resident #1's Power of Attorney (POA) gave written consent for this medication.Review of Resident #1's clinical record revealed Psychotropic/Antipsychotic medication Informed consent for medication [b] dated 11/6/25 states Medication Category: Psychotropic/Antipsychotic; Medication: Clover; diagnoses Dementia with behaviors further review of this document lacks evidence that Resident #1's Power of Attorney (POA) gave written consent for this medication.Review of Anti-Depressant Informed Consent for Medication dated 11/6/25 states .Medication Category: Antidepressant; Medication: [blank] Diagnosis: Dementia with behaviors. further review of this document lacks evidence that Resident #1's Power of Attorney (POA) gave written consent for this medication.Review of Medication Informed Disclosure dated 11/13/25 states .Antipsychotic Medication: Mirtazapine/Aricept/Naproxen/Depakote/Risperdal. Signature of Resident/Responsible Party: Verbal consent given from [POA] date: 11/13/25. Further review of this document lacks evidence that Resident #1's Power of Attorney (POA) gave written consent for this medication.During a telephone interview on 11/24/25 at 3:28 p.m., Resident #1's Power of Attorney (POA) stated that she was aware Resident #1 was going to receive Seroquel but was never asked to sign consent forms for any psychotropic medications.2.Review of facility policy Psychotropic Medication Usage . dated 8/19/24 states Anti-psychotic medication.The licensed nurse shall also enter and order on the MAR/TAR for Behavior Monitoring. Review of Resident #1's active MAR/TAR dated November 20205 lacked evidence he/she was being monitored for behaviors. During an interview on 11/24/25 at 3:40 p.m., the Director of nursing stated that residents on psychotropic medications should be monitored for behaviors. At this time confirmed Resident #1 showed no evidence on MAR/TAR the he/she was being monitored for behaviors.3 Review of Resident #2's clinical record revealed the following:-Order with start date 2/21/24 for antidepressant Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth one time a day for insomnia.-Order with start date 10/17/25 for anti-depressant Trazodone HCL Tablet 50 MG. Give 0.5 tablet by mouth in the morning for agitation. Give one hour before care.-Order with start date 11/15/25 for opioid Tramadol HCL Oral Tablet 25 MG (Tramadol HCL). Give 25 MG by mouth one time a day for pain. Review of Resident #2's clinical record lacked evidence that written consent was obtained for the use of the above medications. During an interview on 11/24/25 at 3:40 p.m., the Director of Nursing (DON) stated that she normally contacts the resident representative over the phone to get consent for psychotropic/pain medications and at some point, in time if/when they come in, they sign them. At this time DON confirmed the consents were not done in writing.

Based on interviews and record reviews, the facility failed to provide safety and supervision when a Certified Nursing Assistant (CNA#1) left a resident (#1) unattended in a bed with an air mattress, in the high position, and Resident #1 subsequently fell out of bed. This failure created an immediate jeopardy situation.On [DATE] the Department of Licensing and Certification received a facility reported incident indicating on [DATE] at 11:30 a.m., Resident #1 had sustained a fall from bed and was transferred to the Emergency Department. Review of the clinical record for Resident #1 revealed diagnoses which included Multiple Sclerosis, Muscle Weakness, and Stage III Pressure Ulcer of the Sacral region. The quarterly Minimum Data Set (MDS) 3.0., dated on [DATE], indicated Resident #1 had impairment of both lower extremities and one upper extremity. Resident #1 was dependent on staff for transfers and required substantial to maximum assistance by 2 staff for bed mobility and personal hygiene. The brief interview of mental status (BIMS) score was 13, indicating Resident #1 was cognitively intact. Resident #1's comprehensive care plan, last revised [DATE], stated the resident required total assistance by 2 staff to turn and reposition in bed, and use of a mechanical lift and total assistance by 2 staff to transfer between surfaces. Resident #1 required a low air loss mattress to help decrease pressure on areas prone to pressure ulcers. On [DATE] at 8:50 a.m., in a telephone interview with a surveyor, CNA #1 stated he/she had turned Resident #1 onto the resident's right side, approximately half-way between the side and the middle of the bed. Resident #1 was facing the doorway. There had been a pillow between his/her legs, but CNA #1 removed it. One knee was on top of the other one. The CNA stated Resident #1 told him/her that he/she was going to have to go get help and that Resident #1 was ok in the current position. Resident #1 was holding onto the edge of the air mattress with the left hand and Resident #1 told staff he/she was ok. CNA #1 stated Resident #1 was unable to move his/her legs and required staff to move them. The CNA stated he/she went to get the LPN (Licensed Practical Nurse) and had been out of the room for only 2 minutes. There was no type of bed rail on the bed. When the CNA returned, Resident #1 was observed lying on his/her back on the floor with his/her head against the wall and his/her legs in the frog-leg position. At that time, Resident #1 was alert, awake and answering questions, but in significant pain. CNA #1 stated the LPN arrived at the same time and after evaluating Resident #1, instructed staff to transfer Resident #1 back to bed using a hoyer lift. Another CNA had arrived and assisted with the transfer. Shortly thereafter, Resident #1 stated she was going to vomit. When Emergency Medical Services staff arrived, Resident #1 was transferred to a stretcher and suddenly turned ashen in color, eyes fixed in a stare, with gulping movements, and became nonresponsive. Resident #1 was transferred to the Emergency Department and died later that day. In the interview on [DATE] at 8:50 a.m. with a surveyor, CNA#1 stated he/she usually worked on the [NAME] unit, but on [DATE], was floated to the [NAME] unit. When asked what information CNA #1 had received concerning the assignment, CNA #1 stated I ask the other CNAs for help and they explain it to me. Regarding Resident #1, CNA #1 stated I didn't know anything about MS (multiple sclerosis) or what it is or that he/she had it. The only mistake I made is I should've put the bed down before I left. On [DATE] at 9:18 a.m., in a telephone interview with a surveyor, the LPN on duty at the time of the incident, stated he/she had instructed CNA#1 to come get the nurse when ready to perform perineal care and the nurse would complete Resident #1's wound care to the sacral area at that time. The LPN stated he/she heard Resident #1 yelling from the hallway and observed the resident lying on the floor. The LPN stated The first thing I noticed was the bed was in a high position. (The CNA) is shorter than me so it was at his/her working height, which was at least 3 and a half feet off the floor. The LPN completed a brief assessment and determined transport to the Emergency Department was indicated and called 911. The LPN stated Resident #1 had demonstrated no signs of illness or concerns prior to the fall, but had considerable pain afterwards, however, this was baseline for Resident #1. The resident had demanded to be put back to bed. On [DATE] at 2:50 p.m., in an interview with two surveyors, the Administrator confirmed the facility had no policy or procedure regarding bed safety or bed height. On [DATE] at 11:45 a.m., in a telephone interview with a surveyor, the Interim Director of Nursing confirmed Resident #1 did not have bed rails. At one time, Resident #1 had a halo assistive device, but it had been removed at the resident's request. Based on the above information, IJ was determined to exist on [DATE] at 3:25 p.m. for the facility's failure to provide adequate supervision to a dependent resident left alone in a side-lying position on an air mattress, without a side rail and with the bed left at an unsafe height, approximately 3 and a half feet from the floor, resulted in an avoidable accident. The facility's failure to ensure safety and supervision constituted an immediate jeopardy situation. Please see F-000 Initial Comments related to the IJ removal plan.

Based on the facility assessment, record review, interviews, and the facility policy statement the facility failed to develop, implement, and maintain an effective training program for all new and existing staff that includes training to meet the resident's behavioral health care needs for 6 of 8 employee files reviewed, Certified Nursing Assistant (CNA) #3, #4, #5, #6, #7, and #8. A review of the Facility Assessment for 2025, stated its facility resident profile includes residents admitted with psychiatric/mood conditions which is 35-65% of the facility's' population. The Specific Care or Practices for mental health states to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (Post Traumatic Stress Disorder), other psychiatric diagnoses, intellectual or developmental disabilities, specialized program. 1. Review of Certified Nursing Assistances (CNA) #3 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #3 was hired on 7/14/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. 2. Review of CNA #4 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #4 was hired on 7/28/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. 3. Review of CNA #5 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #5 was hired on 7/28/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. 4. Review of CNA #6 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #6 was hired on 3/31/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. 5. Review of CNA #7 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #7 was hired on 4/28/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. 6. Review of CNA #8 education files on 8/13/25 lacked evidence that training in behavioral health care needs had been provided. CNA #8 was hired on 5/12/25, and review of the education file on 8/13/25 lacked evidence of behavioral health training/trauma informed care education being completed. On 8/13/25 at 12:48 p.m. during an interview, the Interim Director of Nursing confirmed she could not find behavioral health training/trauma informed care for the staff above stating, the previous Social Worker, who left approximately in February 2025 would provide education during orientation. On 8/13/25 at 1:50 p.m. during an interview, the Administrator and the Director of Nursing confirmed the lack of the Behavioral Health Care training for existing staff and new staff has not been completed since February. The Administrator stated, she was unaware and figured out that the Behavioral Health Care training/ Trauma informed care training had dropped off the learning platform the facility utilizes and they, after surveyor intervention, have assigned it to everyone to complete by end of month. On 8/14/25 at 5:49 p.m. the surveyor received an email from the Area Director of Clinical Operations in reply to the surveyor's request for the Behavioral Health/Trauma informed care policy, stating they do not have access to the policy due to converting from one policy portal to another. On 8/15/25 at 11:21 a.m. the Executive Director sent a copy of the Behavioral Health services policy statement that had no initial or revision date listed. A review of the policy statement, #5 states: Staff training regarding behavioral health services includes, but is not limited to: recognizing changes in behavior that indicate psychological distress; implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; monitoring care plan interventions and reporting changes in condition; and protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder and #6 states: Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care.

Based on record review and interviews, the facility failed to implement a resident's care for 1 of 3 residents reviewed for falls with injury (Resident #1).On 7/20/25 the Department of Licensing and Certification received notification of a facility reported incident which stated on 7/19/25 at 11:30 a.m., Resident #1 had sustained a fall from bed and was transferred to the Emergency Department.A review of the clinical record for Resident #1 revealed diagnoses that included Multiple Sclerosis (MS), Muscle Weakness, and Stage III Pressure Ulcer of the Sacral Region. The quarterly Minimum Data Set (MDS) 3.0., dated on 6/26/25, indicated Resident #1 had impairment of both lower extremities and one upper extremity. Resident #1 was dependent on staff for transfers and required substantial to maximum assistance by 2 staff for bed mobility and personal hygiene. The brief interview of mental status (BIMS) score was 13, indicating Resident #1 was cognitively intact. The comprehensive care plan, with a revision date of 6/20/25 stated the resident required total assistance by 2 staff to turn and reposition in bed, and use of a mechanical lift and total assistance by 2 staff to transfer between surfaces.On 8/5/25 at 12:30 p.m., in an interview with 2 surveyors, CNA#3 stated that on 7/19/25, CNA #1 had been assigned as a float to work on the [NAME] unit. CNA #3 was asked what information had been provided to CNA#1 for providing care to Resident #1. CNA#3 stated Resident #1 needed 2 people. I told him/her to coordinate with me when he/she was ready. CNA #3 stated that Resident #3 requires a lot of rolling and positioning. He/she has a lot of pain with turning and requires 2 staff to do it appropriately for better positioning. CNA#3 stated he/she has access to resident care plans and Kardexes.On 8/6/25 at 8:50 a.m., in a telephone interview with a surveyor, CNA#1 was asked how he/she obtains information about resident care needs. CNA #1 stated I ask the other CNAs for help and they explain it to me. The surveyor asked on 7/19/25, what type of information had CNA#1 received regarding Resident #1's care needs. CNA#1 stated I didn't know anything about MS (multiple sclerosis) or what it is or that he/she had it. The only mistake I made is I should've put the bed down before I left. The surveyor asked if CNA#1 had read Resident #1's care plan or Kardex. CNA#1 stated I've never looked at one. I don't think so (regarding the Kardex). Only the nurses have access. All the nurses tell me something different about how they want things done.The surveyor asked CNA#1 to describe the incident in which Resident #1 fell on 7/19/25. CNA #1 stated he/she had turned Resident #1 onto his/her right side, approximately half-way between the side and the middle of the bed. One knee was on top of the other one. CNA#1 stated Resident #1 said to go get help and he/she was ok lying on the right side and holding onto the edge of the air mattress. CNA #1 stated Resident #1 was unable to move his/her legs and required staff to move them. CNA#1 stated he/she went to get the nurse to provide wound care and had been out of the room for only 2 minutes. Upon the CNA's return with the nurse, Resident #1 was observed lying on the floor.On 8/5/25 at 10:30 a.m., in an interview with two surveyors, the Administrator discussed the facility's efforts to immediately address the situation after Resident #1's fall, and stated administration identified that staff were not following care plans.

Based on water temperature observations, water temperature log reviews, interviews, and review of facility's Water Temps[temperatures] policy the facility failed to identify hazards in a resident's environment and implement interventions to prevent potential accidents/injuries by ensuring that hot water temperatures, accessible to residents did not exceed 120 degrees Fahrenheit on 3 of 4 units ([NAME], [NAME] and [NAME]) for 1 of 5 days of survey (5/5/25). The failure of the facility to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit created the potential for residents to be scalded/burned by the domestic hot water. This created an Immediate Jeopardy (IJ) situation for residents. In addition, the facility failed to provide supervision, a protective apron, and ensure safety for 1 of 1 residents reviewed for smoking (Resident #45). Findings: 1. On 5/5/25 at 10:50 a.m., a surveyor identfied that hot water in Resident room [ROOM NUMBER] was too hot to the touch, and additional hot water temperatures of other resident rooms on all units were taken: [NAME] Unit: At 10:52 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 129.5 degrees Fahrenheit(F). At 10:55 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 131.1 degrees (F). At 10:57 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 123.9 degrees (F). At 10:59 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 125.9 degrees (F). [NAME] Unit: At 11:15 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 121.9 degrees (F). At 11:22 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 127.0 degrees (F). At 11:33 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 123.9 degrees (F). [NAME] Unit: At 11:05 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 122.5 degrees (F). At 11:08 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 123.1 degrees (F). At 11:10 a.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 122.1 degrees (F). [NAME] Unit: On 5/5/25, a surveyor took hot water temperatures on the units again and found the following: At 3:42 p.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 127.2 degrees (F). At 3:46 p.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 128.4 degrees (F). At 3:49 p.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 121.2 degrees (F). Gallway Unit: At 3:34 p.m., the hot water temperature in Resident room [ROOM NUMBER]'s sink was 121.2 degrees (F) All three of the above named units have residents who are able to ambulate and could potentially assess sinks with the noted hot water temperatures without staff assistance. On 5/5/25 at 11:33 a.m. in an interview with a surveyor, CNA6 said, regarding water temperatures, burnt me this a.m. (morning), the surveyor asked, you burned yourself?, CNA6 said, No, but I was like, it's too hot. She stated it's usually hotter early in the morning after breakfast time. She did not make anyone aware of the hot temperatures. On 5/5/25 at 11:40 a.m., in an interview with the Administrator, the surveyor asked if there were any hot water issues in the facility. The Administrator stated that there were no issues she knew about. The surveyor informed the Administrator of the hot water temperatures taken by the surveyors in the resident rooms above 120 degrees. The Administrator stated that she was not aware of the hot water being above 120 degrees F. At this time, the Administrator confirmed the findings and stated a call would be made to get a mechanical contractor into the facility to fix the problem. On 5/5/25 at 1:00 p.m., in an interview, the Director of Plant Operations stated that he had only been at the facility for a month and that he has never calibrated his digital thermometer or documented any resident room hot water temperatures. The surveyor requested and received the last documented hot water temperatures for resident rooms/areas and the documentation showed December 2024 as the last time hot water temperatures were monitored and documented. He stated that he has taken temperatures approximately once a week in the last month but does not document them. He stated that there is a mixing valve and he does not adjust it. He gave the surveyors a form from Direct Supply that states what the hot water temperatures are supposed to be and to monitor them and log them. At this time, the Director of Plant Operations confirmed that the facility is not monitoring, documenting them and adjusting the resident area hot water to ensure they stay below 120 degrees F. On 5/5/25 at 2:20 p.m., a mechanical services company arrived at the facility. The contractor worked on the facility hot water system and told the facility the hot water mixing valve was set too high, they adjusted the temperature and was corrected. The mechanical services company stated they had taken hot water temperatures throughout the facility and all were below 120 degrees F. The work was signed off and accepted by the facility. On 5/5/25 at 4:20 p.m., two surveyors met with the Regional Director of Operations and the Administrator to confirm that the [NAME] and [NAME] units still had resident areas that were above 120 degrees Fahrenheit and still an accident hazard concern. The Administrator confirmed the findings and stated that the mechanical services company would come back to fix it. On 5/5/25 at 4:50 p.m., in an interview, the Director of Plant Operations stated and confirmed that he had not taken hot water temperatures after he was told by the mechanical services company the hot water had been fixed and adjusted below 120 degrees F. On 5/5/25 at approximately 5:38 p.m., the mechanical services company returned to the facility and found that the hot water mixing valve was broken and causing huge fluctuations in the hot water temperatures to the resident areas. The mechanical services company completed additional work on the hot water system and additional testing of water temperatures found them to be in acceptable ranges (below 120 degrees F). The facility's Water Temps[temperatures] policy was reviewed. The policy indicated the following: Test water temperatures: 1. Ensure patient room water temperatures are 120 degrees Fahrenheit (or as specified by state requirements). 3. Check resident rooms at the end of each wing on a rotating basis. Record results in the water temperature log: 1. Note any discrepancies. 2. Adjust water heater settings as required. 3. Retest as necessary The immediate jeopardy began on 5/5/25 when the facility failed to identify hazards in a resident environment and implement interventions to prevent injury including the risk of scalding and burning. The Administrator was notified of the immediate jeopardy at 2:45 p.m. on 5/5/25. Please See F-000 Initial Comments related to the IJ removal plan. 2. On 5/5/25 at 10:21 a.m., a surveyor observed an unsecured container of PDI Sani-Cloth Bleach Germicidal Disposable Wipes in resident room [ROOM NUMBER]. At this time, after surveyor intervention, the Facility Administrator removed the chemical from the room, confirming the chemicals should not be available for resident use. The Safety Data Sheet for PDI Sani-Cloth Bleach Germicidal Disposable Wipes states in Section 4: First Aid Measures Eye: Rinse thoroughly with water. Get medical attention if irritation occurs and persists . Skin: No first aid should be required. Wash skin with water. Get medical attention if irritation develops or persists . Inhalation: Not a normal route of exposure. If symptoms develop move victim to fresh air. Get medical attention if symptoms develop . Ingestion: Ingestion is unlikely for solid products. No first aid is required for small amounts transferred from hands to mouth. On 5/5/25 at 10:21, the above information was discussed with the Facility Administrator. 3. Record review of Resident #45's clinical record showed smoking assessments were completed on 11/21/24 and 3/6/25 and indicated he/she requires supervision when smoking. On 5/7/25 at 2:10 p.m., during an interview with a surveyor, Certified Nursing Assistant- Medication Technician #1 (CNA-M) who stated Resident #45 usually goes out on his/her own to smoke. On 5/7/25 at 2:14 p.m., during an interview, Licensed Practical Nurse #1 (LPN) stated that Resident #45 smokes a couple times a day and he/she typically goes out on his/her own, but the LPN will occasionally go out with the resident as he/she has a hard time getting back to the facility entrance on his/her own. On 5/7/25 at 2:52 p.m., during an interview a surveyor, Resident #45 stated they typically smoke in the morning, and he/she will go outside on his/her own. On 5/7/25 at 12:07 p.m., during an interview with the Area Manager of Clinical Reimbursement the above information was discussed. On 5/8/25 at 9:26 a.m. a surveyor observed Resident #45 outside, at the end of [NAME] unit, sitting in wheelchair, smoking. He/she had on a t-shirt. LPN3 is observed standing near Resident #45. Resident #45 was not wearing a protective apron for safety. Resident #45s assessment for safety stated he/she needs a smoking apron, needs supervision with smoking. On 5/8/25 at 9:35 a.m. in an interview with a surveyor, LPN3 stated she took Resident #45 outside to smoke this morning, she stated that she did not encourage him/her to wear a protective apron while he/she was smoking and was not aware that he/she was assessed to need a protective apron while smoking for safety. The surveyor confirmed the accident hazard at this time.

12. Resident #59 was admitted in April of 2022. A review of the entire electronic and paper medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 13. Resident #83 was admitted in August of 2024. A review of the entire electronic and paper medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive for 13 of 14 residents reviewed (Residents #3, 6, 24, 29, 45, 47, 54, 59, 77, 81, 83, 88, 204, 206). Findings: 1. Resident #29 was admitted in February of 2021. A review of the entire electronic and paper medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 2. Resident #204 was admitted in April of 2025. A review of the entire electronic and paper medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. 3. Resident #206 was admitted in May of 2025. A review of the entire electronic and paper medical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. On [DATE] at 1:00 p.m., in an interview with a surveyor, the Clinical Reimbursement Manager confirmed there was no evidence in the clinical records of any discussion held with the residents or their designated representatives regarding advanced directives. On [DATE] at 1:50 p.m., in an interview with five surveyors, the Social Services Assistant confirmed the records did not contain evidence that residents or their representatives were asked to provide a copy of their advanced directives, or if they had none, were provided with information or assistance to formulate one. 4. Resident #3 was admitted to the facility in March of 2021. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 5. Resident #24 was admitted to the facility in December of 2021. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 6. Resident #47 was admitted to the facility in January of 2022. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 7. Resident #88 was admitted to the facility in December of 2024. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 10. Resident #45 was admitted to the facility in [DATE]. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 11. Resident #54 was admitted to the facility in [DATE]. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 8. Resident #77 was admitted in February 2025. A review of the entire electronic medical record and the paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advance directive to the resident and/or resident representative. 9. Resident #81 was admitted in [DATE]. A review of the entire electronic medical record and the paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advance directive to the resident and/or resident representative. On [DATE] at 1:42 p.m., during an interview in the presence of 5 surveyors, the Social Services Assistant stated she did not offer, review, or provide written information concerning advance directives to the above residents and/or resident representatives and stated she did not know what an advance directive includes other than cardiopulmonary resuscitation (CPR).

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 4 of 4 units (Belfast, [NAME], [NAME] and [NAME]) for 2 of 2 facility tours(5/5/25 and 5/9/25). Findings: 1. On 5/5/25 at 9:55 a.m., a surveyor and the Food Service Director observed the following in the Laundry room: > There were 2 black laundry carts with ripped duct tape on the inside of the carts creating uncleanable surfaces. > The floor had chipped/missing paint, on a wooden trap door, creating an uncleanable surface. On 5/5/25 at 9:55 a.m., in an interview, the Food Service Director confirmed the findings. On 5/9/25 from 8:15 a.m. to 9:15 a.m., a surveyor conducted an Environmental Tour with the Administrator, the Director of Plant Operations, the Assistant Director Plant Operations, the Housekeeping Supervisor and the Regional Director of Operations, in which the following findings were observed: 2. Belfast Unit: > The sit-to-stand patient lift had food debris and dirt in the foot base area. > Resident room [ROOM NUMBER] - The baseboard heater had chipped/missing paint creating an uncleanable surface. > Resident room [ROOM NUMBER]- The bathroom/shower ceiling light was missing a lens cover. > Resident room [ROOM NUMBER] - The room entrance door frame had chipped/missing paint creating an uncleanable surface. > Resident room [ROOM NUMBER]- Bathroom/shower ceiling light is missing lens cover. [NAME] Unit: > The wheelchair, scale in the whirlpool room, had a non-skid surface that was ripped/torn and created an uncleanable surface. > The inside entrance doors to the unit marred with black marks on the lower part of door. > Resident room [ROOM NUMBER]-2 - The wheelchair arm rests were worn and presented with an uncleanable surface. The right wheel was rubbing against the resident's seat causing the wheelchair to steer and roll to the right. > Resident room [ROOM NUMBER]- There were two ceiling tiles with brown stains on them. > Resident room [ROOM NUMBER]- There was an unbagged bedpan on shelf above toilet. > Resident room [ROOM NUMBER] - The heating unit had chipped/missing paint creating an uncleanable surface. [NAME]: > A dining room table has 2 pieces of untreated wood, approximately 6 inches long, under 2 of the table legs. > A sit-to-stand lift had food debris and dirt in foot base area. > The exit doors hallway walls were marred with black marks and had chipped/missing paint exposing sheetrock. > The wall heater, in the center core, had metal that had come apart and was sticking out and not secured together. > Resident room [ROOM NUMBER] - The caulking around the base of the toilet was stained and dirty. > Resident room [ROOM NUMBER] - The wall by bed 2 was scuffed/marred with black marks. > Resident room [ROOM NUMBER] bathroom- The walls were scuffed/marred with black marks and had chipped/missing paint. > Resident room [ROOM NUMBER]- The walls were scuffed/marred with black marks. The ceiling light had debris in them. > Resident room [ROOM NUMBER] - There were multiple ceiling tiles with brown stains. > Resident room [ROOM NUMBER] - The was a cracked/broken ceiling tile above the toilet. There were two stained ceiling tiles above bed 1. > Resident room [ROOM NUMBER]-2 - The wall behind the bed had chipped/missing paint. > Resident room [ROOM NUMBER] - There was a dirty plunger on floor next to the toilet that was not bagged. There was a wash basin on the floor by the toilet. The bathroom walls had chipped/missing paint. There was a ceiling tile over the head of the bed with a large brown stain. The room heating unit had chipped/missing paint. > Resident room [ROOM NUMBER] - A ceiling tile in the bathroom was stained and dirty. [NAME] Unit > The exit 8 cement floor had chipped/missing paint creating an uncleanable surface. > The sitting area past the nurse's station had a small table with missing laminate on the top. > Resident room [ROOM NUMBER] - The room heater has chipped/missing paint. The room entrance door and door frame had chipped/missing paint and black marks on them. > > Resident room [ROOM NUMBER] - There was a dirty plunger on floor and unbagged. The wall by the bathroom entrance had chipped/missing paint and was marred with black marks. On 5/9/25 at 9:15 a.m., in an interview, the Administrator, the Director of Plant Operations, the Assistant Director Plant Operations, the Housekeeping Supervisor and the Regional Director of Operations, confirmed the findings.

2. Resident #3's clinical record contained a Quarterly MDS Assessment, dated 2/6/25. Further review of Resident #3's record revealed that the last IDT meeting were held on 3/12/2025 and lacked evidence that an IDT meeting was held within 7 days following the latest MDS assessment. 3. Resident #19's clinical record contained a Quarterly MDS Assessment, dated 4/14/25. Further review of Resident #19's record revealed that the last IDT meeting were held on 5/6/2025 and lacked evidence that an IDT meeting was held within 7 days following the latest MDS assessment. 4. Resident #24's clinical record contained a Quarterly MDS Assessment, dated 3/22/25. Further review of Resident #24's record revealed that the last IDT meeting were held on 4/17/2025 and lacked evidence that an IDT meeting was held within 7 days following the latest MDS assessment. 5. Resident #47's clinical record contained a Quarterly MDS Assessment, dated 3/16/25. Further review of Resident #47's record revealed that the last IDT meeting were held on 1/31/25 and lacked evidence that an IDT meeting was held within 7 days following the latest MDS assessment. 6. Resident #88's clinical record contained a Quarterly MDS Assessment, dated 4/2/25. Further review of Resident #88's record lacked evidence that an IDT meeting was held within 7 days following the latest MDS assessment. On 5/07/25 at 12:31 p.m., in an interview, the Social Service Assistant confirmed that the residents did not have their IDT meetings within 7 days of MDS completion date. On 5/07/25 12:40 p.m., the surveyor discussed the findings with the Area Manager of Clinical Reimbursement. Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 7 residents reviewed for care planning (Residents #3, 19, #24, #47, and #22). Findings: 1. Review of Resident #22's clinical record revealed MDS Quarterly Assessments were completed on 10/7/24, 1/5/25, and 3/31/25. Further review of Resident #22's record revealed that IDT meetings were held on 10/25/24, 1/30/25, and 4/22/25 and lacked evidence that an interdisciplinary team (IDT) meeting was held within 7 days following the assessments.

Based on clinical record review and interview, the facility failed to ensure physician orders were followed for urine collection for urinalysis/culture a week prior to surgery for 1 of 1 sampled residents (Resident #24). Additionally, the facility failed to adequately assess and monitor a resident after an unwitnessed fall for 1 of 2 residents reviewed for falls (Resident #77). Findings: 1. Resident #24 was admitted to the facility in December of 2024 with diagnosis to include medically complex conditions, Multiple Sclerosis and the use of an indwelling urinary catheter. A Nurse Note dated 4/17/2025 7:30 a.m. stated: Resident due for catheter change to obtain clean catch urine in preparation for Botox treatment that resident has requested. Changes without difficulty using new #18 French with 10 ml (milliliter) balloon and received immediate return of straw-colored urine that is slightly hazy. Set up specimen in refrigeration for pick up. On 5/5/25, a surveyor reviewed Resident 24's clinical record. On 4/17/25, orders were received by the facility from a Family Nurse Practitioner (FNP) at a urology center in a hospital noting; Please have patient perform a clean catch urine collection for urinalysis (UA)/culture a week prior to surgery on 5/9/25. A Nurse Note dated 5/8/2025 2:50 p.m. stated: Called Nordx, urine was received on May 4th but was not accompanied by an order. Reported that charge nurse received call from lab on 5/5 at 8:58 a.m. and confirmed no order, due to instability of specimen past 24 hours, the urine in not usable for a UA. Urology appointment will be May 23rd at 9:30 a.m. On 5/9/25 at 9:25 a.m., in an interview, a Licensed Practical Nurse (LPN) stated, We had received instructions from the FNP at the Urology Center at the hospital to please have the patient perform a clean catch urine collection for urinalysis/culture a week prior to surgery on 5/9/25. The specimen was collected on 5/2/25 and sent to the lab on 5/3/25. The facility called the lab on 5/8/25 and the facility was told by the lab that the urine was received on May 4th but was not accompanied by an order. The lab reported that a charge nurse received a call from the lab on 5/5/255 at 8:58 (a.m.) and confirmed no order and due to instability of the specimen for the past 24 hours, the urine was not usable for a UA. The Urology appointment will be re-scheduled for May 23rd at 9:30 (a.m.). It was not true that there was no order. What happened was that the nurse at our facility did not fill out the paperwork that accompanied the specimen so the lab could not perform the analysis/culture. At this time, the LPN confirmed the FNP's preoperative orders were not carried out resulting in the cancellation of the resident's surgery on 5/9/25. On 5/9/25 at 9:40 a.m., in an interview, the surveyor discussed the finding with the Administrator, the Assistant Director of Nursing/Infection Preventionist(ADON/IP), the Area Director of Clinical Operation and Regional Director of Reimbursement. On 5/09/25 at 11:15 a.m., in an interview, the ADON/IP and the Area Director of Clinical Operation confirmed that the facility did not fill the lab paperwork out correctly and they cannot locate the lab paperwork and that is why the resident's surgery was cancelled for 5/9/25. 2. Review of facility policy, Neurological Review-Skilled, revised 7/8/21, states, .Following an unwitnessed fall .neurological parameters to be completed every 15 minutes x2, every 30 minutes x2, every 1 hours x2, and every 4 hours x2 or as per specific physician order .When assessing neurological status, vital signs must be included .Any changes .will be reported to the physician immediately . Resident #77 was recently admitted with diagnoses to include dementia and difficulty in walking. Review of Resident #77's clinical record revealed he/she sustained an unwitnessed fall on 4/12/25 and 4/19/25. A nursing progress note, dated 4/12/25 states, CNA [Certified Nursing Assistant] called this nurse to room res [resident] was sitting on the right side of bed in the floor with back against the bed .res stated she was trying to get up to get to the rest room . A nursing progress note, dated 4/19/25, states, Fall: CNA notified this writer that the resident is on the floor. This writer found the resident on the floor in the hallway . Further review of the electronic medical record (EMR) and paper chart lacked evidence of neurological monitoring and vital sign monitoring. On 5/8/25 at 9:47 a.m., during an interview, Licensed Practical Nurse (LPN) #1 stated when a resident has an unwitnessed fall, neurological checks and vital signs are started. On 5/8/25 at 10:45 a.m., during an interview, the Director of Nursing (DON) stated after a resident falls, the nurse documents in Risk Management in the EMR, and neurological checks are documented in the resident's paper chart or a progress note. On 5/8/25 at 12:30 p.m. during a follow up interview, the DON stated the Area Director for Clinical Operations informed her that a neurological checklist was implemented in the EMR. At this time, the DON reviewed Resident #77's entire clinical record and confirmed it lacked evidence that neurological monitoring was completed and documented for the above unwitnessed falls.

Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4, CNA5). Findings: 1. CNA1 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 2. CNA2 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 3. CNA3 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 4. CNA4 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. 5. CNA5 was hired on 12/1/2023. The facility was unable to provide evidence of a completed annual performance evaluation for 2024. On 5/9/2025 at 12:24 p.m., in an interview with the surveyor, the Administrator and Regional Director of Operations stated that when the previous administration sold the company, all employee records were taken. All employees became new with the company on 12/1/2023. All employees were due to have performance reviews completed in January to April, 2025, for 2024. The surveyor confirmed none had been completed at this time.

Based on observations, interviews, and review of the facility's Dish Machine Temperature Monitoring policy/procedure, the facility's Refrigerator and Freezer Monitoring Standard policy/procedure and the facility's Food Preparation -Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ice machine, ceiling tiles, ceiling vents, fans, walls and floors; failed to ensure kitchen staff with facial hair wore facial protection; failed to ensure foods were dated in the reach in refrigerator; and failed to ensure the ice machine was properly installed to prevent backflow as required by the Maine State Plumbing Code requirements to prevent food contamination for 1 of 1 kitchen tour. (4/28/25) Findings: The facility's Dish Machine Temperature Monitoring policy/procedure last reviewed 8/23/2018 noted: Policy: Dish machine should be monitored at each meal to ensure proper washing, rinsing and sanitizing. Procedure: 2. At each meal the temperature of the wash and rinse cycle are to be recorded on the dish machine temperature log for the high temperature machine. 5. Any variation from acceptable temperature or sanitizing range will be reported to the supervisor for corrective action. The facility's Food Preparation -Food Storage policy/procedure last reviewed 8/20/2018 noted: Policy: food items should be stored following good sanitary practices and local codes and manufacturers specifications. Procedure: 1. All products should be dated upon receipt and upon use when the entire amount of the product is not prepared. Where required by state regulations, use by dates are put on the products. Leftovers should be dated according to the leftovers policy. 2. Tightly wrap, label, and date all food items. The facility's Refrigerator and Freezer Monitoring Standard policy/procedure last reviewed 8/30/2018 noted: Standard: refrigerators and freezers should be monitored twice daily and temperatures recorded on temperature logs. All refrigerators and common areas should be monitored. Procedure: 3. Temperatures are to be recorded once in the morning and once in the evening by writing the temperature on the temperature log. 4. Whenever the temperatures are out of range or nearing out of range, the department head and property manager will be notified to take corrective action. Any malfunctions need to be communicated to the supervisor immediately. This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one-inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 5/5/25 from 9:15 a.m. to 9:55 a.m., an initial kitchen tour was completed with the Food Service Director in which the following findings were observed: -There were two kitchen workers with facial hair that were observed not wearing facial hair protectors. -There were six ceiling tiles throughout the kitchen with brown stains on them. -The fan sitting on a wall in the dish room was dusty/dirty. -There were seven ceiling vents that were dusty/dirty and two of the seven had excessive amounts of rust on them as well. -There were 16 ceiling tiles, around ceiling vents, that had large amounts of dust build up on them. -The wall over the reach-in freezer and reach-in refrigerator was heavily soiled with dust. -The dry storage room floor had chipped/missing paint. Additionally, there was trash and debris on the floor around the entire room and under shelving. -The reach-in refrigerator had a 16-ounce package of whipped topping with no thaw date. Manufacturer's instructions on the package state that it is only good for 14 days after thawing. -The ice machine was observed to not have an air gap. On 5/5/25 at 9:55 a.m., in an interview, the Food Service Director confirmed the findings. On 5/6/25 at 2:40 p.m., a surveyor reviewed the kitchen dish washer and refrigerator/freezer temp logs and found missing and/or low temps for dish washer rinse sanitizing monitoring/documenting temps and missing monitoring/documentation for refrigerator/freezer. For January, February, March, April and May 2025. Dish Washer Temperature dates missing and/or low for 2025: January: Missing - 4, 5, 11, 12, 18, 19, 20, 25, 26, and 28. Rinse under 180 degrees Fahrenheit(F.) - 1-31 February: Missing - 1, 2, 8-10, 15, 16, 21-23, and 28. Rinse under 180 degrees F. - 1-31 March: Missing - 1, 2, 7-9, 15, 16, 22, 23, 29 and 30. Rinse under 180 degrees F. - 1-31 April: Missing - 4-9, 18, 19, 25, 26, 29 and 30. Rinse under 180 degrees F. - 1-30 Refrigerator/Freezer Temperature dates missing for 2025: January: Kitchen refrigerator - No documentation Milk refrigerator - 4, 5, 11, 12, 17-20, 24-26, 28 and 31. Prep refrigerator - 8, 12, 16, 19, 20, 21, 23, 26 and 27. Always available refrigerator - 9, 10, 12, 15, 19 20, 21-23, 25 and 26. Kitchen Freezer - No documentation. Unit Refrigerator/Freezer Belfast - No documentation. [NAME] -. No documentation. [NAME] - No documentation. [NAME] - No documentation. February: Kitchen refrigerator - 1, 2, 4, 6-10, 13-16, 21-23, and 28. Milk refrigerator - 1, 6, 9, 10, 13, and 20. Prep refrigerator - 1, 6, 9, 10, 13, and 20. Always available refrigerator - No documentation. Kitchen Freezer - 6, 8, 9, 13, 17, and 20. Unit Refrigerator/Freezer Belfast - 1-4, 8-10, 14-16, 18, 21-23, and 28. [NAME] - 1-3, 6, 8-10, 14-16, 21-24, and 28. [NAME] - 1-3, 8-10, 14-16, 21-24, and 28. [NAME] - 1-3, 4, 7-9, 14-16, 21-23, and 28. March: Kitchen refrigerator - No documentation. Milk refrigerator - 1, 2, 7-9, 14-16, 21-24, 29 and 30. Prep refrigerator - No documentation. Always available refrigerator - No documentation. Kitchen Freezer - No documentation. Unit Refrigerator/Freezer Belfast - 1, 8, 21, 22, 24, and 28-30. [NAME] - 1, 7, 8, 14, 15, 21-23, 25, 28 and 29. [NAME] - No documentation. [NAME] - No documentation. April: Kitchen refrigerator - No documentation Kitchen Freezer - 20, and 26-31. Milk refrigerator - No documentation. Snack refrigerator - 4-12, 19, 25, 26, 29, and 30. Always available refrigerator - 29 and 30. Unit Refrigerator/Freezer Belfast - 18, 19, 25-28, and 30. [NAME] - 25-29. [NAME] - No documentation. [NAME] - No documentation. On 5/6/25 at 3:00 p.m., the FSD confirmed the findings of missing dates for monitoring of temperatures for the dish washer and refrigerators/freezers. The FSD also confirmed Rinse Temperatures of breakfast dishes for January, February, March, April 2025 were too low to sanitize adequately. There was no widespread outbreak of illness during those months.

Based on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for activities of daily living care. (Resident #67) Findings: Review of Resident #67's medical record lacked evidence of completed documentation for: -Missing documentation of ADL Bathing/Showering for day shift on 4/4/25, 4/8/25, and 4/10/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of B&B-Elimination, Urinary for day shift on 4/4/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of Oral Hygiene for day shift on 4/4/25, 4/8/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of Toileting Hygiene for day shift on 4/4/25, 4/8/25, 4/10/25, 4/16/25, and 4/25/25. Missing documentation for night shift on 4/2/25, 4/10/25, 4/12/25, 4/14/25, 4/19/25, and 4/30/25. -Missing documentation of B&B Scheduled Toileting Program for day shift on 4/16/25, 4/23/25, and 4/26/25. Missing documentation for night shift on 4/20/25, 4/23/25, 4/24/25, 4/25/25, 4/26/25, and 4/29/25. -Missing documentation of Elimination, Bowel for day shift on 4/10/25, 4/16/25, 4/23/25, and 4/25/25. Missing documentation for night shift on 4/10/25, 4/12/25, 4/14/25, 4/19/25 and 4/30/25. -Missing documentation for Eating for day shift on 4/2/25, 4/10/25, 4/16/25, 4/23/25, 4/25/25, 4/26/25, and 5/5/25. On 5/7/25 at 9:00 a.m., the above information was discussed with the Facility Administrator.

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 5/9/25, were effective. The Federal citations F684 and F812 were cited again during the re-visit for the Annual Long Term Care Recertification Survey, completed 6/30/25. Finding: During the follow-up survey on 6/30/25, it was determined that F684 and F812 would be re-cited for the same reasons: F684 for failure to adequately assess and monitor a resident after an unwitnessed fall and F812 for failure to ensure the kitchen was maintained in a clean and sanitary manner and ensure foods were labeled and dated. (see F684 and F812) On 6/30/25 at 4:55 p.m., the above was discussed during the exit conference with the Executive Director and interim Director of Nursing.

Based on record reviews and interview, the facility failed to ensure staff received mandatory training on it's Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 5 of 5 employee files reviewed (Certified Nurse Assistant #1 [CNA1], CNA2, CNA3, CNA4, CNA5). Findings: Review of the facility's Quality Assurance/Assessment and Performance Improvement Plan policy, undated, stated Education: All staff, including contracted staff are educated on the principles of QAPI. QAPI is included in the orientation of new employees and in the annual education that all staff are required to attend. Staff will be trained in using QAPI principles, identifying areas for improvement, and how they can be involved in the QAPI process including participation on a PIP (performance improvement project) team. The QAPI program is sustained during transitions in leadership and staffing through all-staff education and involvement in the QAPI process. A review of employee education files lacked evidence that CNA1, CNA2, CNA3, CNA4, and CNA5, received mandatory training regarding the facility's QAPI program. On 5/9/24 at 11:30 a.m., in an interview with a surveyor, the Administrator and the Regional Director of Operations confirmed the finding.