Every finding on record at Eastport Memorial Nursing Home

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair in 2 of 2 environmental tours. Findings: On 2/09/26 at 12:00 p.m., an environmental tour was done with the Administrator and Director of Nursing. The following were observed and confirmed by the administrator at the time of observation. Facing room [ROOM NUMBER] and to the right, the flooring was peeled up creating a potential tripping hazard. Facing the threshold to the nurse's station and toward the left, the flooring was peeled up creating a potential tripping hazard. In front of room [ROOM NUMBER], the flooring is lifted creating an area of potential tripping hazard. In the laundry room, the clothes drier with the open back was covered heavily with dust inside the back and on top of the drier. In addition, the metal tubing leading into the back of the second drier was covered with dust. On 2/9/26 and 2/10/26 during the initial and a second tour of the kitchen the surveyor observed yellow and black tape on the floor around the stove and other kitchen fixtures. On 2/10/26 at approximately 8:00 a.m. This was identified with the Food Service Director and it was identified as an uncleanable surface, The above finding was confirmed at that time.

Based on record reviews and interviews, the facility failed incorporate recommendations from the Preadmission Screening Resident Review (PASRR) level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care, and 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 to determine if a change in services was required for 2 of 3 sampled resident (Resident #12 and Resident #2 [R12, and R2]). Findings: On 2/10/26 at 12:40 p.m., during a clinical record review for R12, the PASRR II dated 6/2/25 has the PASRR determination explanation that R12 met the State of Maine's definition for serious mental illness due to a diagnosis of schizophrenia over the past three to six months, your diagnosis has led to intermittent functional limitations in interpersonal functioning, concentration or adaptation to change. Onset of symptoms and persistence causes significant distress and impairment in your ability to function independently. R12's PASRR Level II required: Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services: you may benefit from ongoing medication management and behavioral health treatment to be sure your mental health medications continue to work for you and you are getting the services you need. Rehabilitative services: You will need to be provided with the following services and/or supports Service or Support for socialization/leisure/recreation activities, Family involvement in the individual's care and Supportive Counseling from NF Staff. The reasons for these supports are below. Socialization/Leisure/Recreation Activities: Being around others is important to reduce loneliness and isolation and provide support. You also enjoy music. Supportive Counseling from NF staff: Support and validation from caregivers is important for emotional wellbeing and could assist with symptoms as they occur. Family involvement in the individual's care: your family is very important to you. Your caregivers should promote a continued connection with your sister. On 2/10/26 12:40 p.m., during an interview and a review of R12's care plan and clinical record with the Minimum Dats Set (MDS) nurse there is no evidence that the Level II services were included in R12's care plan or provided to R12. During the interview with the MDS nurse she stated the Mental Health Nurse Practitioner that sees other residents in the facility has not seen R12. The facility failed to make the referral for R12 to receive the specialized services as outlined in his/her PASRR level II. The above finding was confirmed with the MDS nurse at this time. 2. On 2/11/26, R2's clinical record indicated, on 4/6/21, R2 was diagnosed with a new mental health disorder. The clinical record lacked evidence that R2 was referred to the State mental health authority for a new PASRR level II determination after a new qualifying diagnosis. On 2/11/26 at 12:46 p.m., during an interview with a surveyor and the MDS Nurse, R2's PASRR was reviewed. At this time, the surveyor confirmed that an updated PASRR was not submitted to the State mental health authority for a new PASRR level II determination after a new qualifying diagnosis.

Based on record reviews and interviews, the facility failed to ensure baseline care plans was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 4 sampled residents reviewed for baseline care plans (Resident #12 [R12], R15). Findings: 1. On 2/11/26, a review of R15's clinical record was completed. Documentation in R15's clinical record indicated the resident was a recent admission to the facility. There was no evidence that a baseline care plan was developed within 48 hours to direct staff as to what R15's care needs were. On 2/11/26 at 10:50 a.m., in an interview with the surveyor, the Director of Nursing confirmed that a baseline care plan was not developed. 2. On 2/10/26 at 10:00 a.m., during a clinical record review, surveyor asked for R12's Baseline Care plan, surveyor was told they are in a paper form kept in front of the clinical records. Review of R12's clinical record with the charge nurse LPN1 and RN2 the form used for Baseline Care Plans is labeled Interim Plan of Care was found, this form was not completed or filled out it did not include the instructions needed to provide minimum healthcare information necessary to properly care. There is no evidence in the clinical record that a Baseline Care Plan was completed and no evidence of the resident or resident representative being informed of or provided a copy of his/her Baseline Care plan within 48 hours. The surveyor confirmed the above finding at that time.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 2 of 3 days of survey (2/9/26 and 2/10/26).Findings:On 2/9/26 at 11:12 a.m., a surveyor observed a soiled bed pan stored on the floor under R3's bed. On 2/10/26 at 10:37 a.m., during an interview with a surveyor, the Licensed Practical Nurse (LPN1) stated that bed pans are reused, they are washed, then bagged and should not be stored under a resident's bed. At 10:41 a.m., a surveyor and LPN1 observed and confirmed that a used bed pan was stored under R3's bed.

Based on record reviews and interview, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 months reviewed (December 2025 and January 2026). This has the potential to affect all residents receiving an antibiotic.Finding:Review of the facility's Antibiotic Stewardship policy, Last Revised: 08/2024, indicated: 14. The [Infection Preventionist (IP)], or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: a. The organism is not susceptible to the antibiotic chosen; b. The organism is susceptible to narrow spectrum antibiotics; c. Therapy was ordered for prolonged surgical prophylaxis; or d. Therapy was started awaiting culture, but culture results and clinical findings do not indicate the continued need for antibiotics. 15. After the review, the provider will be notified of the review findings.On 2/10/26 from 3:10 p.m., during an interview with a surveyor, the IP stated she was unable to provide evidence that the antibiotic stewardship was completed because the pharmacist took the only copy. The IP stated that she would track which residents were on an antibiotic to ensure the order was placed correctly but did not track culture and sensitivity results for the ASP. At 3:56 p.m., the IP reconfirmed with the surveyor that after looking in multiple locations she was unable to find evidence of antibiotic stewardship monitoring.

Based on record review, interview, and facility policy review, the facility failed to ensure residents were offered influenza and pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 4 of 5 residents reviewed for immunizations (Resident #2 [R2], R3, R5 and R10).Findings:On 2/10/26 at 2:30 p.m., record review indicated:1. R2 was admitted on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of PCV15, PCV20, or PCV21 to complete the vaccine series. The clinical record lacked evidence that R2 had received, been offered, or refused a pneumococcal vaccination.2. R3 was admitted on [DATE]. The clinical record lacked evidence that R3 had received, been offered, or refused the Influenza Vaccination.3. R5 was admitted on [DATE]. The clinical record lacked evidence that R2 had received, been offered, or refused a pneumococcal vaccination.4. R10 was admitted on [DATE]. The CDC recommendation was based on shared clinical decision-making, administer one dose of PCV20 or PCV21 to complete the vaccine series. The clinical record lacked evidence that R10 had received, been offered, or refused a pneumococcal vaccination.On 2/10/26 at 3:00 p.m., during an interview, a surveyor and the Infection Preventionist (IP) reviewed the vaccine records and confirmed the above findings.

Based on interview and employee personnel record reviews, the facility failed to implement and maintain an effective training program by failing to ensure that 5 of 5 Certified Nursing Assistant's (CNA) employed, completed training (CNA1, CNA2, CNA3, CNA4 and CNA5).Findings:1.CNA1 was hired on 4/22/2010. A review of CNA1's education records her record lacked evidence that she has received the required in-service trainings for dementia, behavioral trainings Infection control (IC), communication and Quality Assurance and Performance improvement (QAPI).2. CNA2 was hired on 2/1/2022. A review of CNA2's education records her record lacked evidence that she has received the required in-service trainings for Abuse, Neglect and Exploitation, Dementia, communication, IC, behavioral trainings, and QAPI.3. CNA3 was hired on 7/20/2020. A review of CNA3's education record her record lacked evidence that she has received the required in-service trainings for Abuse, Neglect and Exploitation, Dementia, communication, IC, behavioral trainings, and QAPI.4. CNA4 was hired on 4/19/2021. A review of CNA4's education record her record lacked evidence that she has received the required in-service trainings for Abuse, Neglect and Exploitation, Dementia, communication, IC, behavioral trainings, and QAPI.5. CNA5 was hired on 12/8/2025. A review of CNA5's education record her record lacked evidence that she has received the required in-service trainings for Abuse, Neglect and Exploitation, Dementia, communication, IC, behavioral trainings, Resident Rights and QAPI.On 2/11/26 at 11:30 a.m., during an interview and a record review of CNA trainings with the Administrator, the records reviewed showed the missing or incomplete trainings. She also stated that she had not assigned all trainings required, she was using the list on the Health Care Academy system and was not aware they needed additional trainings. It did not include Dementia, communication, behavioral training and QAPI. The surveyor confirmed the above findings during this interview.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity while providing care for 2 of 2 residents reviewed for Dignity [Resident #10 (R10) and R3].Findings: 1. On 2/9/26 at 11:55 a.m., a surveyor observed Certified Nursing Assistant #5 (CNA5) place R10's lunch tray on their bedside table. CNA5 removed 2 cups, one with water and one with a brown beverage. R10 complained to CNA5 that CNA3 brought the beverages to him/her but did not boost him/her up in bed or lift the HOB to drink the beverages. R10 stated he/she still wanted the hot cocoa. CNA5 stated the hot cocoa was cold and would make R10 a new hot cocoa. R10 complained to CNA5 that he/she had not been washed up and cannot eat or drink without sitting up.On 2/9/26 at 11:58 a.m., CNA3 came to R10's room and stated, just so you know [he/she] keeps refusing to let me wash [him/her] up. [He/she] won't let me touch [him/her], so I don't know what to tell you. CNA5 stated, if [he/she] is refusing for you to provide [him/her] care we need to change the assignment so [he/she] is not on your care list. CNA3 stated, I've tried to trade [him/her] off, but no one will take [him/her]. CNA3 then walked away leaving CNA5 to care for the Resident. 2. On 2/10/26 at 8:56 a.m., during an observation of R3's morning care, a surveyor and the Assistant Director of Nursing (ADON) observed the following: the curtain between Bed A and Bed B was pulled for privacy, but the curtain between the foot of R3's bed and the door to R3's room was not pulled to provide privacy from door. At 9:12 a.m., while R3 was exposed from the waist down CNA6 pressed the call bell for the nurse and CNA5 left the room to find the nurse. At 9:13 a.m., 2 additional staff opened R3's door, and held the door open to inquire about the call bell. CNA6 dismissed them and shut off the call bell. The 2 staff closed the door, but it opened again as CNA5 returned to the room. At 9:14 a.m., the Licensed Practical Nurse (LPN1) entered the room, leaving the door ajar. LPN assessed R3 then left the room to obtain supplies. At 9:16 a.m., the surveyor requested the curtain be pulled to protect R3's privacy from the door.On 2/10/26 at 9:30 a.m., during an interview with the ADON, a surveyor discussed and confirmed the above findings.

Based on interviews and clinical record reviews, the facility failed to follow a Physicians order for in-house Physical Therapy for 1 of 2 sampled residents reviewed for position, mobility (Resident #24).Finding:On 2/9/26 at 1:35 p.m. during an interview with R24 he/she was observed to have a deficit on his/her right side, R24 stated that staff do not help with any Range of Motion (ROM) exercises and that he/she was told they are not allowed to do therapy here in the facility. On 2/10/26 during a review of Resident #24's clinical record, there is a physician order dated 1/20/26 for a request for in-house occupational (OT) and physical therapy (PT) for strengthening and behavioral modification. Review of therapy notes that is in a binder outside the Administrators office, the notes reflect that the OT evaluation was completed on 1/20/26 and will receive OT up to 16 times in 8 weeks. Review of PT notes indicates that he/she has not had a PT eval completed.On 2/10/26 at 3:30 p.m., during an interview with the Charge Nurse RN2, OT has been working with R24 but PT has not been working with R24.On 2/10/26 at 3:59 p.m. during an interview with the Administrator the surveyor confirmed that the PT eval and tx have not occurred for R24 as of this date. On 2/11/26 at 12:00 p.m. PT came in to talk to surveyors stating that he did not complete the evaluation because he thought it was for OT only. He acknowledged that he had not completed an evaluation until today 2/11/26.

Based on record review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Coronavirus (COVID-19) vaccine for 1 of 5 residents reviewed (Resident #3 [R3]).Finding:On 2/10/26 at 3:00 p.m., during an interview, a surveyor and the Infection Preventionist reviewed and confirmed that clinical record review indicated R3 was admitted on [DATE], and the clinical record lacks evidence that R3 had received, been offered, or refused the updated COVID-19 vaccination.

Based on observation and interview, the facility failed to ensure that the environment was free from potential risk of accidents by allowing 2 of 3 egresses on the resident's ground floor to be blocked by snow and not easily passable.Findings:On 1/27/26 at 9:00 a.m., during entrance to the facility, observed the walkways to the two front entrance/egress doors hindered with snow that was approximately 15 inches at the street and approximately 4 to 6 inches on the walkways and ramps leading up to the egress doors. The one walkway and door shoveled free of snow was the employee entrance that is at the left side of the building. To go from the inside of the building out through the only egress that wasn't hindered with snow (employee entrance), the 25 current residents would have to be taken through one of two locked doors and navigated through narrow corridors and out the side of the building or out through the front egresses hindered by snow. Two maintenance staff were observed in the building doing other tasks.On 1/27/26 at a little after 9:00 a.m., in an interview with the Administrator, she stated she had asked the maintenance staff to clear the egresses of snow, but they had not gotten to it.

Based on interview, the facility failed to conduct regular inspections of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattress and bed frame are compatible and identify areas of entrapment for 1 of 5 beds reviewed. (Resident #1) Finding:On 1/27/26 at 12:05 p.m., along with the Director of Nursing (DON), an observation of Resident #1's bed was done. The mattress fit well with the bed frame and there were no unsafe gaps observed in regards to the quarter bedrails. The DON stated there were four other residents with air mattresses and side rails. These beds were observed and no entrapment or safety issues were observed.On 1/27/26 at 12:45 p.m., in an interview with the Maintenance Supervisor, he stated he measures the bed mattress and bed frame to ensure a proper fit. He stated he assesses the bed mattress, frame, and bed rails to ensure that there are no gaps or entrapment hazards. He stated he does not document his assessments for when he initially places a new mattress in a bed frame and does not have a regular maintenance program for checking the beds for safety.

Based on record review and interviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's representative status and a change in the resident's medical plan of care for 1 of 1 resident representative not notified of resident changes. (Resident #1 [R1]) Finding: On 7/1/25, a review of R1's clinical record was completed. An advanced directive indicted that family member #1 (FM1) was designated by R1 in 2017 to be his/her legal representative. On 6/10/25, R1's primary physician made a medical visit. At that time, family member #2 (FM2) was visiting and requested that R1 be transitioned to end of life care. FM2 delivered a copy of a legal document indicating that FM2 is the Power of Attorney (POA). There is no evidence in R1's clinical record that the facility contacted FM1 to discuss the conflict of who is R1's legal representative and if FM1 wanted medical care changes. On 6/25/25, the primary physician documented in R1's progress note that they had discovered in the physician's office file a legal document that revoked FM2's POA status in 2015. The current legal representative is FM1. On 6/30/25, in an interview with FM1, they stated they had not been notified of a change in the resident's representative status and a change in the resident's medical plan of care until visiting R1 on 6/23/25. On 7/1/25, in an interview with the Director of Nursing, she confirmed that the facility did not contact the current legal resident representative (FM1) on 6/10/25 regarding R1's conflicting POA status and the physician's order to implement comfort care and discontinue medications.

Based on record review, facility reported incident and investigation reviews, and interviews, the facility failed to implement a comprehensive care plan for Resident #1 (R1) for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25). Findings: On 6/23/25, R1's clinical record was reviewed. R1 had been identified as an elopement risk and wore a wander guard bracelet on his/her ankle which should trigger a secured exit (doors with alarms, security codes, and other locking mechanisms to prevent unauthorized exit) to activate. R1's care plan, dated 11/26/24 and last reviewed on 5/21/25, under the care area of I am at risk for elopement, directed staff to redirect me from exits and at times when I am really upset and trying to leave have available staff sit with me. 1. On 5/13/25, the State Agency received a facility reported incident that indicated R1 was found outside after he/she exited the building unwitnessed. A review of the facility's investigation, dated 5/18/25, indicated that R1 had been redirected from the Sunroom exit door at least 3 times before he/she was able to exit the building. On 6/23/25 at 12:10 p.m., during an interview with a surveyor, Certified Nursing Assistant #1 (CNA1) stated R1 tried to get out the Sunroom exit door and got the door open. Housekeeping was present also and we redirected R1 out of the area and closed the wooden (swinging) Sunroom doors. On 6/23/25 at 2:10 p.m., during an interview with the Director of Nursing (DON), a surveyor confirmed that for the 5/13/25 elopement, there was no evidence that anyone sat with R1 during the elopement behaviors and staff just kept redirecting the resident from the area. 2. On 5/18/25, the State Agency received a facility reported incident that indicated the evening of 5/17/25, R1 was found outside when he/she exited the building, unwitnessed. A review of the facility's investigation, dated 5/22/25, indicated there were 3 staff on duty that evening. The DON interviewed the Charge Nurse on duty as part of the investigation who stated that R1 had made multiple attempts to elope that evening, but was able to be redirected. On 6/23/25 at 12:00 p.m., during an interview with a surveyor, CNA2 stated that she heard the alarm going off and she figured it was R1. On 6/23/25 at 2:10 p.m., during an interview with the DON, a surveyor confirmed for the 5/17/25 incident at occurred at 9:27 p.m., R1 again was exit seeking that shift, and with only 3 staff present, there was no one able to provide adequate supervision for R1 who figured out how to open the alarmed Smokers door and get outside unwitnessed. There was no evidence that anyone sat with R1 during the elopement behaviors and just kept redirecting the resident from the area. The DON stated that she asked Charge Nurse on why he did not immediately notify her or call her or ask for help for someone to come in and sit with R1 until she calmed down.

Based on the facility's incident report forms and investigations, facility policy review, and interviews, the facility failed to provide adequate supervision to a resident who was actively exit seeking and was able to leave the facility unwitnessed and/or failed to follow it's own Elopement and Wandering Policy by ensuring secured exits were in working order for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25) for Resident #1 (R1). Findings: The facility's Elopement and Wandering Policy, reviewed 3/12/25, indicated the following: Environmental Modifications: Secure exits: Doors with alarms, security codes, and other locking mechanisms to prevent unauthorized exit. Door alarms should continue alarming after the door is closed and the alarm should be deactivated by staff entering the code to end the alarm. At any time staff finds that door alarms are not functioning properly, it must be reported immediately to maintenance staff or the Administrator and/or the Director of Nursing. Facility Notification: In the event of a resident's elopement, staff need to inform the Director of Nursing or Administrator immediately. On 6/23/25, R1's clinical record was reviewed. R1 had been identified as an elopement risk and wore a wander guard bracelet on his/her ankle which should trigger a secured exit (doors with alarms, security codes, and other locking mechanisms to prevent unauthorized exit) to activate. 1. On 5/13/25, State Agency received a facility reported incident that indicated a staff member (Housekeeping) taking out the garbage observed R1 walking, without their walker, on the sidewalk outside, towards a parked vehicle. The State Agency received the facility's investigation on 5/19/25 for this incident; a review of the facility's investigation, dated 5/18/25, indicated (via cameras) on 5/13/25, between 9:01 a.m. - 9:51 a.m., R1 was observed 4 times to be pushing on the Sunroom exit door with his/her walker, but was unable to push the door open. R1 was observed and redirected by staff 3 times during those attempts at opening the door. At 10:00 a.m., R1 was at the Sunroom exit door again, pushing on the handle and managed to get the door open with the front wheels of the walker, making it outside. Housekeeping was present and called for assistance from a Certified Nursing Assistant (CNA) and R1 was redirected from the area. Housekeeping then closed the wooden swinging doors to the Sunroom. At 10:12 a.m., R1 opened the wooden swinging doors to the Sunroom, pushed on the Sunroom exit door handle and pushed the door open, exiting the building while holding his/her walker with one hand and pushing the door with the other hand. (R1 exited the building on to concrete steps, stepping off those, and on to the level ground). At 10:16 a.m., staff was observed exiting the building through the Sunroom exit door after receiving notification from Housekeeping who was outside at the dumpster and observed R1 outside, walking without their walker, towards a parked car. The facility's investigation concluded that the secure exit (door keypad/alarm system) was not working and therefore when R1 opened the outside door, R1's secure care bracelet did not trigger the exit to be secure or sound an alarm; a loose power connection was found to the the reason the exit was not secured. On 6/23/25 at 12:10 p.m., during an interview with a surveyor, Certified Nursing Assistant #1 (CNA1) stated R1 tried to get out the Sunroom exit door and got the door open, but it did not sound the alarm. Housekeeping was present also and we redirected R1 out of the area and closed the wooden (swinging) Sunroom doors. CNA1 stated that she attempted to contact the Maintenance Supervisor after the first attempt of getting the door opened when the alarm did not sound, but he did not answer so she called the kitchen to see if they could track him down; R1 ended up getting out before the Maintenance Supervisor could make it upstairs to check the door. On 6/23/25 at 2:10 p.m., during an interview with the Director of Nursing (DON), a surveyor confirmed that for the 5/13/25 elopement, staff knew that the Sunroom door exit was not secured and left the unsecured door unattended and failed to provide adequate supervision for R1, knowing that R1 was actively exit seeking and was able to open an unsecured exit door and leave the building unwitnessed. 2. On 5/18/25, the State agency received a facility reported incident that indicated that on 5/17/25 at 9:30 p.m., had exited out a side door (Smoker's exit) and down steps; R1 was caught by staff who were made aware of R1's elopement because the alarm was sounding. The facility's investigation, dated 5/22/25, indicated the DON was in the facility on 5/18/25, working on the investigation for R1's 5/13/25 elopement, when she discovered that R1 had eloped again on 5/17/25. She noted that she had not informed immediately of this incident (as directed by Elopement policy) by the Charge Nurse. The facility completed an investigation for this incident by reviewing cameras and conducting interviews that indicated on 5/17/25 at 9:27 p.m., R1 was seen on camera leaving the building through the Smoker's exit and at 9:28 p.m., CNA3 was observed exiting the building to bring R1 back inside. The DON gathered statements from staff that were on duty the evening of 5/17/25. On 5/19/25 at 1:59 p.m., CNA3 reported she heard the door alarm go off at the back door. She went towards the back door, opened the back door and saw R1 going down the steps. CNA3 attempted to redirect R1, however the resident was resistant but she was able to get R1 to turn around and walk towards the ambulance entrance. On 5/21/25 at 6:06 a.m., Charge Nurse stated that R1 had made multiple attempts to elope that evening, but was able to be redirected; when staff had brought R1 back into the building, they reported to him that R1 had eloped from the building. On 6/23/25 at 12:00 p.m., during an interview with a surveyor, CNA2 stated that she heard the alarm going off and she figured it was R1. CNA3 went out brought R1 back inside. (R1 must of held the door handle down 15 seconds to open the door [per life safety code] but the alarm sounded as it should have.) On 6/23/25 at 12:15 p.m., during an interview with a surveyor, Family Member stated that R1's wandering behavior is not new for the resident and that she has been this way for at least 4 years. On 6/23/25 at 2:10 p.m., during an interview with the DON, the surveyor confirmed that for the 5/17/25, R1 again was exit seeking that shift, and with only 3 staff present, there was no one able to provide adequate supervision for R1 who figured out how to open the alarmed door and get outside at 9:27 p.m. The DON stated that she asked Charge Nurse on why he did not immediately notify her or call her or ask for help for someone to come in and sit with R1 until she calmed down. The DON stated that education was provided to Charge Nurse about immediate notification of resident elopements to either the DON or Administrator.

Based on interviews, the facility failed to employ a qualified Activity Director (AD) to manage resident centered activities for all residents (24 residents). Finding: On 1/27/25 at 10:45 a.m. in an interview with a surveyor, the Administrator stated that the AD has not completed a State-approved program to become qualified as an AD. On 1/29/25 at 11:02 a.m., in an interview with a surveyor, the AD stated she hasn't completed the State-approved program to take the exam to become an Activity Professional, and does not have other requirements to ensure the activities program is directed by a qualified professional. The surveyor confirmed at this time that the AD has not completed the State-approved program and is not qualified to be the AD. The Administrator and AD state the AD is enrolled in the program and is in the process of completing a State-approved program to become qualified as an AD.

Based on observations, record review, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 1/29/25, were implemented / effective. The facility lacked evidence that the PoC for deficiencies F636 (Comprehensive Assessments & Timing), F637 (Comprehensive Assessments After Significant Change), F656 (Develop/Implement Comprehensive Care Plan), F684 (Quality of Care), and F689 (Free of Accident Hazards/Supervision/Devices) was implemented in order to prevent repeat deficient practice. The deficiencies F695 (Respiratory Care), and F761 (Label/Store Drugs and Biologicals) were again identified during the re-visit survey on 3/18/25. Findings: 1. The facility's accepted PoC for F636, signed on 2/14/25, indicated the facility would print weekly MDS reports to identify residents needing assessments, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents have a Comprehensive Minimum Data Set (MDS) assessment timely. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence the PoC was implemented, that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly. 2. The facility's accepted PoC for F637, signed on 2/14/25, indicated the Director of Nursing would monitor nursing documentation of resident significant change and MDS assessment submission, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents with a significant change in status have a Comprehensive Minimum Data Set (MDS) assessment timely. The PoC indicated an anticipated date of compliance of 3/5/25. The facility lacked evidence that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by the MDS coordinator, that a monitor was completed weekly, and deficient practice was identified after the PoC's anticipated date of compliance. 3. The facility's accepted PoC for F656, signed on 2/14/25, indicated nursing staff would receive education on how to add a diagnosis to a resident's diagnosis list and update the care plan to correspond with the diagnosis, and the Director of Nursing would monitor all physician's notes after visits and ensure any new diagnoses were updated. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by nursing staff, or that monitoring was completed. 4. The facility's accepted PoC for F684, signed on 2/14/25, indicated staff would receive education, and the Director of Nursing would monitor all orders and Gradual Dose Reduction (GDR) recommendations for 6 months. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided to staff, that education was received by staff, or that monitoring was completed for GDR recommendations. 5. On 2/14/25, the facility signed a Plan of Correction (PoC) indicating an Elopement/Wandering policy would be established by 3/15/24, staff would be educated on the new policy, drill would be conducted at randomly selected times, and a monitor of staff response to the drills would be completed. The PoC indicated the anticipated date of compliance as 3/5/25. The facility lacked evidence that the policy was established, education was provided to staff, received by staff, drills completed, and/or a monitor of staff response was completed. On 3/18/25 at 10:15 a.m., during an interview with a surveyor and the Director of Nursing, the Elopement and Wandering Policy draft was reviewed. The DON indicated staff had not received education as this policy has not been approved by the board of directors. At this time the surveyor confirmed the Plan of Correction had not been implemented to prevent a resident identified as an elopement risk from leaving the building unnoticed. 6. The facility's accepted PoC for F695, signed on 2/14/25, concentrators will be cleaned, weekly walking rounds would be completed to residents with oxygen orders, staff would receive education, and monitored results would be documented. The PoC identified 3/5/25 as the anticipated date of compliance. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, that weekly walking rounds and/or monitoring were completed / documented. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance. 7. The facility's accepted PoC for F761, signed on 2/14/25, indicated staff would receive education on dating insulin vials / pens, discarding insulin after the expiration date, and weekly monitors would be conducted for 6 months. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, or that weekly audits were completed. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance.

Based on observations, record review, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 1/29/25, were implemented / effective. The facility lacked evidence that the PoC for deficiencies F636 (Comprehensive Assessments & Timing), F637 (Comprehensive Assessments After Significant Change), F656 (Develop/Implement Comprehensive Care Plan), F684 (Quality of Care), and F689 (Free of Accident Hazards/Supervision/Devices) was implemented in order to prevent repeat deficient practice. The deficiencies F695 (Respiratory Care), and F761 (Label/Store Drugs and Biologicals) were again identified during the re-visit survey on 3/18/25. Findings: 1. The facility's accepted PoC for F636, signed on 2/14/25, indicated the facility would print weekly MDS reports to identify residents needing assessments, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents have a Comprehensive Minimum Data Set (MDS) assessment timely. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence the PoC was implemented, that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly. 2. The facility's accepted PoC for F637, signed on 2/14/25, indicated the Director of Nursing would monitor nursing documentation of resident significant change and MDS assessment submission, the MDS coordinator would receive education on the process, and a monitor would be completed to ensure all residents with a significant change in status have a Comprehensive Minimum Data Set (MDS) assessment timely. The PoC indicated an anticipated date of compliance of 3/5/25. The facility lacked evidence that education was provided, that education was received by the MDS coordinator, or that a monitor was completed weekly. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by the MDS coordinator, that a monitor was completed weekly, and deficient practice was identified after the PoC's anticipated date of compliance. 3. The facility's accepted PoC for F656, signed on 2/14/25, indicated nursing staff would receive education on how to add a diagnosis to a resident's diagnosis list and update the care plan to correspond with the diagnosis, and the Director of Nursing would monitor all physician's notes after visits and ensure any new diagnoses were updated. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided, that education was received by nursing staff, or that monitoring was completed. 4. The facility's accepted PoC for F684, signed on 2/14/25, indicated staff would receive education, and the Director of Nursing would monitor all orders and Gradual Dose Reduction (GDR) recommendations for 6 months. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was implemented, that education was provided to staff, that education was received by staff, or that monitoring was completed for GDR recommendations. 5. On 2/14/25, the facility signed a Plan of Correction (PoC) indicating an Elopement/Wandering policy would be established by 3/15/24, staff would be educated on the new policy, drill would be conducted at randomly selected times, and a monitor of staff response to the drills would be completed. The PoC indicated the anticipated date of compliance as 3/5/25. The facility lacked evidence that the policy was established, education was provided to staff, received by staff, drills completed, and/or a monitor of staff response was completed. On 3/18/25 at 10:15 a.m., during an interview with a surveyor and the Director of Nursing, the Elopement and Wandering Policy draft was reviewed. The DON indicated staff had not received education as this policy has not been approved by the board of directors. At this time the surveyor confirmed the Plan of Correction had not been implemented to prevent a resident identified as an elopement risk from leaving the building unnoticed. 6. The facility's accepted PoC for F695, signed on 2/14/25, concentrators will be cleaned, weekly walking rounds would be completed to residents with oxygen orders, staff would receive education, and monitored results would be documented. The PoC identified 3/5/25 as the anticipated date of compliance. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, that weekly walking rounds and/or monitoring were completed / documented. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance. 7. The facility's accepted PoC for F761, signed on 2/14/25, indicated staff would receive education on dating insulin vials / pens, discarding insulin after the expiration date, and weekly monitors would be conducted for 6 months. On 3/18/25 at 11:15 a.m., during an interview with the Administrator and the Director of Nursing, a surveyor confirmed the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, that education was received by staff, or that weekly audits were completed. Deficient practice was identified at the time of the revisit, after the PoC's anticipated date of compliance.

Based on record review and interview, the facility failed to complete an annual Comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment timely for 1 of 1 residents reviewed for hospice (Resident #23 [R23]) Finding: On 1/28/25, a review of R23's clinical record was completed. R23 was admitted on [DATE]. An admission Comprehensive MDS assessment was completed and submitted on 6/17/23. Quarterly MDS assessments were completed on 9/15/23, 12/14/23, 3/15/24, 6/16/24, 9/15/24 and 12/16/24. The record lacked evidence that an annual Comprehensive MDS assessment was completed. On 1/29/25 at 10:05 a.m., during an interview with a surveyor, The Interim Director of Nursing reviewed her records and stated the MDS completed on 6/16/24 should have been an annual Comprehensive MDS assessment. At the time of the interview, it was 592 days since R23's last Comprehensive assessment. At this time a surveyor confirmed the above finding.

Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 1 of 1 sampled residents (Resident #23 [R23]). Finding: On 1/28/25, a review of R23's clinical record was completed. R23 was admitted on [DATE]. An Admission MDS was completed and submitted on 6/17/23. On 7/29/24, R23 transitioned to hospice level of care. The record lacked evidence that a significant change in status MDS was completed after R23 transitioned to hospice level of care. On 1/29/25 at 10:05 a.m., during an interview with a surveyor, The Interim Director of Nursing reviewed her records and stated she had not completed a change in condition when R23 transitioned to hospice. At this time a surveyor confirmed the above finding.