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

Based on interviews, observations, and record reviews, the facility failed to develop and/or implement policy and procedures for residents to file grievances to ensure timely resolution to resident concerns. This has the potential to affect all residents. Findings: 1. The facility's Grievance Policy, revised 11/16, indicated the following: The resident/responsible party can bring forward their concerns verbally and or by the writing grievance process. Grievance/concerns forms are available on the nursing units and in the front lobby where applicable. Facility staff Is encouraged to attempt to resolve the verbal grievance/concern at the time it is brought forward whenever possible. in the case that a concern cannot be resolved promptly the staff member will complete the grievance form or give it to the person with the concern to complete. Upon receive of the completed form, the social worker will follow up with the person who filed the grievance/concern and discuss the resolution and have the complainant sign and or verbally acknowledge that they agree that the issue has been resolved. The complainant will then be offered a signed copy of the grievance form. During a group interview on 3/31/26 at 9:25 a.m., 7 residents were asked if they knew how to file a grievance or complaint with one resident responding that they would go to the social worker or Activities Director but that there hasn't been a social worker for a while here, but they have a new one coming. Surveyor asked if the group knew how to file anonymously and the response was no. On 3/31/26 at 9:40 a.m., during an interview with a surveyor, the Activities Director (AD) explained that Resident Council is a safe place for residents to vent and if there was a complaint or grievance, the process was that she would complete the grievance form and give it to the Administrator. The surveyor reviewed the form and asked the AD what would you put on the Grievance/Concern Form where it says resident involved if they wanted to be anonymous. The AD stated that she would put the room number and bed number if they didn't want to give their name. She would then give the form to the Administrator when completed. On 3/31/2026 at 10:17 a.m., during an interview with a surveyor, the Administrator stated the facility has a website that anonymous complaints can be submitted and that a name is not required. Surveyor explained not every resident has access to or capability to use a computer. The Administrator stated that staff do not have to complete the resident name on the Grievance/concern form, they could just leave it blank. The surveyor stated that some residents and staff are unaware of this process. On 3/31/26 at 3:20 p.m., during an interview with the Administrator, a surveyor reviewed the facility's policy and confirmed that the policy does not mention a way to complete a grievance anonymously. 2. On 3/29/26 at 10:53 a.m., during an interview with a surveyor, R3 stated that his/her glasses have been missing for 3 or more weeks, and he/she can't see well without them. No glasses were observed in use or within the room at the time of the interview. On 3/30/26 at 2:15 p.m., during an interview with a surveyor, R3 stated his/her glasses are still missing. R3's roommate stated that they have been missing for more than 3 weeks now. No glasses were observed in use or within the resident's room at the time of the interview. On 3/30/26, R3's clinical record was reviewed and indicated R3's cognition is moderately impaired. The Care Plan indicated R3 has impaired visual function, interventions included Ensure glasses are clean and available. Remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family. Certified Nursing Assistant documentation indicated R3 wore glasses each morning and removed them each night (See F842). The clinical record lacked evidence that the glasses were missing or that the facility took steps to locate them. On 3/30/26 at 2:56 p.m., during an interview with a surveyor and the Administrator, R3's clinical record and the grievance book were reviewed. The Administrator confirmed that the glasses were reported missing on 2/6/26, that the facility does not know if the glasses were lost in the facility or at dialysis, and that the facility did not call dialysis to assist R3 in locating the glasses when they were reported missing. The Administrator stated he believed R3 would look for them at the next dialysis appointment on 2/9/26. At this time, the surveyor confirmed that the facility did not assist the resident to locate his/her missing glasses to prevent permanent loss and did not follow up with R3 to assist in locating or replacing his/her glasses.

Based on record review and interview, the facility failed to recognize a potential significant weight loss and a potential significant weight gain for 1 of 6 residents reviewed for nutrition. (Resident #12 [R12])On 3/30/26, a review of R12's clinical record was complete. R12 was care planned for diabetes with an intervention to monitor, document/report any signs or symptoms of weight loss . R12 also had a care plan problem for overweight/obesity/risk of malnutrition related to chronic disease (diabetes mellitus Type II) with an intervention to monitor/evaluate weight/weight changes.Documentation indicated that on 3/5/26, R12 weighed 294 pounds (#). Then on 3/12/26, R12 weighed 263 #'s, indicating a potential for a significant weight loss of 30.6 #.On 3/16/26, R12 weighed 266.1 #'s. Then on 3/26/26, R12 weighed 310.2 #'s, indicating a potential for a significant weight gain of 44.1 #'s.There was no evidence that the care plan interventions were followed, that potential significant weight changes were assessed for accuracy and/or evaluated for potential medical intervention.On 3/31/26 at 7:00 a.m., in an interview with the Director of Nursing Services, the surveyor discussed this finding.

Based on record reviews and interviews, the facility failed to ensure the attending Provider signed the medication Order Review History Report (Physician block orders) that is required during a visit at least every 60 days plus a 10 day grace period for 3 of 5 sampled residents reviewed for unnecessary medications. (Resident #2 [R2] R9, R46) and 2 of 3 reviewed for Activities of Daily Living (R6 and R14) In addition, the facility failed to ensure the attending Provider signed the medication Order Review History Report (Physician block orders) that is required during a visit for a new admission at least every 30 days plus a 10 day grace period for 1 of 1 sampled resident reviewed for hospitalization (Resident #58 [R58]). Finding: 1. On 3/31/26, a review of R2's clinical record was completed. Documentation indicated a required regulatory visit was completed on 1/15/26. A provider progress note was completed on 1/15/26, but there was no evidence that the physician block orders were signed. The facility was unable to provide evidence that the physician block orders were signed on the day of the required recertification visit. On 3/31/26 at 9:45 a.m., the surveyor discussed this finding with the Regional Director of Clinical Operations. 2. On 3/31/26, a review of R6's clinical record was completed. Documentation indicated a required regulatory visit and signing of physician block orders was completed on 2/4/26. R6's physician block orders were signed on 2/4/26, but there was no evidence that the provider progress note (visit) was completed and signed until 6 days after the physician block orders were signed. The facility was unable to provide evidence that the providers progress note (visit) was completed on the day the physician block orders were signed for the required recertification visit which instructs the provider to review the residents' total care to include medications and treatments with each visit. 3. On 3/31/26, a review of R9's clinical record was completed. Documentation indicated a required regulatory visit and signing of physician block orders was completed on 1/13/26. R9's physician block orders were signed on 1/13/26, but there was no evidence that the providers progress note (visit) was completed and signed the following day after the physician block orders were signed. The facility was unable to provide evidence that the providers progress note (visit) was completed on the day the physician block orders were signed for the required recertification visit which instructs the provider to review the residents' total care to include medications and treatments with each visit. 4. On 3/31/26, a review of R14's clinical record was completed. Documentation indicated a required regulatory visit and signing of physician block orders was completed on 1/28/26. R14's physician block orders were signed on 1/28/26, but there was no evidence that the providers progress note (visit) was completed and signed until 5 days after the physician block orders were signed. The facility was unable to provide evidence that the providers progress note (visit) was completed on the day the physician block orders were signed for the required recertification visit which instructs the provider to review the residents' total care to include medications and treatments with each visit. 5. On 3/31/26, a review of R46's clinical record was completed. Documentation indicated a required regulatory visit and signing of physician block orders was completed on 1/28/26. R46's physician block orders were signed on 1/28/26, but there was no evidence that the providers progress note (visit) was completed and signed until 5 days after the physician block orders were signed. The facility was unable to provide evidence that the providers progress note (visit) was completed on the day the physician block orders were signed for the required recertification visit which instructs the providers to review the residents' total care to include medications and treatments with each visit. On 3/31/26 at 9:45 a.m., surveyors discussed this finding with the Regional Director of Clinical Operations. 6. On 3/31/26, R58's clinical record was reviewed and indicated that R58 was readmitted to the facility as a skilled resident the first week of December 2025. The Medical Provider visited R58 and signed the medication Order Review History Report (physician block orders) on 12/10/25 with the next required provider visit and signing of physician block orders due by 1/19/26 (30 days plus 10 day grace). Providers made multiple visits between 12/10/26 - 1/19/26, but the next time physician block orders were signed was 1/7/26, but that provider did not have a documented visit on that day. On 3/31/26 at 10:42 a.m., the Regional Director of Clinical Operations and a surveyor reviewed R58's clinical record. The next time a Medical Provider visited R58 and signed the physician block orders was on 2/5/26, 17 days late. The surveyor confirmed a provider signed the physician block orders with no physician visit, thus making them late when a provider actually visits the resident, reviews the resident's total care, and signs the physician block orders.

Based on observations and interviews, the facility failed to ensure that plastic scoops were not left in the flour and sugar bins, in the walk in refrigerator the facility failed to prevent cross contamination when they had a plastic container with lettuce leaves, bag of carrots, unpeeled cucumber and an onion wrapped in plastic wrap all in the same container on 1 of 4 days of survey (3/29/26) in addition the facility failed to ensure all kitchen staff were wearing facial hair restraints on 2 of 4 days of survey (3/29/26 and 3/30/26). Findings: On 3/29/26 at 10:55 a.m. during the initial tour of the kitchen an observation of the flour and sugar bins showed the scoops were left in the flour and sugar bins. On 3/29/26 at 10:57 a.m. during the initial tour of the kitchen, the surveyor observed that the cook did not have his facial hair restraint on completely leaving his mustache uncovered while performing food preparation tasks. This observation was confirmed with the cook at the time of the observation.On 3/29/26 during lunch meal tray service the dietary aide was observed preparing the lunch trays with desserts and the plated food without having his facial hair covered. On 3/30/26 during lunch preparation observation the cook was observed having his facial hair restraint that was not on completely leaving his mustache uncovered. The dietary aide did not have a facial hair restraint on leaving his beard and mustache uncovered. On 3/30/26 at 10:49 the surveyor confirmed with the Food Service Director (FSD) that the cook and the dietary aide did not have a facial hair restraint on while performing food handling tasks.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was admitted with a diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 1 sampled residents reviewed for PASRR (Resident #8 [R8]).Finding:On 3/31/26, R8's clinical record was reviewed. Documentation indicated that R8 was admitted with a PASRR Level I screening that did not include R8's active diagnoses of Post Traumatic Stress Disorder (PTSD) or anxiety disorder. The clinical record lacked evidence that the resident was referred to the State mental health authority for a new PASRR determination.On 3/31/26 at 11:44 a.m., during an interview with a surveyor and the Director of Nursing Services (DNS), R8's medical record and PASRR were reviewed. At this time the surveyor confirmed with the DNS that the clinical record lacked evidence that R8 was resubmitted for a PASRR determination to include R8's active diagnoses of PTSD and anxiety.

Based on record review and interview, the facility failed to ensure a care plan was developed and implemented to address the needs of a resident to minimize triggers that may cause re-traumatization for 1 of 1 resident(s) reviewed for Pre-admission Screening and Resident Review (Resident #8 [R8]).Finding:On 3/31/26, R8's clinical record was reviewed and indicated that R8 was admitted with an active diagnosis of Chronic Post Traumatic Stress Disorder (PTSD). R8's Initial assessment indicated R8 had experienced physical/emotional trauma that is triggered by certain sounds. The clinical record lacked evidence that interventions were put in place to prevent re-traumatization.On 3/31/26 at 11:44 a.m., during an interview with the surveyor and the Director of Nursing Services (DNS), R8's medical record was reviewed. The DNS confirmed with the surveyor that the care plan does not address PTSD to include goals, or interventions to prevent re-traumatization.

Based on interviews, and record reviews, the facility failed to assist a resident with scheduling a follow-up appointment for Eye Care or assist the resident to obtain new eyeglasses when they were lost for 1 of 1 resident(s) reviewed for vision and hearing (Resident #3 [R3]).Findings:On 3/29/26 at 10:53 a.m., during an interview with a surveyor, R3 stated he/she cannot see without his/her glasses, and they have been missing for approximately 3 weeks. R3 stated that nursing staff and the Administrator looked for them, but R3 does not know if there is a plan to find or replace them.On 3/30/26 at 2:21 p.m., during an interview with a surveyor, a Certified Nursing Assistant (CNA) stated R3's glasses have been missing for a while. She stated there was a screw that had come out of one of the hinges and would not go back in. The CNA stated she thought R3 went to the eye doctor recently. The appointment book was reviewed with the CNA. On 2/3/26, R3's Eye Care appointment was crossed off with a note stating Will need to reschedule. Call to reschedule when glasses are found. The book was reviewed for the year ahead and no future appointments were scheduled. The CNA stated that when an item goes missing such as glasses, staff will do a search for the item, then they report it to the charge nurse, and staff will notify family of the missing item.On 3/30/26 at 2:46 p.m., during an interview with a surveyor, the Regional Director of Clinical Operations and the Director of Nursing Services (DNS), R3's medical record and the appointment book were reviewed. At this time a surveyor confirmed the clinical record lacked evidence that the glasses were missing or that R3's family was notified (see F842).On 3/30/26 at 2:56 p.m., during an interview with a surveyor, the Regional Director of Clinical Operations and the Administrator, the grievance book was reviewed. The Administrator stated the glasses went missing on 2/3/26, that they were found at dialysis on 2/5/26, and were reported missing again on 2/6/26. The Administrator stated R3 was going to ask about them at dialysis on 2/9/26. The Administrator confirmed that the facility did not assist the resident in locating the lost eyeglasses (See F585) and did not know if they were missing from the facility or from the dialysis center. At this time the surveyor confirmed that R3's Eye Care appointment was not rescheduled, and the facility did not follow up with the resident to assist with obtaining new eyeglasses after they were lost.

Based on observation, facility policy review, and interview, the facility failed to ensure that staff followed Enhanced Barrier Precautions during a pressure ulcer dressing change for 1 of 1 resident (Resident #32 [R32]).Finding: The facility's policy, Precautions to Prevent Infection, revised 6/24, indicated that Enhanced Barrier Precautions requires gown and glove use for certain residents during specific high-contact resident care activities that included those with indwelling medical devices and/or wounds, even if the resident is not known to be infected or colonized with a Multi-Drug Resistant Organism (MDRO). The high contact care activities list included wound care and dressing change for pressure injuries On 3/29/26, R32's clinical record was reviewed, and indicated on 3/25/26, a Medical Provider observed and documented that R32 had an unstageable pressure ulcer on the spine. On 3/31/26, R32's care plan for the care area of the resident has a pressure injuries mid back was updated to include Enhanced Barrier Precautions and to don (apply) gloves and gown when performing high contact activities which included wound care. On 3/31/26 at 10:46 a.m., a surveyor observed Registered Nurse #1 (RN1) complete a dressing change to R32's spine pressure ulcer. RN1 completed the dressing change but did not wear a gown during the procedure. On 3/31/26 at 11:25 a.m., during an interview with RN1, a surveyor confirmed this finding.

Based on record reviews and interview, the facility failed to notify the Ombudsman of transfers/discharge to a hospital for 2 of 3 residents reviewed (Resident #48 [R48] and R58).Findings: 1. On 3/30/26, R48's clinical record was reviewed an indicated that the resident was transferred and admitted to the hospital on [DATE]. 2. On 3/30/26, R58's clinical record was reviewed and indicated that the resident was transferred and admitted to the hospital on [DATE]. On 3/30/26 at 12:22 p.m., during an interview with a surveyor, the Regional Director of Clinical Services stated Ombudsman notifications were not sent for the months of November thru January.

Based on observations, record reviews and interviews, the facility failed to ensure that a resident record contained accurate, complete, and/or readily accessible information for 2 of 22 residents reviewed on survey (Resident #3 [R3], and R10).Findings: 1. On 3/29/26 at 10:53 a.m., during an interview with a surveyor, R3 stated that his/her glasses have been missing for 3 or more weeks, and he/she can't see well without them. No glasses were observed in use or within the room at the time of the interview. On 3/30/26 at 2:15 p.m., during an interview with a surveyor, R3 stated his/her glasses are still missing. R3's roommate stated that they have been missing for more than 3 weeks now. No glasses were observed in use or within the resident's room at the time of the interview. On 3/30/26, review of R3's Certified Nursing Assistants (CNA) documentation indicated that R3's glasses were put on each morning and removed every evening. The clinical record lacked evidence that the glasses were missing. On 3/30/26 at 2:46 p.m., during an interview with a surveyor, the Regional Director of Clinical Operations and the Director of Nursing, R3's medical record was reviewed. At this time, a surveyor confirmed R3's clinical record lacked evidence that the glasses were missing, that the resident representative was notified, and CNA documentation had inaccurate information regarding the R3's glasses. On 3/30/26 at 2:56 p.m., during an interview with the surveyor, the Regional Director of Clinical Operations, and the Administrator, the grievance book was reviewed. The Administrator stated that the glasses were reported missing on 2/6/26. At this time the surveyor confirmed that the clinical record lacked evidence that the glasses were missing, or that the resident representative was notified. 2. On 3/31/26, a clinical record review was completed for R10. In the clinical record a monthly pharmacist recommendation dated 9/28/25 for the diagnosis for the medication Olanzapine (Zyprexa) to be more specific than agitation/increased behaviors The nurse updated the diagnosis on 12/7/25 to behaviors of hitting, punching, kicking, agitation and screaming which are not a diagnosis but rather behaviors. On 3/31/26 at 8:50 a.m. during an interview with the Director of Nursing the surveyor confirmed the above finding. On 3/31/26 at 10:15 a.m. during an interview with the Regional Director of Clinical Operations, she stated the diagnosis for the use of Olanzapine (Zyprexa) was updated to vascular dementia with behaviors by the in-house provider.

Based on observations and interview, the facility failed to maintain a clean/sanitary environment on 1 of 1 days of survey (12/30/25). This has the potential to effect all residents.Findings:On 12/22/25 at 8:00 a.m., the State of Maine, Division of Licensing and Certification received an anonymous complaint including an allegation that there was standing water in the basement.On 12/30/25 at 12:12 p.m., during the environmental tour 2 surveyors and the Regional Director of Clinical Operations observed and confirmed the presence of standing water in a basement storage room located below the kitchen and in the basement space located below resident rooms.On 12/30/25 at 12:40 p.m., during an interview with a surveyor, the Maintenance Director stated the standing water located in the storage closet is from water leaking in from the loading dock (connected to the kitchen), and the water traveled down through the wall to the storage room.On 12/30/25 at 3:00 p.m., during an interview with a surveyor, the Maintenance Director stated the water in the basement below the resident rooms is from leaking windows, and that the landscaping angles toward the building sending snow melt and/or runoff water in.

Based on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, by not storing food in a sanitary manner and not maintaining a clean kitchen floor for 1 of 1 days of survey (12/30/25).Findings:On 12/30/25 at 11:25 a.m., during a tour of the kitchen and food storage, a surveyor and the Food Service Director observed and confirmed the following:-In the meal prep area food debris was observed on the floor under kitchen surfaces and shelves that was not associated with the current meal service.-Behind the stove a large pile of food debris was observed on the floor against the wall with cooking utensils partially buried in the debris.-In dry food storage area across from the walk-in freezer, loose fries and a biscuit were observed on the floor.-In the walk-in freezer, food debris was observed on the floor including a fish filet and loose fries, an open box containing packages of green beans was stored on the floor, and boxes of hamburger patties, chicken breasts, and creamer were observed to be stacked in a pile, and stored on the floor.-Within the walk-in refrigerator, a large mesh bag of onions was observed to be stored on the floor.

Based on review of the Complete IDDSI [International Dysphagia (difficulty swallowing) Diet Standardisation Initiative] Framework guidance, record review, and interviews, the facility failed to provide a resident with a minced and moist meal as ordered by a physician for 1 of 2 residents reviewed with a therapeutic diet (Resident #1 (R1). Findings:Review of the Complete IDDSI [International Dysphagia Diet Standardization Initiative] Framework Detailed definitions 2.0 l 2019 are to describe texture modified foods and thickened liquids used for individuals with dysphagia [difficulty swallowing] of all ages, in all care settings, and all cultures. IDDSI Level 5, minced & moist, listed under the heading, BREAD, states, No regular, dry bread, sandwiches or toast of any kind. On 9/29/25 at 10:06 a.m. R1's Physician Assistant-Clinical (PA-C) order stated under, Assessment and Plan, Patient recently seen in the ER twice for increased cough congestion as well as dysphagia concerning for aspiration pneumonia.will get speech therapy involved due to concerns for stricture (narrowing) in his/her esophagus (swallowing tube). Did speak with speech therapy and changed diet to minced and moist with thin liquids. Upright with all meals.On 9/30/25 at 12:30 p.m. R1's Nursing observations, evaluation, and recommendations are: Pt [R1] was given a roll for lunch while on a minced and moist diet. Now unable to swallow own secretions and vomits anytime he/she swallows a drink or food.On 9/30/25 at 13:18 (1:18 p.m.) R1's Heath Status Note states, During lunchtime pt [R1] began vomiting and it was noted that pt [R1] had a half eaten roll on plate (pt [R1] attempted to eat again and instantly vomited. Pt [R1] unable to swallow own secretions. Concerned about an esophageal stricture-sent to ED (emergency department).On 12/30/25 at 11:44 a.m. in an interview with a surveyor, the Rehab Director stated the facility follows the IDDSI and stated that Level 5, minced and moist does not include bread.On 12/30/25 at 4:18 p.m. in an interview with the Director of Nursing, a surveyor confirmed that after R1's ED visits over the weekend, R1's diet was changed on 9/29/25 by the PA-C to minced and moist, thin liquids. On 9/30/25 R1 received a roll and attempted to eat it causing further coughing and vomiting which necessitated another visit to the emergency department on 9/30/25, and subsequent return to the facility.

Based on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 1 survey days. (12/30/25). Findings:On 12/30/25 at 11:00 a.m., 2 surveyors observed several bags of trash stored on the ground next to the facility dumpsters. The hinges for the lids of the dumpster on the right were observed to be broken and did not cover the refuse. At 11:04 a.m., 2 surveyors observed, in the outside area by the loading dock, a used food container frozen in the snow on top of a snow covered cooler, and a round trash barrel without a lid containing trash/debris and a milk crate frozen in place with accumulated ice expanding over the edges of the barrel.On 12/30/25 at 12:12 p.m., during an interview with 2 surveyors and the Regional Director of Clinical Operations, the above findings were confirmed.

Based on observation and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and spread of infection related to laundry room storage for 1 of 1 laundry room tour (12/30/25).Finding:On 12/30/25 at 12:12 p.m. a surveyor observed a buildup of lint behind the dryer, and the floor in the laundry room was covered with dirt and debris. Slings (devices used to place residents on/in while being transported via a mechanical device) were observed piled up on the floor between a door and a wall leading out of the laundry area, and there were slings on wall hooks near the dryer hanging in such a way that part of the slings were touching the floor and touching the inside of a lint filled garbage can.On 12/30/25 at 12:26 p.m. during an interview and tour of the laundry room, a surveyor confirmed with the Regional Director of Clinical Operations that slings were stored on the floor and on wall hooks touching the floor.

Based on observations, interviews, facility policy review, and record review, the facility failed to monitor a resident's bowel movements and initiate the Bowel Regime protocol on shift 7 for 1 of 1 residents reviewed (Resident # [R] 46). This failure resulted in R46 not having a bowel movement for an additional 16 shifts which resulted in R46 screaming out for help and crying because of the pain due to gas buildup and constipation. Findings: The facility's policy, Bowel Regime last revised 3/23 indicated: - Certified Nursing Assistant (CNA) is responsible for accurate documentation of bowel moments in Point Click Care (PCC) [electronic medical record]. - The Licensed Nurse reviews the PCC Clinical Alerts daily for residents in need of the bowel regime. -Residents will have an Medical Doctor (MD) order that reads as follows unless otherwise specified by a healthcare provider: Milk of Magnesium (MOM) 30 cubic centimeter (cc) by mouth (PO) as needed (PRN) if no bowel movement (BM) after six shifts; Dulcolax suppository 10 milligrams per rectum (PR) PRN/ if MOM ineffective; Fleet Enema 1 PR PRN if Dulcolax Suppository ineffective. -The Licensed nurse will review PCC daily for residents in need of the bowel regime and list residents who have not had sufficient BM's within the last six shifts, MOM will be administered per order at the beginning of the 7th shift. If insufficient BM after the MOM is administered, the Licensed Nurse will administer a Dulcolax suppository the following shift. Residents not having results after Dulcolax Suppository will receive enema. R46's care plan, last revised 1/19/25, identified that The resident is at risk for alteration in gastro-intestinal status related to constipation and directed staff to follow the facility bowel protocol for bowel management. On 2/25/25 at approximately 10:30 a.m., a surveyor heard a resident crying out for help saying, please help me, help me. The surveyor observed a CNA enter R46's room and heard the CNA ask R46 what they needed; R46 said, I can't poop, I hurt so bad, I can't push it out. The CNA asked R46 if he/she wanted to try the bed pan and resident said, I can't use that. (R46 has a wound on coccyx). On 2/25/25 at 10:45 a.m., a surveyor again heard R46 crying and observed the resident laying on his/her left side rocking his/her body back and forth, crying and stating, someone please help me. The surveyor observed a medical provider in the room and heard the provider say to a Registered Nurse (RN) that R46 refused a rectal exam and to give fluids and an extra dose of oxycodone (narcotic) to treat the pain and requested an abdominal x-ray. On 2/25/25 at 12:07 p.m., during an interview with multiple staff and a surveyor, CNA1 stated that it was the CNAs responsibility to document the bowel movement. She stated that R46 was calling out and she went into the room. R46 told me to call the police because his/her butt hurts. R46 refused the bed pan and wanted the Doctor. RN1 then stated that R46 was visibly in pain and that she contacted the Doctor and since the resident received his/her scheduled Miralax and Senna plus, the Doctor ordered a suppository (Bisacodyl), which RN1 stated she administered (at 10:47 a.m.). Review of R46's physician orders indicated that R46 was receiving scheduled Miralax daily and Senna plus twice daily. R46's Medication and Treatment Administration Records for February 2025 lacked evidence that R46 had been offered or given PRN Bowel Regime medications or treatments until the Doctor was called on 2/25/25 when R46 was screaming and crying because of the pain and not being able to have a bowel movement. Review of the Physiatry Medical Provider documentation, dated 2/25/25, indicated that R46 had been without a bowel movement, contributed due to a lack of adequate by mouth intake. They have increased Miralax to twice a day, continuing the scheduled Senna twice a day and have ordered a suppository as well as an enema with a plan to give as-needed oxycodone to the patient. Monitor for any changes in bowel habits and adjust interventions as needed to maintain regular bowel function. On 2/25/25 at 12:18 p.m., during an interview with multiple surveyors present, the Director of Nursing (DON) stated that the last documented BM for R46 was 2/17/25 and confirmed that the facility did not initiate the bowel protocol for R46. On 3/10/25 at 3:20 p.m., during an interview with a surveyor, the Administrator reviewed the x-ray results with the surveyor that confirmed non obstructive bowel gas pattern with fecal residue which may corrilate with clinical constipation. On 3/10/25 at 3:55 p.m., during an interview with a surveyor, the DON stated that the bowel protocol for R46 should have started on shift 7 with a suppository because R46 was already receiving Miralax. Review of the bowel documentation provided indicated that R46 had 1 small and 2 medium BMs after bowel treatment intervention on 2/25/25. On 3/11/25 at 11:07 a.m., during an interview, Physiatry Medical Provider stated R46 was having minimal oral intake/mobility as R46 got closer to end of life care and has had history of constipation, therefore it was regular for R46 to go several days without BMs. This is why on the 19th, I recommended to continue the current regiment and recommended to make adjustments if continued constipation. I did not see this patient again until 2/25, and there were no nursing complaints prior to this time. This is where I became concerned regarding lack of BM and change in behaviors as this was not normal for R46. I then brought this to the primary team's attention, and made several changes myself to R46's regiment as soon as I saw R46 including increasing miralax, addition of suppository and other regiment per Doctor's recommendations. In the past if patients did not have a bowel movement and there was nursing concern there are standing orders that can be ordered such as fleet enema, MOM and suppositories as stronger agents if without BM or call out to Third Eye (off hours physician service). This did not occur from the last time I saw R46 on the 19th until I saw R46 again on the 25th. On 3/11/25 at 11:09 a.m., during an interview, Nurse Practioner stated Nursing never brought to our attention that she was constipated or hadn't had a BM in a week.

Based on Payroll Based Journal staffing report and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the fourth quarter (July 1 - September 30, 2024). Finding: A payroll based journal (PBJ) report for the fourth quarter of 2024 indicated the facility triggered for low weekend staffing. On 2/23/25 at 11:07 a.m., during an interview with the Administrator, the surveyor stated that the facility triggered for low weekend staffing for the 4th quarter per the PBJ report. The Administrator stated that Human Resources was responsible for the PBJ data. On 2/24/25 at 1:35 p.m., during an interview with a surveyor, Human Resources stated that the facility's (payroll) system computes the data for the PBJ report. No additional information was provided to indicate that the PBJ information was incorrect which identified low weekend staffing.

Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information to formulate an advanced directive or appoint a surrogate, was completed for 4 of 7 residents reviewed for advanced directives.(Resident #[R] 7 , R46, R214, and R17). Findings: 1. On 2/24/25 R7's clinical record was reviewed and indicated R7 was admitted to the facility the middle of January 2025. Review of R7's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to formulate an advance directive or appoint a surrogate. 2. On 2/24/25, R46's clinical record was reviewed and indicated R46 was admitted to the facility the middle of January 2025. Review of R46's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to formulate an advance directive or appoint a surrogate. 3. On 2/24/25, R214's clinical record was reviewed and indicated R214 was admitted to the facility on the middle of February 2025. Review of R214's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to formulate an advance directive or appoint a surrogate. On 2/24/25 at 1:58 p.m., during an interview with surveyors, the Administrator confirmed there was no evidence of offering Advance Directives or obtaining Power of Attorney (POA) paperwork (if applicable) in the clinical records. 32540 4. On 2/24/25 during a clinical record review it is documented that R17 was admitted to the facility in 2020. A review of R17's clinical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 2/24/25 at 1:58 p.m. During an interview with the Administrator the surveyor confirmed R17's clinical record does not have any evidence of an Advanced Directive.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building and resident equipment in good repair and in a sanitary condition for 2 of 3 days of survey (2/23/25, 2/24/25). Findings: 1. On 2/23/25 at 11:30 a.m., in the bathroom for room [ROOM NUMBER], a surveyor observed the vinyl covering on the inside of the bathroom door to be torn and sticking out. At 11:50 a.m., the surveyor and Administrator observed the torn vinyl door covering; the surveyor confirmed this finding at this time. At 11:55 a.m., the surveyor observed the Interim Maintenance Director remove the torn vinyl from the bathroom door. 2. On 2/24/25 at 1:40 p.m., the Interim Maintenance Director and surveyor completed an environmental tour and the following were confirmed: In room [ROOM NUMBER], the wood trim on the wall behind the head of the bed was broken; In room [ROOM NUMBER], the blind slats were broken; In room [ROOM NUMBER], the blind slats were broken; In room [ROOM NUMBER] bathroom, the paint was chipped in multiple areas; and The wheelchair arms for Resident # 34 were both cracked and uncleanable.

Based on record reviews and interviews, the facility failed to ensure residents with a specialized mental health diagnosis had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review (PASRR) evaluation and determination for 1 of 2 residents reviewed for PASRR evaluation (Resident #48 [R48]). Finding: Clinical record review indicates R48 was readmitted to the facility on [DATE], diagnoses to include bipolar disorder, anxiety disorder, and major depressive disorder. Review of R48's PASRR Level I dated 5/10/24 indicates R48 had a Convalescence Categorical exemption (a time-limited 30-day exemption). R48's clinical record lacks evidence that the resident had been re-evaluated for a PASRR Level II determination after the Convalescent period ended on 6/11/24, 8 months later. On 2/24/25 at 11:42 a.m., in an interview with the Director of Nursing Services, a surveyor confirmed R48 had not been re-evaluated for a PASRR Level II determination after the Convalescent period ended.

Based on review of the Facility Reported Incident report, facility's investigation, facility's policies and procedures, record review, and interviews, the facility failed to follow their own policy and procedures for Transfer Techniques, Fall Prevention Program, Accident/Incidents and failed ensure that care plan interventions for the use of a gait belt during transfers were followed for 1 of 2 sampled residents (#1). This failure to use a Gait Belt resulted in a distal femur fracture. Finding: Review of the Facility's Reported Incident form, dated 4/13/23 and the 5 day follow up report, dated 4/17/23, stated on 4/11/23 resident sustained an injury while two students and one CNA were transferring. The resident had an x-ray and right femoral fracture was found. Review of the facility's 5 day follow up report, dated 4/17/23, indicates Resident #1 was lowered to the floor during the transfers due to becoming very weak. Resident #1 was then placed in the whirlpool chair with the assistance of a Certified Nursing Assistance (CNA) and CNA student. Once in the whirlpool, [Resident #1] complained of right knee pain. He/she was removed from the whirlpool, provided ice and remained comfortable throughout the afternoon. The following morning the resident was seen by the provider, complaining of some pain and swelling of the right knee, an X-ray of the knee found a right distal femur shaft fracture with malalignment. Review of the facilities investigation contained statements from the witnesses: CNA Student #1 witness statement, dated 4/13/23 at 8:44 a.m.: On 4/11/23 during clinical .resident was brought in on his/her wheelchair by the CNA. The CNA was transferring him/her to the Whirlpool chair by herself. [Resident #1] was weak and started to lower to the floor. CNA guided him/her down to the floor, and I noticed residence leg was in an awkward position on the floor. [Resident] was in distress at the time and he/she appeared in pain. The other CNA student I was with, assisted CNA to get [Resident #1] from the floor to the Whirlpool chair. [Resident #1] was then lifted into the whirlpool by CNA . as the other CNA student and I were helping [resident] in the Whirlpool. [Resident] began crying and complaining of leg pain. This was reported to the CNA instructor who then got the nurse. CNA Student #2 witness statement, dated 4/13/23 at 8:44 a.m.: On 4/11/23 during clinical .The CNA went to transfer [resident] from his/her wheelchair to the whirlpool chair lift but resident was not strong enough to stand so CNA lowered him/her to the floor. I helped the CNA lift [resident] from the floor to the whirlpool lift chair. During the whirlpool [resident] complained of pain in his/her knee and was crying so I went to get my instructor. CNA Student #3 stated dated 4/13/23: when I came into the area where {Resident #1] was, the CNA was in the middle of transferring the patient from his/her wheelchair to the whirlpool chair when the patient couldn't hold his/her weight. CNA was still holding on to him/her and slowly brought him/her down to the floor. The patient's leg on the right side was at an awkward angle. CNA then asked one of the CNA students to help her transfer [resident] into the whirlpool chair. On 4/18/23 at 10:16 a.m., during an interview Resident #1 stated, That day I slipped out. It was a total accident, and when I did my leg bent backwards. I screamed, my leg my leg . I slipped out of the CNA 's hands .I slipped out of their hands and when I fell my knees went back from my thigh. On 4/18/23 at 11:38 a.m., during an interview with the involved CNA, the CNA stated if she's unaware of what assistance a resident needs, I usually ask it in report and then there's also the Kardex, which I did not check for [Resident #1] transferring. She was told by another CNA that Resident #1, was just a stand pivot which he/she was supposed to be with a gait belt and I didn't know that. Surveyor asked the CNA if she used a gait belt during the transfer. CNA stated, no, no gait belt was used. CNA confirmed she attempted to stand pivot Resident #1 stating, The first time I stood [him/her] up and I just had the student pull his/her brief out, and resident stated oh, I got to sit. So, I sat resident down in his/her wheelchair .I stood resident up again and then he/she just wouldn't stand, like he/she just like deadweight . So, we lowered resident to the ground CNA then confirmed that both her and student CNA picked the resident up off the floor and placed him/her on the whirlpool chair without the use of a Hoyer lift and then transferred him/her to the tub. CNA stated when she asked the resident if he/she was ok, resident replied, I think I might have twisted my knee. The CNA went to get the nurse, however, was redirected by answering call bells. When she talked to the nurse, the Nurse stated, he was already made aware by the CNA student's instructor of the residents twisting of the knee and had already evaluated the resident knee pain. At this time, the CNA stated she did not notify the nurse of the resident being lowered to the floor/fall stating, I also didn't know that qualified as a fall. I had been told before that if a staff was present and they were lowered, it doesn't qualify. Obviously, I was still going to tell the nurse but I didn't get him right then and there, and I should have. I should have left him/her on the floor. On 4/18/23 at 12:29 p.m., during a telephone interview with the involved Licensed Practical Nurse (LPN #1), he stated on 4/11/23 the CNA and the students put Resident #1 in the tub, when he/she was getting in he/ she hurt his/her leg. At the time of the report the LPN was not told of the resident being lowered to the floor. He stated, he had given Resident #1 Tylenol and he/she was sleeping approx. 45 mins later. He went back after an additional hour to look at the resident's leg, as soon as I touched it, he/she cried out with pain, said it hurt terrible. I put a call out to PA (physician assistant). Stating, he filled out an SBAR (Situation Background Assessment and Recommendation) and the Physician Assistant (PA) did not call back during his shift. He reported off to the oncoming LPN #2 what had happened with Resident #1 and that there was a call out to the PA and he left the facility at 6:30 p.m. On 4/19/23 at 9:00 a.m., during a telephone interview with LPN #2, she stated, it was reported that 2 CNA 's transferred him/her in a stand pivot and his/her knee twisted the opposite way and he/she bumped his/her knee. Upon evaluation of Resident #1's knee was very swollen and [resident] and I talked about the fact [resident] already had surgery on that knee. So, I iced it, I gave him/her Tylenol .I checked on resident all night . made sure report in the morning said I think his/her knees should be X-rayed just to rule out the possibility of a new fracture on an old site. The knee was where he/she had the pain .she told me she had a fall, that sounded not good. On 4/18/23 Resident #1's care plan, with a revision date of 8/18/22, under the Focus area of Activities of Daily Living (ADL) self-performance deficit, contained an intervention that directed staff that Resident #1 was a Squat pivot transfers in/out of bed with 1 assist and gait belt. Nurse note, dated 4/11/23 at 10:13 a.m., states, Late entry, this writer in to check on resident who had been asleep. Upon awaking he/she had c/o pain 7/10 in RLE (right lower extremity). attempts to move leg causes resident to cry out. Right LE (lower extremity) continues with 0 redness or edema. Placed call to provider to question need for X-ray with no answer. Message left to return call. Nurse note, dated 4/11/23 at 10:31 a.m., states, upon transfer with 2 asst to shower chair res c/o twisting his/her knee Nurse note, date 4/11/23 at 9:45 p.m., states patient complained of pain right knee. The knee is swollen, tender . unable to move leg without pain to knee. Ice applied per request x 10 minutes. with patient stating some relief. states that this knee is also the one he/she injured requiring surgery years ago. Bruising noted below the knee, with patient stating that's where he/she landed when he/she fell . Will continue to monitor and leave note for oncoming and MD. Dated 4/12/23 at 4:08 p.m., states resident seen by provider today for pain and swelling in right knee. And X-ray was ordered, showing fracture of distal femur shaft . family notified by (PA) . resident will be NWB (non-weight bearing) and no Hoyer lift to be used. Provider notes, dated 4/12/23, patient did have a whirlpool yesterday and with this he/she slipped onto the ground affecting his/her right knee with increased edema and discomfort .pain in right knee. s/p fall to the floor hitting his/her right knee. History of right total knee arthroplasty many years ago. We'll check X-rays of right knee to rule out fracture. Will place patient on Tylenol 650 mg (milligrams) 3 times Daily x 5 days. Will utilize biofreeze every 2 hours as needed pain. Patient is essentially bed bound and does not ambulate or place weight onto his/her legs at this point. Provider notes, dated 4/13/23, seen today for increased pain secondary to right femur fracture . the day before yesterday patient was going for a whirlpool and after discussion with CNA what was found is that patient had a 2 person assist from his/her wheelchair to the whirlpool chair while they were doing this patient became dead weight and fell to his/her right knee in an awkward angle to his/ her leg. Staff helped lower him/her to the ground and he/she did complain of right knee pain at that time and was noted to have swelling. Patient did have X-rays yesterday that did show a femur fracture distally above his/her total right knee replacement on the right side . we will place a long brace right leg on at all times. Patient is non weight bearing and no Hoyer lift at this point. Facility Transfer Technique Policy and Procedure, issued 10/2019 states, Purpose: To ensure that all resident transfers are completed in a safe and efficient manner for both the resident and the person and/or persons performing the transfer. Policy: Based on the residence needs, a gate belt may be used. All residents must be lifted or transferred according to the determined procedure. Transfer status will be documented on the resident's care plan, CNA Kardex/assignment. prior to transferring the resident, the staff member will check the transfer status on the Kardex/assignment to determine the proper transfer technique for the resident. Review of the facility's Accident/Incident policy and procedure with a revision date of 1/2023, directs staff to notify the nursing supervisor/licensed nurse when an incident occurs . The licensed nurse or the nursing supervisor will complete and document the evaluation of the residence condition. This evaluation is to include but not limited to: type of injury with location on body . the health care provider will be notified with the date and time of notification documentation in RMS (risk Management System) in nurses notes. Document any new orders or recommendations made by the health care provider. If unable to reach the healthcare provider in a timely manner, call the medical director .The responsible party will be notified by the licensed nurse/designee with the date and time of notification documented in RMS and nurses' notes. Review of the facility's Fall Prevention Program with a revision date of 3/23 states, A fall: an observed or unobserved, unexpected drop to a lower level or loss of erect position and directs staff to includes fall prevention measures on the CNA Kardex/assignment .Follows directions for care as indicated on the resident care flow sheets. If a fall occurs, keeps the resident in mobile until resident is examined and determined to be free from fractures. Review of the No lift expectations: Eastside Rehabilitation Center is a no lift facility if any resident falls they must be Hoyer lifted back to a chair or bed, it is never acceptable to lift a resident up off the floor. On 4/18/23 at 1:47 p.m. the surveyor discussed with the Administrator, the Director of Nursing and the Regional Director of Operations that the CNA did not use the gait belt during this transfer that resulted Resident #1 sustaining a distal femur fracture, staff did not to use a manual lift to get the resident off the floor and staff did not to notify the nurse immediately of the fall. At this time, the Administrator notified the surveyor that the facility had identified and acted upon these findings on 4/13/23 (2 days) after the resident was lowered to the floor to prevent future occurrences. See list below for actions facility initiated. As a result of the facility's investigation, the following corrective actions were initiated on 4/13/23: - Wrote a plan of action for this event which included, care plan for transferring not followed, resident experienced a fall and nurse was not notified. - Resident care plan was reviewed for how to transfer resident safely - Audit care plans to see who is supposed to be transferring with a gait belt and ensure there is one available in the room. - Review residents who transfer with gait belt with therapy to ensure this is how the resident should be transferring. - Created audits for monitoring transfers being completed per care plans - All clinical staff will be education on the fall policy and procedures as well as accidents in injuries policy and procedure. - Clinical staff will be educated that facility is a no lift facility. Staff involved in the incident will be educated prior to working again including a gate belt competency. - CNA involved was provided education on gait belt application and techniques, utilizing a Hoyer lift if resident is on the floor, resident and the facility, accident/incident policy and fall prevention policy and procedure. - 2 Audits have been completed since fall. - Results will be reviewed in Quality Assurance Performance Improvement meetings until 3 months of compliance have been reached.

Based on interviews, review of facility's policies and procedures for Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) use, and review of the Bangor Fire Department Emergency Medical Service (EMS) Patient Care Report, the facility failed to provide CPR to a resident (Resident #1) who was a full code, when found unconscious, not breathing, and pulseless. This failure resulted in delay of basic life support care to a resident and created an immediate jeopardy situation for 1 of 22 residents who were a full code status. Findings: On [DATE], the Department of Licensing and Certification received a complaint from an anonymous source indicating that CPR was not provided by the nurse and the AED device was not functioning. On [DATE], the Department of Licensing and Certification received a second complaint that indicated the nurse caregiver did not know the resident's code status which caused an eight to ten minute delay before the Paramedics were able to initiate CPR and life saving care. On [DATE] at 12:29 p.m., interview with the Bangor Fire Department Chief. He stated on [DATE] at 9:08 p.m., the EMS crew received a call to go to the facility for a cardiac arrest. He stated the next day one of the Paramedics told him that when they arrived at the facility, a Registered Nurse (RN) stated the resident had passed away and asked the Paramedic to assist the resident back into bed. The Paramedic asked for the code status of Resident #1 and the RN stated she thought it was a DNR. The Paramedic asked for a copy of the resident's DNR form. At this time, the RN did not know the resident's code status. The RN looked at the clinical record and discovered the resident had been a full code. From the time the Paramedics arrived at the facility to the time the RN realized the resident was a full code, eight to ten minutes had passed and delayed initiating CPR. On [DATE], the Bangor Fire Department EMS Patient Care Report was reviewed. The Paramedic documented that when they arrived at the facility, the RN stated the resident passed away and asked for assistance in lifting the resident onto the bed. The Paramedic asked the RN if the resident was a DNR and the RN stated yes. The Paramedic asked for a copy of the DNR form (which is standard practice). The RN looked at the resident's clinical record and found that the resident was a full code. The ambulance crew initiated CPR and lifesaving support care for 45 minutes. At 10:00 p.m., resuscitation attempts were terminated, and time of death was called. On [DATE] at 8:00 a.m., in an interview with the Director of Nursing (DNS). The DNS stated a resident's code status is obtained upon admission and is in the electronic clinical record in a banner under the resident's name and is on a pink piece of paper in the paper chart and should be in the care plan. The DNS stated on [DATE], she was informed that the RN did not perform CPR the evening of [DATE] when Resident #1 was unresponsive, not breathing and had no pulse. She stated she also was informed that the RN did not know the resident's code status until after the Paramedics arrived and asked her. The DNS stated on [DATE], she was given the AED device that would have been used to assist in the CPR on [DATE], but it was not in working order. The Paramedics used their own equipment. The DNS stated she started an investigation, and the RN was put on suspension until investigation over. On [DATE], Resident #1's clinical record was reviewed. Resident #1 was admitted for Skilled Services with a diagnosis of ischemic cardiomyopathy, atrial fibrillation, heart failure and other co-morbidities. On [DATE] at 11:43 a.m., interview with the RN. The RN stated that on [DATE] at approximately 8:30 p.m., she was called to Resident #1's room. The RN stated at that time the resident was on the floor, unconscious but breathing. She stated she told C.N.A. #1 and C.N.A. #2 to get vital signs and she went and called 911. During the call, C.N.A. #1 interrupted her call with 911 and stated C.N.A. #2 said the resident had passed. RN stated she went back to the room to find the resident unconscious, not breathing and no pulse. RN#1 stated she did not start CPR because she saw the EMS crew coming to the facility door. RN stated she left C.N.A. #1 with the resident and went to let the EMS crew into the facility. RN stated she did not initiate CPR on Resident #1 when discovering he/she had no pulse, no breath and was unconscious. She also stated she had not known the resident's code status until looking in the clinical record for the Paramedic. On [DATE] at 12:13 p.m., interview with C.N.A. #1. C.N.A. #1 stated that Resident #1 rang the call bell and needed assistance to the bathroom. On the way to the bathroom, C.N.A. #1 stated the resident's legs bucketed and she lowered Resident #1 to the floor. C.N.A. #1 stated she rang the room call bells to get help. After five or six minutes passed, C.N.A. #1 stated she looked out the door and saw C.N.A. #2 and yelled to her to get RN #1. C.N.A. #1 stated the resident was talkative to her after being lowered to the floor, but by the time RN#1 got to the room, Resident #1 was breathing but unconscious. C.N.A. #1 stated RN #1 went to call 911 and C.N.A. #1 went to get the blood pressure cuff while C.N.A. #2 stayed with the resident. She stated when she got back to the room with the cuff, C.N.A. #2 told her the resident had passed and to get the RN. C.N.A. #1 stated the RN said the resident was not breathing and had no pulse. C.N.A. #1 stated the RN left her in the room with the resident while RN let EMS in the facility. On [DATE] at 4:01 p.m., interview with C.N.A. #2. C.N.A. #2 stated all she remembered was C.N.A. #1 calling for help because something happened to Resident #1. She stated that C.N.A. #1 called out for her to get RN #1 and she did. The resident stopped breathing and I told C.N.A. #1 to go tell the nurse. C.N.A. #2 stated the ambulance came and she stayed out of the way. On [DATE], a review of the facility's CPR policy and procedure was completed. The policy stated that the facility will initiate CPR on all residents without an advanced directive order in the event of a cardiac arrest. Under the 'Guidelines' it indicated to verify that the resident is a full code. Under 'Procedure' #2: the licensed staff member will immediately assess the resident for responsiveness, checking for pulse and respirations. #3: If the resident is not a do not resuscitate (DNR) CPR will be initiated immediately. #7: Basic life support will continue to be provided by CPR certified staff and will not be discontinued until it has been determined that the resident is breathing on his own and has a pulse, or when the ambulance response team has taken over. On [DATE], the RN's personnel file was reviewed. On [DATE], the RN completed and passed the American Heart Association Basic Life Support (CPR and AED) program. Based on the above information, Immediate Jeopardy (IJ) was called on [DATE] for RN #1's failure to initiate CPR/lifesaving support to Resident #1 on [DATE] when he/she was found to be unconscious, not breathing and no pulse. The facility's failure to provide this service constituted an Immediate Jeopardy situation. Please see F-0000 Initial comments related to IJ removal plan.

Based on observations, documentation reviews and interviews; the facility failed to protect the residents from possible injury by allowing a known hot water temperature problem to exist in 8 of 8 resident rooms sampled (Rooms #202, #204, #206, #207, #208, #212, #216, and #217). Findings: On 2/29/16 at 10:45 a.m., during the initial tour of the facility, it was discovered that there were unsafe hot water temperatures in the following resident room sinks: Room #204 was 124.2 degrees Fahrenheit, Room #207 was 124.2 degrees Fahrenheit, Room #206 was 124 degrees Fahrenheit and, and Room #216 was 122.9 degrees Fahrenheit. The surveyor immediately notified the Maintenance Supervisor. On 2/29/16 at 11:00 a.m., the surveyor and the Maintenance Supervisor monitored the hot water temperatures simultaneously. The following was observed. 1. On 2/29/16 at 11:00 a.m., the hot water temperature in Room 202's sink was 122.4 degrees Fahrenheit. Four residents shared this bathroom. All four residents are wheelchair bound. No burns from hot water were reported. 2. On 2/29/16 at 11:03 a.m., the hot water temperature in Room 204's sink was 125.2 degrees Fahrenheit. Four residents share this bathroom. One is ambulatory and stated he/she doesn't use the sink. The other three residents are wheelchair bound. No burns from hot water were reported. 3. On 2/29/16 at 11:07 a.m., the hot water temperature in Room 207's sink was 128.1 degrees Fahrenheit. One resident uses a wheelchair and the other resident is ambulatory. No burns from hot water were reported. 4. On 2/29/16 at 11:11 a.m., the hot water temperature in Room 208's sink was 126 degrees Fahrenheit. Four residents share this bathroom. One is bed bound and the other three are wheelchair bound. No burns from hot water were reported. 5. On 2/29/16 at 11:15 a.m., the hot water temperature in Room 212's sink was 127.4 degrees Fahrenheit. Four residents share this bathroom. All four are wheelchair bound. No burns from hot water were reported. 6. On 2/29/16 at 11:19 a.m., the hot water temperature in Room 217's sink was 124.9 degrees Fahrenheit. Both residents in this room are wheelchair bound and stated they have not been burned by hot water. On 2/29/16, after checking the hot water temperatures, the Maintenance Supervisor immediately adjusted the facility water mixing valve and water temperatures were lowered to a safe temperature. A plumber was called in to address the hot water issues. Water temperatures were checked frequently for safe temperature levels during the rest of the survey. On 2/29/16 at 11:40 a.m., a review of a Renovation Request Form indicated that on 2/19/16, the purchase of a new mixing valve was approved. On 2/29/16 at 11:50 a.m., the Administrator stated the mixing valve that had been approved on 2/19/16 had not yet been installed. On 2/29/16, a review of the Maintenance Supervisor's Domestic Hot Water Temperature log for the month of February 2016 indicated that on February 1st the Maintenance Supervisor identified that the facility had unsafe hot water temperatures in some resident room sinks. The log reveals that the Maintenance Supervisor adjusted the water mixing valve on the following days: - 2/1/16 water temperature 121 degrees in Room 206 and Shower B. - 2/2/16 water temperature 125 degrees in Shower A. - 2/4/16 water temp 122 degrees in bathroom. - 2/10/16 water temp 121 degrees in Shower A. - 2/18/16 water temp 122 degree. - 2/23/16 water temp 121 degrees in room 211. - 2/25/16 water temp 128 degrees in Room 117. In addition, the Maintenance Supervisor's Domestic Hot Water Temperature log lacked evidence that hot water temperatures were monitored on the following days: 2/7/16, 2/8/16, 2/12/16, 2/13/16, 2/14/16, 2/15/16, 2/20/16, 2/26/16, 2/27/16, and 2/28/16. On 03/02/2016 at 11:48 a.m., in an interview with the Administrator, she stated she was aware of the hot water problems in the resident room sinks but did not put a plan of action in place to alert staffs about hot water and did not put a safety plan of action in place for resident safety. On 3/2/16 at 1:16 p.m., in an interview the Maintenance Supervisor, he stated that he did not inform the staff to be aware of unsafe hot water in resident sinks. In addition, he confirmed that he did not monitor for unsafe hot water temperatures in resident room sinks on a daily basis in February 2016. On 3/2/16 at 3:29 p.m., a corrective plan of action for the the unsafe hot water temperatures (Water Temperature Monitoring Program) was provided to this surveyor and it was accepted. Facility Administration informed staff of the unsafe hot water problem and were instructed to take water temperatures several times each shift. On 3/11/16, the State Agency confirmed that the facility installed a new mixing valve on 3/2/16.

Based on record reviews and interviews, the facility neglected to ensure treatments and interventions were provided to an open skin area when first identified on 9/14/15 that developed into an unstageable pressure ulcer by 9/25/15 for 1 of 1 Stage 2 Residents reviewed for pressure ulcers (#45). Finding: A review of Resident #45's clinical record contained a weekly skin integrity check, dated 9/14/15, which indicated that Resident #45 had an open skin area to the sacrum and a note was left in the book for the Physician to review. Review of physician progress notes [REDACTED]. Review of physician orders, from 9/14/15 thru 9/25/15, revealed no new ordered interventions or treatments for the open skin area identified on 9/14/15 were implemented. On 9/25/15, a weekly pressure ulcers flow sheet was started for Resident #45 which indicated that the Resident had an unstageable pressure ulcer to the right upper buttocks that measured 8 centimeters by 7.5 centimeters and was covered with eschar. On 3/3/16 at 4:05 p.m., during an interview with a surveyor, the Assistant Director of Nursing reviewed Resident #45's clinical record and was unable to find any evidence of interventions and/or treatments to the open skin area identified on 9/14/15. On 3/4/16 at 9:04 a.m., during an interview with a surveyor, the corporate Clinical Services Coordinator and the Unit Manager stated that they would review Resident #45's clinical record for interventions and/or treatments to the open skin area identified on 9/14/15. On 3/4/16 at 10:50 a.m., during an interview with a surveyor, the Minimum Data Set (MDS) Registered Nurse (RN) confirmed that they were unable to to find any evidence in Resident #45's clinical record of interventions and/or treatments put into place after the discovery of an open skin area to the sacral on 9/14/15.

Based on record reviews and interviews, the facility failed to provide treatments and interventions to an open skin area when first identified on 9/14/15 that developed into an unstageable pressure ulcer, by 9/25/15, for 1 of 1 Stage 2 Residents (#45) reviewed for pressure ulcers. Finding: Review of Resident #45's clinical record contained a weekly skin integrity check, dated 9/14/15, which indicated that Resident #45 had an open skin area to the sacral and a note was left in the book for the Physician to review. Review of physician progress notes [REDACTED]. Review of physician orders, from 9/14/15 thru 9/25/15, revealed no new ordered interventions or treatments were implemented for the open skin area identified on 9/14/15. On 9/25/15, a weekly pressure ulcers flow sheet was started for Resident #45 which indicated that the Resident had an unstageable pressure ulcer to the right upper buttocks that measured 8 centimeters by 7.5 centimeters and was covered with eschar. On 3/3/16 at 4:05 p.m., during an interview with a surveyor, the Assistant Director of Nursing reviewed Resident #45's clinical record and was unable to find any evidence of interventions and/or treatments to the open skin area identified on 9/14/15. On 3/4/16 at 9:04 a.m., during an interview with a surveyor, the corporate Clinical Services Coordinator and the Unit Manager stated that they would review Resident #45's clinical record for interventions and/or treatments to the open skin area identified on 9/14/15. On 3/4/16 at 10:50 a.m., during an interview with a surveyor, the Minimim Data Set (MDS) Registered Nurse (RN) stated that they were unable to to find any evidence in Resident #45's clinical record of interventions and/or treatments put into place after the discovery of an open skin area to the sacral on 9/14/15.

Based on observations, record reviews and interviews, the facility failed to maintain windows in a functional manner which allows for the introduction of pests into the facility. This failure to maintain an effetive pest control program contributed to the admittance of flies into the building that infested 1 of 3 residents wound area with larvae (#2). Findings: 1. On 9/8/14, the Division of Licensing and Regulatory Services (DRLS) received an anonymous report that on 9/7/14 around 11:00 p.m., a Registered Nurse (RN) responded to Resident #2's concern that he/she was experiencing burning and itching at his/her dressing site on his/her chest. This report indicated that when the bandage was removed, the staff observed that the resident had maggot larvae coming coming out of the resident's chest open area. On 9/9/14 at 9:40 a.m., in an interview with a surveyor, the Administrator and the RN, Director of Nursing, confirmed that Resident #2's dressing and chest tumor was contaminated with larvae and that interventions were in place to treat the area and prevent the further incidents. 2. On 9/9/14 at 10:15 a.m., a surveyor observed a fly in Resident Room #107, on the A-Unit. Resident #1 was present in the room at the time. The surveyor notified staff, who immediately entered the room and removed the fly. Resident #1 treatment forms for September 2014, indicated the resident had a Stage IV open area of the left hip with a dressing. On 9/9/14 at 1:30 p.m., in an interview with a surveyor, the RN, DON stated that the resident's pressure ulcer was being monitored and he/she did not have any larvae present. 3. On 9/9/14, from 11:30 a.m. through 2:00 p.m., a tour of the facility was completed by surveyors and the following observations were made: In Resident Room 202, on the left side of a three pane crank out style window, the screen was observed not to fit tight against the window frame. The right side of the frame had a gap area, measuring approximately 1/4 inch at the widest point, which would allow insects into the building. The window was closed at the time of the observation. No bugs were observed in the room or in overhead light covers at the time of the observation. In Resident Roon #203, the three pane window was observed to be closed; however, there was no screen on the left side of the window and a crank to open the window was in place. At the time of the observation Resident #3 was present in the room and stated that he/she does not like the air conditioner and rarely uses it. The resident stated he/she would open the window if he/she got hot. When the surveyor point out that there was no screen in the window, the resident stated "that's okay, I only open it a little bit and have never had anything come in." The resident stated that he/she has not asked the facility to put a screen in the window and that it wasn't needed as he/she has never had anything come in. The resident denies seeing flies on food or in the building. The window was closed at the time of the observation and no bugs were observed in the room or in overhead light covers. In the Therapy Room across from the B-Unit Nursing Station and B-Unit resident dining area, there were two sets of 3 pane crank out sytle windows on either side of a door labeled as a fire exit. The 3 pane window to the left of the door lacked a screen in the far left pane. There was a crank out handle so the window could be opened and in the lower left hand corner of this pane, was a web with a dead fly in it. The set of windows to the right side of the fire door were missing the crank style handles and had screens in the two outside panes. Both of these screens were bent and damaged so that the frames of the screens did not fit tight against the window frame. Dead bugs were observed on the sills of these windows. No bugs were observed in ceiling light covers and the windows were closed at the time of the observation. At 11:30 a.m., in an interview with a surveyor, the Rehabilitation Clerk stated that "sometimes" staff will open the windows, but not all that frequently as the windows are pretty much broken. The Rehabilitation Clerk stated that if you opened the window you had to try to remember to go outside to push against the windows to close them and that staff tries to remember to do that before they leave at night. The Rehabiliation Clerk stated that she has not seen any flies or bugs in the building. In the "OT Kitchen" on the B-Unit the three pane windows were observed closed, with no handles to crank open the windows. The window pane next to the washing machine was observed to be dusty and soiled. In Resident Rooms: 108, 118; 120; 103 and 101 on the A-Unit, the screens were loose and had gaps between the screen and window frame. No bugs were observed on the window sills or in overhead lights in these rooms. The windows were all closed at the time of the observations. In Resident Rooms #106 and 103, the three pane windows were observed with crank style handles present to open the windows, but were missing screens. The windows were closed at the time of the observations and no bugs were observed on the window sills or in overhead light covers. On 9/9/14 at 12:45 p.m., in an interview with a surveyor, a day shift, A-Unit Certified Nursing Assistant stated that if a resident wanted the window open she would open them, but they generally want them closed, even when it is hot outside. The CNA stated that the resident in room 111 likes the window open so I open it. 4. On 9/9/14 at 3:10 p.m., in an interview with a surveyor, an evening shift B-Unit CNA stated that some of the resident's like to have the windows open so we will open them. Some of the windows are broken and will not open or they don't have a handle to open them. If there is no screen we won't open the window and will let Maintainance know to get a screen. 5. On 9/9/14 at 3:30 p.m., in an interview with a surveyor, a CNA who works the 12-hour day shift stated that she has not seen any flies in the building. She stated that she would kill any flies or bugs that she saw. She stated that some of the residents like to open their windows, that most of the windows have screens and the ones that do not have screens usually don't have handles so the windows cannot open. The CNA stated that the staff do not leave the doors open and that there is no real need to open windows as the rooms have air conditioning. 6. On 9/10/14 at 4:15 a.m., in an interview with a surveyor, the night shift Licensed Practical Nurse (LPN) A-Unit Charge Nurse stated that we don't leace the doors open at night or the windows. If the windows don't have screens then we don't open them. There are a few residents who like to open their windows a crack and they (the residents) will open the windows. Staff will close them if they don't have a screen and open the other window that has a screen. The LPN Charge Nurse stated that he has had an occasional fly in the building which they kill, but the "funny thing" is that he has seen little to no flies in this building this summer as compared to last summer. 7. On 9/10/14 at 4:38 a.m., a tour of the facility was completed. No windows were observed open and no bugs were observed in overhead light covers or on window sills. In the B-Unit dining room, in the 3 pane window overlooking the parking lot, the left pane was observed with a crank style handle to open the window and no screen in this portion of the window. 8. On 9/10/14 at approximately 5:00 a.m., in an interview with a surveyor, the night shift B-Unit RN, Charge Nurse stated she has not seen any flies in the building that she remembers and never seen any in Resident #2's room. Some residents like to open their windows, we only open the ones with screens and we do not prop open any doors as we don't want people wandering into the faciltiy at night. Ther are a couple of resident's who like to crack their windows but not usually at night. 9. On 9/10/14 at approximately 5:10 a.m., a surveyor observed that the 3 pane window in the A-Unit kitchenette was missing a screen. The closed window had a crank style handle to open the window in place allowing the window to be opened without a screen. No bugs were observed in the over head light covers or on the window sills. 10. On 9/10/14 at 5:15 a.m., in an interview with a surveyor, the Administrator stated that since the incident the vectra bug light from the kitchen was moved to the hallway outside Resident #2's room and a replacement light was being purchased for the kitchen. The Administrator stated that he is looking into purchasing more for the hallways, dining areas. Staff have been instructed not to open windows without screens and that screens would be either fixed or replaced today. The Administrator stated he had put in a request to the corporate offices to replace the windows earlier this year. On 9/10/14 at approximately 1:45 p.m. a surveyor discussed the missing or damaged screens with the Administrator and the RN, Director of Nursing. 11. On 9/10/14, a surveyor received copies of the Modern Pest control invoices which indicated that the facility had been sprayed for investation on 8/1/14 and on 9/9/14. On 9/10/14 at approximately 10:00 a.m., a surveyor observed maintance staff working on replacing screens in the facility.

Based on observations, record reviews and interviews, the facility failed to ensure failed to ensure the environment was free from hazards associated with windows with broken and missing screens. This failure to have functional screens contributed to the admittance of flies into the building that infested 1 of 3 residents wound area with larvae (#2). Findings: 1. On 9/8/14, the Division of Licensing and Regulatory Services (DRLS) received an anonymous report that on 9/7/14 around 11:00 p.m., a Registered Nurse (RN) responded to Resident #2's concern that he/she was experiencing burning and itching at his/her dressing site on his/her chest. This report indicated that when the bandage was removed, the staff observed that the resident had maggot larvae coming coming out of the resident's chest open area. On 9/9/14 at 9:40 a.m., in an interview with a surveyor, the Administrator and the RN, Director of Nursing, confirmed that Resident #2's dressing and chest tumor was contaminated with larvae and that interventions were in place to treat the area and prevent the further incidents. 2. On 9/9/14 at 10:15 a.m., a surveyor observed a fly in Resident Room #107, on the A-Unit. Resident #1 was present in the room at the time. The surveyor notified staff, who immediately entered the room and removed the fly. Resident #1 treatment forms for September 2014, indicated the resident had a Stage IV open area of the left hip with a dressing. On 9/9/14 at 1:30 p.m., in an interview with a surveyor, the RN, DON stated that the resident's pressure ulcer was being monitored and he/she did not have any larvae present. 3. On 9/9/14, from 11:30 a.m. through 2:00 p.m., a tour of the facility was completed by surveyors and the following observations were made: In Resident Room 202, on the left side of a three pane crank out style window, the screen was observed not to fit tight against the window frame. The right side of the frame had a gap area, measuring approximately 1/4 inch at the widest point, which would allow insects into the building. The window was closed at the time of the observation. No bugs were observed in the room or in overhead light covers at the time of the observation. In Resident Room #203, the three pane window was observed to be closed; however, there was no screen on the left side of the window and a crank to open the window was in place. At the time of the observation Resident #3 was present in the room and stated that he/she does not like the air conditioner and rarely uses it. The resident stated he/she would open the window if he/she got hot. When the surveyor point out that there was no screen in the window, the resident stated "that's okay, I only open it a little bit and have never had anything come in." The resident stated that he/she has not asked the facility to put a screen in the window and that it wasn't needed as he/she has never had anything come in. The resident denies seeing flies on food or in the building. The window was closed at the time of the observation and no bugs were observed in the room or in overhead light covers. In the Therapy Room across from the B-Unit Nursing Station and B-Unit resident dining area, there were two sets of 3 pane crank out style windows on either side of a door labeled as a fire exit. The 3 pane window to the left of the door lacked a screen in the far left pane. There was a crank out handle so the window could be opened and in the lower left hand corner of this pane, was a web with a dead fly in it. The set of windows to the right side of the fire door were missing the crank style handles and had screens in the two outside panes. Both of these screens were bent and damaged so that the frames of the screens did not fit tight against the window frame. Dead bugs were observed on the sills of these windows. No bugs were observed in ceiling light covers and the windows were closed at the time of the observation. At 11:30 a.m., in an interview with a surveyor, the Rehabilitation Clerk stated that "sometimes" staff will open the windows, but not all that frequently as the windows are pretty much broken. The Rehabilitation Clerk stated that if you opened the window you had to try to remember to go outside to push against the windows to close them and that staff tries to remember to do that before they leave at night. The Rehabilitation Clerk stated that she has not seen any flies or bugs in the building. In the "OT Kitchen" on the B-Unit the three pane windows were observed closed, with no handles to crank open the windows. The window pane next to the washing machine was observed to be dusty and soiled. In Resident Rooms: 108, 118; 120; 103 and 101 on the A-Unit, the screens were loose and had gaps between the screen and window frame. No bugs were observed on the window sills or in overhead lights in these rooms. The windows were all closed at the time of the observations. In Resident Rooms #106 and 103, the three pane windows were observed with crank style handles present to open the windows, but were missing screens. The windows were closed at the time of the observations and no bugs were observed on the window sills or in overhead light covers. On 9/9/14 at 12:45 p.m., in an interview with a surveyor, a day shift, A-Unit Certified Nursing Assistant stated that if a resident wanted the window open she would open them, but they generally want them closed, even when it is hot outside. The CNA stated that the resident in room 111 likes the window open so I open it. 4. On 9/9/14 at 3:10 p.m., in an interview with a surveyor, an evening shift B-Unit CNA stated that some of the resident's like to have the windows open so we will open them. Some of the windows are broken and will not open or they don't have a handle to open them. If there is no screen we won't open the window and will let Maintenance know to get a screen. 5. On 9/9/14 at 3:30 p.m., in an interview with a surveyor, a CNA who works the 12-hour day shift stated that she has not seen any flies in the building. She stated that she would kill any flies or bugs that she saw. She stated that some of the residents like to open their windows, that most of the windows have screens and the ones that do not have screens usually don't have handles so the windows cannot open. The CNA stated that the staff do not leave the doors open and that there is no real need to open windows as the rooms have air conditioning. 6. On 9/10/14 at 4:15 a.m., in an interview with a surveyor, the night shift Licensed Practical Nurse (LPN) A-Unit Charge Nurse stated that we don't leave the doors open at night or the windows. If the windows don't have screens then we don't open them. There are a few residents who like to open their windows a crack and they (the residents) will open the windows. Staff will close them if they don't have a screen and open the other window that has a screen. The LPN Charge Nurse stated that he has had an occasional fly in the building which they kill, but the "funny thing" is that he has seen little to no flies in this building this summer as compared to last summer. 7. On 9/10/14 at 4:38 a.m., a tour of the facility was completed. No windows were observed open and no bugs were observed in overhead light covers or on window sills. In the B-Unit dining room, in the 3 pane window overlooking the parking lot, the left pane was observed with a crank style handle to open the window and no screen in this portion of the window. 8. On 9/10/14 at approximately 5:00 a.m., in an interview with a surveyor, the night shift B-Unit RN, Charge Nurse stated she has not seen any flies in the building that she remembers and never seen any in Resident #2's room. Some residents like to open their windows, we only open the ones with screens and we do not prop open any doors as we don't want people wandering into the facility at night. There are a couple of resident's who like to crack their windows but not usually at night. 9. On 9/10/14 at approximately 5:10 a.m., a surveyor observed that the 3 pane window in the A-Unit kitchenette was missing a screen. The closed window had a crank style handle to open the window in place allowing the window to be opened without a screen. No bugs were observed in the over head light covers or on the window sills. 10. On 9/10/14 at 5:15 a.m., in an interview with a surveyor, the Administrator stated that since the incident the vectra bug light from the kitchen was moved to the hallway outside Resident #2's room and a replacement light was being purchased for the kitchen. The Administrator stated that he is looking into purchasing more for the hallways, dining areas. Staff have been instructed not to open windows without screens and that screens would be either fixed or replaced today. The Administrator stated he had put in a request to the corporate offices to replace the windows earlier this year. On 9/10/14 at approximately 1:45 p.m. a surveyor discussed the missing or damaged screens with the Administrator and the RN, Director of Nursing.

Based on record review, observations and interviews, the facility failed to assure the exterior exit ramp and walkway from the building was safe and in good repair, resulting in 1 of 3 sampled residents sustaining a fall with injury (#1). Finding: On 8/7/12, Resident #1's clinical record indicated that the resident had a fall with injury when the resident was attempting to enter the facility's building from the outside court yard. The nurse's notes indicated that the resident had sustained an abrasion to his/her forehead. On 9/19/12 at 12:00 noon, during an interview with the surveyor, Resident #1 stated that when attempting to enter the facility from the outside court yard, the right wheel of his/her electric wheelchair caught the side of the ramp and went off the walkway. This caused the resident's wheelchair to tip over and the resident landed on the grass on his/her forehead. The resident confirmed that he/she had sustained an abrasion on his/her forehead. On 9/19/12 at 11:45 a.m., two surveyors observed the exterior ramp and walkway to the facility's outside court yard entrance where the incident had occurred. The exterior exit walkway had an unsecured plastic tray ramp approximately 24 inches wide in front of a 36 inch door to prevent a 3 inch drop from the base of the doorway to the walkway. At the side of the ramp and walkway, there was erosion causing a hole approximately 5 inches deep and 12 inches long next to the walkway creating a potential tripping/safety hazard. On 9/19/12 at 12:05 p.m., during an interview with the Maintenance Supervisor, he stated to the surveyor that the erosion had been there for "awhile." The surveyors discussed this finding in an interview with the Administrator, on 9/19/12 at 11:50 a.m. and 1:30 p.m.

Based on record review and interviews, the facility neglected a resident by failing to prevent a significant medication error, which resulted in 1 of 1 sampled residents (Resident #1) having a [MEDICAL CONDITION] and being admitted to the hospital. Finding: Documentation on the hospital "Discharge Orders/Summary," indicated that Resident #1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Documentation in the hospital "Medications Administered for date/time entered" form, indicated the resident had doses of [MEDICATION NAME] 100 mg administered at 5:25 am and 1:09 pm on 8/14/10. The resident was discharged to the facility on [DATE] with a physician's orders [REDACTED]. Documentation in the facility Nurse's Notes, dated 8/14/10, indicated the resident was admitted to the facility at 5:30 pm on 8/14/10. Documentation in Resident #1's "Medication Record," dated 8/14/10, indicated the resident was to receive the [MEDICATION NAME] at 10:00 pm, 6:00 am and 2:00 pm. Documentation on Resident #1's "Medication Record," dated 8/14/10 through 8/31/10, indicated the resident did not receive Phentyoin until 10:00 pm on 8/15/10, 33 hours after the previous dose, administered at the hospital on [DATE] at 1:09 pm. Documentation in Resident #1's "Medication Record," dated 8/17/10, indicated the resident did not receive the 6:00 am dose of [MEDICATION NAME]. Documentation in the Nurse's Note, dated 8/17/10 at 2:30 pm, indicated the resident began having [MEDICAL CONDITION] activity and became unresponsive with no detectable blood pressure. Due to the resident's [MEDICAL CONDITION] and subsequent transfer to the hospital, the resident did not receive the 2:00 pm dose of [MEDICATION NAME]. Documentation on the hospital admission "history and physical examination [REDACTED]. On 11/05/10 at 2:00 pm, the facility Director of Nursing stated to the surveyor that, on 8/14/10, Resident #1's medication order was not received and the order had to be re faxed to the pharmacy the next day. She confirmed that the resident did not receive his/her anticonvulsant medication [MEDICATION NAME] until the 10:00 pm dose on 8/15/10, did not receive the 6:00 am dose of Phentyoin on 8/17/10, had [MEDICAL CONDITION] activity and was transferred to the hospital before the 2:00 pm dose of Phentyoin could be administered. On 11/08/10 at 1:05 pm, the surveyor interviewed Pharmacist A by phone. He stated that there would be a direct link between the resident's missed doses of the anticonvulsant medication and the subsequent [MEDICAL CONDITION] activity.