Every finding on record at Hawthorne House

Based on observation, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure hazardous chemicals were properly secured on 1of 1 day of survey. (3/24/26)Findings: During the environmental tour on 3/24/26 at 11:50 a.m. a soiled utility closet door on the Somerset unit was observed unlocked. The door was equipped with a keypad locking mechanism. The following chemical products stored on a shelf inside the soiled utility closet were observed: Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, Damp Rid Moisture Absorbers. At the time of observation CNA #1 and CNA #2 indicated the keypad lock had not been functioning properly and were unaware of how long it had been inoperable. Staff acknowledged the door should have been secured due to the hazardous chemicals and presence of residents with cognitive impairment on the unit. The Safety Data Sheet for Tropiclean states in Section 4.1 First aid measures: skin contact: Remove affected clothing and wash all exposed skin area with mild soap and water, followedby warm water rinse. eye contact: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If eye irritation persists: Get medical advice/attention. Get medical advice/attention. ingestion: Rinse mouth. Do NOT induce vomiting. Obtain emergency medical attention. The Safety Data Sheet for Virex TB Ready-To-Use Disinfectant Cleaner states in Section 4: First Aid Measures. Eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing for at least 15 minutes. If eye irritation persists: Get medical advice/attention Skin: In case of contact, immediately flush with plenty of water. If irritation occurs or persists, get medical attention Inhalation: no specific first aid measures are required Ingestion: if swallowed: rinse mouth. Drink a cupful of water or milk.The Safety Data Sheet (SDS) Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner Section 4: Eye: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses, if present, after the first 5 minutes, then continue rinsing eye. Call a poison control center or doctor for treatment advice. Skin: Take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes. Call a poison control center or doctor for treatment advice. Ingestion: Call a poison control center or doctor immediately for treatment advice. Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by the poison control center or doctor. The Safety Data Sheet for Damp red moisture absorbers. Skin contact Immediately flush skin with. Plenty of water. Remove contaminated clothing. Get medical attention if irritation develops or persists. Eye Contact Immediately flush eyes with water for at least 15 minutes while holding eyelids open. If swallowed, do not induce vomiting unless directed to do so by medical personnel.On 3/24/26 at 12:00 p.m., the Administrator confirmed the concern at the time of observation and the Maintenance Director immediately repaired the keypad lock to ensure the door was secured properly.

Based on record reviews, and interviews, the facility failed to implement an Antibiotic Stewardship Program (ASP) that includes protocols and a system to effectively monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of the Infection Preventionist monthly log for antibiotics Infections 2025 spreadsheet lists a total of 13 resident infections from 1/1/25 through 3/11/25. The spreadsheet includes the Resident name, antibiotic given with start and stop date; however, the spreadsheet is not complete. There are six columns that have the headings, Bacteria, UTI, Soft tissue, Blood, Influenza, Surgery that are blank. Review of Infection Preventionist monthly log for antibiotics lacks evidence of the Infection Preventionist following through on the antibiotic use, the trends of infections and/or organisms, clusters of infections, and type of antibiotics used. On 5/1/25 at 12:08 p.m., during an interview with a surveyor, the Administrator and Director of Nursing discussed tracking infections of what residents have and what antibiotic they are originally on, but the infections tracking is not complete. It does not include if a culture was completed, what the culture indicated/what the organism is, and if it is the correct antibiotic. The Administrator stated that the previous Infection Preventionist quit with no notice, and a current employee was hired as the Infection Preventionist and started on 5/1/25. The surveyor confirmed at this time that the facility failed to implement an ASP.

Based on observations and interviews, the facility failed to ensure that the resident's environment was free of accident hazards by ensuring that cleaning supplies were secured, a toilet was secured to the floor room, closet and bathroom doors had laminate that was not gouged and splintered creating sharp edges, medication and wound care supplies, and a sharp object secured on 3 of 4 units ([NAME] Unit, Geriatric Psychiatric Kennebec Unit (GPKU), and [NAME] Unit) for 1 of 2 environmental tours (4/28/25, and 4/29/25). In addition, the facility failed to store oxygen tanks securely for 1 of 4 days (4/28/25). 1. On 4/28/25 at 10:04 a.m., a surveyor observed a unsecured container of Sani-Cloth Plus Germicidal Disposable Cloth on Resident #51s nightstand. At this time, after surveyor intervention, the Unit Manager of the GPKU removed the chemical from the residents room. The Safety Data Sheet for Sani-Cloth Plus Germicidal Disposable Cloth states in Section 4: First Aid Measures Eyes: Flush eyes with large quantities of water for several minutes. Remove contact lenses if easy to do so. Continue rinsing. Get medical attention if irritation persists Skin: No first aid should be required. Wash skin with water. Get medical attention if irritation develops or persists Inhalation: Not a normal route of exposure. If symptoms develop move victim to fresh air. Get medical attention if symptoms develop Ingestion: Ingestion is unlikely for solid products. No first aid is required for small amounts transferred from hands to mouth. On 4/28/25 at 11:25, the above information was confirmed with the Quality Improvement Manager. 2. On 4/28/25 at 11:25 a.m., observation, with the House Keeping Team Lead and the Quality Improvement Manager on the Geriatric Psychiatric Kennebec Unit, of a spray bottle containing Virex TB Ready-To-Use Disinfectant Cleaner sitting on a railing in the common area, available to use for all residents residing on the unit. At this time the House Keeping Team Lead removed the chemical from the unit. The Safety Data Sheet for Virex TB Ready-To-Use Disinfectant Cleaner states in Section 4: First Aid Measures. Eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing for at least 15 minutes. If eye irritation persists: Get medical advice/attention Skin: In case of contact, immediately flush with plenty of water. If irritation occurs or persists, get medical attention Inhalation: no specific first aid measures are required Ingestion: if swallowed: rinse mouth. Drink a cupful of water or milk. 37440 3. On 4/28/25 at 12:20 p.m., a surveyor observed on [NAME] Unit the toilet in Resident room [ROOM NUMBER] to be loose and not secured to the floor. On 04/28/25 at 12:33 p.m., in an interview, a Registered Nurse confirmed that the toilet was loose and not secured to the floor which created an accident hazard. On 4/28/25 at 12:50 p.m., in an interview the Administrator, the surveyor discussed the loose and unsecured toilet, which created an accident hazard. 35904 4. On 4/29/25 at 11:42 a.m. a surveyor observed wound care for Resident #30, on the GPKU room [ROOM NUMBER]. The treatment nurse brought a two shelf utility cart that had 2 tubes of Antifungal cream, 1 can of Brava skin barrier spray, 2 bottles of Vashe, 1 Tuberculin Purified Protein vial, and Cavilon barrier cream on the top shelf of the utility cart that was left in the hallway, accessible to resident's on the GPKU. The surveyor confirmed, with the treatment nurse, an accident hazard when the treatment nurse closed the door to room [ROOM NUMBER], Resident #30's room leaving the utility cart unattended and accessible to other residents wandering on the unit. The treatment nurse took the utility cart to a locked room behind the nursing station at this time. 5. On 4/29/25 at 11:45 a.m., a surveyor observed wound care for Resident #30, on the GPKU room [ROOM NUMBER]. The treatment nurse was observed removing a pair of scissors from Resident #30 bedside drawer to use during wound care treatment for Resident #30. Once the nurse was done with wound care, she left the scissors on the windowsill accessible to other residents wandering on the unit. The scissors were left out in the open creating an accident hazard and was confirmed with the treatment nurse by the surveyor at the time of observation. The treatment nurse stated that staff usually leave the scissors in the room. 6. On 4/29/25 at 3:09 p.m. a surveyor observed on the [NAME] Unit in room [ROOM NUMBER], Resident #45 wearing headphones that has a cord plugged into a television on a dresser at the opposite end of the room. The cord is taped to the floor crossing the walkway from the dresser to the bed with the tape lifting up on both ends of the tape creating a tripping, accident hazard. On 4/29/25 at 3:35 p.m. in an interview with the Administrator, a surveyor confirmed the accident hazard in [NAME] Unit room [ROOM NUMBER], Resident #45. Maintenance removed the accident hazard immediately.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 4 units ([NAME], [NAME] and Somerset) and the laundry room for 2 of 2 facility tours (4/28/25 and 5/5/25). Findings: 1. On 4/28/25 at 12:20 p.m., a surveyor observed in Resident room [ROOM NUMBER] that the bathroom floor was black around the base of the toilet and there was a pink wash bucket on floor under the sink. On 4/28/25 at 12:33 p.m., in an interview, a Registered Nurse confirmed the findings. 2. On 5/01/25 from 8:43 a.m. to 9:30 a.m., an Environmental tour was completed with the Administrator and the Director of Nursing in which the following findings were observed: Laundry: > There were 2 laundry carts that had untreated wooden wheeled bases. [NAME]: > Resident room [ROOM NUMBER]- The privacy curtain was missing hooks, hanging down and in disrepair. > Resident room [ROOM NUMBER] - The floor around the base of the toilet was stained and dirty. The flooring was lifting next to the wall around the room. >The wheelchair scale, in the sitting area, had a ripped/missing non-skid surface creating an uncleanable surface. [NAME]: > The dining room baseboard heater had chipped/missing paint creating an uncleanable surface. > The nurse's station baseboard heater has chipped/missing paint creating an uncleanable surface. > Resident room [ROOM NUMBER] - The laminate was peeling off from the bottom of the bathroom door and the bathroom door was missing finish on a large area around door handle creating an uncleanable surface. The floor was stained and dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The baseboard heater had broken parts that had fallen on the floor. The floor was stained and dirty around the base of the toilet. > Resident room [ROOM NUMBER] - The sink was rusty around the sink faucet. The transition strip at the base of the bathroom door was stained and dirty. The floor was stained and dirty around the base of the toilet. > Resident room [ROOM NUMBER]- The floor and caulking were stained and dirty around the base of the toilet. The room wall fan was dusty/dirty. Somerset: > Resident room [ROOM NUMBER] - The walls behind the resident's beds were marred with black marks and had chipped/missing paint exposing sheetrock. On 5/01/25 at 9:30 a.m., in an interview, the Administrator and the Director of Nursing confirmed the findings.

Based on record reviews, facility policy review, and interviews, the facility failed to ensure a resident's Advanced Directive documentation was accurate and in the clinical record for 20 of 24 records sampled. Findings: - A review of Resident #20s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #35s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #36s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #45s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #65s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 37440 - A review of Resident #1s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #16s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #27s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #33s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #43s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #57s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 44049 - A review of Resident #9s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. -A review of Resident #46s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate advanced directive to the resident and/or resident representative. -A review of Resident #29s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate and advanced directive to the resident and/or resident representative. - A review of the Resident #226s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. -A review of Resident #227s electronic medical record and their paper record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. -A review of Resident #230s electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 51331 - A review of Resident #30s electronic medical record and their paper medical record lacked evidence that facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. - A review of Resident #31s medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. -A review of Resident #51s medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident respresentative. On 5/1/25 at approximately 10:30 a.m. in an interview with the Director Nursing and the Administrator, the lack of Advanced Directive documentation was confirmed. They stated that they had identified Advance Directives as an issue that they were having problems with it and had developed an Action Plan, but as yet no audits have been done for review.

Based on observation, interview and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents, staff and visitors regarding linen handling on 1 of 4 units([NAME]) for 1 of 4 days of survey (4/28/25). Findings: The facility's Laundry and Bedding, Soiled policy and procedure revised 03/2025 noted: Policy: Soiled laundry/bedding shall be handled, transported and processed according to the best practices for infection prevention and control. Handling: 1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). a. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). On 4/28/25 at 11:11 a.m., a surveyor observed Certified Nursing Assistant (CNA #5) exit Resident room [ROOM NUMBER] carrying unbagged soiled linen with her bare hands and take it to the soiled linen room and place it in a soiled linen hamper. At this time, CNA #5 confirmed she had carried unbagged soiled linen with her bare hands out of the resident room and had taken it to the soiled room. On 4/28/25 at 11:29 a.m., in an interview, the surveyor discussed the finding with a Registered Nurse/Unit Manager.

Based on observations, interviews, and review of the facility's Dish Machine Temperature policy/procedure(High Temp Dishwashers), the facility's Refrigerator and Freezer Temperatures policy/procedure, and the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling lights, table legs, floors, chemical hoses, sink drains, and a standing floor mixer: failed to ensure dishes and cups were not wet stacked; failed to ensure foods were dated and labeled in the walk-in refrigerators, the walk-in freezer and the dry storage area and failed to ensure that liquids on a juice/liquid delivery cart, used for unit service, were not expired for 2 of 2 observations on 1 of 4 days of survey ([DATE]). Findings: The facility's Dish Machine Temperature policy/procedure(High Temp Dishwashers) dated 2021 noted: Policy: Dishwashing staff will monitor and record dish machine wash and rinse temperatures to assure proper sanitizing of dishes. 2. Staff will monitor dish machine temperatures throughout the dishwashing process. 4. Staff will record dish machine temperatures for the wash and rinse cycle each meal. 5. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring and documenting dish machine temperatures. The facility's Refrigerator and Freezer Temperatures policy/procedure revised [DATE] noted: Policy: refrigerators and freezers are to be kept at adequate temperatures to ensure food safety. Temperatures are to be taken twice per day to verify temperatures are being sustained throughout the day. 1. Each temperature will be documented and any concerns or corrective actions will be noted. The facility's Food Storage policy/procedure dated 2021 noted: Procedure: 7. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat food should be consumed, sold, or discarded. 8. All containers must be legible and accurately labeled and dated. 1. On [DATE] from 9:10 a.m. to 9:45 a.m., an Initial Kitchen Tour with the morning cook in which the following findings were observed: > The dish room had a 4-foot ceiling light that had a broken lens. > The legs of the dish machine tables had dried liquid residue on them and were extremely rusty. > There was an approximately 4-foot long by 1-foot-wide section of floor tiles missing under one of the dish machine tables exposing untreated cement. > There was a basin of approximately 45 desert cups that were wet stacked and available for use(interview with kitchen staff at this time in which they stated they were just washed and ready for use). > There were 2 trays of approximately 70 stacked plastic glasses that were stained/spotted with dried liquid residue that were available for use (interview with kitchen staff at this time in which they stated they were just washed and ready for use). > The triple bay pot sink had a chemical hose hanging down in the center bay touching the bottom of the sink. > The vegetable sink with an appropriate air gap had a bus bucket under it, which was ,d+[DATE] full of drain water, due to the drain line overflowing when the sink is drained. > The kitchen floor had food debris and dirt on the entire floor and under the equipment and shelving. > The standing floor mixer had dried liquid residue on the base and the shroud. > The dry storage room had 2 large bags of noodles, 5 large bags of cereal and a small, covered bin of cereal that were not dated and labeled. > The dry storage room floor had food debris and dirt on the entire floor and under the equipment and shelving. > The walk-in refrigerator had a previously opened bag of what appeared to be coleslaw that was not dated and labeled. The floor had dried liquid residue, spilled liquids and dirt on the floor and under the equipment and shelving. > The walk-in freezer had a large package of what appeared to be ravioli and a large package of what appeared to be chicken patties that were not labeled and dated. On [DATE] at 9:45 a.m., in an interview with a surveyor, the morning cook confirmed the findings. At this time, the surveyor asked for the monitoring and documenting of February, March and [DATE] dish machine temperature checks, and temperature checks for refrigerators and freezers on the Somerset, [NAME], Kennebec and [NAME] units. On [DATE] at 10:00 a.m., in an interview, the surveyor discussed the findings with the Administrator. 2. On [DATE] at 12:47 p.m., a surveyor observed, on the [NAME] juice/liquid cart, a 46-ounce container of Thickened Orange juice with a best if used by date of [DATE]. At this time, in an interview, Certified Nursing Assistant #6 (CNA #6) confirmed that the juice was 10 days past its best use by date. 3. On [DATE] at 3:45 p.m., a surveyor reviewed the monitoring and documenting of dish machine temperature checks for the kitchen and temperature checks for refrigerators/freezers for February, March and [DATE] on the Somerset, [NAME], Kennebec and [NAME] units. February - No documentation was provided by the facility for dish machine and refrigerators/freezers. March: Dish machine missing dates: Breakfast: 1, 2, ,d+[DATE], ,d+[DATE], 20, 21, ,d+[DATE], 29 and 31. Lunch: 1, 2, ,d+[DATE], 10, ,d+[DATE], 21, 22, 26, 29 and 31. Dinner: ,d+[DATE], 24 and ,d+[DATE]. Refrigerator/Freezer Temperatures: Missing monitoring and documentation Somerset - 1, 2, 3, 6, ,d+[DATE], 13, 15, 16, 18, 20, 22, 23, 25, 29 and 30. [NAME] - 1, 2, 4, 6, 8, 9, 11, 15, 16, 19, 20, 22, 23, 25, 29 and 30. Kennebec - 1, 2, 4, 6, 8, 9, 13, 15, 16, 18, 20, 22, 23, 25, 27, 29 and 30. [NAME] - 1, 2, 4, 9, 13, 15, 18, 22, 23, 25 and 29. April: No documentation was provided by the facility for dish machine and refrigerators and freezers. On [DATE] at 4:05 pm., in an interview with a surveyor, the Administrator confirmed the findings of missing/low monitoring/documenting for dish machine temperature checks and temperature checks for refrigerators/freezers of [DATE]. Additionally, the Administrator confirmed there was no documentation of temperatures for refrigerators/freezers for February and [DATE] on the Somerset, [NAME], Kennebec and [NAME] units.

Based on clinical record review, immunization record review, and interview, the facility failed to administer vaccines for 1 of 5 residents whose immunization records were reviewed (Resident #45). Finding: On 10/4/24 Resident #45s clinical record included a form, Pneumonia, Covid, and Influenza Vaccines that was checked off, I understand the information provided and would like the pneumonia vaccine. Resident #45s immunization records lack evidence that a pneumococcal vaccine was reviewed and/or administered. On 4/30/25 at 3:04 p.m. in an interview with the Administrator, a surveyor confirmed that the pneumococcal vaccine has not been reviewed and/or administered to Resident #45.

Based on record review, and interview, the facility failed to review and/or offer a Coronavirus (COVID-19) vaccine for 1 of 5 residents reviewed for immunizations (Resident #45). Findings: On 10/4/24 Resident #45s clinical record included a form, Pneumonia, Covid, and Influenza Vaccines that was checked off, I understand the information provided and would like the Covid vaccine. Resident #45s immunization records lack evidence that a Covid-19 immunization was reviewed and/or administered. On 4/30/25 at 3:04 p.m. in an interview with the Administrator, a surveyor confirmed that the Covid-19 vaccine has not been reviewed and/or administered to Resident #45.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the mandatory yearly dementia training for 1 of 5 CNA's reviewed. (CNA#2) Findings: On 4/40/25 a surveyor reviewed the following employee files: CNA #2 was hired in 6/2022. Review of the CNA's employee in-service/attendance record lacked evidence of dementia training for the year 2024. On 4/30/25 at 10:20 a.m., the above information was confirmed with the Facility Administrator.

Based on record review and interviews, the facility failed to adequately follow physician orders for 15 minute checks for 1 of 1 resident reviewed for 15 minute checks (Resident #30). Findings: Review of Resident #30s clinical record shows a physician order for 15 minute checks. Ensure 15 minute check paper sheet is filled out which was initiated on 3/27/25 and discontinued on 4/16/25 for suicidal ideation. Review of Resident #30s 15 minute checks from 3/27/25 through 4/16/25 shows missing checks on the below dates: -On 3/30/25 there are 29 missing checks. -On 3/31/25 there are 59 missing checks. -On 4/1/25 there are 26 missing checks. -On 4/3/25 there are 11 missing checks. -On 4/7/25 there are 75 missing checks. -On 4/9/25 there are 28 missing checks. -On 4/11/25 there are 7 missing checks. On 4/30/25 at 10:30 a.m., the above information was confirmed with the Director of Nursing.

Based on record reviews and interview, the facility failed to coordinate assessments for the Pre-Admission Screening and Resident Review (PASRR) Level I and Level II program for 1 of 3 sampled residents with a possible serious mental disorder (Resident #45). Findings: During review of Resident #45s clinical record, a surveyor noted that a PASRR Level I completed by Maximus on 4/19/24 required a face-to-face Level II evaluation. The surveyor could not find evidence that the PASRR Level II instructions were followed to ensure completion of a PASRR Level II for determination of potential recommended specialized services. In an interview with the Administrator on 4/30/25 at 12:35 p.m., a surveyor confirmed that there is no evidence that a face-to-face Level II evaluation was completed to ensure completion of a PASRR Level II for determination of potential recommended specialized services.

Based on performance evaluation reviews and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled employees. (Certified Nursing Assistant (CNA) #1, #3, #4) Findings: 1. CNA#1 was hired in 7/2001. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 2. CNA#3 was hired in 7/2023. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 3. CNA#4 was hired in 3/1990. The facility was unable to provide evidence of completed annual performance evaluations for 2024. On 4/30/25 at 10:20 a.m., the above information was confirmed with the Facility Administrator.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 4 medication carts observed ([NAME] Unit]. Findings: On 4/29/25 at 7:34 a.m., a surveyor observed a medication cart on the Long Hall of the [NAME] Unit. A surveyor observed a medication punch card of Codeine Sulfate 30mg that expired on 1/2025, still in the medication cart and available for use. This was called to the attention of Certified Nursing Assistant - Medications #1 that was adminstering medications from the cart that day and then given to Registered Nurse #2. This was confirmed with the Director of Nursing on 4/29/25 at approximately 9:00 a.m.

Based on record reviews and interviews, the facility failed to provide effective treatment for 1 resident (Resident #1) reviewed for care in the area of mental disorders and a post-traumatic stress disorder (PTSD). (Resident #1) Findings: On 1/14/25, the Division of Licensing and Certification (DLC) received a referral from Adult Protective Services regarding Resident #1 and became aware of allegations of neglect in the area of Behavioral Health. Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bipolar, PTSD along with a Preadmission Screening and Resident Review (PASRR) Level II assessment indicating care needs that required a Medical Psychiatric Long-Term Care Unit. A record review of Resident #1's medical record showed a Trauma Screening form with the date of 1/6/25 that indicated a Trauma History. The rest of the form was incomplete, missing the assessment of trauma triggers. There is no indication a trauma assessment was completed upon admission or prior to 1/6/25. On 1/28/25 at 11:45 a.m., a surveyor interviewed RN #1 and was shown the form used for 15-minute checks that are initiated for safety. RN#2 stated that this form would be filed in the Medical Record once completed. On 1/29/25 at 9:35 a.m., a surveyor interviewed Registered Nurse (RN) #2 by phone and confirmed RN#2 had worked with Resident #1. It was shared with this surveyor that Resident #1 felt re-traumatized every time Emergency Medical Services (EMS) and the police came to take her to the hospital because in the past it was men who would hold her down and abuse her and that was why she fought so much. Male staff are also very triggering. This was not documented in Resident #1's medical record. RN #2 stated this should have been documented in the medical record. A record review of Resident #1's care plan showed it failed to include a focus, goals and interventions in the area of PTSD. A record review of Resident #1's Electronic Medical Record (EMR) under progress notes found the following: - 11/26/24 at 8:54 p.m., showed a Behavior note Resident is stating that the voices in his/her head are telling him/her to kill him/herself. He/She states he/she can't stop them or make them go away. He/She states that he is telling him/her how to kill him/herself. Telling him/her to hang him/herself or take a fork and stab him/herself with it until he/she bleeds to death. Resident #1 stated he/she doesn't plan on harming him/herself but does state he/she doesn't want to live like this anymore. He/She says the voices are getting stronger and harder to ignore. There is no documentation that the provider was notified. There is no documentation that any additional safety measures were put in place to ensure Resident #1's safety. - 11/29/24 at 1:21 p.m., a CNA reported to RN #1 that resident stated I am having hallucinations, and the voices are telling me to hurt myself. The documentation indicates the unit manager was notified and safety checks were performed. There is no documentation indicating when or if those safety checks were done. There is no documentation that the provider was notified. -12/3/24 at 7:47 pm., the physician was notified that the \resident is complaining that the voices she/he is hearing are getting stronger and more frequent. They are telling resident to kill self and telling resident ways to do it. An order for Hydroxyzine, a medication used for anxiety, was changed. The documentation does not show any additional measures were taken to ensure resident safety. - 1/8/25 around 10:00 a.m Resident #1 stated to a provider that she/he had suicidal thoughts and a plan with intent to carry out the plan. The provider's note indicates that Resident #1 stated they told a CNA last night. There is no record of this. Orders for 15-minute checks for safety and replace the oxygen tubing with a shorter tube were immediately implemented. There is no documentation that 15-minute checks were performed. Resident #1 was transferred to the ER around 7:30 p.m. due to safety concerns. - 1/9/25 at 11:30 a.m., Resident #1 returned to the facility. There were no changes to his/her care plan following the return. No documentation that additional safety measures were initiated. A safety plan was located in the Medical Record with a date of 1/8/25. There is no evidence this prompted any new orders or updates to the care plan. RN #2, during interview above, stated that she/he was unaware of the safety plan. A safety plan is completed with the patient and outlines what to do in the event of self-harm thoughts, it includes warning signs, interventions and is in the patient's own words. - 1/10/25 at 5:30 a.m Resident #1 was found with a pillow case and a sheet tightly around his/her neck. When assisted, Resident #1 yelled Leave me alone, I want to die 911 was called and Resident #1 was transferred to the hospital. - 1/17/25 that Resident #1 returned from the hospital with a new prescription for an antipsychotic medication and a plan for the hospital Nurse to fax the safety plan and psych notes. Following Resident #1's return, the care plan was not updated with additional safety measures. No documentation that additional safety measures were initiated. The facility was unable to locate Resident #1's safety plan. - 1/21/25 at around 3:00 p.m Resident #1 was again found on the floor with a blue sheet tied tightly around his/her neck. 911 was called and Resident #1 returned to the hospital where she/he remained at the time of this investigation. On 1/28/25 at 12:40 p.m. a surveyor met with the Administrator and the Director of Nursing to discuss the above findings.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 3 of 5 units ([NAME] - Long Hall, Kennebec, and Somerset units). Findings: On 5/8/24, from 11:55 a.m. to 12:10 p.m., a surveyor completed an environmental tour with the Director of Maintenance and the Maintenance Assistant. The following findings were confirmed: On the [NAME] unit, Long Hall: >room [ROOM NUMBER], the center of the floor was observed with 7 cracked floor tiles, creating an uncleanable surface. In the bathroom of room [ROOM NUMBER], a black substance was noted around the base of the toilet. >In the common area, the nonslip adhesive covering on the base of the wheelchair scale was observed to be torn and lifting up. On the Somerset unit: >The shared bathroom for rooms [ROOM NUMBERS] was observed with a stained floor tile under the sink. >The shared bathroom for rooms [ROOM NUMBERS] was observed with peeling and missing areas of laminate on the sink vanity, with the underlying wood exposed, creating an uncleanable surface. >The shared bathroom for rooms [ROOM NUMBERS] was observed with an area of patched drywall requiring paint. >The base and frame of the sit to stand lift was observed with dirt, debris, and a white powdered substance. >The wheelchair for Resident #3 was observed with a ripped right armrest, and a torn seat cushion exposing the foam padding. On the Kennebec Unit: >The shared bathroom for rooms [ROOM NUMBERS] was observed with a black substance at the base of the toilet.

Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to oxygen and nebulizer mask/tubing for 6 of 6 residents reviewed for respiratory care (Residents #2, #3, #16, #37, #69 and #172). In addition, the facility failed to follow the physician order for 1 of the 6 sampled residents (Resident #172) for 2 of 3 day of survey (5/6/24 and 5/7/24). Findings: The facilities Respiratory Therapy policy and procedure, revised to 2/2022 States, under Infection Control Considerations Related to Oxygen Administration instructs nursing to . Change the oxygen cannula and tubing every seven (7) days or as needed. Keep the oxygen cannula in tubing used PRN in a plastic bag they're not in use. Check and clean filters for oxygen concentrators every seven days. Under Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol instructs nursing to, after completion of therapy remove the nebulizer container, rinse the container with fresh tap water, dry on a clean paper towel or gauze sponge . store the circuit in plastic bag, marked with date and residents name, between uses . Discard the administration setup every seven (7) days. 1. On 5/6/24 at 9:54 a.m. and on 5/7/24 at 12:24 p.m., observations of Resident #2's unlabeled or dated oxygen nasal cannula being stored by lying across his/her bed. Review of Resident #2's medical record lacked evidence of an order or documentation of the nasal cannula changed weekly. 2. On 5/6/24 at 10:04 a.m. and on 5/7/24 at 12:25 p.m., observations of Resident #3's oxygen nasal cannula with a date of 4/14/24 wrapped up and stored on top of the bedside dresser. In addition, Resident #3's Treatment Administration Record (TAR) had documentation of the nasal cannula being changed on 4/21/24, 4/28/24 and 5/5/24. 3. On 5/6/24 at 11:55 a.m. and on 5/7/24 at 12:27 p.m., Resident #16's nebulizer mouth piece and nebulizer container still assembled and stored on the back of the nebulizer machine, there was no bag available for storage. 4. On 5/6/24 at 10:37 a.m. and on 5/7/24 at 12:38 p.m., observations of Resident #37's room to have an Oxygen tank with a unlabeled or dated nasal cannula tubing wrapped up and stored hanging on the handle of the oxygen caddy. Review of Resident #37's TAR indicated he/she has not utilized oxygen within the past month. 5. On 5/6/24 at 10:07 a.m. and on 5/7/24 at 10:02 a.m., observations of Resident #69's unlabeled or dated oxygen nasal cannula wrapped up and stored on top of the bedside dresser. Review of Resident #69's medical record lacked evidence of documentation of the nasal cannula being changed weekly. 6. On 5/6/24 at 12:58 p.m. and 5/7/24 at 12:39 p.m., observation of Resident #172 wearing an unlabeled or dated oxygen nasal cannula with the concentrator set at 1 liter per minute (LPM). At this time, Resident #172 stated that he/she is on 1 LPM of oxygen for his/her shortness of breath (SOB). Review of Resident #172's medical record lacked evidence of an order or documentation of the nasal cannula being changed weekly. However the surveyor noted a Physician order dated 5/1/24 states, for Dyspnea, apply Oxygen at 2L[Liters] per NC [Nasal Cannula] of SOB and/or O2 sat less than 90% and Notify Provider as needed. On 5/7/24 at 1:43 p.m., both the surveyor and the Acting Director of Nursing (DON) observed the above oxygen nasal cannula's storage, the unlabeled or dated tubing, Resident #3's TAR which documented the nasal cannula tubing had been changed weekly x3 and R#172's oxygen concentrator set at 1LPM. The Acting DON adjusted Resident #172's the oxygen to reflect the current physician orders at 2 LPM and confirmed the above stating that oxygen tubing should be changed weekly and documented on the TAR and should be stored in a plastic bag when not in use. 33639

Based on record review, the Centers for Disease Control (CDC) guidance, observations and interviews the facility failed to adequately monitor vaccine storage temperatures on 1 of 1 immunizations refrigerator (Kennebec unit) and failed to ensure an expired medication was removed from the supply available for use on 1 of 4 medications carts observed ([NAME] Short Hall) Findings: Facilities Vaccine Storage and Handling Requirements and Considerations, states under Handling Vaccine: Maintain a daily temperature log that clearly shows when temperatures are not correct .check unit temperature two times per day, once in the morning and once in the evening, and record them on the temperature log posted on the storage unit. Review of CDC guidance Vaccine Storage and Handling Toolkit dated ,d+[DATE] states .Refrigerators should maintain temperatures between 2 C and 8 C (36 F and 46 F) .Every vaccine storage unit must have a Temperature Monitoring Device (TMD). An accurate temperature history that reflects actual vaccine recommended temperature range. 1. On [DATE] at 11:36 a.m., observation of Immunization refrigerator on the Kennebec unit with the Licensed Practical Nurse (LPN). The refrigerator contained the following immunizations: 14 boxes of Influenza vaccines, 11 individual COVID-19 vaccines and 2 Pneumonia vaccines, a Prevnar 13 and a Prevnar 20. Review of the Maine Immunization Program Refrigerator Temperature Log which was attached to the front of the refrigerator indicates temperature monitoring to be completed twice daily. Review of the following months lacked monitoring of temperatures twice daily: > [DATE] out of 31 days a temperature was documented once a day. The remaining days there was no temperature monitoring. > February 2024, 11 out of 29 days a temperature was documented once a day. The remaining days there was no temperature monitoring. > [DATE] out of 31 days a temperature was documented once a day. The remaining days there was no temperature monitoring. > [DATE] out of 30 days documented temps once daily. The remaining days there was no temperature monitoring. > As of [DATE] 1 of 5 days a temperature was documented once a day. At this time, the lack of temperature monitoring for immunizations was confirmed with the LPN. 2. On [DATE] at 10:32 a.m., during observation of the [NAME] Short Hall medication cart with the Certified Medication Technician (CNA-M) an opened bottle of Milk of Magnesium with the expiration date of ,d+[DATE] was noted. At this time, the CNA-M confirmed and discarded the expired medication. On [DATE] at approx. 2:15 p.m., the above was discussed with the Acting Director of Nursing.

Based on observations and interviews, the facility failed to serve and store food in a sanitary manner on 2 of 3 survey days. Findings: 1. On 5/6/24 at 9:05 a.m., during initial kitchen tour, with the Director of Food Service, a surveyor observed in the walk-in refrigerator, a bag of hard-boiled eggs that were not dated and not labeled. This was confirmed with the Director of Food Service at that time. 2. On 5/8/24 at 10:30 a.m., during a return observation of the Kitchen with the Food Service Director, a surveyor observed a light to moderate amount of dust & debris on all ceiling vents. Also observed a large stand mixer that the cook stated that they rarely use it and have not used it in over a month, had a small amount of dark liquid on the bottom of the bowel and the entire mixer was cover with a light amount of dust and scattered food particles. This was confirmed with the Food Service Manager at that time.

Based on record review and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 2 sampled residents transferred/discharged to an acute care facility. (#13, #31) Findings: Documentation in Resident 13's clinical record indicated that he/she was discharged /transferred to an acute hospital on 3/24/24 and 7/2/23 and subsequently admitted . The clinical record lacked evidence that the facility issued a written discharge/transfer notice to the resident and/or legal representative. Documentation in Resident 31's clinical record indicated that he/she was discharged /transferred to an acute hospital on 5/25/23 and 9/21/23 and subsequently admitted . The clinical record lacked evidence that the facility issued a written discharge/transfer notice to the resident and/or legal representative. On 5/7/24 at 3:26 p.m., the surveyor confirmed the above findings in an interview with the Licensed Clinical Social Worker.