Every finding on record at Katahdin Health Care LLC

Based on facility policy review, record reviews and interviews, the facility failed to ensure that the Consultant Pharmacist (CP) reported an irregularity to the Director of Nursing (DON) and Physician after completing the monthly medication regimen review (MRR) for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #19 [R19]). Finding: The facility policy, Medication Regimen Reviews, revised 3/2025, indicated that within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. On 3/18/26, R19's clinical record was reviewed. The electronic record indicated that the CP completed the MRR for January on 1/7/26 with a note that stated, Please evaluate for potential GDR [gradual dose reduction]. Thank you. On 3/18/26 at 10:59 a.m., the DON and surveyor reviewed R19's paper chart, and the DON was unable to find the Physician's response to the CP's request based on the MRR note left by the CP in R19's electronic record. The DON also looked in a binder that contained January's MRR that was provided by the CP for all residents, and still was unable to locate the written request form for R19. On 3/18/26 at 12:15 p.m., during a telephone interview with the CP, DON, and surveyor, the CP stated that due to a computer issue that she was unaware of until today (3/18/26), R19's January MMR irregularity written report was not sent anywhere and therefore neither the DON nor the Physician received a copy for evaluation. The CP stated she has corrected this setting as of today.

Based on record reviews, facility policy review, and interviews, the facility failed to ensure that physician orders were followed for 1 of 5 residents reviewed for unnecessary medications (Resident #19 [R19]). Finding: On 3/18/26, R19's clinical record was reviewed. The surveyor observed on March's Treatment Administration Record (TAR) that orders for insulin and blood sugar checks were not completed on the evening shift of 3/2/26 and 3/10/26. On 3/18/26 at 10:10 a.m., the surveyor and Director of Nursing (DON) reviewed R19's March's TAR for the evening of 3/2/26 and noted that insulins and blood sugar checks were not completed by Licensed Practical Nurse #1 (LPN1). The DON stated that she would look into this further. On 3/18/26 at 10:47 a.m., during an interview with a surveyor, the DON stated that there was nothing documented to indicate why these treatments were not completed, and she had called LPN1 and left a message. The physician orders not completed were as follows:- Check blood glucose at 7:30 p.m. - Sliding scale Humalog insulin before meals and at bedtime to be administered at 8:00 p.m. based on the blood sugar results at 7:30 p.m. - Scheduled Lantus insulin 24 units to be administered at 8:00 p.m. The facility's policy, Prescribing, Obtaining, Dispensing, Administering, Controlling, storing, and Disposing of all drugs and biologicals, revised 10/11/22, indicated that a record shall be kept of all medications administered, including name of drug, route, dosage, and time given. The surveyor had reviewed the process for completing blood sugars and administering insulin the day before, on 3/17/26 between 4:00 p.m. and 4:25 p.m., when a surveyor observed a Registered Nurse completing a couple of medication administrations. The insulin was kept in the Nurse's treatment cart, and a laptop was on top of the cart so staff could see what medication and dose was needed, and staff would document as given accordingly. It was explained by staff that once you enter the blood sugar results into the TAR, the amount of sliding scale insulin needed highlights automatically, and then you document accordingly. On 3/18/26 at 12:50 p.m., during an interview with the DON, a surveyor stated that LPN1 also had not completed the same orders for R19 on 3/10/26 either.

Based on observations and interviews, the facility failed to label supplements with a thaw date that were located in the walk-in refrigerator and reach in refrigerator which were located in the kitchen, failed to label and date bags of cereal in the dry food storage area and failed to ensure kitchen staff properly wore hairnets by leaving hair uncovered and unrestrained for 2 of 3 days of survey (2/10/25, 2/11/25). Findings: On 2/10/25 at 10:30 a.m., during the initial kitchen tour, a surveyor observed in the walk-in refrigerator, on a shelf was a carton of 30 Vital Cuisine nutritional juice drinks that were thawed that were not labeled with a thaw date. Storage and handling instructions on the carton after thawing keep refrigerated, use within 14 days. In the reach in refrigerator there were 6 thawed Healthy shakes with no thaw date with storage and handling instructions on the carton after thawing keep refrigerated, use within 14 days, there were 4 thawed Vital Cuisine nutritional juice drinks with the same handling instructions. In the dry food storage area, there were bags of cereal that were out of the original packages they were not labeled and did not have an expiration date. (the original packages had expiration dates) The surveyor confirmed the above findings with the Food Service Director at the time of the observations. On 2/11/25 at 9:00 a.m., during the second tour of the kitchen the surveyor observed the cook with a hat that did not contain all her hair. The surveyor confirmed this finding at the time of the observation.

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 12 sampled residents reviewed for code status or advanced directive for 4 of 12 sampled residents (Resident #6 [R6]), R23, R15, R25) and 1 of 3 reviewed for hospitalization (R16). Findings: 1. On 2/12/25, a reviewed of R6's electronic clinical record was completed. There was no evidence in the electronic record for information regarding R6's code status. A review of R6's current paper chart was completed and there was no evidence of a completed Physician Orders for Life-Sustaining Treatment (POLST) and did not have an Advanced Directive. On 2/12/25 at 9:42 a.m., in an interview with the surveyor, the Administrator presented a paper copy of a signed physician order dated 10/5/24, that indicated R6's code status as 'full code'. This information was not readily available unless you looked through the old filed paper chart. On 12/12/25 at 9:42 a.m., the Administrator confirmed R6's code status was not readily available in their current chart and would immediately be added to the current electronic record. 32540 2. On 2/12/25, a review of R23's electronic clinical record and paper clinical record was completed. In the paper clinical record admission form acknowledgement of important information and policies number 6, advanced directives are checked off indicating that R23 had an advanced directive and was provided to the facility. R23's electronic and paper clinical record lacked evidence of R23's advanced directives. On 2/12/25 7:41 a.m., during a review of clinical records with the Administrator the form is in his/her clinical record, but the advanced directive was not there. During an interview later at approximately 9:00 a.m. the Administrator stated that R23's POA was called and there was a misunderstanding and that the POA stated they thought the POLST was R23's advanced directive, the facility failed to explain the advanced directive, they will review with POA and will put a copy in clinical record when completed. 33242 3. On 2/12/25, a surveyor reviewed R15's electronic clinical record, the surveyor could not find information about R15's code status. The surveyor reviewed the paper chart and noted that R15 did not have a completed Physician Orders for Life-Sustaining Treatment (POLST) and did not have an Advanced Directive. At 10:00 a.m., the Director of Nursing was able to find a signed physician order in the paper chart, dated 9/6/24, that indicated R15's code status was a full code but this information was not readily available unless you looked through the paper chart. The DON entered R15's code status into the electronic orders at this time. 4. On 2/10/25, R25's clinical record was reviewed. The surveyor reviewed the Acknowledgement of Important Information and Policies, dated 1/17/25, and noted that the Advanced Directives were not checked to indicate whether or not R25 had an Advanced Directive. On 2/10/25 at 10:39 a.m., during an interview with a surveyor, the [NAME] Hospice Nurse stated that R25 was admitted to the facility already receiving Hospice services and continued at the nursing facility. On 2/10/25 at 12:59 p.m., during an interview with a surveyor, the Administrator stated R25 was asked if he/she wanted an Advance Directive and the information was provided but she forgot to check the form to indicate so. The surveyor reviewed R25's physician orders that were printed on 1/17/25 and signed by the Medical Provider on 1/18/25 and noted that neither a code status or Hospice was included on the physician orders. On 2/12/25 at 10:52 a.m., during an interview with the Director of Nursing (DON), a surveyor confirmed these findings. 5. On 2/10/25, R16's clinical record was reviewed. A review of the signed physician orders that were printed on 12/3/24 indicated that the Medical Provider signed the physician orders but the date signed was 11/23/24, 7 days prior to R16's admitted and 10 days prior to the orders being printed. On 2/11/25 at 1:30 p.m., during an interview with the Director of Nursing, a surveyor confirmed this finding.

Based on record reviews and interviews the facility failed to verify/clarify admission orders when residents returned from an Acute Care Hospital stay, the facility failed to get an order for the use of a Foley catheter and failed to follow a Physicians order for 3 of 4 Residents who returned from the hospital (Resident #3, [R3, R17 and R16]). Findings: 1. On 2/11/25, R3's clinical record was reviewed, documentation showed that R3 was sent to the hospital on 2/4/25 and returned to the facility on [DATE]. The discharge orders from the hospital were not clarified with a Provider and did not match the current medications R3 was currently receiving. The following medications and treatments on R3's discharge orders were not on the active Medication Administration Record (MAR) or Treatment Administration Record (TAR): albuterol sulfate 2 inhalation 6 hours as needed (PRN), Foley catheter, and trolamine salicylate 10% cream. The following medications were not clarified for the frequency of the doses, R3's MAR indicates that R3 was receiving the following: Flonase allergy relief nasal suspension 2 spray in both nostrils daily in the am and the discharge orders are written for PRN use. R3 received 5 doses, Lactulose oral solution 20 grams(gm)/30 milliliters (ml) give 20gm, 20 ml every other day. The concentration being used 20gm/30ml, the facility was giving 20 ml which is less than the 20gm ordered for 2 doses, Eliquis 5 (milligram) mg twice a day and the discharge orders did not specify the frequency, R3 received Eliquis twice a day for 4 days before clarification. Metoprolol 25 mg 1/2 tablet twice a day when the discharge orders did not specify the frequency, potassium citrate-citric acid oral solution 110-334 mg/5ml give 5 ml by mouth two times a day, the discharge orders did not specify the frequency, refresh tears 0.5% instill 1 drop in both eyes two times a day the discharge orders did not specify the frequency. Senna oral tablets give 2 tablets by mouth two times a day the discharge orders did not specify the frequency. Tylenol extra strength 500 mg tablets- 2 tables by mouth three times a day, the discharge order was for Tylenol extra strength 1,000mg every 6 hours as needed. The following medications were received by R3 without a physician order: Vitamin D 25 microgram (mcg) by mouth one time a day was being received for 5 days without a Physician order. ProAir inhalation aerosol solution 2 puffs inhale orally three times a day and received 14 doses, sucralfate oral tablet 1 tablet by mouth four times a day, received 16 doses without a physicians order. On 12/12/24, a physicians order was written for a dose reduction of Risperidone of 0.25 mg every week and to inform if it's not tolerated. The clinical record lacks evidence that this reduction was followed. The facility discontinued R3's morning 0.25mg dose and decreased the bedtime dose from 1 mg to 0.5mg and did not continue with the 0.25mg weekly reduction. On 2/12/25 at 4:00 p.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that the discharge orders were not verified/clarified with the Provider and that the facility assumed they were to continue R3's medications as previously ordered. She did not get clarification orders for the medications listed in the discharge and did not get an order for the use of the Foley catheter. The discharge orders for R3 and R17 were not clarified with a provider upon their returns to the facility. 2. On 2/12/25, R17's clinical record was reviewed, documentation indicated that R17 went to the hospital on 1/6/25 and returned to the facility on [DATE]. Hospital discharge orders were reviewed and compared to current MAR/TAR. Upon discharge the following medications were discontinued: Fluticasone furoate-vilanterol 200-25 mcg/dose inhalation the facility failed to follow this order and R17 continued to receive a daily dose from 1/11/25 to 2/11/25 when it was brought to the DON's attention who then discontinued the medication. Januvia 100 mg tablet was not discontinued and received 33 doses after discontinuation order. The following medications were ordered to be held until resumed by usual care Providers or as directed on discharge orders: Cephalexin 250 mg by mouth daily was ordered to be held until 1/15/25, R17 received 5 doses, and medication was not held as ordered. Furosemide 40 mg daily was ordered to be held until restarted at the discretion of primary provider. This medication was not held and order to restart was not received. Tamsulosin 0.4 mg daily was held until reviewed by primary providers since suprapubic catheter in place. This medication was not held as ordered and an order to restart was not received. The following orders were reviewed and R17 received incorrect doses of the following medications: Metformin HCI ER was ordered for 500 mg ER 1,000 mg twice a day and R17's MAR indicates that R17 has received Metformin 1,000 mg once a day. Vitamin C 500mg is ordered once a day and R17 has been receiving 1,000 mg a day. Pantoprazole sodium 40 mg by mouth daily, MAR indicates R17 has been receiving 40mg twice a day. Potassium chloride ER 20 Meq (milliequivalent) by mouth once a day, R17's MAR indicates that he/she has been receiving 20 Meq twice a day. Bisacodyl 5 mg tablet was ordered three times a day as needed, R17's MAR indicates that R17 has been receiving this medication three times a day. Discharge orders dated 1/10/25 have orders for the following: acetaminophen-codeine 300-30 mg twice a day as needed for pain. R17's MAR/TAR does not have this order and R17 reported pain 7 times and was given regular strength acetaminophen 650 mg for his/her discomfort instead of the acetaminophen-codeine as ordered for pain. Aspirin 81 mg daily, this order is not on the MAR/TAR and R17 has not received this medication since 1/10/25 when ordered. R17's TAR was reviewed and indicates the following treatments are being used without a current physician orders. Lidocaine external patch apply one time a day and remove per schedule. R17 does not have a current order for this treatment. Treatment for blood glucose monitoring is being done 4 times a day, R17 does not have an order for this treatment. Insulin sliding scale using Humalog insulin has been used with no active order, R17 received 53 doses of Humalog insulin. On 2/12/25 at 20:28 a.m., during an interview with the DON the above findings were reviewed and confirmed. She stated the discharge orders were not verified/clarified with the Provider. The facility just continued all previously ordered medications without getting them reordered by the physician. 33242 3. On 2/11/25, R16's clinical record was reviewed and indicated R16 was admitted to the facility on [DATE]. R16 was sent to the hospital and admitted on [DATE] and returned to the facility on [DATE]. The admitting orders from the hospital included Amiodarone 200 milligrams (mg) daily and sucralfate 1 gram tablet four times a day. A review of the orders entered into R16's electronic record upon re-admission to the facility did not include Amiodarone 200 mg daily (heart arrhythmia medication) and the frequency of the sucralfate (ulcer treatment medication) was three times a day and not the ordered four times a day. In addition, ferrous sulfate 325 mg (iron medication) and folic acid 0.8 mg (vitamin B medication) were added to the facility's physician orders but were not on the orders from the hospital. On 2/11/25 at 4:00 p.m., the surveyor reviewed R16's current orders and hospital discharge orders with the DON. The hospital orders had not been signed by the facility's Medical Provider and there were no progress notes or written physician orders that indicated the hospital discharge orders were changed. At the time of this review, R16 was receiving the folic acid, ferrous sulfate, and sucralfate three times a day, but was not receiving the Amiodarone. On 2/12/25 at 7:06 a.m., during an interview with a surveyor, the DON stated she confirmed with the Medical Provider last night that the Amiodarone, ferrous sulfate and folic acid should have been on the physician orders and clarified the that the sucralfate was to be three times a day. When asked if the orders were reviewed or clarified with the Medical Provider at time of readmission from the hospital, the DON stated that was done last night, 7 days after admission.

Based on record reviews and interviews, the facility failed to ensure that baseline care plans were completely developed and implemented within 48 hours that included health care instructions needed to provide minimum healthcare for 4 of 4 residents reviewed that were admitted in the last 30 days (Resident #16 [R16], [R25], [R31], R37]). Findings: 1. On 2/10/25, R16's clinical record was reviewed which indicated that R16 was admitted to the facility on [DATE]. R16 was admitted with the diagnosis of diabetes mellitus receiving oral medication, heart failure and receiving a diuretic medication and blood thinner, oxygen dependent, limited physical mobility requiring activities of daily living assistant and was to receive therapy, and received a psychotropic medication for depression. These care areas were not added to the baseline care plan until after 48 hours of admission. On 02/11/25 at 1:19 p.m., during an interview with the Minimum data Set (MDS) nurse, a surveyor confirmed that this finding. 2. On 2/10/25, R25's clinical record was reviewed which indicated that R25 was admitted to the facility on [DATE]. R25 was admitted already receiving Hospice services due to cancer, with the diagnosis of type 2 diabetes mellitus receiving insulin medication and blood glucose monitoring, Chronic obstructive pulmonary disease (COPD) with as needed nebulizer medications, psychotropic medication use, and pain medications in addition to limited physical mobility needing activities of daily living assistance. On 02/11/25 at 10:38 a.m., during an interview with the Minimum data Set (MDS) nurse, a surveyor confirmed that this finding. 17282 3. On 2/12/25, R31's clinical record was reviewed which indicated that R31 was admitted to the facility on [DATE]. R31 was admitted with the diagnoses of insulin dependant diabetes, which requires monitoring, physical weakness requiring activities of daily living assistance and depression. These care areas were not added to the baseline care plan until after 48 hours of admission. On 2/12/25 at 7:10 a.m., in an interview with the surveyor, the Director of Nursing confirmed that there was not a complete baseline care plan developed addressing the resident's immediate needs to monitor diabetes, activities of daily living assistance and depression. 4. On 2/12/25, R37's clinical record was reviewed which indicated that R37 was admitted to the facility on [DATE]. R37 was admitted with the diagnoses of acute and chronic respiratory failure requiring oxygen treatment, Chronic Obstructive Pulmonary Disease, Opioid abuse-requiring suboxone (used to treat narcotic addiction) and a Stage 2 pressure ulcer on the left gluteal fold. These care areas were not added to the baseline care plan until after 48 hours of admission. On 2/12/25 at 10:45 a.m., in an interview with the surveyor, the Director of Nursing confirmed that there was not a complete baseline care plan developed addressing the resident immediate needs: suboxone use due to opioid addiction, activity of daily living assistance due to shortness of breath, and skin care, wound prevention, monitoring and caring for a Stage 2 pressure ulcer on the left gluteal fold.

Based on record reviews, facility policy review, and interviews, the facility failed to ensure residents were offered Pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 2 of 5 residents reviewed for immunizations (Resident #20 ([R20] and R12). Findings: The facility's policy, Pneumococcal Vaccine, last revised 10/2023, indicated that administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. 1. On 2/11/25, R20's clinical record was reviewed. The surveyor could not find evidence that R20 was offered or had received the PCV20 vaccine, a type of pneumococcal vaccine. The CDC recommendation was based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last Pneumococcal vaccine dose, which was administered in 2017. 2. On 2/11/25, R12's clinical record was reviewed. The surveyor could not find evidence that R12 was offered or had received the PCV20 vaccine. The CDC recommendation was to give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23, a type of pneumococcal vaccine, which was administered in 2017. On 2/11/25 at 1:42 p.m., the Director of Nursing (DON) stated that the facility does offer the PCV20 and uses the CDC recommendations for offering/administration of the vaccine; she would review R20 and R12's clinical records. On 2/12/25 at 7:03 a.m., the DON stated that both residents will be offered the PCV20 as she found no evidence that they were offered to R20 and R12.

Based on review of the facility's Legionella Water Management Program and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens in the area of testing protocols for 1 of 1 review of water management program. Finding: On 2/11/25, a review of the facility's Legionella Water Management Program (revised on 2/2023) was completed. The facility's program identified areas where Legionella could grow and spread that included: sinks located in resident rooms, kitchen, hair care room, whirlpool room, staff bathroom, visitors bathroom, A-wing day room bathroom, and medication room, showers, water heaters, boiler room, ice machine, medical devices, and water cooler. Control measures and monitoring included: visual testing of ice machine and water cooler on a scheduled basis, temperature monitoring of water heaters to be maintained at or above 140 degrees Fahrenheit (F) and chemical analysis of free chlorine when sections of the building have been offline or damage has been found to the water main. The verification process to make sure the program was running as designed and was effective included documentation of process control that would be reviewed monthly and that random testing will also be done to insure testing reliability. On 2/11/25 at 11:05 a.m., during an interview with a surveyor, the Maintenance Supervisor stated that he has no documentation to verify the process for control measures and monitoring in areas that the program identified as areas where Legionella could grow and spread (including monitoring areas that have not been frequently used that included sinks and showers) and the facility does not send water samples out for testing at all.

Based on record review and interview, the facility failed to ensure that a care plan was created after a comprehensive assessment in the area of diabetes and pain for 1 of 1 resident received for Hospice (Resident #25 [R25]). Finding: On 2/10/25, R25's clinical record was reviewed which indicated that R25 was admitted to the facility, already receiving Hospice services for a terminal illness. Review of the admission orders indicated that R25 was admitted with physician orders for an Opioid pain medication for chronic pain and required pain monitoring and was receiving insulin for diabetes. R25's Admission Minimum Data Set (MDS), dated [DATE], was coded under section I2900 to indicate R25 had a diagnosis of diabetes mellitus and under section J0100A to indicate that the Resident was receiving scheduled pain medication. R25's care plan as of 2/10/25, lacked evidence of chronic pain or diabetes being addressed in the comprehensive care plan. On 2/11/25 at 10:45 a.m., during an interview with the MDS nurse, a surveyor confirmed this finding.

Based on record review and interview, the facility failed to review, revise and update a care plan in the area for a pressure ulcer 1 of 1 resident reviewed for pressure ulcer (Resident #16 [R16]). Finding: On 2/10/25, R16's clinical record was reviewed and included a physician order for a treatment for a pressure ulcer to the left lateral 5th digit toe (pinky toe). The surveyor reviewed the care plan but could not find a pressure ulcer care area. On 2/11/25 at 11:09 a.m., during an interview with a surveyor, the Director of Nursing (DON) stated that R16's Stage II pressure ulcer to the pinky toe started on 12/12/24 and resolved on 1/15/25. R16 went to the hospital and was admitted on [DATE] and returned on 2/4/25 with the pressure ulcer reopened to the same area. The Minimum Data Set (MDS) Nurse updated R16's care plan late yesterday afternoon for the pressure ulcer. The surveyor confirmed the care plan had not been updated to reflect that R16 had a pressure ulcer when it first started 12/12/24 and the care plan was not updated when R16 was readmitted with an open pressure ulcer on 2/4/25, until 6 days after re-admission.

Based on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 2 of 3 days of survey (2/10/25 and 2/11/25) for Resident #16 (R16). Finding: The manufacturer's instructions for DeVilbiss 5 Liter Oxygen Concentrator indicated that the air filter should be inspected periodically and cleaned as needed by the user or caregiver. On 2/10/25 at 11:00 a.m. and 2/11/25 at 12:15 p.m., a surveyor observed R16 wearing oxygen via nasal cannula that was attached to a DeVilbiss oxygen concentrator and observed the filter on the back of the concentrator to be dusty. The surveyor confirmed this finding with the Director of Nursing (DON) after the second observation. The DON stated she never thought of cleaning the filter and will add that to the orders when they change the tubing.

Based on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 12 residents reviewed (Residents #31 [R31]). Finding: On 02/12/25, R31's clinical record was reviewed and included block orders (30 day) signed by the physician on 12/18/24. The next block order, including a 10-day grace period, needed review and the Physician's signature by 1/28/25; there are no further visits from the physician. On 2/12/25 at 7:10 a.m., in an interview with the surveyor, the Director of Nursing, confirmed that the last block order was signed on 12/18/24, making them now 15 days late.

Based on clinical record review and interview, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 1 of 12 sampled residents (Resident #31 [R31,]. Findings: On 2/12/25 a review of R31's clinical record indicated that R31 was admitted on [DATE] and had a physician visit on 12/18/24. The next 30 day physician visit, including a 10-day grace period, which needed a review and written progress note was due on 1/28/25; there are no further visits from the physician. On 2/12/25 at 7:10 a.m., in an interview with the surveyor, the Director of Nursing, confirmed that the last physician visit and written progress note was signed on 12/18/24, now making the visit 15 days late.

Based on observation, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 1 medication storage refrigerator. Finding: Review of United States (U.S.) Centers for Disease Control and Prevention: Vaccine Storage and Handling Toolkit dated 3/24/24 states .Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. On 2/11/25 at 3:00 p.m., a surveyor and a Licensed Practical Nurse observed in the medication storage room, a dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door). The refrigerator contained multiple vials of vaccines that included: influenza, Prevnar 20, measles, and Coronavirus (Covid-19). The surveyor confirmed that the vaccines were stored in the combination refrigerator/freezer during this observation. On 2/11/25 at 3:20 p.m., during an interview with the Director of Nursing, the surveyor confirmed that the facility follows CDC recommendations for the administration of vaccines. The surveyor confirmed that the vaccines are being stored in a dormitory style refrigerator with a built-in freezer compartment.

Based on record reviews, Medication Administration Records (MARs) and interviews, the facility failed to follow physician orders for 4 of 9 sampled residents (Resident #15 [R15], R4, R19, and R31). Findings: 1. On 3/12/24, R15's clinical record was reviewed. R15 had a medication order for Sucralfate (a protectant) 1 gram, give 1 tablet by mouth three times a day at 6:00 a.m., 11:00 a.m. and 4:00 p.m. for gastroesophogeal reflux disease. A review of R15's MAR indicated that R15 did not receive Carafate on 12/3/23, 12/4/23, 12/5/23 and 12/6/23. On 3/12/24 at 11:00 a.m., in an interview with a surveyor, the Clinical Supervisor confirmed that R15 had not received Carafate for four days. She stated they have had problems getting medications from the Pharmacy and medications are not always ordered timely. 33242 2. On 3/12/24, R4's clinical record was reviewed and included a physician order for Lantus (long-acting insulin) , dated 2/12/24, to administer 40 units in the a.m. and 50 units in the p.m. The order for the Lantus did not include parameters to hold. Documentation on the Medication Exception Report indicated that Lantus was held multiple times due to low blood sugar between 2/12/24 and 3/11/24. The physician orders contained a standing order, dated 10/5/23, that indicated the physician should be notified prior to holding any insulin; this standing order was displayed on the MAR. On 3/12/24 at 10:54 a.m., during an interview with a surveyor, Licensed Practical Nurse (LPN)1 stated that she used her nursing judgement to hold the Lantus (multiple times) but did not notify the physician or obtain an order to hold the insulin. R4's clinical record included a physician order, dated 10/5/23, to administer Duloxetine (an antidepressant) 60 milligrams (mg) in the morning. The medication administration record (MAR) for February 2024 indicated that this medication was held on 2/4/24 with no reason documented on the Medication Exception Report but the MAR indicated this medication was reordered on 2/3/24. Duloxetine 30 mg tablets were available in the emergency stock. R4's clinical record included a physician order, dated 2/15/24, to administer Tramadol (an opioid pain reliever) 50 mg, 3 times a day for pain. The MAR for February 2024 indicated that this medication was held on 2/27/24 for the 3:00 p.m. 9:00 p.m., and on 2/28/24 for the 9:00 a.m. dose, with documentation on the Medication Exception Report because the medication was not available. This medication was reordered on 2/27/24 and was available in the emergency stock. 3. On 3/12/24, R19's clinical record was reviewed and included a physician order, dated 2/4/24, to start Mucinex (an expectorant work by thinning and lossening mucus in the airways, clearing congestion, and making breathing easier) on 2/5/24, twice a day for 7 days. A review of the MAR and Medication Exception Report indicated the medication was never given because it was not available. On 3/12/24 at 12:42 p.m., during an interview with a surveyor, the Clinical Supervisor stated that she was unaware that this medication was not available, and we could have gone to [NAME] to go get it. We are supposed to get an order to hold a medication if needed. 49635 4. On 3/12/24, R31's clinical record was reviewed and included a physician order, dated 1/25/24, for Sucralfate 1 gram (GM) tablet for R31, to be given by mouth four times a day (7:30 a.m., 11:30 a.m., 4:30 p.m., and 8:00 p.m.) for a diagnosis of gastroesophageal reflux disease. The clinical record indicated that on 2/3/24 R31's refill order was sent to the pharmacy for Sucralfate 1GM. R31 did not receive Sucralfate on 2/4/24 or 2/5/24 (a total of 8 missed doses), the record indicated medication [not available], waiting on pharmacy. On 2/18/24 at 1:39 p.m., R31's indicated Sucralfate 1GM was not given due to morning meds given too late. On 2/26/24 at 1:47 p.m., R31's clinical record indicated Sucralfate 1GM was not given due to morning meds given too late. On 3/03/24 at 2:32 p.m., R31's clinical record indicated Sucralfate 1GM was not given due to morning meds given too late. On 03/13/24 at 10:09 a.m., in an interview with a surveyor, LPN2 stated, normally we order a medication refill when the card (medication blister pack) reaches the blue strip (the last row on the card). LPN2 stated there are times when they don't have the medicine residents need because the pharmacy does not deliver the medications in time. LPN2 stated she usually gives R31's Sucralfate before meals. LPN2 stated there is no documentation to indicate the medication needs to be given before meals. LPN2 stated the physician was not notified of held doses as the computer automatically notifies the charge nurse electronically. LPN2 stated sometimes she gets stuck down at the other end helping, then it is too late to pass the medication. On 03/13/24 at 10:14 a.m., a surveyor confirmed with LPN2 that R31 did not receive Sucralfate as ordered by the physician on 2/4/24, 2/5/24, 2/18/24, 2/26/24, and 3/3/24.

Based on observations, and interviews, 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, not sanitizing the thermometer used for food temperature checks, as well as not monitoring sanitizer levels in the chemical sanitizer bucket to prevent food borne illness for 2 of 3 days of survey (3/11/24, 3/12/24). This has the potential to effect all residents in the facility. Findings: 1. On 3/11/24 at 10:15 a.m., during initial tour of the kitchen a surveyor observed: In the dry storage area, within the deep freezer, 1 open bag of garlic bread sticks, unlabeled and open to the environment. In the walk-in freezer, 1 bag of chicken patties, and 1 open bag containing bread rolls, unlabeled and open to the environment. In the walk-in fridge, 1 open, unwrapped box labeled 15 pounds sliced bacon, open to the environment. On 3/11/24 at 10:30 a.m., a surveyor and Cook #1 observed and confirmed each of the above findings. On 3/12/24 at 11:28 a.m., a surveyor observed 1 open bag containing bread rolls, open to the environment within the walk-in freezer. The surveyor confirmed the bread rolls were not stored in a sanitary manner with Cook #2 at the time of the observation. 2. On 3/11/24 at 11:21 a.m., a surveyor observed Cook #1 check food temperatures. During the observation Cook #1 attempted to use a thermometer to check food temperatures after the thermometer had been dropped on the floor and then swirled it in a red bucket. At this time the surveyor asked what was in the red bucket. On 3/11/24 at 11:45 a.m., in an interview with a surveyor, the Dietary Supervisor (DS) stated the red bucket contained sanitizer solution. DS stated you don't use this with dishes. You use the dishwasher to sanitize dishes. On 3/11/24 at 11:50 a.m., the surveyor confirmed with DS that the thermometer was not sanitized in manner to prevent food borne illness. On 3/12/24 at 11:25 a.m., the surveyor observed Cook #2 check food temperatures. During this observation Cook #2 sanitized the thermometer with alcohol wipes, lifted a trash lid (while holding the thermometer), rinsed the thermometer with water, used a towel to wipe the thermometer, then attempted to check food temperatures with the same soiled gloves and thermometer. At this time the surveyor confirmed with Cook #2 that the gloves were contaminated, and the thermometer was not sanitized in a manner to prevent food borne illness. 3. On 3/11/24 at 11:45 a.m., in an interview with a surveyor, the DS performed a test strip on the sanitizer solution which resulted in a concentration of 100 parts per million (ppm). According to manufacturer's specifications, the appropriate concentration result should be 200-400ppm to prevent food borne illness. On 3/11/24 at 11:50 a.m., the surveyor confirmed with DS that the sanitizer bucket did not meet the appropriate concentration to prevent food borne illness. On 3/12/24 at 11:25 a.m., a surveyor observed Dietary Aid#1 test the sanitizer solution, the test strip result indicated a concentration of 100-200ppm. This finding was confirmed at the time of the observation.

Based on observation, record review, and interview the facility failed to update a care plan for the problem area of care/assistance for 1 of 1 residents reviewed for fall with major injury (Resident #10 [R10]). Finding: On 3/11/24 at 11:26 a.m., a surveyor observed R10 sitting in a wheelchair with a cast on his/her left lower leg. On 3/13/24, R10's clinical record was reviewed which indicated that the resident fell on [DATE] and sustained a fractured left lower leg and is now non-ambulatory and wheelchair dependent. As of 3/11/24, R10's care plan had not been revised and/or updated with interventions related to his/her fall with major injury. Review of Minimum Data Set (MDS) 3.0 Nursing Home Comprehensive (NC) Version 1.18.11 Effective 10/01/2023 significant change form was completed on 2/27/24 and signed by MDS Coordinator on 2/28/24 indicated care area triggered related to falls and addressed in the care plan. Review of the care plan, dated 1/23/24, lacked evidence that it was updated to reflect the change in ambulation status from I walk without help I use a roller walker, to non-weight bearing. On 3/12/24 at 2:19 p.m., during an interview with a surveyor, the MDS Coordinator stated that the care plan for the ambulation status, and falls was not updated after a fall with major injury, and it should have been. The above finding was confirmed at this time.

Based on time card reviews and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 2 of 2 weekend dates reviewed for RN coverage (2/25/24 and 3/9/24). Finding: On 3/11/24, a surveyor requested from the Business Office Manager a printed copy of time cards for RNs for the dates of Sunday 2/25/24 and Saturday 3/9/24. On 3/12/24 at 8:36 a.m., the Business Office Manager and surveyor reviewed the time cards for RNs for those dates and the surveyor confirmed that there was not RN coverage for 8 consecutive hours for either of those 2 dates reviewed. On 3/12/24 08:45 a.m., during an Interview a surveyor, the Director of Nursing (DON) stated that there was a RN that was out on medical leave at this time that worked every other weekend. The DON stated that she does not punch a time card herself but has been filing in on those weekends, but denied working either 2/25/24 or 3/9/24.

Based on record review and interviews, the facility failed to ensure that physician ordered labs (bloodwork) were attempted or completed for 1 of 6 sampled residents reviewed (Resident # [R]19). Finding: On 3/12/24, R19's clinical record was reviewed and contained a physician order, dated 1/14/24, to attempt to draw blood for 5 laboratory tests (if possible); this order was entered into the electronic treatment administration record (TAR) to be completed on 1/16/24 but was not signed off as being completed. The surveyor was unable to find evidence that this was attempted or completed in the clinical record. On 3/12/24 at approximately 12:15 p.m., during an interview with a surveyor, Licensed Practical Nurse 1 stated that the Clinical Supervisor draws blood for laboratory work. At 12:28 p.m., during an interview with a surveyor, the Clinical Supervisor stated that R19 was a hard stick (difficult to draw blood) and that if she cannot draw blood, she will let the Director of Nursing know so she can try; she will do some research on what happened. At 12:44 p.m., the Clinical Supervisor stated she called the lab and the bloodwork was not done. The surveyor confirmed that there was no evidence that these were attempted.

Based on employee file reviews and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, annual training on dementia for 2 of 3 Certified Nursing Assistants (CNA) reviewed (CNA4, CNA5). Findings: On 3/13/24, the following employee records were reviewed: 1. CNA4 was hired on 12/15/22. There was no documented dementia training completed by CNA4 in the employee file. 2. CNA5 was hired on 12/31/21. The most recent dementia training completed by CNA5 was 8/13/22. There was no documented dementia training completed by CNA5 for 2023. On 3/13/24 at 8:51 a.m., during an interview with the Business Office Manager, a surveyor confirmed this finding.

Based on Observation, Interview, and Record Review the facility failed to implement their facility policy and CDC guidelines to prevent the introduction and spread of COVID-19 into the facility by failing to appropriately screen staff and visitors, prohibit a staff member with symptoms of COVID-19 from working, and establish an effective infection surveillance system within the facility. This has the potential to affect all residents in the facility. A finding of Immediate Jeopardy was identified in the facility when the facility failed to accurately screen and prohibit a staff member who had a cough, sore throat, and headache from working in the facility as a CNA. Findings Include: Record Review on 9/15/2020 of a document entitled Staff Screening Worksheet updated 05/15/2020 that has entries dated 08/1/2020 and 08/2/2020 revealed that CNA#1 completed the worksheet but did not date his/her line on the screening form, however the lines on the screening form above and below CNA#1's line are both 08/1/2020. CNA#1 reported that he/she had a cough, headache, and sore throat on the screening worksheet. Interview on 09/15/2020 via telephone with CNA#1 at around 2:30pm confirmed that CNA#1 worked on 08/01/2020 and that he/she had a cough, sore throat, and headache when he/she reported to work on 08/01/2020 and had those symptoms while he/she was working as a CNA. He/She reported that they thought that the sore throat and cough were just allergies [REDACTED].#2) and that RN#2 checked on him/her and allowed him/her to work.CNA#1 also stated that he/she saw a healthcare provider and was diagnosed with [REDACTED]. Interview on 09/15/2020 with RN#2 at around 2:55pm confirmed that RN#2 was the charge nurse on 08/01/2020, that CNA#1 reported to RN#2 that he/she had a cough, sore throat and headache and, that RN#2 assessed CNA#1 and felt that there was no obvious illness and allowed CNA#1 to work. Record Review on 09/15/2020 of the facility document entitled Staff Screening Worksheet updated 5/15/2020 revealed that the form states Check all that apply, If employee reports: 1. Cough or SOB (shortness of breath) OR 2. At least TWO of other symptoms, Employee is restricted from working. Additional Record Review on 09/15/2020 of the facility document entitled Staff Screening Policy and Procedure updated 7/8 states Purpose: Existing CDC guidelines recommend healthcare facilities to implement screening of all employees before entering a facility. The screening includes taking the person's temperature and a set of questions looking for symptoms that are consistent with COVID-19. An employee should NOT report to work if they experience fever and/or other COVID-19 related symptoms consistent with COVID-19 and should call out sick and notify their supervisor immediately. Additionally, the document states Procedure - 1. Any employee entering the building will be screened prior to their shift, 2. Each person will be screened and both temperature and answers to the questions will be documented, and the record will be maintained ., 3. A person will not be allowed to enter the building if they meet the following criteria: . b. Any of the following symptoms: i. Cough OR ii. Shortness of Breath. 4. If any person develops symptoms while at the facility, they must immediately report to their supervisor and should leave work. Record Review on 09/15/2020 of the US Centers for Disease Control and Prevention's document entitled Preparing for COVID-19 in Nursing Homes last updated June 25, 2020 states Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Record Review on 09/15/2020 of the timecard for CNA#1 confirmed that CNA#1 worked from 10:25pm on 08/01/2020 until 6:49am on 08/02/2020. Observation on 09/15/2020 around 12:10pm revealed that two visitors to the facility were allowed to enter the facility prior to the facility reviewing the answers to the COVID-19 screening questions the visitors answered. Interview on 09/15/2020 around 12:10pm of LPN#1 revealed that LPN#1 was responsible for screening the visitors, however LPN#1 thought that another staff member had reviewed the visitors screening logs and that is why she/he did not review the screening log prior to allowing the visitors to enter the facility. Observation on 09/15/2020 around 2pm revealed CNA#2 enter the facility, take his/her own temperature, fill out the screening log and then enter the facility without wearing a face covering or having another staff member review his/her temperature and/or their screening form. Interview on 09/15/2020 around 2pm revealed CNA#2 works in the afternoon and he/she stated In the morning they have someone to screen you, however in the afternoon you screen yourself. Record Review on 9/15/2020 of a document entitled Staff Screening Worksheet updated 05/15/2020 revealed that multiple entries in the month of August 2020 were missing answers to the screening questions on the form and that a few temperatures were low (for example there was a temperature recorded at 93° F) without any follow-up documented on the form. Observation on 9/15/2020 at approximately 11:50 a.m., shortly after entering the facility, two surveyors observed two staff members in the kitchen wearing facemasks without their nose covered. Observation on 9/15/2020 at approximately 12:05 p.m. during an initial kitchen tour that the facility's Administrator, the Dietary Supervisor, and a dietary aide were wearing their face masks without their nose covered. The surveyor confirmed the finding at this time with the Administrator that the masks were not covering their noses. Observation on 9/15/2020 at 12:13 p.m. revealed that a Certified Nursing Assistant/Medication Technician (CNA/M) on the A-Wing, was wearing a face mask without his/her nose covered. The surveyor asked if he/she knew the facility's policy on the correct way to wear a facemask. He/she told the surveyor he/she did and it was to wear the mask over the mouth and nose. At this time, the CNA/M and the Administrator confirmed with the surveyor that the CNA/m was not wearing the facemask correctly. Record Review on 09/15/2020 of the US Centers for Disease Control and Prevention's document entitled Preparing for COVID-19 in Nursing Homes last updated June 25, 2020 states Implement Source Control Measures. HCP should wear a facemask at all times while they are in the facility. Healthcare Personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). Source Control: Use of a cloth face covering or facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Interview on 09/15/2020 with RN#2 at around 2:55pm revealed that RN#2 reported to the DON (RN#1) that CNA#1 had a cough and worked on 08/01/2020. Record Review on 09/15/2020 of the facilities Respiratory Illness Line List revealed that CNA#1 was not tracked on the Line List. Interview on 09/15/2020 with the facility Infection Control Nurse (ICN) revealed that he/she was not informed about CNA#1 having respiratory symptoms and that he/she should have been told so that he/she could track CNA#1 on the Line List. Review of the facility's Kitchen Audits documentation on 9/15/2020 revealed that on 8/10/2020 there were 3 staff members who were wearing their facemasks below their nose at the noon meal. Interview with the Dietary Supervisor on 9/15/2020 at 1:20 p.m. revealed that the staff were spoken to, washed their hands, changed their gloves, and returned to service at the noon meal. It further revealed that this breach of infection control practice was not reported to the facility's Infection Control Nurse at that time. Interview with the Infection Control Nurse on 9/15/2020 at 1:25 p.m. revealed that he/she did not know about the 3 staff members in the kitchen not wearing their masks properly (a breach of infection control practice) on 8/10/2020 and was not made aware of it at the time. Interview with the Administrator, the Director of Nursing (DON), and the Infection Control Nurse on 09/15/2020 at around 5:00pm revealed that all infection control breaches are reviewed at the QAPI meetings at the end of the month and that the Infection Control was made aware that three staff members in the kitchen were not wearing their masks properly at the QAPI committee meeting on 08/28/2020 (18 days after the breech occurred). They also confirmed that the Infection Control Nurse may not be informed about breeches in infection control protocol until the monthly QAPI meeting no matter what day of the month it happened on. At this time, the surveyor confirmed with the Administrator, the Director of Nursing (DON), and the Infection Control Nurse that informing the infection control nurse who is responsible for the facilities infection control program about breeches in the program is not a timely notification. Record Review on 09/15/2020 of the facility policy entitled Infection Preventionist dated 06/2016 revealed that it is the facility policy that the Infection Preventionist is responsible for coordinating the implementation and updating of our established infection control policies and practices. The Infection Preventionist (or designee) shall coordinate the development and monitoring of our facility established infection control policies and practices. and The infection preventionist will collect, analyze and provide infection data and trends to nursing staffing and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection control practices. The Infection Preventionist shall report information related to compliance with our facility's established infection control policies and practices to the Administrator and Quality Assurance and Assessment Committee. Based on the above information, it was determined that the facility's failure to ensure CNA #1 did not work after reporting symptoms of COVID-19 and to have a system in place for the monitoring of symptoms reported during screening procedures constituted an immediate jeopardy. Please see F000 Initial Comments for details related to the IJ template, removal plan and abatement of the IJ.