Every finding on record at Maine Veterans Home - Bangor

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair in 1 of 1 tour of the D-Unit dishwashing room, dining room and kitchenette.Findings:On 12/16/25 from 8:45 a.m. to 8:55 a.m., a surveyor and Maintenance Assistant conducted a tour of the D-Unit dining area in which the following findings were observed and confirmed:The metal molding at the base of the kitchenette counter is soiled with dried liquids.In the dining room, four floor tiles located at the outside wall across from the dishwasher room are cracked creating an uncleanable surface.In the dining room, the ceiling air vent over the middle room dining tables and the ceiling air vent next to the cooking area are heavily soiled with dust.At the nurse's station, the protective plastic panel, facing the dining room, is cracked, missing pieces and has sharp edges.

Based on observation and interview, the facility failed to provide care for residents in a manner that maintained the residents dignity and respect when resident treatments; that were labeled with room number and body area to be treated, were left in a D-Unit corridor for 1 of 1 observation (Resident #1 [R1], R2, R3). Finding:On 12/16/25 at 8:30 a.m., during a tour of the D-Unit, treatments were observed left on a counter/storage area in the corridor across from Room D1 and D2. All residents and visitors have access to the area. Three medication cups were observed along with two packets of cream. One medication cup contained an ointment and was labeled with room [ROOM NUMBER]/big toe. A second medication cup contained a powder and was labeled room [ROOM NUMBER]/groin and the third medication cup contained a gel and was labeled room [ROOM NUMBER]/penis. At 8:35 a.m., in an interview with the surveyor, the RN-Charge Nurse, confirmed that she dispensed and left the treatments out for the Certified Nurse Assistants (C.N.A.s). She confirmed that she labeled the medication cups with the room number and where the treatment was to be applied. She immediately removed the treatments from the area.

Based on observations and interview, the facility failed to ensure that the a ware washer was maintained in good repair and in safe operating condition on 1 of 2 units (D-Unit).On 8/11/25 at 11:45 a.m., a surveyor observed a wet bath blanket on the floor in front of the ware washer in the D-Unit kitchenette. A Food Service Worker (FSW) put dirty dishes in the ware washer and turned the washer on. Once turned on, hot, steaming water spewed out from the bottom of the washer door onto the bath towel on the floor. At that time, in an interview with the FSW, she stated it has been that way for a while. On 8/11/2025 1:47 p.m., during an interview with a surveyor, a FSW stated that the dishwasher leaked which is why the towels were currently on the floor. When asked how long it had been that way, FSW stated she has been employed about a month and it has been that way since she has been here.

Based on facility policy review, record review, observation, and interviews, the facility failed to ensure administration of medications for 2 of 3 sampled residents using insulin were done correctly and in accordance to their medication administration policies (Resident #33 [R33] and R30). Facility's Medication Administration policies and procedures that was provided by their Pharmacy with a revision date of October 2017 titled Policies and Procedures Pharmacy Services for Nursing Facilities Section II- Medication Administration lists the following steps for medication administration: On page 87 Section B under number 4. When medications are administered by mobile cart taken to the resident's location medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time, number 5. instructs: When medications are administered from a central location, such as the medication room, medications for the immediate administration time may be prepared not more than 60 minutes in advance for all residents. In no case shall more than that one dose time be prepared in advance. On page 88 under number 7. The policy instructs that the person who prepares the dose for administration is the person who administers the dose. 1.On 8/13/25 during a clinical record review a surveyor identified in R33's clinical record an order, dated 7/22/25, for Lantus Insulin Glargine dose 0.3ml/30 units sub-q (subcutaneous) daily at 9:00 am, with administration instructions: if blood sugar less than 120 give 1/2 dose of Lantus, if blood sugar less than 100, hold Lantus. Review of R33's Treatment administration record (TAR) shows the order for Lantus with a block for a second person to verify to sign as completed. These blocks for the second person to verify had time stamps of when the verification occurred: the following dates of August 1 thru August 13 had the time stamps documented that the second verification occurred on the previous shifts. With a range time of 11:38 p.m. the previous night shift to 4:15 a.m. the morning of the scheduled dose, all these verifications occurred up to 9.5 hours prior to the scheduled administration time of 9:00 a.m. On 8/13/25 at 12:45 p.m. during an interview with the Director of Nursing (DON) the surveyor discussed this practice. The DON stated that because of being cited in previous surveys the facility had put the second person verify in to prevent any incorrect doses of insulin being administered. She explained that the nurse on the previous shift will dial up the scheduled dose of insulin (they use insulin pens for all insulin orders) and when the insulin is due the next nurse is supposed to verify the dose is correct then administer the insulin. The surveyor confirmed at this time that the nurse who is administering the insulin is not the person preparing the insulin to be administered. On 8/13/25 at 2:45 p.m. R33's TAR/nursing notes and pharmacy policy were reviewed with the nurse clinical support and confirmed the above findings. 2.On 8/14/25 at 9:45 a.m., during a medication observation pass, Registered Nurse #2 (RN2) stated that the night shift already set the dose on the insulin pen. She then checks the dose herself and administers it to the resident. The surveyor observed the insulin pen and it was pre-set to the insulin dose R30 was to receive when RN2 opened the baggy.

Based on observations and interviews, the facility failed to maintain their Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection by keeping a water-soaked bath blanket on the floor in front of the ware washer in the D-Unit kitchenette for 2 of 3 observations. In addition, the facility failed to ensure medications were prepared in a sanitary manner during 1 of 5 medication observation passes. 1.On 8/11/25 at 11:45 a.m., observed a wet bath blanket on the floor in front of the ware washer in the D-Unit kitchenette. A Food Service Worker put dirty dishes in the ware washer and turned the washer on. Once turned on, hot, steaming water spewed out from the bottom of the washer door onto the bath towel on the floor. At that time, in an interview with the Food Service Worker, she stated it has been that way for a while. On 8/11/25, at approximately 1:45 p.m., in a second observation, the water soaked bath blanket remained on the floor. On 8/12/25 at 7:20 a.m., the surveyor showed the Administrator and Director of Nursing (DON)/Infection Preventionist (IP), the wet bath towel on the floor and discussed the ware washer spewing water on the floor. At the time of this observation, in an interview with the DON, she confirmed that the wet blanket left on the floor was an infection control concern and would be removed. 2. On 8/14/25 at 7:45 a.m., a surveyor observed Certified Nursing Assistant-Medication (CNA-M) prepare medications for a resident. CNA-M popped a pill from a medication card and it fell on to a piece of paper that was on the medication cart. CNA-M picked up the pill with her bare hands and place it in the medication cup with other medications. The surveyor confirmed this observation at this time.

Based on observation, record reviews, and interviews, the facility failed to ensure physician orders were followed for the use on insulin for 2 of 3 sampled residents (Resident #2 [R2] and R33). 1. On 8/12/25 at 12:49 p.m., a surveyor observed a medication pass completed by Registered Nurse #1 (RN1) for R2. When the surveyor asked RN1 how much Insulin Aspart R2 was to receive, RN1 stated 6 units and changed the pre-set Insulin pen from 5 units to 6 units; RN1 administered the Insulin subcutaneously to R2. On 8/12/25 at 1:25 p.m., a surveyor reviewed R2's clinical record and noted that the physician order for the Insulin Aspart was to administer 5 units, and not 6 units. The surveyor confirmed this finding with RN1 at this time. 2. On 8/13/25 during a clinical record review a surveyor identified in R33's clinical record two orders, dated 7/22/25, for Lantus Insulin Glargine dose 0.3 milliliters (ml)/30 units sub-q (subcutaneous) daily at 9:00 am, with administration instructions: if blood sugar (BS) less than 120 give 1/2 dose of Lantus, if blood sugar less than 100, hold Lantus. and for Lantus Insulin Glargine dose 0.26ml/26 units sub-q (subcutaneous) daily at hour of sleep (HS), with administration instructions: if blood sugar (BS) less than 120 give 1/2 dose of Lantus, if blood sugar less than 100, hold Lantus Review of R33's Treatment Summary Report for August shows that on 8/1/25 R33's BS at 8:42 a.m. was 107. R33 was scheduled to receive his/her Lantus insulin and per the instructions he/she should have received 1/2 dose to equal 15 units, R33's clinical record and Summary report indicate that he/she was given the full 30-unit dose instead of the 1/2 dose as ordered. On 8/7/25 R33's BS at 8:58 a.m. was 115, R33 was scheduled to receive his/her Lantus insulin and per the instructions he/she should have received 1/2 dose to equal 15 units, R33's clinical record and Summary report indicate that he/she was given the full 30-unit dose instead of the 1/2 dose as ordered. On 8/5/25 R33's BS at 8:30 p.m. was 118, R33 was scheduled to receive his/her Lantus insulin and per the instructions he/she should have received 1/2 dose of 13 units, R33's clinical record and Summary report indicate that he/she was given the full 26-unit dose instead of the 1/2 dose as ordered. On 8/13/2025 at 1:50 p.m. during an interview with the Director of Nursing, the surveyor confirmed that there is no evidence in R33's clinical record that he/she received the correct doses of Lantus in relation to his/her BS results. On 8/13/25 at 2:45 p.m. the surveyor and the nurse clinical support reviewed R33's Treatment administration record and his/her nursing notes the surveyor confirmed the above findings.

Based on record review and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 1 of 2 residents reviewed for Dialysis (Resident #91 [R91]).On 8/14/25, R91's clinical record was reviewed, and indicated R91 has an active diagnoses of Type 1 Diabetes Mellitus with insulin dependence and End Stage Renal Disease with dependence on renal dialysis. The Physician's Orders (signed on 7/9/25), contained orders for insulin to treat Type 1 Diabetes, blood glucose checks four times per day, and if [blood sugar (BS)] is higher than 500 and the resident has two of the following symptoms (nausea, vomiting, abdominal pain, fever, pulse >100, or [respiratory rate (RR)] >25) the provider is called. The Physician Orders also stated R91 has an arteriovenous (AV) fistula (a surgically created connection between an artery and vein for hemodialysis access) in the right arm requiring daily monitoring and interventions to including palpate thrill over right arm AV fistula site daily, auscultate bruit at right arm AV fistula site daily, No [blood pressures [BPs]) or blood draws from right arm where AV fistula site has been created, and If site begins to drain or resident complains of numbness or pain in extremity, notify Dialysis center immediately.The clinical record lacked evidence that R91's Comprehensive care plan was developed and implemented to include problems, goals, and interventions, for the monitoring and treatment of Type 1 Diabetes Mellitus with insulin dependence, and/or End Stage Renal Disease with dependence on renal dialysis. On 8/14/25 at 10:57 a.m., during an interview with a surveyor and the B-unit Manager, R91's medical record was reviewed. The B-Unit Manager stated the facility does not formulate a Baseline Care Plan separate from the Comprehensive Care Plan. She stated if a resident is diabetic on admission, they should have a Care Plan for Diabetes and/or other needs such as insulin and dialysis. At this time the surveyor confirmed with the B-unit Manager that the Comprehensive care plan was not developed and implemented to include problems, goals, and interventions, for the monitoring and treatment of Type 1 Diabetes Mellitus with insulin dependence, and/or End Stage Renal Disease with dependence on renal dialysis.

Based on clinical record review and interview, the facility failed to ensure a Baseline Care Plan was developed and implemented within 48 hours, that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed for Dialysis (Resident #91 [R91]).On 8/14/25, R91's clinical record was reviewed and indicated that R91 was admitted to the facility in July 2025. The clinical record lacked evidence that R91's baseline care plan was developed and implemented within 48 hours of admission to include problems, goals, and interventions, for the monitoring and treatment of Type 1 Diabetes Mellitus with insulin dependence, and/or End Stage Renal Disease with dependence on renal dialysis. On 8/14/25 at 10:57 a.m., during an interview with a surveyor and the B-unit Manager, R91's medical record was reviewed. The B-Unit Manager stated the facility does not formulate a Baseline Care Plan separate from the Comprehensive Care Plan. She stated if a resident is diabetic on admission, they should have a Care Plan for Diabetes and/or other needs such as insulin and dialysis. The Care Plan is then updated over time as needed. At this time the surveyor confirmed that R91's Care Plan was not developed and implemented within 48 hours of admission for the monitoring and management of diabetes, use of insulin medication, or End Stage Renal Disease with dependence on renal dialysis.

Based on record review and interviews, the facility failed to ensure that a resident record contained accurate and complete information for 1 of 3 residents reviewed for hospitalization (Resident #7 [R7]). On 8/12/25, a surveyor observed documentation in R7's clinical record from Third Eye Health with a service date and time of 8/10/25 at 9:17 a.m., Central Time that named R7 with a Primary Chief Complaint of transfer notification on Page 1 and included R7's information for Patient data on page 3. However, the second page, which included the Summary with chief complaint, Orders and follow up, and disposition lists another persons name that did not reside in the Long Term Care Facility. On 8/12/25 10:13 a.m., during an interview with a surveyor, D Unit Manager stated she would check into this. On 8/12/25 at 10:40 a.m., during an interview with a surveyor, D Unit Manager stated that the documentation from Third Eye Health belonged to a non long term care resident and they have reached out to the provider to correct this documentation, removing R7 from this documentation. On 8/12/25 at 2:35 p.m., during an interview with the Administrator, a surveyor further confirmed this finding stating that staff could have picked this up when filing in the papers in R7's clinical record if all the pages had been reviewed.

Based on a review of the reports from Adult Protective Services (APS), the facility's internal investigations, facility policies, clinical record reviews and interviews, the facility failed to assess a resident (Resident#5 [R5]) for the ability to consent to sexual behavior with another resident (R6). The failure to assess R5 for the ability to consent resulted in R5 not being free from potential sexual abuse. Additionally, the facility failed to ensure that residents were free from verbal and physical abuse by a Certified Nursing Assistant (CNA) for 3 of 3 residents reviewed for abuse. This failure created an immediate jeopardy situation. (R5, R3 and R2). Findings: 1.On 1/31/25, the State Survey Agency, (also known as Division of Licensing and Certification (DLC) received an Adult Protective Services (APS) report which stated on 1/30/25 the facility called R5's court appointed guardian informing her that, R5 was in a male patient's room and his pants were down. The staff wheeled R5 back to his/her room and are doing 15-minute checks on R5. The court appointed guardian stated to APS intake staff, facility didn't share the male patient's name and R5 is unable to communicate if anything happened. On 2/18/25, the DLC received another APS report which stated that R5's court appointed guardian called APS and stated that a Hospice nurse reported to her that on 2/13/25 the same male patient [in the 1/30/25 incident] had exposed himself to R5 and attempted to enter R5s room on 2/14/25. R5s guardian called the facility, and the facility stated that the incidents were consensual. However, the report states that R5 has dementia and is under guardianship. A review of the facility's investigation titled Internal Fact-Finding Summary dated 2/27/25 stated, Synopsis of Issues: On 1/30/25 R5 was found in R6's room. R6 had pants down and R5's mouth was on R6's penis. And stated On 2/14/25 RN4 reported to RN5 that R5 was being pushed in a wheelchair by R6. RN4 reported that R5 cowered into the nurse's station and appeared to be afraid of R6. At this time R6 was moved to another unit. A review of R5s clinical record states [he/she] has a diagnosis that includes but is not limited to, vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). R5s current care plan includes an approach dated 1/31/25 Resident may exhibit sexual behaviors with male residents. If resident displays sexual behaviors, assess resident for signs of behavior changes related to sexual behaviors. If resident appears agitated, anxious, or is crying, redirect resident away from male residents. Notify the supervisor or nurse manager if sexual behavior is occurring and is creating an unwanted interaction. If resident is engaging in consensual sexual behavior, provide privacy. A review of R5s clinical record lacks evidence that R5 was assessed for the ability to consent to sexual behaviors with male residents. Additionally, review of A State of Maine Physician's/Psychologist's report (Guardianship and/or conservatorship Proceedings) document signed on 4/6/23 by a registered physician assistant states under the evaluation of Respondent's mental and physical condition [R5] lacks executive function and cannot make [his/her] own decisions During the clinical record review for Resident 6 [R6] the surveyor noted a Provider Request form dated 10/28/2024, which stated On Sunday R6 was found in [his/her] room with a female resident. The door was shut, and when staff entered both had their pants down and were touching one another. I am not sure if this is a one-time thing or increased sexual behavior and another notification to the medical provider in January of 2025 resulted in new medications added to the medication regime for R6 related to inappropriate sexual behaviors. On 3/12/25 at 11:23 a.m. in a telephone interview with a surveyor, R5's court appointed guardian confirmed that R5 does not have the capability to consent and has no history of sexual behavior. It was reported to her from the facility that on 1/30/25 an incident occurred with R5 that was consensual, and when she asked what that meant, she was told by the facility that consensual meant they are both participating. The court guardian confirmed that R5 is not able to make his/her own decisions and would not have the capacity to consent to sexual behavior with male residents. On 3/13/25 at 1:14 p.m. in a telephone interview with a surveyor, CNA5 stated that: -R6 has had several observed incidents of trying to get female residents to enter [his/her] room, with many of the female residents stating, get away from me. -R6 was observed in rooms of female residents with pants down, standing over the female resident as they were lying in their beds. -CNA5 recalled looking for R5 and went to R6s room but the door had been barricaded shut with two wheelchairs, once she did gain entry, she found R5 in there sitting in [his/her] wheelchair crying. After this incident, CNA 5 stated R6 was on 15-minute checks. On 3/13/25 at 1:36 p.m. in an interview with the Director of Nursing Services (DNS), a surveyor confirmed that the facility failed to protect R5 from potential sexual abuse by R6, who has a known history of hypersexual behaviors (as evidenced by R6's provider notes and orders), by barricading R5 in R6's room and performing a sexual act. The DNS stated that we determined that no harm had happened, and R5 was okay with the act. R5 wasn't crying, yelling, didn't seem upset. We don't feel all sexual acts are abuse. The facility did not report the incident of 1/30/25 to DLC or any other authority of potential sexual abuse of R5 by R6. R5's right to be free from sexual abuse was violated. The facility failed to take action to ensure that R5 was assessed for the capacity to consent to sexual behavior with R6. A reasonable person would potentially suffer psychological distress, emotional harm, embarrassment, and deep sadness due to lack of control over the situation and would experience fear of R6. 2. On 2/26/25 the Division of Licensing and Certification (DLC) received a facility report with an allegation that a Certified Nursing Assistant 1 (CNA1) witnessed CNA2 swearing towards residents. [R3] And that CNA2 was placed on administrative leave effective 2/20/25 and voluntarily resigned his position on 2/21/25. A review of the facility's investigation titled Internal Fact-Finding Summary dated 2/28/25 stated that on 2/20/25 CNA1 reported that in the past month she heard and witnessed on five occasions CNA2 make inappropriate remarks to residents; forcefully grab residents by the arms and take them to their rooms. Additionally, CNA1 stated that CNA2 stated the following to R3: -[R3] needs to get the fuck back to bed and stay there and grabbed R3s arm and forcefully took R3 back to their room. R3 stated Please don't hurt me three times, CNA1 noted that R3 was visibly uncomfortable. -CNA2 stated he [R3] needs to shut the fuck up CNA1 heard R3 get into bed while CNA2 was in the room, R3 stated don't do that please CNA2 told CNA1 That should calm [R3] down for a while then stated to R3 I'm not going to hurt you, but you'll know when I do. CNA1 also reported the following between CNA2 and R2: -CNA2 called R2 a stupid bastard CNA1 did not observe any physical interaction between CNA2 and R2, but she did hear R2 yell out AHHH! -CNA2 stated R2s really going to regret coming back out again referring to R2 coming out of his/her room. CNA1 also reported that she noticed more often than not residents have very notable injuries that occur the nights [CNA2] is present. Additionally, under Facts Summary CNA1 stated that these incidents/events had occurred over the last month, maybe three weeks. CNA1 stated CNA2 told her You just take your knee and hit them [residents] in thigh, and they won't get out of bed. CNA2 was interviewed by the facility and denied the allegations. CNA1 completed the facility's abuse training on 11/21/24 and CNA2 completed the training on 11/18/24. The clinical record review for R3 revealed a nursing note dated 12/22/24 at 11:38 a.m., a bruise was observed on the back of his/her right thigh measuring 15 centimeters (cm) by 7.5 cm in width. Additionally, during review of the CNA documentation for R3, it showed that CNA2 was the staff who provided care to R3 for the two-night shifts before the bruising was observed (bruising can be observed 24 to 48 hours after injury). Comparing the markings on R3 and the statement that CNA2 made claiming that all you have to do is knee the resident in the thigh and this will keep them in bed for the night. The bruise measuring 15 cm x 7.5 cm and matches the possibility of being struck by a knee. R3's clinical record does not show that R3 had any falls prior to this bruise being found making a fall the reason for this bruised area. A review of staffing schedules was completed within the timeframe CNA1 reports that she observed the incidents between CNA2 and residents. Because of the delay in CNA1 reporting, CNA2 continued to be able to work with residents for a total of 36 shifts. (See F609 for details). On 3/12/25 at 1:09 p.m. during an interview with facility administration, the surveyor confirmed that the facility failed to ensure residents were free from psychological, verbal and physical abuse. Please see F-0000 Initial comments for details related to the IJ template, removal plan, and removal of the IJ. 32540

Based on clinical record reviews and interviews, the facility failed to investigate an injury of unknown origin after a resident was found with a bruise for 1 of 6 residents reviewed for abuse (Resident #3 [R3]). Findings: On 3/12/25 at 11:30 a.m. during a clinical record review for R3, there is a nursing note dated 12/22/24 at 11:38 a.m. documenting a bruise on the back of the right thigh measuring 15 centimeters (cm) by 7.5 cm. additional note at 11:43 a.m. documents the bruise is to the back right hip/upper thigh area. The clinical record lacks evidence that this area of bruising injury of unknown origin was investigated by the facility. On 3/12/25 at 1:09 p.m. during an interview with a Unit Manager RN3, the surveyor confirmed that the injury of unknown origin was not investigated.

Based on clinical record review and interviews, the facility failed to ensure physician orders were followed for 1 of 2 sampled residents (Resident #6, [R6]). Findings: Review of R6's physician order sheet, handwritten, dated 10/28/24, stated, in one month present case to Doctor #1 (DR1). Review of R6's physician order sheet, handwritten, dated 10/29/24, stated, medroxyprogesterone 2.5 m.g PO (by mouth) daily for hypersexual behaviors. POA (power of attorney) consented for use. Review of R6's physician order sheet, handwritten, dated 11/11/24, stated, increase medroxyprogesterone to 5 m.g QD (every day). Review of R6's physician orders signed 11/14/24, page 3, stated under medications, 11/11/24 medroxyprogesterone acetate 5 m.g tablet by mouth daily given for antisocial sexual behavior (sexual-associated behavior disruptive to others). Review of R6's physician order sheet, handwritten, dated 12/13/24, increase medroxyprogesterone to 10 m.g PO daily. Re-present to DR1 next opportunity. Review of R6's physician orders signed on 1/16/25, page 2, stated diagnoses to include, Z72.51 high risk for heterosexual behavior. Review of R6's clinical record dated 2/14/25, acute visit, provider PA-C, stated, R6, [AGE] years old, was seen today for escalation of sexually inappropriate behaviors. Staff reports that the patient has been going after several female residents, trying to get them alone closing doors in order to attempt to have inappropriate sexual relations. He/she has been seen making sexual gestures to several female residents. Medroxyprogesterone was resumed subsequently increased. On 1/31/25, medroxyprogesterone 5 m.g daily was initiated due to inappropriate sexual behaviors, with a plan to increase to 10 m.g daily on 2/15/25.Given the fact that the patient has been targeting certain female residents and attempted again today, nursing reached out to management and the patient will be moved to a different room off of the unit to avoid any further incidents. On 3/13/25 at approximately 12:50 p.m., during record review and interview with RN3, a surveyor could not find evidence that R6's case has been presented to DR1 as ordered on 10/28/24 and 12/13/24. RN3 stated DR1 is no longer available, and RN3 and surveyor could not find evidence of follow-up pertaining to DR1 referrals with ordering PA-C as of 3/13/25, 121 days beyond the first order from the PA-C for case to be presented to DR1.

Based on a review of the Nursing Facility Reportable Incident submitted to the Division of Licensing and Certification (DLC) on 2/26/25, the incident report from Adult Protective services on 2/26/25, the facility's internal investigations, written statements by staff, facility policies, clinical record reviews and interviews, the facility failed to ensure staff reported allegations of psychological, physical, verbal, and sexual abuse immediately for 4 of 4 residents reviewed during complaint investigations, (Resident #1[R1], R2, R3, and R5) and failed to report an injury of unknown origin for 1 of 3 residents sampled R3. Findings: A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation of Property revised 4/24/23, under the heading, on page 1, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, punishment that causes or is likely to cause physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is the use of oral, written or gestured language that includes disparaging and/or derogatory terms to residents or their families within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse is physical assaults, cruel discipline, excessive use of physical or chemical restraints, or unnecessary or incorrect medication that may cause pain, inability to move a limb, burns, cuts, internal injuries, marks or bruises. Mental abuse is verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. On page 3 under section 5.4 Identification/detection: 5.4.1 Resident abuse may be overt or covert. It may be perpetrated by anyone, including but not limited to a staff member, another resident, a family member or another visitor. 5.4.2 reasons to suspect that abuse has taken place may include but are not limited to: 5.4.2.1 Resident complaints of abuse 5.4.2.2 actual observation of physical, verbal or sexual attack 5.4.2.4 unexplained bruises or other injuries 5.4.2.5 resident complaints of pain that are new or sudden and cannot be correlated to any of the resident's diagnosis. 5.4.2.6 resident's apparent fear of another person, whether staff, resident or visitor. 5.4.3 any of the reasons listed above, or any unexplained changes in a resident physical condition or behavior may indicate the possibility that the resident has been subjected to abuse and should be brought to the attention of the Supervisor immediately, but not later than 2 hours if serious bodily injury is involved. Section 5.6 protection 5.6.1 staff will intervene immediately to protect the resident(s) in any situation of actual or potential abuse, neglect, exploitation, or mistreatment. 5.7 Reporting and Response: 5.7.1 staff members will be expected to report actual or suspected abuse, neglect, exploitation or misappropriation of property to their supervisor immediately with subsequent reports to the Administrator and DNS (Director of Nursing Services) 5.7.2 licensed or certified staff and unlicensed assistive personnel are required by Maine law to report actual or suspected abuse, neglect, or exploitation to DHHS and APS. 5.7.5 as required by Maine law and regulation, a report must be made to DHHS with 24 hours and followed up by a written report if requested by DHHS. On 2/26/25 the DLC received a facility report with an allegation that a Certified Nursing Assistant (CNA) was witnessed swearing towards residents. The date of the alleged abuse was 2/20/25 and was not reported to the DLC until 2/26/25. On 2/26/25 at 3:24 p.m., the DLC received a reportable incident from the facility, alleging that on 2/20/25 CNA1 reported that she witnessed CNA2 being physically and verbally abusive to residents (R1, R2, and R3) she stated this has been going on for approximately 3 weeks to a month and did not report it. This allowed CNA2 to work 36 shifts continuing to subject the residents to his verbal and physical abuse. On 3/11/25 at 12:14 p.m. during an interview with the DON she stated she asked CNA1 why this wasn't reported sooner, CNA1 stated she had told her charge nurse, the charge nurse RN1 denied being told until the morning of 2/20/25. DNS stated that CNA1 was re-educated on the spot about reporting things immediately and not waiting. CNA1 reported to DNS that she was afraid of CNA2. At this time the surveyor confirmed that an observed allegation of verbal and physical abuse was not reported to the State timely. On 3/12/25 during a clinical record review for R3 there was a note dated 12/23 for an order to x-ray right hip and upper thigh due to bruise to back of right hip and upper thigh measuring 15cm x 7.5 cm. It is documented that this bruise was found on 12/22/24 and there is no evidence that this injury of unknown origin was reported or investigated. On 3/12/25 at 1:09 p.m. during an interview with a Unit Manager RN3, a surveyor confirmed that this injury of unknown origin was not reported to the DLC. 35904 A review of a facility Internal Fact-Finding Summary dated 2/27/25 stated, Synopsis of Issues: On 1/30/25 R5 was found in R6's room. R6 had pants down and R5's mouth was on R6's penis. On 2/14/25 RN4 reported to RN5 that R5 was being pushed in a wheelchair by R6. RN4 reported that R5 cowered into the nurse's station and appeared to be afraid of R6. At this time R6 was moved to another unit. On 3/13/25 at 1:36 p.m. in an interview with the DNS, a surveyor confirmed that the facility failed to notify DLC of potential sexual abuse on 1/30/25 involving R6 to R5.

Based on record reviews and interviews, the facility failed to ensure a care plan was resident centered and updated accurately for 1 of 6 residents reviewed during complaint investigations (Resident #5 [R5]). Findings: 1. Clinical record review indicated R5 has a diagnosis of vascular dementia. The care plan updated 2/26/25 identified the following: -A care area identified on 9/21/23, indicated Dementia. No goal listed. An approach dated 1/31/25 indicated Resident may exhibit sexual behaviors with male residents and If resident displays sexual behaviors, assess resident for signs of behavior changes related to sexual behaviors. If resident appears agitated, anxious, or is crying, redirect resident away from male residents. Notify supervisor or nurse manager if sexual behavior is occurring and is creating an unwanted interaction. If resident is engaging in consensual sexual behavior, provide privacy. On 3/12/25 at 2:28 p.m., during an interview with a surveyor and RN6, R5's care plan was reviewed. The care plan did not address R5's cognitive ability to engage in consensual sexual activity. At this time the surveyor confirmed R5's care plan was not resident centered or updated for an accurate approach due to R5 diagnosis of dementia and inability to consent to sexual activity. At this time the surveyor confirmed R6's care plan was not updated and implemented to meet R5's needs.

Based on facility policy review, record reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of the facility policy Antibiotic Stewardship Program dated 2/2/23 states .To improve patient safety and assist in the prevention of multi-drug resistant organisms (MDRO) and Clostridium difficile infections (CDI) by optimizing use of antibiotic drugs and to provide continuous improvement by utilizing prescribing and outcomes data to identify opportunities of targeted initiatives and optimal antibiotic prescribing .Tracking and trending for appropriate antibiotic selection and identification . Review of facility policy Medication Regimen Review dated 1/2019 states .The consultant pharmacist compiles and analyzes data collected from MMR's and presents findings to the Quality Assurance and Process Improvement (QAPI) Committee as part of the facility continuous improvement (CQI) program. Review of facility provided Infection Report revealed the following: -During the month of 6/2024, there were 25 documented facility acquired infections that were prescribed antibiotics. -During the month of 7/2024, there were 20 documented facility acquired infections that were prescribed antibiotics. -From 8/1/24 through 8/29/2024 there were 15 documented facility acquired infections that were prescribed antibiotics. Further review of infection report lacked evidence these antibiotics were reviewed or discussed. Review of facility provided Quality Pharmacy Report for Quarter #3 dated 10/9/23, Quarter #4 dated 1/8/24, Quarter #1 dated 4/1/24, and Quarter #2 dated 6/26/24, lacked evidence that the pharmacist/facility reviewed antibiotic use during these meetings. During an interview on 8/21/24 at 12:01 p.m., Director of Nursing (DON) indicated that for the most part the providers put their own orders in the electronic medical record (EMR) and the infection report is generated through the EMR, and that is what they review during the monthly Antibiotic Stewardship meetings, but they have not looked at trends or root cause. During a follow-up interview on 8/21/24 at 3:01 p.m., with 2 surveyors, the DON indicated she spoke with pharmacist confirming the provided pharmacy reports contain everything that is discussed in QAPI, and antibiotic stewardship has not been discussed. During an interview on 8/22/24 at 9:20 a.m., Infection Preventionist (IP) indicated the facility does have a lot of antibiotic use and realized through the survey process that there are a lot of antibiotic prescriptions that do not meet McGuires criteria. IP further indicated that at this point no one had discussed antibiotic use with the providers before and they have not implemented any tracking systems.

Based on facility policy review, record review, and interview, the facility failed to maintain an effective infection control program, and failed to analyze and follow-up on known infections in the facility. This has the potential to affect all residents receiving an antibiotic in the facility. In addition, the facility failed to ensure a shared glucometer was cleaned after each use for 1 of 2 observations (8/20/24), Findings: Review of facility policy Infection Prevention and Control Program dated 9/25/23 states will establish, implement and maintain an infection prevention and control program that will provide safe, sanitary and comfortable environment to help prevent, recognize, and control, the onset, development and transmission of communicable disease and infection to residents . Surveillance and investigation to prevent and control the onset and spread of infection within the facility.Program Record Keeping maintains records of incidents and corrective actions related to infections . 1. Review of facility provided Infection Report revealed the following: -During the month of 6/2024, there were 25 documented facility acquired infections that were prescribed antibiotics. -During the month of 7/2024, there were 20 documented facility acquired infections that were prescribed antibiotics. -From 8/1/24 through 8/29/2024 there were 15 documented facility acquired infections that were prescribed antibiotics. Further review of infection report lacked evidence the facility analyzed and followed up on known infections in facility. During an interview on 8/21/24 at 12:01 p.m., Director of Nursing (DON) confirmed they review antibiotics during the monthly Antibiotic Stewardship meetings but have not looked at trends or root cause of the infections. During an interview on 8/22/24 at 9:20 a.m., Infection Preventionist indicated the facility does have a lot of antibiotic use and realized that there are a lot of antibiotic prescriptions that do not meet McGuires criteria and haven't done any tracing/surveillance to form a root cause of the infections. 33242 2. On 8/20/24 at 8:23 a.m., a surveyor observed Certified Nursing Assistant #4 (CNA4) complete a blood sugar on a resident, using a shared glucometer. At 8:25 a.m., the surveyor then observed CNA4 walk over to another resident and complete another blood sugar, without cleaning the glucometer inbetween use. On 8/20/24 at 8:26 a.m., during an interview with CNA4, the surveyor asked if she cleaned the glucometer after using on one resident, before completing the blood sugar check on the other resident. CNA4 stated that she does have the Sani Cloths to clean the glucometer and that sometimes she cleans it when she remembers. The surveyor confirmed during this interview that the glucometer was not cleaned inbetween resident use.

Based on facility policy review, record reviews and interviews, the facility failed to ensure that resident records contained accurate, complete, and/or readily accessible information for 3 of 5 resident records reviewed for falls (Resident #84 [R84], R74 and R7). Findings: The facility's policy, Neurological Assessments, (neuro checks) last reviewed 5/8/24, indicates that a neurological assessment will be completed and documented in ECS (electronic medical record) after any incident or fall in which a head injury is suspected. In the case of an unwitnessed fall, the resident will be considered to have hit their head unless he/she can reliably state he/she did not. Assessments will be completed every 15 minutes for the first hour after the fall, every 30 minutes for the subsequent 4 hours, every shift for the next 72 hours. 1. On 8/21/24, R84's clinical record was reviewed and indicated that on 8/15/24 at 12:00 p.m., R84 was observed on the floor in the dining room and neuro checks were started. A review of R84's Treatment Administration Record (TAR) and documented neurological assessments indicated the following: On 8/9/24, the TAR indicated when the 15 and 30 minute neuro checks were to be completed but upon review of the clinical record, the neurological assessments were not documented at the time the assessment occurred. The assessment that was completed for a 15 minute check at 12:00 p.m., was not documented in the clinical record until 5:53 p.m.; The assessment that was completed for a 15 minute check at 12:15 p.m., was not documented in the clinical record until 5:54 p.m.; The assessment that was completed for a 15 minute check at 12:30 p.m., was not documented in the clinical record until 5:55 p.m.; The assessment that was completed for a 15 minute check at 12:45 p.m., was not documented in the clinical record until 5:56 p.m.; The assessment that was completed for a 15 minute check at 1:00 p.m., was not documented in the clinical record until 5:58 p.m.; The assessment that was completed for a 30 minute check at 1:30 p.m., was not documented in the clinical record until 5:59 p.m.; The assessment that was completed for a 30 minute check at 2:00 p.m., was not documented in the clinical record until 5:59 p.m.; The assessment that was completed for a 30 minute check at 2:30 p.m., was not documented in the clinical record until 6:00 p.m.; The assessment that was completed for a 30 minute check at 3:00 p.m., was not documented in the clinical record until 6:01 p.m.; The assessment that was completed for a 30 minute check at 3:15 p.m., was not documented in the clinical record until 6:02 p.m.; The assessment that was completed for a 30 minute check at 4:00 p.m., was not documented in the clinical record until 6:03 p.m.: and The assessment that was completed for a 30 minute check at 4:30 p.m., was not documented in the clinical record until 6:04 p.m. The above documentation does not indicate a late entry or mention of what time the documented assessment actually was completed. 2. On 8/21/24, R74's clinical record was reviewed and indicated that on 8/9/24 at 5:45 p.m., R74 was observed on the floor in his/her room and neuro checks were started. A review of R74's Treatment Administration Record (TAR) and documented neurological assessments indicated the following: On 8/9/24, the TAR indicated when the 15 and 30 minute neuro checks were to be completed but upon review of the clinical record, the neurological assessments were not documented at the time the assessment occurred. The assessment that was completed for a 15 minute check at 6:00 p.m., was not documented in the clinical record until 9:51 p.m., and did not include vitals; The assessment that was completed for a 15 minute check at 6:15 p.m., was not documented in the clinical record until 9:51 p.m. and did not include vitals; The assessment that was completed for a 15 minute check at 6:30 p.m., was not documented in the clinical record until 9:51 p.m., and indicated refusing vitals; The assessment that was completed for a 15 minute check at 6:45 p.m., was not documented in the clinical record until 9:52 p.m., and indicated refusing vitals; There was an extra 15 minute check documented at 10:00 p.m. per assessment (not listed on the TAR), and indicated refusing vitals; The assessment that was completed for a 30 minute check at 7:15 p.m., was not documented in the clinical record until 10:01 p.m., and indicated refusing vitals; The assessment that was completed for a 30 minute check at 7:45 p.m., was not documented in the clinical record until 10:02 p.m., The assessment that was completed for a 30 minute check at 8:15 p.m., was not documented in the clinical record until 10:02 p.m., and indicated refusing vitals; The assessment that was completed for a 30 minute check at 8:45 p.m., was not documented in the clinical record until 10:02 p.m., and indicated refusing vitals; The assessment that was completed for a 30 minute check at 9:15 p.m., was not documented in the clinical record until 10:47 p.m., and indicated refusing vitals; The assessment that was completed for a 30 minute check at 9:45 p.m., was not documented in the clinical record until 10:47 p.m., and indicated refusing vitals; and The assessment that was completed for a 30 minute check at 10:15 p.m., was not documented in the clinical record until 10:47 p.m., and indicated refusing vitals. The above documentation does not indicate a late entry or mention of what time the documented assessment actually was completed. On 8/22/24 at 10:23 a.m., a surveyor reviewed documentation of the neuro checks with the Director of Nursing. The Treatment Administration Record (TAR) was reviewed and the time on the TAR included the time that an assessment was done but the documentation of the assessment in the clinical record does not correlate with the time on the TAR. The surveyor confirmed that the documentation of the assessments are not reflective of the time that they were completed. On 8/22/24 at 11:14 a.m., in an interview with a surveyor, a Certified Nursing Assistant (CNA) #5 stated vitals are completed as part of the post fall packet. The CNAs take the vitals and keep them with the packet and the nurses are responsible for entering them into the ECS (electronic medical record) when the packet is completed. 49635 3. Clinical Record Review indicated R7 was admitted on [DATE] with a diagnosis of Vascular Dementia. According to the Minimum Data Set (a standardized assessment tool) on 6/19/24, R7 had a Brief Interview for Mental Status (BIMS) score of 1, and a BIMS of 3 on 8/16/24 (a score of 0-7 suggests severe cognitive impairment). Nurse documentation indicated R7 had two unwitnessed falls on 8/14/24. The clinical record lacked evidence that neurological assessments were completed after the unwitnessed falls. Between 8/19/24 through 8/22/24, during an interview with a surveyor, Anonymous (A) Staff Members (A3 and A4) stated: A4 stated, after an unwitnessed fall, R7's initial neurological assessment and vitals were documented in a fall packet on the morning of 8/14/24, but then staff were directed by management to discard them (prior to completion) without being recorded in the electronic medical record (ECS). A3 stated, R7 was found on the floor after an unwitnessed fall, neurological assessments and vitals were documented in the fall packet but then discarded (prior to completion), without being recorded in ECS. On 8/22/24 at 11:14 a.m., in an interview with a surveyor, a Certified Nursing Assistant (CNA) #5 stated vitals are completed as part of the post fall packet. The CNAs take the vitals and keep them with the packet and the nurses are responsible for entering them into the ECS when the packet is completed. On 8/22/24 at 11:22 a.m., in an interview with a surveyor, the Director of Nursing stated, within 20 minutes a post fall investigation has to be filled out. It includes multiple staff members input (medication technician, charge nurse, certified nursing assistants, and supervisors) The information is used to for a mini root cause analysis. The provider and family are supposed to be called, and it should be documented. Care plans are reviewed to see if new interventions need to be put in place. If a resident puts themself on the floor, the need to complete a post fall evaluation varies. If a noise is heard from outside the room, and they are found on the floor. It's considered a fall, no matter what, and the post fall investigation needs to be completed. On 8/22/24 at 12:06 p.m., in an interview with the B Unit Manager and the Director of Nursing, the B Unit Manager stated post fall assessments may be discarded after step 4 if staff feel it was not a fall based on assessments. At this time the surveyor confirmed that resident medical records are not retained when assessments and vitals are discarded before being entered into the electronic record.

Based on observations, and interviews, the facility failed to ensure that bowls were dried properly and failed to ensure the kitchen was free from insects for 1 of 2 kitchen tour ([DATE]). In addition, the facility failed to ensure that milk was not expired during 1 of 2 meal observations on the B Unit ([DATE]). Findings: 1. On [DATE] at 10:20 a.m. an initial tour of the kitchen was done with the Nutrition Manager. Observed on a shelf, available for use, were 30 cereal bowl and 30 small white bowls that were wet stacked/nestled. Near the baking station area, fruit flies were observed coming from and around the floor drain. These findings were confirmed at the time of the observation. 33242 2. On [DATE] at 12:39 p.m., during a lunch observation in the East Wing dining room on B Unit, a surveyor observed in the beverage trays with ice, 2 unopened 1% milk with an expiration date of [DATE]. The surveyor confirmed this with the Registered Nurse.

Based on facility policy review, record reviews, and interviews, the facility failed to ensure that the resident and/or resident representative written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate and advanced directive, was completed for 9 of 32 residents reviewed for advanced directives. (Resident [R] [R9], R27, R30, R37, R19, R49, R45, R76, and R87). Findings: Review of facility policy Advance Directives . dated 4/26/23 states .policy to provide to all residents at the time of their admission, and subsequently upon request, written information concerning their rights under Maine law to make decisions concerning their health care, including the right to accept or refuse medical treatment and health care services. 1. Resident #45 was admitted to the facility on [DATE]. Review of R45's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #76 was admitted to the facility on [DATE]. Review of R76's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 3. Resident #87 was admitted to the facility on [DATE]. Review of R87's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 4. Resident #19 was admitted on [DATE]. A review of R19's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. 5. Resident #49 was admitted on [DATE] . A review of R49's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. 6. Resident #9 was admitted on [DATE]. A review of R9's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. 7. Resident #27 was admitted on [DATE]. A review of R27's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. 8. Resident #30 was admitted on [DATE]. A review of R30's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. 9. 3. Resident #37 was admitted on [DATE]. A review of R37's clinical record lacked evidence that the facility followed up and/or assisted the resident/resident representative with the written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. During an interview on 8/20/24 from 10:09 a.m. to 10:12 a.m., in presence of 3 surveyors, the Licensed Social Worker confirmed residents/representatives were not asked/offered the opportunity to form an advanced directive, and that she did not follow up with resident and/or resident's representatives to assist with completing advanced directives.

Based on observation and interview the facility failed to promote care to residents in a manner that maintains each resident's dignity for 3 of 4 meal observations in 2 dining rooms on the B Unit. Findings: 1. On 8/19/24 between 12:30 p.m. - 12:55 p.m., during lunch observation in the East Wing dining room on B Unit, a surveyor observed the following: A surveyor observed Certified Nursing Assistant #1 (CNA1) assisting Resident (R46) with eating at 12:43 p.m. The surveyor observed R46 in his/her chair with CNA1 standing up as she was feeding R46. During an interview with a surveyor, CNA1 stated that she was standing because there were no extra chairs to sit in, in the dining room. R46's tablemate did not receive his/her meal tray until 12:53 p.m. Resident #79 (R79) was observed eating at 12:35 p.m., but his/her tablemate(s) did not receive their food until 12:49 p.m. There was a table with 6 residents, R65 received his/her lunch at 12:43 p.m. The surveyor left the dining room at 12:55 p.m., and 3 of 6 tablemates had not received their lunch by this time. On 8/19/24 at 12:51 p.m., a surveyor asked CNA2 how the meal service is supposed to be delivered. CNA2 stated that they are supposed to serve by table. CNA3 stated that typically we give the kitchen our tickets so they know where the residents are but they wanted to do it themselves today. The kitchen staff was observed bringing the trays into the dining room but with no direction of whose trays were coming in and when. 49635 2. On 8/19/24 at 12:49 p.m., during lunch observation in the [NAME] Wing dining room, a surveyor observed R6 request a sliced turkey sandwich. R6 stopped eating when he/she did not receive one. The Licensed Practical Nurse publicly provided education to R6 regarding their medication, diagnosis, and dietary restrictions. 3. On 8/20/24 at 8:40 a.m., during breakfast observation in the [NAME] Wing dining room, a surveyor observed R94 and R41 sitting at a table with 4 other residents. All residents at the table were served except R94 and R41. Staff observed serving other tables. At 8:46 a.m., R94 was served, staff then served other tables. At 8:52 a.m., R41 was the last resident served in the dining room On 8/22/24 at approximately 10:30 a.m., the above observations were reviewed and confirmed with the Administrator.

Based on record review and interviews, the facility failed to protect a resident ' s right to be free from physical abuse by staff, when a Certified Nursing Assistant (C.N.A.) held a residents arms down during care, causing the resident to sustain bruising on arms and causing the resident to be angry for 1 of 1 residents reviewed (Resident #1 [R1]). Finding: On 5/6/24, R1's clinical record was reviewed. The record indicated R1 was diagnosed with dementia, anxiety, severe agitation, and psychosis and resides on the secured [memory care] unit. A nurse note, dated 4/3/24, indicated that the R1 had new bruises on his/her left upper and lower forearm and a bruise on the upper right arm. On 5/6/24 at 8:35 a.m., in an interview with Registered Nurse-Nurse Manager (RN-NM), she stated that on 4/3/24, C.N.A.2 wheeled R1 to her office. C.N.A.2 stated that R1 shouted out angrily that C.N.A.1 threw him/her around. RN-NM and C.N.A.2 observed new bruises on R1's arms. RN-NM assessed the resident and no other injuries were observed. RN-NM stated in her interview that she immediately interviewed C.N.A.1 about the bruising on R1's arms. C.N.A.1 stated he assisted R1 to the toilet and was trying to bath R1. R1 was trying to hit him during morning care so C.N.A.1 stated he grabbed R1's left arm and held it down on the toilet's safety rail while he finished the bath. On 5/6/24 at 9:42 a.m., in an interview with C.N.A.1, he stated in an interview that he did not hold R1's arm down. He stated R1 was trying to hit him so he pushed the resident's arm away. On 5/6/24 at 10:05 a.m., in an interview with C.N.A.2, he stated he took care of R1 on 4/2/24, the day before the incident and he did not notice any bruising on R1's arms. C.N.A.2 stated on 4/3/24, R1 wheeled up to C.N.A.2 and was very angry. R1 pointed at C.N.A.1 and said he threw [R1] around. C.N.A. 2 stated he noticed some red bruising on his arms, so wheeled R1 to RN-NM office. and reported the incident. On 5/6/24 at 10:20 a.m., in an interview with the day Charge Nurse, she stated the RN-NM asked her to take care of R1. Charge Nurse stated she noticed the new bruises on his/her arms. On 5/6/24 at 11:02 a.m., in an interview with C.N.A.3, she stated she worked on 4/2/24, the day before the incident and she stated she observed R1 in the corridor several times that day and did not notice any bruises on R1's arms. On 4/3/24, C.N.A.3 stated that C.N.A.1 asked her to switch residents with him because R1 was trying to hit him. C.N.A.3 stated she took care of R1 for a while. She stated she washed him up and noticed the bruises on R1's arms. C.N.A.3 also stated that R1 told her C.N.A.1 grabbed [him/her]. On 5/6/24, a review of the facility's Abuse Policy, page 1, paragraph 2, indicated staff will protect each resident from abuse. Defined physical abuse as physical assaults, cruel discipline, excessive use of physical or chemical restraints, or unnecessary or incorrect medication that may cause pain, inability to move limbs, burns, cuts, internal injuries, marks or bruises. As a result of this isolated incident, the following corrective actions were initiated on 4/3/24. -The RN-NM terminated C.N.A.1. -The Staff Development Coordinator and the Assistant Director of Nursing provided all direct care staff and licensed nurses on all the facility's Units (B-Unit, C-Unit and D-Unit) on Resident Abuse, Neglect and Exploitation. In addition, staff were in-serviced on 'Burn Out'.

Based on interviews, verbal statements and review of the facility reportable incident forms, the facility failed to ensure that 1 of 3 residents reviewed (Resident #1) was free from physical abuse. Finding: A review of the facility's Nursing Facility Reportable Incident Form dated 6/22/18, indicated that Resident #1 reported that a certified nursing assistant (CNA) during care on the evening of 6/21/18 at approximately 9:00 p.m. was pissed off while providing care and caused an injury to his/her left abdominal fold. The area was assessed and an injury was found measuring 4 centimeters by 0.5 centimeters. During the facility's internal investigation, interviews were conducted with the alleged perpetrator and the staff members who worked with CNA #1 on 6/21/18. Interviews were documented, CNA #1 stated in her interview that she entered Resident #1's room at approximately 9:20 p.m. and that she was feeling stressed out and if Resident #1 said she had given him/her attitude it wasn't directed at him/her. She stated she was upset about a staff being pulled to another unit and that Resident #1 freaked out on her saying that she was digging too hard while washing under their abdominal fold. When asked if she recalled any injury to Resident #1's abdominal fold, CNA #1 stated that when she removed the wash cloth, she had noted red blood on the cloth but did not report this to the charge nurse. During the interview with CNA #2 she stated that when CNA #1 left Resident #1's room she stated I was mad and I took it out on Resident #1. CNA #2 stated she remembers Resident #1 raising his/her voice at CNA #1 and complaining of pain. On 10/16/18 at 11:08 a.m., during an interview with the surveyor, Resident #1 stated that CNA #1 was late coming into his/her room and when she finally came in she was rough, and further stated that CNA #1 was aware that under his/her abdominal fold is tender and she was rough anyway's. I could see when she came in my room she was upset and constantly complaining about how she had to add other residents to her list and she didn't want to do me. When she got to the bed and she took the rag and she rubbed it hard on my abdominal fold, I told her she was hurting me but I grinned and bared it. I told another CNA the next a.m. that CNA #1 was rough with me. The girl told me that CNA #1 had told her that she (CNA #1) tore my belly open and that I would be mad at her. When she said it to the other CNA I knew, she knew what she had done. On 10/19/18 at 1:47 p.m. during a phone interview with CNA #2 she stated that CNA #1 told her at the change of shift that she was frustrated and took it out on Resident #1. CNA#1 didn't tell me she caused an injury but during morning care Resident #1 told her that CNA #1 was rough and caused pain to his/her groin area. When the area was assessed a slit was found in his/her abdominal fold, and that Resident #1 was very upset with how CNA #1 had hurt him/her, prior to this incident CNA#1 and Resident #1 had a good rapport which seemed to upset Resident #1 even more that she would be so rough with him/her. On 10/16/18 at 9:27 a.m., in an interview with the surveyor, the Director of Nursing Services (DNS) indicated that CNA #1 was immediately removed from duty, and after their internal investigations, CNA #1 was terminated on 6/25/2018.

Based on record reviews and interviews, the facility failed to follow a physician's order for a blood test for 1 of 5 sampled residents reviewed for the use of the anticoagulant [MEDICATION NAME] (#128). The failure to follow the physician's order for a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR), a test to check the therapeutic level of [MEDICATION NAME], resulted in Resident #128 not receiving the anticoagulant [MEDICATION NAME] from [DATE] through [DATE]. The resident subsequently developed new onset of right upper thigh pain and was hospitalized with acute right lower extremity ischemia and sub-therapeutic INR. Findings: Resident #128 was admitted to the facility from the hospital, on [DATE]. The hospital discharge summary included the [DIAGNOSES REDACTED]. The [DATE] hospital discharge summary indicated the resident was to receive [MEDICATION NAME] 2 milligrams (mgs) by mouth daily, but to hold the [MEDICATION NAME] for today, then resume [DATE], depending on the INR( International Normalized Ratio) to be drawn on [DATE]. The laboratory reference range for a resident with [MEDICAL CONDITION] Fibrillation is to maintain a INR between 2XXX,[DATE].0 with a target of 2.5. Resident #128 laboratory testing results, dated [DATE], indicated the resident's INR was 4.2. A physician's telephone order, dated [DATE], directed staff to hold the [MEDICATION NAME] on [DATE] and [DATE], then to recheck the INR on [DATE] for further orders. Resident #128's laboratory testing results form indicated the resident's INR, on [DATE], was 4.5. The physician order, dated [DATE], directed staff to hold the [MEDICATION NAME] on [DATE] and [DATE] and obtain an INR on [DATE]. The INR on [DATE] was 3.7 and the physician directed staff to continue to stop the [MEDICATION NAME] and obtain the next INR on [DATE]. The clinical record for Resident #128 did not contain a PT/INR for [DATE]. The resident continued to not receive the anticoagulant [MEDICATION NAME] and did not have any further PT/INRs done until [DATE] after Resident #128 presented with right upper thigh pain on [DATE]. A physician's progress note, dated [DATE] indicates that Resident #128 was experiencing right upper and lower leg pain. The note also indicates that the resident was supposed to have had an INR done on [DATE] but no results were available and that the resident was at risk for [MEDICAL CONDITIONS]. A [DATE] physician progress notes [REDACTED]. The resident was transferred to the hospital at 9:36 a.m. on [DATE]. Upon assessment at the hospital Resident #128 was found to have no pulses below the right knee by Doppler and palpation. The resident's INR was found to be subtherapeutic at 1.1. The resident was scheduled for a surgical embolectomy (removal of clot) however shortly into the procedure Resident #128 suffered cardiac instability and the procedure was cancelled. The resident was placed on comfort care and ultimately died on [DATE]. The failure to follow the physician's order for an INR, on [DATE], resulted in a lack of monitoring of the INR to evaluate the requirements of anticoagulant therapy in a resident with a history of chronic left ventricular thrombus and identified at risk for [MEDICAL CONDITION]. Resident #128 did not receive a single dose of [MEDICATION NAME] throughout his/her entire stay at the facility from [DATE] to [DATE]. On [DATE] at 1:40 p.m. in an interview with the surveyors, the Director of Nursing Services (DNS) and the Registered Nurse (RN) Unit Manager for C Unit, confirmed that an INR for Resident #128 was not drawn, on [DATE], as ordered by the physician. The RN Unit Manager stated measures that were in place when the order was received, on [DATE], were: noting of the order by the first RN indicating the order was entered in the Electronic Charting System (ECS) and that a laboratory requisition slip was completed. A 24 hour check of the order by a second RN, on the night shift, was to confirm this was all completed by the first RN. The physician's order, dated [DATE] was signed by both the first and second nurse indicating the order had been entered into ECS and the lab requisition had been completed and placed in the lab book on the unit. The DNS stated this lab order was not entered into ECS nor was the lab requisition completed and placed in the lab book on the unit. The DNS stated as a result of the facility's [DATE] investigation of this incident there are now two lab books on the C unit and the night charge nurse prints the lab list from ECS every morning and cross checks the list with the lab requisitions. In addition, the DNS stated both nurses who signed this order were trained in the facility's procedure which was put in place, on [DATE], on the C Unit only. The DNS stated to the surveyor that this procedure was being implemented on C unit only and the plan was to discuss implementation on D unit at the next nurse manager's meeting. When a surveyor asked if any audits had been done on other residents on anticoagulants the DNS stated that no audits had been completed on any other residents in the facility receiving anticoagulant therapy and that as of [DATE] only the two nurses involved had been educated.

Based on record reviews and interviews, the facility failed to ensure 1 of 5 stage 2 sampled residents reviewed for the use of the anticoagulant [MEDICATION NAME] (#128) was free from significant medication errors. The facility's failure to obtain and monitor the [MEDICATION NAME] Time/International Normalized Ratio (PT/INR), a test to check the therapeutic level of [MEDICATION NAME], resulted in Resident #128 not receiving the anticoagulant [MEDICATION NAME] from [DATE] through [DATE]. The resident subsequently developed new onset of right upper thigh pain and was hospitalized with acute right lower extremity ischemia and subtherapeutic INR. Findings: Lippincott "Nursing 2014 Drug Handbook," page 1444, indicates [MEDICATION NAME] is an anticoagulant for the use of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. Under "administration" it states, "PT and INR determinations are essential for proper control... recommended INR range is usually ,[DATE]." Resident #128 was admitted to the facility from the hospital, on [DATE]. The hospital discharge summary included the [DIAGNOSES REDACTED]. The [DATE] hospital discharge summary indicated the resident was to receive [MEDICATION NAME] 2 milligrams (mgs) by mouth daily but to hold the [MEDICATION NAME] for today, then resume [DATE], depending on the INR ( International Normalized Ratio) to be drawn on [DATE]. Clinical record review for Resident #128 indicated the [DATE] INR was 4.2. A physician' s telephone order, dated [DATE], directed staff to hold the [MEDICATION NAME] [DATE] and [DATE] and to recheck the INR on [DATE] for further orders. Resident #128's INR, on [DATE], was 4.5. The physician order, dated [DATE] directed staff to hold the [MEDICATION NAME] on [DATE] and [DATE] and obtain an INR on [DATE]. The INR on [DATE] was 3.7 and the physician directed staff to continue to stop the [MEDICATION NAME] and obtain the next INR on [DATE]. The clinical record for Resident #128 did not contain a PT/INR for [DATE]. The resident continued to not receive the anticoagulant [MEDICATION NAME] and did not have any further PT/INRs done until [DATE] after Resident #128 presented with right upper thigh pain on [DATE]. A [DATE] physician's progress note indicates that Resident #128 was experiencing right upper and lower leg pain. The note also indicates that the resident was supposed to have had an INR done on [DATE] but no results were available and that the resident was at risk for [MEDICAL CONDITIONS]. A [DATE] physician progress notes [REDACTED]. The resident was transferred to the hospital at 9:36 a.m. on [DATE]. Upon assessment at the hospital Resident #128 was found to have no pulses below the right knee by Doppler and palpation. The resident's INR was found to be subtherapeutic at 1.1. The resident was scheduled for a surgical embolectomy (removal of clot) however shortly into the procedure Resident #128 suffered cardiac instability and the procedure was cancelled. The resident was placed on comfort care and ultimately died on [DATE]. The failure to follow the physician's orders [REDACTED]. Resident #128 did not receive a single dose of [MEDICATION NAME] throughout his/her entire stay at the facility from [DATE] to [DATE]. On [DATE] at 1:40 p.m. in an interview with the surveyors the Director of Nursing Services (DNS) and the Registered Nurse (RN) Unit Manager for C Unit, confirmed that an INR for Resident #128 was not drawn, on [DATE], as ordered by the physician. The RN Unit Manager stated measures that were in place when the order was received, on [DATE], were: noting of the order by the first RN indicating the order was entered into the Electronic Charting System (ECS) and that a laboratory requisition slip was completed. A 24 hour check of the order by a second RN, on the night shift, was to confirm this was all completed by the first RN. The physician's orders [REDACTED]. The DNS stated this lab order was not entered into ECS nor was the lab requisition slip completed and placed in the lab book on the unit. The DNS stated as a result of the facility's [DATE] investigation of this incident there are now two lab books on the C unit and the night charge nurse prints the lab list from ECS every morning and cross checks the list with the lab requisition slips. In addition, the DNS stated both nurses who signed this order were trained in the facility's procedure which was put in place, on [DATE], on the C Unit only. The DNS stated to the surveyor that this procedure was being implemented on C unit only and the plan was to discuss implementation on the D unit at the next nurse manager's meeting. When a surveyor asked if any audits had been done on any other residents receiving an anticoagulant the DNS stated that no audits had been completed on any other residents in the facility receiving anticoagulant therapy and that as of [DATE] only the two nurses involved had been educated.