Every finding on record at Maine Veterans Home - Caribou

Based on record review and interview, the facility failed to notify the physician of significant change in condition for 1 of 1 resident reviewed for Abuse [Resident #16 (R16)]. This failure delayed physician intervention that resulted in harm to R16 when R16 had requested to go to the hospital on 1/27/26 while experiencing respiratory distress which included needing increased supplemental oxygen above physician order, increased anxiety and restlessness which required frequent staff intervention and redirection. The Medical Provider was not notified of the change in condition until 1/29/26. Findings: R16 is a [AGE] year-old resident with diagnoses to include, but not limited to, Congestive Heart Failure Systolic Acute, Chronic Idiopathic Pulmonary Fibrosis, Pulmonary Hypertension, Chronic Respiratory Failure and a Right Humerus Fracture. On 2/5/26, review of R16's clinical record indicated the following:-R16's oxygen order, start date 12/30/25, directed staff to administer oxygen (O2) continuously up to 5 Liters Per Minute (LPM) via nasal cannula to keep O2 saturation greater than 88%.-On 1/26/26 at 10:45 a.m., a nurse note indicated the physician (MD) spoke to/with resident examined resident at 9:32 a.m., and there were no new orders.- Provider progress note, dated 1/26/26, indicated R16 was seen for acute shortness of breath, oxygen saturation not improving despite increased O2, and feeling weak. R16 had diffuse crackles, rhonchi (snore-like lung sounds heard with a stethoscope, often described as a wet or rattling sound caused by air passing through mucus or narrowed, obstructed airways) at that time.-On 1/26/26 at 3:42 p.m., a nurse note indicated R16's oxygen was increased to 8 LPM. The clinical record lacked evidence that the provider was notified of R16's change in condition that required increased oxygen LPM above what the physician ordered (See F695).-On 1/27/26 at 2:05 p.m., a late entry nurse note stated, Time: 11:40 [a.m.] REGARDING: [R16's Power of Attorney (POA)] stated that another family member had called [him/her] and told [him/her] that R16 had been requesting to go to the hospital and [he/she] was wondering if any staff had been with [R16] recently. The nurse indicated R16 had increased anxiety and restlessness requiring frequent staff intervention/redirection, that R16 was on 8L via non-rebreather mask, but resident also appears to be having some anxiety [related to] having to use the mask - however, [R16] has been consistently [dropping oxygen saturation to [80% range (80's)] or lower on nasal cannula. The nurse stated that comfort measures meant that nursing staff would try to keep resident comfortable here at facility without further interventions that would be an option at the hospital. [the nurse] informed [R16's POA] that changing [R16's] code status or treatment goals is [his/her] choice/right as [R16's] POA, but that this would also involve communicating with emergency department staff as [R16's] POA that there were changes to resident's code status per [his/her] wishes. At Time [1:15 p.m. (13:15)] the nurse called R16's POA with an update, indicating the resident had settled down after the 12:00 p.m. scheduled dose of Ativan and [as needed (PRN)] options for pain/anxiety such as morphine discussed at this time and [R16's POA] was receptive to these options if the provider would like to try them. The clinical record lacked evidence that the provider was notified of the resident's change in condition and that the resident had requested to transfer to the hospital. Additionally, a change in code status is not required to receive treatment for respiratory distress in the emergency room.-On 1/27/26 at 6:50 p.m., a late entry nurse note indicated, spoke with attending [MD] at [2:02 p.m. (1402)] REGARDING: increased agitation RESULT: new orders received and noted 01/27/2026 discontinue scheduled Oxycodone, start Morphine Sulfate Concentration 5mg [by mouth every 4 hours as needed. The clinical record lacked evidence that the provider was notified of the increase oxygen demand or that the resident had requested to transfer to the hospital.-On 1/29/26 at 7:51 a.m., a nurse note indicated, spoke with attending physician [Family Nurse Practitioner (FNP)] REGARDING: blood sugar of 39 and administration of glucagon injection and blood sugar now 42 RESULT: order to administer second glucagon injection. requested to be called back after next blood sugar check. The clinical record lacks evidence that the provider was notified of the resident's change in condition regarding oxygen needs.-On 1/29/26, the Provider (Family Nurse Practitioner [FNP]) progress note stated when I entered the room [R16] was struggling to breath - oxygen mask on [he/she] was trying to take it off - using accessory muscles to breath - [R16's] eyes were wide looking at me. [R16] is not speaking to me. [R16] does not appear comfortable. If we cannot get R16 comfortable the next step would be the house of comfort. On 2/5/26 at 3:18 p.m., during an interview with 3 surveyors, the Provider (FNP) stated she entered R16's room at approximately 1:00 p.m. to follow up on R16's low blood glucose results from that morning. FNP stated she was not aware R16 was uncomfortable or in respiratory distress until she entered R16's room. FNP stated when she entered the room, [R16] looked at her wide eyed, was in respiratory distress, using accessory muscles to breathe, and that R16 was anxious and trying to remove his/her oxygen mask. The FNP stated she was not aware that R16's oxygen demand had increased to 8 LPM, and she had to order a loading dose of morphine in addition to the existing order to get R16 comfortable. The FNP stated, people starving go to the House of Comfort or the hospital when we couldn't get them under control like that. During the interview, FNP reviewed the Provider records and stated the last communications with a Provider prior to FNP entering the room on 1/29/26, were with the Medical Doctor (MD) on 1/26/26 at 9:32 am for the in-person visit, and the phone call on 1/27/26 at 1:59 p.m. regarding the prescription change from Oxycodone to Morphine. At 3:36 p.m., the surveyor confirmed with FNP that the Medical Providers were not made aware of R16's request to go to the hospital on 1/27/26, R16's oxygen increase to 8 LPM via non-rebreather or incidents of discomfort / respiratory distress prior to FNP entering the room on the 1/29/26.On 1/29/26 at 1:40 p.m., a written order listed the following new orders:- 0.5 [milliliters (mL)] morphine concentrate (100 [milligrams (mg)]/5ml). Give 0.5mL (10mg) [one time] (loading dose) [orally].- Morphine concentrate (100mg/5ml). Give 0.25mL (5mg) [orally(PO)] [every(Q)] 1 hour [as needed (PRN)] [Diagnosis (Dx)]: Difficulty breathing - comfort care- [Discontinue (D/C)] Lorazepam patch (gel)- Lorazepam (2mg/mL) solution - 0.5mL (1mg) [orally every] 4 hours [as needed] AgitationOn 1/29/26 at 2:42 p.m., a nurse note stated, OTHER Hospice information for an urgent admission sent in to [Northern Light (NL)] Hospice. On 2/5/26 at 3:55 p.m., during an interview with a surveyor, Registered Nurse (RN4) stated R16 had shortness of breath with minimal exertion but appeared comfortable at rest and was observed sitting in bed and able to speak with the provider during the visit on 1/26/26. RN4 stated the visit on 1/26/26 was nothing compared to the absolute distress R16 was in on 1/29/26. On 2/5/26 at 3:45 p.m., during an interview with the Director of Nursing (DON) and 2 surveyors, R16's clinical record was reviewed regarding the above findings. The DON stated that she was unaware that R16 had requested to go to the hospital and should have been permitted the choice, and that staff need more education. At this time 2 surveyors confirmed the providers were not notified of R16's change in condition or R16's request to go to the hospital.

Based on observations, facility policy reviews, and interviews, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to ensure staff wore the proper personal protective equipment (PPE) in enhanced barrier precaution and contact precaution rooms and failing to ensure staff discarded a medication pill after if fell on top of the medication cart on 3 of 4 days of survey (2/2, 2/4 and 2/5/26). Findings: The facility policy, Enhanced Barrier Precautions indicates that Enhanced Barrier Precautions (EBP) expands the use of PPE beyond situations in which exposure to blood and bodily fluids is anticipated, and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of [Multidrug-resistant organisms (MDROs)] to staff hands and clothing. 1. On 2/2/26 at 1:22 p.m., a surveyor observed an EBP sign outside R41's room. R41 was observed lying in bed while working with Physical Therapist Assistant (PTA) and Occupational Therapy Assistant (OTA). PTA observed to be sitting on R41's bed next to R41's foley bag, while assisting R41 with foot and leg exercises. PTA was not wearing PPE to prevent contamination of his/her clothing while providing care. OTA observed to be kneeling next to R41's bed and leaning his/her upper body and arms on the bed while massaging lotion onto R41's arm. OTA was not wearing PPE to prevent contamination of his/her clothing while providing care. On 2/2/26 at 1:30 p.m., during an interview with a surveyor, a Certified Nursing Assistant (CNA) stated R41 is on EBP related to his/her foley. PPE is needed when providing direct care like bathing or when draining the foley collection bag but not when resident is up in his/her chair. The facility policy, Infection Prevention and Control Program indicated that Contact Precautions were used for residents that have an infection that can be spread by contact with the person's skin, mucous membranes, feces, vomit, urine, wound drainage, or other body fluids or contact with equipment or environmental surfaces. In addition to standard precautions, wear a gown and gloves upon room entry. 2. On 2/4/26 at 9:30 a.m. a surveyor observed Certified Nursing Assistant - Medications (CNA-M) giving Resident #35 (R35) their medications; CNA-M was not wearing a gown or gloves during this interaction. When CNA-M exited the room, a surveyor asked CNA-M if she knew why R35 was on contact precautions? CNA-M stated, I don't know, I think a rash and that you would need to wear PPE when doing care. Surveyor pointed to the sign that on the wall outside the door that stated, Contact Precautions and that Staff and Medical Providers were to wear gown and gloves when entering the room. The surveyor explained to CNA-M that R35 was on contact precautions because he/she had shingles. On 2/4/2026 at 9:36 a.m., during an interview with a surveyor, the Infection Preventionist stated that CNA-M should have worn PPE (gown and gloves) when giving R35 their medications. 3. On 2/5/26 at 7:33 a.m., during a medication observation pass for a resident, CNA-M tipped over a medication cup with a couple of pills in it, causing one pill to fall on the top of the medication cart. CNA-M picked up the fallen pill with a spoon and was in the process of putting the fallen pill back into the medication cup when the surveyor stopped CNA-M, explaining that the top of the medication cart was considered contaminated (not clean). After this interaction, CNA-M picked up an empty medication cup and then placed the fallen pill into this cup for disposal. On 2/5/26 at 8:30 a.m., during an interview with a surveyor, the Infection Preventionist stated that the fallen pill should be thrown away once it fell on top of the cart. 4. On 2/5/26 at 2:45 p.m., a surveyor asked RN3 why a room had a Contact Precautions sign outside the door which directed Staff and Providers to wear gowns and glove when entering the room; RN3 explained that one of the residents was suspected to have shingles and was placed on precautions yesterday afternoon. At this time, a surveyor observed Provider and RN4 in the room as the Provider was removing her gloves and moving away from the resident suspected of having shingles. The Provider was not wearing a gown and RN4 was not wearing the appropriate PPE either. On 2/5/26 at 2:55 p.m., during an interview with a surveyor with RN4 present, the Provider stated that she just diagnosed the resident with having shingles. The surveyor confirmed that there was a contact precaution sign outside the door that directed Staff and Providers to wear gowns and gloves before entering the room, but they were not wearing the proper PPE.

Based on record review and interviews, the facility failed to provide respiratory care as order by the Provider for 2 of 16 residents reviewed on survey [Resident #61 [R16] and R5).Findings: 1. On 2/2/26 at 12:04 p.m., during a dining observation, a surveyor observed R5 sitting at a table in the dining room wearing nasal cannula tubing connected to an empty oxygen tank. At this time the surveyor observed and confirmed with RN2 that R5's portable oxygen tank was empty. RN2 stated R5 is supposed to be on 2 Liters (L) oxygen continuously. 2. On 2/5/25, clinical record review indicated R16 had orders, dated 12/30/25, Administer [oxygen (O2)] Therapy [continuously/daily (cont/daily)] up to 5 [Liter Per Minute (LPM)], nasal cannula continuous to keep O2 [greater than (>)] 88%, and Albuterol Sulfate (2.5 [milligrams (MG)]/3 [milliliters (ML)]) 0.083% Nebulization Solution Dose: (3ml) inhalation three times a day [as needed (PRN)] . For Dyspnea (difficult or labored breathing). Review of R16's Treatment Administration Record indicated from 2/26/26 through 1/29/26 R16 received continuous oxygen at 8 LPM. The clinical record lacked evidence that new orders were obtained for the increased administration of oxygen, that PRN nebulizer treatments were given for dyspnea, or that the provider was notified of the change in condition (See F580). On 2/5/26 at 3:45 p.m., during an interview with Director of Nursing (DON) and 2 surveyors, R16's clinical record was reviewed. At this time 2 surveyors confirmed that respiratory care was not implemented as directed.

Based on record reviews and interviews, the facility failed to implement the written policy and procedures for preventing the abuse and neglect of residents after a resident reported an allegation of abuse [Resident #41 (R41)]. This had the potential to affect all residents.Findings: Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property, dated November 19, 2025, states the following:Under the 5.4 Identification/Detection heading:- 5.4.2.1 Resident complaints of abuse.- 5.4.2.4 Unexplained bruises or other injuries- Resident's apparent fear of another person, whether staff, resident or visitor.- Resident refusal to be with a specific personUnder the 5.6 Protection heading:- 5.6.1 Staff will intervene immediately to protect the resident(s) in any situation of actual or potential abuse, neglect, exploitation, or mistreatment.- 5.6.2 If the person accused of the abuse is an employee, that person will be suspended with pay pending the outcome of the investigation.Under the 5.7 Reporting and Response heading:- 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 [Director of Nursing Services (DNS)]. On 1/27/26 at 9:24 p.m., Certified Nursing Assistant #2 (CNA2) emailed a reported allegation to the DNS stating, [R41] made me lean in and whispered watch that nurse, she scares me, I watched her be rough with [R16] (pointing at R16) If you hear me yell please come, I am scared of her while [R1] was on the other side of the curtain putting [R16's] oxygen back on telling [him/her] to leave it on. On 1/28/26 at 9:40 p.m., CNA3 emailed a reported allegation to the DNS stating, I wanted to let you know a concerns a resident is having. [R41] whispered to me that [he/she] doesn't feel safe around the nurse [RN1]. [R41] stated that she was being too rough towards [his/her] roommate [R16]. [R41] also said if you hear screaming run to my room because [he/she] doesn't know what is going to happen. The DNS confirmed with CNA3 that this email was a delayed report for an allegation made on 1/27/26. On 2/5/26 at 9:05 a.m., during an interview with a surveyor, R41stated that R16 was confused and had an oxygen mask but he/she kept trying to take it off. RN1 came into the room and was scolding R16 to leave the mask on. R41 stated the nurse used both hands on R16's shoulder and pushed R16 back into bed so forcibly that RN1 was over R16 in the bed. R41 stated she is afraid of RN1. R41 stated he/she reported the incident to the CNAs. On 2/5/26 at 10:59 a.m., during an interview with 2 surveyors, the DNS stated RN1 was the only nurse on as it was the night shift. The facility's scheduled on-call nurse could have come in to cover the remainder of the shift, but CNAs are not typically aware of the on-call schedule or how to contact them. At this time 2 surveyors confirmed that CNAs were unable to report an allegation of abuse immediately to a supervisor as they did not have access to the on-call information, and that RN1 was permitted to continue working the remainder of her scheduled shift after an allegation of abuse (See F600).

Based on record reviews and interviews, the facility failed to ensure a clinical record contacted accurate and complete information for 3 of 17 sampled residents (Resident #41 [R41], R5, and R16).Findings: 1. On 2/5/26 at 12:08 p.m., during an interview with a surveyor and the Director of Nursing Services (DON), R41's clinical record was reviewed. The DON confirmed R41 was admitted with an indwelling foley catheter and that the nurse documentation, dated 1/28/26 at 1:02 a.m., stating Resident does not have an indwelling catheter in place at present. Sudden onset of incontinence was inaccurately documented. At this time the surveyor confirmed the above finding with the DON. 2. On 2/4/25, R5's clinical record was reviewed and indicated that R5 had a pressure injury to the right Achilles heel according to physician orders dated 12/2/25 and 12/16/25. Review of the weekly wound documentation for 1/27/26 contained documentation that this was a healing stage 2 to the back of the left ankle/Achilles and the care plan, dated 2/2/26, also indicated the pressure was on the left Achilles heel. On 2/5/26 at 8:56 a.m., during an interview with a surveyor, Registered Nurse #2 (RN2) stated that the pressure injury was on the right heel and not the left heel and that she documented incorrectly on 1/27/26 on the weekly wound documentation. The care plan was also reviewed and the surveyor confirmed that both the 1/27/26 documentation and the care plan identified the wrong heel as having the pressure injury. 3. On 2/5/26, R16's activities documentation was reviewed and contained the following documentation: Activity attended: One to one socialization Hung Activities Calendar Activity Type: PM (afternoon) activities Date: 2/1/26 Participation: Active On 2/5/26 at 4:00 p.m., during an interview with a surveyor, the Staff Development Coordinator stated that R16 passed away on 1/30/26. The surveyor confirmed R16's clinical record was inaccurately documented.

Based on record reviews and interviews the facility failed to ensure a care plan was resident centered, updated, and implemented for 2 of 14 residents reviewed on survey (Resident #6 [R6] and [R33]). Findings: 1. Clinical record review indicated R6 transitioned to hospice level of care on 12/13/24. The care plan identified the following: -A care area identified on 1/5/24 and revised on 12/31/24, indicated the Potential for Constipation. The approach indicated Keep fluids in reach and encourage fluid intake. -A care area identified on 1/5/24 and revised on 12/31/24, indicated the Potential for Fluid volume [deficit] manifested by Dry mucous membranes. The approaches listed included Encourage fluid intake and Offer fluids frequently, Keep fluids within reach. - A care area last revised on 12/31/24, identified verbally and physically disruptive behaviors related to dementia, manifested by outbursts and agitation. Approach for this care area, indicated Provide auditory or tactile stimulation for excess vocalization and Use headset to provide music or puzzles for distraction when behaviors are increased . Do not leave Hoyer sling underneath R6 when Hoyer is not being used. -A care area identified on 1/5/24 and revised on 12/31/24, identified Mood Disturbance manifested by agitation. Approach to this care area directed staff to decrease environmental stimulation, and provide temporary isolation as indicated. On 1/6/25 at 9:44 a.m., a surveyor observed R6 resting in a chair at bedside. The Hoyer sling was observed under the resident. There were no fluids observed within reach. On 1/7/25 at 11:52 a.m., a surveyor observed R6 sitting in a chair at bedside. The Hoyer sling was observed under the resident. There were no fluids observed within reach. At 1:07 p.m., during an interview with a surveyor, a staff member stated that leaving the Hoyer pad under the resident is easier due to R6 being easily agitated. On 1/7/24 at 3:36 p.m., during an interview with a surveyor, the Director of Nursing Services (DNS) stated the care plan should be updated to allow the Hoyer sling to remain under R6 for comfort purposes, clarified R6 responds better to reduce stimulation, and stated that staff offer fluids but may not be documenting each attempt. At this time the surveyor confirmed R6's care plan was not updated and implemented to meet R6's needs. 2. Clinical record review indicated R33 was admitted on [DATE]. On 9/23/24 the provider ordered 240 milliliters (ml) of House Supplement (CIB) to be given at breakfast, lunch and dinner. R33's weights were as follows: - On 9/7/24, R33 weighed 98.6 pounds (lbs). - On 10/3/24, R33 weighed 98.4 lbs. -On 11/4/24, R33 weighed 87.6 lbs. -On 12/2/24, R33 weighed 86.6 lbs. -On 1/1/25, R33 weighed 86.6 lbs. R33 had a 12.17 percent weight loss in less than 6 months. On 1/8/25 at 2:28 p.m., during an interview with a surveyor and the Director of Nursing Services (DNS), R33's care plan was reviewed. The care plan indicated a care area of Potential for Alteration in nutrition on 10/26/24, with a goal that R33 will consume 50 percent to 75 percent of meals and maintain a weight of 95 lbs to 105 lbs. This care area was revised on 12/13/24 indicating Alteration in Nutrition with a goal that R33 would consume 25 percent to 50 percent of meals and maintain a body weight of 85 lbs to 95 lbs. The care plan did not address the use of CIB with meals, resident preferences for meals, or weight monitoring parameters , and was not revised when the care area and goals were changed to prevent further weight loss. At this time the surveyor confirmed R33's care plan was not resident centered, or updated for the monitoring, and treatment of unintended weight loss.

Based on observations, record review, and interview, the facility failed to maintain the dignity of 1 resident (Resident #29 [R29]) related to urinary collection bags during 2 of 3 days of survey (1/7/25 and 1/8/25). Findings: R29's care plan under Self Care Deficit included an approach, dated 5/25/23, references that R29 has a Foley Catheter and to cover bag to maintain dignity when out of room. 1. On 1/6/25 at 12:15 p.m. two surveyors observed R29's Foley catheter bag under his/her Tilt in Space wheelchair while R29 was in the dining room at lunch time. The blue covering of the Foley Catheter bag was riding up bottom to top and urine was visible at the bottom of the bag. 2. On 1/7/25 at 11:35 p.m. two surveyors observed R29's Foley catheter bag under his/her Tilt in Space wheelchair while resident was in the doorway of his/her room, facing the hallway. The blue covering of the Foley Catheter bag was riding up from the bottom to the top and urine was visible at the bottom of the bag. 3. On 1/7/24 11:46 p.m., a surveyor observed R29 in the dining room at lunch time sitting in his/her Tilt in Space wheelchair. The blue covering of the Foley catheter bag was riding up and urine was visible at the bottom of the bag. The surveyor confirmed this finding with Staff Development Coordinator at this time.

Based on interview and record review the facility failed to ensure that a resident's choice in bathing was being followed for 1 of 1 sampled resident reviewed for Choices (Resident #30 [R30]). Finding: On 1/6/25 at 9:30 a.m., during an interview with a surveyor, R30 stated that he/she does not get their shower every week, stating that it is more like once a month that they are able to go into the shower. R30 stated that staff are saying they just don't have time to do showers. Upon review of the scheduled whirlpool list R30 is scheduled on Monday. Certified Nursing Assistant (CNA) documentation shows that R30 has received 2 showers since November 1st, 2024, to current day (1/7/25). Documentation shows that R30 received a shower on 11/11/24 and 12/9/24 supporting R30's statement of only receiving a shower once a month. R30 was scheduled to receive his/her shower on 1/6/25 during this survey, there is no evidence that R30 received a shower. During an observation of the whirlpool and shower room with a CNA there was no evidence showing that the shower/whirlpool room was used (floors in shower were dry, whirlpool tub was dry). On 1/7/25 at approximately 1:30 p.m. during an interview with the Director of Nursing Services and review of CNA documentation for R30's showers, the surveyor confirmed that R30 has not had his/her showers weekly as scheduled, with 2 scheduled days being documented that R30 had refused bathing.

Based on record review and interviews, the facility failed to address significant weight loss for 1 of 1 sampled residents reviewed for nutrition (Resident #33 [R33]). Finding: On 1/8/25, a clinical record review was done for R33. The record indicated R3 was admitted on [DATE]. On 9/23/24 the provider ordered 240 milliliters (ml) of House Supplement Carnation Instant Breakfast (CIB) to be given at breakfast, lunch and dinner. R33's weights were as follows: - On 9/7/24, R33 weighed 98.6 pounds (lbs). - On 10/3/24, R33 weighed 98.4 lbs. -On 11/4/24, R33 weighed 87.6 lbs. -On 12/2/24, R33 weighed 86.6 lbs. -On 1/1/25, R33 weighed 86.6 lbs. R33 had a 12.17 percent weight loss in less than 6 months. On 10/26/24 at 1:13 p.m., a dietary note indicated the resident had an involuntary 5 percent weight loss. A goal was set to have no weight loss and continue to maintain a weight of 95 lbs to 105 lbs for three months. On 12/13/24 at 8:36 a.m., the dietary note identified alteration in nutrition and change the goal to maintain a body weight of 85 lbs to 95 lbs for three months. On 1/8/25 at 1:15 p.m., during an interview with a surveyor, 2 staff reviewed resident charts but were unable to find food preferences. They stated the dietary details come on the meal tray on a slip, but they do not have access otherwise. On 1/8/25 at 1:30 p.m., during an interview with a surveyor, the Dietary Manager (DM) stated that she meets with residents within the first 7 days of admission. She will mark off resident's preferences and take the slip back to the kitchen. Residents will be sent a meal avoiding dislikes. If a resident does not like the meal, they are offered an alternative (soup and sandwich). If a resident does not eat the food, the DM will sometimes come meet with the resident to ask what else they might like but is unable to do this with residents who are cognitively impaired. DM stated, she does not notify the physician of weight loss but addresses it at interdisciplinary team meetings for care planning. DM stated she does not communicate food preferences to staff. At this time the surveyor confirmed that the weight goals were changed for R33, but no interventions were initiated to prevent further weight loss. On 1/8/25 at 2:28 p.m., during an interview with a surveyor and the Director of Nursing Services (DNS), R33's care plan was reviewed. The care plan indicated that on 10/26/24 the care plan identified a care area Potential for Alteration in nutrition with a goal that resident will eat 50 percent to 75 percent of meals and maintain a weight of 95 lbs to 105 lbs. This was revised on 12/13/24 indicating Alteration in Nutrition with a goal that R33 would consume 25 percent to 50 percent of meals and maintain a body weight of 85 lbs to 95 lbs. The approach did not address the use of CIB with meals, R33's preferences for meals, or weight monitoring parameters, and was not revised when the care area and goals were changed. At this time the surveyor confirmed R33's care plan was not resident centered or updated to prevent further unintended weight loss. The DNS stated, residents with weight loss are reviewed weekly in a meeting, it is run by the Staff Development Coordinator (SDC). On 1/8/25 at 3:08 p.m., during an interview with a surveyor, the SDC stated, we monitor weights for residents on supplements, to make sure weights are done. The SDC does not notify the provider of weights discussed in the meeting. The SDC reviewed the previous meeting notes and stated R33 was not on the list for monitoring. At this time the surveyor confirmed R33 was not monitored for significant weight loss.

Based on observations, record reviews and interviews, the facility failed to have complete orders that contained the specific amount of liters per minute (LPM) for the use of oxygen and the facility failed to ensure that one oxygen concentrator was operated and maintained per manufacturer's directions for 2 of 3 residents reviewed with oxygen (Resident #19 [R19 and R1]). Findings: 1. On 1/6/24 at 12:00 p.m. R19 was in the dining room using his/her oxygen concentrator with a flow rate of 3 liters using a nasal cannula. The surveyor observed that the oxygen concentrator was missing the side filter. A surveyor asked RN #1 to observe the oxygen concentrator with the surveyor and acknowledged the side filter was missing. On 1/7/25 at 8:50 a.m. an observation of R19's oxygen concentrator was observed and showed the side filter was still missing. At this time the surveyor confirmed the side filter was missing with the RN MDS Coordinator. The RN MDS Coordinator cut a filter to replace the missing side filter after the observation was made. On 1/7/25 during a review of the manufacturer's manual for the Rhythm Healthcare oxygen concentrator that R19 was using the manual reads on page 17, section 5.2, do not operate the concentrator without the filter installed. The Administrator was shown the manufacturer's manual that instructed to not operate the concentrator without the filter installed. On 1/7/25 during a clinical record review R19 had an order dated 11/15/24 to apply humidified oxygen via nasal cannula to keep O2 sat (saturation) above 88%. The order does not contain a specific flow rate (the amount of oxygen to be delivered) making the order incomplete. 33242 2. On 1/6/25, R1's clinical record was reviewed and it was noted that R1 had a medical diagnosis that included chronic obstructive pulmonary disease. The current physician order entered into the electronic record on 9/14/24 was, Apply humidified Oxygen via Nasal Cannula to keep O2 sat above 88%. On 9/21/24, R1 was transferred to the hospital and returned with an order for oxygen to be administered at 2 liters per minute (LPM) to keep saturation (sats) above 90% but this was not the current order and was not entered into the clinical record. On 1/6/25 at 11:49 a.m., a surveyor observed R1's oxygen concentrator set at 3 LPM. On 1/7/25 at 12:27 p.m., during an interview with a surveyor, the Director of Nursing Services stated that the physician orders for oxygen should include the amount of liters to administer and will follow up on the oxygen orders. The surveyor confirmed the oxygen orders did not include the amount of liters to administer during this interview.

Based on a review of a Facility Reportable Incident Form, the facility's internal investigations, and interview, the facility failed to ensure that 1 of 1 sampled resident had the right to refuse care when a Certified Nursing Assistant (CNA) used body contact (physical restraint) that limited a residents voluntary movement. (Resident #30 [R30]) Finding: R30 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia with agitation, insomnia, Alzheimer's disease, unspecified injury of head, difficulty in walking. R30's Admission Minimum Data Set (MDS), dated [DATE], was coded for Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS) with a score of 2, indicating cognitive impairment. The facility reported that a CNA was observed by the Licensed Practical Nurse (LPN) physically restraining R30 by placing both of R30's arms across his/her chest and held them there until incontinence care was completed. The LPN assisted with the incontinence care while the CNA held R30's arms across his/her chest. The LPN did not redirect or stop the restraint which would have allowed R30 to refuse the care. On 12/4/23 at 2:43 p.m., during an interview with the LPN, she confirmed that she witnessed the CNA holding (restraining) R30's arms by taking his hands and putting R30's arms across his/her chest and held them. He held his/her arms for about 2 minutes. I was able to help change the brief, it was at this time R30 said let go of me. After the brief was changed, that's when I said let's take a step back This was an attempt to quiet the resident and stop him/her from hitting them, this physical restraint restricted Resident #30's voluntary movement. On 12/6/23 at 10:01 a.m during an interview with the alleged perpetrator (CNA), he confirmed that he had held the residents arms across his/her chest restricting his/her voluntary movements. He stated that he was attempting to get him/her ready for bed when he/she became aggressive and He/she was sitting at the nurses station. I walked him/her down to his/her room, and when in his/her room I tried to get him/her ready for bed and he/she was getting physically combative hitting and kicking at me. I put the call light on, and he/she was still hitting and kicking me. The Med person (LPN) came in to help. She was trying to help me change his/her brief and we had to roll him/her from side to side so we could change his/her brief because it was soiled. He/she was trying to hit and kick us, so I had to hold his/her hands for him/her not to punch me. I was holding them by the wrists on his/her stomach (arms crossed and held them there). I wasn't holding them tight and just long enough to get his/her brief on and I let go. I only held them once just when the LPN was in the room, and it was only long enough to get done with the brief change. On 12/6/23 at 9:15 a.m during an interview with the Administrator and the Director of Nursing the surveyor confirmed that R30 was physically restrained by a CNA and the restraint was observed by the LPN who did not redirect the CNA resulting in the restriction of R30's voluntary movement when R30 requested to be let go.

Based on interviews and record review, the facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS) assessment within 14 days after a resident experienced a significant change of condition when hospice services were discontinued for 1 of 2 sampled residents who had received hospice services (Resident #19 [R19]). Finding: On 12/4/23, during a review of R19's clinical record, a surveyor noted a hospice note discontinuing hospice services; however, the clinical record, which included Physician Orders, signed on 11/2/23 indicated that the resident was still receiving hospice services. On 12/4/23 at approximately 3:00 p.m., during an interview with a surveyor, Registered Nurse (RN) stated that R19 had improved and no longer qualified for hospice services (which were initiated on 8/8/23 and discontinued on 11/8/23). There was no comprehensive MDS assessment, that addressed Hospice services, completed within 14 days of the cessation of hospice services on 11/8/23 . In an interview on 12/4/23 at approximately 3:00 p.m. with RN, and on 12/5/23 at 3:34 p.m. with the Director of Nursing Services, a surveyor confirmed the above finding.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 2 of 2 newly admitted residents that were reviewed for baseline care plans. (Resident [R] 37 and R2). Findings: 1. On 12/5/23, R37's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. R37's discharge summary from the hospital included information that the resident had a Foley catheter, was a diabetic, on a psychotropic medication Trazodone, on medication for pain, and needed therapy evaluations. Review of the baseline care plan, developed within 48 hours from admission, only included problems and/or interventions on bowel elimination and that the resident had dentures. On 12/5/23 at 12:52 p.m., during an interview with the Director of Nursing Services (DNS), a surveyor confirmed this finding. 2. On 12/5/23, R2's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE], coming from another facility. R2's clinical record included an admission listing of medications and a visit from this facility's medical doctor on 9/18/23 which summarized the resident's history, prior to admission to this facility. The medication listing and MD provider notes indicated that R2 was receiving anticoagulant injections daily, on a psychotropic medication for depression, received medication for diabetes, received two antibiotics, had chronic pain, and had a pace maker. Review of the baseline care plan, developed within 48 hours from admission, included a problem with no interventions for social adjustment-ineffective coping and did not include problems or interventions for the use of an anti-coagulant, psychotropic medication use, or having a pace maker. On 12/5/23 at 2:34 p.m., during an interview with the DNS, a surveyor confirmed this finding.

Based on record reviews and interviews, the facility failed to the resident representative in writing for the reason of a transfer/discharge from the facility for 2 of 3 sampled residents reviewed for hospitalization (Resident [R] 13, R37). Findings: 1. On 12/4/23, R13's clinical record was reviewed which indicated that the resident was transferred to the hospital on 10/29/23 and returned to the facility on [DATE]. On 12/5/23 at 1:16 p.m., during an interview with a surveyor, the Administrator was not able to provide evidence that the Resident Representative received a written copy of the transfer/discharge notice. 2. On 12/4/23, R37's clinical record was reviewed which indicated that the resident was transferred to the hospital on 11/24/23 and returned to the facility on [DATE]. On 12/5/23 at 1:16 p.m., during an interview with a surveyor, the Administrator was not able to provide evidence that the Resident Representative received a written copy of the transfer/discharge notice.

Based on record review, interviews, and facility policy review, the facility failed to supervise 1 of 1 residents (Resident #1) when the resident, who was wearing a secure care bracelet, was let outside while in their wheelchair by a staff member and left unsupervised. Because of the facility's failure, the resident while in their wheelchair left the paved sidewalk, rolled down a slight incline on a grassy hill which resulted in the wheelchair tipping over the parking lot curb and the resident sustained a forehead laceration that required sutures, facial abrasion, bruises, knee pain and left wrist pain. Finding: On 6/23/23, a facility reported incident and a complaint were received by the Division of Licensing and Certification that indicated that on 6/21/23 at 4:30 p.m., Resident #1 asked a staff member to go outside to which the staff member let Resident #1 outside and left him/her unsupervised. Resident #1 left the paved sidewalk, rolled down a slight include on a grassy hill and the wheelchair tipped over the parking lot curb which resulted in the resident hitting his/her head. Staff that were outside tending to a facility event (barbeque/cookout) immediately ran to assist the person in the tipped over wheelchair. On 6/21/23 at 4:45 p.m., Resident #1 arrived at the emergency room and was treated for a 2.0 centimeter forehead laceration with moderate tenderness and swelling that required 4 sutures, a large abrasion with controlled bleeding of the upper central forehead, and both knees had a small abrasion located on each patella [kneecap]. On 6/21/23 following the incident, a Fall Scene Investigation Report was completed by the Charge Nurse (CN) that indicated at 4:30 p.m., [Resident #1's] wheelchair hit curb, flipping [Resident] out of chair into parking lot. A Huddle and Staffing was completed at 5:00 p.m., which the discussion was about what happened and what can we (facility) do to prevent future falls. It was noted that, [Resident] was outside unattended and that [Resident #1] told employee (Activities Aide) that the CN said the resident can go outside - this was not verified with CN before letting resident outside. [Resident] was wearing secure care at time of fall. The cause of the fall, was outside unattended. Interventions initiated, not to be outside without supervision, secure care, education to staff. The investigation section included relevant health history that could have contributed to falls of dementia and history of falls. On 6/22/23, Resident #1 was re-examined by a Primary Care Provider. Resident #1 complained of left hand/wrist and knee pain since the fall. X-ray images were ordered for the left knee and left wrist due to pain and were negative for fractures. On 6/26/23 at 9:05 a.m., the surveyor observed Resident #1 who was in a wheelchair and seated at a table with his/her brother. The surveyor observed Resident #1 with bruising to both eyes and a large bandage to the forehead. The left arm was also wrapped with an elastic-like bandage and the surveyor observed a staff member place a pillow under Resident #1's left arm. The surveyor asked Resident #1 what happened. Resident #1 stated, I fell off the step outside as he/she was looking out the door they had been let out. The surveyor also asked Resident #1 if he/she usually went outside by him/herself and the resident replied, no. On 6/26/23, a review of Resident #1's current care plan indicated the resident was care planned for care areas of behavior of wandering related to dementia with exit seeking behaviors on 1/26/23 and potential for falls on 11/9/22. The facility policy, Elopement Alert System, last reviewed 5/23/23, included the following procedure: When a resident is found to be an elopement risk the resident will be fitted for the alert system (secure care). Residents with an alert system desiring to leave will be allowed to do so with resident representative, family, staff or other visitors and that facility staff are responsible for responding to door alarms to ensure resident safety. On 6/26/23 at 8:10 a.m., during an interview with a surveyor, the Administrator stated that there were four staff outside tending to a staff barbeque (herself included) and they watched this person in a wheelchair roll (down the slight incline of a hill). As soon as the wheelchair tipped over, they ran to assist the person. The Administrator stated, At first, we didn't know that it was our resident and thought it could be someone from the hospital going to their car. Resident #1 has a laceration across his/her forehead but no broken bones. On 6/26/23 at 9:30 a.m., during an interview with a surveyor, the Activities Supervisor (AS) stated that Resident #1 is not 100% cognitively with it and that the resident moves about the facility slow, not strong or quick and gets pushed from place to place usually, but can move about on his/her own. When asked about the secure care alarm system, AS stated that you have to enter a code to deactivate it and the alarm will not go off once you enter a code even if the resident wears a secure care. On 6/26/23 at 10:10 a.m., during an interview with a surveyor, the CN stated, Resident #1 was alert to person, place, and time but forgets his/her own limitations and gets confused to his/her own abilities. Resident #1 thinks he/she can walk sometimes. Resident #1 never talked to me about going outside, he/she was in activities and the music thing was all done before he/she went outside. After the incident the CN stated she told the Activities Aide (AA), we don't let any residents outside without supervision. AA told the CN that Resident #1 told her that he/she had permission to go outside by the nurse, which he/she did not. On 6/26/23 at 11:07 a.m., during a telephone interview with a surveyor, AA stated that Resident #1 said to her, I want to go out. I asked Resident #1 if he/she had permission and Resident #1 told me that he/she could go out anytime he/she wanted. AA stated she asked Resident #1 three times if he/she had permission, all to which Resident #1 told AA, yes. AA stated that Resident #1 had never lied to her before so she had no reason not to believe the resident. AA stated she entered the code and Resident #1 kicked open the door and that she helped Resident #1 out the door in the wheelchair and locked the wheels. AA stated that no sooner then she turned her back, the Administrator came running in the door. The surveyor asked AA if she would normally let a resident outside unsupervised. AA stated that is not her normal duty which is why she questioned Resident #1 about the permission part several times. AA stated, I figured that if Resident #1 said that he/she had permission 3 times, I figured it must be fine, but it was not and he/she lied to me. The surveyor asked AA about the Resident Monitoring System and secure care bracelets. AA stated, when they talked to me the next day, I was asked if I knew he/she had a bracelet .I thought everyone had a bracelet. I thought that once they were put in there, they all had it .I don't know why I had to enter the code to get out .I thought you had to enter a code to just get out. I didn't even know what that was until I asked the next day. I didn't know that is what it was called. I assumed that because they put bracelets on, they all had them. AA stated that she completed orientation in November 2022, when she was hired per-diem, but does not remember this. On 6/26/23 at 11:30 a.m., during an interview with a surveyor, the Staff Development Coordinator (SDC) stated she was the one that completed the orientation with AA and that she did go over the Resident Monitoring Systems which included the secure care. The SDC also stated that she tells the new staff if they have any questions to always go to their Charge Nurse or Supervisor. She stated that the New Employee Orientation Classroom Checklist was signed by the employee and herself after orientation was completed. As a result of the this isolated incident, the following corrective actions were initiated: - On 6/21/23, Resident was assessed immediately by Charge Nurse and sent to emergency room ; - On 6/21/23, the Charge Nurse, educated the evening shift staff (1:45 p.m. - 10:15 p.m.), after the incident, by informing staff of the following: Residents are not to go outside by themselves and while in an outdoor setting, residents need supervision by a staff member or a family member that has gotten permission by a nurse. The Charge Nurse also shared this information with the oncoming nurse, who was relieving her at 6:15 p.m. - On 6/22/23, the Charge Nurse, educated the day shift (6:15 a.m. - 2:15 p.m.) during report that Residents are not to go outside by themselves and while in an outdoor setting, residents need supervision by a staff member or a family member that has gotten permission by a nurse. - On 6/22/23, Primary Care Provider also evaluated Resident #1 and additional x-rays were ordered which were negative; - Neuro checks and wound care were completed as ordered for Resident #1; - Activities Aide was suspended pending investigation and was terminated 6/26/23; - A mass email was sent to staff on 6/26/23 reminding staff about the practice of residents going outside; - The facility will provide education on Elopement Alert System and the Elopement Risk Assessment and develop a Resident Outdoor Protocol with staff education on the steps involved, both to start immediately with a target date of completion of July 8th.

Based on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for Unnecessary Medication use (Residents #25). Finding: On 9/22/22, during review of Resident #25's clinical record, the monthly pharmacy medication review, dated 5/25/22, documents Resident #25 is taking [MEDICATION(S)] for the off-label diagnosis of depression. Recommendation to review accepted diagnosis for use of [MEDICATION(S)]. Pharmacist requested documentation that Physician is aware of the off-label use for this resident. The Physician documented on 6/20/22, clinically stable, continue current regimen and he did not address the off-label diagnosis. On 9/22/22 at 10:46 a.m., the surveyor confirmed during an interview with the Director of Nursing, that the Pharmacist's recommendation had not been addressed correctly and did not address the off-label diagnosis for [MEDICATION(S)] use.

Based on observations and interviews, the facility failed to ensure that hot water temperatures in areas that were accessible to residents did not exceed 120 degrees Fahrenheit in 4 of 4 resident rooms during 1 of 3 days of survey (9/20/22). Finding: On 9/20/22 two surveyors measured and observed the following hot water temperatures: At 1:38 p.m. room 39/40, water temperature 127.8-degrees Fahrenheit. At 1:39 p.m. room 19/20, water temperature 127.9-degrees Fahrenheit. At 1:40 p.m. room 11/12, water temperature 123.3-degrees Fahrenheit. At 1:44 p.m. room 31/32, water temperature 121.6-degrees Fahrenheit. On 9/20/22 at 1:45 p.m., 2 surveyors had an interview with the Environmental Service Manager and the above water temperatures were confirmed. He then stated he got called on Saturday for cold water, there was no hot water. He came in and worked on the mixing valve that and found it was not working properly. He called the mechanical company and until they could come in, they were checking the water temperatures 4 times a day with a thermometer. He informed the charge nurse to tell her staff there was no hot water. On 9/20/22 he had the part overnighted and will be delivered on 9/21/22. On 9/21/22, Mechanical Services came to the facility and the mixing valve was replaced. During the remainder of the survey, random resident room checks for hot water revealed no hot water temperatures in excess of 120 degrees Fahrenheit.

Based on record review and interviews, the facility failed to revise a care plan to reflect the current needs of a resident in the area of the Preadmission Screening Resident Review (PASRR) Level II determination for 1 of 2 sampled residents reviewed for PASRR (Resident #26). Finding: On 3/24/22 the facility submitted a new Maine Level I Form, Preadmission Screening and Resident Review for evaluation due to Resident #26 showing signs or symptoms that indicate he/she may have a PASRR condition (mental health diagnoses, substance related diagnoses, dementia/neurocognitive disorders) that would require a PASRR Level II evaluation. On 4/6/22 the Notice of PASRR Level II Outcome determined that Resident #26 was approved with specialized service. The PASRR Level II indicated, You meet the State of Maine's definition for serious mental illness due to your diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] As of 9/22/22 the current care plan printed on 9/22/22, and reviewed with a surveyor and the Director of Nursing Services, was not revised to reflect Resident #26's current needs related to the recommendations from the PASRR level II determination of 4/6/22, and 7/12/22. On 9/22/22 at 2:44 p.m., in an interview with the Director of Nursing Services, a surveyor confirmed the finding.

Based on record review and interview, the facility failed to develop a person-centered care plan in the care areas of anxiety, wandering/elopement and [CONDITION(S)] medication (med) use for 1 of 5 resident reviewed for unnecessary medications (Resident #25). Finding: On 9/22/22, during record review of Resident #25 physician orders, it was noted that he/she is receiving the [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)]. Upon review of Resident #25's care plan, care areas were initiated for anxiety related to (r/t) dementia, wandering/elopement r/t dementia and [CONDITION(S)] med use r/t opioid. The approaches (interventions) listed are generic, instructing staff to identify usual habits to maintain familiar routines to establish individualized toileting plan, to identify patterns of behaviors, identify triggers and or underlying causes, to report unusual behavior and change in physical condition. The facility failed to identify and list his/her habits, to establish routines for a toileting plan and to utilize interventions that are effective for Resident #25. On 9/22/22 at 1:00 p.m., a surveyor confirmed the above finding with the Director of Nursing.

Based on record reviews and interviews, the facility failed to ensure as needed (PRN) [CONDITION(S)] medications met the requirements for continued use beyond 14 days, for 1 of 2 residents reviewed on PRN [CONDITION(S)] medications (Resident #26) Finding: On 9/22/22, Resident #26's clinical record was reviewed. The physician orders included a current order for [MEDICATION(S)] (anti-anxiety [CONDITION(S)] medication) 1 milligram by mouth every 6 hours as needed, with a start date of 8/3/22 and an end date of 2/1/23. This was a new medication for Resident #26, first started on 8/3/22. The Physician visited on 8/11/22 and wrote a progress note but this note did not address the use of [MEDICATION(S)] or a rationale to continue this medication beyond 14 days. On 9/22/22 at 9:35 a.m., during an interview with a surveyor, the Director of Nursing (DON) reviewed the Physician's progress note and was unable to to find a written rationale to continue the medication, [MEDICATION(S)], and that indicated a duration for this PRN order.

Based on review of Incident & accident reports, record review, review of the facility ' s investigation and interviews, the facility failed to ensure that a mechanical lift was used during a transfer for 1 of 6 sampled residents (#1). This failure to use a mechanical lift resulted in Resident #1 sustaining a leg fracture. Finding: Resident #1's care plan, dated 7/31/2014, under the problem area of Self Care Deficit, contained an intervention that directed staff to use a mechanical total lift (Hoyer) or a mechanical partial lift (Vera) when transferring the resident. An "Accident & Incident" report, dated 9/30/14, indicated Resident # 1 was transferred on 9/29/14, reports of pain noted transferred to emergency room (ER) which indicated the resident having a [DIAGNOSES REDACTED]. The facility's investigation report, dated 10/1/14, indicated that Certified Nursing Assistants (CNAs) #1 and #2 failed to use the mechanical lift when transferring Resident #1, resulting in the resident sustaining left distal Tibia fracture. On 11/6/14 a surveyor discussed this finding with the Administrator and the Director of Nursing.

Based on record review, review of the facility ' s investigation, and interviews, the facility failed to ensure that physician's order [REDACTED].#1). This failure to use a mechanical lift during a transfer resulted in Resident #1 sustaining a leg fracture. Finding: Resident #1's physician orders, dated 7/ 17/ 2014, directed staff to use a mechanical lift when transferring Resident #1. The resident's care plan, dated 7/31/2014, under the problem area of Self Care Deficit, directed staff to use either a mechanical total lift (Hoyer) or a mechanical partial lift (Vera) during transfers. The resident's significant change Minimum Data Set, Version 3.0 (MDS) assessment, dated 7/29/2014, was coded, (in Section G0110B), to indicate the resident required extensive assistance of two staff for transfers and was coded, (in Section G0300 & G0400), to indicate the resident was not able to transfer from surface to surface without human assistance and had no impairments of the lower extremities. An "Incident and Accident" report form, dated 9/30/14, indicated Resident #1 was transferred on 9/29/14, reports of pain noted transferred to emergency room (ER) which indicated in the resident having a [DIAGNOSES REDACTED]. The facility's investigation report, dated 10/1/14, indicated that Certified Nursing Assistants (CNAs) #1 and #2 failed to use the mechanical lift when transferring Resident #1, resulting in the resident sustaining left distal Tibia fracture. On 11/6/14 a surveyor discussed this finding with the Administrator and the Director of Nursing.