Every finding on record at Mainegeneral Rehab & Long Term Care - Glenridge

Based on record review, observations, interviews, and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to ensure that two people who are authorized to administer medications signed the Shift Count page of the Bound Book [a logbook used to record controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 3 units observed (Cove Unit, Gardens Unit, and Valley Unit).Findings:1. Facility Policy Controlled Medication Storage and Administration, revised 07/2024 states, .The count of Schedule II, III, IV, and V substances shall be recorded and signed at the change of each shift. All counting of narcotics/controlled medications will be driven by first verifying what is documented in the bound book. The actual supply of medication on hand will be checked against this written documentation for accuracy and verified by both nursing personnel.On 3/24/26 at 8:15 a.m., during a medication storage observation, the Bound Book and Shift Counts for the Cove Unit medication tech med cart were reviewed and revealed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 3/2/26 at 2:00 p.m. (pg. 292)- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 3/2/26 at 10:00 p.m.2. On 3/24/26 at 9:00 a.m., during a medication storage observation, the Bound Book and Shift Counts for the Cove unit Long Hall med cart were reviewed and revealed an undated and untimed entry, located on the line below the 3/24/26 6:00 a.m. entry (pg. 299). The Nurse Going Off Duty column was signed by Registered Nurse (RN) # 2, prior to completing the count at the end of her shift with the oncoming nurse.On 3/24/26 at 9:06 a.m., the above findings were discussed with the Cove Unit Manager during an interview. At this time, the Unit Manager stated that it is her expectation that the nurse coming on duty and the nurse going off duty sign the shift count at the time the count is completed, not ahead of time.3. On 3/24/26 at 10:56 a.m., during a medication storage observation, the Bound Book and Shift Counts for the Garden Unit Short Hall med cart were reviewed and revealed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 3/1/26 at 7:00 a.m. (pg. 282)- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 12/28/25 at 7:00 a.m. (pg. 278) and on 3/1/26 at 7:00 p.m. (pg. 282)- On 12/20/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/27/25, 12/28/25, 12/30/25,12/31/25, 2/22/26, 2/25/26, 2/26/26, 2/27/26, 3/1/26, 3/3/26, 3/5/26, and 3/23/26 there are incomplete entries that lack the time and/or the status of count.- An entry dated 3/24/26 and timed for 7:00 p.m. (pg. 284) indicated yes for status of count exact, and the Nurse Going Off Duty column was signed by RN #3. During an interview at this time, RN #3 confirmed that she already signed and indicated that the count was exact, even though she will not perform the count until the end of her shift with the nurse coming on duty. RN #3 then stated that she usually signs the book before the shift count is done because she does not want to get a reminder note saying that she forgot to sign the book.On 3/24/26 at 11:07 a.m. the above findings were discussed with the Gardens Unit Manager.4. On 3/24/26 at 11:30 a.m., during a medication storage observation, the Bound Book and Shift Counts for the Valley Unit medication tech med cart were reviewed and revealed the following:- The person authorized to administer medications coming on duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 2/18/26 at 2:00 p.m. (pg. 273). Additionally, the status of the count was not indicated.- The person authorized to administer medications going off duty failed to sign the Shift Count page of the Bound Book that indicated the controlled substances count was done on 2/18/26 at 8:40 p.m. (pg. 273)Additionally, 3 of 3 shift count books (Long Hall, Short Hall, and Medication Tech) for the Valley Unit revealed that the nurses on duty for 3/24/26 had already signed the Nurse Going Off Duty column prior to completing the count at the end of their shift with the oncoming nurse.On 3/24/26 at 11:51 a.m., the findings were discussed with the Valley Unit Manager. On 3/24/26 at 1:45 p.m., the surveyor discussed the above findings with the Director of Nursing.

Based on observation and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for an air conditioner, food disposal units, shelving, ceiling vents, a grease trap cover, a fan, and an exit door; failed to ensure foods were labeled and/or dated in the kitchen and walk-in refrigerator; and failed to ensure that kitchen staff members with facial hair wore facial hair protection for 1 of 1 kitchen tour. Findings:The facility's Food Storage policy and procedure, dated 3-22, noted Procedure: 7. B. Food should be dated as it is placed on the shelves . 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated.On 3/23/26 from 8:15 a.m. to 9:10 a.m., a surveyor and the Food Service Director completed an initial kitchen tour in which the following findings were observed:- Dish room: The wall mounted air conditioning unit was heavily soiled with dust/dirt on the top air intake grill. The wall fan was dusty/dirty. The food disposal unit(#1) had dried food particles and dried liquid residue on it.- The food disposal unit(#2) near a shelving unit had dried food particles and dried liquid residue on it and was rusty on the body and the legs. - The shelving unit, next to food disposal unit(#2), was dirty and had dried liquid residue on it.- Three ceiling vents, over food preparation areas, were dusty/dirty. - The grease trap cover had chipped/missing paint creating an uncleanable surface. - A wall fan was dusty/dirty. - The service entrance/exit door had chipped/missing paint creating an uncleanable surface. - There was a large plastic container of a brown powder type substance that was not labeled and dated.- The walk-in refrigerator had a large bag of a diced product that was not labeled. - There were two kitchen workers with facial hair that were not wearing facial hair protection. On 3/23/26 at 9:10 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 1 of 3 Units (Cove Unit), a common area and the laundry room for 2 of 2 facility tours. (3/23/26 and 3/26/26) Findings:1. Laundry Room:On 3/23/26 at 8:07 a.m., the surveyor and Environmental Services Manager observed the walls to be missing cove base on many areas around the room. At this time, in an interview with a surveyor, the Environmental Services Manager confirmed the finding. 2. On 3/26/26 from 8:30 a.m. to 9:10 a.m., a surveyor conducted an Environmental tour with the Maintenance Assistant in which the following findings were observed:Common Area:-The bathroom in main entrance lobby area had chipped/missing paint exposing sheetrock above the baseboard heater. The baseboard heater had chipped/missing paint. This created uncleanable surfaces on both areas. 3. Cove Unit:- Resident room [ROOM NUMBER] - The bathroom door frames and walls had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The floor fan was visibly dusty/dirty. The privacy curtain was missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER]- The floor heating unit was visibly dusty/dirty in the bottom grill area. The bathroom ceiling vent was visibly dusty/dirty. - Resident room [ROOM NUMBER] - The bathroom door frames and walls had chipped/missing paint creating uncleanable surfaces.- Resident room [ROOM NUMBER] - The caulking around the base of the toilet was visibly stained and dirty. The bathroom and room doorframes had chipped/missing paint creating uncleanable surfaces. The fall matt had ripped/torn edges creating uncleanable surfaces. The baseboard heater had chipped/missing paint.- Resident room [ROOM NUMBER] - Two fall mats had ripped/torn edges and sides. The caulking around the toilet was visibly stained and dirty. The bathroom doorframes had chipped/missing paint.- Resident room [ROOM NUMBER] - The caulking around the base of the toilet was visibly stained and dirty. The bathroom doorframes had chipped/missing paint.-Resident room [ROOM NUMBER] - There was an unlabeled bed pan and unlabeled graduated cylinder on the back of the toilet which is shared by two rooms. The caulking around the base of the toilet was visibly stained and dirty. - Resident room [ROOM NUMBER] - The bathroom light was not working. The bathroom door frame and walls had chipped/missing paint creating uncleanable surfaces. The caulking around the base of the toilet was visibly stained and dirty. On 3/26/26 at 9:10 a.m., in an interview with a surveyor, the Maintenance Assistant confirmed the findings.

Based on record reviews and interviews, the facility failed to provide residents/representatives with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 10 residents reviewed for advanced directives (Resident #12, #72). Findings: 1.Resident 72 was admitted to the facility in 2023. Review of the clinical record lacked evidence that resident's representative had been asked/offered the opportunity to formulate an Advanced Directive. 2 Resident 12 was admitted to the facility in 2024. Review of the clinical record lacked evidence that the resident's representative had been asked/offered the opportunity to formulate an Advanced Directive. During an interview with 4 surveyors on 3/24/26 at 2:45 p.m., Licensed Social Worker (LSW) confirmed the clinical record's did not include evidence that Resident representative's were asked/offered the opportunity to formulate an Advanced Directive.

Based on record reviews and interviews, the facility failed to ensure a resident was free from a significant medication error when an antibiotic to which the resident had a known allergy was prescribed and administered for 1 of 5 residents reviewed for unnecessary medications (Resident #40).Finding:Resident #40 was admitted with diagnoses to include, but not limited to, otitis media.A review of Resident #40's clinical record revealed a physician progress note dated 3/23/26 that states, . [Resident #40] is seen. regarding ear pain - on exam [he/she] says [his/her] left ear hurts. [he/she] also had a fever over the weekend. [he/she] has an allergy to amoxicillin so will use cefdinir 300mg BID x 10 days for otitis media .Further review of Resident #40's clinical record revealed the following physician orders:An order for Amoxicillin 875 mg-potassium clavulanate [Augmentin] 125 mg tablet (1) TABLET Oral Two Times Daily for Ten Days Starting 03/23/26.An order for Cefdinir 300 mg capsule (1) CAPSULE Oral Two Times Daily for Ten Days Starting 3/23/26.A review of Resident #40's Medication Administration Record (MAR) indicated that the Augmentin was administered 3/23/26 during the afternoon pass and that the medication was discontinued 3/23/26. Further review of the MAR revealed that the Cefdinir was administered starting 3/23/26 during the night pass. A nursing progress note dated 3/23/26 states, Resident seen by PCP [primary care physician] for (L) ear pain. 2 different ABT [antibiotic therapy] orders placed by PCP with verbal to start immediately. Cefdinir not available in Pixis [Pyxis-an automated machine that dispenses medications] but Augmentin was and initial dose given at 1400 [2:00 p.m.]. Just after 1500 [3:00 p.m.], [Pharmacy] called to verify order for Augmentin as resident has an Amoxicillin allergy in history. Resident not presenting with any s/s [signs/symptoms] of allergic reaction. Will continue to monitor for any s/s of a reaction.On 3/25/26 at 3:13 p.m. during an interview, the surveyor discussed the above finding with the Cove Unit Manager. At this time, the Cove Unit Manager stated that she thinks the physician initially ordered Augmentin and then realized that Resident #40 has an amoxicillin allergy, so she ordered Cefdinir instead. The Cove Unit Manager then stated that the Pyxis does not alert if a resident has an allergy to a medication, so the nurse can pull any medication for any resident and that this has been identified as an issue by the facility previously.On 3/25/26 at 3:27 p.m. during an interview, the surveyor discussed the above finding with the Director of Nursing (DON). At this time, the Director of Nursing reviewed Resident #40's entire clinical record and confirmed that he/she received the Augmentin on 3/23/26 at 2:40 p.m. At approximately 3:45 p.m., the surveyor conducted a telephone interview with Licensed Practical Nurse (LPN) #1 in the presence of the DON. LPN #1 stated that when she saw the orders for two different antibiotics, she was surprised but that she did not think to clarify the orders and thought that Resident #40 must have had a bad infection. LPN #1 then stated that an hour after the Medication Tech had given the Augmentin, the pharmacy called her for clarification due to Resident #40's amoxicillin allergy. LPN #1 stated that she then called the physician, and that the physician stated that she had already caught the allergy and had prescribed Cefdinir instead and discontinued the Augmentin. LPN #1 then stated that at the time she spoke to the physician, the Augmentin order had not actually been discontinued, and that she notified the pharmacy of the clarified order and notified the Cove Unit Manager that Resident #40 received the Augmentin, and that Resident #40 was placed on close monitoring and a medication variance was entered in his/her clinical record.On 3/25/26 at approximately 4:00 p.m. during a follow-up interview, the DON stated that LPN #1 should have clarified the antibiotic order when she noticed two antibiotics had been ordered. The DON then stated that there are no individual resident profiles in the Pyxis system, so there is no way to alert nursing staff of a medication allergy, and that the facility has discussed this with the pharmacy before but there has been no resolution to the identified issue.

Based on observations and interviews, the facility failed to ensure that the resident's environment was free of accident hazards by ensuring doors had wood and/or protective covering that was not gouged/splintered and/or broken creating sharp edges on 1 of 3 units(Cove Unit) and a common area for 2 of 2 environmental observations on 1 of 4 days of survey. (3/23/26)Findings:Cove Unit:1. On 3/23/26 at 10:15 a.m., a surveyor observed the small sitting room door that had a broken door protector covering that was sticking out and sharp, creating a hazardous and unsafe environment.On 3/23/26 at 10:17 a.m., in an observation and interview with a surveyor, a Licensed Practical Nurse confirmed the finding. On 3/23/26 10:27 a.m., in an interview, a surveyor discussed the finding with the Administrator. 2. On 3/23/26 10:27 a.m., a surveyor and the Administrator observed the left wooden double door in the lobby area headed to the units had a gouge/chunk missing exposing untreated wood and sharp edges, creating a hazardous and unsafe environment. At this time, in an interview with a surveyor, the Administrator confirmed the finding.

Based on record reviews, interviews, facility policy, and the facility assessment, the facility failed to ensure a resident's comprehensive care plan was developed and implemented to reflect the current needs of the resident for 2 of 27 residents reviewed for care planning (Residents #9, #40). The facility's Medication Management Policy #LTCMM-11, revised 7/24 noted IV: Procedure: A. Psychopharmacological Medication use: 9. The care plan will be developed/updated as appropriate including goals of therapy and evaluation of progress towards goals. The Facility assessment dated 2025 noted: Part 3:Services and Care Based on Residents Needs:1 Types of care that resident populations require and types of care that are provided at Glen Ridge. General care: medications - Specific Care or Practices: Awareness of any limitations of administering medications, administration of medications that residents need by route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc., assessment/management of polypharmacy 1. Resident #9 was admitted in August 2025 with diagnoses to include Alzheimer's disease, Suicidal ideations, Delusional disorders, Adjustment disorder with mixed anxiety and depressed mood, Unspecified mood [affective] disorder and Bipolar disorder. Review of Resident #9 's clinical record revealed a doctor's orders that stated – 9/3/2025 Active (Current) QUEtiapine 25 mg(milligram) tablet 1 Time Daily 25 mg Route: Oral BIPOLAR DISORDER, CURRENT EPISODE MIXED, UNSPECIFIED Start Date: 09/03/2025 2:33 pm(evening) No Specific # 1 X Daily Scheduled First scheduled time is 9/3/2025 on the Night Pass time period. X's 90 days. Further review of Resident #9's clinical record reveals that Resident #9's current care plan was not developed and initiated for the use of an antipsychotic medication. On 3/26/26 at 10:08 a.m., in an interview with a surveyor, the Cove Unit Nurse Manager confirmed that Resident #9's current care plan was not developed and initiated for the use of an antipsychotic medication. 2. Resident #40 was admitted with diagnoses to include, but not limited to chronic pain and adjustment disorder with mixed anxiety and depressed mood. A review of Resident #40's clinical record revealed the following active physician orders: An order for Sertraline 50 MG (milligram) tablet 1 Time Daily for depression An order for methadone 5 MG tablet, 0.5 tablet 1 Time Daily for chronic pain An order for oxycodone 5 MG tablet PRN [as needed] 2 Times Daily for chronic pain An order for Renew Narcotics Every 30 Days A review of Resident #40's care plan lacked evidence that goals and interventions were developed and implemented for chronic pain and for the use of the antidepressant, including side effect monitoring. On 3/26/26 at 10:59 a.m. during an interview, the surveyor discussed the above finding with the Director of Nursing (DON) and the Gardens Unit Manager. At this time, the DON and the Gardens Unit Manager reviewed Resident #40's care plan and confirmed that it had not been developed and implemented for chronic pain or for the use of the antidepressant.

Based on record reviews, interviews, and facility policy, the facility failed to notify the physician when a resident received an antibiotic to which the resident had a known allergy, resulting in the need for increased monitoring for 1 of 5 residents reviewed for unnecessary medications (Resident #40).Finding:Facility policy, Clinical Variance Reporting, revised 10/2024 states, A variance report is required when a variance occurs with medication, documentation, or other circumstances considered variances.The nurse manager or designee on the neighborhood/community will ensure that the following are completed.Physician notification.Resident #40 was admitted with diagnoses to include, but not limited to, otitis media.A review of Resident #40's clinical record revealed a physician progress note dated 3/23/26 that states, . [Resident #40] is seen. regarding ear pain . [he/she] has an allergy to amoxicillin so will use cefdinir 300mg BID x 10 days for otitis media .Further review of Resident #40's clinical record revealed the following physician orders:An order for Amoxicillin 875 mg-potassium clavulanate (Augmentin) 125 mg tablet (1) TABLET Oral Two Times Daily for Ten Days Starting 03/23/26.An order for Cefdinir 300 mg capsule (1) CAPSULE Oral Two Times Daily for Ten Days Starting 3/23/26.A review of Resident #40's Medication Administration Record (MAR) indicated that the Augmentin was administered 3/23/26 during the afternoon pass and that the medication was discontinued 3/23/26. A nursing progress note dated 3/23/26 states, Resident seen by PCP [primary care physician] for (L) ear pain. 2 different ABT [antibiotic therapy] orders placed by PCP with verbal to start immediately. Cefdinir not available in Pixis [Pyxis-an automated machine that dispenses medications] but Augmentin was and initial dose given at 1400 [2:00 p.m.]. Just after 1500 [3:00 p.m.], [Pharmacy] called to verify order for Augmentin as resident has an Amoxicillin allergy in history. Resident not presenting with any s/s [signs/symptoms] of allergic reaction. Will continue to monitor for any s/s of a reaction.On 3/25/26 at approximately 3:45 p.m., in the presence of the Director of Nursing (DON), the surveyor conducted a telephone interview with Licensed Practical Nurse (LPN) #1, the nurse on duty at the time of the medication error. LPN #1 stated that an hour after the Medication Tech gave the Augmentin, the pharmacy called her for clarification due to Resident #40's amoxicillin allergy. LPN #1 stated that she then called the physician, and that the physician stated that she had already caught the allergy and had prescribed Cefdinir instead and discontinued the Augmentin. LPN #1 then stated that at the time she spoke to the physician, she was unaware that the Medication Tech had administered the Augmentin, so she did not notify the physician that Resident #40 had received the Augmentin. The surveyor then asked if LPN #1 if she had notified the physician once she became aware that Resident #40 had received the Augmentin, and LPN #1 stated that she did not notify the physician, but that she notified the Cove Unit Manager.On 3/25/26 at approximately 4:00 p.m., after the above interview with LPN #1, the surveyor asked the DON if the physician is now aware that Resident #40 had received Augmentin, and the DON stated that she would reach out to the physician to find out if she was notified. At 4:18 p.m., during a follow-up interview in the presence of 3 surveyors, the DON stated that she contacted the physician and confirmed that the physician was not notified that Resident #40 had received a dose of Augmentin.

Based on observations, record review, interviews, and facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care (Residents #11, #82).Findings:Facility policy Obtaining and Use of Oxygen Devices, revised 7/2025 states, .Cleaning/changing of oxygen equipment. nasal cannula (nosepiece) should be detached and discarded once per week.Concentrator-particle filter on concentrator should be removed and cleaned weekly.1.On 3/23/26 at 10:43 a.m. and 3/24/26 at 2:01 p.m., a surveyor observed Resident #27's undated nasal cannula oxygen tubing connected to an oxygen concentrator next to his/her bed. The tubing was stored unbagged on top of the concentrator.On 3/25/26 at 8:29 a.m., a surveyor observed Resident #11 sleeping in bed, wearing oxygen via nasal cannula tubing.A review of Resident #11's clinical record revealed the following active physician orders:An order with a start date of 1/26/26 for Oxygen (O2) at 2L/min [liters per minute] per nasal cannula PRN [as needed]. For dyspnea [shortness of breath] or respiratory distress and comfort.An order with a start date of 1/26/26 for Change Oxygen Tubing PRN 1 Time Weekly. when in use.Review of Resident #11's March 20206 Treatment Administration Record indicated that Resident #11 received oxygen on 3/14/26 and lacked evidence that the oxygen tubing is being changed, or that the concentrator particle filter is being cleaned. On 3/25/26 at 9:09 a.m. during an interview, Registered Nurse (RN) #1 stated that oxygen tubing is stored in a plastic drawstring bag when not in use and that tubing is dated and labeled when it is changed, but that she is not sure how often it is changed. At this time, the surveyor discussed the above observations with RN #1.2. On 3/25/26 at 9:40 a.m. a surveyor and RN #1 observed Resident #82's unbagged nasal cannula tubing, dated 3/24/26, connected to a portable oxygen tank secured to the back of his/her wheelchair, and the nasal cannula prongs were in direct contact with the wheelchair seat cushion. Additional nasal cannula oxygen tubing was connected to Resident #82's oxygen concentrator, located next to his/her bed, and the unbagged oxygen tubing was tucked under the blankets on his/her bed. During an interview this time, RN #1 stated that Resident #82 wears oxygen intermittently throughout the day.On 3/25/26 at 10:00 a.m. the surveyor discussed the above findings with the Director of Nursing (DON) during an interview. At this time, the DON stated that oxygen tubing is changed weekly and is stored in plastic bags when not in use.

Based on observation and interview, the facility failed to maintain a garbage storage area and in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters for 2 of 4 days of survey. (3/23/26 and 3/24/26)Findings:1. On 3/23/26 at 8:15 a.m., a surveyor observed the small garbage/refuse dumpster to have the left-side slide door open and the right-side slide door missing, exposing garbage/refuse.2. On 3/24/26 at 8:07 a.m., the surveyor and a laundry staff observed the small garbage/refuse dumpster to have the left side slide door open and the right-side slide door missing, exposing garbage/refuse. At this time, the laundry staff confirmed the findings. On 3/24/2026 at 8:10 a.m., in an interview, the surveyor discussed the two findings with the Administrator.

Based on record reviews and interviews, the facility failed to ensure written bed hold and transfer/discharge notices were provided in writing to the resident and/or their legal representative for a facility-initiated transfer/discharge for 4 of 4 sampled residents transferred/discharged to an acute care facility (Residents #5, #17, #56, #86). Findings: 1.Documentation in Resident #5's clinical record indicated that he/she was transferred to an acute hospital on [DATE]. The clinical record lacked evidence that the facility issued a written transfer/discharge and bed hold notices to the resident's representative. 2. Documentation in Resident #56's clinical record indicated that he/she was transferred to an acute hospital on [DATE]. The clinical record lacked evidence that the facility issued a written transfer/discharge notice and bed hold notice to the resident's representative. 3. Documentation in Resident 86's clinical record revealed he/she was transferred to and acute care hospital and subsequently admitted o 2/21/26. The clinical record revealed Notice of Transfer or Discharge/Bed Hold Policy dated 2/21/26. The clinical record lacks evidence the notice with provided to the resident representative in writing. 4. Documentation in Resident 17's clinical record indicated that he/she was transferred to an acute hospital on [DATE]. The clinical record lacked evidence that the facility issued a written transfer/discharge notice and bed hold notice to the resident's representative. On 3/25/26 at 10:25 a.m., in an interview with a surveyor, the Social Service Manager confirmed the facility does not send transfer/discharge notices and bed hold notices in writing to the resident representatives. On 3/25/26 at 11:40 a.m., with four surveyors present, a Licensed Social Worker(LSW) confirmed that a packet containing a transfer/discharge notice and bed hold notice goes with the resident and the Ombudsman is notified. A transfer/discharge notice and bed hold notice are not sent in writing to the resident representatives.

Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tours (1/6/25 and 1/7/25). Findings: 1. On 1/6/25 from 8:49 a.m. to 9:04 a.m., 2 Surveyors toured the kitchen with the Food Service Supervisor (FDS) in which the following were observed: > The walk-in freezer had built up ice on the fans and on the ceiling. > The hood frame above the grill had chipped and peeling paint. On 1/6/25 at 9:04 a.m., the above was confirmed with the FSD and the Food Service Manager (FSM) who both stated the walk-in freezer was recently serviced for the built-up ice. 2. On 1/7/25 at 8:08 a.m., during an additional tour of the kitchen, 2 surveyors and the FSD observed the following: > The dishwasher hood exhaust vent coated with thick dust and visible dust clusters. > The prewash sink had an empty rinse aid dispenser on the wall with one of the fluid lines, which enters the dishwasher, had a visibly soiled face cloth, tinged off white with brown colored edges, wrapped around the line. At this time, the FSD stated maintenance was aware, and they had a part on order, but he was not sure how long it has been in that condition. On 1/7/25 at 8:32 a.m., during observation of the dishwasher temps, the Maintenance staff and the FSD entered the dish room. The maintenance staff removed the soiled face cloth from the line, and stated, it was not leaking at all. On 1/7/25 at 8:43 a.m., during an interview, the FSM stated she was not sure why the face cloth was on the line. On 1/8/25 at 9:13 a.m., during an interview with the maintenance staff, the Administrative Director and 3 surveyors, the maintenance staff stated, I guess at one time it was leaking, I was not notified about it. I don't have a work order for it . I told them to let me know if it leaks again. On 1/8/25 at 10:00 a.m., during an interview with both the Administrative Director and the FSM, the FSM provided the surveyor with the Warewash Service Report dated 12/11/24 and stated UNX (servicing company) looked at the whole area including the prewash sink and rinse line and didn't have any problems. Upon review, the Warewash Service Report lacked evidence of the prewash sink and rinse line review. The FSM stated the face cloth must have been placed on the line after the servicing date of 12/11/24.

Based on facility policy, record reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to effectively monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of the facility policy Infection Control last revised on 5/24 states; the facility will Track and trend both infection control rates and antibiotic use .Assess appropriate and safe use of antibiotics .Assess best practices through research, accessing pharmacists and other experienced or trained in antibiotic stewardship to ensure evidenced based practice for the long-term care facility. Furthermore, the role of the Infection Preventionist is to Work with the Medical Director to monitor culture report, investigate any potential clusters or outbreaks, and monitor physician use of antibiotics as deemed appropriate. On 1/8/25 at 11:30 a.m., during an interview with the Clinical Nursing Supervisor/Infection Preventionist. He discusses tracking infections residents have and what antibiotic they are originally on, but does not track if a culture was completed, what the culture indicated/what the organism is, if it is the correct antibiotic, which residents are on precautions and why, he does not cohort if practicable, and does not communicate with Medical Doctors and Pharmacists regarding antibiotic usage. Review of Infection Preventionist monthly log for antibiotics lacks evidence of the Infection Preventionist following through on the antibiotic use, the trends of infections and or organisms, clusters of infections, and type of antibiotics used. On 1/8/24 at 12:45 p.m., during an interview with the Director of Nursing, she discusses that they are not tracking the use of Multi-Drug Resistant Organisms per the facility antibiotic stewardship policy and procedure. On 1/8/25 at 12:20 p.m., during an interview with the Administrator Director the above information was discussed.

Based on interviews, facility policy, and observations, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection on 2 of 4 days of survey. Findings: The Infection Control Program page 18 under Procedures for Contact Precautions indicates Staff will utilize gloves and gowns when in the patient's room and/or providing direct patient care. 1. On 1/6/25 at 10:22 a.m., a surveyor observed a contact precaution sign on Resident #22's door instructing all staff to wear Personal Protective Equipment (PPE) for contact with the patient or the patient's environment. A PPE cart was located outside the room which included gloves, gowns and instructions for staff on donning and doffing PPE. At this time, a surveyor observed a Housekeeping Staff member inside Resident #22's room cleaning the floor and wiping down objects wearing only gloves. A surveyor intervened and asked the Housekeeping Staff member if Resident #22 was on contact precautions and what should be worn. The Housekeeping Staff member stated that she is not working directly with the resident and only needs to wear gloves. On 1/6/25 at 10:36 a.m., the above was discussed with the Cove Unit Nurse Manager who stated that only staff providing incontinence care for Resident #22 need to wear both gloves and gown. On 1/6/25 at 10:39 a.m. during an interview with the Clinical Nursing Supervisor/Infection Preventionist about the Contact Precautions sign and PPE cart located outside Resident #22's room. He confirmed that all staff, including Housekeeping should be wearing both gloves and gown when entering the room. On 1/6/25 at 3:00 p.m., a surveyor discussed the above findings with the Administrator who confirmed that all staff who will have contact with the resident or the resident's environment should be wearing both gloves and gown when entering a contact precautions room. On 1/7/25 at 9:00 a.m. a surveyor observed Certified Nurses Aide #3 (CNA) and CNA #4 enter the room of Resident #22 wearing only gloves assisting Resident #22 with her breakfast tray. When CNA #3 and CNA #4 exited the room. A surveyor asked about the Contact Precautions sign posted outside of Resident #22's room. CNA #3 and CNA #4 stated that both gloves and gown are only needed with incontinence care. CNA #4 stated that Resident #22 has Extended-Spectrum Beta-Lactamase (ESBL) in the urine. On 1/7/25 at 9:06 a.m., a surveyor discussed the above finding with the Cove Unit Nurse Manager who stated that only gloves and gown are needed for Resident #22 when providing incontinence care. On 1/7/25 at 3:30 p.m. during an interview with the Administrator. She stated that Resident #22's precaution sign has been changed to Enhanced Barrier Precautions which would only require gloves and gown when providing incontinence care for Resident #22. 2. On 1/8/25 at 10:50 a.m., during an interview with Licensed Practical Nurse #1 (LPN#1), she states that she would use the purple top wipes to clean shared glucometers and shared medical equipment contaminated with Clotridoides Difficile Colitis (C.Diff). On 1/8/25 at 11:00 a.m., during an interview with CNA#1, she states that she was unaware how often staff would clean shared equipment, she then states she would use the purple top wipes to clean shared equipment contaminated with C.Diff. On 1/8/25 at 11:06 a.m., during an interview with CNA #2, She states that she is unaware what disinfectant to use to properly clean shared equipment for residents with C.Diff or Methicilin-Resistant Staphylococcus Areus (MRSA). On 1/8/25 at 11:17 a.m., during an interview with Registered Nurse #1 (RN#2), She states she is unaware of how to disinfect clean shared equipment for residents with C.Diff. On 1/8/25 at 11:30 a.m., during an interview with the Clinical Nursing Supervisor/Infection Preventionist, with 4 surveyors present, he states that he has been in this role for 4 years and does not provide education relating to infection control practices to the staff. The surveyor asked how he would properly disinfect shared medical equipment contaminated with C.Diff. The Infection Preventionist stated he would use purple top wipes. At this time the surveyor requested the Infection Preventionist to obtain the purple top wipes. Upon review, the purple top wipes are the Super Sani Cloth Germicidal Wipes. Further review by both surveyor and the Infection Preventionist shows that the sani cloth is not effective against C.Diff. At this time the Infection Preventionist confirmed that the purple top wipes would not be effective against residents with C.Diff. Further review of the facility policy Infection Control last revised on 5/24 states the role of the Infection Preventionist is to Work with Staff Development Coordinator to develop in-service education programs pertinent to infection control and sanitation issues. On 1/8/24 at 12:20 p.m., during an interview with the Administrator Director, the above information was discussed.

Based on observations, interviews and record reviews the facility failed to provide Activities of Daily Living (ADL) care in the area of oral hygiene for 2 of 2 residents reviewed for dental care (Resident #40 and #10) and failed to follow the Self-care deficit care plan in the area of oral hygiene for 1 of 2 reviewed. (Resident #10) Findings: 1. On 1/6/25 at 10:55 a.m., observation of Resident #40 sitting in the common area. His/her teeth were coated with a thick whitish substance at the gum line. At this time, in a brief interview, he/she states staff will help when needed for brushing his/her teeth. On 1/7/25 at 10:31 a.m., observation of Resident #40 dressed, hair combed back into a ponytail and seated in a chair in the common area. His/her teeth were coated with a thick whitish substance at the gum line. On 1/7/25 at 12:46 p.m., the Administrator, Director of Nursing (DON) and the surveyor observed Resident #40's teeth coated with a thick whitish substance at the gum line. At this time, the DON stated she will look further into Resident #40's dental care and stated he/she does refuse help or care at times. Review of Resident #40's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/8/24 revealed he/she had a Brief Interview for Mental Status (BIMS) of 12 of 15 indicating [he/she] is moderately impaired and requires partial to moderate assistance for oral hygiene. Review of Certified Nurses Aide (CNA) documentation from 1/1/25 - 1/7/25 indicates that he/she fluctuates from maximum assistance to limited assist with oral care. Review of the most recent care plan for Self-Care Deficit R/T Cognitive Impairment, Major neurocognitive disorder with Dementia . has a goal of, [Resident] Personal hygiene needs will be met with staff assistance during the next 90-120 days and interventions of . [Resident] will require limited to extensive with bathing, dressing, toileting and personal hygiene. Observations and interviews on 1/8/25 at 7:52 and 1/9/25 at 8:20 a.m., show Resident #40 appearing clean, dressed appropriately and his/her teeth without the presence of a thick whitish substance. Additionally, he/she stated staff helped him/her brush his/her teeth. 2. On 1/8/25 at 7:44 a.m., a surveyor observed Resident #10 being pushed out of the room by CNA #1. Resident #10 stated, I want to brush my teeth, the CNA stated Ok, you want to brush your teeth, I'll bring you back in. The resident then stated, yeah, I didn't brush my teeth. The CNA brought the resident back and set him/her up at the sink. The CNA applied toothpaste to the toothbrush and handed it to the resident. At this time in an interview, CNA #1 stated she is one of the primary CNA's and familiar with Resident #10 stating, [he/she] is usually up by 5:30 a.m., and I just have to bring [him/her] out. [He/she] is passionate about hygiene, I just spaced. Review of the Annual MDS with an ARD of 11/8/24 revealed Resident #10 had a BIMS of 11 of 15 indicating [he/she] is moderately impaired and is dependent on staff for Activities of Daily Living including oral hygiene. Review of the most recent care plan for Self-care deficit - Extensive assistance required with bathing, hygiene, dressing, and grooming R/T dementia has an intervention of clean mouth, brush teeth/dentures after meals and at bedtime. Review of CNA documentation from 12/24/24 - 1/8/25 states that he/she requires extensive assistance of 1 for Activities of Daily Living. Further review lacks evidence of oral care being completed after lunch on the following days: 12/24/24 through 12/28/24, 12/30/24 through 1/4/25 and 1/6/25 through 1/7/25. In addition, 1/2/25 lacks evidence of oral care being completed after breakfast. On 1/8/25 at 3:11 p.m., during an interview with Resident #10, the surveyor asked if his/her teeth are brushed every morning. He/she stated, I wish it would be. I have to ask them. Sometimes it feels so thick. Most of the time I have to remind them. On 1/8/25 at 3:22 p.m., the above was discussed with the Administrative Director.

Based on record review and interview, the facility failed to obtain a physician's order with a supporting diagnosis for the use of an indwelling foley catheter and failed to ensure the physician order for the foley catheter included the size of the catheter and the size of the catheter balloon for 1 of 3 residents reviewed with urinary catheters (Resident #110). Finding: On 1/6/25 at 12:21 p.m., during an interview with Resident #110, he/she was unaware of why he/she has an indwelling foley catheter stating, he/she did not have one at home .Wish I didn't have one, they might take it out. On 1/8/25 at 7:21 a.m., during an interview, Registered Nurse #2 (RN#2) stated she was not sure why Resident #110 had a foley catheter. At this time, Certified Nursing Aide #5 (CNA #5) stated, Resident #110 has a foley catheter due to not being able to manage his/her urinal, soaking his/her bed and his/her difficulty with getting out of bed due to his/her seizures. The Surveyor asked what the medical diagnosis was for having the foley catheter, neither RN #2 nor CNA #5 could describe. Resident #110 was admitted on [DATE] with diagnosis of, Encounter for palliative care, Malignant neoplasm of brain, unspecified convulsions, abnormalities of gait and mobility, pain, pruritus, seizure disorder, cancer and anxiety. The Admission Minimum Data Set with the Assessment Reference Date of 12/11/24 revealed he/she had a Brief Interview for Mental Status of 15 out of 15 indicating [he/she] is cognitively intact. Further review, physician orders dated 12/4/24 stated, Catheter care - change catheter bag 1 Time Weekly and Follow routine catheter care two times daily for the Related Diagnoses of Unspecified Convulsions. Review of providers notes from admission to 1/8/25 lacked evidence of the providers acknowledging the indwelling foley catheter and/or the diagnosis for the indwelling foley catheter. On 1/8/25 at 10:01 a.m., during an interview with the Administrative Director, she confirmed the above stating, she was only able to find documentation of the resident having the foley upon admission but no diagnosis or provider notes relating to the indwelling foley catheter.

Based on record review and interview, the facility failed to ensure that 1 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #26). Finding: Clinical record review revealed Resident #26 was readmitted to the facility on [DATE] with diagnoses to include bipolar disorder. A review of Resident #26's PASRR Level I dated 8/2/24 revealed Resident #26 had a Convalescence Categorical exemption (a time-limited 30-day exemption). Resident #26's clinical record lacked evidence that the resident had been re-evaluated for a PASRR Level II determination after the Convalescent period ended. On 1/7/25 at 1:30 p.m., the Care Manager Supervisor confirmed the finding.

Based on record review and interviews, the facility failed to ensure that an injury of unknown origin observed on a resident included a documented assessment, treatment, and monitoring for 1 of 3 residents sampled for injuries/accidents. (#1) Finding: A review of Resident #1's clinical record noted a nursing note written by the RN, Charge Nurse on 4/11/2022 at 20:05 (8:05 p.m.) indicating Resident has a massive bruise to [his/her] right arm. Starts at [his/her] shoulder and goes down to [his/her] inner elbow area. Resident is not able to articulate how this happen due to [his/her] level of dementia. No recent notes reporting this bruise. Deep purple in color. Will continue to monitor. On 11/15/22, a surveyor reviewed Resident #1's clinical record and was unable to find any documentation on how this injury occurred or assessment when first observed, any monitoring of the area, or any treatments already provided or to be provided. On 11/15/22 at 4:25 p.m., in an interview, the Administrator and the Director of Nursing Services(DNS) confirmed that the facility failed to ensure that an injury of unknown origin observed on Resident #1 included a documented assessment, treatment, and monitoring.

Based on record review and interviews , the facility failed to report in a timely manner, an injury of unknown origin to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) for 1 of 3 residents sampled for injuries/accidents. (#1) Finding: Review of the facility's Resident Rights Policy # LTCRI-01, revised 5/21, noted in Section IV - G. Injuries of Unknown Origin: 1. Staff will immediately report to nurse, supervisor or manager any injury of unknown origin. 2. Staff who witnessed the event will assure a DHHS Nursing Facility Reportable Incident form (www.maine.gov) is completed within 24 hours and faxed to [PHONE NUMBER]; State of Maine Division of Licensing and Certification. 3. Charge nurse or supervisor will complete an EMR Incident Report. 4. All injuries of unknown origin of a suspicious nature will follow all of the above protocols. 5. Refer to the Incident Reporting Policy (LTCP C-20). Review of the facility's Provisions of Care # LTCPC-20, revised 10/21, noted in Section II. Policy: Maine general rehabilitation and long term care staff will participate in protecting resident rights nursing will accurately document incidents that occur and report to licensing and DHS as appropriate and indicated. 3. Injury of unknown origin: Two elements needed to be present in order for an event to be reportable: a. The source of the injury was not observed or the resident cannot explain the source of the injury. b. The injury is suspicious because of the extent or place of the injury. A review of Resident #1's clinical record noted a nursing note written by the RN, Charge Nurse on 4/11/2022 at 20:05 indicating Resident has a massive bruise to [his/her] right arm. Starts at [his/her] shoulder and goes down to [his/her] inner elbow area. Resident is not able to articulate how this happen due to [his/her] level of dementia. No recent notes reporting this bruise. Deep purple in color. Will continue to monitor. On 11/15/22 at 11:25 a.m. during an interview, the Director of Nursing Services(DNS) confirmed that the facility did not send a report to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) regarding this injury of unknown origin.

Based on record review and interviews, the facility failed to ensure that the Medical Provider and resident representative were notified of a change in the resident's medical condition after observing a potentially serious injury of unknown origin for 1 of 3 residents sampled for injuries/accidents. (#1) Findings: Review of the facility's Resident Rights Policy # LTCRI-01, revised 5/21, noted in Section IV - G. Injuries of Unknown Origin: 1. Staff will immediately report to nurse, supervisor or manager any injury of unknown origin. 2. Staff who witnessed the event will assure a DHHS Nursing Facility Reportable Incident form (www.maine.gov) is completed within 24 hours and faxed to [PHONE NUMBER]; State of Maine Division of Licensing and Certification. 3. Charge nurse or supervisor will complete an EMR Incident Report. 4. All injuries of unknown origin of a suspicious nature will follow all of the above protocols. 5. Refer to the Incident Reporting Policy (LTCP C-20). A review of Resident #1's clinical record noted a nursing note written by the RN, Charge Nurse on 4/11/2022 at 20:05 (8:05 p.m.) indicating Resident has a massive bruise to [his/her] right arm. Starts at [his/her] shoulder and goes down to [his/her] inner elbow area. Resident is not able to articulate how this happen due to [his/her] level of dementia. No recent notes reporting this bruise. Deep purple in color. Will continue to monitor. On 11/15/2022 at 1:45 p.m., in an interview, the Nurse Manager stated that she had just talked to the Charge Nurse on the phone and the Charge Nurse stated that she recalled the bruising. However she thought she had included additional documentation of the Resident #1's wandering and combative behaviors, and that the Resident #1 was ambulatory at that time. A review of Resident #1's clinical record lacked evidence that an Incident Report was completed, that there was continued monitoring of the injury, that the Medical Provider was notified of the injury and that the resident representative was made aware of the injury. On 11/15/ 2022 at 11:06 a.m., in an interview, the Nurse Practitioner (NP) stated that she has taken care of Resident #1since the resident was admitted . When asked about a massive bruise from April 2022, the NP looked through her laptop and stated that she didn't see the resident for any massive bruising to his/her arm and that she wasn't aware that he/she had any. She confirmed that, the massive bruising noted by the Charge Nurse in April 2022 was not reported to her. On 11/15/22 at 12:05 p.m., in an interview, the Medical Provider stated that she did not know that the resident had a massive bruise of unknown origin on his/her arm and it had never been reported to her in April 2022. She stated that she had not observed and assessed the resident for a massive bruise. She stated that she would have looked at the resident if she had been told or have the NP look at the resident. The Medical Provider confirmed that she should have been notified if there had been a massive bruise and questionable of where it came from. On 11/15/22 at 11:25 a.m. during an interview, the Director of Nursing Services(DNS) confirmed that the facility failed to ensure that the Medical Provider and the resident representative were notified of a change in the resident's medical condition after observing a potentially serious injury of unknown origin.

Based on record reviews and interviews, the facility failed to ensure 1 of 5 sampled residents reviewed for medications were free of significant medication errors, resulting in a resident requiring transfer to the hospital for emergency evaluation (#1) Finding: The Division of Licensing and Certification received a facility reported incident that indicated on 8/7/2020, at 7:30 a.m., Resident #1 received both 36 units of Basaglar insulin and 36 units of [MEDICATION NAME]in error which resulted in [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Resident #1 was transported to the emergency room and subsequent admission to the hospital. A review of Resident #1's Medication Administration Record [REDACTED] 1. Order dated 7/31/2020 instructing nursing to administer Basaglar KwikPen U-100 Insulin 100 units/ml Subcutaneous One time daily for seven days starting 7/31/2020 with a note indicating Do not reorder Basaglar. Order [MEDICATION NAME] when Basaglar supply is depleted. See new order for [MEDICATION NAME] to start on 8/7/2020 because insurance will not pay for Basaglar. 2. Order dated 7/16/2020 instructing nursing to administer Basaglar KwikPen U-100 Insulin 100 units/ml Subcutaneous Every one day. 3. Order written on 7/31/2020 instructing nursing to administer [MEDICATION NAME] U-100 Insulin 100/unit/ml 36 units one time daily starting 8/7/2020. On 9/3/2020 at 3:22 p.m., in an interview with the Licensed Practical Nurse (LPN), she confirmed that on the morning of 8/7/2020, she administered to Resident #1, 36 units of Basaglar insulin and 36 units of [MEDICATION NAME]in error. A review of the nursing notes dated 8/7/2020 indicated the resident was sent to the emergency room due to having [MEDICAL CONDITION]. A review of the hospital discharge summary dated 8/11/2020 stating Resident #1 was admitted to the hospital from the facility after accidentally being given two doses of his/her long-acting insulin for a total of 70 units of insulin and with concern for [MEDICAL CONDITION] activity. A review of facility's Root Cause Analysis Significant Event timeline stated the order for Basaglar insulin (dated 7/16/20) did not have a stop date and still showed up on the MAR, resulting in the insulin being administered incorrectly. Education was provided to nursing staff regarding double checking the medication orders. On 9/2/2020 at 11:14 a.m. the surveyor confirmed the significant medication error resulting in hospitilization with the Senior Director of Nursing Services. As a result of the facility's investigation, the following corrective action was taken: 1. Med change was made due to insurance non-coverage. Medications left from previous orders will be discarded and new orders will be started immediately. 2. Staff will ensure all orders are double checked by a second Registered Nurse (RN) RN is not to activate their own orders. If a second check is not done a medication variance would be created and education provided to the RN. 3. A notification will be added to the ALERT ribbon in My Unity. 4. Education was provided to nursing staff on regarding double checking of orders and will be reviewed at the September licensed staff meeting.

Based on record reviews and interviews, the facility failed to clarify advance directives for a resident over an eleven day stay at the facility. In addition, the facility neglected to immediately initiate Cardio-Pulmonary Resuscitation for a resident who was a full code and had an episode of unresponsiveness with an absence of both a pulse and respirations for 1 of 4 sampled Residents (#1). Resident #1 expired during this event. Finding: Resident #1 was admitted to the facility in early [DATE] following a hospitalization for [MEDICAL CONDITION], a Urinary Tract Infection and [MEDICAL CONDITION] and generalized deconditioning. The resident was receiving skilled services at the facility. The documents provided to the facility from the hospital included a 7 day Med Summary Form which indicated that the resident's code status was "Resuscitate." An integrated Progress Note from the physician at the facility, dated [DATE], indicated that the resident was a "Full Code." A Skilled Nursing Home History and Physical Note completed by a physician at the facility, dated [DATE], and electronically signed by the physician on [DATE], also indicated that the resident was a "Full Code." There was no evidence that this record was flagged as a "Full Code" consistent with the facility's practice. The clinical record contained a Nurse's Progress note, dated [DATE], which indicated that the resident had a "good day" and the facility staff was frequently checking on Resident #1 for increased wondering at least every fifteen to twenty minutes. The note indicated, at 1:20 a.m., the facility staff saw the resident sleeping in the bed. At 1:45 a.m., the staff found the resident on his/her knees on the floor at the foot of the bed, bent over the footboard with his/her head on the mattress and his/her forehead resting on his/her cupped hands. A small, dime size red mark was noted on resident's left upper forehead and the resident had no heartbeat or respirations. The resident was removed from the floor and was placed on to his/her bed. The facility failed to immediately initiate Cardio-Pulmonary Resuscitation for the resident whose clinical record indicated was a "Full Code" or call 911. The physician was notified of the event. On [DATE] at 4:00 p.m., in an interview with the surveyor, a son stated that he had concerns about Resident's #1's pathology report findings from an autopsy that was performed on [DATE]. According to the intake report, the family stated that the pathologist found that the resident had experienced a trauma hemorrhage of the scalp, not in the brain, a hemorrhage in the lung, and that the resident expired from complications of pneumonia. On [DATE] at 9:00 a.m., the son stated that he had had no discussions regarding the resident's code status, but had seen in the resident's clinical record that the resident was a "Full Code." In an interview with the surveyor, on [DATE] at 12:00 p.m., the charge nurse stated that when the resident was found kneeling on the floor, she had assessed Resident #1, reviewed the clinical record to verify the resident's code status and had called the physician. The charge nurse stated there was no sticker on the resident's clinical record to indicate a "Full Code" status and therefore Cardio-Pulmonary Resuscitation was not initiated. The nurse stated that she had referred to a history sheet for the resident's code status which indicated "Do Not Resuscitate." The Director of Nursing provided the surveyor a copy of this document which was a hospital discharge summary, dated [DATE]th, 2009. On [DATE] at 3:05 p.m., in an interview with the surveyor, the Nurse Manager stated that a resident would automatically be a "Full Code" status unless there was a "Do Not Resuscitate" order. The Nurse Manager confirmed that Cardio-Pulmonary Resuscitation was not initiated for Resident #1. The surveyor discussed the lack of clarification of advance directives with the Director of Nursing on [DATE] at 1:40 p.m. On [DATE] at 12:30 p.m., the surveyor discussed with the Director of Nursing and the Administrator that Resident #1's clinical record for the [DATE] admission indicated that the Resident was a "Full Code" based on documents from the hospital and the facility's physician.