Every finding on record at Maplecrest Rehab & Living Center

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 4 Wings (Lakewood, Embden, [NAME]) and the common area/hallway for 2 of 3 days of survey.1. On 7/7/25 at 9:14 a.m., and on 7/8/25 at 8:11 a.m., observation of room [ROOM NUMBER] to have trash/debris including tissues, a pen, papers, food and a sticky layer of a dried substance under the bed. 2. On 7/8/25 from 2:41 p.m. through 2:58 p.m., an environmental tour was conducted with Director of Nursing and the Maintenance Director for which the following was observed:Lakewood unit:- room [ROOM NUMBER] had a stained ceiling tile above the bed and marred wallpaper at the head of the bed- room [ROOM NUMBER]'s windowsill had chipped paint and was separated from the brick below the window. - room [ROOM NUMBER]'s windowsill had chipped and peeling paint.- The hallway near room [ROOM NUMBER] and [ROOM NUMBER] had several cracked tiles spanning the width of the hallway. Embden unit:- room [ROOM NUMBER] the cabinet door below the sink has a chunk of missing laminate and the wall next to the bathroom has a large area of marred wall with exposed sheetrock.- The hallway railing had chipped and peeling paint on the wood. - The shower room had several missing tiles around the drain; the edge caulking is brown and orange in color with rust and multiple broken tiles along the shower perimeter. [NAME] Unit:- room [ROOM NUMBER]'s bathroom ceiling tiles above the toilet appear dirty/stained and chipped.- room [ROOM NUMBER]'s heater cover was off exposing the sharp metal fins. The common area across from the nurse's station has multiple areas of marred walls exposing sheetrock. The right corner of the nurse station wall has missing laminate exposing raw wood. The dining room entrance door panel has missing plastic with exposed wood leaving sharp edges, 2 stained ceiling tiles and multiple windowsills with chipped and peeling paint.On 7/8/25 at 2:58 p.m., the Director of Nursing and Maintenance Director confirmed the above concerns.

Based on observations, record reviews, interviews and the 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 4 of 5 residents reviewed for respiratory care (Resident #45, #151, #29 and #35). In addition, the facility failed to ensure physician orders were followed for 1 of 5 residents receiving oxygen therapy (Resident #10)Oxygen use & Storage Policy last revised on 6/25 states under respiratory care A Sanitary environment must be maintained to prevent the transmission of disease and infection. A. Nasal Cannula's will be discarded and changed every 2 weeks. The respiratory set up bag will be labeled with resident's name and the date the equipment was changed or the date changed can be directly labeled on the cannula with a piece of tape. When the nasal cannula is not in use, on both the concentrator and portable tank, the cannula will be stored in a plastic bag to avoid the risk of it becoming contaminated.B. Nebulizer parts should be rinsed after each use, allowed to air dry while being covered with a paper towel and placed in respiratory set up bag once dried. Respiratory set-ups for nebulizers will be changed every 2 weeks. Nebulizer filters will be rinsed every 2 weeks and changed on a monthly basis.D. Staff changing the tubing should document on the Treatment Administration Record (TAR) when the tubing has been changed following this policy.E. When the tubing is changed, the filter in the concentrator must also be removed and rinsed off to ensure the filter remains free from dust.Continuous positive airway pressure (CPAP)/ Bilevel positive airway pressure (BIPAP) Management policy last revised on 6/25 states under Daily Cleaning RecommendationsMask and/or nasal pillows wash in warm soapy water, allow to air dry, out of direct sunlight or wipe down with a recommended CPAP wipe. Once completed, place clean equipment into plastic bag. Water chamber empty any remaining water after treatment. 1. On 7/7/25 at 10:01 a.m., and on 7/8/25 at 8:11 a.m., observations of Resident #151's nasal cannula with foam protectors taped to the tubing, unlabeled and stored on the bedside dresser. Review of the medical record lacked evidence of nursing changing the nasal cannula every 2 weeks. 2. On 7/7/25 at 9:20 a.m., and on 7/8/25 at 8:11 a.m., observations of Resident #45's nebulizer pipe and tubing, unlabeled and stored on top of the bedside dresser and a Continuous positive airway pressure (CPAP) mask draped over the CPAP machine. There was no respiratory set up bag for storage observed.Review of Resident #45's Treatment Administration Record lacked evidence of the changing and/or cleaning of the Nebulizer tubing/pipe and CPAP mask.On 7/8/25 at 10:12 a.m., during an interview, the above was observed and confirmed with the Director of Nursing (DON).On 7/8/25 at 2:58 p.m., an additional observation of Resident #45's CPAP mask draped over the machine and hanging between the wall and the bedside dresser. At this time, it was again confirmed with the DON 3. On 7/7/25 at 9:27 a.m., a surveyor observed Resident #10 wearing oxygen via nasal cannula with the oxygen concentrator set at 3 liters.On 7/8/25 at 1:07 p.m., a surveyor observed Resident #10 asleep and wearing oxygen via nasal cannula with the oxygen concentrator set at 2.5 liters.A review of Resident #10's medical record revealed a physician's order, dated 8/22/24 for Oxygen (O2) at 2 liters per minute via nasal cannula without humidification. May use as needed for complaints of cluster headaches (effective historically per resident).A review of Resident #10's Treatment Administration Records (TAR) for June and July, 2025, noted no documentation for the use of oxygen, though the oxygen tubing was changed every 2 weeks per facility policy.On 7/8/25 1:33 p.m., in an interview with the [NAME] President of Quality Improvement & Nursing Services, the surveyor discussed the observations of Resident #10 and the lack of documentation for Resident #10's oxygen use. The [NAME] President of Quality Improvement and Nursing Services confirmed the findings did not reflect the physician's order and stated she would clarify the correct order at this time. 4. On 7/7/25 at 9:03 a.m. and on 7/8/25 at 10:15 a.m., observation of Resident #29's unbagged nebulizer mask and tubing on the bedside table dated 1/21. Review of Resident #29's clinical record indicated an active physician order for Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg/3 mL (0.083 %) with directions to use every 6 hours as needed. Review of the medication administration record/treatment administration record indicated that his/her last time using the nebulizer was on 5/26/25.On 7/8/25 at 10:15 a.m., the above information was confirmed with the DON. 5. On 7/7/25 at 8:57 a.m. and on 7/8/25 at 8:26 a.m., Resident #35's unbagged nebulizer mask was observed hanging on the nebulizer machine on his/her nightstand. Review of Resident #35's active physician orders revealed an order for, ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3mL .Nebulization As Needed . Review of Resident #14's Treatment Administration Record lacked evidence of when the nebulizer tubing has been changed. On 7/8/25 at 9:56 a.m. a surveyor observed Resident #35's unbagged nebulizer mask with the DON. At this time, the DON stated after a nebulizer treatment is administered, the mask should be rinsed and air dried, then stored in a bag.

Based on record review, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked for 1 of 1 medication refrigerator reviewed (nurses station), and failed to ensure controlled medications were stored appropriately for 1 of 3 medication carts observed (Embden and [NAME] medication cart), in addition, the facility failed to ensure treatment carts were locked when unattended on 1 of 1 unit ([NAME] Chase [NAME] Unit) for 1 of 3 days of survey.1. During a review of Embden and [NAME] medication cart with Certified Nursing Assistant/Medication Technician (CNA-M) #3 on 7/7/25 at 8:35 a.m., CNA-M #3 confirmed the cart contained controlled medications and proceeded to open the metal box with a lock on the top, using her pinky fingernail, sticking it under the lid and popping the lid open. The metal box contained approximately 15 cards of controlled medications. At this time, CNA-M #3 stated she did not close the lid all the way, which would engage the lock and she should have. 2. During an observation of medication storage refrigerator with Registered Nurse (RN) #2 on 7/7/25 at 8:42 a.m., 4 boxes of liquid Lorazepam were observed in the bottom draw of the refrigerator, not in a permanently fixed compartment. At this time RN #2 stated this is her first day at the facility, and she thought it was odd that the controlled medications weren't in a fixed compartment but had not asked about it yet. On 7/7/25 at approximately 2:45 p.m., the above was discussed with the Director of Nursing. 3. On 7/7/25 at 9:41 a.m., a surveyor observed an unlocked and unattended treatment cart on the [NAME] Chase [NAME] Unit, at this time the surveyor opened the treatment cart, which contained multiple vials of insulin, blood thinners, and Narcan. Approximately 3 minutes later, the surveyor observed Registered Nurse #3 coming out of room [ROOM NUMBER] where she was then made aware of the unlocked and unattended treatment cart. On 7/7/25 at 10:11 a.m. the above information was discussed with the Director of Nursing.

Based on observations, record review and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors and walls for 1 of 3 days of survey (7/7/25) and failed to monitor refrigerator, freezer and the steam table/tray line temperatures for 3 of 4 months reviewed.1. On 7/7/25 from 8:33 a.m. to 9:00 a.m., a surveyor conducted a kitchen tour with the Food Service Director in which the following findings were observed and confirmed: -There was trash and food debris on the floor under the equipment and around the edges of the floor.-The first-floor food storage room had a hole in the wall exposing sheetrock, making the surface uncleanable. -In the kitchen by the fire extinguisher there was exposed sheetrock, making the surface uncleanable.2. On 7/8/25 a surveyor reviewed the facilities Freezer and Refrigerator Temperatures Form which indicates temperatures are to be taken in the morning and at night. Further review showed the following missing temperatures: May 2025:- The diet kitchen freezer and refrigerator showed 5 out of 31 days missing. - The dairy cooler, upright freezer, and chest freezer showed 8 out of 31 days missing.- The bread freezer showed 9 out of 31 days missing.- The true freezer showed 4 out of 31 days missing.- The upright refrigerator (veg) showed 10 out of 31 days missing.- The dietary refrigerator showed 6 out of 31 days missing.- The cooks freezer showed 1 out of 31 days missing.- The cooks refrigerator showed 2 out of 31 days missing.April 2025:-The Bread freezer, true freezer, upright freezer, chest freezer, and upright refrigerator showed 8 out of 30 days missing. - The dairy cooler showed 9 out of 30 days missing. - The dietary refrigerator showed 11 out of 30 days missing. 3. On 7/8/25 a surveyor reviewed April 2025 through June 2025 facilities Steam Table and Tray Line Temperature Record which indicates temperatures are to be taken 3 times daily with meals. Further review showed the following missing meal temperatures: - Breakfast 26 out of 91 days are missing. - Lunch 26 out of 91 days are missing. - Dinner 41 out of 91 days are missing. On 7/8/25 at 12:30 p.m., the above was reviewed and confirmed with the Food Service Director.

Based on observations, record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to conduct ongoing surveillance, tracking and educations to prevent the spread of Infections, failed to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP), and failed to develop and implement elements of a Legionella Water Management Program. This has the potential to affect all 47 residents.Infection Control: Multidrug-Resistant Organism (MDRO's) policy, last revised 4/18/24 states Enhanced Barrier Precautions (EBP): gowns and gloves are worn during high-contact resident care activity. Examples of high-contact activity are: Preforming ADLS (activity of daily living) - bathing, dressing, transfers and toileting. Providing device care and/or wound care. Device are would include central lines, catheters . Under procedure states, Residents being treated for an active MDRO infection will be placed on Contact precautions. Residents who have competed treatment for MDRO's will then be placed on Enhanced Barrier Precautions (EBP). Gloves and Gowns will be used when preforming high-contact care activities. 1. On 7/7/25 at 9:14 a.m., observation of Resident #45's room door with a small Stop see nurse for instructions sign posted on the door frame, no directions on what Personal Protective Equipment (PPE) to utilize prior to entering the room. Directly inside the room was a cart containing Personal Protective Equipment (PPE). Resident #45 was receiving an Intravenous (IV) antibiotics via a peripherally inserted central catheter (PICC) line. At this time, the resident stated he/she has an infection in the wound on the coccyx which requires daily dressing changes and is followed by infectious disease. On 7/8/25 at 8:11 a.m., an additional observation of resident #45's room to have only a stop see nurse for instructions sign posted on the door frame. There were no additional directions on what type of precautions or what PPE to wear prior to going into the room. Review of the medical record confirmed he/she has a diagnosis of an unstageable coccygeal pressure ulcer with osteomyelitis containing Methicillin-resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamases (ESBL) Klebsiella, both a Multidrug - Resistant Organism (MDRO's) with an active order for a dressing to the coccyx wound daily. On 7/8/25 at 2:58 p.m., both the Director of Nursing (DON) and the Surveyor observed Resident #45 room to have the small Stop see nurse for instructions sign on the door frame. The surveyor asked the DON what precautions were needed and why when caring for resident #45. The DON stated, he/she is being treated for an active infection involving MDRO's and contact precautions should be utilized when providing wound care and enhanced barrier precautions when providing IV care. At this time, the surveyor asked why the precaution is not posted and which precaution is to be used, being that they are 2 very different types i.e., Contact requires appropriate PPE when entering the room while EBP requires PPE using gowns and gloves during specific high-contact resident care activities. The DON did not have an answer. On 7/9/25 at 11:14 a.m., observation of Resident #45's room to now have an EBP sign posted on the door instructing staff to use gloves and gowns when performing high-contact resident care activities. At this time, Registered Nurse (RN #1) stated he/she is on EBP for both the wound and the IV line, has an active infection and is on 2 different antibiotics to treat 3 different bugs since admission. The surveyor asked what organism or bug he/she is being treated for. RN #1 stated, I'm not sure, one is MRSA, I think. The surveyor asked what type of precautions he/she should be on while being treated for an MDRO. RN#1 stated, EBP and originally I had put [resident #45] on contact precautions when [he/she] came to us and she is not sure why or when it was changed. At this time, the surveyor discussed the facilities policy of when a resident has an active MDRO infection, they are to be Contact precautions. RN #1 did not have response. 2. On 7/7/25 at 10:23 a.m., and on 7/8/25 at 10:20 a.m., observation of Resident #47 to have bilateral feet wrapped in kerlix and wearing orthopedic shoes. At this time in an interview, he/she confirmed both feet had surgical wounds which required dressing changes.Review of the medical record states Resident #47 was admitted [DATE] with diagnosis of chronic osteomyelitis resulting in amputation of toes on both feet and surgical wounds requiring treatments every other day. In addition, he/she has a stage 2 pressure ulcer on the right hip requiring treatment three times daily. The room lacked notification/posting of Enhanced Barrier Precautions and available personal protective equipment. 3. On 7/7/25 at 9:14 a.m., a surveyor observed a small red and white Stop, See Nurse for Instructions sign on Resident #16's door frame. There was no Personal Protective Equipment (PPE) outside or inside the room, and there was no additional signage on the door. At this time, Certified Nurse Medication Aide (CNA-M) #3 was exiting the room, and a surveyor asked about the sign. CNA-M #3 stated the sign indicates precautions, but she is not sure what type of precautions this resident is on because today is her first day back as agency staff. On 7/7/25 at 10:53 a.m., during an interview, Registered Nurse (RN) #2 stated today is her first day at the facility and she is agency staff and is not sure if Resident #16 is on precautions. RN #2 then checked Resident #16's clinical record and stated Resident #16 has MRSA (methicillin-resistant staphylococcus aureus), and that she is not sure where PPE is located but thinks she was told in the closet next to the nurses' station. On 7/7/25 at 2:14 p.m., during an interview, CNA #1 stated today is her first day as a permanent staff member and that she is not sure if any residents on the [NAME] unit are on precautions and that she was not told where to find PPE but that she is training with CNA #2. On 7/7/25 at 2:52 p.m., during an interview, CNA #2 stated no residents on the [NAME] unit are on EBP or TBP and that there are gowns in the linen closet and trash cans in the supply closet, and trash cans get put in front of the door for residents on precautions. On 7/7/25 at 2:58 p.m., during a follow-up interview, CNA-M #3 stated she worked here as an agency staff member from December 2024-June 2025, and typically, residents have the red and white Stop signs hanging outside the door but no signage is posted indicating what type of precautions the resident is on, and if a resident on precautions, a trash can and a 3-drawer bin with gowns and gloves is placed outside the door. CNA-M #3 then stated residents with Foley catheters or wounds are not placed on EBP and that there are no residents on the [NAME] unit on EBP or TBP but she knows Resident #14 has a foot wound and Resident #7 has a Foley catheter. 4. Review of Resident #14's clinical record indicated Resident #14 has a right lateral midfoot diabetic ulcer. Further record review revealed an active physician order for Right lateral foot Cleanse wound for at least 1 minute Apply Medihoney to wound bed .Apply Mepilex .Dressing change daily . On 7/8/25 at 8:30 a.m., a surveyor entered Resident #7 and Resident #14's shared room, and there was no Stop sign or other signage on the door and no PPE outside or inside the room. At this time, Resident #7 stated he/ she has a Foley catheter, and when the Certified Nursing Assistants (CNAs) empty the drainage bag or the nurses change the catheter, they wear gloves but he/she has not noticed anyone wearing a gown or other PPE. On 7/8/25 at 1:08 p.m.-1:45 p.m., during an interview, the above concerns were discussed with the DON and Infection Preventionist (IP), and the DON stated Stop signs are placed outside a resident's door but no signage indicating what type of precautions or what type of PPE is required is placed on the resident's door. The surveyor asked how new staff are educated on infection control upon hire, as CNA #1, CAN-M #3, and RN #2 were day 1 staff on the [NAME] unit yesterday and could not tell a surveyor the location of PPE or if residents were on precautions and what type. The DON then stated Infection Control education is provided as part of a comprehensive orientation, but that does not take place on day 1 and is provided within the first week of employment. At this time, a surveyor requested additional evidence of the facility's ongoing surveillance and tracking for EBP and TBP and evidence of staff education on infection control measures. Review of the provided Educational Program Sign-In Sheet .Topic: Infection Control Enhanced Barrier Precautions, dated 6/24/25 indicates 23 staff members attended, and of those, only 9 were nursing staff (8 CNAs, IP). Review of the provided f Enhanced Barrier Precautions surveillance census was dated 7/9/25 (after survey start date) and indicates 10 residents in the facility are on EBP. The census did not indicate Resident #14 and Resident #47 were on precautions, despite a surveyor previously discussing this with the DON and IP.On 7/9/25, at 12:03 p.m., during a follow-up interview with the DON, a surveyor discussed concern with recent EBP education only including 9 nursing staff and no evidence of EBP/TBP surveillance prior to the survey. The DON stated she posts a monthly calendar of mandatory annual training offerings, but if all required staff does not attend, she posts another calendar the following month offering the training again. At this time the DON confirmed the facility did not have ongoing EBP and TBP surveillance, tracking, and education in place. 5. Review of policy, Legionnaires Prevention Program Policy, dated 7/19, states, .Establish a water management team .The following employees will be on the Water Management Team . The Administrator .The Infection Control Specialist .The Maintenance Director .Corporate Plant Manager .Describe Your Building Water Systems Using a Flow Diagram .Identify Areas Where Legionella Could Grow & Spread on the flow diagram .Decide where Control Measures should be applied & how to monitor them .You will need to monitor to ensure your control measures are performing as designed Staff, residents and their representatives will be informed of the in place to keep the building water systems safe. A copy of the plan will be shared upon request . Further review of the policy lacked evidence of the description of the water system or a flow diagram and did not specify control measures or how the control measures are being monitored.On 7/8/25 at 1:08 p.m., during an interview with the Director of Nursing (DON) and Infection Preventionist (IP), a surveyor requested evidence of the facility's water management program. The DON stated she had asked the Administrator about water testing but could not provide a written plan.On 7/9/25 at 2:01 p.m., during a follow-up interview and after multiple surveyor requests, the DON stated she could not provide evidence of the facility's Legionella Water Management Program.

Based on facility policy, record review, and interview, the facility failed to notify the State Agency after potential abuse concerns were identified, failed to investigate allegations of potential abuse, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 4 incidents reviewed for abuseFacility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property last revised 10/2018 states Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. Under Section E: Investigation, Subsection A. Investigation of Abuse When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with assistance of appropriate personnel. The investigation will include: who was involved .resident statements . For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident. Complete an evaluation of resident behavior, affect and response to interaction, and documentation . Resident's roommate statements .involved staff and witness statements of events .A description of the resident's behavior and environment at the time of the incident . Injuries present including a resident assessment . Observation of resident and staff behaviors during the investigation .Environmental considerations. On 8/21/24 the Division of Licensing and Certification received a facility reported incident in which a Certified Nursing Assistant (CNA) #4 reported by way of a written letter on 8/19/24, that on 8/18/24 she witnessed the following: between 8:30 a.m. to 9:00 a.m., CNA #5 brushed Resident #31's hair, did not stop when he/she stated ouch. CNA #4 stated you are hurting him/her be easy, CNA #5 then stated, watch this and brushed Resident #31's hair again causing the resident more pain. CNA #5 proceeded to laugh and apply blue hair dye to the ends of Resident #31's hair. When the resident left the area, CNA #5 stated I don't like him/her. Around 12:30 p.m.- 12:45 p.m., CNA #4 observed CNA #5 transfer Resident #25 to his/her bed with a stand and pivot machine, the bed was not at appropriate level at the time, causing the resident to cry out in pain upon transfer. Per the letter Resident #25 voiced he/she did not want CNA #5 to provide him/her care. CNA#5 proceeded to climb into bed with Resident #25 and lay down with him/her. Resident #25 proceeded to freak even more stating get away from me and don't touch me. Resident #25 then attempted to hit CNA #5, but the CNA grabbed the resident's hand and proceeded to move it like a car shifter. CNA #4 told CNA #5 to leave the room, CNA#5 got up out of the bed and took the residents glasses away. Around 12:50 p.m.- 1:00 p.m., CNA #4 and CNA #5 were getting Resident #4 changed in bed. Resident #4 rolled toward CNA #5 and hit his leg, CNA #5 stated don't touch my privates. Resident #4 stated he/she did not touch him there and felt CNA #5 was upset with him/her. CNA #4 needed to provide reassurance. Review of the facility investigation lacked evidence that the abuse allegations were reported immediately by CNA #4, the facility failed to report the allegations of abuse to the State Agency within 24 hours, failed to conduct a thorough investigation, and failed to report the results of the investigation within 5 days of the incident. On 7/8/25 at 9:20 a.m., during an interview, the above information was confirmed with the Director of Nursing.

Based on record review and interviews, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 1 sampled resident reviewed for PASRR (Resident #14).Review of Resident #14's Minimum Data Set 3.0 (MDS) revealed an Annual Comprehensive Assessment, dated 11/14/24 that indicates an active primary diagnosis of Dementia and an active diagnosis of Post-Traumatic Stress Disorder (PTSD). Resident #14's most recent Quarterly MDS, dated [DATE], also includes an active diagnosis of mood disorder and indicates Resident #14 exhibited Physical behavioral symptoms directed towards others and Verbal behavioral symptoms directed toward others.Resident #14's Care Plan, last reviewed 5/8/25 revealed, . at risk for alteration in thought process r/t [related to] use of psychoactive medication for management of depression, PTSD, and mood d/o [disorder] . and .at risk for anxiety/behaviors, decreased psychosocial well-being and increased isolation related to PTSD, depression, and mood d/o . Further record review revealed a pre-admission Notice of PASRR Level I Screen Outcome, dated 11/15/22, that indicated Level II screening was not required and states, No mental health diagnosis is known or suspected .There are no known mental health behaviors .no known recent or current mental health symptoms . and lacked evidence that a new screen was submitted for the above diagnoses and symptoms. On 7/8/25 at 11:43 a.m., during an interview, the Director of Social Services stated tracking updated diagnoses and behavioral changes is a team approach with the Director of Nursing (DON) and sometimes the MDS Coordinator, and that it is discussed in the facility's daily morning meeting. After reviewing Resident #14's diagnoses, the Director of Social services stated Resident #14 needs an updated PASRR screening and that she does not even recall the resident being discussed for having mental health diagnoses. On 7/8/25 at approximately 12:00 p.m., the above finding was discussed with the DON. At this time, the DON stated Resident #14 does need a new PASRR, and she will initiate the screening.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of respiratory care for 2 of 5 residents reviewed for respiratory needs (#45 and #10) and in the area of accidents for 1 of 1 reviewed for falls (#43).1. Review of Resident #45's medical record stated he/she was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation and obstructive sleep apnea requiring the use of Continuous positive airway pressure (CPAP) machine and nebulizers. The medical record lacked evidence that a comprehensive care plan had been developed in the area of a respiratory to include the use of the CPAP and nebulizer. On 7/8/25 at 10:12 a.m., during an interview the above was discussed with the Director of Nursing 2. On 7/7/25 at 9:27 a.m., a surveyor observed Resident #10 wearing oxygen via nasal cannula with the oxygen concentrator set at 3 liters.On 7/8/25 at 1:07 p.m., a surveyor observed Resident #10 asleep and wearing oxygen via nasal cannula with the oxygen concentrator set at 2.5 liters.A review of Resident #10's medical record revealed a physician's order, dated 8/22/24 for Oxygen (O2) at 2 liters per minute via nasal cannula without humidification. May use as needed for complaints of cluster headaches (effective historically per resident).A review of Resident #10's current care plan, dated 6/23/25, did not include Resident #10's use of oxygen.On 7/8/25 at 1:33 p.m., in an interview with the [NAME] President of Quality Improvement & Nursing Services, the surveyor discussed the observations of Resident #10 and that the care plan did not include the use of oxygen as per physician orders. 3. On 6/26/25 the Department of Licensing received a complaint indicating Resident #43 had a lot of falls and had a fall mat on the wrong side of the bed. Review of Resident #43's medical record included a diagnoses of dementia, vertigo, anxiety, osteoporosis, and a history of fall with fracture. The current care plan last updated on 5/8/25, lacked evidence to include use of a floor mat as an intervention. On 7/7/25 at 1:25 p.m., observation of Resident #43 to have a fall matt on the right side of bed. On 7/7/25 at 3:30 p.m., during an interview, the Director of Nursing confirmed Resident #43 used a fall mat and stated it should be care planned.

Based on observation, record review and interview, the facility failed to ensure a care plan was accurately revised for 1 of 2 residents reviewed for intravenous (IV) antibiotic use and transmission-based precautions (Resident #24).On 7/7/25 at 10:16 a.m., a surveyor observed Resident #24 receiving an IV infusion of the antibiotic Vancomycin. Resident #24 stated he/she had an infection of the right leg and was receiving 2 IV antibiotics. A review of Resident #24's clinical record noted a history of MRSA (methicillin resistant Staphylococcus aureus), a multidrug resistant organism, and recurrent lower extremity cellulitis. The record noted Resident #24 had been treated with IV antibiotics in May, 2025. The record noted on 6/25/25, Resident #24 had a PICC (peripherally inserted central catheter) line placed at the local hospital and was started on IV vancomycin and cefepime. A review of Resident #24's current care plan, last revised on 6/19/25, included the problem area: risk for infection. Resident #24's need for IV antibiotics was not included in the care plan. One intervention stated use standard precautions unless otherwise indicated. On 7/9/25 at 9:30 a.m., a surveyor observed an Enhanced Barrier Precautions sign had been placed on Resident #24's door. This replaced a previous sign which stated see nurse for instructions.On 7/9/25 at 10:00 a.m., in an interview with a surveyor, the Nurse Manager stated Resident #24 frequently receives IV antibiotics for recurrent wound infections.On 7/9/25 at 12:30 p.m., in an interview with the Director of Nursing, the surveyor discussed that the current care plan had not been revised to address Resident #24's need for IV antibiotics. In addition, the care plan instructed staff to use standard precautions, while a sign on the resident's door advised of the need for Enhanced Barrier Precautions. The Director of Nursing confirmed that Contact Precautions were indicated while Resident #24 was being treated for an active infection.

Based on observations, record review, and interviews, the facility failed to ensure that the resident's environment was free of accident hazards by failing to maintain a clutter-free pathway in the resident's room for 1 of 1 sampled resident reviewed for accidents (Resident #14).On 7/7/25 at 9:02 a.m. and 7/8/25 at 8:33 a.m., a surveyor observed a clear plastic bag containing two siderails, located on the floor next to Resident #14's bed, two wheelchair footrests and multiple pairs of shoes on the floor next to Resident #14's recliner, and a pair of shoes on the floor in front of the recliner. A review of Resident #14's most recent Fall Risk Screen, dated 4/30/25, indicated he/she is at high risk for falls. Review of Resident #14's care plan, updated 5/8/25, includes, .at risk for falls .keep environment free from clutter and pathways clear of obstacles, and .frequently incontinent .implement safety measures (keep path to bathroom clear and well lit .), and .ability to see in adequate light is impaired .Keep areas free of obstructions to reduce the risk of falls or injury . On 7/8/25 at 9:48 a.m., a surveyor and the Director of Nursing (DON) observed the siderails, footrests, and shoes on Resident #14's floor. The DON stated Resident #14 gets out of bed and transfers himself/herself to the chair at times and the environment was cluttered.

Based on record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts on 2 of 3 units observed for medication storage (Embden and [NAME] Control log).1.On 7/7/25 at 8:35 a.m. a review of Embden and [NAME] unit control log with Certified Nursing Assistant/Medication Technician (CNA-M) #3 revealed the following: -control log lacked evidence of oncoming signature during the day shift on 7/4/25 at 06:00, on 6/6/25 at 06:00, on 6/10/25 at 06:00, on 6/27/25 at 06:00, on 6/24/25 at 14:00, and on 6/29/25 at 14:00. -control log lacked outgoing signature on 6/27/25 at 18:00, on 6/29/25 at 22:00, on 6/6/25 at 1:30 p.m., on 6/10/25 at14:00, on 6/11/25 at 11:00, on 6/27/25 at 22:00, on 6/30/25 at 18:00, and on 6/29/25 at 22:00.At this time CNA-M #3 stated that everytime the keys are handed over at the end of shift, the incoming and outgoing staff are supposed to sign the narcotic count book.On 7/7/25 at 9:07 a.m., the above was discussed with Director of Nursing

Based on observations, record reviews, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 7/9/25, were implemented/effective. The facility remains non-compliant with deficiencies F0695 (Respiratory Care), F0755 (Pharmacy Services/Procedures/ Pharmacist/Records), and F0880 (Infection Prevention & Control) which were recited at the re-visit survey on 9/9/25.Findings: 1. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0695 for the failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care. The facility's plan of correction for F0695, signed on 8/7/25, indicated that education regarding Cpap, Bipap, oxygen and nebulizer storage will be provided to nursing staff by August 18th, 2025. 2. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0755 for the failure failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts. The facility's plan of correction for F0755, signed on 8/7/25, indicated that Nursing staff education will be provided, education regarding correct counting procedures by August 18th, 2025. The DNS or designee will auditor narcotic count log weekly for 12 weeks. 3. On 07/09/25 during the Long-Term Care Survey process (LTCSP), a deficiency was cited at F0880 for the failure to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to conduct ongoing surveillance, tracking and educations to prevent the spread of Infections, failed to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). The facility's plan of correction for F0880, signed on 8/7/25, indicated that the nursing staff will receive education regarding Enhanced Barrier Precautions (EBP) and correct Personal Protective Equipment (PPE) by August 18, 2025. On review of the education given on 8/7/25, only 20 out of 40 nursing staff received the education. On 9/9/25 at 4:00 p.m., during an exit interview with three surveyors present, the Administrator, the [NAME] President of Clinical Services and the Director of Nursing, a surveyor discussed that the facility lacked evidence that the PoC was fully implemented, that education was provided to staff, and that education was received by staff. Deficient practices were identified at the time of the revisit, after the PoC's anticipated date of compliance.

Based on record review and interview, the facility failed to ensure a resident who had elected to receive a Pneumococcal immunization received the immunization, for 1 of 5 resident records reviewed for immunizations (Resident #25)Review of Resident #25's clinical record revealed a signed Immunization Consent Form, dated 7/24/24, indicating Resident #25's legal representative consented to the Pneumococcal immunization. Further review of the clinical record lacked evidence that Resident #25 received or refused the Pneumococcal immunization.On 7/9/25 at 12:52 p.m., during an interview with two surveyors, the Infection Preventionist stated the Director of Nursing handles immunization tracking. On 7/9/25 at 12:57 p.m., two surveyors reviewed the above findings with the Director of Nursing.

Based on record review and interview, the facility failed to ensure that a resident's choice in the area of bathing was followed for 1 of 3 sampled residents [Resident #1 (R1)]. Finding: On 12/11/24 at 12:30 p.m., during an interview with a surveyor, R1 stated he/she had not been offered a shower since they broke their leg. R1 stated my hair is long overdue for a washing. On 12/11/24, clinical record review indicated R1 fell from a Hoyer lift resulting in a fracture to the left leg on 11/20/24. R1 had a brief interview for mental status (BIMS) score of 15 on 12/2/24, which indicates the resident is cognitively intact. The care plan states, [R1] has a self care deficit related to [Multiple Sclerosis (MS)] as evidenced by residents inability to perform [activities of daily living (ADLs)] without assist. The orthopedic provider signed orders on 12/4/24 stating 1. Continue [left] knee brace, may remove for hygiene and 2. May transfer [from] bed to chair with brace in place as comfort allows. The record lacked evidence that the resident was offered, provided, or refused a shower after 11/20/24. On 12/11/24 at 1:55 p.m., during an interview, a surveyor and the Director of Nursing reviewed R1's clinical record. At this time the surveyor confirmed the above finding.

Based on record review, and interviews, the facility failed to ensure a care plan was updated in order to meet the physical needs of a resident for 1 of 2 residents reviewed during a complaint investigation [Resident #1 (R1)]. Finding: R1 was admitted on [DATE] with a diagnosis of Multiple Sclerosis (MS). On 11/20/24 R1 experienced a fall from a Hoyer lift resulting in a fracture of the left knee. The provider order dated 11/21/24 states wear left knee immobilizer as tolerated. On 12/4/24, the orthopedic physician signed an order stating (1) Continue [left] knee brace, may remove for hygiene. (2) May transfer [from] bed to chair with brace in place as comfort allows. (3) While in chair should have [left] leg supported. (4) Strictly [non weight bearing] on [left] leg. (5) [follow-up] 4 weeks for re-[check] xray. On 12/11/24, review of R1's care plan indicated, [R1] has a self care deficit related to MS as evidenced by residents inability to perform [activities of daily living (ADLs)] without assist. The surveyor was unable to locate a care plan for the management of a left knee fracture or use of a knee immobilizer. On 12/11/24 at 1:55 p.m., during an interview with a surveyor, the Director of Nursing stated the knee immobilizer should be addressed in the care plan. At this time the surveyor confirmed the above finding.

Based on interviews, record reviews, and facility policy, the facility failed to ensure care plans were updated/implemented for 2 of 3 residents reviewed during a complaint investigation. Findings: 1. Resident #1 was admitted to the facility on [DATE], with diagnoses including: history of heart attack; cerebral infarction; hemiplegia and hemiparesis; dysphagia; and morbid (severe) obesity. Review of Resident #1's care plan, updated 5/2/24, states, Interventions: Supervision/assistance is required at meal and snack times. Open all items .cut into small pieces . Review of Resident #1's active orders, dated October 2024, revealed diet order dated 6/14/24 for, Consistent carbohydrate, regular texture, continuous. Further review of Resident #1's clinical record lacked evidence of the need to cut food into small pieces. During an interview with 2 surveyors, on 10/28/24 at 10:41 a.m., Director of Nursing (DON) stated it was her expectation that a resident's care plan should reflect their personal goals and interventions because they are supposed to be individualized. DON further stated that Resident #1 does not have his/her food cut up and is unsure why it's in his/her care plan. At this time, DON reviewed Resident #1's care plan and confirmed his/her care plan was last reviewed on 8/1/24 and should not include cut into small pieces. 2. Resident #2 was admitted to the facility on [DATE], with diagnoses including dementia; dysphagia. Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 4 out of 15, indicating he/she is not cognitively intact. Review of Resident #2's care plan, updated 9/26/24, states, .uses upper dentures (partial)- assist him with cleaning and putting them in daily as tolerated and as needed . During a lunch observation on 10/28/24 at 12:05 p.m., Certified Nursing Assistant (CNA) 1 was observed providing feeding assistance to Resident #2 in the dining room. Resident #2 did not appear to be wearing any dentures. At this time a surveyor asked CNA 1 if Resident #2 was wearing dentures. CNA 1 indicated that Resident #2 was not wearing dentures but knows Resident #2 has them because there's a cup for them in his/her room. CNA 1 stated Resident #2 doesn't really wear them anymore. During an observation of Resident #2's room on 10/28/24 at 3:37 p.m., CNA 2 confirmed that she has never put dentures in for Resident #2. At this time, CNA 2 located an empty denture cup labeled [Resident #2] in a drawer by the sink. During an interview with 2 surveyors on 10/28/24 at 3:23 p.m., DON confirmed Resident #2 has not been wearing his/her dentures for a while and will ensure the care plan is updated appropriately. Review of facility policy, Comprehensive Person-Centered Care Planning, dated January 2019, states, The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with Resident Rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs .

Based on facility policy, record review, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 6 of 6 residents reviewed for advanced directives (Resident's #7, #23, #27, #39, #304 and #306). Findings: Review of facility policy Advanced Directive Policy and Procedure dated 10/18 states POLICY .Upon admission, the facility will inform and provide the resident/and/or resident's representative with information about advanced directive. PROCEDURE: Upon admission, identify if the resident has an advance directive and if not, determine if the resident wished to formulate an advance directive . All advance directive document copies will be obtained and located in the resident's medical record . 1. Resident #7 was admitted to facility on 3/5/19 with diagnoses to include multiple sclerosis. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) of 14 of 15 indicating he/she is cognitively intact. Review of Resident 7's clinical record lacked evidence that the facility provided resident/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 4/17/24 at 9:00 a.m. Resident #7 indicated that he/she doesn't remember ever being asked or offered an advanced directive. 2. Resident #23 was admitted to facility on 7/18/23 with diagnoses to include cerebral infarction, morbid obesity and the presence of a cardiac pacemaker. Review of Resident 23's clinical record lacked evidence that the facility provided resident/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 4/17/24 at 9:30 a.m., Resident #23 indicated that he/she doesn't remember ever being asked any questions regarding an advanced directive. 3. Resident #27 was admitted on [DATE] with diagnoses to include vascular dementia, and depression. Review of admission MDS dated [DATE] revealed Resident #27 had a BIMS of 5 of 15 indicating that he/she is cognitively impaired. Review of Resident #27's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 4. Resident #39 was admitted to the facility on [DATE] with diagnoses to include multiple myeloma, and atrial fibrillation. Review of quarterly MDS dated [DATE] revealed Resident #39 had a BIMS of 14 of 15 indicating he/she is cognitively intact. Review of Resident #39's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 5. Resident #304 was admitted on [DATE] with diagnosis to include diabetes mellitus, major depressive disorder, and post-traumatic stress. Review of admission MDS dated [DATE] revealed Resident #304 had a BIMS of 4 of 15 indicating he/she is cognitively impaired. Review of Resident #304's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. 6. Resident #306 was admitted on [DATE] with diagnosis to include anxiety, and history of stroke. Review of admission MDS dated [DATE] revealed Resident #306 had a BIMS of 15 of 15 indicating he/she is cognitively intact. Review of Resident #306's clinical record lacked evidence that he/she was offered/refused the opportunity to formulate an advanced directive upon his/her admission. During an interview on 4/17/23 at 12:15 p.m., Resident #306 stated that he/she could not recall being asked or offered an advanced directive. On 4/16/24 at 12:56 and 4/17/24 at 8:14 a.m., during an interview, the Licensed Social Worker confirmed the clinical records lacked evidence the above residents were offered/refused the opportunity to formulate an advanced directive upon his/her admission. On 4/17/24 at 10:54 a.m., during an interview the above was discussed with the Director of Nursing. 37440 Surveyor: [NAME], [NAME] L 42531

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for the 3 of 4 units (Lakewood, [NAME] Chase [NAME] and [NAME]), a common area and the Laundry room for 1 of 1 facility tours (4/18/24). Findings: On 4/18/24 from 8:40 a.m. to 9:00 a.m., a surveyor, the Administrator, the Maintenance Director and the District Manager for Health Care Services conducted a tour of the facility in which the following findings were observed: Lakewood - Resident room [ROOM NUMBER] (bed 2) - The wallpaper was peeling on the wall underneath the overhead bed light and next to the floor by the head of the bed. [NAME] Chase [NAME] - Resident room [ROOM NUMBER] - The wall, by the bed on the right side of the room, was marred and had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The walls by the sink were marred and had chipped/missing paint, the drawers had chipped laminate and the bathroom wooden hand rail had a worn surface exposing untreated wood all of which created uncleanable surfaces. [NAME] Unit - Resident room [ROOM NUMBER] - The bathroom electric wall heating unit had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The bathroom electric wall heating unit had chipped/missing paint creating an uncleanable surface. Nurse's station (common area) - The corner of the Nurse's station, facing the hallway, had a missing/broken piece of laminate near the bottom. Laundry Room - The cement floor had chipped/missing paint creating an uncleanable surface. - There were approximately 10 broken/cracked floor tiles. - The wooden shelving, under the stored chemicals and chemicals in use behind the washing machines, had chipped/ missing paint creating uncleanable surfaces. On 4/18/24 at 9:00 a.m., in an interview, the Administrator, the Maintenance Director, and the District Manager of Health Care Services confirmed the findings.

Based on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions in the areas of enteral feeding (Resident #37), and mobility (Resident #41) for 2 of 14 care plans reviewed. Findings: Review of facility policy Comprehensive Person-Centered Care Planning dated 1/19 states The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with Residents Rights, which includes measurable objectives and timeframes to meet a residents medical nursing, mental, and psychosocial needs . Review of facility policy Vital Signs/Height And Weight Measurements Policy last revised 3/19 states: Procedure: B. Weights will be obtained weekly and documented for the first four weeks after admission (to obtain a baseline) and on a monthly basis unless otherwise ordered by the resident's physician . E. A weight that indicates a variance of +/-3 lbs. from the last obtained weight will necessitate a re-weigh of the resident. a. The original and 2nd weight should be obtained on the same shift and documented. F. The charge nurse will be made aware of the differences in the resident's weight. G. The weight loss/gain will be discussed with the Nutrition and Food Services Director for further dietary interventions. 1. Resident #37 was admitted to facility on 3/6/23 with diagnoses to include amyotrophic lateral sclerosis and peripheral vascular disease. A physician order instructs nursing staff to obtain Weight 2 Times Weekly. The residents current care plan, last reviewed and updated on 2/14/24, states Obtain and document weight as ordered (report a loss or gain greater than 3 pounds to provider and dietician). Adjust tube feeding order as needed. A review of the documented weights reveal the following weighs gains/losses +/- 3 pounds(lbs.): On 2/12/24 weight was 159.50. On 2/16/24 weight was 147.80(11.7 lbs. weight loss and no re-weigh of resident). On 2/22/24 weight was 157.60(9.8 lbs. weight gain and no re-weigh of resident). On 2/26/24 weight was 154.40(3.2 lbs. weight loss and no re-weigh of resident). On 4/1/24 weight was 158.60. On 4/4/24 weight was 150.70(7.9 lbs. weight loss and no re-weigh of resident). On 4/8/24 weight was 157.80( 7.10 lbs. weight gain and no re-weigh of resident). On 4/18/24 at 11:34 a.m., in an interview, the Director of Nursing confirmed that the facility did not implement Resident #37's care plan for weights as written and that he/she was not re-weighed as the facility policy stated. 2. On 4/16/24 at 7:26 a.m., during an interview, Resident #41 stated I don't get my walking, nobody walks me. Surveyor asked if he/she is walked daily, Resident #41 stated, they say but they don't . I can walk by myself, but they don't let me. On 4/16/24 at 12:26 p.m., Resident #41 was observed eating lunch in his/her bedroom. On 4/17/24 at 8:16 a.m., Resident #41 was again observed in his/her bedroom with a breakfast tray on the table. At this time, the resident stated that he/she always eats in his/her bedroom. Review of Resident #41's Activities of Daily Living (ADL) care plan initiated on 5/12/23 states, Restorative Nursing Program(RNP), Ambulation Deficits: [Resident] will maintain his/her ability to ambulate at least 160ft, two times per day with interventions of RNP Walk: Use gait belt, front-wheeled walker, verbal cues and contact guard assist x1. Further, review of the ADL verification worksheet documentation for walking from 2/1/24- 4/16/24, (79 day period), indicated on 25 days the resident was not walked and on 39 days the resident was only walked once a day. On 4/17/24 at 8:22 a.m., during an interview, the Director of Nursing (DON) stated, since COVID they do not have RNP program and no longer have a RNP aid but have started a walking program, Walk to Dining. The DON provided the surveyor with a list of residents who participate in the Walk to Dining program which included Resident #41. On 4/17/24 at 10:13 a.m. during an interview, the facilities Operation Education Coordinator confirmed Resident #41 is not participating in the walk to dining program and has not been walked twice a day as per the individualized care plan. 37440 37648

Based on interviews, record review and facility policy, the facility failed to provide residents with a continuous resident centered activities program for 3 of 4 residents reviewed for activity participation. (Resident's #12, #16, and #47). Findings: Review of facility policy Activities undated states .Activities Calendar: This is done monthly and posted in every room and bedside and beside the dining room door. This will include the daily and weekend scheduled activities and the birthdays for that month Review of activity calendars for June 2023 through April 2024 (11 months), lacked evidence that continuous resident centered activities were held on weekends. Review of Resident #12, #16, and #47's Resident Daily Activities Log dated March and April 2024 lacked evidence that activities were offered/refused on the weekend. During an interview on 4/18/24 at 10:24 a.m., Resident #12 indicated they only have activities on weekends if it's a holiday, because the activity director has no help. During an interview on 4/18/24 at 10:27 a.m., Resident #47 indicated [he/she] would like activities on weekends it gets very boring, During an interview on 4/18/24 at 10:29 a.m., Resident #16 indicated that it really bothers [him/her] that there are no scheduled activities on weekends. During an interview on 4/18/24 at 10:30 a.m., the Activity Director confirmed that there were no continuously scheduled activities on the weekends. During an interview on 4/18/24 at 10:45 a.m., the above was discussed with the Director of Nursing.

Based on record reviews and interviews, the facility failed to implement the United States Centers for Disease Control (US CDC) and the Centers for Medicare and Medicaid Services (CMS) recommendations and guidance related to staff who presented with symptoms of Coronavirus Disease 2019 (COVID-19) and failed to have a system in place for the monitoring of symptoms reported during the screening process. These failures contributed to an outbreak of COVID-19 affecting five (5) residents and four (4) staff as of 8/25/2020 and having the potential to affect the remaining thirty-seven (37) residents. It was determined the facility's failures constituted an immediate jeopardy (IJ) situation beginning on 8/11/2020. Findings: On 8/21/2020, the Division of Licensing and Certification was made aware of an outbreak of COVID-19. An on-site investigation was initiated. On 8/25/2020 at 9:30 a.m., the Director of Nursing (DNS), who is the facility's Infection Preventionist, stated the facility had four (4) residents and two (2) staff who were positive for COVID-19. The facility's COVID-19 [DIAGNOSES REDACTED]-CoV-2 Pandemic plan, last updated May 2020, indicated the following: - In Section 2: Interim Policy - COVID 19: Employees who develop symptoms to COVID-19 (fever, cough, shortness of breath or sore throat) will be referred to public health authorities (their PCP, or to Occupational Health Provider (if exposed while at work) for testing, medical evaluation recommendations and return to work instructions - In Section 4: Surveillance and Monitoring: The Symptom Surveillance (for Respiratory Illness ex.: Covid-19) provides a template for data collection and active monitoring of both visitors and staff during a suspected respiratory illness cluster or outbreak, in the community, at a nursing home or at other LTC facilities of which, shared staff is used, as indicated. Using this tool will provide facilities with a line listing of all individuals monitored for the symptoms of the outbreak illness. Each row represents an individual visitor or staff member who may have signs or symptoms of the outbreak illness. The information in the columns of the worksheet capture data on the person, locations of where they have been (in other facilities), clinical signs/symptoms, and outcomes.; Information gathered on the worksheet is used to determine if visitors or employees are to be excluded from entering the facility (for a specified time period) during this outbreak illness.; and The Director of Nursing Services, or designee, has been assigned responsibility for the overall surveillance and detection of any signs and symptoms of Covid-19 in residents and/or staff. The US CDC's Preparing for COVID-19 in Nursing Homes, updated 6/25/2020, states, under the section Evaluate and Manage Healthcare Personnel, screen all HCP (Health Care Personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. The CMS's Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memo, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revised 3/13/2020, states Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. The facility's Daily Employee/Visitor Screening Log form was reviewed and indicated the following: - If an employee or visitor has one of the following symptoms, they fail the screening: a cough, difficulty breathing, or new shortness of breath; or - If an employee or visitor has two of the following symptoms, they fail the screening: fever greater than 100 degrees Fahrenheit (F), loss of sense of smell or taste, new muscle aches or soreness not from exercise, repeated shaking with chills, sore throat, or headache. The Daily Employee/Visitor Screening Log, dated 8/11/2020, indicated that CNA #1 answered Yes to 4 of the symptoms (cough, new muscle aches or soreness not from exercise, repeated shaking with chills, and sore throat). Based on these symptoms, CNA #1 failed the screening process, therefore, should not work per the CDC and CMS recommendations and guidance. The staffing schedule stated CNA #1 worked from 8:00 p.m. on 8/11/2020 to 6:00 a.m. on 8/12/2020. On 8/25/202 at 9:30 a.m. the DNS was interviewed and stated the following: - On 8/12/2020, CNA #1 called and informed her, that she had been exposed to persons who were positive for COVID-19. The DNS removed CNA #1 from the schedule and instructed the CNA to have COVID-19 testing. On 8/18/2020 CNA #1 test results confirmed that CNA was positive for Covid-19. The facility uses the US CDC and the Maine CDC for guidance in screening and management of COVID-19, and that staff screening logs are reviewed by her, Administrator and Charge Nurses. On 8/25/2020 at 6:14 p.m., the DON sent the surveyor a LTC Respiratory Surveillance Line List, which identified CNA #1 as the first staff confirmed with COVID-19. On 8/27/2020 at 4:44 p.m., the Charge Nurse who worked on 8/11/2020 was interviewed via telephone, and stated the following: - CNA#1 did not indicate she had any Covid-19 symptoms and did not indicate she was not feeling well; - She did not notice a cough, but she (meaning CNA#1) had that for some time; - I do not look at them (meaning the Daily Employee/Visitor Screening Log form). It is a self tool. Everyone know it's their responsibility to let the Charge Nurse if they are not feeling well; and - As far as I know, there's nobody looking at the screening tools. Nobody had ever checked it on my shift, and nobody has checked mine. Maybe the DNS does it. I don't know. Based on the above information, it was determined that the facility's failure to ensure CNA #1 did not work after reporting symptoms of COVID-19 and to have a system in place for the monitoring of symptoms reported during screening procedures constituted an immediate jeopardy. Please see F000 Initial Comments for details related to the IJ template, removal plan and abatement of the IJ.

Based on record review, observations and interviews the facility failed to ensure the environment was free from potential accident hazards, when the wrong type of sling/pad was used during a total assist transfer, resulting in a resident (#1) falling to the floor and sustaining skin tears while using 1 of 3 mechanical lifts observed during a complaint survey. Findings: On 04/12/14 at 3:15 p.m., a resident fell from a mechanical lift during a transfer when two; Certified Nursing Aids (CNA) used the wrong type of sling/pad which was not intended for use with the particular mechanical lift involved. Resident # (1) On 04/14/14 one of the CNAs involved in the transfer, documented in a written statement that he/she was using the wrong type of sling/pad resulting in the resident falling to the floor. On 09/24/14 at 4:29 p.m., a surveyor was informed in a telephone interview with the Licensed Practical Nurse (LPN) who was on duty at the time of the incident, dated 04/12/14, that the CNA staff used the wrong type of sling/pad for the mechanical lift transfer. The LPN stated "The sling/pad used was a Sit to Stand sling/pad and was the wrong type of sling/pad." On 09/25/14 at 10:15 a.m., a surveyor identified in an interview with the Administrator, the mechanical lift that was used during the incident, dated 04/12/14, as an Ultralift 2500X Electric Patient Lifter. The Ultralift 2500X Electric Operating Instructing Manual indicates on page # 18, the approved types of sling/pads recommended for use. Also on page #18 the warning label indicates "Attaching improper items to the lift can cause injury. Use only T.H.E. Medical approved items on the lift." On 09/25/14 at 10:25 a.m., in an interview and observation with the Licensed Practical Nurse who was on duty at the time of the incident, dated 04/12/14, the sling/pad used during the incident was identified as a Medium/Yellow Sit to Stand Lift Pad manufactured by Sunrise Medical Inc. On 09/25/14 at 12:30 p.m., the above findings were discussed and confirmed in an interview with the Administrator and the Director of Nurses. .