Every finding on record at Marshall Health Care And Rehab

Based on record review, review of the facility's Abuse Policy and Procedure and interview, the facility failed to report an injury of unknown origin to the State Agency for 1 of 4 sampled resident who had an injury of unknown origin. On 8/19/25, a review of R1's clinical record was completed. Documentation indicated R1 has many diagnoses including mental health issues, dementia and cognitive impairments. Documentation in a nurse's note dated 7/24/25, indicted that in the early evening R1 told a staff member that they had injured their finger. When asked what happened, R1 told the nurse it happened from a fall.On 8/19/25 at 9:45 a.m., in an interview with Certified Nurse Assistant #1 (CNA1), she stated the resident told her it happened when she fell, but did not know where or when. CNA1 stated the resident is not reliable in what he/she says. CNA1 stated the resident has behavior problems and could have hurt her finger in a number of different ways. A review of the facility's Abuse Policy and Procedure indicated under the Section: Reporting Allegations to the Administrator and Authorities: #1 If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown origin source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law.#2 The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency.On 8/19/25 at 10:45 a.m. in an interview with the surveyor, the Administrator and the Assistant Director of Nursing (ADON) stated R1 has impaired cognition and mental health diagnoses. The ADON stated when they were notified of the incident, they were told that the resident said she fell out of bed. The ADON stated it was an unwitnessed fall with injury. The resident is a poor historian, and it could have been a fall or something else could have caused the injury. The Administrator confirmed that the resident's recall of events could be unreliable, and the injury was of unknown origin and should have been reported to the State Agency.

Based on record review and interviews, the facility failed to monitor and adequately treat 1 of 2 residents (Resident #255 [R255]) reviewed for Skin Conditions, when the facility failed to follow discharge orders for the use of a diuretic medication (a medication used to treat fluid retention [edema] associated with conditions such as heart failure), obtain and monitor daily weights, and failed to report a potentially significant weight gain. These failures resulted in harm to R255 who required hospitalization for the treatment of worsening signs and symptoms of diastolic congestive heart failure. Findings: On 6/26/25, review of R255's clinical record indicated the following: R255 has an active diagnosis of heart failure, and hypertensive heart disease with heart failure, and R255 had a Brief Interview for Mental Status (BIMS) score of 4 (indicates severe cognitive impairment). The hospital discharge instructions were signed into use for admission orders but not dated (See F711). The discharge instructions identified under Assessment and Plan, [Diastolic Congestive Heart Failure (D-CHF)] as chronic, stable - no exacerbation . [continue (cont)] home Lasix, [Potassium Chloride (KCL)]. Under the Special Instructions heading, directed the provider to be notified of the following signs/symptoms, increased difficulty breathing, Weight gain or low of 3 pounds on two consecutive days, and Swelling in your ankle of feet. The clinical record lacks evidence that the home Lasix (a medication used to treat fluid retention [edema] associated with conditions such as heart failure) was continued as directed. On 6/5/25 at 2:57 p.m., R255's admission weight was 164.1 pounds (Lbs). On 6/6/25, doctor's orders indicated, OBTAIN WEIGHT DAILY - notify [Doctor of Medicine (MD)] of weight gain or loss of 3 pounds on 2 consecutive days, one time a day for Monitoring obtain weight daily notify MD of weight gain or loss of 3 pounds on 2 consecutive days, with a start date of 06/07/2025. On 6/6/25 at 2:35 p.m., a skilled evaluation note indicated R255's Skin warm and pink . No edema present and No signs of difficulty breathing, Right lung clear, Left lung clear. The clinical record lacks evidence that a daily weight was obtained. On 6/10/25 at 11:12 a.m., R255 weighed 163.6 Lbs. The clinical record lacked evidence that R255 was weighed on 6/6/25, 6/7/25, 6/8/25, or 6/9/25 (4 days). On 6/14/25, the MD had a scheduled visit with R255 and indicated R255 was receiving furosemide (Lasix) 40 milligrams (mg) once daily. The clinical record lacked evidence that the MD addressed R255's heart failure or reviewed the total program of care at that time (See F711). The record lacks evidence that R255 received furosemide as indicated in the discharge instructions or the MD's note. On 6/19/25 at 12:05 p.m., a skilled evaluation note identified a new onset of non-pitting edema of both feet dependent on R255's position, and No signs of difficulty breathing, No shortness of breath noted, Right lung clear. Left lung clear. The clinical record lacked evidence that R255's weight was obtained on 6/11/25, 6/12/25, 6/13/25, 6/14/25, 6/15/25, 6/16/25, 6/17/25, 6/18/25, or 6/19/25 (9 days). On 6/24/25 at 1:43 p.m., R255 weighed 175.6 Lbs. At 3:32 p.m., a skilled evaluation note identified, non-pitting edema of both feet dependent on R255's position, and No signs of difficulty breathing, No shortness of breath noted. At 5:02 p.m., a health status note indicated [R255's] lower legs have +3 [pitting] edema noted. resident stated that it has been chronic. There is no evidence that the provider was notified of the 12 Lbs weight gain or the new onset of pitting edema, and the record lacked evidence that R255's weight was obtained on 6/20/25, 6/21/25, 6/22/25, or 6/23/25 (13 consecutive days from 6/11/25-6/23/25). On 6/26/25 at 10:29 a.m., a health status note indicated, [R255] was assessed at 1030, [R255] had new onset pitting edema in bilateral lower extremities, [shortness of breath (SOB)], wheezing in upper lobes, and new onset heart murmur. Physician contacted and order to send to [Down East Community Hospital ([NAME])] for evaluation and treatment. Ambulance arrived and resident was taken from facility at 1050 to [NAME]. On 6/26/25 at 3:08 p.m., during an interview with a surveyor and the Unit/Nurse Manager (U/NM), R255's medical record was reviewed. The U/NM stated that she reviewed the discharge instructions with the MD by phone and was directed to follow the discharge instructions completely. She pointed to the direction: OBTAIN WEIGHT DAILY - notify [Doctor of Medicine (MD)] of weight gain or loss of 3 pounds on 2 consecutive days, one time a day for Monitoring obtain weight daily notify MD of weight gain or loss of 3 pounds on 2 consecutive days, and stated this is why she entered the order for daily weights. She stated she followed the discharge medication list for orders as directed by the provider, but the list was handwritten because the hospital's computer systems were down. The order to continue home Lasix was on another page of the discharge instruction packet and not included on the medication list page. At 3:20 p.m., during an interview with a surveyor and U/NM, the MD note dated 6/14/25 was reviewed. U/NM stated the medication list in the note is reviewed and auto populated from the provider's office not from the facility and the provider may not know the resident was not on the furosemide (Lasix) due to a conflict in the computer systems. At this time the surveyor confirmed R255 was not receiving furosemide (Lasix) as ordered in the discharge instructions or as identified by the MD note, that the R255's weights were not obtained for 19 out of 22 days, that the provider was not notified of a 12 pound weight gain, and that R255 was hospitalized due to signs and symptoms of worsening congestive heart failure.

Based on record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, ensure orders were complete, signed and dated for 2 of 4 residents reviewed under the general pathway (Resident #6 [R6] and [R255]). Findings: 1. On 12/27/24, a telephone order for R6 indicated, Update loperamide [a diarrhea medication] order to recommended dosage. This order was incomplete, signed by the provider, but not dated by the provider. A second telephone order indicated Give ½ of Resource juice [with (w/)] meds [twice a day (BID)]. The provider signed but did not date the order. On 6/26/25 at 9:18 a.m., during an interview with a surveyor and the Director of Nursing (DON), R6's medical record was reviewed. The DON stated the loperamide order was placed after pharmacy requested clarification. At this time the surveyor confirmed the order was incomplete, and the provider signed but did not date a total of 11 telephone orders over the past 6 months (12/27/24 (2 separate orders), 12/4/24 (2 separate orders), 12/2/24, 11/30/24, 11/25/24, 11/23/24, 11/22/24, 11/20/24, and 11/19/24). 2. On 6/5/25, R255's discharge instructions indicated under the Assessment and Plan: 1. Left Hip Fracture after mechanical fall, pain controlled with current medication. 2. Hypothyroid, chronic, stable, continue with current medication. 3. Diastolic Congestive Heart Failure (D-CHF), chronic, stable, continue home Lasix. Special Instructions directed to notify the provider for increased difficulty breathing, weight gain or loss of 3 pounds on two consecutive days, and/or swelling of the ankles or feet. These orders were signed by the facility's provider but not dated. The clinical record lacked evidence that the home Lasix was continued in the facility, or that the daily weights were monitored (See F684). On 6/14/25, a provider note addressed R255's Hip Fracture, and directed continue current medications, management, and physical therapy. The provider note also indicated R255 was currently prescribed Furosemide (Lasix). The provider note did not address R255's Diastolic Heart Failure for monitoring or management. On 6/26/25 at 3:20 p.m., during an interview with a surveyor and Unit/Nurse Manager (U/NM), the provider note dated 6/14/25 was reviewed. U/NM stated the medication list in the note is reviewed and auto populated from the provider's office not from the facility and the provider may not know the resident was not on the furosemide (Lasix) due to a conflict in the computer systems. The provider comes to the facility for assessments but returns to his office offsite for documentation and review. At this time the surveyor confirmed the provider did not review the full plan of care for R255 and did not date the signed orders on admission.

2. On 6/24/25 at 10:04 a.m. during a review of R40's EMAR and nursing progress notes, it was noted that R40 had an order for Tramadol HCl [hydrochloric acid] Oral Tablet 50 milligrams (mg) (medication used to treat moderate to moderately severe chronic pain in adults), Give 50 mg by mouth every 4 hours for pain. The EMAR shows documentation that on 5/26/25 at 4:00 p.m. R40 did not receive his/her dose of Tramadol documented that the medication not available but has been ordered and should be here this p.m On 5/27/25 the EMAR documents that his/her 1200 dose was on hold due to waiting for shipment from pharmacy, and the medications had already shipped so pharmacy unable to give this nurse an override code without emergency prescription sent in from MD (doctor of medicine). There is no evidence in R40's clinical record that an emergency prescription was sent into the pharmacy resulting in R40 missing his/her 1200 dose of Tramadol. On 5/27/2025 at 3:30 p.m., the EMAR documents that R40's 4:00 p.m. dose was not available, the medication was coming from pharmacy that evening, the medication was not available from the Pyxis (medication dispensing machine, emergency medicine supply) because they had no override code. On 6/25/25 at 12:17 p.m. during an interview and record review for R40 with the DON and the Unit/Nurse Manager/ICP, the nursing progress notes show that R40 did miss three doses of Tramadol due to unavailability from pharmacy. And the facilities failure to obtain the medication from their Pyxis, the nursing progress notes documents that the pharmacy would not provide a Pyxis code to the nurse that would allow her to get the Tramadol for R40. The DON stated the pharmacy should have given a code to use the Pyxis for the medication needed and that they did not use a local pharmacy to obtain the medication because Pharmerica (pharmacy) would not send the script over to the local pharmacy due to the medication already scheduled for delivery the night of 5/27/25. At this time the surveyor confirmed that R40 missed 3 doses of his/her tramadol for pain control. Based on record reviews and interview, the facility failed to ensure that physician ordered medications were available for use to meet the needs of the residents for 2 of 5 residents reviewed (Resident #202 [R202], and R40). Findings: 1. On 6/25/25, during a review of R202's electronic medication administration record (EMAR), it was noted that R202 had an order for Dexlansoprazole Oral Capsule Delayed Release 60 MG [milligram] (medication that treats lowers stomach acid). Give 1 capsule by mouth one time a day for GERD [gastroesophageal reflux disease] - Start Date- 06/17/25 09:00 [a.m.]. On 6/17/25 through 6/25/25 the EMAR report shows documentation that on 6/17/25 at 9:00 a.m. through 6/25/25 9:00 a.m. R202 did not receive his/her doses of Dexlansoprazole for a total of 9 missed doses due to being on order, ordered or not available (n/a). R202 had another order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (medication that reduces stomach acid) Give 1 tablet by mouth one time a day for GERD - Start Date- 6/17/24 9:00 a.m. by mouth daily for GERD and R202 did not receive his/her doses of Pantoprazole for a total of 6 missed doses due to being on order, ordered or not available (n/a) on the following days 6/17/25 through 6/20/25, 6/22/25, 6/23/25. On 6/25/25 at 12:14 p.m. in an interview with the Director of Nursing [DON], a surveyor confirmed that R202 missed 9 doses of Dexlansoprazole and 6 doses of Pantoprazole.

Based on observations and interviews, the facility failed to ensure medications were stored properly in two medication storage refrigerators for 2 of 3 medication storage refrigerators reviewed (1 on [NAME] Wing, and 1 on South Wing), failed to ensure that an expired immunization was removed from the supply available for use in 1 of 3 medication storage refrigerators reviewed (West Wing), and failed to monitor medication refrigerator temperatures for 3 of 3 medication storage refrigerators (West Wing Medication refrigerator/freezer, South Wing Immunization refrigerator, and South Wing refrigerator/freezer). Findings: On [DATE] at 8:44 a.m., in an observation and interview with the Unit/Nurse Manager/Infection Control Preventionist (Unit/NM/ICP], a surveyor and the Unit/NM/ICP observed, on the [NAME] Wing, in the medication storage room, significant ice buildup in the dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door) which is inappropriate for storing medications due to temperature fluctuations. The refrigerator contained several medications along with an expired vial of Prevnar 20, 0.5 ml (millimeter) filled syringe (pneumonia vaccine) available for use with an expiration date of [DATE], 43 days past its expiration date. On [DATE] at approximately 8:50 a.m., in an observation and interview with the Unit/NM/ICP, a surveyor and the Unit/NM/ICP observed, on the South Wing, in the medication storage room, significant ice buildup in the dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door) which is inappropriate for storing medications due to temperature fluctuations. The refrigerator contained several medications. On [DATE] at approximately 8:51 a.m., in an observation and interview with the Unit/NM/ICP, a surveyor and Unit/NM/ICP observed, on the South Wing, in the medication storage room, a refrigerator intended to store immunizations lacked evidence that refrigerator temperatures were monitored. On [DATE] at 9:10 a.m., in an observation and interview with the Director of Nursing (DON), a surveyor and DON observed, on the South Wing that the vaccine refrigerator was noted to have an internal temperature reading of 40 degrees Fahrenheit. The DON confirmed that vaccines were kept in the refrigerator for resident use. There was no observed temperature log to ensure that the refrigerator temperatures were being monitored to ensure medications and vaccines were stored at appropriate temperature. On [DATE] at 9:11 a.m., the DON produced a temperature logbook, titled Medication, refrigerator/freezer temperature, Wing South, Month, Jun (June), Year, 2025. The temperature logbook was missing documented temperatures for [DATE] and [DATE], 2 of 25 days. On [DATE] at 9:11 a.m., the DON produced a temperature logbook, titled Immunization, Refrigerator Temperature, Wing South, Month Jun (June), Year 2025. The temperature logbook was missing documented temperatures for [DATE]-[DATE], [DATE]-[DATE], 21 of 25 days. On [DATE] at 9:23 a.m., the DON produced a temperature logbook, titled Medication, Refrigerator/Freezer Temperature, Wing West, Month June, Year 2025. The temperature logbook was missing documented temperatures for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], 6 of 25 days. On [DATE] at 9:25 a.m. in an interview with the DON, a surveyor confirmed the above findings.

Based on observation and interviews, the facility failed to promote care for all residents in a manner that maintains each resident's dignity and respect during repositioning on 1 of 4 survey days (6/23/25), and during breakfast meal service on 1 of 4 survey days (6/26/25). Findings: 1. On 6/23/25 at 12:15 p.m., during a resident observation in the South wing dining room, Resident #38 [R38] was sitting in their wheelchair slouching/sliding out of the wheelchair. a Certified Nursing Assistant (CNA) was observed walking over to R38 and grabbed the pants/waistband of his/her pants and pulled the resident up to a proper sitting position which resulted in R38's pants being pulled up causing their incontinence brief being shifted to the side and bulging in the crotch area. On 6/23/25 at 12:20 p.m., during an interview with the CNA, the surveyor confirmed that using a residents pants as a repositioning tool is a dignity and respect concern, the CNA stated that she should have used a gait belt for repositioning. 2. On 6/26/25 at 8:00 a.m., during a resident observation in the [NAME] wing dining room, two surveyors observed R34 sitting in a wheelchair, positioned in the aisle between 2 tables. R34 looked around watching the other residents eat. R30 pointed out that R34 hasn't eaten to staff and invited R34 to sit at his/her table. At 8:30 a.m., a staff member asked R34 if he/she would like to eat and assisted R34 to sit at R30's table. R34 was served breakfast without silverware, at the time of positioning to table. At 8:37 a.m., staff gave R34 silverware to eat their meal. This was observed and confirmed with the Administrator at the time of the observation.

Based on interview and employee personnel record reviews, the facility failed to implement and maintain an effective training program by failing to ensure that 2 of 5 Certified Nursing Assistant's (CNA) employed, completed training (CNA1 and CNA2). Finding: 1. CNA1 was hired on 6/24/24. A review of CNA1's education record lacked evidence that she received the required in-service trainings for abuse, resident rights and behavioral trainings. On 6/26/25 at 2:27 p.m., during an interview and a record review of CNA1's training with the Business Office Manager she stated that CNA1 has not had the trainings listed above, that she is always calling them to get the trainings done. At this time the surveyor confirmed this finding. 2. On 6/26/25, review of CNA2's employee file indicated the date of hire was 5/2/22. The employee file lacked evidence that CNA2 received annual in-service trainings for communication, resident rights, behavioral health, dementia management, abuse prevention, and/or training to ensure continuing competency of nurse aids for a minimum of 12 hours per year. At 2:49 p.m., during an interview with a surveyor, the Business Office Manager confirmed CNA2 had an annual evaluation but has not completed the annual trainings. At this time the surveyor confirmed this finding.

Based on observations and interviews, the facility failed to ensure that the resident's environment was free of accident hazards regarding water temperatures for 1 of 4 days (6/26/25) and water spills for 4 of 4 days of survey (6/23/25, 6/24/25, 6/25/25, and 6/26/25). Findings: 1. On 6/23/25 at 1:41 p.m., a surveyor observed a fluid puddle in the entry area of the [NAME] wing dining room. The fluid puddle covered the surface of 3 square foot tiles with a trail running along an additional 4 tiles. There were 3 residents observed at the other end of the dining room. At 1:43 p.m., a surveyor observed and confirmed the presence of the fluid puddle with a Dietary Aide. 2. On 6/24/25 at 8:37 a.m., a surveyor observed fluid on the floor in room [ROOM NUMBER] of the [NAME] wing. The fluid extended from the side of the furthest bed in the room to the doorway. Wet shoe prints observed past the spill in the direction of the window. Resident #42 (R42) was observed sitting in bed while eating breakfast. At 8:46 a.m., during an interview with R42, a surveyor observed a staff member walk through the fluid spill to talk to R42 then returned to the hall without addressing the hazard. At 8:53 a.m., a surveyor observed and confirmed with CNA3 the fluid on the floor in room [ROOM NUMBER] [NAME] wing, including the wet shoe prints, created an accident hazard for residents. 3. On 6/25/25 at 8:23 a.m., a surveyor and the Unit/Nurse Manager/Infection Control Preventionist (U/NM/ICP) observed fluid on the floor in the South wing hallway. The fluid extended down the hallway past approximately 6 resident rooms, there were 6 areas of fluid streaks and puddles in the hallway with no staff or wet floor signs to alert residents and staff of the wet floor areas. The surveyor confirmed the presence of the fluid streaks and puddles with the U/NM/ICP at the time of observation, she said it was probably from the floor machine. No staff were observed cleaning the floor at time of observation. 4. On 6/26/25 at 12:02 p.m., two surveyors identified hot water temperatures as follows on the: South Wing: Hallway bathroom at 12:01 p.m. = 121.4 degrees Fahrenheit room [ROOM NUMBER] at 12:06 p.m. = 121.8 degrees Fahrenheit West Wing: room [ROOM NUMBER] at 12:23 p.m. = 120.2 degrees Fahrenheit room [ROOM NUMBER] at 12:27 p.m. = 123.1 degrees Fahrenheit Repeat temperatures with Maintenance Director: room [ROOM NUMBER] at 12:45 p.m. = 125.0 degrees Fahrenheit room [ROOM NUMBER] at 12:50 p.m. = 124.3 degrees Fahrenheit On 6/26/25 at 12:30 p.m., during an interview with a surveyor, the Maintenance Director stated that water temperatures are taken every Monday, and maintenance on the mixing valve is completed every 6 months and is due. The above findings were observed and confirmed with the Maintenance Director at the time of the repeat temperatures.

Based on clinical record reviews and interviews, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 5 of 11 sampled residents (Resident #25 [R25,] R31, R11, R40, R44). Findings: 1. Documentation in R25's clinical record, under the progress notes section, indicates that R25 had a Physician visit on 2/23/24. His/her next Physician visit would have been due on 5/3/24 (this includes a 10-day grace period). Documentation in R25's clinical record indicates that the next Physician visit was completed on 5/31/24 making it 28 days overdue and beyond the 10-day grace period. 2. Documentation in R31 clinical record, under the progress notes section, indicates that R31 had a Physician visit on 2/6/24. His/her next Physician visit would have been due on 5/15/24 (this includes a 10-day grace period). Documentation in R31's clinical record indicates that the next Physician visit was completed on 5/23/24 making it 8 days overdue and beyond the 10-day grace period. On 6/12/24 at 1:00 p.m., during an interview with the RN, ICP/Unit Manager and the Administrator, a surveyor confirmed that the above residents R31 and R25's physician visits were not completed timely. 33242 3. On 6/11/24, Resident #11's clinical record was reviewed and included Physician progress notes for a visit completed on 11/8/23. The next 60-day Physician visit was due by 1/17/24 (including a 10-day grace period) but the resident's next 60-day Physician visit wasn't completed until 2/28/24, 42 days beyond the grace period. The next 60-day Physician visit was due by 5/8/24 (including a 10-day grace period) but the resident's next 60-day Physician visit wasn't completed until 5/24/24, 16 days beyond the grace period. On 6/12/24 at 12:59 p.m., during an interview with RN, ICP/Unit Manager and the Administrator, a surveyor confirmed this finding. The RN ICP/Unit Manager stated she thought they were due every 90 days. 4. On 6/11/24, R40's clinical record was reviewed and indicated that R40 was admitted to the facility on [DATE]. R40's first 30 day Physician visit was completed on 2/8/24 with the next 30 day Physician visit due on 4/18/24 (including a 10-day grace period) but was not completed until 5/24/24, 36 days beyond the grace period. On 6/12/24 at 7:51 a.m., during an interview with the Administrator, a surveyor confirmed this finding. 5. On 6/11/24, R44's clinical record was reviewed with the Director of Nursing and Administrator and included Physician progress notes for a visit completed on 5/19/23. The next 60-day Physician visit was due by 7/28/23 (including a 10-day grace period) but the resident's next 60-day Physician visit wasn't completed until 9/11/23, 42 days beyond the grace period. The next 60-day Physician visit was due by 11/20/23 (including a 10-day grace period) but the resident's next 60-day Physician visit wasn't completed until 12/14/23, 16 days beyond the grace period. The next 60-day Physician visit was due by 2/22/24 (including a 10-day grace period) but the resident's next 60-day Physician visit wasn't completed until 3/13/24, 18 days beyond the grace period. On 6/11/24 at 1:02 p.m., during an interview with the Administrator and Director of Nursing, a surveyor confirmed these findings.

Based on observations and interviews, the facility failed to remove fresh food items and out dated meat timely from the walk in cooler for 1 of 1 initial tours (6/10/24). In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code and failed to ensure that equipment/cabinets were kept clean on 2 of 3 survey days (6/10/24 and 6/11/24). Findings: 1. On 6/10/24 at 11:30 a.m., an initial tour of the kitchen was completed with the Dietary Manager and a surveyor. The following were observed: - In the walk in cooler Cooked Turkey bacon in plastic bag, dated 5/11/24, and 12 heads of celery that had some brown, slimy stalks. The Dietary Manager stated that the bacon was good for 5 days. All items were removed from the stock available for use at the time of observation. A metal cabinet with doors, where dishes were stored, had dirty shelves. A photo was taken of the ice machine air gap for review as equipment needed to be moved in order to properly view. The air gap did not appear to be in compliance in the photo. 2. On 6/11/24 at 8:17 a.m., during an interview with the Maintenance Director, a surveyor reviewed the photo of what appeared to be an improper air gap on the ice machine. On 6/11/24 at 1:50 p.m., two surveyors returned to the kitchen as the Maintenance Director had moved the equipment out of the way so a surveyor could properly observe the ice machine air gap. During this observation, a surveyor confirmed with the Maintenance Director that the air gap was not in compliance and was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm). During this visit to the kitchen, two surveyors also observed dust on the back of the juice machine and on the front of the ice maker with the Dietary Manager.

Based on record review and interview, the facility failed to update a care plan for services outlined on the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings, dated 4/20/23, for 1 of 1 sampled resident (Resident #11 [R11]). Finding: On 06/10/24, R11's clinical record was reviewed and included a PASRR level II determination explanation, dated 4/20/23 that indicated R11 met the State of Maine's definition for serious mental illness due to a diagnosis of bipolar disorder. R11's PASRR indicated that the nursing facility was required to provide: ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. On 6/12/24 at 11:22 a.m., during an interview with a surveyor, the Licensed Social Worker reviewed R11's care plan which did include a care area Mental Wellbeing and mentioned PASRR Level II but she was unable to find an intervention about psychiatrist medication management. The surveyor confirmed this finding during this interview.

Based on record reviews and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 5 of 6 residents reviewed for immunizations (Resident #5 [R] , R18, R2, R39, and R244). Findings: 1. R5 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. 2. R18 was admitted to the facility on [DATE]. The CDC recommendation was to administer one dose of Prevnar 20 which had not been done. 3. R2 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. 4. R39 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. 5. R244 was admitted to the facility on [DATE]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. R244'a pneumococcal vaccination status was reviewed for pneumococcal vaccines that did not include a Prevnar 20 vaccination. On 6/12/24 at 9:45 a.m. in an interview with the Unit Manager-Infection Preventionist and the Director of Nursing, a surveyor confirmed they are not following CDC recommendations and were unaware of the CDC recommendation to review, offer, and administer the Prevnar 20 vaccination.

Based on record review and interview, the facility failed to ensure that the Annual Minimum Data Set (MDS) 3.0 was coded accurately to indicate that a resident had a state Level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 sampled residents reviewed for PASRR (Resident #11 [R11]). Finding: On 6/10/24, R11's clinical record was reviewed. On 4/20/23, R11's PASSR was completed and indicated that R11 qualified for Level II services. Review of R11's Annual MDS, dated [DATE], Section: A1500 was coded to indicate that R11 did not have a Level II PASRR. On 6/12/24 at 8:29 a.m., during an interview with a surveyor, the Licensed Social Worker (LSW) stated that R11 did have a Level II PASRR and that the MDS was coded inaccurately. The surveyor confirmed this finding during this interview.

Based on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 of 1 sampled resident (Resident #11 [R11]). Finding: On 06/10/24, R11's clinical record was reviewed and included a PASRR level II determination explanation, dated 4/20/23 that indicated R11 met the State of Maine's definition for serious mental illness due to a diagnosis of bipolar disorder. R11's PASRR indicated that the nursing facility was required to provide: ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. On 6/12/24 at 11:22 a.m., during an interview with a surveyor, the Licensed Social Worker (LSW) stated that she did not realize that R11's PASRR recommended psychiatric services for medication management and that there was provider available to provide these services. She stated that the Social Worker was responsible to obtain these services and could not find documentation that indicated that these services had been offered or refused.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents that were reviewed for new admissions (Resident #195 [R195]). Finding: R195 was admitted to the facility on [DATE]. R195's diagnosis list included Chronic obstructive pulmonary disease and admission orders included use of oxygen and nebulizer treatments. The baseline care plan lacked evidence for the use/care of these respiratory treatments. On 6/11/24 at 1:18 p.m., during an interview with the Director of Nursing, a surveyor confirmed this finding.

Based on record reviews and interviews, the facility failed to implement a care plan approach in the area of nutrition for 1 of 2 residents reviewed for nutrition (Resident #31 [R31] and failed to develop a care plan for respiratory care for 1 of 2 residents reviewed for oxygen (R195). Findings: 1. On 6/11/24 at 9:15 a.m., during an interview with R31, he/she stated that he/she needed help with meals. R31stated that sometimes after their meals he/she still feels hungry and does not get more food to eat. On 6/11/24 at 10:43 a.m., during record review for R31 his/her record has documentation that shows he/she has had an 8-pound weight loss in a 5-month time span. R31's care plan for nutrition was initiated on 4/23/24 to address swallowing precautions, with an approach that he/she needed dietary staff to provide him/her with pureed meals with large portions with enough calories. Review of R31's diet order slip used by the dietary staff, does not include the large portions for meals. On 6/11/24 at 2:20 p.m., during an interview with the Director of Nursing and the Administrator a surveyor confirmed the above finding. 33242 2. On 6/10/24 at 2:29 p.m., a surveyor observed R195 wearing oxygen via nasal cannula and observed a nebulizer treatment setup in the room on a nightstand. R195's clinical record indicated that the resident was admitted to the facility on [DATE] and the admission orders included use of oxygen and nebulizer treatments. R195's admission minimum data set (MDS) 3.0 care area assessment (CAA) was completed and signed on 6/3/24, making the care plan due to be completed within 7 days thereafter, or 6/10/24. On 6/11/24 at 2:00 p.m., R195's comprehensive care plan was reviewed with the Director of Nursing and the surveyor confirmed that the care plan lacked evidence of a care area and interventions related to R195's respiratory treatments which included the use of oxygen and nebulizer treatments.

Based on observations, interviews, and record review, the facility failed to follow physician orders and care plan for 1 of 4 residents reviewed for weight loss (Resident #40 [R40]). Finding: On 6/10/24, R40's clinical record was reviewed and indicated that on 2/06/24, the resident weighed was 137.4 pounds (lbs) and on 4/30/2024, the resident weighed 126.4 pounds, which was an 8.01 percent loss. R40's physician orders for diet, dated 4/10/24, included carnation instant breakfast (CIB) mixed with thrive supplement, to be provided with breakfast, lunch, and supper, and a physician order, dated 3/6/24, for adaptive equipment-Kennedy cup (light weight, easy to grip with handle, spill proof cup). R40's nutrition care plan, dated 5/8/24, indicated that the staff were to provide all drinks in Kennedy cups and the that a thrive shake was to be provided 3 times a day. On 6/10/24 at 12:40 p.m., a surveyor observed R40 in the dining room, and noticed that there was an empty round cup with a straw poked thru the plastic wrap over the top of the cup on the table by R40, but there was no Kennedy cup. On 6/11/24 at 9:07 a.m., two surveyors observed R40 done eating breakfast, with a large plastic cup with no handles, with some beverage left in the cup. During an interview with two surveyors, the cook, who was in the room because he had plated the breakfast meal from the steam table, was unsure what a Kennedy cup was. The cook had R40's meal slip that identified the adaptive equipment as a Kennedy cup was to be used for R40. On 6/11/24 at 12:40 p.m., during an interview with a surveyor, Certified Nursing Assistant (CNA)1 and CNA2 stated they were unaware that R40 needed a Kennedy cup for beverages. CNA2 stated that R40 did not get her CIB shake at lunch time because the plastic wrap with writing fell into the cup (provided from the kitchen in what was not a Kennedy cup). On 6/11/24 at 12:52 p.m., during an interview with a surveyor, the Dietary Manager stated that the CNA was responsible for transferring the beverages over to the Kennedy cups. The surveyor explained that R40 did not get her shake today because the plastic wrap with writing fell into the beverage and that Kennedy cups were not being used.

Based on observations, record reviews and interviews, the facility failed to provide respiratory care consistent with professional standards of practice by failing to follow physician orders for oxygen administration, failing to date and label oxygen tubing/nebulizer set ups, and/or failing to ensure that respiratory equipment was clean, for 2 of 2 sampled residents (Resident #195 [R195] and R2). Findings: 1. On 6/10/24 at 2:29 p.m,. a surveyor observed R195 wearing oxygen via nasal cannula with the concentrator set at 1.5 liters per minute (LPM). The surveyor also observed a nebulizer treatment setup with neither the oxygen or nebulizer setup dated to indicate when the tubing/setup was last changed and the concentrator filter located on the back of the machine was dusty. On 6/11/24 at 7:55 a.m., a surveyor observed R195 wearing oxygen via nasal cannula with the concentrator set at 1.5 LPM and the concentrator filter was still dusty. A review of R195's clinical record included physician orders included the following: -5/21/24 - apply oxygen at 2 LPM for shortness of breath and/or oxygen saturations of less than 90% and Albuterol Sulfate nebulization solution as needed. The surveyor was unable to find treatments that directed staff to document when the tubing/nebulizer setup was changed and the equipment to be cleaned on the treatment record. On 6/11/24 at 1:18 p.m. the Director of Nursing (DON) and surveyor observed R195 wearing oxygen with the concentrator set at 1.5 LPM, and not the physician ordered 2 LPM. R195 also stated that he/she had to ask for the oxygen tubing to be changed recently because he/she wasn't getting any air out of it. R195 stated that the nebulizer setup was changed this morning. The surveyor also confirmed that the concentrator filter was dirty with the DON at this time. After this observation, the DON stated that she was adding a treatment for R195 to change the tubing setups and clean the filter weekly. 35904 2. On 6/10/24 at 2:27 p.m., a surveyor observed R2 wearing oxygen via nasal cannula and the concentrator filter was dusty. A picture of the dusty filter was taken at this time. On 6/11/24 at 10:21 a.m., a surveyor observed R2 wearing oxygen via nasal cannula and the concentrator filter was dusty. R2's treatment administration (TAR) was reviewed and there are orders for cleaning of the concentrator filters 1 x wk, Tuesday PM (one time per week on Tuesday evenings). On 6/12/24 at approximately 10:00 a.m. during an interview with the Administrator, a surveyor showed the picture of the dusty concentrator, and confirmed that R2's concentrator filter was dusty. The TAR was signed that the concentrator filter was cleaned on 6/4/24 as directed; however, the amount of dust on the filter was not consistent with being cleaned 6 days prior to 6/10/24's observation.

Based on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 4 newly admitted residents reviewed (Residents #40 [R40]). Finding: On 6/12/24, R40's clinical record was reviewed and indicated R40 was admitted to the facility on [DATE]. The Physician signed the admission orders on 2/5/24 and these were in effect for 30 days. The next Physician Orders (block orders), including a 10-day grace period, needed review and the Physician's signature by 3/16/24, but weren't signed until 3/19/24, 3 days late; these orders were in effect for 30 days. The next Physician Orders (block orders), including a 10-day grace period, needed review and the Physician's signature by 4/28/24, but were signed on 5/1/24, 3 days late. On 6/12/24 at 7:51 a.m., a surveyor confirmed with the Administrator that the Physician Orders were signed late.

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 6/12/24, was effective. The Federal citations F712, and F812 were cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 8/13/24. Findings: 1. During the annual Long Term Care survey, dated 6/12/24, a deficiency was cited at F712 for the facilities failure to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission), and wrote a progress note. The facility's POC, dated 6/21/24, stated, Residents #40, #31, #11, #44, and #25's attending physician progress notes have been reviewed, updated, and signed off on per their individual plans of care accordingly. Administrator has provided education to each facility physician individually and reviewed Maine State rules and regulations regarding timeliness and frequency of physician documentation. All residents have the potential to be affected by this practice. To ensure compliance going forward the facility [NAME] Clerk and/or Designee will fax physician documentation, complete in-person runs to physician offices, and conduct follow-up phone calls to physician offices. The facility will also implement regular medical chart audits to ensure completion of documentation. Physician progress notes documentation will be reviewed and reported for compliance during monthly Quality Assurance and Performance Improvement (QAPI) meetings for a full quarter. The Administrator and/or Designee will ultimately be responsible for the process going forward, with the POC completion date of 7/1/24. During the re-visit on 8/13/24, record review revealed the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission), and wrote a progress note. It was determined the same tag F712 would be recited. On 8/13/24 at 3:15 p.m., the above concerns were discussed with the Administrator and Director of Nursing. 2. During the annual Long Term Care survey, dated 6/12/24, a deficiency was cited at F812 for the facilities failure remove fresh food items and outdated meat timely and ensure plumbing fixtures were properly installed to prevent backflow. The facility's POC, dated 6/21/24, stated, All non-servable food items were removed immediately. Metal cabinets, juice machine, and ice machine were also cleaned and sanitized accordingly during survey. The Maintenance Director fixed the ice machine air gap during survey as well. All residents have the potential to be affected by this practice. To ensure compliance going forward weekly sanitization audits of kitchen equipment as well as air gap compliance will be conducted for completeness. If deficient practice is identified throughout the audit process, corrective action will be taken immediately and education will be provided to the appropriate staff members accordingly. Kitchen equipment sanitization as well as air gap compliance will be reviewed and reported during monthly Quality Assurance and Performance Improvement (QAPI) meetings for a full quarter. The Dietary Supervisor and/or Designee will ultimately be responsible for the process going forward with the POC completion date of 7/1/24. During the re-visit on 8/13/24, observations of the kitchen and food storage revealed ongoing concerns regarding removal of food items timely. It was determined the same tag F812 would be recited. On 8/13/24 at 3:15 p.m., the above concerns were discussed with the Administrator and Director of Nursing.

Based on review of the facility's initial report and investigation summary, observations of both an audio and video recording, and photographs, the facility failed to protect three residents from mental abuse and extreme humiliation perpetuated by Certified Nursing Assistant (CNA) #1 for 3 of 3 residents sampled for abuse (Resident #3, #2, and #1). CNA #1 posted, on social media, two photographs of residents not groomed appropriately and with an insulting statement captioned on one of the photographs, an audio recording with CNA #1 making insulting remarks while care was being provided to the resident who can be heard sobbing and calling CNA #1 names, and a short video of a resident who was talking to him/herself while eating. Findings: On 4/13/22, the facility completed a Report a Medical Facility Incident and sent it to the Division of Licensing and Certification. See F583 for reference. On 4/20/22 at 9:40 a.m., during an interview with a CNA #1, the surveyor asked about a photo of Resident #3 and explained it was a photo of Resident #3 sitting on the edge of the bed wearing a shirt and a brief with the words Are you [OBSCENITY] ing crazy written along the lower half of the photo. CNA #1 stated, that must be old, I don't remember that. The surveyor asked about the short six second video of Resident #3 while the resident was eating in his/her room, talking to him/herself and the resident stated your ass out there in that kitchen and CNA #1 stated again, I think that video is old of Resident #3 .that must have been like the first time I worked there. The surveyor asked about a six-minute long audio recording of Resident #2's personal care while Resident #2 was displaying verbal behaviors and sobbing; CNA #1 stated my car was in the garage and CM #3 had been my transportation back and forth to work. I threw my phone in my pocket (we had been talking on messenger) and I didn't know it was recording. The surveyor asked about the photo with Resident #1 was wearing a [NAME] and sitting in bed, bedside table in front of the resident with beverage cups and the resident's lips were glossy and white. CNA #1 stated, - I recall taking that one. We were having a little date and he/she needs help eating. I just remember answering CM #3 back because he/she was asking me what I was doing. On 4/20/22 at 11:45 a.m., Community Member (CM) #1 stated that he/she received two photos, an audio recording, and a video recording from CM #2 who told him/her that he/she had received them from CM #3. CM #1 stated that he/she notifed the facility about them. On 4/20/22 at 5:18 p.m., during a telephone interview with a surveyor, CM #3 stated that CNA #1 had sent him/her these photos and audio and video recording. CM #3 stated, CNA #1 got her CNA at age 17 and we have been receiving photos of residents since she was 17. CM #2 who was also present during this interview but spoken to separately stated that there were a lot more photos sent but CNA #1 just deactivated her (snapchat) account, and the photos are now gone. CM #2 stated that he/she was talking with CM #3 about CNA #1. CM #3 shared with CM #2 the photos, video, and audio and CM #1 overheard them talking and asked for the copies to be sent to him/her. 1. Documentation in Resident #3's clinical record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was dependent on staff for extensive assist with personnel hygiene. It would be reasonable that Resident #3 would be very distraught and emotionally harmed knowing that he/she was violated by the video recording and photograph wearing a brief being shared with others in the community. 2. Documentation in Resident #2's clinical record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was dependent on staff for extensive assist with personnel hygiene. It would be reasonable that Resident #2 would be very distraught and emotionally harmed knowing that he/she was violated by the audio recording shared with others in the community with comments from CNA #1 that stated: the resident needed to be changed, was dirty, and that the resident had hair on his/her face and asking if the resident wanted a beard and stating, let me shave yours off, because you have one. 3. Documentation in Resident #1's annual Minimum Data Set (MDS), dated [DATE], stated that Resident #1 was care planned for dementia/cognitive loss. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was dependent on staff for extensive assist with eating. It would be reasonable that Resident #1 would be very distraught and emotionally harmed knowing that he/she was violated by a photograph of him/her wearing a [NAME] with white glossy lips after eating, shared with others in the community. Resident #3, #2, or #1 did not have the capability to get out of these situations and were under the control of CNA #1. A reasonable and prudent person would suffer [MEDICATION(S)] embarrassment and emotional distress due to lack of control over the situations of these being posted on social media and shared with the public. Based on the results of the facility's investigation of this incident, the following were being done: On 4/19/22 at 11:30 a.m., during an interview with a surveyor, the Administrator stated that she was working on CNA #1's termination paperwork today. On 4/19/22 at 1:15 p.m., during an interview with a surveyor, the Administrator stated, Because of this incident, we will schedule an in-service and go over Cell Phone, Social Media, Resident Rights and Abuse policies with all staff. On 4/20/22, at 8:15 a.m., during an interview with a surveyor, the Administrator stated that she educated the staff that was on yesterday afternoon on the policies. The facility will continue with a goal of 4/29/22 to complete everyone. On 4/20/22 at 8:55 a.m., during an interview with a surveyor, the Director of Nursing stated that CNA #1's last day worked was 4/12/22. Based on the above information, Resident #3, Resident #2, and Resident #1's right to be free from abuse was violated. Please see F-0000 Initial Comments for details related to the IJ template and abatement of the IJ.

Based on interviews, review of recordings and photos, and review of the facility reportable incident, the facility failed to protect and promote resident dignity when photos, audio recording, and video recording were shared with members of the public by a Certified Nursing Assistant (CNA) #1. A reasonable and prudent person would be distraught that his/her dignity was violated and would suffer from embarrassment for 3 of 3 residents sampled for abuse (Resident #3, #2, and #1). Findings: On 4/19/22 at 11:30 a.m., the Administrator shared with a surveyor, two photos, an audio recording and a video recording taken by CNA #1 that was shared with members of the community. On 4/2022 at 9:15 a.m., during an interview with a surveyor, CNA #2 stated that she was helping CNA #1 with Resident #2's care. CNA #2 stated, I never saw CNA #1 with a cell phone, it must have been in her pocket. CNA #2 further stated she was made aware of the audio recording by the front office when they recognized her voice on the recording. On 4/20/22 at 9:40 a.m., during an interview with CNA #1, a surveyor asked about two photos, one audio recording, and one video recording that was shared on Social Media. The following were discussed: 1. The shared photo on social media for Resident #3 consisted of Resident #3 sitting on the edge of the bed, wearing a shirt and a brief with the words Are you [OBSCENITY] ing crazy written along the lower half of the photo. During the interview, CNA #1 stated, that must be old, I don't remember that. The surveyor asked about the short six second video of Resident #3 while the resident was eating in his/her room, talking to him/herself and the resident stated your ass out there in that kitchen and CNA #1 stated again, I think that video is old of Resident #3 .that must have been like the first time I worked there. On 4/20/22 at 10:50 a.m., the Administrator and surveyor, observed in Resident #3's room, the same items that were in the photo. The calendar in the photo was for the month of March 2022, the cards on the bulletin board were still present, the Christmas tree was still displayed on a stand, and the same shirt was in Resident #3's closet. 2. The shared audio on social media consisted of CNA #1 providing personal care with CNA #2 present (who was unaware she was being audio taped) while CNA #1 was providing personal care to Resident #2. Resident #2 was upset, can be heard sobbing, and calling CNA #1 names while using profanities. CNA #1 is overheard calling the resident by name in the audio recording, telling the resident he/she needed to be changed, was dirty, and that the resident had hair on his/her face and asking if the resident wanted a beard and stating let me shave yours off, because you have one. During this interview, CNA #1 stated my car was in the garage and CM #3 had been my transportation back and forth to work. I threw my phone in my pocket (we had been talking on Messenger (social media platform)) and I didn't know it was recording. 3. The shared photo on social media for Resident #1 consisted of CNA #1 and Resident #1 in the resident's room. Resident #1 was sitting in bed, dressed in a johnny, with a bedside table and cups of beverages in front of the resident. The resident's lips were glossy and white in appearance. In the interview, the CNA #1 stated, I recall taking that one. We were having a little date and he/she needs help eating. I just remember answering CM #3 back because he/she was asking me what I was doing. On 4/20/22 at 11:45 a.m., Community Member (CM) #1 stated that he/she received two photos, an audio recording, and a video recording from CM #2 who told him/her that he/she had received them from CM #3. CM #1 stated that he/she notifed the facility about them. None of the community members were affiliated with the facility and had no current family residing at the facility. On 4/20/22 at 5:18 p.m., during a telephone interview with a surveyor, CM #3 confirmed that the photos, audio recording and video recording were sent to him/her by CNA #1 by social media. During this interview, CM #2 who was also present during this interview but spoken to by the surveyor separately, stated that he/she was copies to be sent to him/her. Based on the results of the facility's investigation of this incident, the following were being done: On 4/19/22 at 11:30 a.m., during an interview with a surveyor, the Administrator stated that she was working on CNA #1's termination paperwork today. On 4/19/22 at 1:15 p.m., during an interview with a surveyor, the Administrator stated, Because of this incident, we will schedule an in-service and go over Cell Phone, Social Media, Resident Rights and Abuse policies with all staff. On 4/20/22, at 8:15 a.m., during an interview with a surveyor, the Administrator stated that she educated the staff that was on yesterday afternoon on the policies. The facility will continue with a goal of 4/29/22 to complete everyone. On 4/20/22 at 8:55 a.m., during an interview with a surveyor, the Director of Nursing stated that CNA #1's last day worked was 4/12/22.

Based on review of the facility's report and investigation, photos and recordings review, policy reviews, and interviews, the facility failed to ensure residents' rights to privacy and confidentiality were not violated when unauthorized video recording, audio recording, and photographs taken by a Certified Nursing Assistant (CNA) and shared on social media for 3 of 3 residents reviewed for abuse (Resident #3, #2, and #1). A reasonable and prudent person would be distraught and embarrassed and would suffer from anger and deep sadness due to lack of control over the situation. Findings: Documentation in the facility's Report a Medical Facility Incident submitted on 4/13/22 to the Division of Licensing and Certification (DLC) stated, a community member brought forth photos and audio taken of residents during care by a staff member. Community Member (CM) #1 came into the facility and met with the Social Worker (SW), Director of Nursing (DON), and Unit Manager and presented two photos taken of residents, one audio recording, and one short video that were sent to his/her cell phone by CM #2 who received them from CM #3. CM #1 stated that these were taken by Certified Nursing Assistant (CNA) #1. CM #1 stated that per CM #2, the photos were shared via CNA #1's Snapchat (Social Media Platform). The facility started an immediate investigation and CNA #1 was suspended. The Facility's 5-day investigation, submitted to DLC on 4/18/22 stated that on 4/14/22, CNA #1 was interviewed by a Corporate Consultant (CC) and the DON; CNA #1 was told that they had received an audio recording of a resident during care, a short video of a resident, and two still photos that were sent via Snapchat and Facebook Messenger (both Social Media platforms). CNA #1 stated that she shared this with only one person (CM #3) and that she had no cruel intentions and wanted to show her friend (CM #3) what it was like to work there. The facility's Social Media Acknowledgement Form stated I acknowledge and understand the facilities' Social Media Policy. As an employee of First Atlantic Healthcare, I agree to: -Never mention our employees or residents on any social media networking site, such as Facebook, Twitter, etc. -At no time will I post pictures of residents, or staff online including all social networking sites. -I will refrain from using a cell phone within the facility. The facility's policy, Cell Phones/Personal wireless Communication Devices, Use of, effective 5/1/2018, stated, Staff must not take pictures of residents on their cell phones or other personal camera devices. Other photographs must be approved by the Administrator and in writing by the resident/responsible party. The facility's Acknowledgement of Confidentiality of Resident Information stated, I recognize it is my duty to protect confidential information including paper, electronic and verbal resident healthcare information. Disclosure of confidential resident information to any unauthorized person is prohibited. The policy, Employee Confidentially Statement, developed 6/2013, stated. As an employee of Marshall Healthcare Facility, I acknowledge that one of the most serious responsibilities all employees assume is the resident's right to privacy. Marshall Healthcare rules, personal employee ethics, and legal considerations require that any information concerning a resident's treatment be kept in complete confidence, even from other employees unless they require the information to carry out their own duties. CNA #1's most recent hire date was 3/14/22 and documentation in the employee file stated that she signed the above-mentioned policies on 3/14/22. On 4/20/22 at 9:40 a.m., during an interview with a surveyor, CNA #1 stated, I have been a CNA for 4 years; I just signed paperwork, I didn't read what I was signing but I know the rules and I know you are not supposed to share (resident information) on social media, and you are not supposed to disturb privacy in their own home. CNA #1 stated that she only shared these to CM #3. During this interview, the following were discussed: 1. The shared photo on social media for Resident #3 consisted of Resident #3 sitting on the edge of the bed, wearing a shirt and a brief with the words Are you [OBSCENITY] ing crazy written along the lower half of the photo. During the interview, CNA #1 stated, that must be old, I don't remember that. The surveyor asked about the short six second video of Resident #3 while the resident was eating in his/her room, talking to him/herself and the resident stated your ass out there in that kitchen and CNA #1 stated again, I think that video is old of Resident #3 .that must have been like the first time I worked there. Documentation in Resident #3's clinical record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] behavioral disturbance and generalized anxiety disorder. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 2/24/22, stated the resident was not oriented to time, place, and person and had an abnormal memory. Resident #3 was dependent on staff for extensive assist with personnel hygiene. Documentation in Resident #3's clinical record showed no outwardly signs of emotional distress from the incident. Resident #3 was incapable of giving his/her consent to be videotaped while using vulgar language and talking to self while eating in his/her room or incapable of giving his/her consent to be photographed while wearing a shirt and brief with a photo caption of Are you [OBSCENITY] ing crazy. It would be reasonable that Resident #3 would be very distraught knowing that his/her privacy was violated by the video recording and photograph being shared with others in the community. 2. The shared audio on social media consisted of CNA #1 providing personal care to Resident #2. Resident #2 was upset, can be heard sobbing, and calling CNA #1 names while using profanities. CNA #1 is overheard calling the resident by name in the audio recording, telling the resident he/she needed to be changed, was dirty, and that the resident had hair on his/her face and asking if the resident wanted a beard and stating let me shave yours off, because you have one. During this interview, CNA #1 stated my car was in the garage and CM #3 had been my transportation back and forth to work. I threw my phone in my pocket (we had been talking on Messenger (social media platform)) and I didn't know it was recording. Documentation in Resident #2's clinical record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] (primary) and Generalized anxiety disorder (secondary). A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 3/23/22, stated the resident's current problems included Alzheimer's Disease and Mental Confusion. Resident #2 was dependent on staff for extensive assist with personnel hygiene. Documentation in Resident #2's clinical record, showed no outwardly signs of emotional distress from the incident. Resident #2 was incapable of giving his/her consent to be audio taped while displaying behaviors during personal care and shared with others with his/her first name mentioned in the audio recording by CNA #1. It would be reasonable that Resident #2 would be very distraught knowing that his/her privacy was violated by this audio recording with his/her name mentioned was shared with others in the community. 3. The shared photo on social media for Resident #1 consisted of CNA #1 and Resident #1 in the resident's room. Resident #1 was sitting in bed, dressed in a johnny, with a bedside table and cups of beverages in front of the resident. The resident's lips were glossy and white in appearance. In the interview, the CNA #1 stated, I recall taking that one. We were having a little date and he/she needs help eating. I just remember answering CM #3 back because he/she was asking me what I was doing. Documentation in Resident #1's annual Minimum Data Set (MDS), dated [DATE], stated that Resident #1 was care planned for dementia/cognitive loss. A physician progress note, dated 2/24/22, stated that Resident #1 was confused, anxious, depressed, and had a disordered thought process with orientation to time, place, and person as abnormal. Resident #1 was dependent on staff for extensive assist with eating. Documentation in Resident #1's clinical record showed no outwardly signs of emotional distress from the incident. Resident #1 was incapable of giving his/her consent to be photographed wearing a [NAME] and eating with white, glossy lips. It would be reasonable that Resident #1 would be very distraught knowing that his/her privacy was violated by a photograph of him/her with soiled lips shared with others in the community. Based on the results of the facility's investigation of this incident, the following were being done: On 4/19/22 at 11:30 a.m., during an interview with a surveyor, the Administrator stated that she was working on CNA #1's termination paperwork today. On 4/19/22 at 1:15 p.m., during an interview with a surveyor, the Administrator stated, Because of this incident, we will schedule an in-service and go over Cell Phone, Social Media, Resident Rights and Abuse policies with all staff. On 4/20/22, at 8:15 a.m., during an interview with a surveyor, the Administrator stated that she educated the staff that was on yesterday afternoon on the policies. The facility will continue with a goal of 4/29/22 to complete everyone. On 4/20/22 at 8:55 a.m., during an interview with a surveyor, the Director of Nursing stated that CNA #1's last day worked was 4/12/22.

Based on record review and interviews, the facility failed to ensure a bed alarm was in place to prevent falls, in accordance with a care plan for 1 of 4 sampled residents (#1). This failure resulted in the resident getting out of bed and falling, without the staff being aware that the resident was getting out of bed. The resident sustained [REDACTED]. Finding: Resident #1's care plan dated 3/7/13 and updated 6/6/13, under the identified problem area of "Potential for Injury, related to a history of falls" directed staff to ensure all fall prevention devices were in place, applied appropriately and were in working order. The resident's "Guidelines for Daily Care-Extension of the Care Plan" indicated the resident was to have a bed pad sensor alarm, use a hi-lo bed and wear a wanderguard bracelet. A "Nursing Facility Reportable Incident Form," dated 10/20/13, indicated Resident #1 had attempted to transfer him/herself to the bathroom and fell on to the floor in his/her room. The report indicated that the interventions of the hi-lo bed and call bell were in place at the time of the fall. However, the report did not indicate that the bed alarm was in place at the time of the fall. On 11/1/13 at 7:53 a.m., in an interview with a surveyor, Certified Nursing Assistant (CNA) #1 stated that Resident #1 did not have a bed alarm on and that she was unaware that the resident needed one. CNA #1 stated that she responded when she heard a "crash" and found the resident on the floor. On 11/4/13 at 6:50 a.m., in an interview with a surveyor, CNA #2 stated that she remembered "not seeing" the bed alarm at the time of the fall. The resident's nursing notes, dated 10/20/13 at 3:58 p.m., indicated the resident was difficult to arouse, had difficulty following commands, had a bruise on the back of the head, had vomited twice and had sluggish pupils. The note indicated the resident's blood Oxygen saturation level was 84 % and the physician was notified. The note indicated the resident was transferred to the hospital. On 10/31/13 at approximately 12:00 p.m., a surveyor discussed the failure to implement the resident's care plan for the use of a bed alarm that resulted in the staff being unaware that the resident was out of bed with the Director of Nursing.