Every finding on record at Marshwood Center

Based on observations and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for walls, floors, air conditioner vents, and ceiling tiles for 1 of 1 kitchen tour (3/16/26).Findings:On 3/16/26 from 8:16 a.m. to 8:48 a.m. two surveyors conducted an initial kitchen tour with the Director of Operations for Dietary for Health Care Services in which the following findings were observed and discussed:-The wall behind the stove has missing sheet rock.-The kitchen floor had food debris and trash under tables and equipment.-The floor in the walk-in freezer had chipped/missing paint creating an uncleanable surface.-The air conditioner vents were soiled with dust/dirt.-Approximately 15 ceiling tiles and the ceiling grids above the stove were stained yellowish and soiled with dust/dirt.On 3/16/26 at 8:48 a.m., in an interview with two surveyors, the Director of Operations of Dietary for Health Care Services confirmed the findings.

Based on record reviews and interviews, the facility failed to ensure the Medication Administration Records (MAR) and Treatment Administration Records (TAR) were accurately completed for 7 of 28 residents reviewed (Resident #1, #3, #8, #14, #35, #60, and #63).Findings: 1. On 4/2/25 a surveyor reviewed Resident #1's clinical record which showed an active physician order initiated on 12/9/25 for Humalog Solution 100 units/milliliters with instructions to Inject per sliding scale if 0-150= 0 units (if blood glucose is less than 70, call MD (medical doctor); 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-230 = 8 units; 351+ = 10 units and 9 (if blood glucose is greater than 400, call MD immediately for further instruction), subcutaneously before meals for sliding scale insulin coverage for diabetes must take finger stick blood glucose prior to administration. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March, lacked evidence that Resident #1's blood sugars were checked and insulin was given on 3/1/26, 3/5/26, 3/8/26, and 3/10/26. On 3/18/26 at 9:25 a.m., during an interview with the Market Clinical Advisor, who confirmed there was no evidence that Resident #1 got his/her blood sugars checked or received insulin for the above dates. 2. On 3/18/26, a surveyor reviewed Resident #3's clinical record which showed the following active physician orders: -HumaLOG Solution 100 UNIT/ML(milliliter) (Insulin Lispro (Human)) Inject as per sliding scale: if 0 - 150 = 0 units (If blood glucose is less than 70, call(MD); 151 - 200 = 2 units;201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351+ = 10 units and (if blood glucose is greater than 400, call MD immediately for further instruction) , subcutaneously before meals and at bedtime for sliding scale insulin coverage for diabetes must take finger stick blood glucose prior to administration -Start Date 01/05/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of January 2026, lacked documented evidence that Resident #3's blood sugars were checked and insulin was given on 1/17/26 (2000). - Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for DM -Start Date 01/07/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of January 2026, lacked documented evidence that Resident #3's blood sugars were checked and insulin was given on 1/17/26(2000). -Dulaglutide Subcutaneous Solution Auto-injector 1.5 MG/0.5ML (Dulaglutide) Inject 3 mg subcutaneously one time a day every Thursday for Diabetes with a start date of 01/01/2026 and D/C date 03/04/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of January 2026, lacked documented evidence that Resident #3's Dulaglutide was given on 1/17/26(2000). -Miconazole External Powder 2 % (Miconazole Nitrate (Topical)) Apply to groin and abdominal folds topically two times a day for yeast related skin condition initiated on 10/22/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of January 2026, lacked documented evidence that Resident #3's Miconazole External Powder 2 % was applied on 1/17/26(2000). -Monitor scabbed wound on left shin until resolved. every day shift for skin care initiated on 10/20/2025 and discontinued on 02/04/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of January 2026, lacked documented evidence that Resident #3's scabbed wound on left shin was monitored on 1/13/26. -Acetaminophen Oral Tablet 500 milligrams (MG) (Acetaminophen) Give 2 tablet by mouth three times a day for back pain initiated on 08/14/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's Acetaminophen was given on 2/12/26 on evening (1900). -1C, BMP (Basic Metabolic Panel) one time only for DM for 1 Day initiated on 02/16/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's 1C, BMP one time only was completed on 2/16/26. -Does the patient need to have the Head of Bed Elevated to Avoid Shortness of Breath while lying flat? every shift initiated on 06/04/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's Head of Bed Elevated 1C was completed 2/13/26 and 2/22/26 on nights. -Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift initiated on 08/12/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's was checked for side effects on 2/22/26 on nights. -Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to bilateral knees topically three times a day for pain 4g initiated on 02/09/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked evidence that the Voltaren External Gel 1 % was applied on 2/11/26, 2/15/26 and 2/17/26 on afternoons. -Wander Guard/Wander Elopement Device due to poor safety awareness every night shift check function and document in supplemental documentation Expiration date:_07/2026 (update the order with the new date when the bracelet is changed) initiated on 08/08/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's wander guard's function was checked on 2/4/26 and 2/22/26 on nights. -Wander Guard/Wander Elopement Device due to poor safety awareness every shift check the placement of the device and in supplemental Documentation document the location initiated on 08/08/2025. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #3's wander guard's placement was checked on 2/4/26 and 2/22/26 on nights. On 3/18/26 at 9:35 a.m., in an interview with five surveyors present, the Market Clinical Advisor confirmed the findings 3. On 3/18/26, a surveyor reviewed Resident #8's clinical record which showed the following active physician orders: -Risperidone oral tablet 1miligram (mg) give 1.5 tablet by mouth two times a day for psychosis, agitation with start date of 2/12/26 and discontinue date 3/2/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #8 was given the medication on 2/12/26. -Does the patient need to have the Head of Bed Elevated to Avoid shortness of Breath while lying flat? every shift with start date 11/12/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #8 was checked for this on 2/2/26 at night, 2/13/26 at night, and 3/4/26 in the evening. -Is resident free from side effects of psychotherapeutic medications? [if no, document side effects in PN (progress note)] every shift with start date 11/12/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #8 was checked for this on 2/2/26 at night, 2/13/26 at night, and 3/4/26 in the evening. -Weigh every day shift every Monday with start date 12/8/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #8 was weighed on 2/23/26. -Vital Signs short term/skilled patient q (every) shift x72 hrs (hours) then daily every, day shift with start date 8/11/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #8 had his/her vital signs taken on 3/5/26. -Check placement of clonidine patch every shift with start date 8/7/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #8's patch placement was checked on 3/5/26 in the evening. -Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) one-time only for 1 day with start date 3/9/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #8 had this done on 3/9/26 or 3/10/26. -Epson salt to right great toe twice a day (BID), follow with Bactroban ointment and cover with 2x2 gauze and tape two times a day for irritation to toe following podiatry care for 7 days with start date 2/28/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that this was done for Resident #8 on 3/4/26 in the evening (PM). -Mupirocin external Ointment 2% apply to right great toe topically two times a day for irritation following podiatry care for 7 days with start date 2/28/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #8 received this on 3/4/26 PM. -Right great toe: cleanse right great toe with wound cleanser, apply thin layer Mupirocin External Ointment 2% two times per day until resolved two times a day for ingrown toe with start date 2/12/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #8 had this done on 3/4/26 from 4 pm to10. On 3/18/26 at 9:35 a.m., in an interview with five surveyors, the Market Clinical Advisor confirmed the findings. 4. On 3/18/26, a surveyor reviewed Resident #14's clinical record which showed the following active physician orders: -Ammonium Lactate External Lotion 12 % (Lactic Acid (Ammonium Lactate)) with instructions to apply to Bilateral LE topically every day and evening shift for dry and flaky skin initiated on 01/31/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March 2026, lacked documented evidence that Resident #14's Ammonium Lactate External Lotion 12 % was applied on 3/4/26 in evening. -Does patient need to have the Head of Bed Elevated to Prevent Shortness of Breath while lying flat? every shift for COPD -Start Date 02/17/2023. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March 2026, lacked documented evidence that Resident #14's Head of Bed Elevated was elevated on 3/10/26 at night. -Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally three times a day for Influenza, wheezing for 7 Days -Start Date 02/19/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #14's Ipratropium-Albuterol Solution was administered on 2/24/26 for afternoon. -IV: Observe IV site routinely for S/S of complications at a frequency based on therapy and resident condition. Document in PN at least q shift. every 2 hours for dehydration -Start Date 02/27/2026 -D/C Date 02/28/2026. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February 2026, lacked documented evidence that Resident #14 was observed for dehydration on 2/28/26 at 0600. On 3/18/26 at 9:35 a.m., in an interview with five surveyors, the Market Clinical Advisor confirmed the findings. 5. On 3/17/26, a surveyor reviewed Resident #35's clinical record which showed the following active physician orders: -Basic Metabolic Panel (BMP) one time only for chronic kidney disease (CKD) for 1 day with start date 2/26/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #35 had this done on 2/26/26 or 2/27/26. -Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift with start date 6/9/23. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #35 had this done on 2/2/26 at night, 2/13/26 at night, 3/1/26 at night, or 3/4/26 in the evening. -Wander Guard/Wander Elopement device due to poor safety awareness every shift, check the placement of the device on Right Left Leg (RLE) and in supplemental documentation document the location with start date 6/9/23. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #35 had this done on 2/6/26 at night, 2/13/26 at night, 3/1/26 at night, or 3/4/26 in the evening. -Bilateral (BIL) knee high teds at bedtime for edema remove teds, rinse and hang with start date 6/13/23. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #35 had this done on 3/4/26 at bedtime (HS). On 3/18/26 at 9:35 a.m., in an interview with five surveyors, the Market Clinical Advisor confirmed the findings. 6. On 3/18/26, a surveyor reviewed Resident #60's clinical record which showed the following active physician orders: -Allow ice chips upon request for quality of life, seat patient fully upright in bed or chair prior to administration. The patient may self-administer ice chips by cup, cue patient to cough after each swallow. Leave head of bed elevated for 20 minutes after ice chips every shift with start date 1/13/21. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. - CeraVe Moisturizing External Cream (Emollient) Apply to dry areas topically three times a day for excessive skin breakdown, rash apply to all areas of redness that patient will tolerate with start date 1/6/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #60 had this done on 2/6/26 at 1400, 2/7/26 at 1400, 2/15/26 at 1400, and 2/17/26 at 1400. -Colostomy care every shift with start date 4/8/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/17/26 during the day, and 3/1/26 at night. - Colostomy Appliance Change one time a day every 3 day(s) with start date 6/24/25. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #60 had this done on 2/13/26. -Does patient elevate Head of Bed (HOB) to prevent Shortness of Breath (SOB)? Every shift with start date 10/10/22. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/13/26 at night, and 3/1/26 at night. -Enteral feed order every shift Jevitty 1.2 Calorie (CAL) administer continuous via pump 100 milliliters (ml) per hour with water flush 25 ml/hour (hr) with start date 9/6/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Enteral feed: elevate head of bed 30-45 degrees during feeding and for 30-45 minutes after every shift with start date 4/7/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Enteral Feed: change syringe every 24 hours with start date 4/7/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #60 had this done on 2/9/26 or 2/17/26. - Enteral Feed: check for gastric residual volume (GRV) every shift prior to medication administration via tube. If GRV is greater than 250 ml or over, hold med notify physician/Advanced Practice Provider and document amount in ml with start date 9/6/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Enteral feed: Flush tube with 30 ml of water before and after each medication pass. Every shift flush tube with at least 15 ml of water between each medication. Auscultate for presence of bowel sounds prior to med administration via tube with start date 9/6/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Flush tube with 25 ml/hr of water during continuous feeding and a total volume of flush = 600 ml/24 hrs (excluding medication flushes). Total volume of nutrients + flush = 3000 ml/24hrs every shift with start date 9/6/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Is resident free from side effects of psychotherapeutic medications? (If no, document side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift with start date 4/8/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February and March lacked evidence that Resident #60 had this done on 2/2/26 at night, 2/13/26 at night, and 3/1/26 at night. -Oral care every day and evening shift with start date 5/24/23. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #60 had this done on 2/17/26 during the day. -Total nutrient 2400 ml/24 hrs. total calories 2880 CAL/ 24 hrs with start date 9/6/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #60 had this done on 2/13/26 at night, 2/22/26 at night, and 2/23/26 at night. -Perform surface disinfection of suction canister as per Genesis policy, change the canister and the connecting tubing, date the canister every night shifts every Sunday with start date 9/6/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #60 had this done on 3/1/26. -Placement and tube length in centimeters (CM) every shift check tube for proper placement prior to each feeding, flush, or medication administration by measuring the length of the tube with start date 4/7/20. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #60 had this done on 3/1/26 at night. On 3/18/26 at 9:35 a.m., in an interview with five surveyors, the Market Clinical Advisor confirmed the findings. 7. On 3/18/26, a surveyor reviewed Resident #63's clinical record which showed the following active physician orders: -CMP, Hemoglobin A1c one time only for diabetes, CKD for 1 day with start date 2/5/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #63 had this done on 2/5/26 or 2/6/26. -Does the patient need to have the Head of Bed Elevated to avoid shortness of Breath while lying flat? Every shift for Asthma with start date 9/4/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #63 had this done on 2/2/26 at night and 2/13/26 at night. -Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift with start date 9/3/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of February lacked evidence that Resident #63 had this done on 2/2/26 at night and 2/13/26 at night. -Levothyroxine sodium Tablet 150 micrograms give 1 tablet by mouth one time a day for low thyroid hormone with start date 11/5/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #63 received this on 3/16/26 at 0600. -Bilateral feet: Monitor feet, apply skin prep to bilateral feet two times per day every day and evening shift may apply foam dressing for added comfort with start date 2/26/26 and discontinue date 3/11/26. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #63 had this done on 3/4/26 in the evening. -Does the patient need to have the Head of Bed Elevated to avoid shortness of Breath while lying flat? Every shift for Asthma with start date 9/4/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #63 had this done on 3/1/26 at night, 3/4/26 in the evening, and 3/8/26 at night. -Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN) every shift with start date 9/3/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #63 had this done on 3/1/26 at night, and 3/4/26 in the evening. -Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (insulin Glargine) inject 25 unit subcutaneously at bedtime for diabetes mellitus with start date 9/3/24. A review of his/her Medication Administration Record/Treatment Administration Record for the month of March lacked evidence that Resident #63 had this done on 3/4/26 HS. On 3/18/26 at 9:35 a.m., in an interview with five surveyors, the Market Clinical Advisor confirmed the findings.

Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 28 residents reviewed for care planning (Residents #1, #8, #35, #60, and #63). Findings: 1. Review of Resident #1's medical record contained a Quarterly Minimum Data Set (MDS) version 3.0 dated 1/6/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the quarterly MDS assessment On 3/18/26 at 9:30 a.m., in an interview with the Market Clinical Advisor, who confirmed that Resident #1's IDT meeting was not held within 7 days of the quarterly MDS assessment. 2. Review of Resident #8's medical record contained a Quarterly MDS version 3.0 dated 12/16/25 and 3/12/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the two quarterly MDS assessments. 3. Review of Resident #60's medical record contained a Quarterly MDS version 3.0 dated 6/24/25 and 9/26/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the two quarterly MDS assessments. 4. Review of Resident #63's medical record contained a Quarterly MDS version 3.0 dated 5/20/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the quarterly MDS assessment. 5. Review of Resident #35's medical record contained a Quarterly MDS version 3.0 dated 12/23/25. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the quarterly MDS assessment. On 3/17/26 at 12:20 p.m. during an interview with the Licensed Social Worker (LSW) he/she stated the expectation for documentation is for whoever spoke with family/representative would put a note in the system with what was decided for a meeting date and time. The LSW stated he/she puts a note in for the actual care plan meeting and Nursing does the actual care plan. On 3/17/26 at 12:37, in an interview with the MDS Coordinator the surveyor requested any documentation that showed the family/representative requested a meeting outside the 7 days for the above concerns, but none was presented. On 3/18/26 at 9:33 a.m. during an interview with three surveyors the Market clinical advisor confirmed the above findings.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 6 of 7 units ([NAME], [NAME], [NAME], [NAME], [NAME] and [NAME]) 2 of 2 facility tours.(3/16/26 and 3/18/26)Findings:On 3/18/26 from 3:00 p.m. to 3:45 p.m., two surveyor conducted an Environmental tour with the Administrator, the Director of Nursing, the Maintenance Director, the Maintenance Assistant and the Housekeeping Supervisor in which the following findings were discussed and/or observed. [NAME] Unit:- There were six(6) cracked/broken floor tiles approximately forty one(41) cracked/broken floor tiles in the dining area. - Resident room [ROOM NUMBER] - The bathroom walls were marred/marked with black marks by the baseboard heater. - Resident room [ROOM NUMBER] - A surveyor had observed the heating unit to be pulled away from the wall. This was confirmed by and with the Market Clinical Advisor 3/16/26 at 11:00 a.m. [NAME] Unit:- The hallway hand rail covering, located between resident room [ROOM NUMBER] and resident room [ROOM NUMBER], was cracked/broken. - There were approximately forty one(41) cracked/broken floor tiles throughout the unit's hallway and dining area. - Resident room [ROOM NUMBER] - The wall by the reclining chair was marred/marked with black marks. - Resident room [ROOM NUMBER] - The bathroom had a stained ceiling tile above the toilet. The base of the bathroom metal door frame was rotted away leaving a hole in it. The floor around the base of the toilet was dirty. The ceiling exhaust fan was covered in dust/dirt. There was debris in the light fixture. [NAME] Unit:- Resident room [ROOM NUMBER] - The paint on the bathroom wall was peeling near the toilet. The baseboard heater had chipped/missing paint and was rusty. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty/stained. The walls were marred and had chipped/missing paint exposing sheet rock.- Resident room [ROOM NUMBER] - The baseboard eating unit had the cover center connector piece that was falling off and hanging down. - Resident room [ROOM NUMBER] - Both bed side tables had dried liquid residue on them. [NAME] unit: - The shower room ceiling exhaust vent was dusty/dirty. - The dining room had three stained/dirty ceiling tiles by the large ceiling air vent. - Resident room [ROOM NUMBER] - On 3/16/26 at 9:38 a.m., a surveyor observed the privacy curtains were missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER]- On 3/16/26 at 9:40 a.m., a surveyor observed the privacy curtains were missing hooks, hanging down and in disrepair. The heating unit by window had chipped/missing paint creating uncleanable surface.- Resident room [ROOM NUMBER] - The bathroom call bell cord was excessively long and lying on the bathroom floor. - Resident room [ROOM NUMBER] - There was a soiled plunger sitting on the bathroom floor next to the toilet.- Resident room [ROOM NUMBER] - The privacy curtain for the left bed, observed by a surveyor on 3/16/26, was missing hooks, hanging down and in disrepair. [NAME] Unit- Resident room [ROOM NUMBER] - The wall by the head of the bed and the bathroom walls were marked/marred and had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The heating unit by the bed on the right side of room had chipped/missing paint and was rusty. - Resident room [ROOM NUMBER] - The floor was dirty around the base of the toilet. - Resident room [ROOM NUMBER]- The table fan, on the right side night stand, was dusty/dirty. - The ceiling air vent, in the dining area by resident room [ROOM NUMBER], was dusty/dirty. [NAME] Unit- Resident room [ROOM NUMBER] - The toilet had a broken plastic type wrap, around the base of the toilet, that was observed on 3/16/26 by a surveyor. On 3/18/26 at 3:45 p.m., in an interview with two surveyors present, the Administrator, the Director of Nursing, the Maintenance Director, the Maintenance Assistant and the Housekeeping Supervisor confirmed the findings.

Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 3 of 3 dumpsters for 1 of 3 days of survey (3/16/26).Finding:On 3/16/26 at 8:18 a.m., a surveyor observed food and trash to be on the ground around 3 of 3 dumpsters.On 3/16/26 at 8:48 a.m., in an interview with two surveyors the Director of Operations for Dietary for Health Care confirmed the finding.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident environment remained free from the potential risk of accidents, relating to the storage of chemicals being properly secured for 1 of 3 days of survey (3/16/26).Findings:On 3/16/26 at 11:18 a.m., observation of the [NAME] unit spa with an unlocked and ajar closet door which residents had access to. Closer observation showed the closet contained 5 gallons of Cid-A-L (tm) II (disinfectant, virucide and fungicide chemical).Safety Data Sheet noted the following:Restrictions of Use: Do not ingest. Avoid contact with skin and eyes. Keep out of reach of children. Do not allow product to go directly down storm sewer.First Aid Measures Eye Contact: Flush eyes with plenty of water for at least 15 minutes. Skin Contact: Wash off skin and remove contaminated clothing. Do not reuse contaminated clothing. Inhalation: If dust, vapors or mist cause distress, remove to fresh air. Use oxygen or artificial respiration, if needed. Ingestion: If swallowed, consult a physician immediately. If symptoms persist, consult a physician.Toxicological Information Effects of Exposure: Product is toxic, may cause death. Eyes: Contact can cause irreversible eye damage or burns. Skin: Prolonged contact may cause burns or irritation. Inhalation: Vapor may cause drowsiness, nausea, loss of motor skills or disorientation. Do not create mist. Ingestion: Causes digestive tract burns.On 3/16/26 at 11:22 a.m. both the Director of Nursing and Surveyor observed the unsecured chemicals. At this time, the Director of Nursing confirmed the chemicals were not secured creating a hazardous and unsafe environment for which residents could access.

Based on observations, interviews, record review and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the management of residents with Clostridium Difficile (C-diff - a highly contagious bacterium (germ) that causes diarrhea and colitis) infection for 1 of 3 residents reviewed for Transmission Based Precautions. (#117)Finding:Resident #117 was admitted with a diagnosis of Clostridioides difficile. The current care plan for actual infection of Clostridioides difficile initiated on 3/14/26, had interventions of Contact Precautions.On 3/16/26 at 10:33 a.m., observation of Resident #117's room with a posted Contact Precautions sign on the door instructing staff to put on gloves and a gown before entering the room. Next to the door was a 3 draw plastic bin containing Personal Protective Equipment (PPE) of gloves and gowns. At this time, Resident #117 stated he/she was on contact precautions due to having C-diff and is on an antibiotic for a couple more days.On 3/16/26 at 11:11 a.m., 2 surveyors observed the Licensed Social Worker (LSW), without gloves or gown, in resident #117's room, sitting in the resident's wheelchair. At this time, Registered Nurse Manager (RN #6) came around the corner, the surveyor asked RN#6 why the LSW was not wearing the required PPE. The RN #6 stated, you only wear PPE if you are touching items. RN#6 then called the LSW out of the room and explained that she should be wearing gown and gloves while in room. At 11:17 a.m., the LSW applied gown and gloves.The facilities Transmission Based Precautions policy and procedure last revised on 5/1/25 states, The Center will have PPE readily available near the entrance of the patient's room and will don appropriate PPE before or upon entry into the environment of a patient on Transmission Based Precautions., Contact Precautions: intended to prevent transmission of pathogens that are spread by direct or indirect contact with the patient or the patient's environment. and Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination, Clostridioides difficile, norovirus and other intestinal tract pathogens.On 3/16/26 at 11:23 a.m., the above was discussed and confirmed with Director of Nursing.

Based on interviews and record review, the facility failed to protect and promote a resident's dignity for 1 of 2 residents sampled for hygiene for 2 of 3 days of survey. (Resident #24).Findings:Resident #24 was admitted to facility in February 2026 with diagnoses of right tibia and fibula fracture.The most recent Brief Interview for Mental Status (BIMS) was 14 out of 15 indicating [he/she] is cognitively intact.Review of Resident#24's current care plan initiated 2/10/26 stated, Resident is at risk for decreased ability to perform ADL(s) (Activities of Dailly Living) in grooming, personal hygiene requires 1 person extensive assistance with bathing, and grooming .On 3/16/26 at 10:56 a.m., observation of Resident #24 sitting in his/her wheelchair with long white facial hair on his/her chin. At this time, during an interview the resident was asked if having facial hair was a concern. The resident replied, Yes it does, I have tried to get someone to help me, there's men here so I know they have shavers. The surveyor asked if he/she is able to shaving his/her own face. Resident stated, he/she can but, I don't have a mirror here either. I wish someone could shave it. On 3/17/26 at 10:39 a.m., an additional observation, Resident #24 with the long white facial hair on his/her chin. Again, the surveyor asked the resident about his/her ability to shave his/her face. Resident stated, The other place I had a hot towel and [NAME] 3 and 1 cream and I would shave. It bugs the hell out of me, I'm sure a lot of people notice it, they just don't say anything to me and stated the facility must has razors because there are men here. On 3/17/26 at 10:45 a.m., during an interview, Certified Nurses Aid (CNA #1) confirmed she was providing care for Resident #24. The surveyor asked about the resident's facial hair. CNA #1 stated, I haven't shaved [him/her] and they would not leave razors in the resident's rooms.On 3/17/26 at 1:38 a.m., during an interview, the above concern was discussed with Director of Nursing Services, who after surveyor intervention, discussed the resident being shaved by either staff or shaving him/herself and the facility will obtain mirror and electric shaver.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the floor, the walk-in freezer, a sink, a food mixer, ceiling tiles, a food disposal unit, a blender and a convection oven; failed to ensure food in the dry storage room was closed and secured shut; and failed to ensure that the kitchen ice machine was plumbed in accordance with code requirements to prevent food contamination for 1 of 1 kitchen tour for 1 of 1 day of survey (12/16/24). Findings: This direct connection of waste water and potable water 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) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 12/16/24 from 9:10 a.m. to 9:45 a.m., 2 Surveyors did an Initial Kitchen Tour with the Food Service Director, the Director of Operations, and the District Manager in which the following findings were observed: - There was food, paper/ plastic trash on the entire floor and under the equipment and shelving. - The dish room spray sink was leaking liquid into a bucket sitting under the corner of the sink. - The food mixer had chipped/missing paint on the mix arm and base. - There were 5 ceiling tiles, above a food preparation area, that had dried liquid spatter on them. - There was a broken ceiling tile next to the ceiling air conditioner near the walk-in freezer. - The food disposal unit outside surface was covered with dried food particles and dried liquid residue. - The blender had dried food particles and dried liquid residue on the outside surface of the unit. - The convection oven had dried food particles and dried liquid residue on the outside surface of the unit. - The dry storage room had a 50 pound bag of previously open sugar, which was not secured shut and was sitting in an opened bin. - The walk-in freezer had a large box of sandwich buns that had a large ice build-up on the opened box. - The ice machine was not plumbed in accordance with code requirements to prevent food contamination. On 12/16/24 at 9:45 a.m., in an interview with 2 surveyors, the Food Service Director, the Director of Operations, the District Manager confirmed the findings.

Based on interviews and record reviews, the facility failed to ensure that 8 out of 25 licensed staff had current certification in Healthcare Basic Life Support (BLS) as required by facility. Licensed Practical Nurse (LPN) #2, Registered Nurse (RN) #2, RN#3, RN#4, RN#5, RN#6, RN #7 and RN#8. Findings: A surveyor reviewed the Job Descriptions for Registered Nurses and Licensed Practical Nurses at the facility and found under Specific Educational/Vocational Requirements: Maintains current BLS/CPR certification A surveyor reviewed the documentation provided by the facility for the 25 licensed staff currently employed and found 8 staff without documentation of a current BLS/CPR certification. LPN #2, RN #2, RN#3, RN#4, RN#5, RN #6, RN#7 and RN #8. On [DATE] at 1:13 p.m. a surveyor met with the Director of Nursing and discussed the above findings.

Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for Excessively Low Weekend Staffing during the fourth quarter 4 (July 1, 2024 through September 30, 2024). On 12/19/24 at approx. 11:00 a.m., review of weekend staffing from July 1, 2024 through September 30, 2024, both the Director of Nursing and the Scheduler/Payroll/Human Resource personal confirmed the facility did not have enough staff to meet resident needs on the weekends.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 3 of 3 observations for 2 of 4 days of survey (12/16/24 and 12/18/24). Findings: The Safety Data Sheet for Clorox Healthcare Bleach Germicidal Wipes noted the following: 4. First Aid Measures Eye contact: Rinse thoroughly with water as necessary. If symptoms persist, call a physician. Skin contact: Wash with soap and water. If skin irritation persist, call a physician. Inhalation: Remove to fresh air. If breathing is difficult, trained personnel should give oxygen. If symptoms persist, call a physician. Ingestion: Drink one to two glasses of water. Get medical attention if symptoms occur. The Safety Data Sheet for Pure Bright Germicidal Ultra Bleach noted the following: 4. First Aid Measures Eye contact: Immediately flush with plenty of water. After initial flushing, remove any contact lenses and continue flushing for at least 15 minutes. Skin contact: Wash skin with soap and water. If symptoms persist, call a physician. Inhalation: Remove to fresh air. Ingestion: Do not induce vomiting. Clean mouth with water and drink afterwards plenty of water. If symptoms persist, call a physician. 1. On 12/16/24 at 10:25 a.m., a surveyor observed an unsecured 1 pound 10 ounce container of Bleach Germicidal Wipes stored on top of a soiled utility cart in the unlocked shower room. On 12/16/24 at 10:30 a.m., in an interview, [NAME], LPN #1 confirmed the finding and stated that there were confused and compromised residents that can move around the unit and access this room even in their wheelchairs. On 12/16/24 at 11:18 a.m., a surveyor discussed the finding with the Director of Nursing. 2. On 12/16/24 at11:59 a.m., a surveyor observed in the [NAME] unit the shower room, three(3) unsecured 1 pound 10 ounce containers of Bleach Germicidal Wipes in the unlocked shower room. On 12/16/24 at 12:02 p.m., in an interview, the Director of Nursing confirmed the chemicals were being stored in the unsecured and unlocked [NAME] shower room. She removed the chemicals and confirmed that there were confused and compromised residents that can move around the unit and access this room even in their wheelchairs. 3. On 12/18/24 at 10:50 a.m., a surveyor observed in the [NAME] unit shower room a 12 ounce spray bottle marked Bleach and Water. The bottle had no labeling and the ratio of bleach to water was unknown. On 12/18/24 at 11:00 a.m., in an interview, the Administrator confirmed that the bleach/water spray bottle was not labeled appropriately and it should have been secured and stored behind a locked door. She additionally confirmed that the unit had residents that can get around and that are confused, have dementia and are compromised.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 7 of 7 units ([NAME], [NAME], [NAME], [NAME], [NAME], [NAME] and [NAME]) and the Activity Room for 1 of 1 facility tour. Findings: On 12/19/24 from 8:05 a.m. to 8:40 a.m., 2 surveyors conducted an Environmental Tour with the Maintenance Director, the Director of Nursing and the Administrator in which the following findings were observed: [NAME] Unit(100s) - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. The room heating unit had a cracked/broken top plastic grill with rough edges. The bathrooms walls were marred/marked with black marks. - Resident room [ROOM NUMBER] - The bathroom floor was heavily soiled with dirt. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty. The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The ceiling is dirty and has holes in it where a curtain track used to be. [NAME] Unit (200s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The walker had white nursing tape on the cross brace holding an arm rest attachment secure. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. [NAME] Unit(300s) - Resident room [ROOM NUMBER] - The closet had a ceiling tile missing. - Resident room [ROOM NUMBER] - There was a bed pan and a urinal stored behind the toilet with the bed pan tucked in between toilet and wall. There were fruit flies observed in the room. Activity Room- The activity room doors had chipped/missing paint and black marks on them. [NAME] Unit(500s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - There was a dried brown substance next to the head of the bed #1. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - There was a large amount of a dried pink substances on the floor to the left of bed #1. - Resident room [ROOM NUMBER] - The bathroom had a broken ceiling tile sitting on the back of the toilet. The caulking around the base of the toilet was dirty. The bathroom floor tiles, around the toilet, have a light brownish substance coming up between the seams and the floor is dirty. The sink is dirty. The room walls had chipped/missing paint exposing sheetrock. - Resident room [ROOM NUMBER] - The wall thermostat was missing the cover exposing the wires. The sit-to-stand patient lift, in the hallway, had food and debris in the foot base area and dried liquid residue on the back of the kneepads. [NAME] Unit(600s) - The linen closet had linen and trash/debris on the floor. - The dining room window is fogged and hard to see out. - The table fan on the windowsill was dusty/dirty. [NAME] Unit (700s) - The linen closet had linen and trash/debris on the floor. - Resident room [ROOM NUMBER] - The room had a very strong odor of urine that extended down the hall past two other rooms even with the room door closed. - Resident room [ROOM NUMBER] - The ceiling, directly next to the room air vent, was soiled with dust/dirt. [NAME](800s) - Two ceiling tiles around the dining room ceiling air conditioning unit were dusty/dirty. - The storage room had linen and trash/debris on the floor. - The shower room walls had caulking, in the grout areas between the tiles, around the base of the room that had a black substance on it. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks and hanging down and in disrepair. The bathroom ceiling light had debris in it. On 12/19/24 at 8:40 a.m., in an interview, the Maintenance Director, the Director of Nursing and the Administrator confirmed the findings. 51331

Based on record reviews and interview, the facility failed to ensure that the resident and/or resident representative written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate and advanced directive, was completed for 4 of 10 residents reviewed for advanced directives. (Residents #70, #90, #306, and #405) Findings: 1. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #90 was admitted to the facility on [DATE]. Review of Resident #90 's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 12/17/24 at 3:25 p.m., in an interview, the Licensed Social Worker confirmed the Resident's clinical records did not include evidence that the residents and/or representatives were asked or offered and refused assistance filling out an advanced directive. 44049 3. Resident #306 was admitted to the facility on [DATE]. Review of Resident #306's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 12/17/24 at 3:25p.m. The social worker stated that this resident did not have advance directive paperwork given to her because she was out on leave, and it was not done. 51331 4. Resident #405 was admitted to the facility on [DATE]. Review of Resident #405 clinical record lacked evidence of an advance directive being offered or completed.

Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that an Infection Preventionist attended 2 of 4 quarterly QAA meetings. Finding: A review of the quarterly QAA meeting attendance sheets indicated that an Infection Preventionist did not attend the 7/25/24 and 10/31/24 quarterly QAA meetings. On 12/18/24 at approximately 9:00 a.m., in an interview with the surveyor, the Administrator stated, she does not know why the Infection Preventionist (I/P) was not at the July meeting, but she left the facility in mid-October, so she was not at the October meeting. Since that time there has not been anyone in that role. A new I/P has been hired. She was just here on Monday to finalize her position. The above was confirmed with the Marketing Clinical Advisor on 12/18/24 at 2:00p.m.

Based on facility policy, observations, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care (Resident 98 and 405). Findings: Review of facility procedure titled Oxygen: Nasal Cannula last revised on 8/7/23 states Date and store cannula in a treatment bag when not in use. On 12/16/24 at 1:09 p.m. and on 12/17/24 at 7:48 a.m., observation of Resident 98's nebulizer tubing stored on bedside table. On 12/16/24 at 2:36 p.m. and on 12/17/24 at 7:44 a.m., observation of Resisent 405's oxygen tubing stored under the oxygen concentrator handle. 12/17/24 3:42 p.m., during an interview with the Director of Nursing, the above information was confirmed.

Based on Interviews and record reviews, the facility failed to prevent a decrease in the Range of Motion (ROM) and/or mobility for 2 of 11 residents screened for maintenance of physical abilities following discharge from physical/occupational therapies. (Resident #45 and Resident #500) Findings: 1. On 12/18/24 at 10:13 a.m. a surveyor reviewed a binder provided by therapy services with Restorative Nursing Program Goals Sheets for residents discharged from Physical and/or Occupational therapy. This binder contains the after therapy plans recommended to maintain the physical abilities the resident achieved during therapy. A surveyor located a plan for Resident #500 in this binder, dated 7/9/24, that stated: Ambulate with walker, gait belt and wheelchair follow 1-2 times a day as patient allows. Have patient do lower extremity home exercise program once a day as patient allows (program in patient room). Record review of Resident #500's care plan failed to find the above program as an intervention. Facility was unable to provide any documentation that the above program was followed or the reason for not following. Record review of Electronic Medical Record (EMR) indicated that Resident #500 experienced falls on 8/28/24 and 9/2/24 and was once again referred to Physical therapy on 9/3/24. 2. On 12/18/24 at 10:30 a.m., a surveyor interviewed Resident #45 and learned she/he does not get to walk every day or perform exercises since ending therapy last summer. I'm noticing that I'm more weaker. Resident #45 Restorative plan dated 6/5/24 states Ambulate with CNAs or Restorative CNA daily with walker and gait belt. Encourage patient to perform lower extremity home exercise program Record review of Resident #45 care plan failed to show the restorative plan as an intervention. Facility was unable to provide documentation that the above program was followed or the reason for not following. On 12/18/24 at 10:39 a.m., a surveyor interviewed Certified Nursing Assistant (CNA) #4 and learned that while she/he was trained to be a restorative aide (RA) in addition to a CNA, it was rare she/he was able to perform the RA role. I usually have a CNA assignment and can't do the restorative plans. Confirmed that therapy went over the restorative plans with him/her as shown by his/her signature on the plans. On 12/18/24 at 11:48 a.m., a surveyor interviewed CNA#3 and learned she/he does not have time to assist residents with exercise programs or range of motion beyond getting dressed and undressed. She/he was unaware of any exercise programs for residents. Residents are lucky to get a walk to the bathroom in the morning. CNA#3 was working with Resident #45 today and was unaware of an exercise or ambulation plan. On 12/18/24 at 12:35 p.m., a surveyor interviewed a Unit Manager and learned the recommendations are not added to the care plan because there is no restorative nursing program due to lack of staffing. Confirmed that ambulation and range of motion were important nursing tasks to prevent falls, contractures, loss of range of motion, pressure ulcers, circulation and breathing difficulties. A surveyor reviewed the Facility Assessment for the facility and found under A.1. Function - Care Requirements Facility provides Mobility/fall prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. On 12/18/24 at 2:24 p.m. a surveyor reviewed the above with the Administrator.

Based on facility policy, interviews, and record review the facility failed to complete an personal property list, identify, and assist resident to get new eye glasses when they were lost for 1 of 41 resident reviewed during survey. Findings: Review of the facility policy titled Personal Property: Patient's revised on 8/15/23 states that personnel will identify and record the patient/patient's belongings upon admission to a center Any loss or breakage of a patient's personal item will be documented on the property loss form be the person receiving the report, and then referred to the Administrator . Administrator or designee will investigate the lost item. On 12/16/24 at 11:06 a.m., during an interview with Resident #63, stated his/her glasses have been missing for several months. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she s cognitively intact. Reviwe of quarterly Minimum Data Set (MDS) dated [DATE], Section B1200 was checked yes, that Resident #63 wears glasses. Review of nursing documentation on 4/7/23 shows Resident #63 wears glasses. Review of care plan meeting notes, dated 6/18/24, shows that Resident #63 enjoys watching T.V. On 12/17/24 at 2:00 p.m., during an interview Resident 63 states that she is unable to see the T.V. without his/her glasses. On 12/17/24 at 2:10 p.m., during an interview with CNA #2, who stated that she saw Resident #63 wearing glasses a few months ago. On 12/17/24 at 2:20 p.m., during an interview with the Registered Nurse Manager of the second floor, stated that when residents are admitted to the facility an inventory sheet has to be completed. She also discusses that if a resident advises staff of a missing item an incident report is to be filled out. On 12/17/24 at 2:13 p.m., during an interview with the Director of Nursing, it was confirmed that no inventory sheet , incident report was filled out for Resident #63. In addition, the facility did not assist Resident #63 with obtaining new glassess after they were lost.

Based on record review and interview, the facility failed to ensure that 1 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #91). Finding: Resident #91 was admitted to the facility on [DATE] with diagnosis of Major Depressive Disorder and Suicidal Ideations. Resident #91's clinical record contained a PASRR Level I determination letter dated 8/27/24 that stated further PASRR evaluation was not required due to a Time Limited Waiver of 30 days. Resident #91 had a suspected or confirmed PASRR Condition: Mental Health Disability. Resident #91 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed after the Residents stay changed from short-term to long-term. On 12/17/24 at 2:15 p.m., in an interview, the Licensed Social Worker confirmed that Resident #91 has been at the facility for longer than 30 days and the facility did not submit a new PASRR Level I to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was needed.

Based on interviews, observations and record reviews, the facility failed to meet the reasonable needs of residents in the areas of beverage choices and bed size for 2 out of 16 residents screened for accomodation of needs (Resident #42 and Resident #356) Findings: 1. On 12/17/24 at 1:30 p.m., during a resident council meeting, Resident #42 complained that she cannot get Ginger Ale to drink unless the nurse calls the Kitchen and says that the resident is sick. On 12/18/24 at 11:50 a.m., a surveyor asked the staff on [NAME] Unit if they had ever been told that the residents could not have Ginger Ale unless the resident was ill? Medication Technician (MT) #1 and Certified Nursing Assistant (CNA) #1 stated that they have both been told that. When we call to the Kitchen and ask, we have been told that residents cannot get Ginger Ale unless they are sick. On 12/18/24 11:45 a.m., a surveyor asked the Food Service Director if the residents can get Ginger Ale. He stated that if their diet allows them, they can have Ginger Ale. On 11/18/24 at 12:45 p.m., In an interview with Food Service Director and Director of Operations of Health Care Services the finding of lack of Ginger Ale being provided to the residents was confirmed with them. 48648 2. On 12/16/24 at 10:00 a.m., a surveyor met with Resident #356 in their room. Resident #356 was admitted on [DATE] with a new Right Below the Knee amputation. Resident #356 stated that she/he fell out of bed the other day reaching for the call bell and hurt their left knee. Stated that the bed was too small and it was difficult to move around in the bed. The resident is 6 feet 2 inches. The surveyor observed that Resident #356's upper torso fills the width of the bed and with the head of the bed elevated their leg cannot be straightened. Resident #356 stated she/he had spoken with staff about the size of the bed. Record review of Resident #356's electronic medical record (EMR) revealed a fall out of bed on 12/11/24 due to reaching for the call bell. No mention was made regarding the size of the bed. An x-ray was obtained for left knee pain following the fall. On 12/17/24 at 12:40 p.m. a surveyor met with Resident #356 in their room and was told that they almost fell out of bed again this morning but managed to catch themselves on the overbed table. On 12/17/24 at 1:13 p.m a surveyor met with RN#1 regarding the size of Resident #356's bed. RN#1 stated they were unaware of any issues with the bed. On 12/17/24 at 1:30 p.m., a surveyor met with the Director of Nursing and was told that they were unaware the bed for Resident #356 was an issue. Stated that anyone can request a larger bed for a resident. Confirmed that a bed assessment was completed upon admission with no issues noted.

Based on record reviews and interviews, the facility failed to ensure 2 of 3 sampled residents reviewed for medications were free of significant medication errors (Resident #5 and #6), resulting in a resident requiring transfer to the hospital for emergency evaluation (#5). Findings: 1. On 2/24/20 at 9:00 a.m., the Director of Nursing (DON), notified a surveyor that an incident involving a medication error had been reported. The DON stated some of the physician's orders [REDACTED]. As a result, the medications were not ordered and not available from the pharmacy for administration. The DON stated Resident # 5 missed the evening and morning doses of an anticonvulsant, and on the morning of 2/21/20, the resident began experiencing [MEDICAL CONDITION] and was transferred to the emergency room . Upon return to the facility, the DON stated the resident's family member discharged the resident against medical advice. A review of Resident #5's clinical record, noted an admission date of [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. A review of nursing documentation indicated that on 2/21/20, at approximately 10:30 a.m., Resident #5 reported not feeling well and began having [MEDICAL CONDITION]. Staff called 911 and contacted a nurse practitioner. The nurse practitioner ordered staff to administer an injection of [MEDICATION NAME] 2 mg intramuscularly at 11:00 a.m., and the [MEDICAL CONDITION] were noted to stop. Emergency personnel arrived and transferred the resident to the emergency room . On 2/25/20 at 11:50 a.m., in an interview with the surveyor, the DON stated the investigation into the incident revealed a newly hired Registered Nurse (RN) was receiving orientation from an RN employed by a staffing agency. The newly hired nurse was entering the physician orders [REDACTED]. The DON stated when a new order is entered into the computer, it goes into a queue until the order can be verified, then it is 'activated,' and will show up on the resident's MAR (electronic medication administration record). Some orders were done and some were not. It was not communicated to the nurse coming on. He/she was not aware there were some orders still in the queue. On 2/25/20 at 12:35 p.m., in an interview with the surveyor, the RN providing the orientation stated he/she did not review the physician orders [REDACTED]. On 2/25/20 at 12:40 p.m., in an interview with the surveyor, a Licensed Practical Nurse (LPN), stated that on the evening of 2/21/20, he/she did not know Resident #5 had an order for [REDACTED]. The LPN stated Usually the night shift double checks (the orders). I was on the evening shift. If I have time, I will go in and check the orders. The LPN stated the orienting RN did not communicate that orders remained in the queue. On 2/25/20 at 2:20 p.m., in an interview with the surveyor, Resident #5's family member stated He/she kept asking for his/her medications and they said 'we're waiting for them.' The next day I received a call around 11:30 in the morning saying he/she had a [MEDICAL CONDITION] and was sent to the ED (emergency department). I went to the ED and they said 'Marshwood told us they didn't give him/her (the) pills.' I called Marshwood and the nurse said it was a new nurse who had put it in the computer and didn't activate it. The morning nurse noticed it and activated it. He/she requested the morning meds ASAP and before they got there, he/she had a [MEDICAL CONDITION]. At the hospital, they said 'you had a [MEDICAL CONDITION] because you missed your meds.' The surveyor asked why the family member had discharged Resident #5 from the facility against medical advice. The family member stated them not giving the meds and he/she had to keep asking for them. It didn't feel like anyone even knew he/she was there. On 2/25/20, at approximately 6:00 p.m., the findings were discussed with the Director of Nursing, the Clinical Quality Specialist, and the Vice President of Operations. 2. Resident #6's Physician order [REDACTED]. Resident only received 3 of 5 doses on anti-biotic. Resident #6's Physician order [REDACTED]. Resident #6's Physician order [REDACTED]. On 2/25/20 at 2:45 p.m., during an interview with the Clinical Quality Specialist, a surveyor confirmed Resident #6 should have received the [MEDICATION NAME] for 5 days as prescribed, but only received 3 days worth and that medications are not being given administered as ordered by the Physician.

Based on record review and interview, the facility failed to ensure that 1 of 3 sampled residents (#1) receiving the medication [MEDICATION NAME], was free from significant medication errors. Finding: Resident #1's physician orders, dated 3/14/17, directed staff to give the resident [MEDICATION NAME] Immediate Release (IR) 20 milligrams (mg) by mouth every 4 hours as needed for pain, and to give [MEDICATION NAME] Extended Release (ER, [MEDICATION NAME]) 40 mg by mouth twice a day. On 3/30/17, a review of the facility's bound narcotic count book indicated that a dose of [MEDICATION NAME] ER 40 mg was given on 3/15/17 at 1:35 a.m., and on 3/15/17 at 5:30 a.m. The resident received a regularly scheduled dose of [MEDICATION NAME] ER 40 mg on 3/15/17 at 8:30 a.m. This resulted in medication errors when the resident received the extended release [MEDICATION NAME] twice, rather than the immediate release [MEDICATION NAME]. On 3/30/17 at 12:50 p.m., the findings were confirmed by the Director of Nursing.

Based on record review, review of incident reports and interviews, the facility failed to assess, care plan and implement interventions to assist in preventing falls for 1 of 4 sampled residents with falls (#4). This failure contributed to the resident experiencing 7 falls between 6/5/12 through 7/2/12, and ultimately sustaining a fractured humerus. Finding: Resident #4's admission Minimal Data Set, Version 3.0 (MDS) assessment, dated 6/4/12, was coded, (in section H0300), to indicate the resident was occasionally incontinent of urine and required the assistance of one staff to toilet using a rolling walker. The admission MDS assessment also was coded, (in Section JI1800), to indicate the resident had fallen multiple times prior to admission while at a hospice home. The resident's "Care Area Assessment" (CAA) form indicated the resident triggered for further assessment in the areas of urinary incontinence and falls. The resident's clinical record lacked evidence of further assessment of the residents urinary incontinence, with a three day continence management diary to determine if the residents voiding patterns, could be maintain or if pattens could be established to assist staff in anticipating the resident's need to use the bathroom. The resident's incident reports, dated 6/5/12; 6/8/12, 6/11/12, 6/15/12, 6/25/12, 7/1/12 and 7/2/12 at 11:30 PM and 7/2/12 at 3:00 am indicated that the resident had experienced 7 falls in the last month. The incident reports indicated that for 5 of the 7 falls, the resident was attempting to toilet him/herself and had fallen. On 7/19/12 at 11:20 AM, in an interview with a surveyor, the Director of Nursing confirmed that there was not a complete continence assessment with a voiding pattern for this resident. Resident #4's care plan did not indicate that the resident had a history of [REDACTED]. The Hospice assessment recommended keeping the resident's bed in the lowest position and recommended observing the resident at least every 60 minutes and to increase monitoring to every 15 minutes checks if needed. Review of incident accident report indicated the resident had fallen seven times between 6/5/12 and 7/2/12. On 6/12/12 (seven days after the hospice recommendations were made), the resident's care plan, under the area of at risk for falls was updated to reflect the intervention of keeping the resident's bed in the lowest position and using floor mats. There was no evidence that the facility updated the resident's care plan after each of the residents falls and the care plan continued to indicate the resident was at risk for falls instead of the resident having actual falls. An incident report, dated 7/3/12 at 1:30 PM, indicated Resident #4 had "crawled out of bed," was found lying on his/her back and sustained a skin tear. On 6/8/12 at 10:30 AM, an incident report indicated the resident was found "sitting on the floor" at the foot of the bed. On 6/11/12 at 5:45 AM, the resident was found sitting on the floor in front of his/her closet. The incident reports did not indicate if the resident's bed was in the low position or if fall mats were used. The resident's nursing notes and Certified Nursing Assistant (CNA) documentation forms did not indicate if the low bed and mats were being used. On 7/20/12, during an interview with a surveyor, a CNA stated that she had not used mats or put the bed in low positions until just a few days before the resident was transferred to the hospital. The CNA indicated the kardex would have the interventions listed that the CNAs would use to provide care for a resident. An incident report, dated 7/3/12 at 1:30 PM, indicated the resident had crawled out of bed, because he/she was attempting to go to the rest room. The resident had fallen and was noted to have a skin tear. A progress note, dated 7/3/12 at 11:26 PM, indicated that this was a follow up not to the resident's falls within the past 48 hours and that the resident was at the hospitals having x-rays for a fractured right humerus. The facility's failure to assess, care plan and implement interventions to prevent falls contributed to the resident falling and sustaining a fractured humerus. On 7/20/12 at 11:30 PM, a surveyor discussed this finding with the Registered Nurse, Manager.

Based on record review and interviews, the facility failed to ensure that physician's orders and plans of care were followed for 1 of 1 sampled resident (#1). The facility's failure to follow the physician's orders, resulted in an aspiration pneumonia requiring hospitalization , and hospital admission records attributed the pneumonia to the resident being provided thin liquids. Findings: Resident #1 had a physician's order, dated 5/3/10, for nectar thick liquids. The resident's care plan indicated that the resident had impaired swallowing and was to receive nectar thick consistency liquids as ordered. The resident's clinical record contained a Speech Therapy evaluation and Dietary evaluations which indicated that the resident needed nectar thick liquids as well. Additionally, the surveyor noted that the resident's Medication Reference Sheet, (a form used by the CNA-M to ensure proper identification of the resident and specific, individualized, instructions for how to administer the resident's medications) indicated that Resident #1 was to receive his/her medications whole, one at a time and with thickened water. A nurse's note dated, 5/14/10 at 8:42 a.m., indicated that the nurse observed a Certified Nursing Assistant- Medications (CNA-M) give thin liquid (water) to Resident #1; the nurse documented that a respiratory assessment was done and that they would continue to monitor the resident. A nurse's note, dated 5/15/10 at 8:17 a.m., indicated that the resident had complained of coughing during the night and had fine crackles in the right lower lung along with a wet, non-productive cough, but a normal temperature. A nurse's note, dated 5/15/10 at 12:58 p.m., indicated that the resident had spiked an oral temperature of 101.0 Fahrenheit, and that the resident's oxygen saturation level would go down when the resident talked or tried to walk. The clinical record indicated that the resident was sent to the hospital on [DATE]; hospital admission documents indicated that the resident was admitted for aspiration pneumonia which was attributed to being provided thin liquids on 5/14/10. The surveyor discussed this finding in an interview with the Director of Nurses, on 10/14/10 at 2:35 p.m.

Based on record review, and interviews, the facility failed to provide interventions outlined in the resident's care plan for thickened liquids for 1 of 1 sampled resident (#1). Finding: Resident #1's care plan indicated that the resident had impaired swallowing and was to receive nectar thick consistency liquids as ordered. A nurse's note, dated 5/14/10 at 8:42 a.m., indicated that the nurse observed a Certified Nursing Assistant - Medications (CNA-M) give thin liquid (water) to Resident#1. The surveyor noted that the resident's Medication Reference Sheet (a form used by the CNA-M to ensure proper identification of the resident and specific, individualized, instructions for how to administer the resident's medications) indicated that Resident #1 was to receive his/her medications whole, one at a time and with thickened water. Subsequent nurses notes indicated that the resident's respiratory status was monitored closely after being provided the water by the CNA-M on 5/14/10. On 5/15/10, the resident was sent to the hospital for evaluation due to a change in condition which the hospital admission records indicated was due to an aspiration pneumonia attributed to the resident being provided water on 5/14/10. The surveyor discussed this finding in an interview with the Director of Nurses, on 10/14/10 at 2:35 p.m.